tag:blogger.com,1999:blog-32605023324218416162024-03-16T08:09:26.006+07:00LifenursesLifenurses aims to provide high quality resources, article and information to help nurses and student nurses achieve their goal to become a full-fledge" Nurseslifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.comBlogger53125tag:blogger.com,1999:blog-3260502332421841616.post-32691430470921410302011-03-27T03:59:00.000+07:002014-11-20T20:58:14.224+07:00NCP Nursing care plans for Cerebral Contusion<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwvox7kHCUUDAJZmZGq1UmOFwMrUdIeDuAHxvzKwHUTjp4Kqrel0dWfQLOPn3RtkY7COmsdS1MU81QzgsETno9ffK3enz_W3BJnpX7jnJnT4s4cGUfPGbPGEQTS4suaSsT5vXET5ZIQIqn/s1600/contre_coup_contusions.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwvox7kHCUUDAJZmZGq1UmOFwMrUdIeDuAHxvzKwHUTjp4Kqrel0dWfQLOPn3RtkY7COmsdS1MU81QzgsETno9ffK3enz_W3BJnpX7jnJnT4s4cGUfPGbPGEQTS4suaSsT5vXET5ZIQIqn/s1600/contre_coup_contusions.jpg" height="200" width="145" /></a></div>
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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.</div>
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Causes For Cerebral Contusion</div>
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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.</div>
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Complications for Cerebral Contusion<br />
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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.</div>
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Treatment for Cerebral Contusion<br />
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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.</div>
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<a href="http://www.lifenurses.com/">Nursing</a> Assessment<br />
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.<br />
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<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
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Diagnostic tests for Cerebral Contusion<br />
Cerebral angiography outlines vasculature, and a
Computed tomography (CT) scan CT scan
MRI (magnetic resonance imaging)<br />
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Nursing diagnosis<br />
Common <a href="http://www.lifenurses.com/search/label/Nursing%20Diagnosis">Nursing diagnosis</a> found in Nursing care plans for Cerebral Contusion<br />
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<ul>
<li>Acute pain </li>
<li>Anxiety </li>
<li>Decreased intracranial adaptive capacity </li>
<li>Disturbed sensory perception: Kinesthetic, tactile </li>
<li>Disturbed thought processes </li>
<li>Impaired verbal communication </li>
<li>Ineffective coping </li>
<li>Risk for deficient fluid volume </li>
<li>Risk for infection </li>
<li>Risk for injury </li>
<li>Risk for post trauma syndrome</li>
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<b><a href="http://www.lifenurses.com/search/label/Nursing%20Intervention">Nursing Intervention</a> and Rationale</b></div>
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Acute pain
Related factors injuring agents (Cerebral Contusion)</div>
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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</div>
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Nursing diagnosis Anxiety
Related to Threat to or change in health status progressive debilitating disease, illness, interaction patterns, role function/status</div>
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Nursing Interventions:</div>
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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</div>
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Nursing diagnosis Ineffective cerebral tissue Perfusion
Related to Interruption of blood flow by space-occupying lesions (hemorrhage, hematoma), cerebral edema</div>
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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.</div>
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Nursing diagnosis Disturbed sensory perception: Kinesthetic, tactile
Related to Altered sensory reception, transmission, and/or integration: Neurologic disease, trauma</div>
Nursing Interventions<br />
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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</div>
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Nursing diagnosis Disturbed thought processes </div>
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Nursing diagnosis Impaired verbal communication
Related to decrease in circulation to brain, Cerebral Contusion </div>
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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 </div>
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Nursing diagnosis </div>
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Ineffective coping
Related to Impairment of nervous system cognitive, sensory, perceptual impairment, memory loss, Severe/chronic pain. </div>
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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 </div>
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Nursing diagnosis </div>
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Risk for deficient fluid volume </div>
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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 </div>
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Nursing diagnosis </div>
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Risk for infection
Risk factor inadequate primary defenses broken skin, traumatized tissue </div>
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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 </div>
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Nursing diagnosis<br />
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Risk for injury </div>
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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 </div>
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Nursing diagnosis </div>
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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 </div>
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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 </div>
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Patient Teaching And Home Healthcare Guidance For Patient With Cerebral Contusion<br />
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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. </div>
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Patient teaching and home healthcare guidance for patient with Cerebral Contusion </div>
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<li style="text-align: justify;">Tell the patient not to cough, sneeze, or blow his nose because these activities can increase ICP. </li>
<li style="text-align: justify;">Instruct the patient to observe for CSF drainage and to be alert for signs of infection. </li>
<li style="text-align: justify;">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.</li>
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lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-14085091979928975202011-03-11T03:14:00.000+07:002014-10-31T18:59:53.116+07:00Nursing Care Plan for Thyroid Cancer<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfMdxiUY22_96RF24j_HqIMmehMrsi0xxmEyNgooVdaielxA50NAD-LGaw3B0fltSHHpzyB6kuo9A5Y08QfoJfE8rArNkgUkkzQaE3u-8OUR99vX5ON-yCAd4QTssifDZKA0CkK4fBTLcC/s1600/thyroid-gland.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfMdxiUY22_96RF24j_HqIMmehMrsi0xxmEyNgooVdaielxA50NAD-LGaw3B0fltSHHpzyB6kuo9A5Y08QfoJfE8rArNkgUkkzQaE3u-8OUR99vX5ON-yCAd4QTssifDZKA0CkK4fBTLcC/s1600/thyroid-gland.gif" height="232" width="320" /></a></div>
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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. </div>
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Types characteristics of thyroid cancers </div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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 ) </li>
<li style="text-align: justify;">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 ) </li>
<li style="text-align: justify;">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) </li>
<li style="text-align: justify;">Thyroid lymphoma (Appears after age 40 years, May have history of goiter, hoarseness, Dyspnea, pain, and pressure, Good prognosis ) </li>
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Complications For Thyroid Cancers</div>
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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. </div>
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Clinical Manifestations for Thyroid Cancers </div>
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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. </div>
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Symptoms of Thyroid Cancer </div>
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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. </div>
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Nursing . Assessment</div>
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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. </div>
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Diagnostic Evaluation </div>
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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 </div>
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Nursing Diagnosis </div>
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Commong Nursing Diagnosis That Could Be Found In Patient With Thyroid Cancer:
Fear/Anxiety [specify level]
Acute/chronic Pain
Risk for ineffective Airway Clearance
Impaired verbal Communication
Risk for Injury, [tetany, thyroid storm]
Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs
Nursing Care Plan for Thyroid Cancer. </div>
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Nursing Intervention and Rationale Nursing Care Plan for Thyroid Cancer
Nursing Diagnosis Fear/Anxiety
Could be related to: </div>
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<li style="text-align: justify;">Situational crisis cancer Thyroid Cancer </li>
<li style="text-align: justify;">Threat to, or change in, health, socioeconomic status, role functioning, interaction patterns </li>
<li style="text-align: justify;">Threat of death </li>
<li style="text-align: justify;">Separation from family hospitalization, treatments, diagnostic procedures, diagnosis of chronic/life-threatening condition </li>
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Nursing Outcomes Evaluation Criteria, Client Will: </div>
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<li style="text-align: justify;">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. </li>
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Nursing Interventions and rationale Nursing diagnosis Fear/Anxiety: </div>
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<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">Encourage client to share thoughts and feelings. Rationale Provides opportunity to examine realistic fears and misconceptions about diagnosis. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
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Nursing Diagnosis Acute pain/Chronic Pain
Related to: </div>
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<ul>
<li style="text-align: justify;">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 </li>
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Nursing Outcomes Evaluation Criteria Client Will </div>
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<li style="text-align: justify;">Report maximal pain relief or control with minimal interference with activities of daily living (ADLs). </li>
<li style="text-align: justify;">Follow prescribed pharmacological regimen. </li>
<li style="text-align: justify;">Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.</li>
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Nursing Interventions and Rationale Nursing Diagnosis Acute/Chronic Pain </div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Provide cutaneous stimulation, such as heat and cold packs, or massage. Rationale May decrease inflammation, muscle spasms, reducing associated pain. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
</ul>
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Nursing Diagnosis Risk for Ineffective Airway Clearance
Related to </div>
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<ul>
<li style="text-align: justify;">Tracheal obstruction, swelling, bleeding, laryngeal spasms. </li>
</ul>
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Nursing Outcomes Evaluation Criteria
Client Will </div>
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<ul>
<li style="text-align: justify;">Maintain patent airway, with aspiration prevented. </li>
</ul>
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Nursing Interventions and Rationale Nursing Diagnosis Risk for Ineffective Airway Clearance </div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Auscultate breath sounds, noting presence of rhonchi. Rationale Rhonchi may indicate airway obstruction and accumulation of copious thick secretions. </li>
<li style="text-align: justify;">Assess for Dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice. Rationale Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Investigate reports of difficulty swallowing and drooling of oral secretions. Rationale May indicate edema and sequestered bleeding in tissues surrounding operative site. </li>
<li style="text-align: justify;">Keep tracheostomy tray at bedside. Rationale Compromised airway may create a life-threatening situation requiring emergency procedure. </li>
<li style="text-align: justify;">Provide steam inhalation, humidify room air. Rationale Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions. </li>
<li style="text-align: justify;">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. </li>
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Nursing Diagnosis Impaired Verbal Communication
Related to: </div>
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<ul>
<li style="text-align: justify;">Vocal cord injury, laryngeal nerve damage. Tissue edema; pain and discomfort </li>
</ul>
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Nursing Outcomes Evaluation Criteria
Client Will </div>
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<ul>
<li style="text-align: justify;">Establish method of communication in which needs can be understood. </li>
</ul>
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Nursing Interventions and Rationale: </div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Keep communication simple. Ask yes and no questions. Rationale Reduces demand for response; promotes voice rest. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Anticipate needs as much as possible. Visit client frequently. Rationale Reduces anxiety and client’s need to communicate. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Maintain quiet environment. Rationale Enhances ability to hear whispered communication and reduces necessity for client to raise and strain voice to be heard. </li>
</ul>
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Nursing Diagnosis Risk For Injury
Related to: </div>
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<ul>
<li style="text-align: justify;">tetany, thyroid storm. Chemical imbalance, such as with hypocalcemia, increased release of thyroid hormones, excessive central nervous system (CNS). Stimulation </li>
</ul>
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Nursing Outcomes Evaluation Criteria Client Will </div>
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<ul>
<li style="text-align: justify;">Demonstrate absence of injury with complications minimized or controlled. </li>
</ul>
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Nursing Interventions And Rationale </div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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.) </li>
<li style="text-align: justify;">Monitor serum calcium levels. Rationale : Clients with levels less than 7.5 mg/100 mL generally require replacement therapy. </li>
<li style="text-align: justify;">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. </li>
</ul>
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<b>Nursing Diagnosis Deficient Knowledge Regarding Condition, Prognosis, Treatment, Self-Care, And Discharge Needs
Related to</b>: </div>
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<ul>
<li style="text-align: justify;">Lack of exposure and recall; misinterpretation, Unfamiliarity with information resources </li>
</ul>
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Nursing Outcomes Evaluation Criteria
Client Will </div>
<br />
<ul>
<li style="text-align: justify;">Verbalize understanding of surgical procedure and prognosis and potential complications. </li>
<li style="text-align: justify;">Verbalize understanding of therapeutic needs.</li>
<li style="text-align: justify;"> Participate in treatment regimen. </li>
<li style="text-align: justify;">Initiate necessary lifestyle changes. </li>
</ul>
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Nursing Interventions and Rationale </div>
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<ul>
<li style="text-align: justify;">Review surgical procedure and future expectations. Rationale Provides knowledge base from which client can make informed decisions. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Stress necessity of continued medical follow-up. Rationale Provides opportunity for evaluating effectiveness of therapy and prevention of complications. </li>
</ul>
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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. </div>
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Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer: </div>
<br />
<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Instruct the patient on thyroid hormone replacement and follow-up blood tests. </li>
<li style="text-align: justify;">Stress the need for periodic evaluation for recurrence of malignancy. </li>
<li style="text-align: justify;">Supply additional information or suggest community resources dealing with cancer prevention and treatment. </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">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</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-19177595199303154032011-02-15T02:11:00.000+07:002014-10-31T18:59:53.144+07:00Nursing Care Plan for Laryngeal Cancer<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.massey.vcu.edu/media/massey-cancer-center/content-assets/images/headandneck-diagram300.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: justify;"><img border="0" src="http://www.massey.vcu.edu/media/massey-cancer-center/content-assets/images/headandneck-diagram300.jpg" height="178" width="200" /></a></div>
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Cancer of the larynx is a malignant tumor in the larynx (voice box). It is potentially curable if detected early. It represents less than 1% of all cancers and occurs about four times more frequently in men than in women, and most commonly in persons 50 to 70 years of age. Squamous cell carcinoma constitutes about 95% of laryngeal cancers. Rare laryngeal cancer forms adenocarcinoma and sarcoma account for the rest. An intrinsic tumor is on the true vocal cords and tends not to spread because underlying connective tissues lack lymph nodes. An extrinsic tumor is on some other part of the larynx and tends to spread easily. Laryngeal </div>
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Cancer is classified by its location: </div>
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Supraglottis (false vocal cords)
Glottis (true vocal cords)
Sub glottis (rare downward extension from vocal cords). </div>
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<b>Pathophysiology and Etiology of Laryngeal Cancer </b></div>
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Occurs predominantly in men older than age 60. Most patients have a history of smoking; those with Supraglottis laryngeal cancer frequently have a history of smoking and a high alcohol intake. Other risk factors include vocal straining, chronic laryngitis, industrial exposure, nutritional deficiency, and family predisposition.
About two-thirds of carcinomas of the larynx arise in the glottis, almost one-third arise in the Supraglottis region, and about 3% arise in the subglottic region of the larynx. When limited to the vocal cords (intrinsic), spread is slow because of lessened blood supply. When cancer involves the epiglottis (extrinsic), cancer spreads more rapidly because of abundant supply of blood and lymph and soon involves the lymph nodes of the neck.
A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords), Supraglottis area (area above the glottis or vocal cords, including epiglottis and false cords), and sub glottis (area below the glottis or vocal cords to the cricoid).
Two thirds of laryngeal cancers are in the glottis area. Supraglottis cancers account for approximately one third of the cases, subglottic tumors for less than 1%. Glottic tumors seldom spread if found early because of the limited lymph vessels found in the vocal. </div>
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<b>Causes for Laryngeal Cancer </b></div>
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The cause of laryngeal cancer is unknown. Major risk factors include smoking and alcoholism. Minor risk factors include chronic inhalation of noxious fumes and familial disposition. An initial assessment includes a complete history and physical examination of the head and neck. This will include assessment of risk factors, family history, and any underlying medical conditions.
Varied assessment findings in laryngeal cancer depend on the tumor’s location and its stage. With stage I disease, the patient may complain of local throat irritation or hoarseness that lasts about 2 weeks. In stages II and III, he usually reports hoarseness. He may also have a sore throat, and his voice volume may be reduced to a whisper. In stage IV, he typically reports pain radiating to his ear, dysphagia, and dyspnea. In advanced (stage IV) disease, palpation may detect a neck mass or enlarged cervical lymph nodes. </div>
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<b>Diagnostic tests </b></div>
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The usual workup includes laryngoscopy, xeroradiography, biopsy, laryngeal tomography and computed tomography scans, and laryngography to visualize and define the tumor and its borders. Chest X-ray findings can help detect metastases.
An indirect laryngoscopy, using a flexible endoscope, is initially performed in the otolaryngologist’s office to visually evaluate the pharynx, larynx, and possible tumor. Mobility of the vocal cords is assessed; if normal movement is limited, the growth may affect muscle, other tissue, and even the airway. The lymph nodes of the neck and the thyroid gland are palpated to determine spread of the malignancy.
If a tumor of the larynx is suspected on an initial examination, a direct laryngoscopic examination is scheduled. This examination is done under local or general anesthesia and allows evaluation of all areas of the larynx. Samples of the suspicious tissue are obtained for histologic evaluation. The tumor may involve any of the three areas of the larynx and may vary in appearance.
Computed tomography and magnetic resonance imaging (MRI) are used to assess regional adenopathy and soft tissue and to help stage and determine the extent of a tumor. MRI is also helpful in post-treatment follow-up in order to detect a recurrence. Positron emission tomography (PET scan) may also be used to detect recurrence of a laryngeal tumor after treatment. </div>
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Treatment Management For Laryngeal Cancer Depends on sites and stages of cancer. Early malignancy may be removed endoscopically. Early lesions may respond to laser surgery or radiation therapy; advanced lesions to laser surgery, radiation therapy, and chemotherapy. Treatment aims to eliminate cancer and preserve speech. If speech preservation isn’t possible, speech rehabilitation may include esophageal speech or prosthetic devices. Other surgical procedures vary with tumor size and include cordectomy, partial or total laryngectomy, Supraglottic laryngectomy, and total laryngectomy with laryngoplasty. </div>
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Risk Factors for Laryngeal Cancer
Carcinogens: Tobacco (smoke, smokeless), Combined effects of alcohol and tobacco, Asbestos, Second-hand smoke, Paint fumes, Wood dust, Cement dust, Chemicals, Tar products, Mustard gas, Leather and metals.
Other Factors: Straining the voice, chronic laryngitis, Nutritional deficiencies (riboflavin), History of alcohol abuse
Familial predisposition, Age (higher incidence after 60 years of age), Gender (more common in men), Race (more prevalent in African Americans), weakened immune system. </div>
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Clinical Manifestations for Laryngeal Cancer
Varied assessment findings in laryngeal cancer Depend on tumor location and its stage; sequence in appearance related to pattern and extent of tumor growth.
Supraglottic Cancer:
Tickling sensation in throat
Dryness and fullness (lump) in throat
Painful swallowing (odynophagia) associated with invasion of extra laryngeal musculature
Coughing on swallowing
Pain radiating to ear (late symptom)
Glottic Cancer (Cancer of the Vocal Cord):
Most common cancer of the larynx
Hoarseness or voice change
Aphonia (loss of voice)
Dyspnea
Pain (in later stages)
Subglottic Cancer (Uncommon):
Coughing
Short periods of difficulty in breathing
Hemoptysis; fetid odor, which results from ulceration and disintegration of tumor
With stage I disease Hoarseness of more than 2 weeks’ duration is noted early in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Affected voice sounds are not early signs of subglottic or supraglottic cancer.
In stages II and III, he usually reports hoarseness. He may also have a sore throat that does not go away, and his voice volume may be reduced to a whisper and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck.
Later symptoms In stage IV typically reports pain radiating to his ear dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis. palpation may detect a neck mass or enlarged cervical lymph nodes. </div>
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<b>Treatment Management For Laryngeal Cancer </b></div>
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Radiation therapy:
Singly or in combination with surgery.
Complications of radiation including airway obstruction, edema of larynx, soft tissue and cartilage necrosis, chondritis, pain, and loss of taste (xerostomia).
Surgery therapy:
Carbon dioxide laser for early-stage disease.
Partial laryngectomy removal of small lesion on true cord, along with a substantial margin of healthy tissue.
Supraglottic laryngectomy removal of hyoid bone, epiglottis, and false vocal cords, tracheostomy may be done to maintain adequate airway, radical neck dissection may be done.
Hemilaryngectomy removal of one true vocal cord, false cord, one half of thyroid cartilage, arytenoid cartilage.
Total laryngectomy removal of entire larynx (epiglottis, false or true cords, cricoid cartilage, hyoid bone; two or three tracheal rings are usually removed when there is extrinsic cancer of the larynx [extension beyond the vocal cords]). A radical neck dissection may also be done because of metastasis to cervical lymph nodes.
Total laryngectomy with laryngoplasty voice rehabilitation may be attempted through the Asai operation: A dermal tube is made from the upper end of the trachea into the hypo pharynx. The tracheostomy opening is closed off with a finger. The patient expires air up the dermal tube into the pharyngeal cavity. The sound produced is transformed into almost normal speech. </div>
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<b>Complications of Surgery therapy </b></div>
<ul>
<li style="text-align: justify;">Salivary fistula may develop after any surgical procedure that involves entering the pharynx or esophagus. (Monitor for saliva collecting beneath the skin flaps or leaking through suture line or drain site. Management NG tube feeding, meticulous local wound care with frequent dressing changes, promotion of drainage) </li>
<li style="text-align: justify;">Hemorrhage (carotid artery rupture) or hematoma formation. A major postoperative complication (e.g. skin necrosis or salivary fistula) usually precedes carotid artery rupture. Management immediate wound exploration in operating room. </li>
<li style="text-align: justify;">Stomas stenosis. </li>
<li style="text-align: justify;">Aspiration. </li>
<li style="text-align: justify;">Long-term complications: Chest infections (from repeated aspiration), Recurrence of cancer in stoma </li>
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<b>Nursing Assessment</b> for Laryngeal Cancer
The nurse assesses the patient for the following symptoms: hoarseness, sore throat, dyspnea, dysphagia, or pain and burning in the throat. The neck is palpated for swelling. If treatment includes surgery, the nurse must know the nature of the surgery to plan appropriate care. If the patient is expected to have no voice, a preoperative evaluation by the speech therapist is indicated. The patient’s ability to hear, see, read, and write is assessed. Visual impairment and functional illiteracy may create additional problems with communication and require creative approaches to ensure that the patient is able to communicate any needs.
In addition, the nurse determines the psychological readiness of the patient and family. The idea of cancer is terrifying to most people. Fear is compounded by the possibility of permanently losing voice and, in some cases, of having some degree of disfigurement. The nurse evaluates the patient’s and family’s coping methods to support them effectively both preoperatively and postoperatively.<br />
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<b>Nursing Diagnosis</b><br />
Common Nursing Diagnosis found in patient with Laryngeal Cancer
Ineffective airway clearance
Impaired verbal communication
Impaired skin/tissue integrity
Impaired oral mucous membrane
Acute pain
Imbalanced nutrition: less than body requirements
Disturbed body image/ineffective role performance deficient knowledge [learning need] regarding prognosis, treatment, self-care, and discharge needs
Impaired swallowing
Risk for infection<br />
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<b>Nursing interventions</b><br />
<b>Ineffective Airway Clearance May be related to: </b><br />
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<ul>
<li>Partial or total removal of the glottis, altering ability to breathe, cough, and swallow </li>
<li>Temporary or permanent change to neck breathing dependent on patent stoma </li>
<li>Edema formation surgical manipulation and lymphatic accumulation </li>
<li>Copious and thick secretions </li>
</ul>
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Nursing Outcomes Evaluation Criteria, Client Will:<br />
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<ul>
<li>Respiratory Status: Airway Patency
Maintain patent airway with breath sounds clear or clearing. </li>
<li>Clear secretions and be free of aspiration. </li>
</ul>
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Nursing Intervention and Rationale Nursing Diagnosis Ineffective Airway Clearance:<br />
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<ul>
<li>Monitor vital sign respiratory rate and depth note ease of breathing. Auscultate breath sounds. Investigate restlessness, Dyspnea, and development of cyanosis. Rationale Changes in respirations, use of accessory muscles, and presence of crackles or wheezes suggest retention of secretions. Airway obstruction can lead to ineffective breathing patterns even partial Airway obstruction and impaired gas exchange, resulting in complications, such as pneumonia and respiratory arrest. </li>
<li>Elevate head of bed 30 to 45 degrees. Rationale Facilitates drainage of secretions, work of breathing, and lung expansion. </li>
<li>Encourage swallowing, if client is able. Rationale reducing risk of aspiration with Prevents pooling of oral secretions </li>
<li>Encourage and teach effective coughing and deep breathing. Rationale Mobilizes secretions to clear airway and helps prevent respiratory complications. </li>
<li>Suction laryngectomy and tracheostomy tube and oral and nasal cavities. Note amount, color, and consistency of secretions. Rationale Changes in character of secretions may indicate developing problems, such as dehydration and infection, and need for further evaluation and treatment. Prevents secretions from obstructing airway, especially when swallowing ability is impaired. </li>
<li>Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. Rationale Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. </li>
<li>Maintain proper position of laryngectomy or tracheostomy tube. Check and adjust ties as indicated. Rationale As edema develops or subsides, tube can be displaced, compromising airway. Ties should be snug but not constrictive to surrounding tissue or major blood vessels. </li>
<li>Observe tissues surrounding tube for bleeding. Change client’s position to check for pooling of blood behind neck or on posterior dressings. Rationale bleeding or sudden eruption of uncontrolled hemorrhage presents a sudden and real possibility of airway obstruction and suffocation. </li>
<li>Provide supplemental humidification Rationale: Normal physiological on nasal passages means of filtering and humidifying air are bypassed. Supplemental humidity decreases mucous crusting and facilitates coughing or suctioning of secretions through stoma. </li>
<li>Resume oral intake with caution Rationale Changes in muscle mass and strength and nerve innervations increase likelihood of aspiration. </li>
<li>Monitor serial ABGs or pulse oximetry and chest x-ray. Rationale Pooling of secretions or presence of atelectasis may lead to pneumonia, requiring more aggressive therapeutic measures. </li>
</ul>
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<b>Nursing Diagnosis Impaired Verbal Communication related to: </b><br />
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<ul>
<li>Anatomical deficit removal of vocal cords </li>
<li>Physical barrier tracheostomy tube </li>
<li>Required voice rest </li>
</ul>
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Nursing Outcomes Evaluation Criteria Client Will:<br />
<br />
<ul>
<li>Communication Enhancement: Speech Deficit Independent </li>
<li>Communicate needs in an effective manner. </li>
<li>Identify and plan for appropriate alternative speech methods after healing.
Nursing Intervention and Rationale </li>
</ul>
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Nursing Diagnosis Impaired Verbal Communication:<br />
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<ul>
<li>Review preoperative instructions and discussion of why speech and breathing are altered, Rationale Reinforces teaching at a time when fear of surviving surgery is past. </li>
<li>Determine whether client has other communication impairments, such as hearing, vision, and literacy. Rationale Presence of other problems influences plan for alternative communication. </li>
<li>Provide immediate and continual means to summon nurse Prearrange signals for obtaining immediate help Rationale Client needs assurance that nurse is vigilant and will respond to summons. May decrease client’s anxiety about inability to speak. </li>
<li>Allow sufficient time for communication. Rationale Loss of speech and stress of alternative communication can cause frustration and block expression, especially when caregivers seem “too busy” or preoccupied. </li>
<li>Encourage ongoing communication with “outside world,” such as newspapers, television, radio, calendar, and clock. Rationale Maintains contact with “normal lifestyle” and continued communication through other avenues. </li>
<li>Caution client not to use voice until physician gives permission. Rationale Promotes healing of vocal cord and limits potential for permanent cord dysfunction. </li>
<li>Consult or refer with appropriate healthcare team members, therapists, speech pathologist, and social services. Refer to hospital-based rehabilitation, and community resources, such as Lost Chord or New Voice Club, International Association of Laryngectomees, and American Cancer Society. Rationale Ability to use alternative voice and speech methods, such as electrolarynx, TEP, voice prosthesis, and esophageal speech. Rehabilitation time may be lengthy and require a number of agencies and resources to facilitate or support learning process. </li>
</ul>
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<b>Nursing diagnosis Impaired Skin/Tissue Integrity related to: </b><br />
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<ul>
<li>Surgical removal of tissues and grafting </li>
<li>Radiation or chemotherapeutic agents </li>
<li>Altered circulation or reduced blood supply </li>
<li>Compromised nutritional status </li>
<li>Edema formation </li>
<li>Pooling or continuous drainage of secretions oral, lymph, or chyle </li>
</ul>
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Nursing Outcomes Evaluation Criteria Client Will:<br />
<br />
<ul>
<li>Wound Healing: Primary Intention </li>
<li>Display timely wound healing without complications. </li>
<li>Demonstrate techniques to promote healing and prevent complications. </li>
</ul>
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Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:<br />
<br />
<ul>
<li>Assess skin color, temperature, and capillary refill in operative and skin graft areas. Rationale Cyanosis and slow refill may indicate venous congestion, which can lead to tissue ischemia and necrosis. </li>
<li>Protect skin flaps and suture lines from tension or pressure. Provide pillow or rolls and instruct client to support head and neck during activity. Rationale Pressure from tubing and tracheostomy tapes or tension on suture lines can alter circulation and cause tissue injury. </li>
<li>Monitor bloody drainage from surgical sites, suture lines, and drains Rationale Bloody drainage usually declines steadily after first 24 hours. Steady oozing or frank bleeding indicates problem requiring medical attention. </li>
<li>Note and report any milky-appearing drainage. Rationale Milky drainage may indicate thoracic lymph duct leakage, which can result in depletion of body fluids and electrolytes. Such a leak may heal spontaneously or require surgical closure. </li>
<li>Change dressings, as indicated. Rationale Damp dressings increase risk of tissue damage and infection. </li>
<li>Cleanse thoroughly around stoma and neck tubes (if in place), avoiding soap or alcohol. Show client how to do self-care of stoma and tube with clean water and peroxide, using soft, lint-free cloth, not tissue or cotton. Rationale Keeping area clean promotes healing and comfort. Soap and other drying agents can lead to stomal irritation and possible inflammation. Materials other than cloth may leave fibers in stoma that can irritate or be inhaled into lungs. </li>
<li>Monitor all sites for signs of wound infection, such as unusual redness; increasing edema, pain, exudates; and temperature elevation. Rationale Impedes healing, which may already be slow because of changes induced by cancer, cancer therapies, or malnutrition. </li>
<li>Administer oral, IV, and topical antibiotics, as indicated. Rationale Prevents or controls infection. </li>
</ul>
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<b>Nursing Diagnosis Impaired Oral Mucous Membrane related to </b><br />
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<ul>
<li>Dehydration or absence of oral intake, decreased saliva production secondary to radiation or surgical procedure </li>
<li>Poor or inadequate oral hygiene </li>
<li>Pathological condition oral cancer, mechanical trauma oral surgery </li>
<li>Difficulty swallowing and pooling of secretions and drooling </li>
<li>Nutritional deficits </li>
</ul>
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Nursing Outcomes and Evaluation Criteria Client Will:<br />
<br />
<ul>
<li>Tissue Integrity: Skin and Mucous Membranes </li>
<li>Report or demonstrate a decrease in symptoms. </li>
<li>Identify specific interventions to promote healthy oral mucosa. </li>
<li>Demonstrate techniques to restore and maintain mucosal integrity. </li>
<li>Oral Health Restoration </li>
</ul>
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Nursing Intervention and Rationale Nursing Diagnosis Impaired Oral Mucous Membrane:<br />
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<ul>
<li>Inspect oral cavity, Tongue, Lips Teeth and gums and Mucous membranes note changes in: Saliva Rationale Surgery or Damage to salivary glands Tongue, Lips Teeth and gums and Mucous membranes may decrease production of saliva, resulting in dry mouth. Pooling and drooling of saliva may occur because of compromised swallowing capability or pain in throat and mouth. </li>
<li>Suction oral cavity frequently. Have client perform self-suctioning when possible or use gauze wick to drain secretions. Rationale Saliva contains digestive enzymes that may be erosive to exposed tissues. </li>
<li>Show client how to brush inside of mouth, palate, tongue, and teeth. Rationale Frequent oral care reduces bacteria and risk of infection and promotes tissue healing and comfort. </li>
<li>Apply lubrication to lips; provide oral irrigations as indicated. Rationale Counteracts drying effects of therapeutic measures and negates erosive nature of secretions. </li>
<li>Avoid alcohol based mouthwashes. Rationale: Alcohol can be drying and irritating. </li>
</ul>
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<b>Nursing Diagnosis Acute Pain related to: </b><br />
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<ul>
<li>Surgical incisions </li>
<li>Tissue swelling </li>
<li>Presence of nasogastric or orogastric feeding tube </li>
</ul>
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Nursing Outcomes and Evaluation Criteria Client Will:<br />
<br />
<ul>
<li>Report pain is relieved or controlled. </li>
<li>Demonstrate relief of pain and discomfort by reduced tension and relaxed manner.
Nursing Intervention and Rationale </li>
</ul>
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Nursing Diagnosis Acute Pain:<br />
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<ul>
<li>Evaluate pain level frequently. Rationale : Pain is a major concern for clients undergoing laryngectomy and it is believed as many as 32% still suffer severe distress, with the administered dosing less than needed to obtain optimal pain relief </li>
<li>Investigate changes in characteristics of pain. Check mouth and throat suture lines for fresh trauma. Rationale May reflect developing complications requiring further evaluation or intervention. </li>
<li>Provide comfort measures, such as back rub and position change, and Diversional activities, such as television, visiting, and reading. Rationale Promotes relaxation and helps client refocus attention on something beside pain. </li>
<li>Schedule care activities to balance with adequate periods of sleep or rest. Rationale Prevents fatigue or exhaustion and may enhance coping with stress or discomfort. </li>
<li>Administer analgesics such as on a scheduled basis or via patient-controlled analgesia; adjust dosages according to pain level per protocols. Rationale Degree of pain is related to extent and psychological impact of surgery as well as general body condition. </li>
</ul>
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<b>Patient Teaching Discharge and Home Healthcare Guidelines</b><br />
Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer. Teach the patient signs and symptoms of potential complications and the appropriate actions to be taken. Complications include infection (wound drainage, poor wound healing, fever, achiness, chills), airway obstruction and tracheostomy stenosis (noisy respirations, difficulty breathing, restlessness, confusion, increased respiratory rate), vocal straining; fistula formation (redness, swelling, secretions along a suture line), and ruptured carotid artery (bleeding, hypotension).Teach the patient the name, purpose, dosage, schedule, common side effects, and importance of taking all medications.<br />
Teach the patient the appropriate devices and techniques to ensure a patent airway and prevent complications. Explore methods of communication that work effectively. Encourage the patient to wear a Medic Alert bracelet or necklace, which identifies her or him as a mouth breather. Provide the patient with a list of referrals and support groups, such as visiting nurses, American Cancer Society, American Speech-Learning-Hearing Association, International Association of Laryngectomees, and the Lost Cord Club<br />
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<ul>
<li>Before partial or total laryngectomy, instruct the patient in good oral hygiene practices. If appropriate, instruct a male patient to shave off his beard to facilitate postoperative care. </li>
<li>Explain postoperative procedures, such as suctioning, NG tube feeding, and laryngectomy tube care. Carefully discuss the effects of these procedures (breathing through the neck and speech alteration, for example). </li>
<li>After surgery Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. To Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. </li>
<li>Also, prepare the patient for other functional losses. Forewarn him that he won’t be able to smell aromas, blow his nose, whistle, gargle, sip, or suck on a straw. </li>
<li>Reassure the patient that speech rehabilitation measures (including laryngeal speech, esophageal speech, an artificial larynx, and various mechanical devices) may help him communicate again. </li>
<li>Encourage the patient to take advantage of services and information offered by the American Speech-Language-Hearing Association, the International Association of Laryngectomees, the American Cancer Society, or the local chapter of the Lost Chord Club.</li>
</ul>
</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-9325456282225828862011-01-17T01:18:00.000+07:002014-10-31T18:59:53.354+07:00NCP Nursing Care Plan For Lung Cancer<div style="text-align: justify;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyc6hk3aNr_n01tpakVUi8w7wrOCnPrZDPExVV3lQ3EgUYvRFcZhdmu97pDWNquppHOypDE27ApuNrplmPIU642l48idRKuyuccjXJu-WF9tXXcM9G2Pq0GJFbMjI092kgE7qWtHC7W3pu/s1600/Lung-Cancer.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Lung Cancer" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyc6hk3aNr_n01tpakVUi8w7wrOCnPrZDPExVV3lQ3EgUYvRFcZhdmu97pDWNquppHOypDE27ApuNrplmPIU642l48idRKuyuccjXJu-WF9tXXcM9G2Pq0GJFbMjI092kgE7qWtHC7W3pu/s1600/Lung-Cancer.jpg" height="200" title="Lung Cancer" width="173" /></a></div>
Lung cancer is the uncontrolled growth of abnormal cells, which may occur in the lining of the trachea, bronchi, bronchioles, or alveoli. Ninety five percent of lung cancers are bronchogenic (arise from the epithelial lining of the bronchial tree).</div>
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Cause for Lung Cancers</div>
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<b>Carcinogenesis</b>, Initiation by a carcinogen (cancer-causing agent), for example, cigarette smoke, asbestos, or coal dust. Promotion by a secondary factor, for example, number of years smoking or number of cigarettes smoked. Progression, that is, the growth of pre-malignant cells and their ability to metastasize.</div>
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<b>Lifestyle risk factors</b>: Smoking, most common risk factor: 85% of people are or were former smokers. Others risk factor is Environmental tobacco smoke (secondhand smoke).About 3,400 lung cancer deaths in nonsmoking adults. Nonsmokers chronically exposed to secondhand smoke may have as much as a 24% increased risk for developing lung cancer.</div>
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<b>Occupational risks</b>: Radon, Asbestos fibers e.g. insulation and shipbuilding (7 times increased risk of death in asbestos workers & Asbestos exposure combined with cigarette smoking act synergistically to produce an increased risk of lung cancer), Arsenic (copper refining and pesticides), Beryllium (airline industry and electronics), Metals (nickel or copper), Chromium, Cadmium, Coal tar (mining), Mustard gas, Air pollution: diesel exhaust, Radiation, Tuberculosis.</div>
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<b>Biological risks Sex/age</b>: Males have a greater risk of lung cancer than do females, although incidence rate is declining significantly in men, from high of 102 per 100,000 in 1984 to 77.8 per 100,000 in 2002. Lung cancer incidence doubled in females from 1975 to 2000 and now has stabilized. Increased risk is associated with increasing age. 70% of all lung cancers diagnosed in individuals over the age of 65 and the number of cases diagnosed at 50 or earlier is increasing.</div>
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<b>Family history</b>: Lung cancer in one parent increases their children’s risk of the diagnosis of lung cancer before age 50.</div>
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<b>Genetic predisposition</b>: Genetic susceptibility is a contributing factor in those that develop lung cancer at a younger age. A single gene for lung cancer has not been identified. Abnormalities of p53 gene, a tumor-suppressor gene, have been suggested to be mutated in many people with lung cancer. EGFL6 gene identified as potential tumor marker.</div>
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<b>Race</b>: African Americans, native Hawaiians, and non-Hispanic whites have greater risk of lung cancer. Black men between the age of 35 and 64 years of age have twice the risk compared to non-Hispanic Whites.</div>
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<b>Chronic inflammation</b>, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis: Tuberculosis: Scarring of healthy lung tissue may lead to lung cancer development. Pulmonary fibrosis: Silica is the probable lung carcinogen. COPD: Airflow limitation results in a 6.44 times greater risk for lung cancer compared with the risk associated with absence of ventilator impairment.
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To categorize lung cancers visible Pathologic features on light microscopy, are used. Lung cancers are divided into two major groups, Small Cell Lung Cancer and Non–Small Cell Lung Cancer</div>
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Non-Small Cell Lung Cancer</div>
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<ul>
<li style="text-align: justify;">Squamous cell (epidermoid forms in the lining of the bronchial tubes). Most common type of lung cancer in men. Decreasing incidence in last two decades. Typically develops in segmental bronchi, causing bronchial obstruction and regional lymph node involvement. Symptoms are related to obstruction : nonproductive cough, pneumonia, atelectasis, that is, a collapsed lung, chest pain is a late symptom associated with bulky tumor, Pancoast Tumor, or pulmonary sulcus tumor, begins in the upper portion of the lung and commonly spreads to the ribs and spine causing classic shoulder pain that radiates down the ulnar nerve distribution. Treatment: surgical resection is preferred before the development of metastatic disease, chemotherapy and radiation therapy to decrease the incidence of recurrence. </li>
<li style="text-align: justify;">Adenocarcinoma. Most common form in Unites States, Increasing incidence in females. Occurs in non smokers. adenocarcinoma develops in the periphery of the lungs and frequently metastasizes to brain, bone, and liver. Symptoms: no symptoms with small peripheral lesions, Identifi ed by routine chest radiograph/CT scan. Treatment: surgical resection and chemotherapy and radiation therapy to decrease the incidence of recurrence. </li>
<li style="text-align: justify;">Bronchioalveolar (BAC). Form near the lung’s air sacs. BAC may have abnormal gene in their tumor cells. Targeted chemotherapy treatment appears to be effective. </li>
<li style="text-align: justify;">Large cell. Large cell: 10% of all lung cancer cases. Bulky peripheral tumor. Metastasizing to brain, bone, adrenal glands, or liver. Symptoms related to obstruction or metastatic spread pneumonitis and pleural effusions. Treatment: surgical resection (limited because of the often aggressive course of this tumor type) and chemotherapy and radiation therapy (palliative role to minimize symptoms of advanced disease). </li>
</ul>
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Small-Cell Lung Cancer</div>
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Patients with SCLC often have widespread disease at the time of diagnosis. Rapid clinical deterioration in patients with chest masses often indicates SCLC</div>
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<ol>
<li style="text-align: justify;">Oat cell carcinoma Oat cell carcinoma: 13% of all lung cancers. Most aggressive type, greater tendency to metastasize than Non-Small Cell Lung Cancer Strongly related to cigarette smoking often occurs within the mainstem bronchi and segmental bronchi; 80% of cases have hilar and mediastinal node involvement. Symptoms: Paraneoplastic syndrome: syndrome of inappropriate antidiuretic hormone (SIADH), Hyponatremia, fluid retention, weakness, and fatigue, Ectopic adrenocorticotropic hormone (ACTH) production, Hypokalemia, hyponatremia, hyperglycemia, lethargy, and confusion. Treatment for Oat cell carcinoma, Surgery rarely indicated even in those with limited stage disease because of the need for immediate systemic therapy and chemotherapy and radiation therapy offers the best hope for prolonged survival and quality of life. Majority of the patients respond to chemotherapy and radiation therapy but recurrence rate is very high. Two-thirds of patients demonstrate evidence of extensive disease at the time of diagnosis. </li>
<li style="text-align: justify;">Non-Bronchogenic Carcinomas. Undifferentiated non-small cell lung cancer (NSCLC). Non-bronchogenic carcinomas undifferientated non-small cell lung cancer (NSCLC) :</li>
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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)</div>
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Stage of Lung cancer TNM (Tumor, Nodes, Metastases) system of staging</div>
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TNM Stage of Lung cancer Description:</div>
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<b>Primary tumor (T) </b></div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">T0 : No evidence of primary tumor </li>
<li style="text-align: justify;">Tis : Carcinoma in situ </li>
<li style="text-align: justify;">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) </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">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 </li>
</ul>
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Regional lymph nodes (N)</div>
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<ul>
<li style="text-align: justify;">NX Regional lymph nodes cannot be assessed </li>
<li style="text-align: justify;">N0 No regional lymph node metastasis </li>
<li style="text-align: justify;">N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor </li>
<li style="text-align: justify;">N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s) </li>
<li style="text-align: justify;">N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral scalene, or supraclavicular lymph node(s) </li>
</ul>
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Distant Metastasis (M)</div>
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<ul>
<li style="text-align: justify;">MX Presence of distant metastasis cannot be assessed </li>
<li style="text-align: justify;">M0 No distant metastasis </li>
<li style="text-align: justify;">M1 Distant metastasis present </li>
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Stage grouping (TNM subsets):</div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Stage IV (Any T Any N M1) Evidence of metastatic disease. Treatment often palliative (to relieve symptoms). Clinical trials may offer some survival benefit. </li>
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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.</div>
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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.</div>
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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,</div>
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Lung cancer usually cause breathing and heart problems such as:</div>
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<ul>
<li style="text-align: justify;">Pleural effusion </li>
<li style="text-align: justify;">Pericardial effusion </li>
<li style="text-align: justify;">Coughing up large amounts of bloody sputum. </li>
<li style="text-align: justify;">Collapse of a lung (pneumothorax). </li>
<li style="text-align: justify;">Blockage of the airway (bronchial obstruction). </li>
<li style="text-align: justify;">Recurrent infections, such as pneumonia. </li>
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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.</div>
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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: <span style="background-color: white; color: #333333; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 16.7999992370605px; text-align: justify;"><b><14% combined 5-year survival rate</b></span></div>
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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. </div>
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Common treatment methods of Lung Cancer: </div>
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<b>Surgery Treatment for Lung Cancer </b></div>
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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 </div>
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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. </div>
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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. </div>
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<b>Chemotherapy Treatment for Lung Cancer </b></div>
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Researchers are continually looking at different ways of combining new and old drugs for advanced non-small cell lung cancer. </div>
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Chemotherapy Treatment for Non-Small Cell Lung Cancer </div>
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<ul>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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). </li>
<li style="text-align: justify;">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 </li>
<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">Progression of disease: Single-agent Docetaxel, Gemcitabine, Paclitaxel </li>
<li style="text-align: justify;">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 </li>
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Chemotherapy Treatment for Small-Cell Lung Cancer </div>
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<li style="text-align: justify;">Limited-stage disease; Pulmonary resection stage I or stage II, Etoposide and Cisplatin and Radiation, Etoposide and Carboplatin </li>
<li style="text-align: justify;">Extensive stage disease: Etoposide and Carboplatin +/− Paclitaxel, Adriamycin, Cyclophosphamide </li>
<li style="text-align: justify;">Investigational: Vaccine-autologous dendritic cell-adenovirus p53 </li>
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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. </div>
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Radiation therapy Treatment for Lung Cancer </div>
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<li style="text-align: justify;">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. </li>
<li style="text-align: justify;">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). </li>
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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). </div>
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Treatment alternatives </div>
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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) </div>
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Home care considerations </div>
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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. </div>
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<b>During and after radiation therapy</b>: 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. </div>
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<b>During and after chemotherap</b>y, 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 </div>
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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.</div>
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<b>Nursing Assessment </b></div>
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<b>Patient History</b>
Establish a history of persistent cough, chest pain, Dyspnea, weight loss, or hemoptysis. Smoking history, other risk factors (family history, occupational risks), associated diseases (COPD, tuberculosis, and emphysema), symptom description and onset. Ask if the patient has experienced a change in normal respiratory patterns or hoarseness. Some patients initially report pneumonia, bronchitis, and epigastria pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body. Ask if the sputum has changed color, especially to a bloody, rusty, or purulent hue. Elicit a history of exposure to risk factors by determining if the patient has been exposed to industrial or air pollutants. Check the patient’s family history for incidence of lung cancer </div>
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<b>Physical examination</b>
The clinical findings of lung cancer may be localized to the lung or may result from the regional or distant spread of the disease. Lung auscultation, respiratory rate and depth, palpitation of supraclavicular area for tumor or lymphatic involvement or both, clubbing, nicotine stains to skin, hair, teeth. Lung cancer clinical manifestations depend on the type and location of the tumor. Because the early stages of this disease usually produce no symptoms, it is most often diagnosed when the disease is at an advanced stage. In 10% to 20% of patients, lung cancer is diagnosed without any symptoms, usually from an abnormal finding on a routine chest x-ray.
Auscultation may reveal a wheeze if partial bronchial obstruction has occurred. Auscultate for decreased breath sounds, rales, or rhonchi. Note signs of an airway obstruction, such as extreme shortness of breath, the use of accessory muscles, abnormal retractions, and stridor. Monitor the patient for oxygenation problems, such as increased heart rate, decreased blood pressure, or an increased duskiness of the oral mucous membranes. Metastases to the mediastinum lymph nodes may involve the laryngeal nerve and may lead to hoarseness and vocal cord paralysis. The superior vena cava may become occluded with enlarged lymph nodes and cause superior vena cava syndrome; note edema of the face, neck, upper extremities, and thorax. </div>
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<b>Psychosocial examination</b>
The patient is faced with a psychological adjustment to the diagnosis of a chronic illness that frequently results in death. Patient undergoes major lifestyle changes as a result of the physical side effects of cancer and its treatment. Interpersonal, social, and work role relationships change. Evaluate the patient for evidence of altered moods such as depression or anxiety, and assess the patient’s coping mechanisms and support system. </div>
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Diagnostic tests For Lung Cancer </div>
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Chest radiographs plain anterior-posterior and lateral views not reliable to find lung tumors in their earliest stage.
Chest Computed Tomography (CT) three-dimensional image of the lungs and lymph nodes (can detect tumors as small as 5 millimeters). CT is only about 80% accurate in predicting mediastinum node involvement.
Spiral computed tomography of the chest.
Magnetic Resonance Imaging (MRI) 92% accuracy in the diagnosis of mediastinum invasion.
Positron Emission Tomography (PET) scan is based upon increased glucose metabolism in cancer cells. The PET scan uses a glucose analogue radiopharmaceutical to identify increased glycolysis in tumor tissues. The PET scan is a highly sensitive test in the diagnosis and staging of lung cancer.
Bronchoscopic detection of tumor auto fluorescence could improve cure rates in selected groups at high-risk.
Sputum cytology
Percutaneous transthoracic needle biopsy
Fine needle aspiration or biopsy
Bronchoscopy.
Mediastinoscopy to evaluate lymph node involvement.
Scalene node biopsy (evaluate lymph node involvement)
Photodynamic therapy; An injection of a light-sensitive agent with uptake by cancer cells, followed by exposure to a laser light within 24 to 48 hours, will result in fluorescence of cancer cells or cell death. Especially helpful in identifying developing cancer cells or “carcinoma in-situ.” Also used to determine the extent of disease and the response to treatment (experimental).
Assessment of distant metastasis: Abdominal CT (identify adrenal or liver metastasis), Head CT, MRI (brain), Bone scan; Thoracentesis (detect malignant cells in the pleural fluid). </div>
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Nursing Diagnosis for Lung Cancer </div>
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Common Nursing diagnosis found in nursing care plans for patient with Lung Cancer: </div>
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Impaired gas exchange related to Removal of lung tissue, altered oxygen supply.
Ineffective Airway Clearance May be related to Increased amount or viscosity of secretions, Restricted chest movement, pain, Fatigue, weakness
Acute Pain May be related to Surgical incision, tissue trauma, and disruption of intercostals nerves, Presence of chest tube, Cancer invasion of pleura, chest wall
Fear/Anxiety [specify level] May be related to Situational crises, Threat to or change in health status, Perceived threat of death.
Deficient Knowledge [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs. May be related to Lack of exposure, unfamiliarity with information or resources, Information misinterpretation, Lack of recall </div>
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Sample Nursing care Plan for Lung Cancer with interventions and rationale </div>
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Impaired gas exchange </div>
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May be related to: </div>
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<ul>
<li style="text-align: justify;">Removal of lung tissue (Surgery Treatment for Lung Cancer) </li>
<li style="text-align: justify;">Altered oxygen supply hypoventilation </li>
<li style="text-align: justify;">Decreased oxygen-carrying capacity of blood (blood loss). </li>
</ul>
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Nursing outcomes and evaluation criteria client will: </div>
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Respiratory status: gas exchange, Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client normal range, be free of symptoms of respiratory distress, the patient will maintain adequate ventilation. The patient will maintain a patent airway. </div>
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Nursing Interventions Nursing care Plan for Lung Cancer Nursing diagnosis Impaired gas exchange:
Respiratory Management: </div>
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Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, or changes in skin or mucous membrane Rationale Respirations may be increased as a result of compensatory mechanism to accommodate for loss of lung tissue or pain.
Auscultate lungs for air movement and abnormal breath sounds. Rationale Consolidation and lack of air movement on operative side are normal in the client who has had a pneumonectomy; but in a client who has had a lobectomy should demonstrate normal airflow in remaining lobes.
Investigate restlessness and changes in mentation and level of consciousness. Rationale May indicate increased hypoxia or complications such as mediastinum shift in a client who has had a pneumonectomy when accompanied by tachypnea, tachycardia, and tracheal deviation.
Assess client response to activity. Encourage rest periods, limiting activities to client tolerance. Rationale Increased oxygen consumption and demand and stress of surgery may result in increased Dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. Adequate rest balanced with activity can prevent respiratory compromise.
Note development of fever. Rationale Fever within the first 24 hours after surgery is frequently due to atelectasis. Temperature elevation within postoperative day 5 to 10 usually indicates an infection, such as wound or systemic. </div>
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Airway Management: </div>
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Maintain patent airway by positioning, suctioning, and use of airway adjuncts. Rationale Airway obstruction impedes ventilation, impairing gas exchange. (Refer to ND: ineffective Airway Clearance).
Reposition frequently, placing client in sitting and supine to side positions. Rationale Maximizes lung expansion and drainage of secretions.
Avoid positioning client with a pneumonectomy on the operative side. Rationale Research shows that positioning clients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion.
Encourage and assist with deep-breathing exercises and pursed lip breathing, as appropriate. Rationale Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis.
Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated. Rationale Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during period of compensatory physiological shift of circulation to remaining functional alveolar units.
Assist with and encourage use of incentive spirometer. Rationale Prevents or reduces atelectasis and promotes reexpansion of small airways.
Monitor and graph ABGs and pulse oximetry readings. Note hemoglobin (Hgb) levels. Rationale Decreasing PaO2 or increasing PaCO2 may indicate need for ventilatory support. Significant blood loss results in decreased oxygen-carrying capacity, reducing PaO2. </div>
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Tube Care Chest: </div>
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Maintain patency of chest drainage system following lobectomy and segmental wedge resection procedures. Rationale Drains fluid from pleural cavity to promote re expansion of remaining lung segments.
Note changes in amount or type of chest tube drainage. Rationale Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses. A sudden increase in amount of bloody drainage or return to frank bleeding suggests thoracic bleeding or a hemothorax, sudden cessation suggests blockage of tube, requiring further evaluation and intervention.
Observe for presence of bubbling in water-seal chamber. Rationale Air leaks appearing immediately postoperatively are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems in client versus a problem in the drainage system. </div>
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Nursing diagnosis Ineffective Airway Clearance </div>
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May be related to: </div>
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<ul>
<li style="text-align: justify;">Increased amount or viscosity of secretions </li>
<li style="text-align: justify;">Restricted chest movement, pain </li>
<li style="text-align: justify;">Fatigue, weakness </li>
</ul>
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Nursing Outcomes and Evaluation Criteria Client Will: </div>
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<ul>
<li style="text-align: justify;">Respiratory Status: Airway Patency </li>
<li style="text-align: justify;">Demonstrate patent airway, with fluid secretions easily expectorated, clear breath sounds, and noiseless respirations. </li>
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Nursing Interventions nursing care Plan for Lung Cancer Nursing diagnosis Ineffective Airway Clearance </div>
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<li style="text-align: justify;">Auscultate chest for character of breath sounds and presence of secretions. Rationale: Noisy respirations, rhonchi, and wheezes are indicative of retained secretions or airway obstruction. </li>
<li style="text-align: justify;">Assist client with and provide instruction in effective deep breathing, coughing in upright position (sitting), and splinting of incision. Rationale Upright position favors maximal lung expansion, and splinting improves force of cough effort to mobilize and remove secretions. Splinting may be done by nurse placing hands anteriorly and posterior over chest wall and by client, with pillows, as strength improves. </li>
<li style="text-align: justify;">Observe amount and character of sputum and aspirated secretions. Investigate changes, as indicated. Rationale Increased amounts of colorless (or blood-streaked) or watery secretions are normal initially and should decrease as recovery progresses. Presence of thick, tenacious, bloody, or purulent sputum suggests development of secondary problems for example, dehydration, pulmonary edema, local hemorrhage, or infection that require correction or treatment. </li>
<li style="text-align: justify;">Suction if cough is weak or breathe sounds not cleared by cough effort. Avoid deep endotracheal and nasotracheal suctioning in client who has had pneumonectomy if possible. Rationale Suctioning increases risk of hypoxemia and mucosal damage. Deep tracheal suctioning is generally contraindicated. If suctioning is unavoidable, it should be done gently and only to induce effective coughing. </li>
<li style="text-align: justify;">Encourage oral fluid intake, within cardiac tolerance. Rationale Adequate hydration aids in keeping secretions loose and enhances expectoration. </li>
<li style="text-align: justify;">Assess for pain and discomfort and medicate on a routine basis and before breathing exercises. Rationale Encourages client to move, cough more effectively, and breathe more deeply to prevent respiratory insufficiency. </li>
<li style="text-align: justify;">Provide and assist client with incentive spirometer and postural drainage and percussion, as indicated. Rationale Improves lung expansion and ventilation and facilitates removal of secretions. Note: Postural drainage may be contraindicated in some clients, and, in any event, must be performed cautiously to prevent respiratory embarrassment and incision discomfort. </li>
<li style="text-align: justify;">Use humidified oxygen and ultrasonic nebulizer. Provide additional fluids intravenously (IV), as indicated. Rationale Maximal hydration helps promote expectoration. Impaired oral intake necessitates IV supplementation to maintain hydration. </li>
<li style="text-align: justify;">Administer bronchodilators, expectorants, and analgesics, as indicated. Rationale Relieves bronchospasm to improve airflow. Expectorants increase mucus production and liquefy and reduce viscosity facilitating removal of secretions. </li>
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Nursing Diagnosis Acute Pain </div>
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May be related to: </div>
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<li style="text-align: justify;">Surgical incision, tissue trauma, and disruption of intercostals nerves </li>
<li style="text-align: justify;">Presence of chest tubes </li>
<li style="text-align: justify;">Cancer invasion to pleura or chest wall </li>
</ul>
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Nursing Outcomes and Evaluation Criteria Client Will: </div>
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<li style="text-align: justify;">Pain Level </li>
<li style="text-align: justify;">Report pain relieved or controlled. </li>
<li style="text-align: justify;">The patient will express feelings of comfort and decreased pain </li>
<li style="text-align: justify;">Appear relaxed and sleep or rest appropriately. </li>
<li style="text-align: justify;">Participate in desired as well as needed activities. </li>
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Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Acute Pain </div>
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<li style="text-align: justify;">Ask client about pain. Determine pain location and characteristics. Have client rate intensity on a scale of 0 to 10. Rationale Helpful in evaluating cancer related pain symptoms, which may involve viscera, nerve, or bone tissue. Use of rating scale aids client in assessing level of pain and provides tool for evaluating effectiveness of analgesics, enhancing client control of pain. </li>
<li style="text-align: justify;">Assess client verbal and nonverbal pain cues. Rationale Discrepancy between verbal and nonverbal cues may provide clues to degree of pain and need for and effectiveness of interventions. </li>
<li style="text-align: justify;">Note possible pathophysiological and psychological causes of pain. Rationale Fear, distress, anxiety, and grief can impair ability to cope. Posterolateral incision is more uncomfortable for client than an anterolateral incision. Discomfort can greatly increase with the presence of chest tubes. </li>
<li style="text-align: justify;">Evaluate effectiveness of pain control. Encourage sufficient medication to manage pain; change medication or time span as appropriate. Rationale Pain perception and pain relief are subjective, thus pain management is best left to client’s discretion. If client is unable to provide input, the nurse should observe physiological and nonverbal signs of pain and administer medications on a regular basis. </li>
<li style="text-align: justify;">Encourage verbalization of feelings about the pain. Rationale Fears and concerns can increase muscle tension and lower threshold of pain perception. </li>
<li style="text-align: justify;">Provide comfort measures such as frequent changes of position, back rubs, and support with pillows. Encourage use of relaxation techniques including visualization, guided imagery, and appropriate Diversional activities. Rationale Promotes relaxation and redirects attention. Relieves discomfort and therapeutic effects of analgesia. </li>
<li style="text-align: justify;">Schedule rest periods, provide quiet environment. Rationale Decreases fatigue and conserves energy, enhancing coping abilities. </li>
<li style="text-align: justify;">Assist with self care activities, breathing, arm exercises, and ambulation. Rationale Prevents undue fatigue and incision strain. Encouragement and physical assistance and support may be needed for some time before client is able or confident enough to perform these activities because of pain or fear of pain. </li>
<li style="text-align: justify;">Assist with patient-controlled analgesia PCA or analgesia through epidural catheter. Administer intermittent analgesics routinely, as indicated, especially 45 to 60 minutes before respiratory treatments, and deep-breathing and coughing exercises. Rationale Maintaining a constant drug level avoids cyclic periods of pain, aids in muscle healing, and improves respiratory function and emotional comfort and coping. </li>
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Nursing Diagnosis Fear/Anxiety [specify level] </div>
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May be related to: </div>
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<ul>
<li style="text-align: justify;">Situational crises </li>
<li style="text-align: justify;">Threat to or change in health status </li>
<li style="text-align: justify;">Perceived threat of death </li>
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Nursing Outcomes and Evaluation Criteria Client Will: </div>
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<li style="text-align: justify;">Fear Self-Control or Anxiety Self-Control </li>
<li style="text-align: justify;">Acknowledge and discuss fears and concerns. </li>
<li style="text-align: justify;">Demonstrate appropriate range of feelings and appear relaxed and resting appropriately. </li>
<li style="text-align: justify;">Verbalize accurate knowledge of situation. </li>
<li style="text-align: justify;">Report beginning use of individually appropriate coping strategies. </li>
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Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Fear/Anxiety: </div>
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<li style="text-align: justify;">Evaluate client and significant other (SO) level of understanding of diagnosis. Rationale Client and SO are hearing and assimilating new information that includes changes in self-image and lifestyle. Understanding perceptions of those involved sets the tone for individualizing care and provides information necessary for choosing appropriate interventions. </li>
<li style="text-align: justify;">Acknowledge reality of client’s fears and concerns and encourage expression of feelings. Rationale Support may enable client to begin exploring and dealing with the reality of cancer and its treatment. Client may need time to identify feelings and even more time to begin to express them. </li>
<li style="text-align: justify;">Provide opportunity for questions and answer them honestly. Be sure that client and care providers have the same understanding of terms used. Rationale Establishes trust and reduces misperceptions or misinterpretation of information. </li>
<li style="text-align: justify;">Accept, but do not reinforce, client’s denial of the situation. Rationale When extreme denial or anxiety is interfering with progress of recovery, the issues facing client need to be explained and resolutions explored. </li>
<li style="text-align: justify;">Note comments and behaviors indicative of beginning acceptance or use of effective strategies to deal with situation. Rationale Fear and anxiety will diminish as client begins to accept and deal positively with reality. Indicator of client’s readiness to accept responsibility for participation in recovery and to “resume life.” </li>
<li style="text-align: justify;">Involve client and SO in care planning. Provide time to prepare for events and treatments. Rationale May help restore some feeling of control and independence to client who feels powerless in dealing with diagnosis and treatment. </li>
<li style="text-align: justify;">Provide for client’s physical comfort. Rationale It is difficult to deal with emotional issues when experiencing extreme or persistent physical discomfort. </li>
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Nursing Diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs
Related to: </div>
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<li style="text-align: justify;">Lack of exposure, unfamiliarity with information or resources </li>
<li style="text-align: justify;">Information misinterpretation </li>
<li style="text-align: justify;">Lack of recall </li>
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Nursing Outcomes and Evaluation Criteria Disease Process and Treatment Regimen Client Will:</div>
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<li style="text-align: justify;">Verbalize understanding of ramifications of diagnosis, prognosis, and possible complications. </li>
<li style="text-align: justify;">Participate in learning process Knowledge of the Disease Process. </li>
<li style="text-align: justify;">Verbalize understanding of therapeutic regimen. </li>
<li style="text-align: justify;">Correctly perform necessary procedures and explain reasons for the actions. </li>
<li style="text-align: justify;">Initiate necessary lifestyle changes. </li>
</ul>
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Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs: </div>
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<ul>
<li style="text-align: justify;">Discuss diagnosis, current and planned therapies, and expected outcomes. Rationale Provides individually specific information, creating knowledge base for subsequent learning regarding home management. Radiation or chemotherapy may follow surgical intervention, and information is essential to enable the client and SO to make informed decisions. </li>
<li style="text-align: justify;">Reinforce surgeon’s explanation of particular surgical procedure, providing diagram as appropriate. Incorporate this information into discussion about short- and long-term recovery expectations. Rationale Length of rehabilitation and prognosis depend on type of surgical procedure, preoperative physical condition, and duration and degree of complications. </li>
<li style="text-align: justify;">Discuss necessity of planning for follow-up care before discharge. Rationale Follow-up assessment of respiratory status and general health is imperative to assure optimal recovery. Also provides opportunity to readdress concerns or questions at a less stressful time. </li>
<li style="text-align: justify;">Identify signs and symptoms requiring medical evaluations, such as changes in appearance of incision, development of respiratory difficulty, fever, increased chest pain, and changes in appearance of sputum. Rationale Early detection and timely intervention may prevent or minimize complications. Stress importance of avoiding exposure to smoke, air pollution, and contact with individuals with upper respiratory infections (URIs). </li>
<li style="text-align: justify;">Review nutritional and fluid needs. Suggest increasing protein and use of high-calorie snacks as appropriate. Rationale Meeting cellular energy requirements and maintaining good circulating volume for tissue perfusion facilitate tissue regeneration and healing process. </li>
<li style="text-align: justify;">Identify individually appropriate community resources, such as American Cancer Society, visiting nurse, social services, and home care. Rationale Agencies such as these offer a broad range of services that can be tailored to provide support and meet individual needs. </li>
<li style="text-align: justify;">Help client determine activity tolerance and set goals. Rationale Weakness and fatigue should decrease as lung heals and respiratory function improves during recovery period, especially if cancer was completely removed. If cancer is advanced, it is emotionally helpful for client to be able to set realistic activity goals to achieve optimal independence. </li>
<li style="text-align: justify;">Evaluate availability and adequacy of support system(s) and necessity for assistance in self-care and home management. Rationale General Weakness and activity limitations may reduce individual’s ability to meet own needs. </li>
<li style="text-align: justify;">Encourage alternating rest periods with activity and light tasks with heavy tasks. Stress avoidance of heavy lifting and isometric or strenuous upper body exercise. Reinforce physician’s time limitations about lifting. Rationale Generalized weakness and fatigue are usual in the early recovery period but should diminish as respiratory function improves and healing progresses. Rest and sleep enhance coping abilities, reduce nervousness (common in this phase), and promote healing. Note: Strenuous use of arms can place undue stress on incision because chest muscles may be weaker than normal for 3 to 6 months following surgery. </li>
<li style="text-align: justify;">Recommend stopping any activity that causes undue fatigue or increased shortness of breath. Rationale Exhaustion aggravates respiratory insufficiency. </li>
<li style="text-align: justify;">Instruct and provide rationale for arm and shoulder exercises. Have client or SO demonstrate exercises. Encourage following graded increase in number and intensity of routine repetitions. Rationale Simple arm circles and lifting arms over the head or out to the affected side are initiated on the first or second postoperative day to restore normal range of motion ROM of shoulder and to prevent ankylosis of the affected shoulder. </li>
<li style="text-align: justify;">Encourage inspection of incisions. Review expectations for healing with client. Rationale Healing begins immediately, but complete healing takes time. As healing progresses, incision lines may appear dry with crusty scabs. Underlying tissue may look bruised and feel tense, warm, and lumpy (resolving hematoma). </li>
<li style="text-align: justify;">Instruct client and SO to watch for and report places in incision that do not heal or reopening of healed incision, any drainage (bloody or purulent), and localized area of swelling with redness or increased pain that is hot to touch. Rationale Signs and symptoms indicating failure to heal, development of complications requiring further medical evaluation and intervention. </li>
<li style="text-align: justify;">Suggest wearing soft cotton shirts and loose fitting clothing, cover portion of incision with pad, as indicated, and leave incision open to air as much as possible. Rationale Reduces suture line irritation and pressure from clothing. Leaving incisions open to air promotes healing process and may reduce risk of infection. </li>
<li style="text-align: justify;">Shower in warm water, washing incision gently. Avoid tub baths until approved by physician. Rationale Keeps incision clean and promotes circulation and healing. </li>
<li style="text-align: justify;">Support incision with butterfly bandages as needed when sutures and staples are removed. Rationale Aids in maintaining approximation of wound edges to promote healing. </li>
</ul>
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Patient Teaching, Discharge And Home Healthcare Guidelines </div>
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Patient Teaching, Discharge and Home Healthcare Guidelines for patient with Lung Cancer usually divide in to before surgery and post surgery. Be sure the patient understands any medication prescribed, including dosage, route, action, and side effects. Teach the patient about medical procedure before surgery and post surgery. Teach the patient how to maximize her or his respiratory effort. </div>
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<b>Before surgery</b>, supplement and reinforce what the physician has told the patient about the disease and the operation.
Teach the patient about postoperative procedures and equipment. Discuss urinary catheterization, chest tubes, endotracheal tubes, dressing changes, and I.V. therapy.
If the patient is receiving chemotherapy or radiation therapy, explain possible adverse effects of these treatments. Teach him ways to avoid complications, such as infection. Also review reportable adverse effects.
Educate high-risk patients about ways to reduce their chances of developing lung cancer or recurrent cancer.
Refer smokers to local branches of the American Cancer Society or Smokenders. Provide information about group therapy, individual counseling, and hypnosis.
Urge all heavy smokers older than age 40 to have a chest X-ray annually and cytologic sputum analysis every 6 months. Also encourage patients who have recurring or chronic respiratory tract infections, chronic lung disease, or a nagging or changing cough to seek prompt medical evaluation. </div>
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<b>Post Surgery</b>, Provide the patient with the names, addresses, and phone numbers of support groups, such as the American Cancer Society, the National Cancer Institute, the local hospice, the Alliance for Lung Cancer Advocacy, Support & Education (ALCASE), and the Visiting Nurses Association
Teach the patient to recognize the signs and symptoms of infection at the incision site, including redness, warmth, swelling, and drainage. Explain the need to contact the physician immediately
Warn an outpatient to avoid tight clothing, sunburn, and harsh ointments on his chest. Teach him exercises to prevent shoulder stiffness.
Teach him how to cough and breathe deeply from the diaphragm and how to perform range-of-motion exercises. Reassure him that analgesics and proper positioning will help to control postoperative pain.</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-26423793011875584022010-11-30T00:27:00.000+07:002014-10-31T18:59:53.154+07:00Nursing Care Plans for Bladder Cancer<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3_ntcUDnzcYaelQ5E-bbiw5BpdE9Ng7-rQYQ2e1RiqEN6hiXXDGpF39kJvL8ItEj9k8XZ92MvLBl3p1nAkit-O_zX2Pa2t8ZJk0XSM6itOLos1DgChuXle7UIn5xjglf948D6NZU1FPLa/s1600/Bladder.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3_ntcUDnzcYaelQ5E-bbiw5BpdE9Ng7-rQYQ2e1RiqEN6hiXXDGpF39kJvL8ItEj9k8XZ92MvLBl3p1nAkit-O_zX2Pa2t8ZJk0XSM6itOLos1DgChuXle7UIn5xjglf948D6NZU1FPLa/s1600/Bladder.gif" height="258" width="320" /></a></div>
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Benign or malignant tumors may develop on the bladder. Bladder tumors can develop on the surface of the bladder wall (benign or malignant papillomas) or grow within the bladder wall (usually more virulent) and quickly invade underlying muscles. </div>
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Most bladder tumors are transitional cell carcinomas, arising from the transitional epithelium of mucous membranes. Less common are adenocarcinomas, epidermoid carcinomas, squamous cell carcinomas, sarcomas, tumors in bladder diverticula, and carcinoma in situ. Bladder tumors are most prevalent in men older than age 50 and are more common in densely populated industrial areas, but women are diagnosed at more advanced stages. </div>
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The most common presenting symptom of bladder cancer is hematuria. Gross hematuria obviously warrants a thorough evaluation of the genitourinary system. When gross hematuria is painless and total (present during the entirety of the urinary stream), it especially causes concern for bleeding from the bladder or upper tracts. Irritative urinary symptoms are relatively common at presentation, including frequency, urgency, and dysuria. The combination of these symptoms with hematuria is very suggestive and warrants full urologic evaluation. Depending on the location of their tumors, patients may have symptoms of bladder-outlet obstruction or ureteral obstruction. A small subset, 5% to 10% of patients, have symptoms related to metastatic disease. </div>
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Causes for Bladder cancer </div>
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Environmental carcinogens are known to predispose a person to transitional cell tumors such as 2-naphthylamine, benzidine, tobacco, coffee, and nitrates.Thus, workers in certain industries (rubber workers, weavers, leather finishers, aniline dye workers, hairdressers, petroleum workers, and spray painters) are at high risk for such tumors. The period between exposure to the carcinogen and development of symptoms is about 18 years.
Squamous cell carcinoma of the bladder is common in geographic areas where schistosomiasis is endemic, such as Egypt. What is more, it’s also associated with chronic bladder irritation and infection in people with renal calculi, indwelling urinary catheters, chemical cystitis caused by cyclophosphamide, and pelvic irradiation. </div>
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Complications of bladder cancer</div>
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If bladder cancer progresses, complications include bone metastases and problems resulting from tumor invasion of contiguous viscera. </div>
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Nursing Assessment </div>
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The patient typically reports gross, painless, intermittent hematuria and often with clots. Patients may complain of suprapubic pain after voiding, and also complain of bladder irritability, urinary frequency, nocturia, and dribbling. If he reports flank pain, he may have an obstructed ureter. </div>
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<b>Patient’s histor</b>y
Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occurs. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia. </div>
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<b>Physical assessment</b>
The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures. </div>
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<b>Psychosocial assessment</b>
Diagnosis of cancer and treatment of cancer with radical cystectomy and creation of a urinary diversion system can threaten sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido. </div>
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Diagnostic tests for bladder cancer </div>
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To confirm a bladder cancer diagnosis, the patient typically undergoes
Cystoscopy should be performed when hematuria first appears.
Biopsy (If the test results show cancer cells, further studies will determine the cancer stage and treatment).
Excretory urography can identify a large, early-stage tumor or an infiltrating tumor; delineate functional problems in the upper urinary tract; assess hydronephrosis; and detect rigid deformity of the bladder wall.
Urinalysis can detect blood and malignant cells in the urine.
Retrograde cystography evaluates bladder structure and integrity. Test results also help confirm a bladder cancer diagnosis. A bone scan can detect metastases. A computed tomography scan can define the thickness of the involved bladder wall and disclose enlarged retroperitoneal lymph nodes. Ultrasonography can find metastases in tissues beyond the bladder and can distinguish a bladder cyst from a bladder tumor.
Laboratory tests, such as a complete blood count and chemistry profile, may be ordered to evaluate conditions such as anemia that are associated with bladder cancer. </div>
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Nursing diagnosis </div>
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Common nursing diagnosis found in nursing care plans for bladder cancer </div>
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<ul>
<li style="text-align: justify;">Acute pain </li>
<li style="text-align: justify;">Anxiety </li>
<li style="text-align: justify;">Disturbed body image </li>
<li style="text-align: justify;">Fear </li>
<li style="text-align: justify;">Impaired skin integrity </li>
<li style="text-align: justify;">Impaired urinary elimination </li>
<li style="text-align: justify;">Ineffective coping </li>
<li style="text-align: justify;">Ineffective therapeutic regimen management </li>
<li style="text-align: justify;">Risk for infection </li>
<li style="text-align: justify;">Sexual dysfunction </li>
</ul>
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Nursing Interventions </div>
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<b>Acute Pain related to activity of disease process (cancer) </b></div>
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Nursing Outcomes Evaluation Criteria:
Client will </div>
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<ul>
<li style="text-align: justify;">verbalize relief or control of pain. </li>
<li style="text-align: justify;">Client will appear relaxed and be able to sleep and rest appropriately. </li>
</ul>
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Nursing Intervention nursing diagnosis Acute Pain related to activity of disease process (cancer): </div>
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<ol>
<li style="text-align: justify;">Assess pain level, location, characteristics, and intensity Rationale Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Pains in Surgical causes usually subside gradually as healing begins. Continued or increasing pain may be a sign of infection. </li>
<li style="text-align: justify;">Listen to the patient’s fears and concerns. Stay with him during periods of severe stress and anxiety, and provide psychological support Rationale Reduction of anxiety and fear can promote relaxation and comfort. </li>
<li style="text-align: justify;">Encourage and maintain bed rest during acute phase, if indicated Rationale Minimizes stimulation and promotes relaxation </li>
<li style="text-align: justify;">Administer analgesics, as indicated Rationale Reduce or control pain and decrease stimulation of the sympathetic nervous system </li>
</ol>
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Anxiety related to underlying Pathophysiology response, change in health status </div>
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Nursing Outcomes</div>
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<ul>
<li style="text-align: justify;">verbalize awareness of feelings of anxiety and healthy ways to deal with them. </li>
<li style="text-align: justify;">Patients will Report that anxiety is reduced to a manageable level. </li>
<li style="text-align: justify;">Patients will express concerns about effect of disease on lifestyle and position within family and society. </li>
<li style="text-align: justify;">Patients will demonstrate problem-solving skills and effective coping strategies and Use resources/support systems effectively. </li>
</ul>
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Nursing Intervention Anxiety </div>
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<ul>
<li style="text-align: justify;">Observe behavior indicative of anxiety which can be a clue to the client’s level of anxiety Rationale </li>
<li style="text-align: justify;">Explain purpose of tests and procedures in bladder cancer treatment Rationale Reduces anxiety attributable to fear of unknown diagnosis and prognosis. </li>
<li style="text-align: justify;">Encourage family and friends to treat client as before. Rationale Reassures client that role in the family and business has not been altered. </li>
<li style="text-align: justify;">Administer sedatives and tranquilizers, as indicated. Rationale May be desired to help client relax until physically able to reestablish adequate coping strategies. </li>
<li style="text-align: justify;">Review coping skills used in past and Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, lack of problem solving. Rationale These may be useful for the moment, but may eventually interfere with resolution of current situation </li>
</ul>
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Nursing Diagnosis Impaired urinary elimination </div>
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Nursing Outcomes Evaluation Criteria </div>
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<ul>
<li style="text-align: justify;">Patients will Display continuous flow of urine, with output adequate for individual situation </li>
<li style="text-align: justify;">Patients will verbalize understanding of condition. </li>
<li style="text-align: justify;">Patients will achieve normal elimination pattern. </li>
<li style="text-align: justify;">Patients will demonstrate behaviors/techniques to prevent urinary infection. </li>
<li style="text-align: justify;">Manage care of urinary catheter, or stoma and appliance following urinary diversion. </li>
</ul>
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Patient Teaching and Home Health Guidance for Bladder Cancer </div>
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Patient teaching, discharge and home healthcare guidelines for patient with Bladder Cancer. In early stages, bladders Cancer have no symptoms. Commonly, the first sign is gross, painless, intermittent hematuria. Patients with invasive lesions often have suprapubic pain after voiding. Other symptoms include bladder irritability, urinary frequency, nocturia, and dribbling. Provide complete information about disease, disease process and treatment. Provide complete preoperative teaching. Include an explanation of the operation the patient is to undergo. Discuss equipment and procedures that the patient can expect postoperatively. Teach the patient the specific procedure to catheterize the continent coetaneous pouch or reservoir. </div>
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Patient Teaching and Home Health Guidance for Bladder Cancer: </div>
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<ul>
<li style="text-align: justify;">Tell the patient what to expect from diagnostic tests. For example, make sure he understands that he may be anesthetized for cystoscopy. </li>
<li style="text-align: justify;">After the test results are known, explain the implications to the patient and his family. </li>
<li style="text-align: justify;">Demonstrate essential coughing and deep breathing exercises. </li>
<li style="text-align: justify;">In patient with orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding. </li>
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Following creation of an ileal conduit, teach the patient how to care of the stoma and urinary drainage system: </div>
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<ul>
<li style="text-align: justify;">If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist. </li>
<li style="text-align: justify;">Tell the patient that the ileal conduit stoma should reach its permanent size about 2 to 4 months after surgery. </li>
<li style="text-align: justify;">Teach the patient how to care for his urinary stoma. Instruction usually begins 4 to 6 days after surgery. Encourage appropriate relatives or other caregivers to attend the teaching session. Advise them beforehand that a negative reaction to the stoma can impede the patient’s adjustment. </li>
<li style="text-align: justify;">If the patient is to wear a urine collection pouch, teach him how to prepare and apply it. First, find out whether he will wear a reusable pouch or a disposable pouch. If he chooses a reusable pouch, he needs at least two to wear alternately. </li>
<li style="text-align: justify;">Teach the patient to select the right-sized pouch by measuring the stoma and choosing a pouch with an opening that leaves a (0.3 cm) margin of skin around the stoma. </li>
<li style="text-align: justify;">Instruct the patient to remeasure the stoma after he goes home in case the size changes. </li>
<li style="text-align: justify;">Tell the patient to empty the pouch every 2 to 3 hours or when it’s one-third full. </li>
<li style="text-align: justify;">Advise him to check the pouch frequently to ensure that the skin seal remains intact. </li>
<li style="text-align: justify;">Teach the patient to provide stoma care. </li>
<li style="text-align: justify;">To ensure a better seal and minimize skin breakdown, teach the patient how to use various products to level uneven abdominal surfaces, such as gullies, scars, and wedges. </li>
<li style="text-align: justify;">Postoperatively, tell the patient with a urinary stoma to avoid heavy lifting and contact sports. Encourage him to participate in his usual athletic and physical activities.</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-31312685974095647932010-11-16T00:25:00.000+07:002014-10-31T18:59:53.158+07:00Nursing Procedure Count the Respiratory Rate<div style="text-align: justify;">
The respiratory rate is a count of one full inspiration/expiration cycle for 1 full minute. Assessing respirations includes checking rate, rhythm, and depth. It includes assessing inspiration (taking oxygen into the lungs) and expiration (removing carbon dioxide from the lungs). The normal respiratory rate varies with age. The newborn’s respiratory rate is quite rapid, averaging about 40 breaths per minute. The respiratory rate gradually decreases with age until it reaches the adult rate of 12 to 20 breaths per minute. Respiratory rates that are within normal range are termed eupnea, those above normal range are termed Tachypnea; and those below normal range are called bradypnea. Absent breathing is apnea, and difficult breathing is Dyspnea. Respirations are diaphragmatic on children younger than 7 years of age observe or place hand on abdomen. Respirations are thoracic in children older than 7 years of age observe or place hand on chest. </div>
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Client education Count the respiratory rate: </div>
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<li>Instruct the client about the reason for assessing respiration. </li>
<li>Teach the caregiver to count respiration while the client is not aware. </li>
<li>Instruct the caregiver to contact the nurse if there is an alteration in the client’s respiration’s. </li>
<li>Clients should be taught to notify their caregiver or nurse when they feel a change in their respiration’s. </li>
<li>Clients who have decreased ventilation may benefit from being taught deep-breathing and coughing techniques. </li>
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Equipment Needed for Count the respiratory rate </div>
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<li>Stethoscope </li>
<li>Watch with a second hand </li>
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General Guidelines for Vital Signs Count the Respiratory Rate </div>
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<li>Check record for baseline and factors (age, illness, medications, etc.) influencing vital signs. </li>
<li>Gather equipment, including paper and pen, for recording vital signs. </li>
<li>Wash hands. </li>
<li>Prepare child and family in a quiet and nonthreatening manner. </li>
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Nursing Procedure Count the respiratory rate: </div>
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<ol>
<li>General Guidelines 1-4. </li>
<li>Be sure chest movement is visible. Client may need to remove heavy clothing. </li>
<li>Observe one complete respiratory cycle. If it is easier, place the client’s hand across his abdomen and your hand over the client’s wrist. </li>
<li>Start counting with first inspiration while looking at the second hand of a watch. Infants and children: Count Respiration’s for one full minute for infants and younger children because respiration’s are normally irregular Adults: count for 30 seconds and multiply by 2 to obtain the rate per minute, if an irregular rate or rhythm is present, count for one full minute. </li>
<li>Observe character of respiration’s; Depth of respiration’s by degree of chest wall movement (shallow, normal, or deep) Rhythm of cycle (regular or interrupted) </li>
<li>Observe movement of chest and abdomen; Assess chest movements for symmetry, in infants observe movement of abdomen. Paradoxical abdominal movement, abdomen rises on inspiration as chest retracts (see or saw movement), is abnormal except in premature infants. </li>
<li>Auscultate for normal, abnormal, and diminished and/or absent breath sounds on both back and chest; use a regular pattern; compare breath sounds side-to-side. </li>
<li>Replace client’s gown if needed. </li>
<li>Record rate and character of respiration’s. </li>
<li>Wash hands.</li>
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lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-75588861223663466142010-11-16T00:04:00.000+07:002014-10-31T18:59:53.320+07:00Nursing Procedure Measuring Blood Pressure<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXNuXaDq5IV41Ttf1loWNL0HohlX-aKJl-4sK0TQmXD7PuFafEX5Ikoebf2U4eJ188SwgprZ5GoHP_hdpGTT503-1qxbmLXQ3AZC8-Kk3cpqEviSvwM6QtA-V-2X5oqwazFa6mN0t52sdD/s1600/Nursing+care+plans+for+Hypertension.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: justify;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXNuXaDq5IV41Ttf1loWNL0HohlX-aKJl-4sK0TQmXD7PuFafEX5Ikoebf2U4eJ188SwgprZ5GoHP_hdpGTT503-1qxbmLXQ3AZC8-Kk3cpqEviSvwM6QtA-V-2X5oqwazFa6mN0t52sdD/s1600/Nursing+care+plans+for+Hypertension.jpg" height="161" width="200" /></a></div>
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Nursing Procedure Measuring Blood Pressure. Blood pressure (BP) is a measurement of the pressure within the vascular system as the heart contracts (systole) and relaxes (diastole). BP indirectly reflects your patient’s overall cardiovascular functioning. It is equal to CO time’s peripheral vascular resistance (BP CO PVR). Normal BP varies with age. Other factors that can affect BP include stress, genetics, medications, heavy meals, diurnal variations, exercise, and weight. Normal BP for an adult ranges from 100 to less than 120 mmHg (systolic) and from 60 to less than 80 mm Hg (diastolic). Normal BP for children and infants are much lower. A systolic reading 120 to 139 mmHg and a diastolic reading 80 to 89 mmHg is considered prehypertension; a systolic 140 to 159 mm Hg with a diastolic 90 to 99 mmHg, stage 1 hypertension; a systolic 160 mm Hg or higher with a diastolic 100 mm Hg or higher, stage 2 hypertension; and a systolic reading lower than 90 mm Hg and a diastolic reading lower than 60 mm Hg is considered hypotensive. Do not take a blood pressure (BP) on an injured or painful extremity or one where there is an intravenous line (IV). Cuff inflation can temporarily interrupt blood flow and compromise circulation in an extremity already impaired or a vein receiving IV fluids. </div>
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Indirect Blood Pressure Measurement </div>
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<ul>
<li>Bladder width should equal 40% and length should be at least 60% of the circumference of the extremity. </li>
<li>Auscultatory pressure is the traditional method using a sphygmomanometer cuff. It correlates poorly with directly measured values at the extremes of pressure. </li>
<li>Palpatory systolic pressure is defined as the pressure when a pulse is detected in the radial artery as the cuff is deflated. </li>
<li>Automated indirect devices measure without manual inflation and deflation. </li>
<li>Oscillometric methods correlate well with group average values, but they correlate poorly with intra-arterial pressures in individual patients. </li>
<li>Doppler sensing devices are slightly better but still vary quite a bit. </li>
<li>Volume clamp devices respond rapidly to changes in blood pressure and may be appropriate for use in critical care in the future. </li>
<li>Automated noninvasive monitors have a role in following trends of pressure change but are of little value in situations in which blood pressure fluctuates rapidly. Critical management decisions should not be made based on their results unless use of a direct method is impossible. </li>
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Direct Invasive Blood Pressure Measurement </div>
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Advantages of arterial catheters: </div>
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<ul>
<li>measure the end-on pressure propagated by the arterial pulse </li>
<li>detect pressures at which Korotkoff sounds are either absent or inaccurate </li>
<li>provide beat-to-beat changes in blood pressure </li>
<li>eliminate the need for multiple punctures when frequent blood draws needed </li>
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Disadvantages of arterial catheters: </div>
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<li>Require invasive procedure with complications including arterial injury, ischemia, thrombus formation, infection, and blood loss, among others. </li>
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Equipment Needed Measuring Blood Pressure: </div>
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<li>Stethoscope </li>
<li>Mercury sphygmomanometer with bladder and cuff </li>
<li>Alcohol wipe </li>
<li>Gloves if required </li>
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Client education needed Measuring Blood Pressure: </div>
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Teach the client to refrain from eating, drinking, or smoking 30 minutes before the procedure.
Ask the client to sit or lie down in a warm, quiet room.
Ask the client to rest for 5 minutes before taking the measurement.
Explain the procedure.
Advise the client regarding the correct size blood pressure cuff to use at home for his individual anatomy.
Advise the client to take his blood pressure at the same site using the same cuff for consistency.
Teach the client that the “top number” in a blood pressure reading is always higher than the “bottom number.” </div>
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ACTION: </div>
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General Guidelines for Measuring Blood Pressure </div>
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<ol>
<li>Check record for baseline and factors (age, illness, medications, etc.) influencing vital signs. Provides parameters and helps in device and site selection. </li>
<li>Gather equipment, including paper and pen, for recording vital signs. Promotes organization and efficiency. </li>
<li>Wash hands. Reduces transmission of microorganisms. </li>
<li>Prepare child and family in a quiet and nonthreatening manner. Enhances cooperation and participation; reduces anxiety and fear, which can affect readings. </li>
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Auscultation Method Using Brachial Artery </div>
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<ol>
<li>General Guidelines for Measuring Blood Pressure 1- 4. </li>
<li>Cleanse ear pieces and bell/diaphragm of stethoscope with an alcohol wipe </li>
<li>Determine which extremity is most appropriate for reading. Do not take a pressure reading on an injured or painful extremity or one in which an intravenous line is running. </li>
<li>Select a cuff size that completely encircles upper arm without overlapping </li>
<li>Remove clothing as necessary to expose extremity. Move clothing away from upper aspect of arm. </li>
<li>Position arm at heart level, extend elbow with palm turned upward. </li>
<li>Make sure bladder cuff is fully deflated and pump valve moves freely. </li>
<li>Locate the artery by palpation. Allows for proper placement of stethoscope to hear BP. Locate brachial artery in the antecubital space. </li>
<li>Apply cuff snugly and smoothly over upper arm, 2.5 cm (1 inch) above antecubital space with center of cuff over brachial artery. </li>
<li>Connect bladder tubing to manometer tubing. If using a portable mercury-filled manometer, position vertically at eye level. </li>
<li>Palpate brachial artery, turn valve clockwise to close and compress bulb to inflate cuff to 30 mm Hg above point where palpated pulse disappears, then slowly release valve (deflating cuff ), noting reading when pulse is felt again. </li>
<li>Insert earpieces of stethoscope into ears with a forward tilt, ensuring diaphragm hangs freely. </li>
<li>Relocate brachial pulse with your nondominant hand and place bell or diaphragm chestpiece directly over pulse. Chestpiece should be in direct contact with skin and not touch cuff. Place stethoscope gently over artery. Too firm a pressure will occlude blood vessel. </li>
<li>With dominant hand, turn valve clockwise to close. Compress pump to inflate cuff until manometer registers 30 mm Hg above diminished pulse point identified. </li>
<li>Slowly turn valve counterclockwise so that mercury falls at a rate of 2–3 mm Hg per second. Listen for five phases of Korotkoff sounds while noting manometer reading. (A faint, clear tapping sound appears and increases in intensity. Swishing sound. Intense sound. Abrupt, distinctive muffled sounds. Sound disappears). </li>
<li>Obtain a blood pressure reading. Systolic pressure: The pressure at which you first hear sounds. . Diastolic pressure: The American Heart Association recommends the onset of muffling as the diastolic pressure in children up to 13 years of age; the pressure when sounds become inaudible is the diastolic pressure in children > 13 years of age. </li>
<li>Deflate cuff rapidly and completely. </li>
<li>Remove cuff or wait 2 minutes before taking a second reading. </li>
<li>Inform client of reading. </li>
<li>Record reading. </li>
<li>If appropriate, lower bed, raise side rails, place call light in easy reach. </li>
<li>Put all equipment in proper place. </li>
<li>Wash hands. </li>
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Measuring Blood Pressure Using Palpation Method on Brachial or Radial Artery </div>
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<li>Palpate brachial or radial artery with fingertips of one hand. Inflate cuff to 30 mm Hg above point at which pulse disappears. </li>
<li>Palpation: Continue to slowly release pressure until a pulse is felt. This is the systolic pressure. The diastolic pressure is recorded as P, e.g., 100/P. The systolic pressure obtained by palpation is 5–10 mm Hg lower than that obtained by auscultation. </li>
<li>Deflate cuff slowly as you note on the manometer when the pulse is again palpable. </li>
<li>Deflate cuff rapidly and completely. </li>
<li>Remove cuff or wait 2 minutes before taking a second reading. </li>
<li>Inform client of reading. </li>
<li>Record reading. </li>
<li>Wash hands.</li>
</ol>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-31720584698590817642010-11-15T23:57:00.000+07:002014-10-31T18:59:53.163+07:00Nursing Care Plans For Nephrotic Syndrome<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihyphenhyphenjvjOEySUx18NP8kwYmYxe0Wopk1Q2brXZQ8WNM-KgCODDXlgn4tCszATfPq3-e5zt9mrH4pIyEI3tvL-beygGF26BH2eaj-8e1XzZaZEuYjHnQuBGygaXUYUXtBNk3nDy9va7UhM0p_/s1600/Kidney_Anatomy.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihyphenhyphenjvjOEySUx18NP8kwYmYxe0Wopk1Q2brXZQ8WNM-KgCODDXlgn4tCszATfPq3-e5zt9mrH4pIyEI3tvL-beygGF26BH2eaj-8e1XzZaZEuYjHnQuBGygaXUYUXtBNk3nDy9va7UhM0p_/s1600/Kidney_Anatomy.jpg" height="160" width="200" /></a></div>
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Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia), edema, and excess lipids in the blood (hyperlipidemia). These occur as a consequence of excessive leakage of plasma proteins into the urine because of increased permeability of the Glomerular capillary membrane. Nephrotic syndrome essentials of Diagnosis: Edema, Hypertension, Hematuria with or without dysmorphic red cells, red blood cell casts. The Nephrotic syndrome is marked by massive proteinuria greater than 3.5 g/d, low levels of serum albumin, high levels of serum lipids, and pronounced edema. Acute onset of the disorder can occur in instances of circulatory disruption producing systemic shock that decrease the pressure and flow of blood to the kidney. Progression to the Nephrotic syndrome may also occur as a complication of the previously discussed forms of glomerulonephritis. </div>
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Causes of Nephrotic syndrome </div>
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About 75% of Nephrotic syndrome cases result from primary idiopathic glomerulonephritis. Classifications include the following: </div>
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<li style="text-align: justify;">With minimal change disease (lipid nephrosis or nil disease) in children it’s the main cause of Nephrotic syndrome the glomeruli appear normal by light microscopy. Some tubules may contain increased lipid deposits. </li>
<li style="text-align: justify;">Membraneous glomerulonephritis the most common lesion in patients with adult idiopathic Nephrotic syndrome is characterized by uniform thickening of the Glomerular basement membrane containing dense deposits. It can eventually progress to renal failure. </li>
<li style="text-align: justify;">Focal glomerulosclerosis can develop spontaneously at any age, follow kidney transplantation, or result from heroin abuse. </li>
<li style="text-align: justify;">With membranoproliferative glomerulonephritis, slowly progressive lesions develop in the subendothelial region of the basement membrane. These lesions may follow infection, particularly streptococcal infection. This disease occurs primarily in children and young adults. </li>
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Other causes of Nephrotic syndrome include All of diseases that increase glomerular protein permeability, which leads to increased urinary excretion of protein, especially albumin, and subsequent hypoalbuminemia. Include metabolic diseases such as diabetes mellitus; collagen-vascular disorders, such as systemic lupus erythematosus and periarteritis nodosa; circulatory diseases, such as heart failure, sickle cell anemia, and renal vein thrombosis; nephrotoxins, such as mercury, gold, and bismuth; infections, such as tuberculosis and enteritis; allergic reactions; pregnancy; hereditary nephritis; and certain neoplastic diseases such as multiple myeloma. </div>
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Pathophysiology of Nephrotic syndrome </div>
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Increased permeability of the Glomerular membrane is attributed to damage to the membrane and changes in the electrical charges in the basal lamina and podocytes, producing a less tightly connected barrier. This facilitates the passage of high-molecular-weight proteins and lipids into the urine. Albumin is the primary protein depleted from the circulation.
The ensuing hypoalbuminemia appears to stimulate the increased production of lipids by the liver. The lower oncotic pressure in the capillaries resulting from the depletion of plasma albumin increases the loss of fluid into the interstitial spaces, which, accompanied by sodium retention, produces the edema. Depletion of immunoglobulin’s and coagulation factors places patients at an increased risk of infection and coagulation disorders. Tubular damage, in addition to Glomerular damage, occurs, and the Nephrotic syndrome may progress to chronic renal failure. </div>
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Clinical Manifestations of Nephrotic syndrome </div>
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The dominant Clinical Manifestations of Nephrotic syndrome is mild to severe dependent edema of the ankles or sacrum, or periorbital edema, especially in children. Such edema may lead to ascites, pleural effusion, weight gain, and high blood pressure.
Insidious onset of pitting dependent edema, periorbital edema, and ascites, weight gain
Fatigue, headache, malaise, irritability
Marked proteinuria leading to depletion of body proteins
Hyperlipidemia may lead to accelerated atherosclerosis </div>
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Complications of Nephrotic syndrome </div>
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Major complications include malnutrition, infection, coagulation disorders, and accelerated atherosclerosis. Thromboembolic complications renal vein thrombosis, venous and arterial thrombosis in extremities, pulmonary embolism, coronary artery thrombosis, cerebral artery thrombosis (especially in the lungs and legs). Hypovolemia. Hypochromic anemia can develop from excessive urinary excretion of transferrin. Opportunistic infections, hypertension, pleural effusion, and pericardial effusion may occur. Acute renal failure may occur. Altered drug metabolism due to decrease in plasma proteins. Progression to end stage renal failure </div>
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Nephrotic Syndrome Treatment </div>
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Nephrotic Syndrome Treatment. Correction of the underlying cause if possible is requires for effective treatment of Nephrotic syndrome. If it is caused by another disease, that underlying disease is treated. Supportive treatment consists of a nutritious, with restricted sodium intake, diuretics for edema, and antibiotics for infection. All nephrotoxins should be avoided. Some patients respond to an 8-week course of a corticosteroid such as prednisone followed by maintenance therapy. Others respond better to a combination of prednisone and azathioprine or cyclophosphamide. Treatment for hyperlipidemia frequently is unsuccessful. Immunosuppressant, antihypertensive, and diuretics can also help control symptoms. Angiotension converting enzyme inhibitors can decrease protein loss in urine. Some patients respond to a course of corticosteroid therapy, followed by a maintenance dose. Patients with chronic Nephrotic syndrome that’s unresponsive to therapy may require vitamin D replacement </div>
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Management of Nephrotic syndrome </div>
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Treatment of causative Glomerular disease
Diuretics (used cautiously) and angiotensin converting enzyme inhibitors to control proteinuria
Corticosteroids or immunosuppressant agents to decrease proteinuria
General management of edema: Sodium and fluid restriction, Infusion of salt-poor albumin, Dietary protein supplements
Low-saturated-fat diet
If the kidneys lose their ability to function, dialysis may be necessary. </div>
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Special considerations in Nephrotic syndrome Treatment </div>
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Frequently check urine protein levels.
Measure blood pressure while the patient is in a supine position and also while he’s standing, be alert for a drop in blood pressure that exceeds 20 mm Hg.
If the patient has had a kidney biopsy, watch for bleeding and shock.
Monitor intake and output, and check weight at the same time each morning after the patient voids and before he eats and while he’s wearing the same kind of clothing.
Ask the dietitian to plan a high protein, low sodium diet.
Provide good skin care because the patient with Nephrotic syndrome usually has edema, if needed provide antiembolism stockings To avoid thrombophlebitis, encourage activity and exercise
Offer the patient and family reassurance and support, especially during the acute phase, when edema is severe and the patient’s body image changes. </div>
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Nursing Assessment of Nephrotic syndrome </div>
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Patient’s history, Patients may report no illness before the onset of symptoms some patient have a history of systemic multisystem disease, such as lupus erythematosus, diabetes mellitus, amyloidosis, or multiple myeloma or have a history of an insect sting or venomous animal bite.The patient may complain of lethargy and depression. Your assessment may reveal two common problems: periorbital edema, which occurs primarily in the morning and is more common in children, and mild to severe dependent edema of the ankles or sacrum. Nurses should note orthostatic hypotension, ascites, and swollen external genitalia, signs of pleural effusion, anorexia, and pallor. Obtain history of onset of symptoms including changes in characteristics of urine and onset of edema. </div>
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Physical examination, Perform physical examination looking for evidence of edema and hypovolemic. Assess vital signs, daily weights, intake and output, and laboratory values. In later stages, inspect the patient for massive generalized edema of the scrotum, labia, and abdomen. Pitting edema is usually present in dependent areas. The patient’s skin appears extremely pale and fragile. You may note areas of skin erosion and breakdown. Often, urine output is decreased from normal and may appear characteristically dark, frothy, or opalescent. Some patients have hematuria as well.
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Diagnostic Evaluation of Nephrotic syndrome </div>
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Urinalysis marked proteinuria, microscopic hematuria, urinary casts, appears foamy
24-hour urine for protein (increased) and creatinine clearance (decreased)
Protein electrophoresis and immunoelectrophoresis of the urine to categorize the proteinuria
Needle biopsy of kidney for histological examination of renal tissue to confirm diagnosis
Serum chemistry decreased total protein and albumin, normal or increased creatinine, increased triglycerides, and altered lipid profile </div>
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Nursing Diagnosis of Nephrotic syndrome </div>
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Common nursing diagnosis found in nursing care plans for patients with Nephrotic syndrome </div>
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<li style="text-align: justify;">Imbalanced nutrition: Less than body requirements </li>
<li style="text-align: justify;">Disturbed body image </li>
<li style="text-align: justify;">Excess fluid volume </li>
<li style="text-align: justify;">Ineffective tissue perfusion: Renal </li>
<li style="text-align: justify;">Risk for injury </li>
<li style="text-align: justify;">Risk for Deficient Fluid Volume related to disease process </li>
<li style="text-align: justify;">Risk for Infection related to treatment with immunosuppressant </li>
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Nursing Interventions </div>
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Risk for Deficient Fluid Volume related to disease process </div>
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Desired Outcomes/Evaluation Criteria Client Will: </div>
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Hydration, Maintain adequate fluid balance as evidenced by vital signs and weight within client’s normal range, palpable peripheral pulses, moist mucous membranes, and good skin turgor. </div>
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Risk for Deficient Fluid Volume related to disease process: </div>
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Nursing Goal Increasing Circulating Volume and Decreasing Edema </div>
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<li style="text-align: justify;">Monitor daily weight, intake and output, and urine specific gravity. Rationale: Comparing actual and anticipated output may aid in evaluating presence and degree of renal stasis or impairment. </li>
<li style="text-align: justify;">Monitor CVP (if indicated), vital signs, orthostatic blood pressure, and heart rate to detect hypovolemic. Rationale: Indicators of hydration and circulating volume and need for intervention. </li>
<li style="text-align: justify;">Monitor serum BUN and creatinine to assess renal function. Rationale: Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction. </li>
<li style="text-align: justify;">Administer diuretics or immunosuppressant as prescribed, and evaluate patient’s response. Rationale: May be used short-term to reduce tissue edema to facilitate movement of stone. </li>
<li style="text-align: justify;">Infuse I.V. albumin as ordered. Rationale: NS is associated with significant protein loss. Serum albumin levels below 3.4 g/dL suggest need for IDPN infusions. </li>
<li style="text-align: justify;">Encourage bed rest for a few days to help mobilize edema; however, some ambulation is necessary to reduce risk of Thromboembolic complications. Rationale: Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation. </li>
<li style="text-align: justify;">Enforce mild to moderate sodium and fluid restriction if edema is severe; provide a high-protein diet. Rationale: As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia. </li>
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Risk for Infection related to treatment with immunosuppressant </div>
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Desired Outcomes Evaluation Criteria Client Will: </div>
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Immune Status, Experience no signs or symptoms of infection. </div>
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Nursing Intervention : </div>
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Nursing Goal Preventing Infection </div>
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<li style="text-align: justify;">Monitor for signs and symptoms of infection. Rationale: Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response. </li>
<li style="text-align: justify;">Monitor temperature routinely; check laboratory values for neutropenia. Rationale: A shifting of the differential to the left is indicative of infection. </li>
<li style="text-align: justify;">Use aseptic technique for all invasive procedures and strict hand washing by patient and all contacts; prevent contact by patient with persons who may transmit infection. Rationale: Reduces risk of cross-contamination. </li>
<li style="text-align: justify;">Monitor effectiveness of antimicrobial therapy. Rationale: within 24 to 48 hours Signs of improvement in condition should occur. </li>
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Patient Teaching Discharge and Home Healthcare Guidelines </div>
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Patient Teaching Discharge and Home Healthcare Guidelines for patient with Nephrotic syndrome. The most common sign of Nephrotic syndrome is mild to severe edema of the ankles or sacrum, and periorbital edema, especially in children. Edema may lead to ascites, pleural effusion, weight gain, and high blood pressure. Accompanying signs and symptoms include orthostatic hypotension, lethargy, anorexia, depression, and pallor. Major complications are malnutrition, infection, coagulation disorders, Thromboembolic vascular occlusion, and accelerated atherosclerosis. </div>
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<li style="text-align: justify;">Patient Teaching Discharge and Home Health-care Guidelines for patient with Nephrotic syndrome: </li>
<li style="text-align: justify;">Teach the patient and family about the disease process, prognosis, and treatment plan for Nephrotic Syndrome.
Teach the patient and family the purpose, dosage, route, desired effects, and side effects for all prescribed medications </li>
<li style="text-align: justify;">Explain that they need to monitor the urine daily for protein and keep a diary with the results of the tests. </li>
<li style="text-align: justify;">Have the patient or family demonstrate the testing techniques before discharge to demonstrate their ability to perform these monitoring tasks. </li>
<li style="text-align: justify;">Instruct the patient and family to avoid exposure to communicable diseases and to engage in scrupulous infection control measures (e.g. frequent hand washing). </li>
<li style="text-align: justify;">Encourage patients with hypercoagulability to maintain hydration and mobility and to follow the medication regimen. Inform patients on anticoagulant therapy of the need for laboratory monitoring of activated partial thromboplastin time or prothrombin time. </li>
<li style="text-align: justify;">Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as GI bleeding, stunted growth (children), bone fractures, and immunosuppressant. </li>
<li style="text-align: justify;">If the patient is taking immunosuppressant, teach him and family members to report even mild signs of infection. If he’s undergoing long-term corticosteroid therapy, teach him and family members to report muscle weakness and mental changes, Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as Gastrointestinal GI bleeding, stunted growth (children), bone fractures, and immunosuppressant. </li>
<li style="text-align: justify;">Suggest to the patient that he take steroids with an antacid or with cimetidine or ranitidine, to prevent Gastrointestinal GI complications, explain that the adverse effects of steroids subside when therapy stops, but warn the patient not to discontinue the drug abruptly or without a physician’s consent. </li>
<li style="text-align: justify;">Show the patient how to safely apply and remove anti-embolism stockings, If the physician prescribes anti-embolism stockings for home use. </li>
<li style="text-align: justify;">Stress the importance of adhering to the special diet or Ask the dietitian to plan a high-protein, low-sodium diet </li>
<li style="text-align: justify;">Encourage patients to resume normal activities as soon as possible.</li>
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lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-83770539573910770822010-11-01T23:38:00.000+07:002014-10-31T18:59:53.339+07:00Nursing Procedure Taking Temperatures<div class="separator" style="clear: both; text-align: center;">
<a href="http://studenthealth.uiowa.edu/assets/Uploads/thermometer.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: justify;"><img border="0" src="http://studenthealth.uiowa.edu/assets/Uploads/thermometer.jpg" height="132" width="200" /></a></div>
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What is Body temperature? Body temperature is the difference between heat produced and heat lost. The hypothalamus acts as the body’s thermostat to maintain a constant body temperature. The balance is maintained between the body’s heat producing functions (metabolism, shivering, muscle contraction, exercise, and thyroid activity) and the heat-losing functions (radiation, convection, conduction, and evaporation). When one temperature becomes greater than the other, temperature changes are seen greater heat-producing functions result in temperature elevations (fever/hyperthermia), and greater heat losing functions result in temperature decreases (hypothermia). </div>
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Sites of measurement of Body temperature: </div>
<br />
<ul>
<li style="text-align: justify;">Core temperature true body temperature. Rectal, bladder, and tympanic temperatures are in general the most reliable sites for maesuring body temperature. </li>
<li style="text-align: justify;">Sublingual convenient site to measuring body temperature. Tachypnea and consumption of hot or cold substances affect result. Best for intermittent measurement. </li>
<li style="text-align: justify;">Axillary temperatures average 1.5° to 1.9°C lower than tympanic. The accuracy of axillary temperatures is affected by inability to maintain probe position. </li>
<li style="text-align: justify;">Tympanic measured with specifically designed thermometer. In theory, correlates well with core temperature. In practice, correlates poorly because of difficulty performing the technique and technical malfunctions, with a high degree of user dissatisfaction. </li>
<li style="text-align: justify;">Skin poor correlation with core temperature. </li>
</ul>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">ROUTE<o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">ADVANTAGES<o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">DISADVANTAGES<o:p></o:p></span></div>
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<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 135.2pt;" valign="top" width="180">
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</span></span><!--[endif]--><b>Oral </b>(Normal: 98.6_F; 37_C)<o:p></o:p></div>
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<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"> ·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><b>Rectal </b>(Normal: 99.5_F; 37.5_C)<o:p></o:p></div>
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</span></span><!--[endif]--><b>Tympanic </b>(Normal: 99.5_F; 37.5_C)<o:p></o:p></div>
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</span></span><!--[endif]--><b>Axillary </b>(Normal: 97.6_F; 36.5_C)<o:p></o:p></div>
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</span></span><!--[endif]--><b>Forehead </b>(Normal: 94_F; 34.4_C)<o:p></o:p></div>
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<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"> ·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><b>Temporal arterial </b>(Normal: Close to
rectal temperature, 1_F or 0.5_C higher than an oral temperature, and 2_F or
1_C higher than an axillary temperature)<o:p></o:p></div>
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<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Easy,
fast, accurate<o:p></o:p></li>
</ul>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 36pt;">
<br /></div>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">More
reflective of core Temperature<o:p></o:p></li>
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Fast<o:p></o:p></li>
</ul>
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<br /></div>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">More
reflective of core temperature<o:p></o:p></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Safe,
good for children<o:p></o:p></li>
</ul>
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<br /></div>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Safe,
good for children and newborns<o:p></o:p></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Safe
and easy<o:p></o:p></li>
</ul>
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<br /></div>
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<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Cannot
be used for clients who are unconscious, confused, prone to seizures,
recovering from oral surgery, or under age 6.<o:p></o:p></li>
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Need
to wait 15–20 minutes after eating.<o:p></o:p></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Cannot
be used for clients who have rectal bleeding, hemorrhoids, or diarrhea
or who are recovering from rectal surgery.<o:p></o:p></li>
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Contraindicated
for cardiac clients because it may stimulate the vagus nerve and decrease
heart rate.<o:p></o:p></li>
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Not
recommended for newborns because of risk of perforating anus.<o:p></o:p></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Reports
of accuracy are conflicting.<o:p></o:p></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Measures
skin surface, which can be variable.<o:p></o:p></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Measures
skin surface temperature.<o:p></o:p></li>
</ul>
<ul style="margin-top: 0cm;" type="disc">
<li class="MsoNormal" style="margin-bottom: 0.0001pt;">Least
accurate method.<o:p></o:p></li>
</ul>
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Equipment Needed: </div>
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<ul>
<li style="text-align: justify;">Thermometer: Glass, oral, or rectal, at client’s bedside. Or Electronic thermometer with disposable protective </li>
<li style="text-align: justify;">Sheath Tympanic membrane thermometer with probe </li>
<li style="text-align: justify;">Cover Disposable, single-use chemical strip thermometer </li>
<li style="text-align: justify;">Lubricant for rectal and glass thermometer </li>
<li style="text-align: justify;">Two pairs of nonsterile gloves </li>
<li style="text-align: justify;">Tissues </li>
</ul>
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Purpose of Nursing Procedure Taking Temperatures: </div>
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The thermometer measures body temperature. Measurements may be oral, rectal, temporal artery, tympanic, axillary, or skin. A rectal measurement is most reflective of core temperature, whereas skin or surface measurements are the least reflective. Thermometers measure temperature in either degrees Fahrenheit (F) or centigrade/Celsius (C). </div>
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Types of thermometers include: </div>
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<ul>
<li style="text-align: justify;">Glass mercury thermometer: Used for oral, rectal, or axillary temperature measurements. </li>
<li style="text-align: justify;">Electronic digital thermometer: Used for oral, rectal, or axillary temperature measurements. </li>
<li style="text-align: justify;">Tympanic thermometer: Uses infrared sensors to sense temperature measurements of the tympanic membrane. </li>
<li style="text-align: justify;">Temporal artery thermometer: Measures arterial temperature through infrared scanning of the temporal artery. </li>
<li style="text-align: justify;">Disposable paper strips with temperature sensitive dots: Used for oral or skin/surface temperature measurements. </li>
</ul>
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Client education needed when measuring Body temperature: </div>
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Explain to client why an accurate body temperature is needed.
Describe the equipment to the client and explain what to expect during the procedure.
Answer any questions regarding the procedure and fears the client may have. </div>
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General Guidelines for Nursing Procedure Taking Temperatures: </div>
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<ul>
<li style="text-align: justify;">Review medical record for baseline data and factors that influence vital signs. </li>
<li style="text-align: justify;">Explain to the client that vital signs will be assessed. </li>
<li style="text-align: justify;">Encourage client to remain still and refrain from drinking, eating, and smoking. </li>
<li style="text-align: justify;">Assess client’s toileting needs and proceed as appropriate. </li>
<li style="text-align: justify;">Gather equipment. </li>
<li style="text-align: justify;">Provide for privacy. </li>
<li style="text-align: justify;">Wash hands and apply gloves. </li>
<li style="text-align: justify;">Adjust Position the client in a sitting or lying position with the head of the bed elevated 45° to 60° for measurement of all vital signs except those designated otherwise. </li>
<li style="text-align: justify;">Remove gloves and wash hands. </li>
</ul>
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Oral Temperature: Glass Thermometer </div>
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<ol>
<li style="text-align: justify;">Select correct color tip of thermometer from client’s bedside container </li>
<li style="text-align: justify;">Remove thermometer from storage container and cleanse under cool water. </li>
<li style="text-align: justify;">Use a tissue to dry thermometer from bulb’s end toward fingertips. </li>
<li style="text-align: justify;">Read thermometer by locating mercury level. It should read 35.5°C (96°F). </li>
<li style="text-align: justify;">If thermometer is not below normal body temperature reading, grasp thermometer with thumb and forefinger and shake vigorously by snapping the wrist in a downward motion to move mercury to a level below normal. </li>
<li style="text-align: justify;">Place thermometer in client’s mouth under the tongue and along the gum line to the posterior sublingual pocket. Instruct client to hold lips closed. </li>
<li style="text-align: justify;">Leave in place as specified by agency policy, usually 3–5 minutes. </li>
<li style="text-align: justify;">Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end. </li>
<li style="text-align: justify;">Read at eye level and rotate slowly until mercury level is visualized. </li>
<li style="text-align: justify;">Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container. </li>
<li style="text-align: justify;">Remove and dispose of gloves in receptacle. </li>
<li style="text-align: justify;">Wash hands. </li>
<li style="text-align: justify;">Record reading and indicate site as “OT.” </li>
<li style="text-align: justify;">Wash hands. </li>
</ol>
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<div style="text-align: justify;">
Oral Temperature Electronic Thermometer </div>
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<ol>
<li style="text-align: justify;">Repeat Procedure 1–8 of General Guidelines </li>
<li style="text-align: justify;">Place disposable protective sheath over probe </li>
<li style="text-align: justify;">Grasp top of the probe’s stem. Avoid placing pressure on the ejection button. </li>
<li style="text-align: justify;">Place tip of thermometer under the client’s tongue and along the gumline to the posterior sublingual pocket lateral to center of lower jaw. </li>
<li style="text-align: justify;">Instruct client to keep mouth closed around thermometer. </li>
<li style="text-align: justify;">Thermometer will signal (beep) when a constant temperature registers. </li>
<li style="text-align: justify;">Read measurement on digital display of electronic thermometer. Push ejection button to discard disposable sheath into receptacle and return probe to storage well. </li>
<li style="text-align: justify;">Inform client of temperature reading. </li>
<li style="text-align: justify;">Remove gloves and wash hands. </li>
<li style="text-align: justify;">Record reading and indicate site “OT.” </li>
<li style="text-align: justify;">Return electronic thermometer unit to charging base. </li>
<li style="text-align: justify;">Wash hands. </li>
</ol>
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<div style="text-align: justify;">
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<div style="text-align: justify;">
Rectal Temperature </div>
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<ol>
<li style="text-align: justify;">Repeat Procedure 1–8 of General Guidelines. </li>
<li style="text-align: justify;">Place client in the Sims’ position with upper knee flexed. Adjust sheet to expose only anal area. </li>
<li style="text-align: justify;">Place tissues in easy reach. Apply gloves. </li>
<li style="text-align: justify;">Prepare the thermometer. </li>
<li style="text-align: justify;">Lubricate tip of rectal thermometer or probe (usually a rectal thermometer has a red cap). </li>
<li style="text-align: justify;">With dominant hand, grasp thermometer. With other hand, separate buttocks to expose anus. </li>
<li style="text-align: justify;">After Instruct client to take a deep breath. Insert thermometer or probe gently into anus: infant, 1.2 cm (0.5 inches); adult, 3.5 cm (1.5 inches). If resistance is felt, do not force insertion. </li>
<li style="text-align: justify;">Hold thermometer in place for about 2 minutes. </li>
<li style="text-align: justify;">Wipe secretions off glass thermometer with a tissue. Dispose of tissue in a receptacle. </li>
<li style="text-align: justify;">Read measurement and inform client of temperature reading. </li>
<li style="text-align: justify;">While holding glass thermometer in one hand, use other hand to wipe anal area with tissue to remove lubricant or feces. Dispose of soiled tissue. Cover client. </li>
<li style="text-align: justify;">Cleanse thermometer. </li>
<li style="text-align: justify;">Remove and dispose of gloves in receptacle. Wash hands. </li>
<li style="text-align: justify;">Record reading and indicate site Rectal Temperature RT </li>
</ol>
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<div style="text-align: justify;">
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<div style="text-align: justify;">
Axillary Temperature </div>
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<ol>
<li style="text-align: justify;">Repeat Procedure 1–8 of General Guidelines. </li>
<li style="text-align: justify;">Remove client’s arm and shoulder from one sleeve of gown. Avoid exposing chest. </li>
<li style="text-align: justify;">Make sure axillaries skin is dry; if necessary, pat dry. </li>
<li style="text-align: justify;">Prepare thermometer. </li>
<li style="text-align: justify;">Place thermometer or probe into center of axilla. Fold client’s upper arm straight down and place arm across client’s chest. </li>
<li style="text-align: justify;">Leave glass thermometer in place as specified by agency policy (usually 6–8 minutes). Leave an electronic thermometer in place until signal is heard. </li>
<li style="text-align: justify;">Remove and read thermometer. </li>
<li style="text-align: justify;">Inform client of temperature reading. </li>
<li style="text-align: justify;">Cleanse glass thermometer. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container. </li>
<li style="text-align: justify;">Assist client with replacing gown. </li>
<li style="text-align: justify;">Record reading and indicate site Axillary Temperature </li>
<li style="text-align: justify;">Wash hands. </li>
</ol>
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<div style="text-align: justify;">
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<div style="text-align: justify;">
Disposable (Chemical Strip) Thermometer </div>
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<ol>
<li style="text-align: justify;">Repeat Procedure 1–8 of General Guidelines. </li>
<li style="text-align: justify;">Apply tape to appropriate skin area, usually forehead. </li>
<li style="text-align: justify;">Observe tape for color changes. </li>
<li style="text-align: justify;">Record reading and indicate method. </li>
<li style="text-align: justify;">Wash hands. </li>
</ol>
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<div style="text-align: justify;">
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<div style="text-align: justify;">
Tympanic Temperature: Infrared Thermometer </div>
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<ol>
<li style="text-align: justify;">Repeat Procedure 1–8 of General Guidelines. </li>
<li style="text-align: justify;">Position client in Sims’ position. </li>
<li style="text-align: justify;">Remove probe from container and attach probe cover to tympanic thermometer unit. </li>
<li style="text-align: justify;">Turn client’s head to one side. For an adult, pull pinna upward and back; for a child, pull down and back. Gently insert probe with firm pressure into ear canal. </li>
<li style="text-align: justify;">Remove probe after the reading is displayed on digital unit (usually 2 seconds). </li>
<li style="text-align: justify;">Remove probe cover and replace in storage container. </li>
<li style="text-align: justify;">Return tympanic thermometer to storage unit. </li>
<li style="text-align: justify;">Record reading and indicate site </li>
<li style="text-align: justify;">Wash hands.</li>
</ol>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-55977610337306428722010-10-19T22:12:00.000+07:002014-10-31T18:59:53.253+07:00Nursing Care Plans Chronic Renal Failure CRF<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.uchospitals.edu/images/gs/ei_1884.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: justify;"><img border="0" src="http://www.uchospitals.edu/images/gs/ei_1884.gif" height="198" width="200" /></a></div>
<div style="text-align: justify;">
Chronic renal failure CRF or end-stage renal disease, ESRD is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous wastes in the blood) and its complications unless dialysis or kidney transplantation is performed. Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous wastes in the blood). Few symptoms develop until after more than 75% of Glomerular filtration is lost. Then, the remaining normal parenchyma deteriorates progressively and symptoms worsen as renal function decreases. </div>
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Pathophysiology of Chronic renal failure </div>
<div style="text-align: justify;">
End result of the gradual, progressive destruction of nephrons and decrease in Glomerular Filtration Rate (GFR), resulting in loss of kidney function that produces major changes in all body systems. Chronic kidney disease (CKD), although ultimately irreversible, may be slowed by improved standardized blood tests and availability of new drugs to control blood pressure </div>
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<br /></div>
<div style="text-align: justify;">
Stages of renal failure</div>
<div style="text-align: justify;">
Chronic kidney disease CKD stages correspond to the degree of nephron loss:</div>
<br />
<ul>
<li style="text-align: justify;">Decreased renal reserve, Glomerular Filtration Rate GFR may be normal; slightly higher than normal, stage I: greater than or equal to 90 mL/min/1.73 m2; or somewhat less than normal, stage II: 60 to 89 mL/min/1.73 m2. Kidney dysfunction is present, however, it may be undiagnosed due to lack of symptoms blood urea nitrogen/creatinine (BUN/Cr) ratio is normal and nephron loss at less than 75%.</li>
<li style="text-align: justify;">Renal insufficiency, Nephron loss at 75% to 90%; GFR is moderately (stage III: 30 to 59 mL/min/1.73 m2) to severely (stage IV: 15 to 29 mL/min/1.73 m2) reduced. Slight elevation in BUN/Cr. Polyuria and nocturia present high output failure</li>
<li style="text-align: justify;">Renal Failure (GFR 20% to 25% of normal)</li>
<li style="text-align: justify;">End Stage Renal Disease (ESRD). Nephron loss at greater than 90% with a GFR of only 10% to 15% (stage V: less than 15 mL/min/1.73 m2). Fluid and electrolyte abnormalities, Azotemia and uremia present Dialysis required</li>
</ul>
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<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Clinical Manifestations of Chronic renal failure</div>
<br />
<ul>
<li style="text-align: justify;">Gastrointestinal GI anorexia, nausea, vomiting, hiccups, ulceration of Gastrointestinal GI tract, and hemorrhage </li>
<li style="text-align: justify;">Cardiovascular hyperkalemic ECG changes, hypertension, pericarditis, pericardial effusion, pericardial tamponade </li>
<li style="text-align: justify;">Respiratory pulmonary edema, pleural effusions, pleural rub </li>
<li style="text-align: justify;">Neuromuscular fatigue, sleep disorders, headache, lethargy, muscular irritability, peripheral neuropathy, seizures, coma </li>
<li style="text-align: justify;">Metabolic and endocrine glucose intolerance, hyperlipidemia, sex hormone disturbances causing decreased libido, impotence, amenorrhea </li>
<li style="text-align: justify;">Fluid, electrolyte, acid base disturbances usually salt and water retention but may be sodium loss with dehydration, acidosis, hyperkalemia, hypermagnesemia, hypocalcemia </li>
<li style="text-align: justify;">Dermatologic pallor, hyperpigmentation, pruritus, ecchymoses, uremic frost </li>
<li style="text-align: justify;">Skeletal abnormalities renal osteodystrophy resulting in osteomalacia </li>
<li style="text-align: justify;">Hematologic anemia, defect in quality of platelets, increased bleeding tendencies </li>
<li style="text-align: justify;">Psychosocial functions personality and behavior changes, alteration in cognitive processes</li>
</ul>
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Etiology Causes Renal Failure Chronic CRF</div>
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Multiple causes;</div>
<br />
<ul>
<li style="text-align: justify;">Acute tubular necrosis (ATN) from unresolved acute renal failure (ARF) </li>
<li style="text-align: justify;">Chronic infections: glomerulonephritis, pyelonephritis, beta hemolytic streptococci infection </li>
<li style="text-align: justify;">Vascular diseases: hypertensive nephrosclerosis, renal artery stenosis, renal vein thrombosis, vasculitis </li>
<li style="text-align: justify;">Obstructive processes: long-standing renal calculi, Benign Prostatic Hyperplasia (BPH) </li>
<li style="text-align: justify;">Cystic disorders: polycystic or medullary kidney disease </li>
<li style="text-align: justify;">Collagen diseases: systemic lupus erythematosus (SLE) and collagen vascular disease </li>
<li style="text-align: justify;">Tumors: malignant (multiple myeloma) or benign </li>
<li style="text-align: justify;">Nephrotoxic agents: drugs, such as aminoglycosides, tetracyclines, contrast dyes, heavy metals </li>
<li style="text-align: justify;">Endocrine diseases: diabetes mellitus (DM), hyperparathyroidism </li>
<li style="text-align: justify;">Long-standing systemic hypertension</li>
</ul>
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Such comorbidities as diabetes and hypertension are responsible for more than 70% of all cases of End Stage Renal Disease ESRD. Highest incidence of End Stage Renal Disease ESRD occurs in individuals older than age 65 years. over the last decade, there has been a 98% increase in incidence in those aged 75 years and older</div>
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Complications</div>
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If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal physiologic changes in all major organ systems. Even in patient with life sustaining maintenance Renal dialysis or a kidney transplant, the patient may still have:</div>
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<br /></div>
<ul>
<li style="text-align: justify;">Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids) </li>
<li style="text-align: justify;">Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis </li>
<li style="text-align: justify;">Hypertension due to sodium and water retention and malfunction of the rennin angiotensin aldosterone system </li>
<li style="text-align: justify;">Anemia due to decreased erythropoietin production, decreased Red Blood Cell RBC life span, bleeding in the GI tract from irritating toxins, and blood loss during hemodialysis </li>
<li style="text-align: justify;">Bone disease and metastatic calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels </li>
<li style="text-align: justify;">Peripheral neuropathy, Restless leg syndrome, one of the first symptoms of peripheral neuropathy, causes pain, burning, and itching in the legs and feet. Eventually, this condition progresses to paresthesia and motor nerve dysfunction unless dialysis is initiated </li>
<li style="text-align: justify;">Sexual dysfunction </li>
</ul>
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Treatment Goal for Chronic renal failure CRF End Stage Renal Disease ESRD conservation of renal function as long as possible. Correct specific symptoms, minimize complications, and slow progression of the disease. Underlying conditions that cause chronic renal failure must be controlled.</div>
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Treatment For Chronic renal failure CRF End Stage Renal Disease ESRD</div>
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<ul>
<li style="text-align: justify;">Detection and treatment of reversible causes of renal failure (e.g. bring Diabetes Mellitus under control, treat hypertension) </li>
<li style="text-align: justify;">Dietary regulation low-protein diet supplemented with essential amino acids or their keto analogues to minimize uremic toxicity and to prevent wasting and malnutrition </li>
<li style="text-align: justify;">Fluid status maintaining fluid balance requires careful monitoring of vital signs, weight changes, and urine volume. Loop diuretics, such as furosemide only if some renal function remains, and fluid restriction can reduce fluid retention. </li>
<li style="text-align: justify;">A cardiac glycoside may be used to mobilize edema fluids; an antihypertensive, especially an angiotensin-converting enzyme inhibitor, to control blood pressure and associated edema. </li>
<li style="text-align: justify;">Treatment of associated conditions to improve renal dynamics </li>
<li style="text-align: justify;">Anemia recombinant human erythropoietin (Epo-gen), a synthetic hormone. Anemia necessitates iron and folate supplements; severe anemia requires infusion of fresh frozen packed cells or washed packed cells. </li>
<li style="text-align: justify;">Acidosis replacement of bicarbonate stores by infusion or oral administration of sodium bicarbonate </li>
<li style="text-align: justify;">Hyperkalemia restriction of dietary potassium; administration of cation exchange resin </li>
<li style="text-align: justify;">Phosphate retention decrease dietary phosphorus (chicken, milk, legumes, carbonated beverages); administer phosphate-binding agents because they bind phosphorus in the intestinal tract </li>
<li style="text-align: justify;">Drug therapy, surgery, and dialysis Maintenance renal dialysis or kidney transplantation when symptoms can no longer be controlled with conservative management. Antiemetic taken before meals may relieve nausea and vomiting, and cimetidine, omeprazole, or ranitidine may decrease gastric irritation. Methylcellulose or docusate can help prevent constipation.</li>
</ul>
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Nursing Assessment</div>
<br />
<ul>
<li style="text-align: justify;">Patient History, Obtain history of chronic disorders and underlying health status. The patient’s history may include a disease or condition that can cause renal failure, but he may not have any symptoms for a long time. Symptoms usually occur by the time the GFR is 20% to 35% of normal, and almost all body systems are affected. Assessment findings reflect involvement of each system; many findings reflect involvement of more than one system. The patient may report a history of Acute Renal Failure ARF </li>
<li style="text-align: justify;">Assess degree of renal impairment and involvement of other body systems by obtaining a review of systems and reviewing laboratory results. Patient’s description of any central nervous system (CNS) symptoms. Blurred vision is common. Patients may have impaired decision making and judgment, irritability, decreased alertness, insomnia, increased extremity weakness, and signs of increasing peripheral neuropathy (decreased sensation in the extremities, hands, and feet; pain; and burning sensations). </li>
<li style="text-align: justify;">CRF affects all body systems Perform thorough physical examination, including vital signs, cardiovascular, pulmonary, GI, neurologic, dermatologic, and musculoskeletal systems. Hypertension is usually noted in the patient with CRF and may indeed be its cause. Patients often have rapid, irregular heart rates; distended jugular veins; and if pericarditis is present, pericardial frictions rub and distant heart sounds. Respiratory symptoms include hyperventilation, Kussmaul breathing, Dyspnea, orthopnea, and pulmonary congestion. </li>
<li style="text-align: justify;">Assess psychosocial response to disease process including availability of resources and support network. Some patient may have personality and cognitive changes. Sexual dysfunction usually occur in patient with chronic renal failure, carefully assess of the patient’s capabilities, home situation, available support systems, financial resources, and coping abilities is important before any nursing interventions for Chronic Renal Failure CRF can be planned. </li>
</ul>
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Diagnostic Test Chronic Renal Failure CRF </div>
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<ul>
<li style="text-align: justify;">Complete blood count (CBC) anemia (a characteristic sign), Elevated serum creatinine, BUN, phosphorus. Decreased serum calcium, bicarbonate, and proteins, especially albumin. ABG levels low blood pH, low carbon dioxide, low bicarbonate. show elevated blood urea nitrogen, creatinine, and potassium levels; decreased arterial pH and bicarbonate levels, and low hemoglobin (Hb) levels and hematocrit (HCT). </li>
<li style="text-align: justify;">Computed tomography scan, Renal or abdominal X-ray, magnetic resonance imaging, or Ultrasonography shows reduced kidney size. </li>
<li style="text-align: justify;">Kidney biopsy allows histological identification of underlying pathology </li>
</ul>
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Nursing Diagnosis </div>
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Common Nursing diagnosis that could be found in patient with Chronic Renal Failure CRF: </div>
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Risk for decreased Cardiac Output </div>
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Risk for ineffective Protection </div>
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Disturbed Thought Processes </div>
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Risk for impaired Skin Integrity </div>
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Risk for impaired Oral Mucous Membrane </div>
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Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs </div>
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Acute pain </div>
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Disabled family coping </div>
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Excess fluid volume </div>
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Imbalanced nutrition: Less than body requirements</div>
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Impaired gas exchange </div>
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Impaired oral mucous membrane </div>
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Impaired urinary elimination </div>
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Ineffective coping </div>
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Ineffective sexuality patterns </div>
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Ineffective tissue perfusion: Renal </div>
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Interrupted family processes </div>
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Powerlessness </div>
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Risk for infection </div>
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Risk for injury </div>
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Nursing Intervention </div>
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Nursing diagnosis Risk for decreased Cardiac Output </div>
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Risk factors may include </div>
<br />
<ul>
<li style="text-align: justify;">Fluid imbalances affecting circulating volume, myocardial workload, and systemic vascular resistance (SVR) </li>
<li style="text-align: justify;">Alterations in rate, rhythm, cardiac conduction (electrolyte imbalances, hypoxia) </li>
<li style="text-align: justify;">Accumulation of toxins (urea), soft tissue calcification (deposition of calcium phosphate) </li>
</ul>
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Desired Outcomes/Evaluation Criteria Client Will
Circulation Status: </div>
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Maintain cardiac output as evidenced by blood pressure (BP) and heart rate within client’s normal range; peripheral pulses strong and equal with prompt capillary refill time. </div>
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Nursing Intervention Risk for decreased Cardiac Output: </div>
<br />
<ul>
<li style="text-align: justify;">Auscultate heart and lung sounds. Evaluate presence of peripheral edema, vascular congestion, and reports of Dyspnea. Rationale S3/S4 heart sounds with muffled tones, tachycardia, irregular heart rate, Tachypnea, Dyspnea, crackles, wheezes, and edema or jugular distention suggest heart failure (HF). </li>
<li style="text-align: justify;">Assess presence and degree of hypertension Monitor Blood Pressure and note postural changes, such as sitting, lying, and standing. Rationale Significant hypertension can occur because of disturbances in the rennin angiotensin aldosterone system caused by renal dysfunction. Although hypertension is common, orthostatic hypotension may occur because of intravascular fluid deficit, response to effects of antihypertensive medications or uremic pericardial tamponade. </li>
<li style="text-align: justify;">Investigate reports of chest pain, noting location, radiation, severity (0 to 10 scale), and whether or not it is intensified by deep inspiration and supine position. Rationale: Although hypertension and chronic HF may cause myocardial infarction (MI), approximately half of CRF clients on dialysis develop pericarditis, potentiating risk of pericardial effusion and tamponade. </li>
<li style="text-align: justify;">Evaluate heart sounds for friction rub, BP, peripheral pulses, JVD, capillary refill, and mentation. Rationale: Presence of sudden hypotension with paradoxical pulse, narrow pulse pressure, diminished or absent peripheral pulses, marked JVD, pallor, and a rapid mental deterioration indicate tamponade, which is a medical emergency. </li>
<li style="text-align: justify;">Assess activity level and response to activity. Rationale: Weakness can be attributed to heart failure and anemia. </li>
<li style="text-align: justify;">Collaborate in treatment of underlying disease or conditions, where possible. Rationale Delaying or halting progression of CRF in early stages can be aided by interventions, such as controlling BP, managing diabetes, treating hyperlipidemia, and avoiding toxins such as NSAIDs, intravenous (IV) contrast dye, amino glycosides, and so on. </li>
<li style="text-align: justify;">Administer oxygen, as indicated. Rationale: Cardiac function can be improved with use of oxygen if client is severely anemic or metabolic acidosis and electrolyte abnormalities are causing Dysrhythmias. </li>
<li style="text-align: justify;">Prepare for renal replacement therapy, such as hemodialysis. Rationale: Reduction of uremic toxins and correction of electrolyte imbalances and fluid overload may limit or prevent cardiac manifestations, including hypertension and pericardial effusion. </li>
</ul>
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Nursing Diagnosis Risk for ineffective Protection </div>
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Risk factors may include: </div>
<br />
<ul>
<li style="text-align: justify;">Abnormal blood profile decreased RBC production and survival, altered clotting factors (suppressed erythropoietin production or secretion). </li>
<li style="text-align: justify;">Increased capillary fragility </li>
</ul>
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Desired Outcomes/Evaluation Criteria Client Will </div>
<br />
<ul>
<li style="text-align: justify;">Experience no signs and symptoms of bleeding or hemorrhage. </li>
<li style="text-align: justify;">Maintain or demonstrate improvement in laboratory values. </li>
</ul>
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Nursing Intervention: </div>
<br />
<ul>
<li style="text-align: justify;">Note reports of increasing fatigue and weakness. Observe for tachycardia, pallor of skin and mucous membranes, Dyspnea, and chest pain. Plan client activities to avoid fatigue. Rationale May reflect effects of anemia and cardiac response necessary to keep cells oxygenated. </li>
<li style="text-align: justify;">Monitor level of consciousness (LOC) and behavior. Rationale Anemia may cause cerebral hypoxia manifested by changes in mentation, orientation, and behavioral responses. </li>
<li style="text-align: justify;">Evaluate response to activity and ability to perform tasks. Assist as needed and develop schedule for rest. Rationale Anemia decreases tissue oxygenation and increases fatigue, which may require intervention, changes in activity, and rest. </li>
<li style="text-align: justify;">Observe for oozing from venipuncture sites, bleeding or ecchymosis areas following slight trauma, petechiae, and joint swelling or mucous membrane involvement bleeding gums, recurrent epitasis, hematemesis, melena, and hazy or red urine. Rationale Bleeding can occur easily because of capillary fragility and altered clotting functions and may worsen anemia. </li>
<li style="text-align: justify;">Provide soft toothbrush and electric razor. Use smallest needle possible and apply prolonged pressure following injections or vascular punctures. Rationale Reduces risk of bleeding and hematoma formation. </li>
<li style="text-align: justify;">Administer fresh blood and packed red cells (PRCs), as indicated. Rationale May be necessary when client is symptomatic with anemia. PRCs are usually given when client is experiencing fluid overload or receiving dialysis treatment. Washed RBCs are used to prevent hyperkalemia associated with stored blood. </li>
<li style="text-align: justify;">Administer medications, as indicated, for example: Erythropoietin preparations (Epogen, EPO, Procrit) Rationale Stimulates the production and maintenance of RBCs, thus decreasing the need for transfusion.
Iron preparations, such as folic acid and cyanocobalamin Rationale Useful in managing symptomatic anemia related to nutritional and dialysis-induced deficits. Note: Iron should not be given with phosphate binders because they may decrease iron absorption.
Cimetidine, ranitidine, and antacids Rationale May be given prophylactically to reduce or neutralize gastric acid and thereby reduce the risk of GI hemorrhage.
Hemostatics or fibrinolysis inhibitors, such as aminocaproic acid Rationale Inhibits bleeding that does not subside spontaneously or respond to usual treatment.
Stool softeners, such as Colace and bulk laxative, such as Metamucil Rationale straining to pass hard formed stool increases likelihood of mucosal or rectal bleeding. </li>
</ul>
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Nursing Diagnosis Disturbed Thought Processes </div>
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May be related to: Physiological changes accumulation of toxins, such as urea, ammonia; metabolic acidosis; hypoxia; electrolyte imbalances; calcifications in the brain </div>
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Desired Nursing Outcomes Evaluation Criteria Client Will: </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Regain or maintain optimal level of mentation. </li>
<li>Identify ways to compensate for cognitive impairment and memory deficits. </li>
</ul>
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Nursing Intervention nursing diagnosis Disturbed Thought Processes: </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Assess extent of impairment in thinking ability, memory, and orientation. Rationale Uremic syndrome’s effect can begin with minor confusion or irritability and progress to altered personality, inability to assimilate information or participate in care. Awareness of changes provides opportunity for evaluation and intervention. </li>
<li>Provide quiet, calm environment and judicious use of TV, radio, and visitation. Rationale Minimizes environmental stimuli to reduce sensory overload and confusion while preventing sensory deprivation. </li>
<li>Reorient to surroundings, person, and so forth. Provide calendars, clocks, and outside window. Rationale Provides clues to aid in recognition of reality. </li>
<li>Present reality concisely and briefly, and do not challenge illogical thinking. Rationale Confrontation potentiates defensive reactions and may lead to client mistrust and heightened denial of reality. </li>
<li>Communicate information and instructions in simple, short sentences. Ask direct, yes or no questions. Repeat explanations as necessary. Rationale May aid in reducing confusion and increases possibility that communications will be understood and remembered. </li>
<li>Establish a regular schedule for expected activities. Rationale Aids in maintaining reality orientation and may reduce fear and confusion. </li>
<li>Promote adequate rest and undisturbed periods for sleep Rationale Sleep deprivation may further impair cognitive abilities. </li>
<li>Provide supplemental oxygen (O2) as indicated. Rationale Correction of hypoxia alone can improve cognition. </li>
<li>Avoid use of barbiturates and opiates. Rationale Drugs normally detoxified in the kidneys will have increased half-life and cumulative effects, worsening confusion. </li>
</ul>
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<div style="text-align: justify;">
Nursing diagnosis Risk for impaired Skin Integrity </div>
<div style="text-align: justify;">
Risk factors may include: </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy) </li>
<li>Changes in fluid status; alterations in skin turgor edema </li>
<li>Reduced activity, immobility
Accumulation of toxins in the skin </li>
</ul>
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<div style="text-align: justify;">
Desired Outcomes/Evaluation Criteria Client Will: </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Maintain intact skin. </li>
<li>Risk Management </li>
<li>Demonstrate behaviors and techniques to prevent skin breakdown or injury. </li>
</ul>
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<div style="text-align: justify;">
Intervention Nursing diagnosis Risk for impaired Skin Integrity: </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Inspect skin for changes in color, turgor, and vascularity. Note redness and excoriation. Observe for ecchymosis and purpura. Rationale Indicates areas of poor circulation and early breakdown that may lead to decubitus formation and infection. </li>
<li>Monitor fluid intake and hydration of skin and mucous membranes. Rationale Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level. </li>
<li>Inspect dependent areas for edema. Elevate legs, as indicated. Rationale Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation. </li>
<li>Change position frequently, move client carefully, pad bony prominences with sheepskin, and use elbow and heel protectors. Rationale Decreases pressure on edematous, poorly perfused tissues to reduce ischemia. </li>
<li>Provide soothing skin care, restrict use of soaps, and apply ointments or creams such as lanolin or Aquaphor. Rationale Baking soda and cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin. </li>
<li>Keep linens dry and wrinkle free. Rationale Reduces dermal irritation and risk of skin breakdown. </li>
<li>Investigate reports of itching. Rationale Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products, such as phosphate crystals associated with hyperparathyroidism in ESRD. </li>
<li>Recommend client use cool, moist compresses to apply pressure to, rather than scratch, pruritic areas. Keep fingernails short; encourage use of gloves during sleep, if needed. Rationale Alleviates discomfort and reduces risk of dermal injury. </li>
<li>Suggest wearing loose-fitting cotton garments. Rationale Prevents direct dermal irritation and promotes evaporation of moisture on the skin. </li>
<li>Provide foam or flotation mattress. Rationale Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia and necrosis. </li>
</ul>
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Nursing Diagnosis Risk for impaired Oral Mucous Membrane </div>
<div style="text-align: justify;">
Risk factors may include </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Lack of or decreased salivation, fluid restrictions </li>
<li>Chemical irritation, conversion of urea in saliva to ammonia </li>
</ul>
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<div style="text-align: justify;">
Desired Outcomes/Evaluation Criteria Client Will </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Maintain Oral Health </li>
<li>Maintain integrity of mucous membranes. </li>
<li>Identify and initiate specific interventions to promote healthy oral mucosa. </li>
</ul>
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<div style="text-align: justify;">
Nursing Intervention Nursing diagnosis Risk for impaired Oral Mucous Membrane: </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Inspect oral cavity: note moistness, character of saliva, presence of inflammation, ulcerations, and leukoplakia. Rationale Provides opportunity for prompt intervention and prevention of infection. </li>
<li>Provide fluids throughout 24-hour period within prescribed limit. Rationale Prevents excessive oral dryness from prolonged period without oral intake. </li>
<li>Offer frequent mouth care or rinse with 0.25% acetic acid solution. Provide gum, hard candy, or breathe mints between meals. Rationale Mucous membranes may become dry and cracked. Mouth care soothes, lubricates, and helps freshen mouth taste, which is often unpleasant because of uremia and restricted oral intake. Rinsing with acetic acid helps neutralize ammonia formed by conversion of urea. </li>
<li>Encourage good dental hygiene after meals and at bedtime. Recommend avoidance of dental floss. Rationale Reduces bacterial growth and potential for infection. Dental floss may cut gums, potentiating bleeding. </li>
<li>Recommend client stop smoking and avoid lemon and glycerin products or mouthwash containing alcohol. Rationale These substances are irritating to the mucosa and have a drying effect, potentiating discomfort. </li>
<li>Provide artificial saliva as needed, such as Oral-Lube. Rationale Prevents dryness, buffers acids, and promotes comfort. </li>
</ul>
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<div style="text-align: justify;">
Patient Teaching Discharge and Home Healthcare Guidelines </div>
<div style="text-align: justify;">
Patient teaching discharge and home healthcare guidelines for patient with Chronic Renal Failure CRF End Stage Renal Disease ESRD. CRF or ESRD are disorders that affect the patient’s total lifestyle and the whole family. Patient teaching is essential and should be understood by the patient and significant others. To promote adherence to the therapeutic program, and Encourage all people with the following risk factors to obtain screening for chronic kidney disease: elderly people, ethnic minorities, diabetics, and people with hypertension, those with autoimmune disease, and those with family history of kidney disease. Nurses may need to work collaboratively with social services to arrange for the patient’s dialysis treatments. Issues such as the location for outpatient dialysis and follow-up, home health referrals, and the purchasing of home equipment are important. </div>
<div style="text-align: justify;">
Patient Teaching Discharge and Home Healthcare Guidelines Chronic Renal Failure CRF </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Teach the patient how to take his medications and what adverse effects to watch for. Suggest taking diuretics in the morning so that sleep isn’t disturbed. Topics to cover include reason for the procedure; complications; signs and symptoms of the related disease; how to check for bleeding, electrolyte imbalance, and changes in blood pressure; diet; exercise; and the use of equipment. </li>
<li>In patient that requires dialysis, instruct him on how to adjust his medication schedule as needed in relation to dialysis care plan. </li>
<li>Instruct the anemic patient to conserve energy by resting frequently. </li>
<li>Tell the patient to report leg cramps or excessive muscle twitching. </li>
<li>Explained to patients and family the importance of keeping follow-up appointments to have his electrolyte levels monitored. </li>
<li>Explained to patients and family to avoid high-sodium and high-potassium foods. Encourage adherence to fluid and protein restrictions. To prevent constipation, stress the need for exercise and sufficient dietary fiber. </li>
<li>Eat food before drinking fluids to alleviate dry mouth.
If the patient requires dialysis, remember that he and family members are under extreme stress. </li>
<li>If the facility doesn’t offer a course on dialysis nurses need to teach the patient and family members. </li>
<li>A patient undergoing dialysis is under a great deal of stress, as is his family. Refer them to appropriate counseling agencies for assistance in coping with chronic renal failure. </li>
<li>Demonstrate how to care for the shunt, fistula, or other vascular access device and how to perform meticulous skin care. Discourage activity that might cause the patient to bump or irritate the access site. </li>
<li>Suggest that the patient wear a medical identification bracelet or carry pertinent information with him. </li>
<li>Weigh self every morning to avoid fluid overload. </li>
<li>Drink limited amounts of fluids only when thirsty. </li>
<li>Measure allotted fluids, and save some for ice cubes; sucking on ice is thirst quenching. </li>
<li>Use hard candy or chewing gum to moisten mouth.</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-6267649383411321602010-10-17T18:49:00.000+07:002014-11-06T06:47:05.933+07:00NCP Nursing Care Plan Renal Dialysis<div style="text-align: justify;">
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Dialysis treatment replaces the function of the Renal/kidneys, which normally serve as the body’s natural filtration system. Dialysis is performed as critical life support when someone suffers acute or chronic kidney failure. Process that substitutes for kidney function by removing excess fluid and accumulated endogenous or exogenous toxins. It is a mechanical way to cleanse the blood and balance body fluids and chemicals when the kidneys are not able to perform these essential functions. Because kidney function can be reversible in some cases, dialysis can provide temporary support until renal function is restored. Dialysis may also be used in irreversible or chronic kidney shutdown when transplantation is the medical goal and the patient is waiting for donated kidneys. Some critically ill patients, with life-threatening illnesses, such as cancer or severe heart disease, are not candidates for transplantation and dialysis may be the only option for treating what is called End Stage Renal Disease (ESRD).Type of fluid and solute removal depends on the client’s underlying Pathophysiology, current hemodynamic status, vascular access, availability of equipment and resources, and healthcare providers’ training. There are two types of dialysis treatment: hemodialysis and peritoneal dialysis </div>
<div style="text-align: justify;">
Two primary types of Renal/kidneys dialysis </div>
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Peritoneal Dialysis </div>
<br />
<ul>
<li style="text-align: justify;">Continuous Ambulatory Peritoneal Dialysis: Continuous ambulatory peritoneal dialysis (CAPD) is a form of intracorporeal dialysis that uses the peritoneum for the semi permeable membrane. </li>
<li style="text-align: justify;">Continuous cyclic peritoneal dialysis (CCPD). Also called automated peritoneal dialysis (APD), CCPD is an overnight treatment that uses a machine to drain and refill the abdominal cavity; CCPD takes 10 to 12 hours per session. </li>
<li style="text-align: justify;">Intermittent peritoneal dialysis (IPD). This hospitalbased treatment is performed several times a week. A machine administers and drains the dialysate solution, and sessions can take 12 to 24 hours. </li>
</ul>
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<div style="text-align: justify;">
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<div style="text-align: justify;">
Hemodialysis </div>
<div style="text-align: justify;">
Hemodialysis is a process of cleansing the blood of accumulated waste products. It is used for patients with end-stage renal failure or for acutely ill patients who require short-term dialysis. The treatment involves circulating the patient’s blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. Two needles are inserted into the patient’s vein, or access site, and are attached to the ECC, which consists of plastic blood tubing, a filter known as a dialyzer (artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a chemical bath that is used to draw waste products out of the blood. </div>
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<div style="text-align: justify;">
Indications </div>
<br />
<ul>
<li style="text-align: justify;">Treatment for acute renal failure (ARF) or chronic end-stage renal disease (ESRD) </li>
<li style="text-align: justify;">Emergency removal of toxins due to drug overdose, acute life-threatening hyperkalemia, severe acidosis, and uremia </li>
</ul>
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Choice of dialysis is determined by three main factors. </div>
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Type of renal failure (acute or chronic) </div>
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Client’s particular physical condition </div>
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Access to dialysis resources </div>
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<a href="http://www.lifenurses.com/">Nursing</a> assessment for renal dialysis Refer to Acute Renal Failure or <a href="http://www.lifenurses.com/2010/10/nursing-care-plans-chronic-renal.html">Chronic Renal Failure</a>, for assessment<a href="http://www.lifenurses.com/2010/10/nursing-care-plans-chronic-renal.html"> <span style="color: blue;">here</span></a></div>
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Primary focus is at the community level at the dialysis center, although inpatient acute stay may be required during initiation of therapy. </div>
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<a href="http://www.lifenurses.com/search/label/Nursing%20Diagnosis">Nursing Diagnosis</a>. </div>
<div style="text-align: justify;">
Nursing Diagnoses That Could Be Found In Patient with Renal Dialysis </div>
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<ul>
<li style="text-align: justify;">Imbalanced Nutrition: Less than Body Requirements </li>
<li style="text-align: justify;">Impaired physical Mobility </li>
<li style="text-align: justify;">Self-Care Deficit </li>
<li style="text-align: justify;">Risk for Constipation </li>
<li style="text-align: justify;">Risk for disturbed Thought Processes </li>
<li style="text-align: justify;">Anxiety [specify level]/Fear </li>
<li style="text-align: justify;">Disturbed Body Image/situational low Self-Esteem</li>
<li style="text-align: justify;">Deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs </li>
</ul>
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<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<a href="http://www.lifenurses.com/search/label/Nursing%20Care%20Plans">Nursing Care Plan</a> for patient with Renal Dialysis
Nursing diagnosis Imbalanced Nutrition Less than Body Requirements May be related to Gastrointestinal (GI) disturbances (result of uremia or medication side effects)—anorexia, nausea, vomiting, and stomatitis Sensation of feeling full—abdominal distention during continuous ambulatory peritoneal dialysis (CAPD) Dietary restrictions bland, tasteless food; lack of interest in food Loss of peptides and amino acids (building blocks for proteins) during dialysis </div>
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<br /></div>
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Nursing Interventions</div>
<br />
<ol>
<li style="text-align: justify;">Monitor food and fluid ingested and calculate daily caloric intake. Rationale Identifies nutritional deficits and therapy needs, which are extremely variable, depending on client’s age, stage of renal disease, other coexisting conditions, and the type of dialysis being planned </li>
<li style="text-align: justify;">Recommend client keep a food diary, including estimation of ingested calories, protein, and electrolytes of individual concern—sodium, potassium, chloride, magnesium, and phosphorus Rationale Helps client realize “big picture” and allows opportunity to alter dietary choices to meet individual desires within identified restriction </li>
<li style="text-align: justify;">Note presence of nausea and anorexia Rationale Symptoms accompany accumulation of endogenous toxins that can alter or reduce intake and require intervention </li>
<li style="text-align: justify;">Encourage client to participate in menu planning Rationale May enhance oral intake and promote sense of control. </li>
<li style="text-align: justify;">Recommend small, frequent meals. Schedule meals according to dialysis needs Rationale Smaller portions may enhance intake. Type of dialysis influences meal patterns; for instance, clients receiving Hemodialysis HD might not be fed directly before or during procedure because this can alter fluid removal, and clients undergoing Peritoneal Dialysis PD may be unable to ingest food while abdomen is distended with dialysate. </li>
<li style="text-align: justify;">Encourage use of herbs and spices such as garlic, onion, pepper, parsley, cilantro, and lemon Rationale Adds zest to food to help reduce boredom with diet, while reducing potential for ingesting too much potassium and sodium </li>
<li style="text-align: justify;">Suggest socialization during meals Rationale Provides diversion and promotes social aspects of eating. </li>
<li style="text-align: justify;">Encourage frequent mouth care Rationale Reduces discomfort of oral stomatitis and metallic taste in mouth associated with uremia, which can interfere with food intake </li>
<li style="text-align: justify;">Refer to nutritionist or dietitian to develop diet appropriate to client’s needs Rationale Necessary to develop complex and highly individual dietary program to meet cultural and lifestyle needs. </li>
<li style="text-align: justify;">Perform complete nutrition assessment measure muscle mass via triceps skinfold or similar procedure. Determine muscle to fat ratio. Rationale Assesses need and adequacy of nutrient utilization by measuring changes that may suggest presence or absence of tissue catabolism. </li>
<li style="text-align: justify;">Provide a balanced diet, usually of 2,000 to 2,200 calories/day of complex carbohydrates and ordered amount of high-quality protein and essential amino acids. Rationale Provides sufficient nutrients to improve energy and prevent muscle wasting (catabolism); promotes tissue regeneration and healing and electrolyte balance. </li>
<li style="text-align: justify;">Restrict sodium and potassium as indicated; for example, avoid bacon, ham, other processed meats and foods, orange juice, and tomato soup Rationale these electrolytes can quickly accumulate, causing fluid retention, weakness, and potentially lethal cardiac Dysrhythmias. </li>
</ol>
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<div style="text-align: justify;">
Sample Nursing Care Plan for patient with Renal Dialysis</div>
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<td style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 69.2pt;" valign="top" width="92"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Times New Roman","serif";">DIAGNOSE<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">INTERVENTION<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">RATIONAL<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">EVALUATION
<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Imbalanced Nutrition: Less than
Body Requirements May be related to<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Gastrointestinal (GI) disturbances
(result of uremia or medication side effects)—anorexia, nausea, vomiting, and
stomatitis<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Sensation of feeling
full—abdominal distention during continuous ambulatory peritoneal dialysis
(CAPD)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Dietary restrictions—bland, tasteless
food; lack of interest in food<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Loss of peptides and amino acids
(building blocks for proteins) during dialysis<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
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<b><span style="font-family: "Times New Roman","serif";">Nutrition Therapy<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Monitor
food and fluid ingested and calculate daily caloric intake.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Recommend
client/significant other (SO) keep a food diary, including estimation of
ingested calories, protein, and electrolytes of individual concern—sodium,
potassium, chloride, magnesium, and phosphorus.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Note
presence of nausea and anorexia.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
client to participate in menu planning.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Recommend
small, frequent meals. Schedule meals according to dialysis needs.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
use of herbs and spices such as garlic, onion, pepper, parsley, cilantro, and
lemon.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Suggest
socialization during meals.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
frequent mouth care.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Refer
to nutritionist or dietitian to develop diet appropriate to client’s needs.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Perform
complete nutrition assessment—measure muscle mass via triceps skinfold or
similar procedure. Determine muscle to fat ratio.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provide
a balanced diet, usually of 2,000 to 2,200 calories/day of complex
carbohydrates and ordered amount of high-quality protein and essential amino
acids.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Restrict
sodium and potassium as indicated; for example, avoid bacon, ham, other
processed meats and foods, orange juice, and tomato soup.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Administer
multivitamins, including folic acid; vitamins B6, C, and D; and iron
supplements, as indicated.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Administer
parenteral supplements, as indicated, or IDPN, as necessary.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Monitor
laboratory studies, for example:Serum protein, prealbumin or albumin levels Hemoglobin
(Hgb), red blood cell (RBC), and iron levels<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Administer
medications, as appropriate, for example:<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Antiemetics,
such as prochlorperazine (Compazine)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Histamine
blockers, such as famotidine (Pepcid)<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Hormones
and supplements as indicated, such as erythropoietin (EPO, Epogen) and iron
supplement (Niferex)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Insert
and maintain nasogastric (NG) or enteral feeding tube, if indicated.<o:p></o:p></span></div>
</td>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Identifies
nutritional deficits and therapy needs, which are extremely variable,
depending on client’s age, stage of renal disease, other coexisting
conditions, and the type of dialysis being planned.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Helps
client realize “big picture” and allows opportunity to alter dietary choices
to meet individual desires within identified restriction.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Symptoms
accompany accumulation of endogenous toxins that can alter or reduce intake
and require intervention.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">May
enhance oral intake and promote sense of control.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Smaller
portions may enhance intake. Type of dialysis influences meal patterns; for
instance, clients receiving HD might not be fed directly before or during
procedure because this can alter fluid removal, and clients undergoing PD may
be unable to ingest food while abdomen is distended with dialysate.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Adds
zest to food to help reduce boredom with diet, while reducing potential for
ingesting too much potassium and sodium.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provides
diversion and promotes social aspects of eating.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Reduces
discomfort of oral stomatitis and metallic taste in mouth associated with
uremia, which can interfere with food intake.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Necessary
to develop complex and highly individual dietary program to meet cultural and
lifestyle needs within specific kilocalorie and protein restrictions while
controlling phosphorus, sodium, and potassium.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Assesses
need and adequacy of nutrient utilization by measuring changes that may
suggest presence or absence of tissue catabolism.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provides
sufficient nutrients to improve energy and prevent muscle wasting
(catabolism); promotes tissue regeneration and healing and electrolyte
balance. Although client with kidney disease is often advised to limit
protein intake, that changes with the start of dialysis. Protein-rich foods,
such as fresh meats, poultry, fish and other seafood, eggs and egg whites,
and small servings of dairy products are needed for building muscles,
repairing tissue, and fighting infection. However, some protein-rich foods
may contain a high level of phosphorus, so a dietitian’s input is essential
in determining the right amount to eat (Paton, 2007).<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">These
electrolytes can quickly accumulate, causing fluid retention, weakness, and
potentially lethal cardiac dysrhythmias. Note: PD is not as effective in
lowering elevated Na+ level, necessitating tighter control of Na+ intake. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Replaces
vitamin and mineral deficits resulting from malnutrition, anemia, or lost
during dialysis.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Hyperalimentation
may be needed to enhance renal tubular regeneration and resolution of
underlying disease process and to provide nutrients if oral or enteral
feeding is contraindicated.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Indicators
of protein needs. Note: PD is associated with significant protein loss. Serum
albumin levels below 3.4 g/dL suggest need for IDPN infusions.Anemia is the
most pervasive complication affecting energy levels in ESRD.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Reduces
stimulation of the vomiting center.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Gastric
distress is common and may be a neuropathy-induced gastric paresis.
Hypersecretion can cause persistent gastric distress and digestive
dysfunction.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Although
EPO is given to increase numbers of RBCs, it is not effective without iron
supplementation. Niferex is preferred because it can be given once daily and
has fewer side effects than many iron preparations.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">May
be necessary when persistent vomiting occurs or when<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">enteral
feeding is desired.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
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<span style="font-family: "Times New Roman","serif";">Demonstrate
stable weight or gain toward goal with normalization of laboratory values and
no signs of malnutrition.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Impaired physical Mobility May be
related to<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Restrictive therapies—lengthy
dialysis procedure<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Fear of or real danger of
dislodging dialysis lines or catheter<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Decreased strength and endurance;
musculoskeletal impairment<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Perceptual or cognitive impairment<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 177.2pt;" valign="top" width="236"><div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Bed Rest Care<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Assess
activity limitations, noting presence and degree of restriction or ability.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
frequent change of position when on bedrest or chair rest; support affected
body parts and joints with pillows, rolls, sheepskin, and elbow and heel
pads, as indicated.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provide
gentle massage. Keep skin clean and dry. Keep linens dry and wrinkle free.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
deep breathing and coughing. Elevate head of bed, as appropriate.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Suggest
and provide diversion as appropriate to client’s condition—visitors, radio or
TV, and books. Take time to interact with client, showing interest in
client’s life.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Instruct
in and assist with active and passive range-of-motion (ROM) exercises.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Exercise Promotion<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Institute
a planned activity or exercise program as appropriate, with client’s input.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Bed Rest Care<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provide
foam, water, or air flotation mattress or soft chair cushion.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 148.85pt;" valign="top" width="198"><div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Influences
choice of interventions.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Decreases
discomfort, maintains muscle strength and joint mobility, enhances
circulation, and prevents skin breakdown.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Stimulates
circulation; prevents skin irritation.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Mobilizes
secretions, improves lung expansion, and reduces risk of respiratory
complications, such as atelectasis or pneumonia.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Decreases
boredom; promotes relaxation.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Maintains
joint flexibility, prevents contractures, and aids in reducing muscle
tension. Note: A high level of phosphorus may cause calcium-phosphorus
crystals to build up in the joints, muscles, and other body organs, leading
to bone and joint pain. To avoid these risks, client may be prescribed a
phosphate binder such as Basalgel or Renagel (Leydig, 2005).<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Increases
client’s energy and sense of well-being. Studies have shown that regular
exercise programs have benefited clients with ESRD, both physically and
emotionally. Stable clients have not been shown to have adverse effects (Goodman
& Ballou, 2004).<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Reduces
tissue pressure and may enhance circulation, thereby reducing risk of dermal
ischemia and breakdown.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.85pt;" valign="top" width="94"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Maintain
optimal mobility and function.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Display
increased strength and be free of associated complications—contractures and
decubitus ulcers.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 69.2pt;" valign="top" width="92"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Self-Care Deficit (specify) May be
related to<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Intolerance to activity, decreased
strength and endurance, pain or discomfort<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Perceptual or cognitive impairment
(accumulated toxins)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 177.2pt;" valign="top" width="236"><div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Self-Care Assistance<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Determine
client’s ability to participate in self-care activities (scale of 0 to 4).<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provide
assistance with activities as necessary.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
use of energy-saving techniques: sitting, not standing; using shower chair;
and doing tasks in small increments.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Recommend
scheduling activities to allow client sufficient time to accomplish tasks to
fullest extent of ability.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 148.85pt;" valign="top" width="198"><div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Underlying
condition dictates level of deficit, affecting choice of interventions. Note:
Psychological factors, such as depression, motivation, and degree of support,
also have a major impact on the client’s abilities.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Meets
needs while supporting client participation and<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">independence.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Conserves
energy, reduces fatigue, and enhances client’s ability to perform tasks.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Unhurried
approach reduces frustration and promotes client participation, enhancing
self-esteem.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.85pt;" valign="top" width="94"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Participate
in ADLs within level of own ability and constraints of the illness.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 69.2pt;" valign="top" width="92"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Risk for Constipation Risk factors
may include<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Decreased fluid intake, altered
dietary pattern<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Reduced intestinal motility,
compression of bowel (peritoneal dialysate), electrolyte imbalances,
decreased mobility<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 177.2pt;" valign="top" width="236"><div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Constipation/Impaction
Management<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Auscultate
bowel sounds. Note consistency and frequency of bowel movements (BMs) and
presence of abdominal distention.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Review
current medication regimen.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Ascertain
usual dietary pattern and food choices.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Suggest
adding fresh fruits, vegetables, and fiber to diet within restrictions, when
indicated.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
or assist with ambulation, when able.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provide
privacy at bedside commode and bathroom.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Administer
stool softeners, such as Colace or bulk-forming laxatives, such as Metamucil,
as appropriate.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Keep
client nothing by mouth (NPO) status; insert NG tube, as indicated.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 148.85pt;" valign="top" width="198"><div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Decreased
bowel sounds; passage of hard-formed or dry stools suggests constipation and
requires ongoing intervention to manage.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Side
effects of some drugs, such as iron products and some antacids, may compound
problem.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Although
restrictions may be present, thoughtful consideration of menu choices can aid
in controlling problem.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provides
bulk, which improves stool consistency.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Activity
may stimulate peristalsis, promoting return to normal bowel activity.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Promotes
psychological comfort needed for elimination.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Produces
a softer, more easily evacuated stool.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Decompresses
stomach when recurrent episodes of unrelieved vomiting occur. Large gastric
output suggests ileus, a common early complication of PD, with accumulation
of gas and intestinal fluid that cannot be passed rectally.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.85pt;" valign="top" width="94"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Maintain
usual or improved bowel function.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 69.2pt;" valign="top" width="92"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Risk for disturbed Thought
Processes Risk factors may include<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Physiological changes—presence of
uremic toxins, electrolyte imbalances, hypervolemia or fluid shifts,
hyperglycemia (infusion<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">of a dialysate with a high glucose
concentration)<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 177.2pt;" valign="top" width="236"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Delirium
Management<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Assess
for behavioral changes or change in level of consciousness (LOC)—disorientation,
lethargy, decreased concentration, memory loss, and altered sleep patterns.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Keep
explanations simple and reorient frequently as needed. Provide “normal” day
or night lighting patterns, clock, and calendar.\<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provide
a safe environment, restrain as indicated, and pad side rails during
procedure, as appropriate.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Drain
peritoneal dialysate promptly at end of specified equilibration period.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Investigate
reports of headache, associated with onset of dizziness, nausea and vomiting,
confusion or agitation, hypotension, tremors, or seizure activity.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Monitor
changes in speech pattern, development of dementia, and myoclonus activity
during HD.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 148.85pt;" valign="top" width="198"><div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">May
indicate level of uremic toxicity, response to or developing complication of
dialysis such as “dialysis dementia,” and need for further assessment and
intervention.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Improves
reality orientation.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Prevents
client trauma and inadvertent removal of dialysis lines or catheter.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Prompt
outflow will decrease risk of hyperglycemia or hyperosmolar fluid shifts
affecting cerebral function.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">May
reflect development of disequilibrium syndrome, which can occur near
completion of or following HD and is thought to be caused by ultrafiltration
or by the too-rapid removal of urea from the bloodstream not accompanied by
equivalent removal from brain tissue. The hypertonic cerebrospinal fluid
(CSF) causes a fluid shift into the brain, resulting in cerebral edema and
increased intracranial pressure.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Occasionally,
accumulation of aluminum may cause dialysis dementia, progressing to death if
untreated.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.85pt;" valign="top" width="94"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Regain
usual or improved level of mentation.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Recognize
changes in thinking and behavior and demonstrate behaviors to prevent or
minimize changes.<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 169.6pt; mso-yfti-irow: 6;">
<td style="border-top: none; border: solid black 1.0pt; height: 169.6pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 69.2pt;" valign="top" width="92"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Anxiety [specify level]/Fear May
be related to<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Situational crisis, threat to
self-concept, change in health status, role functioning, socioeconomic status<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Threat of death, unknown
consequences or outcome<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 169.6pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 177.2pt;" valign="top" width="236"><div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Anxiety Reduction<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Assess
level of fear of both client and SO. Note signs of denial, depression, or
narrowed focus of attention.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Explain
procedures and care as delivered. Repeat explanations frequently, as needed.
Provide information in multiple formats, including pamphlets and films.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Acknowledge
normalcy of feelings in this situation.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provide
opportunities for client and SO to ask questions and verbalize concerns.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
SO to participate in care, as able and desired.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Acknowledge
concerns of client and SO.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Point
out positive indicators of treatment—improvement in laboratory values, stable
BP, and lessened fatigue.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Arrange
for visit to dialysis center and meeting with another dialysis client, as
appropriate.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Address
financial considerations. Refer to appropriate resources.<o:p></o:p></span></div>
</td>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Helps
determine the kind of interventions required.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Fear
of unknown is lessened by information and knowledge and may enhance
acceptance of permanence of ESRD and necessity for dialysis. Alteration in
thought processes and high levels of anxiety or fear may reduce
comprehension, requiring repetition of important information. Note: Uremia can
impair short-term memory, requiring repetition or reinforcement of
information provided.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Knowing
feelings are normal can allay fear that client is losing control.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Creates
feeling of openness and cooperation and provides information that will assist
in problem identification and solving.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Involvement
promotes sense of sharing, strengthens feelings of usefulness, provides
opportunity to acknowledge individual capabilities, and may lessen fear of
the unknown.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Prognosis
and possibility of need for long-term dialysis and resultant lifestyle
changes are major concerns for this client and those who may be involved in
future care.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Promotes
sense of progress in an otherwise chronic process that seems endless while
client still is experiencing physical deterioration and depression.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Interaction
with others who have encountered similar problems may assist client and SO to
work toward acceptance of chronic condition and focus on problem-solving
activities.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Treatment
for kidney failure is expensive, although Medicare and other health insurance
programs pay much of the cost.<o:p></o:p></span></div>
</td>
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<span style="font-family: "Times New Roman","serif";">Verbalize
awareness of feelings and reduction of anxiety or fear to a manageable level.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Demonstrate
problem-solving skills and effective use of resources.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Appear
relaxed and able to rest and sleep appropriately.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 69.2pt;" valign="top" width="92"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Disturbed Body Image/situational
low Self-Esteem May be related to<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Situational crisis, chronic
illness with changes in usual roles and body image<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 177.2pt;" valign="top" width="236"><div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Body Image [or] Self-Esteem
Enhancement<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Assess
level of client’s knowledge about condition and treatment and anxiety related
to current situation.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Discuss
meaning of loss and change to client. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Note
withdrawn behavior, ineffective use of denial, or behaviors indicative of
overconcern with body and its functions.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Investigate
reports of feelings of depersonalization or the bestowing of humanlike
qualities on machinery.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Assess
for use of addictive substances, primarily alcohol, other drugs, and
self-destructive or suicidal behavior.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Determine
stage of grieving. Note signs of severe or prolonged depression.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Acknowledge
normalcy of feelings.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
verbalization of personal and work conflicts that may arise. Active-listen
concerns.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Determine
client’s role in family constellation and client’s perception of expectation
of self and others.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Recommend
SO treat client normally and not as an invalid.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Assist
client to incorporate disease management into lifestyle.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Identify
strengths, past successes, and previous methods client has used to deal with
life stressors.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Help
client identify areas over which he or she has some measure of control.
Provide opportunity to participate in decision-making process.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Recommend
participation in local support group.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Refer
to healthcare and community resources, such as social service, vocational
counselor, and psychiatric clinical nursespecialist.<o:p></o:p></span></div>
</td>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Identifies
extent of problem or concern and necessary interventions.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Many
clients and their families have difficulty dealing with changes in life and
role performance as well as the client’s loss of ability to control own body.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Indicators
of developing difficulty handling stress of what is happening. Note: Client
may feel tied to and controlled by the technology central to his or her
survival, even to the point of extending body boundary to incorporate
dialysis<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">equipment.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">May
reflect dysfunctional coping and attempt to handle problems in an ineffective
manner.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Identification
of grief stage client is experiencing provides guide to recognizing and
dealing appropriately with behavior as client and SO work to come to terms
with loss and limitations associated with condition. Prolonged depression may
indicate need for further intervention.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Recognition
that feelings are to be expected helps client accept and deal with them more
effectively.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Helps
client identify problems and problem-solve solutions. Note: Home dialysis may
provide more flexibility and enhance sense of control for clients who are
appropriate candidates for this form of therapy.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Long-term
and permanent illness or disability alter client’s ability to fulfill usual
role(s) in family and work setting.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Unrealistic
expectations can undermine self-esteem and affect outcome of illness.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Conveys
expectation that client is able to manage situation and helps maintain sense
of self-worth and purpose in life.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Necessities
of treatment assume a more normal aspect when they are a part of the daily
routine.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Focusing
on these reminders of own ability to deal with problems can help client deal
with current situation.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provides
sense of control over seemingly uncontrollable situation, fostering
independence.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Reduces
sense of isolation as client learns that others have been where client is
now. Provides role models for dealing with situation, problem-solving, and
“getting on with life.” Reinforces that therapeutic regimen can be beneficial.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provides
additional assistance for long-term management of chronic illness and change
in lifestyle.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.85pt;" valign="top" width="94"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Identify
feelings and methods for coping with negative perception of self.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Verbalize
acceptance of self in situation.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Demonstrate
adaptation to changes and events that have occurred, as evidenced by setting
realistic goals and active participation in care and life in general.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 69.2pt;" valign="top" width="92"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Deficient Knowledge [Learning
Need] regarding condition, prognosis, treatment, self-care, and discharge
needs May be related to<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Lack of exposure or recall<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Unfamiliarity with information
resources<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Cognitive limitations<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 177.2pt;" valign="top" width="236"><div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Teaching: Disease Process<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Note
level of anxiety or fear and alteration of thought processes.Time teaching
appropriately.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Review
particular disease process, prognosis, and potential complications in clear
concise terms, periodically repeating and updating information, as necessary.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Encourage
and provide opportunity for questions.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Acknowledge
that certain feelings and patterns of response are normal during course of
therapy.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Emphasize
necessity of reading all product labels—food, beverage, and over-the-counter
(OTC) drugs—and not taking medications or herbal supplements without checking
with healthcare provider.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Stress
importance of establishing and adhering to medication schedule reflecting the
specific form of renal disease, timing of dialysis, and properties of the
individual medications.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Discuss
significance of maintaining nutritious eating habits, preventing wide
fluctuation of fluid and electrolyte balance, and avoidance of crowds or
people with infectious processes.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Instruct
client about epoetin (Epogen) or darbepoetin (Aransep), when indicated. Have
client or SO demonstrate ability to administer and state adverse side effects
and healthcare practices associated with this therapy.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Identify
healthcare and community resources, such as dialysis support group, social
services, and mental health clinic.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span style="font-family: "Times New Roman","serif";">Teaching: Procedure/Treatment<o:p></o:p></span></b></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Discuss
procedures and purpose of dialysis in terms understandable to client. Repeat
explanations as required.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Instruct
client and SO in home dialysis, as indicated:<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Operation
and maintenance of equipment (including vascular shunt), sources of supplies<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Aseptic
or clean technique<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Self-monitoring
of effectiveness of procedure<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Management
of potential complications<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Contact
persons<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Sources
for supplies when away from home<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 148.85pt;" valign="top" width="198"><div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">These
factors directly affect ability to access and use knowledge. In addition,
during the dialysis procedure, client’s cognitive function may be impaired,
and clients themselves state that they feel “fuzzy.” Therefore, learning may
not be optimal during this time.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Providing
information at the level of the client’s and SO’s understanding will reduce
anxiety and misconceptions about what client is experiencing. Note: Research
suggests nocturnal home HD is associated with improved left ventricular
function, decreased BP and pulse pressure, and reduced used of
antihypertensive medications.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Enhances
learning process, promotes informed decision making, and reduces anxiety
associated with the unknown.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Client
and SO may initially be hopeful and positive about the future, but as
treatment continues and progress is less dramatic, they can become
discouraged and depressed, and conflicts of dependence versus independence
may develop.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">It is
difficult to maintain electrolyte balance when exogenous intake is not
factored into dietary restriction; for example, hypercalcemia can result from
routine supplement use in combination with increased dietary intake of
calcium-fortified foods and medicines.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">This
is necessary to ensure that therapeutic levels of the drugs are reached and
that toxic levels are avoided.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Depressed
immune system, presence of anemia, invasive procedures, and malnutrition
potentiate risk of infection.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Epogen
is used for the management of the anemia associated with chronic renal
failure (CRF) and ESRD. The drug is given to increase and maintain RBC
production, which allows client to feel better and stronger. Darbepoetin is a
non-natural recombinant protein that can stimulate RBC production, but the
half-life is about three times longer than erythropoietin, resulting in less
frequent dosing.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Knowledge
and use of these resources assist client and SO to manage care more
effectively. Interaction with others in similar situation provides
opportunity for discussion of options and making informed choices, including
stopping dialysis or renal transplantation.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">A
clear understanding of the purpose, process, and what is expected of client
and SO facilitates their cooperation with regimen and may enhance outcomes.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Home
dialysis is associated with better outcomes in general and better survival
rates as dialysis is usually performed 5 to 7 days/week and is more intensive.
This decreases fluctuations in fluid, solute, and electrolyte balance, more closely
mimicking renal function. However, specific criteria for client and SO
participation and training, home resources, and professional oversight must
be met in order to consider this option.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Information
diminishes anxiety of the unknown and provides opportunity for client to be
knowledgeable about own care.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Prevents
contamination and reduces risk of infection.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Provides
information necessary to evaluate effects of therapy and need for change.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif";">Reduces
concerns regarding personal well-being; supports efforts at self-care.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">Readily
available support person can answer questions, troubleshoot problems, and
facilitate timely medical intervention, when indicated, reducing risk and
severity of complications.Note: Home dialysis clients usually are monitored
by conventional dialysis center or interdisciplinary team.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">Home
dialysis clients are often capable of travel, even overseas, with proper
preplanning and support.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">Verbalize
understanding of condition and relationship of signs and symptoms of the
disease process and potential complications.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">Verbalize
understanding of therapeutic needs.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">Correctly
perform necessary procedures and explain reasons for actions.<o:p></o:p></span></div>
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Patient Teaching Home Health Guidance for Patient with Renal Dialysis</div>
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Patient teaching discharge and home healthcare guidelines for Patient with Renal Dialysis. May require assistance with treatment regimen, transportation, activities of daily living (ADLs), homemaker and maintenance tasks, end-of life decisions, palliative care
Explain to patient and be sure the patient understands All medications, including the dosage, route, action, and adverse effects.
Encourage client to participate in menu planning. Recommend small, frequent meals. Schedule meals according to dialysis needs.
Encourage use of energy-saving techniques: sitting, not standing; using shower chair; and doing tasks in small increments. Recommend scheduling activities to allow client sufficient time to accomplish tasks to fullest extent of ability. </div>
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Lifestyle Management for Renal Dialysis </div>
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Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake.
Ongoing health care monitoring includes careful adjustment of medications that are normally excreted by the kidney or are dialyzable.
Surveillance for complications.
Arteriosclerotic cardiovascular disease, heart failure, disturbance of lipid metabolism (hypertriglyceridemia), coronary heart disease, stroke
Intercurrent infection
Anemia and fatigue
Gastric ulcers and other problems
Bone problems (renal osteodystrophy, aseptic necrosis of hip) from disturbed calcium metabolism
Hypertension
Psychosocial problems: depression, suicide, sexual dysfunction</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-43471534244709512502010-09-30T17:59:00.000+07:002014-10-31T18:59:53.211+07:00Nursing Care Plans Pneumothorax<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4FSt1THorfHadz5JCGW-XmHDGgdMoocG77Jj97h-o-_qlvmsTnEbeWES09WglvDQiU6QQ61jIvrvETitfRxoDV9LFdLeqSFT91O88ptm0l9kmfND3Kn1SknDQH81bcbTQVEQUVAP5S6PP/s1600/Pneumothorax.gif" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="Pneumothorax" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4FSt1THorfHadz5JCGW-XmHDGgdMoocG77Jj97h-o-_qlvmsTnEbeWES09WglvDQiU6QQ61jIvrvETitfRxoDV9LFdLeqSFT91O88ptm0l9kmfND3Kn1SknDQH81bcbTQVEQUVAP5S6PP/s1600/Pneumothorax.gif" height="181" title="Pneumothorax" width="200" /></a></div>
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Definition of Pneumothorax (collapsed lung), Pneumothorax is is defined as the presence of air in the pleural space. Air in the pleural space occurring spontaneously or from trauma. In patients with chest trauma, it is usually the result of a laceration to the lung parenchyma, tracheobronchial tree, or esophagus. The patient’s clinical status depends on the rate of air leakage and size of wound. The amount of air or gas trapped in the intrapleural space determines the degree of lung collapse. </div>
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Classification of Pneumothorax </div>
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<ul>
<li style="text-align: justify;">Spontaneous Pneumothorax sudden onset of air in the pleural space with deflation of the affected lung in the absence of trauma. </li>
<li style="text-align: justify;">Open Pneumothorax (sucking wound of chest) implies an opening in the chest wall large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration. </li>
<li style="text-align: justify;">Tension Pneumothorax buildup of air under pressure in the pleural space resulting in interference with filling of both the heart and lungs. </li>
<li style="text-align: justify;">Traumatic Pneumothorax; Traumatic Pneumothorax may result from insertion of a central venous line, thoracic surgery, or a penetrating chest injury, such as a gunshot or knife wound, or it may follow a transbronchial biopsy. It may also occur during thoracentesis or a closed pleural biopsy. When traumatic Pneumothorax follows a penetrating chest injury, hemothorax (blood in the pleural space) may also occur. </li>
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Other classification of Pneumothorax :
Primary spontaneous Pneumothorax
Secondary spontaneous Pneumothorax
Iatrogenic Pneumothorax
Traumatic Pneumothorax </div>
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Clinical Manifestations of Pneumothorax
Hyperresonance; </div>
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diminished breath sounds.
Reduced mobility of affected half of thorax.
Tracheal deviation away from affected side in tension pneumothorax
Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, and cyanosis
Mild to moderate dyspnea and chest discomfort may be present with spontaneous pneumothorax </div>
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Pneumothorax Etiology </div>
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Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs
Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis
Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus
Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries </div>
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Complications </div>
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Acute respiratory failure.
Cardiovascular collapse with tension Pneumothorax
Hypoxemia </div>
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Pneumothorax Treatment. </div>
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Treatment is conservative for spontaneous pneumothorax in which no signs of increased pleural pressure appear (indicating tension Pneumothorax), lung collapse is less than 30%, and the patient shows no signs of Dyspnea or other indications of physiologic compromise. Such treatment consists of bed rest, careful monitoring of blood pressure, pulse rate, and respirations, oxygen administration, and needle aspiration.
If more than 30% of the lung is collapsed, treatment to reexpand the lung includes placing a thoracostomy tube in the second or third intercostal space in the midclavicular line, connected to an underwater seal or low-pressure suction.
Oxygen therapy and mechanical ventilation are prescribed as needed. Surgical interventions include removing the penetrating object, exploratory thoracotomy if necessary, thoracentesis, and thoracotomy for patients with two or more episodes of spontaneous pneumothorax or patients with pneumothorax that does not resolve within 1 week. </div>
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Spontaneous Pneumothorax </div>
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Treatment is generally nonoperative if Pneumothorax is not too extensive; Observe and allow for spontaneous resolution for less than 50% pneumothorax in otherwise healthy person, Needle aspiration or chest tube drainage may be necessary to achieve reexpansion of collapsed lung if greater than 30% pneumothorax.
Surgical intervention by pleurodesis or thoracotomy with resection of apical blebs is advised for patients with recurrent spontaneous pneumothorax. </div>
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Tension Pneumothorax
Immediate decompression to prevent cardiovascular collapse by thoracentesis or chest tube insertion to let air escape.
Chest tube drainage with underwater-seal suction to allow for full lung expansion and healing </div>
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Open Pneumothorax</div>
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Close the chest wound immediately to restore adequate ventilation and respiration. Patient is instructed to inhale and exhale gently against a closed glottis (Valsalva maneuver) as a pressure dressing (petroleum gauze secured with elastic adhesive) is applied. This maneuver helps to expand collapsed lung.
Chest tube is inserted and water-seal drainage set up to permit evacuation of fluid/air and produce reexpansion of the lung.
Surgical intervention may be necessary to repair trauma.
Recurring spontaneous pneumothorax treated by instilling a sclerosing agent through a thoracostomy tube or during thoracostomy. Thoracotomy and pleurectomy are other procedures that prevent recurrence by causing the lung to adhere to the parietal pleura. Traumatic and tension pneumothoraces require chest tube drainage. Traumatic Pneumothorax may also require surgical repair. </div>
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Nursing Assessment </div>
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Patient History, Obtain history for chronic respiratory disease, trauma, and onset of symptoms. The patient history reveals sudden, sharp, pleuritic pain. The patient may report that chest movement, breathing, and coughing exacerbate the pain. He may also report shortness of breath.
Ask about chest pain; determine its onset, intensity, and location. Ask if the patient has shortness of breath or difficulty in breathing or fatigue. Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Ask if the patient smokes cigarettes
For patients who have experienced chest trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. Specify the type of trauma (blunt or penetrating).
Physical Examination
The severity of the symptoms depends on the extent of any underlying disease and the amount of air in the pleural space. Examine the patient’s chest for a visible wound that may have been caused by a penetrating object. Patients with an open Pneumothorax also exhibit a sucking sound on inspiration.
Inspection typically reveals asymmetrical chest wall movement with overexpansion and rigidity on the affected side. The patient may appear cyanotic. In tension pneumothorax, he may have distended neck veins and pallor, and he may exhibit anxiety. Observe whether the patient has a flail chest. Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe the patient carefully for pallor. Take the patient’s blood pressure and pulse rate, noting the early signs of shock or massive bleeding, such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. Continue to monitor the vital signs frequently during periods of instability to determine changes in the condition or the development of complications.
Palpation, note any tracheal deviation toward the unaffected side, subcutaneous emphysema (also known as crepitus; a dry, crackling sound caused by air trapped in the subcutaneous tissues), or decreased to absent tactile fremitus over the affected area. Percussion may elicit a hyperresonant or tympanitic sound.
Auscultation reveals decreased or absent breath sounds over the affected area and no adventitious sounds other than a possible pleural rub. Auscultate chest for diminished breath sounds and percuss for hyperresonance.
Percussion may reveals hyperresonance on the affected side </div>
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Diagnostic Test For Pneumothorax </div>
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Blood Tests
Arterial blood gases (ABGs): Measures oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia.
Hemoglobin/hematocrit (Hgb/Hct): Assesses relationship of red blood cells (RBCs) to fluid volume or viscosity.
Other Diagnostic Studies
Chest x-ray: Evaluates organs or structures within the chest and is the initial study of choice in blunt force chest trauma.
Thoracic computed tomography (CT): Enhance anatomic views of the chest and locates abnormalities. Early CT may influence therapeutic management.
Thoracic ultrasound: Assists in determining abnormalities in the chest.
Thoracentesis: Performed to relieve the intrathoracic pressure due to accumulation of fluid in the pleural space. </div>
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Nursing diagnosis Pneumothorax </div>
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Common Nursing Diagnosis That Could Be Found In Patient with Pneumothorax: </div>
<div style="text-align: justify;">
Ineffective Breathing Pattern
Risk for Trauma/Suffocation
Deficient Knowledge [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs
Acute pain
Anxiety
Fear
Impaired gas exchange related to decreased oxygen diffusion capacity
Ineffective coping
Ineffective tissue perfusion: Cardiopulmonary
Risk for infection </div>
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Nursing Interventions Nursing Diagnosis Ineffective Breathing Pattern </div>
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Respiratory Monitoring </div>
<div style="text-align: justify;">
Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.
Evaluate respiratory function, noting rapid or shallow respirations, Dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.
Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
Auscultate breath sounds.
Note chest excursion and position of trachea.
Assess fremitus. </div>
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Ventilation Assistance </div>
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Assist client with splinting painful area when coughing, or during deep breathing.
Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible.
Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations. </div>
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Tube Care: Chest</div>
<div style="text-align: justify;">
If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once.
After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage. </div>
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Ventilation Assistance </div>
<div style="text-align: justify;">
Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.
Administer supplemental oxygen via cannula, mask, or mechanical ventilation, as indicated.
Administer analgesics and sedatives, as indicated. </div>
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Complete Sample Nursing Care Plans for Pneumothorax<br />
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<b><span style="font-family: "Times New Roman","serif";">Nursing Diagnosis<o:p></o:p></span></b></div>
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<b><span style="font-family: "Times New Roman","serif";">Intervention<o:p></o:p></span></b></div>
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<b><span style="font-family: "Times New Roman","serif";">Rational<o:p></o:p></span></b></div>
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<b><span style="font-family: "Times New Roman","serif";">Evaluation (Expected Out Come)<o:p></o:p></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Ineffective
Breathing Pattern related to :<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Decreased lung
expansion due to air or fluid accumulation<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Musculoskeletal
impairment<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Pain and
anxiety<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Inflammatory
process<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Respiratory Monitoring<o:p></o:p></span></b></div>
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<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Identify etiology or precipitating factors, such
as spontaneous collapse, trauma, malignancy, infection, and complication of
mechanical ventilation.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Evaluate respiratory function, noting rapid or
shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis,
and changes in vital signs.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
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<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Monitor for synchronous respiratory pattern when
using mechanical ventilator. Note changes in airway pressures.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Auscultate breath sounds.<o:p></o:p></span></div>
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<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Note chest excursion and position of trachea.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assess fremitus.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Ventilation Assistance<o:p></o:p></span></b></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assist client with splinting painful
area when coughing, or during deep breathing.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -15.85pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -15.85pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Maintain position of comfort,
usually with head of bed elevated. Turn to affected side. Encourage client to
sit up as much as possible.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -15.85pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Maintain a calm attitude, assisting
client to “take control” by using slower, deeper respirations.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Tube Care: Chest<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">If thoracic catheter is disconnected or dislodged:
Observe for signs of respiratory distress. If possible, reconnect thoracic
catheter to tubing and suction, using clean technique. If the catheter is
dislodged from the chest, cover insertion site immediately with petrolatum
dressing and apply firm pressure. Notify physician at once.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">After thoracic catheter is removed: Cover
insertion site with sterile occlusive dressing. Observe for signs or symptoms
that may indicate recurrence of pneumothorax, such as shortness of breath and
reports of pain. Inspect insertion site, noting character of drainage.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Ventilation Assistance<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Monitor and graph serial ABGs and pulse oximetry.
Review vital capacity and tidal volume measurements.</span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Administer supplemental oxygen via cannula, mask,
or mechanical ventilation, as indicated.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Administer analgesics and sedatives, as indicated.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-bottom: 0.0001pt;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Understanding the cause of lung collapse is
necessary for proper chest tube placement and choice of other therapeutic
measures.</span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Respiratory distress and changes in vital signs
occur because of physiological stress and pain or may indicate development of
shock due to hypoxia or hemorrhage.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Difficulty breathing with ventilator or increasing
airway pressures suggests worsening of condition and development of complications,
such as spontaneous rupture of a bleb creating a new pneumothorax.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Breath sounds may be diminished or absent in a
lobe, lung segment, or entire lung field (unilateral). Atelectatic area will
have no breath sounds, and partially collapsed areas have decreased sounds.
Regularly scheduled evaluation also helps determine areas of good air
exchange and provides a baseline to evaluate resolution of pneumothorax. <o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Chest excursion is unequal until lung reexpands.
Trachea deviates from affected side with tension pneumothorax.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Voice and tactile fremitus (vibration) is reduced
in fluid-filled or consolidated tissue.</span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Supporting chest and abdominal
muscles makes coughing more effective and less traumatic.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Promotes maximal inspiration;
enhances lung expansion and ventilation in unaffected side.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assists client to deal with the
physiological effects of hypoxia, which may be manifested as anxiety or fear.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="color: #231f20; font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -21.25pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Pneumothorax may recur, requiring
prompt intervention to prevent fatal pulmonary and circulatory impairment.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="color: #231f20; font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Early detection of a developing
complication, such as recurrence of pneumothorax or presence of infection, is
essential.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 72pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 72pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="color: #231f20; font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-indent: -18pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assesses
status of gas exchange and ventilation and need for continuation or
alterations in therapy.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="color: #231f20; font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-indent: -18pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Aids
in reducing work of breathing; promotes relief of respiratory distress and
cyanosis associated with hypoxemia.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-indent: -18pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-indent: -18pt;">
<!--[if !supportLists]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Given
to manage pleuritic pain and reduce anxiety and tachycardia<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">associated
with impaired respiratory function, especially when client is on a ventilator.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.9pt;" valign="top" width="95"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Establish a normal and
effective respiratory pattern with ABGs within client’s normal range.<o:p></o:p></span></div>
<div class="MsoListParagraph" style="margin: 0cm 0cm 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Be
free of cyanosis and other signs or symptoms of hypoxia.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 62.1pt;" valign="top" width="83"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Risk for
Trauma/Suffocation <o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 0cm;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 6.0cm;" valign="top" width="227"><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0cm;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Teaching: Procedure/Treatment<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Review with client purpose and function of CDU,
taking note of safety features.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Instruct client to refrain from lying or pulling
on tubing.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Identify changes and situations that should be
reported to caregivers, such as change in sound of bubbling, sudden “air
hunger” and chest pain, and disconnection of equipment.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Tube Care: Chest<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Anchor thoracic catheter to chest wall and provide
extra length of tubing before turning or moving client.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Secure tubing connection sites. Pad banding sites
with gauze or tape.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Secure drainage unit to client’s bed or on stand
or cart placed in low-traffic area.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Provide safe transportation if client is sent off
unit for diagnostic purposes. Before transporting, check water-seal chamber
for correct fluid level; presence or absence of bubbling; and presence,
degree, and timing of tidaling. Ascertain whether chest tube can be clamped
or disconnected from suction source.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Monitor thoracic insertion site, noting condition
of skin and presence and characteristics of drainage from around the
catheter.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Change and reapply sterile occlusive dressing as
needed.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">7.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Observe for signs of respiratory distress if
thoracic catheter is disconnected or dislodged.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 18pt; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Information on how system works provides
reassurance, reducing client anxiety.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Reduces risk of obstructing drainage or
inadvertently disconnecting tubing.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Timely intervention may prevent serious
complications.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Prevents thoracic catheter dislodgment or tubing
disconnection and reduces pain and discomfort associated with pulling or
jarring of tubing.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Prevents tubing disconnection.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Protects skin from irritation and pressure.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Maintains upright position and reduces risk of
accidental tipping and breaking of unit.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Promotes continuation of optimal evacuation of
fluid or air during transport. If client is draining large amounts of chest
fluid or air, tube should not be clamped or suction interrupted because of
risk of accumulating fluid or air, compromising respiratory status.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Provides for early recognition and treatment of
developing skin or tissue erosion or infection.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">7.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Pneumothorax may recur or worsen, compromising
respiratory function and requiring emergency intervention.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.9pt;" valign="top" width="95"><div class="MsoListParagraphCxSpLast" style="margin-left: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Correct and avoid environmental and
physical hazards.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 62.1pt;" valign="top" width="83"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">Deficient Knowledge [Learning Need] regarding
condition, treatment regimen, self-care, and discharge needs related to<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 0cm;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">Lack of exposure to information</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 6.0cm;" valign="top" width="227"><div class="MsoListParagraphCxSpMiddle" style="margin-left: 0cm;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Teaching: Disease Process<o:p></o:p></span></b></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Review pathology of individual problem.<o:p></o:p></span></div>
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<br /></div>
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<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Identify likelihood for recurrence or long-term
complications.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: 0.0001pt;">
<br /></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
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<br /></div>
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<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Review signs and symptoms requiring immediate medical
evaluation, for example, sudden chest pain, dyspnea, air hunger, and
progressive respiratory distress.</span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Review significance of good health practices, such
as adequate nutrition, rest, and exercise.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Emphasize need for smoking cessation when
indicated.</span></div>
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<br /></div>
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<br /></div>
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<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Information reduces fear of unknown. Provides
knowledge base for understanding underlying dynamics of condition and
significance of therapeutic interventions.</span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> 2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Certain underlying lung diseases, such as severe
COPD and malignancies, may increase incidence of recurrence. In otherwise
healthy clients who suffered a spontaneous pneumothorax, incidence of
recurrence is 10% to 50%.Those who have a second spontaneous episode are at
high risk for a third incident (60%).<o:p></o:p></span></div>
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<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Recurrence of pneumothorax and hemothorax requires
medical intervention to prevent and reduce potential complications.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Maintenance of general well-being promotes healing
and may prevent or limit recurrences.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 19.9pt; text-indent: -19.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Prevents recurrence of pneumothorax or respiratory
complications, such as fibrotic changes.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 70.9pt;" valign="top" width="95"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Verbalize
understanding of cause of problem (when known).<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Identify signs or symptoms requiring
medical follow-up.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 0cm;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Follow therapeutic regimen and
demonstrate lifestyle changes, if necessary, to prevent recurrence.<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
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Patient teaching Discharge and home healthcare guidance for patient with Pneumothorax;<br />
<div style="text-align: justify;">
Review all follow-up appointments, which often involve chest x-rays, arterial blood gas analysis, and a physical exam. Refer for counseling, if necessary. Teach the patient when to notify the physician of complications and to report any sudden chest pain or difficulty breathing </div>
<br />
<ul>
<li style="text-align: justify;">Reassure the patient. Explain what Pneumothorax is, what causes it, and all diagnostic tests and procedures. </li>
<li style="text-align: justify;">If the patient is having surgery or chest tubes inserted, explain why he needs these procedures. Reassure him that the chest tubes are inserted to make him more comfortable. </li>
<li style="text-align: justify;">Encourage the patient to perform deep-breathing exercises every hour when awake. </li>
<li style="text-align: justify;">Discuss the potential for recurrent spontaneous Pneumothorax, and review its signs and symptoms. Emphasize the need for immediate medical intervention if these should occur. </li>
<li style="text-align: justify;">Instruct patient to continue use of the incentive spirometer at home. </li>
<li style="text-align: justify;">For patients with spontaneous Pneumothorax, there is an increased risk for repeat occurrence; therefore, encourage these patients to report sudden Dyspnea immediately.</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-17370116583641820712010-09-22T12:04:00.000+07:002014-10-31T18:59:53.126+07:00Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)<div style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7JQ6Fawe2bgdOXcrMMX0f8hyphenhyphenOhyuhIkbmGjW6ySQBPYhsPUkkTCpH94OCmkpITlHXMly7lqON4SajiV0Wqf3s_itpoaV0YdRr2wgC15L2V4vj5pN6D1haAgnYyk9NgV1bV0OxEDV-hG-k/s1600/copd.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7JQ6Fawe2bgdOXcrMMX0f8hyphenhyphenOhyuhIkbmGjW6ySQBPYhsPUkkTCpH94OCmkpITlHXMly7lqON4SajiV0Wqf3s_itpoaV0YdRr2wgC15L2V4vj5pN6D1haAgnYyk9NgV1bV0OxEDV-hG-k/s1600/copd.gif" height="200" width="200" /></a></div>
Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible, sometimes referred to as chronic airway obstruction or chronic obstructive lung disease. The airflow limitation is generally progressive and is normally associated with an inflammatory response of the lungs due to irritants. COPD includes chronic bronchitis and pulmonary emphysema. Chronic bronchitis is a chronic inflammation of the lower respiratory tract characterized by excessive mucous secretion, cough, and Dyspnea associated with recurring infections of the lower respiratory tract. Pulmonary emphysema is a complex lung disease characterized by destruction of the alveoli, enlargement of distal airspaces, and a breakdown of alveolar walls. There is a slowly progressive deterioration of lung function for many years before the development of illness. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Clinical Manifestations </div>
<div style="text-align: justify;">
Chronic Bronchitis (usually insidious, developing over a period of years) : </div>
<div style="text-align: justify;">
<br /></div>
<ul>
<li style="text-align: justify;">Presence of a productive cough lasting at least 3 months a year for 2 successive years. </li>
<li style="text-align: justify;">Production of thick, gelatinous sputum; greater amounts produced during superimposed infections. </li>
<li style="text-align: justify;">Wheezing and dyspnea as disease progresses </li>
</ul>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Emphysema (Gradual in onset and steadily progressive): </div>
<div style="text-align: justify;">
<br /></div>
<ul>
<li style="text-align: justify;">Dyspnea, decreased exercise tolerance. </li>
<li style="text-align: justify;">Cough may be minimal, except with respiratory infection. </li>
<li style="text-align: justify;">Sputum expectoration mild. </li>
<li style="text-align: justify;">Increased anteroposterior diameter of chest (barrel chest) due to air trapping with diaphragmatic flattening. </li>
</ul>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Causes</div>
<div style="text-align: justify;">
The etiology of Chronic Obstructive Pulmonary Disease COPD includes:</div>
<div style="text-align: justify;">
<br /></div>
<ul>
<li style="text-align: justify;">Cigarette smoking. </li>
<li style="text-align: justify;">Air pollution, occupational exposure. </li>
<li style="text-align: justify;">Allergy, autoimmunity.</li>
<li style="text-align: justify;">Infection. </li>
<li style="text-align: justify;">Genetic predisposition, aging. </li>
</ul>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Etiology of emphysema includes: </div>
<div style="text-align: justify;">
Exposure to tobacco smoke due to smoking preventable cause
Secondhand smoke or passive smoking: nitric oxide, component of smoke, is a potent bronchodilator
Ambient air pollution
Alpha 1 -antitrypsin deficiency: genetic abnormality accounts for less than 1% of Chronic Obstructive Pulmonary Disease (COPD) </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Etiology of chronic bronchitis includes: </div>
<div style="text-align: justify;">
Exposure to tobacco smoke due to cigarette smoking
Secondhand smoke or passive smoking
Ambient air pollution and occupational irritants
Sex, race, and socioeconomic status: higher prevalence of respiratory symptoms in men, higher mortality rates in whites, and higher morbidity and mortality in blue-collar workers.
Occupational dusts and chemicals: vapors, irritants and fumes, particulate matter, organic dust </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Complications </div>
<div style="text-align: justify;">
Dyspnea
Cor pulmonale
Respiratory failure
Pneumothorax
Bronchiectasis: recurrent bouts of bronchitis
Decreased quality of life and functional status
Decreased independence due to difficulty breathing and increased oxygen demands resulting in fatigue
Assistance with activities of daily living (ADLs) as disease progresses
Pneumonia, overwhelming respiratory infection.
Right-sided heart failure, Dysrhythmias
Depression
Skeletal muscle dysfunction </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Stages of COPD Based on the Global Initiative for Chronic Obstructive Lung Disease</div>
<div style="text-align: justify;">
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<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">Stage</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180"><div class="MsoNormal" style="text-align: center;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">Degree of COPD</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 281.45pt;" valign="top" width="375"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">Status of Airflow Post
bronchodilator FEV1<o:p></o:p></span></div>
<div class="MsoNormal" style="text-align: center;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-bidi-font-weight: bold;">(forced expiratory volume in 1
second)</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
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<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">0</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">At Risk</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 281.45pt;" valign="top" width="375"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">normal
spirometry<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">chronic
symptoms cough and sputum production<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 37.5pt;" valign="top" width="50"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">I<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Mild COPD<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 281.45pt;" valign="top" width="375"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">FEV
<b>1</b>/ FVC < 70%,<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">FEV<b>1
</b>≥ 80% predicted with or without chronic symptoms<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 37.5pt;" valign="top" width="50"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">II<o:p></o:p></span></div>
</td>
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<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Moderate COPD<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 281.45pt;" valign="top" width="375"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">FEV
<b>1</b>/ FVC < 70%,<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">50%
≤ FEV<b>1 </b>< 80% predicted with or without chronic symptoms<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 37.5pt;" valign="top" width="50"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">III<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Severe COPD<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 281.45pt;" valign="top" width="375"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">FEV
<b>1 </b>/ FVC < 70%,<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">30%
≤ FEV <b>1 </b>or < 50% predicted plus respiratory failure or right heart
failure<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 37.5pt;" valign="top" width="50"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">IV<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180"><div class="MsoNormal">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Very Severe COPD<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 281.45pt;" valign="top" width="375"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">FEV
<b>1 </b>/ FVC < 70%<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">FEV<b>1
</b>< 30% predicted or<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">FEV<b>1
</b>< 50% predicted plus chronic respiratory failure<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Treatment for Chronic Obstructive Pulmonary Disease (COPD)</div>
<div style="text-align: justify;">
Treatment for Chronic Obstructive Pulmonary Disease (COPD) is designed to relieve symptoms and prevent complications. Because most COPD patients receive outpatient treatment, they need comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. If programs in pulmonary rehabilitation are available, encourage the patient to enroll.</div>
<div style="text-align: justify;">
If the patient is to continue oxygen therapy at home, teach the patient how to use the equipment correctly. Patients with COPD rarely require more than 3 L/minute to maintain adequate oxygenation. Higher flow rates will further increase the partial pressure of arterial oxygen, but patients whose ventilatory drive is largely based on hypoxemia commonly develop a markedly increased partial pressure of arterial carbon dioxide. In such patients, chemoreceptors in the brain are relatively insensitive to the increase in carbon dioxide.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Treatment for Chronic Obstructive Pulmonary Disease (COPD) includes:</div>
<div style="text-align: justify;">
Smoking cessation.
Inhaled bronchodilators reduce Dyspnea and bronchospasm; delivered by metered dose inhalers (MDI) or handheld or mask nebulizer devices.
Methylxanthines, such as theophylline (Theo-Dur), given orally as sustained-release formulation for chronic maintenance therapy (less commonly used).
Inhaled corticosteroids are recommended for patients with symptomatic COPD with documented spirometric improvement from glucocorticosteroids, or in those with an FEV1 that is less than 50% of the predicted value and repeated exacerbations requiring treatment with antibiotics and/or oral glucocorticosteroids.
Antibiotics help treat respiratory tract infections. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures.
Oral corticosteroids are used in acute exacerbations for anti-inflammatory effect; may also be given I.V. in severe cases.
Chest physical therapy, including postural drainage for secretion clearance and breathing retraining for improved ventilation and control of dyspnea.
Supplemental oxygen therapy for patients with hypoxemia. CO2 must be monitored to determine increased CO2 retention.
Pulmonary rehabilitation to improve function, strength, symptom control, disease self-management techniques, independence, and quality of life.
Antimicrobial agents for episodes of respiratory infection.
Lung volume reduction surgery is under investigation for treatment of heterogeneous emphysema.
Treatment for alpha1-antitrypsin deficiency:
Prevent damage to lungs by quitting smoking.
Lung transplantation may be considered for people with severely disabling alphaantitrypsin disease.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Assessment</div>
<div style="text-align: justify;">
The typical patient with Chronic Obstructive Pulmonary Disease (COPD), have a long-term cigarette smoker, remains asymptomatic until middle age. His ability to exercise or do strenuous work gradually starts to decline, and he begins to develop a productive cough. These signs are subtle at first, but become more pronounced as the patient gets older and the disease progresses. Eventually the patient may develop Dyspnea on minimal exertion, frequent respiratory infections, intermittent or continuous hypoxemia, and grossly abnormal pulmonary function studies.</div>
<div style="text-align: justify;">
<b>Patient History</b>:
Exposure to risk factors
Past medical history including asthma, allergy sinusitis, or nasal polyps
Family history of COPD or other chronic respiratory disease
Chronic cough: length of time, daily or intermittent, seldom noc turnal
Chronic sputum production: characteristics of sputum, change with the season amount produced
Dyspnea that is progressive, persistent, worse with exercise, worse during respiratory infections
History of exposure to tobacco smoke, occupational dusts and chemicals, smoke from home cooking and heating fuels
Smoking history: pack years (number of packs per day multiplied by number of years smoking)
Age when fi rst noticed symptoms
Current functional status and ability to perform ADLs
Limitation of activities
Pneumonia and other respiratory illnesses
Use of oxygen: liter flow and years of usage
Weight loss or weight gain
Sleep pattern and position during sleep: number of pillows used</div>
<div style="text-align: justify;">
<b>Physical Examination</b>
Potential abnormal physical exam findings (will vary based on severity of illness):
Assessment of severity based on level of symptoms
Severity of spirometric abnormalities
Characteristics of respiratory pattern: rate, depth, symmetry, and synchrony; breathlessness due to airway narrowing and bronchoconstriction
Use of pursed lip breathing
Breath sounds: normal and adventitious: crackles, rhonchi and wheezes; hyperresonant lung fields; may be distant due to hyperinflation
Cough due to increased sputum production: usually worse in the morning
Sputum production: color, amount; usually increased with chronic bronchitis
Shortness of breath with speech: two or three words per breath
Dyspnea on exertion
Barrel chest as a result of increased RV
Use of accessory muscles
Resting pulse oximetry with potential drop with activity
Presence of complications such as respiratory failure and right heart failure
Cor pulmonale: right-sided heart failure to include edema, heart rate, blood pressure, jugular venous pressure (JVP)
Check for presence of murmurs, gallops, rubs, lifts, heaves, and/or thrills
Fluid retention and edema
Overall appearance: thin with muscle wasting and barrel chest or overweight with barrel chest
Enlarged abdominal girth or cachetic appearance
Enlarged liver with right-sided heart failure
Posture: hunched over with rolled shoulders
Pallor skin color
Generalized edema</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Diagnostic Test</div>
<div style="text-align: justify;">
Chest X-ray: air trapping; hyperinfl ation; increased A-P diameter; flattened diaphragms
Postbronchodilator FEV 1
Pulmonary function test: show decreased FEV 1 (up to 50% loss) and decreased FEF 25%–75%; increased functional residual capacity (FRC) due to air trapping and hyperinflation
Arterial blood gases: may show increased CO 2 due to inability to expel all of the air (air trapping) and low O 2 levels due to ventilation/ perfusion mismatch
Assess Dyspnea using a valid tool such as the Modified Borg scale or the Visual Analog Scale
Oxygen saturation at rest and with activity
Quality-of-life measure: baseline measurement
Six-minute walk distance: baseline measurement</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Diagnosis</div>
<div style="text-align: justify;">
Common nursing diagnosis found in Nursing care plans for Chronic Obstructive Pulmonary Disease (COPD):
Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection
Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane
Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles
Deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources, Information misinterpretation, Lack of recall or cognitive limitation</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Goal</div>
<div style="text-align: justify;">
Respiratory Status: Airway Patency Effective</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing interventions NCP COPD:</div>
<div style="text-align: justify;">
Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi.
Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio.
Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 10 scale or American Thoracic Society’s Grade of Breathlessness Scale to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea.
Assist client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed.
Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation.
Encourage and assist with abdominal or pursed-lip breathing exercises.
Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort.
Increase fluid intake to 3,000 mL/day within cardiac tolerance.
Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals.
Administer medications, as indicated indicated, for example: Beta-agonists.
Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier.
Assist with respiratory treatments, such as spirometry and chest physiotherapy.
Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.</div>
<br />
Sample Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)<br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: none; mso-border-alt: solid black .5pt; mso-border-insideh: .5pt solid black; mso-border-insidev: .5pt solid black; mso-padding-alt: 0cm 5.4pt 0cm 5.4pt; mso-table-layout-alt: fixed; mso-yfti-tbllook: 1184;">
<tbody>
<tr>
<td style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.45pt;" valign="top" width="121"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">NURSING DIAGNOSE<o:p></o:p></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">INTERVENTION<o:p></o:p></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">RATIONALE<o:p></o:p></span></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.65pt;" valign="top" width="121"><div align="center" class="MsoNormal" style="text-align: center;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">EVALUATION<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.45pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Ineffective Airway Clearance
related to bronchoconstriction, increased mucus production, ineffective
cough, possible bronchopulmonary infection</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Auscultate breath sounds. Note adventitious breath
sounds such as wheezes, crackles, or rhonchi.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assess and monitor respiratory rate. Note
inspiratory-toexpiratory ratio.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Note presence and degree of dyspnea, for example,
reports of “air hunger,” restlessness, anxiety, respiratory distress, and use
of accessory muscles. Use a 0 to 10 scale or American Thoracic Society’s
Grade of Breathlessness Scale to rate breathing difficulty. Ascertain
precipitating factors when possible. Differentiate acute episode from
exacerbation of chronic dyspnea.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assist client to maintain a comfortable position
to facilitate breathing by elevating the head of bed, leaning on or over bed
table, or sitting on edge of bed.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Keep environmental pollution from sources such as
dust, smoke, and feather pillows to a minimum according to individual
situation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Encourage and assist with abdominal or pursed-lip
breathing exercises.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Observe for persistent, hacking, or moist cough.
Assist with measures to improve effectiveness of cough effort.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst">
<br /></div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Increase fluid intake to 3,000 mL/day within
cardiac tolerance. Provide warm or tepid liquids. Recommend intake of fluids
between, instead of during, meals.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Administer medications, as indicated indicated,
for example: Beta-agonists, such as epinephrine (Adrenalin, AsthmaNefrin,
Primatene, Sus-Phrine), albuterol (Proventil, Velmax, Ventolin, AccuNeb,
Airet), formoterol (Foradil), levalbuterol (Xopenex); metaproterenol
(Alupent), pirbuterol (Maxair), terbutaline (Brethine), and salmeterol
(Serevent)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Provide supplemental humidification, such as
ultrasonic nebulizer and aerosol room humidifier.</span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assist with respiratory treatments, such as
spirometry and chest physiotherapy.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Symbol; font-size: 12pt; text-indent: -15.9pt;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><span style="font-family: "Times New Roman","serif"; font-size: 12pt; text-indent: -15.9pt;">Monitor and graph serial ABGs, pulse oximetry, and
chest x-ray.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Some degree of bronchospasm is present with
obstructions in airway and may or may not be manifested in adventitious
breath sounds, such as scattered, moist crackles (bronchitis); faint sounds,
with expiratory wheezes (emphysema); or absent breath sounds (severe asthma).<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Tachypnea is usually present to some degree and
may be pronounced on admission, during stress, or during concurrent acute
infectious process. Respirations may be shallow and rapid, with prolonged expiration
in comparison to inspiration.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Respiratory dysfunction is variable depending on
the underlying process; for example, infection, allergic reaction, and the
stage of chronicity in a client with established COPD.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Elevation of the head of the bed facilitates
respiratory function using gravity; however, client in severe distress will
seek the position that most eases breathing. Supporting arms and legs with
table, pillows, and so on helps reduce muscle fatigue and can aid chest
expansion.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Precipitators of allergic type of respiratory
reactions that can trigger or exacerbate onset of acute episode.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Provides client with some means to cope with and
control dyspnea and reduce air-trapping.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Cough can be persistent but ineffective,
especially if client is elderly, acutely ill, or debilitated. Coughing is
most effective in an upright or in a head-down position after chest
percussion.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Hydration helps decrease the viscosity of
secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm.
Fluids during meals can increase gastric distention and pressure on the
diaphragm.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Inhaled β2-adrenergic agonists are first-line
therapies for rapid symptomatic improvement of bronchoconstriction. These
medications relax smooth muscles and reduce local congestion, reducing airway
spasm, wheezing, and mucus production. Medications may be oral, injected, or
inhaled. Inhalation by metered-dose inhaler (MDI) with a spacer is
recommended, but medications may be nebulized in the event client has severe
coughing or is too dyspneic to puff effectively.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Humidity helps reduce viscosity of secretions,
facilitating expectoration, and may reduce or prevent formation of thick
mucous plugs in bronchioles.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Breathing exercises help enhance diffusion;
aerosol or nebulizer medications can reduce bronchospasm and stimulate
expectoration. Postural drainage and percussion enhance removal of excessive
and sticky secretions and improve ventilation of bottom lung segments. Note:
Chest physiotherapy may aggravate bronchospasm in asthmatics.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Establishes baseline for monitoring progression or
regression of disease process and complications. <o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.65pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Maintain
patent airway with breath sounds clear or clearing.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Demonstrate
behaviors to improve airway clearance.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.45pt;" valign="top" width="121"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Impaired Gas Exchange related to
chronic pulmonary obstruction, abnormalities due to destruction of alveolar
capillary membrane</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assess respiratory rate and depth. Note use of
accessory muscles, pursed-lip breathing, and inability to speak or converse.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Elevate head
of bed and assist client to assume position to ease work of breathing.
Include periods of time in prone position as tolerated. Encourage deep, slow
or pursed-lip breathing as individually needed and tolerated.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assess and
routinely monitor skin and mucous membrane color.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Encourage
expectoration of sputum; suction when indicated.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Auscultate
breath sounds, noting areas of decreased airflow and adventitious sounds.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Palpate chest
for fremitus.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Monitor level
of consciousness and mental status. Investigate changes.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst">
<br /></div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Evaluate level
of activity tolerance. Provide calm, quiet environment. Limit client’s
activity or encourage bedrest or chair rest during acute phase. Have client
resume activity gradually and increase as individually tolerated.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Evaluate sleep
patterns, note reports of difficulties and whether client feels well rested.
Provide quiet environment and group care and monitoring activities to allow periods
of uninterrupted sleep. Limit stimulants such as caffeine. Encourage position
of comfort.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Monitor vital
signs and cardiac rhythm.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Monitor and
graph serial ABGs and pulse oximetry.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Administer
supplemental oxygen judiciously via nasal cannula, mask, or mechanical
ventilator, and titrate as indicated by ABG results and client tolerance.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Useful in evaluating the degree of respiratory
distress and chronicity of the disease process.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Oxygen delivery may be improved by upright
position and breathing exercises to decrease airway collapse, dyspnea, and
work of breathing. Note: Recent research supports use of prone position to
increase PaO2.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Cyanosis may be peripheral (noted in nailbeds) or
central (noted around lips or earlobes). Duskiness and central cyanosis
indicate advanced hypoxemia.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Thick,
tenacious, copious secretions are a major source of impaired gas exchange in
small airways. Deep suctioning may be required when cough is ineffective for
expectoration of secretions.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Breath sounds
may be faint because of decreased airflow or areas of consolidation. Presence
of wheezes may indicate bronchospasm or retained secretions. Scattered, moist
crackles may indicate interstitial fluid or cardiac decompensation.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Decrease of vibratory tremors suggests fluid
collection or airtrapping.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Restlessness and anxiety are common manifestations
of hypoxia. Worsening ABGs accompanied by confusion and somnolence are
indicative of cerebral dysfunction due to hypoxemia.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">During severe,
acute, or refractory respiratory distress, client may be totally unable to
perform basic self-care activities because of hypoxemia and dyspnea. Rest
interspersed with care activities remains an important part of treatment
regimen. An exercise program is aimed at improving aerobic capacity and
functional performance, increasing endurance and strength without causing
severe dyspnea, and can enhance sense of well-being.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Multiple
external stimuli and presence of dyspnea and hypoxemia may prevent relaxation
and inhibit sleep.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Tachycardia, dysrhythmias, and changes in BP can
reflect effect of systemic hypoxemia on cardiac function.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">PaCO2 is usually elevated in bronchitis and
emphysema, and PaO2 is generally decreased, so that hypoxia is present in a
greater or lesser degree. Note: A “normal” or increased PaCO2 signals
impending respiratory failure for asthmatics.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Used to correct and prevent worsening of
hypoxemia, improve survival, and quality of life. Supplemental oxygen can
beprovided during exacerbations only, or as a long-term therapy.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.65pt;" valign="top" width="121"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Demonstrate
improved ventilation and adequate oxygenation of tissues by ABGs within
client’s normal range and be free of<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">symptoms
of respiratory distress. Participate in treatment regimen within level of
ability and situation.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.45pt;" valign="top" width="121"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Imbalanced Nutrition: Less Than
Body Requirements related to increased work of breathing, air swallowing,
drug effects with resultant wasting of respiratory and skeletal muscles<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Assess dietary
habits, recent food intake. Note degree of difficulty with eating. Evaluate
weight and body size or mass.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Auscultate
bowel sounds.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Give frequent
oral care, remove expectorated secretions promptly, and provide specific
container for disposal of secretions and tissues.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Encourage a
rest period of 1 hour before and after meals. Provide frequent small
feedings.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Avoid
gas-producing foods and carbonated beverages.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Avoid very hot
or very cold foods.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Weigh, as
indicated.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Client in acute respiratory distress is often
anorectic because of dyspnea, sputum production, and medication effects. In
addition, many COPD clients habitually eat poorly even though respiratory
insufficiency creates a hypermetabolic state with increased caloric needs. As
a result, client often is admitted with some degree of malnutrition. People
who have emphysema are often thin, with wasted musculature.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Diminished or hypoactive bowel sounds may reflect
decreased gastric motility and constipation (common complication) related to
limited fluid intake, poor food choices, decreased activity, and hypoxemia.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Noxious tastes,
smells, and sights are prime deterrents to appetite and can produce nausea
and vomiting with increased respiratory difficulty.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Helps reduce
fatigue during mealtime, and provides opportunity to increase total caloric
intake.<o:p></o:p></span></div>
<div class="MsoListParagraph">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Can produce abdominal distention, which hampers
abdominal breathing and diaphragmatic movement and can increase dyspnea.<o:p></o:p></span></div>
<div class="MsoListParagraph" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Extremes in temperature can precipitate or
aggravate coughing spasms.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Useful in determining caloric needs, setting
weight goal, and evaluating adequacy of nutritional plan. Note: Weight loss
may continue initially despite adequate intake, as edema is resolving. <o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.65pt;" valign="top" width="121"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Display
progressive weight gain toward goal as appropriate.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Demonstrate
behaviors and lifestyle changes to regain and maintain appropriate weight.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 90.45pt;" valign="top" width="121"><div class="MsoNormal">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Deficient
Knowledge [Learning Need] regarding condition, treatment, self-care, and
discharge needs related to lack of information or unfamiliarity with
information resources, Information misinterpretation, Lack of recall or
cognitive limitation<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Explain and
reinforce explanations of individual disease process, including factors that
lead to exacerbation episodes. Encourage client and SO to ask questions.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Identify individual environmental factors such as
excessively dry air, wind, temperature extremes, pollen, tobacco smoke,
aerosol sprays, and air pollution that may trigger or aggravate condition.
Encourage client and SO to explore ways to control these factors in and
around the home and work setting.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Provide
information about benefits of regular exercise while addressing individual
activity limitations.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Discuss importance of regular medical follow-up
care, when to notify healthcare professional of changes in condition, and
periodic spirometry testing, chest x-rays, and sputum cultures.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Discuss
respiratory medications, side effects, drug interactions, and adverse
reactions.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpLast">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Demonstrate
correct technique for using an MDI, such as how to hold it, pausing 2 to 5
minutes between puffs, and cleaning the inhaler.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Understanding
decreases anxiety and can lead to improved participation in treatment plan.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">These can
induce or aggravate bronchial irritation, leading to increased secretion
production and airway blockage.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin-left: 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Having this
knowledge can enable client and SO to make informed choices and decisions to
reduce client’s dyspnea, maximize functional level, perform most desired
activities, and prevent complications.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Monitoring disease process allows for alterations
in therapeutic regimen to meet changing needs and may help prevent
complications.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Frequently, these clients are simultaneously on
several respiratory drugs that have similar side effects and potential drug
interactions. It is important that the client understands the difference
between nuisance side effects (medication continued) and untoward or adverse
side effects (medication possibly discontinued or dosage changed).<o:p></o:p></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Proper administration of drug enhances delivery
and effectiveness.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Verbalize
understanding of condition and disease process and treatment.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Identify
relationship of current signs and symptoms to the disease process and
correlate these with causative factors.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt;">Initiate
necessary lifestyle changes and participate in treatment regimen.<o:p></o:p></span></div>
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Most Chronic Obstructive Pulmonary Disease COPD patients receive outpatient treatment, so provide comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. </div>
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Patient Teaching For Patient With Chronic Obstructive Pulmonary Disease COPD: </div>
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<b>General Health </b></div>
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Teach the patient and his family how to recognize early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures
Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as directed.
Teach good habits of well-balanced, nutritious intake.
Encourage high-protein diet with adequate mineral, vitamin, and fluid intake.
Advise against excessive hot or cold fluids and foods, which may provoke an irritating cough.
Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement.
Encourage five to six small meals daily to ease shortness of breath during and after meals.
Suggest rest periods before and after meals if eating produces shortness of breath. Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics; Watch for weakness, numbness, tingling of fingers, leg cramps, Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes.
Advise patient on restricting sodium as directed.
Limit carbohydrates if CO2 is retained by patient, because they increase CO2.
Use community resources, such as Meals On Wheels or a home care aide if energy level is low. </div>
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<b>Avoid Exposure to Respiratory Irritants</b> </div>
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Advise patient to stop smoking and avoid exposure to second-hand smoke.
Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches, ammonia, and other respiratory irritants.
Advise patient to keep entire house well-ventilated.
Warn patient to stay out of extremely hot/cold weather to avoid bronchospasm and dyspnea.
Instruct patient to humidify indoor air in winter; maintain 30% to 50% humidity for optimal mucociliary function.
Suggest the use of a HEPA air cleaner to remove dust, pollen, and other particulates; this is controversial as to the benefit to the patient. </div>
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<b>Breathing Exercises </b></div>
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Explain that goal is to strengthen and coordinate muscles of breathing to lessen work of breathing and help lung empty more completely.
To promote ventilation and reduce air trapping, teach the patient to breathe slowly, prolong expirations to two to three times the duration of inspiration, and to exhale through pursed lips.
Stress the importance of controlled breathing.
Teach diaphragmatic breathing and pursed-lip breathing for episodes of dyspnea and stress.
To help mobilize secretions, teach the patient how to cough effectively. If the patient with copious secretions has difficulty mobilizing secretions, teach his family how to perform postural drainage and chest physiotherapy. If secretions are thick, encourage the patient to drink 12 to 15 glasses of fluid per day.
Encourage muscle toning by regular exercise.
If the patient use oxygen therapy at home, teach him how to use the equipment correctly.</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-88521486634868396572010-09-08T11:19:00.000+07:002014-10-31T18:59:53.344+07:00NCP: Nursing Care Plans for Bronchiectasis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilWKADq__yR8zpXueBMEUZn7thVSysyAiKo_aZYj2CcUJ-1gRXM78j2K6fs45nLyxse17K_kVHvWIieeGpIotUAYxFZ5W-J2nFJVyxhbigHVoA-l2MxfYI5OqoBPsFUpHrFPzWgm713S3a/s1600/Bronchiectasis_image.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilWKADq__yR8zpXueBMEUZn7thVSysyAiKo_aZYj2CcUJ-1gRXM78j2K6fs45nLyxse17K_kVHvWIieeGpIotUAYxFZ5W-J2nFJVyxhbigHVoA-l2MxfYI5OqoBPsFUpHrFPzWgm713S3a/s1600/Bronchiectasis_image.gif" height="145" width="200" /></a></div>
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Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose, and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis</div>
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Causes Bronchiectasis</div>
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The primary etiology in the development of ordinary acquired Bronchiectasis is inflammatory destruction of the elastic tissue, smooth muscle, and cartilage of bronchial walls usually due to severe preceding infection(s). Fewer cases are caused by genetic or immune deficiencies or result from inhalation injury.
Bronchiectasis results from conditions associated with repeated damage to bronchial walls and with abnormal mucociliary clearance, which causes a breakdown of supporting tissue adjacent to the airways. Such conditions include:</div>
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Predisposing factors:</div>
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Bronchopulmonary infection— Mycobacterium species, bacterial (e.g., Staphylococcus aureus, Bordetella pertussis, Klebsiella pneumoniae, H. influenza ), viral (e.g., measles, HIV, adenovirus, influenza), fungal (histoplasmosis, coccidiomycosis), recurrent aspiration pneumonia.
Bronchial obstruction—foreign body aspiration, lung or bronchogenic neoplasm, airway nodules, hilar adenopathy (e.g., sarcoidosis), mucus impaction (e.g., allergic bronchopulmonary aspergllosis), broncholith, external compression by vascular aneurysm.
Immunodefi ciency states—hypogammaglobulinemia, IgG subclass deficiency, selective IgA deficiency.
Other congenital syndromes—cystic fibrosis, alpha1-antitrypsin deficiency, primary ciliary dyskinesia (e.g., Kartagener’s syndrome), Young’s syndrome (azoospermia and chronic sinopulmonary infections).
Inhalation injury—smoke, ammonia, sulfur or nitrogen dioxide.
Rheumatologic disease—rheumatoid arthritis, Sjogren’s syndrome
Anatomic defects—bronchomalacia, Swyer-James syndrome, bronchial cartilage deficiency (Williams-Campbell syndrome), tracheobronchomegaly (Mounier-Kuhn syndrome)</div>
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Complications Bronchiectasis</div>
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Hemoptysis occurs in nearly 50% of patients with bronchiectasis (Mysliwiec & Pina, 1999); major pulmonary hemorrhage and death from exsanguination are rare (Swartz, 1998).
Empyema, lung abscess, and pneumothorax are serious but rare complications of acute infections in bronchiectasis (Luce, 1994).
Progressive respiratory insuffi ciency and cor pulmonale complicate severe bronchiectasis associated with deteriorating pulmonary function and hypoxemia.</div>
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TREATMENT FOR BRONCHIECTASIS</div>
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<b>Medical interventions </b></div>
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Inhaled bronchodilators may be helpful in diffuse small airway disease; beta adrenergic agents dilate airways and improve ciliary activity (Swartz, 1998).</div>
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Antimicrobial therapy for treatment of acute infectious exacerbations is based on results of sputum gram stain and culture.
Corticosteroids reduce the airway infl ammatory response in bronchiectasis.
Oxygen therapy is prescribed as indicated for patients with hypoxemia at rest, during sleep, and/or with activity.
Gamma globulin replacement for immunoglobulin defi ciency may be effective in reducing the frequency and severity of sinopulmonary infections (George et al., 1995).
Effective reduction and removal of bronchial secretions by a variety of available methods is critical in patients with bronchiectasis. The approach selected should be based upon an individual’s self-care abilities, motivation, breath control, neuromuscular status, preferences, needs, and financial resources (Langenderfer, 1998).
Effective cough
Percussion and postural drainage
Autogenic drainage
Positive expiratory pressure (PEP) therapy
Flutter valve
Vest therapy
Humidifi cation (by cold water, jet nebulizers) as an adjunct to chest physiotherapy enhanced sputum production (Conway, Fleming, Perring, & Holgate, 1992).
Aerosolized recombinant human DNase may lyse the DNA that causes the sputum to be highly viscous. Initial studies for cystic fibrosis are promising, but this therapy is not FDA approved in non-CF bronchiectasis (O’Donnell, Barker, Ilowite, & Fick, 1998; Wills et al., 1996).
Non-invasive intermittent positive pressure ventilation (NIPPV) is an alternative to tracheostomy for respiratory failure due to advanced bronchiectasis.</div>
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<b>Surgical intervention</b></div>
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Surgical resection</div>
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Lung or heart-lung transplantation</div>
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<b>Nursing assessment for Bronchiectasis </b></div>
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<b>Patient’s history </b>of recurrent bronchopulmonary infections and symptoms of chronic productive cough are hallmark features of bronchiectasis. Pain and dyspnea are also common.
The history of acute, even if delayed, onset of bronchiectasis can sometimes be traced to a defi nite illness, pneumonia, or aspiration event in patients with postobstructive or infectious bronchiectasis. Those patients with underlying congenital or immune disorders usually demonstrate a more insidious disease onset (Luce, 1994).
Cough is present in 90% of patients (Nicotra et al., 1995).
Daily (often purulent) sputum production occurs in 75% of patients and varies in volume from 10–500 ml (Nicotra et al., 1995).
Pleuritic chest pain represents distended peripheral airways or distal pneumonitis adjacent to a visceral pleural surface. This symptom occurs in 50% of bronchiectasis patients (Barker, 2002).
Repeated episodes of fever, pleurisy, and/or sinusitis are also common.
Weakness, dyspnea, and weight loss are seen in patients during infectious exacerbations or those with extensive disease.
The St. George’s Respiratory Questionnaire (SGRQ) has been validated as a useful tool for assessment of health-related quality of life in patients with bronchiectasis (Wilson, Jones, O’Leary, Cole, & Wilson, 1997). Test items are divided into three major areas: symptomatology; activity tolerance; and impact of the condition on daily life including employment, need for medications, and sense of control or panic over one’s health.</div>
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<b>Physical examination</b> findings are neither sensitive nor specific for bronchiectasis.
Crackles are the most common adventitious auscultatory finding, followed in frequency by wheezing, rhonchi, and a pleural friction rub (Barker, 2002; Mysliwiec & Pina, 1999; Nicotra et al., 1995).
Digital clubbing is rare (Barker, 2002; Mysliwiec & Pina, 1999).
Nasal polyps and sinusitis may also be evident (Luce, 1994).
Patients may have fetid breath chronically or solely during episodes of purulent sputum production.
Generalized weight loss and use of accessory muscles accompany severe disease.</div>
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<b>Diagnostic Test for Bronchiectasis </b></div>
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Radiographic imaging studies are the principal diagnostic tools for Bronchiectasis (chest roentgenogram, non-contrast computed tomography (HRCT) and spiral volumetric scans.</div>
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Bronchoscopy is used to examine airways for obstructing tumors or foreign bodies, to evaluate the degree and site of hemoptysis, and to detect or remove inspissated secretions (Barker & Bardana, 1988; George, Matthay, Light, & Matthay, 1995).</div>
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Functional assessment of the bronchiectasis patient includes pulmonary function testing with spirometry and lung volumes, and arterial blood gas analysis.</div>
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Laboratory studies are important in the diagnosis and follow-up of patients:</div>
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<ul>
<li style="text-align: justify;">The complete blood count with cell differential may reveal leukocytosis or increased neutrophil levels during acute exacerbations; anemia may be present in chronic infections (Swartz,1998). </li>
<li style="text-align: justify;">Quantitative serum immunoglobulin levels of IgA, IgM, IgE, IgG </li>
<li style="text-align: justify;">Sputum smear reveals large numbers of white blood cells and both gram-positive and gram-negative organisms </li>
<li style="text-align: justify;">Sweat chloride testing is used to screen for cystic fibrosis in young adults with no identifiable predisposing cause for bronchiectasis. </li>
<li style="text-align: justify;">Aspergillus titers are indicated when an Aspergillus organism is cultured or if radiographic exam (chest X-ray or HRCT) demonstrates central bronchiectasis (Barker & Bardana, 1988). </li>
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Nursing Diagnosis That Could Be Found In Patient with Bronchiectasis</div>
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Common nursing diagnosis found in nursing care plans for Bronchiectasis:</div>
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<ul>
<li style="text-align: justify;">Impaired gas exchange related to ventilation–perfusion inequality </li>
<li style="text-align: justify;">Ineffective airway clearance related to bronchoconstriction, increased mucus production, ineffective cough, bronchopulmonary infection, and other complications </li>
<li style="text-align: justify;">Ineffective breathing pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants </li>
<li style="text-align: justify;">Self-care deficits related to fatigue secondary to increased work of breathing and insufficient ventilation and oxygenation </li>
<li style="text-align: justify;">Activity intolerance due to fatigue, hypoxemia, and ineffective breathing patterns </li>
<li style="text-align: justify;">Ineffective coping related to reduced socialization, anxiety, depression, lower activity level, and the inability to work </li>
<li style="text-align: justify;">Deficient knowledge about self-management to be performed at home. </li>
</ul>
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Sample nursing care plans Bronchiectasis:</div>
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<span style="font-family: "Times New Roman","serif";">NURSING
DIAGNOSE<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">INTERVENTION<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">RATIONALE<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">EVALUATION<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";">Impaired
gas exchange related to ventilation perfusion inequality<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Administer
bronchodilators as prescribed:<o:p></o:p></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Inhalation
is the preferred route.<o:p></o:p></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Observe
for side effects: tachycardia, dysrhythmias, central nervous system
excitation, nausea, and vomiting.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 25.4pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Assess
for correct technique of metered-dose inhaler (MDI) administration.<o:p></o:p></span></div>
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<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 11.25pt; text-align: left; text-indent: -11.25pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Evaluate effectiveness of nebulizer
or MDI treatments.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 25.4pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Assess
for decreased shortness of breath, decreased wheezing or crackles, loosened
secretions, decreased anxiety.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Ensure
that treatment is given before meals to avoid nausea and to reduce fatigue
that accompanies eating.<o:p></o:p></span></div>
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<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Instruct
and encourage patient in diaphragmatic breathing and effective coughing.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif";"><br /></span></div>
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<span style="font-family: "Times New Roman","serif";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">d.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Administer
oxygen by the method prescribed.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Explain
rationale and importance to patient.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Evaluate
effectiveness; observe for signs of hypoxemia. Notify physician if
restlessness, anxiety, somnolence, cyanosis, or tachycardia is present.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Analyze
arterial blood gases and compare with baseline values. When arterial puncture
is performed and a blood sample is obtained, hold puncture site for 5 minutes
to prevent arterial bleeding and development of ecchymoses.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Initiate
pulse oximetry to monitor oxygen saturation.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Explain
that no smoking is permitted by patient or visitors while oxygen is in use.</span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.55pt;" valign="top" width="170"><div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Bronchodilators
dilate the airways. The medication dosage is carefully adjusted for each
patient, in accordance with clinical response.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Combining
medication with aerosolized bronchodilators is typically used to control
bronchoconstriction in an acute exacerbation. Generally, however, the MDI
with spacer is the preferred route (less cost and time to treatment).<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">These
techniques improve ventilation by opening airways to facilitate clearing the
airways of sputum. Gas exchange is improved and fatigue is minimized.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">d.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Oxygen
will correct the hypoxemia. Careful observation of the liter flow or the
percentage administered and its effect on the patient is important. If the
patient has chronic CO2 retention, excessive oxygen could suppress the
hypoxic drive and respirations. These patients generally need low-flow oxygen
rates of 1 to 2 L/min. Periodic arterial blood gases and pulse oximetry help
to evaluate adequacy of oxygenation. Smoking may render pulse oximetry
inaccurate because the carbon monoxide from cigarette smoke also saturates
hemoglobin.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.3pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Verbalizes
need for bronchodilators and for taking as prescribed<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.3pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Evidences
minimal side effects; heart rate near normal, absence of dysrhythmias, normal
mentation<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.3pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Reports
a decrease in dyspnea<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.3pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Shows
an improved expiratory flow rate<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.3pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Uses
and cleans respiratory therapy equipment as applicable<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.3pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Demonstrates
diaphragmatic breathing and coughing<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.3pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">7.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Uses
oxygen equipment appropriately when indicated<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 26.75pt; text-align: left; text-indent: -18.45pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Evidences
improved arterial blood gases or pulse oximetry<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 26.75pt; text-align: left; text-indent: -18.45pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Demonstrates
correct technique for use of MDI<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt; text-align: left;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">Ineffective airway clearance
related to bronchoconstriction, increased mucus production,<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin-left: 0cm; text-align: left;">
<span style="font-family: "Times New Roman","serif";">ineffective
cough, bronchopulmonary infection, and other complications <o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 191.4pt;" valign="top" width="255"><div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Adequately
hydrate the patient.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Teach
and encourage the use of diaphragmatic breathing and coughing techniques.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Assist
in administering nebulizer or MDI.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: .0001pt; margin-bottom: 0cm; mso-add-space: auto;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">d.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">If
indicated, perform postural drainage with percussion and vibration in the
morning and at night as prescribed.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">e.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Instruct
patient to avoid bronchial irritants such as cigarette smoke, aerosols,
extremes of temperature, and fumes.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">f.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Teach
early signs of infection that are to be reported to the clinician
immediately:<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 54pt; text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Increased
sputum production<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 54pt; text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Change
in color of sputum<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 54pt; text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Increased
thickness of sputum<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 54pt; text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Increased
shortness of breath, tightness in chest, or fatigue Increased coughing<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 54pt; text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Fever
or chills<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"> g.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Administer antibiotics as
prescribed.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt; text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"> h.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Encourage patient to be
immunized<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: left;">
<span style="font-family: "Times New Roman","serif";">against influenza and
Streptococcus pneumoniae.</span><span style="font-family: 'Times New Roman', serif;"> </span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.55pt;" valign="top" width="170"><div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">This
ensures adequate delivery of medication to the airways.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Uses
gravity to help raise secretions so they can be more easily expectorated or
suctioned.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Bronchial
irritants cause bronchoconstriction and increased mucus production, which
then interferes with airway clearance.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";"> </span><span style="font-family: 'Times New Roman', serif;"> </span><span style="font-family: 'Times New Roman', serif;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">d.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Minor
respiratory infections that are of no consequence to the person with normal
lungs can produce fatal disturbances in the lungs of the person with
emphysema. Early recognition is crucial.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif";"> </span><span style="font-family: 'Times New Roman', serif;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">e.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Antibiotics
may be prescribed to prevent or treat infection.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle">
<br /></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle">
<span style="font-family: "Times New Roman","serif";"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 12pt 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">f.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">People
with respiratory conditions are prone to respiratory infections and are encouraged
to be immunized.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Verbalizes need to drink fluids<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Demonstrates diaphragmatic breathing and coughing<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Performs postural drainage correctly<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Coughing is minimized<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Does not smoke<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Verbalizes that pollens, fumes, gases, dusts, and extremes of
temperature and humidity are irritants to be avoided<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">7.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Identifies signs of early infection<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">8.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Is free of infection (no fever, no change in sputum, lessening
of dyspnea)<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">9.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Verbalizes need to notify health care provider at the earliest
sign of infection<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">10.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Verbalizes need to stay away from crowds or people with colds in
flu season<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">11.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Discusses flu and pneumonia vaccines with clinician to help
prevent infection<o:p></o:p></span></div>
<div class="MsoListParagraph" style="margin-left: 15.85pt; text-align: left; text-indent: -15.85pt;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">Ineffective breathing pattern
related to shortness of breath, mucus, bronchoconstriction,<o:p></o:p></span></div>
<div class="MsoListParagraph" style="margin-left: 0cm; text-align: left;">
<span style="font-family: "Times New Roman","serif";">and
airway irritants<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 191.4pt;" valign="top" width="255"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Teach patient diaphragmatic and
pursedlip breathing.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Encourage alternating activity
with rest periods. Allow patient to make some decisions (bath, shaving) about
care based on tolerance level.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Encourage use of an inspiratory
muscle trainer if prescribed.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.55pt;" valign="top" width="170"><div class="MsoListParagraphCxSpFirst" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Helps
patient prolong expiration time and decreases air trapping. With these
techniques, patient will breathe more efficiently and effectively.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Pacing
activities permits patient to perform activities without excessive distress.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Strengthens
and conditions the respiratory muscles.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Practices pursed-lip and diaphragmatic breathing and uses them
when short of breath and with activity<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Shows signs of decreased respiratory effort and paces activities<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Uses inspiratory muscle trainer as prescribed<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">Self-care deficits related to
fatigue secondary to increased work of breathing and insufficient<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">ventilation and oxygenation<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 191.4pt;" valign="top" width="255"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Teach
patient to coordinate diaphragmatic breathing with activity (eg, walking,
bending).<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Encourage
patient to begin to bathe self, dress self, walk, and drink fluids. Discuss
energy conservation measures.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Teach
postural drainage if appropriate.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.55pt;" valign="top" width="170"><div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">This
will allow the patient to be more active and to avoid excessive fatigue or
dyspnea during activity.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">As
condition resolves, patient will be able to do more but needs to be
encouraged to avoid increasing dependence.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Encourages
patient to become involved in own care. Prepares patient to manage at home.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Uses controlled
breathing while bathing, bending, and walking<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Paces activities of
daily living to alternate with rest periods to reduce fatigue and dyspnea<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Describes energy
conservation strategies<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Performs same
self-care activities as before<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Performs postural
drainage correctly<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<br /></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">Activity intolerance due to
fatigue, hypoxemia, and ineffective breathing patterns<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 191.4pt;" valign="top" width="255"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Support
patient in establishing a regular regimen of exercise using treadmill and
exercycle, walking, or other appropriate exercises, such as mall walking.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Assess
the patient’s current level of functioning and develop exercise plan based on
baseline functional status.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Suggest
consultation with a physical therapist or pulmonary rehabilitation program to
determine an exercise program specific to the patient’s capability. Have
portable oxygen unit available if oxygen is prescribed for exercise.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.55pt;" valign="top" width="170"><div class="MsoListParagraph" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Muscles
that are deconditioned consume more oxygen and place an additional burden on
the lungs. Through regular, graded exercise, these muscle groups become more
conditioned, and the patient can do more without getting as short of breath.
Graded exercise breaks the cycle of debilitation.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Performs activities
with less shortness of breath<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Verbalizes need to
exercise daily and demonstrates an exercise plan to be carried out at home <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Walks and gradually
increases walking time and distance to improve physical condition<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Exercises both upper
and lower body muscle groups<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">Ineffective coping related to
reduced socialization, anxiety, depression, lower activity level,<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">and the inability to work<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 191.4pt;" valign="top" width="255"><ol start="1" style="margin-top: 0cm;" type="a">
<li class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;"><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Help
the patient develop realistic goals.<o:p></o:p></span></li>
</ol>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;"> </span><span style="font-family: 'Times New Roman', serif;"> </span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<ol start="2" style="margin-top: 0cm;" type="a">
<li class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;"><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Encourage
activity to level of symptom tolerance.</span><span style="font-family: 'Times New Roman', serif;"> </span></li>
</ol>
<ol start="3" style="margin-top: 0cm;" type="a">
<li class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;"><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Teach
relaxation technique or provide a relaxation tape for patient.</span></li>
</ol>
<ol start="4" style="margin-top: 0cm;" type="a">
<li class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;"><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Enroll
patient in pulmonary rehabilitation program where available.<o:p></o:p></span></li>
</ol>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.55pt;" valign="top" width="170"><div class="MsoListParagraphCxSpFirst" style="text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"> a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Developing
realistic goals will promote a sense of hope and accomplishment rather than
defeat and hopelessness.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"> b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Activity
reduces tension and decreases degree of dyspnea as patient becomes
conditioned.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"> c.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Relaxation
reduces stress, anxiety, and dyspnea and helps patient to cope with
disability.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="text-align: left; text-indent: -18pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";"> d.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Pulmonary rehabilitation
programs have been shown to promote a subjective improvement in a patient’s
status and selfesteem as well as increased exercise tolerance and decreased
hospitalizations.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Expresses interest in
the future<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Participates in the
discharge plan<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Discusses activities
or methods that can be performed to ease shortness of breath<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Uses relaxation
techniques appropriately<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Expresses interest in
a pulmonary rehabilitation program<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif";">Deficient knowledge about
self-management to be performed at home.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 191.4pt;" valign="top" width="255"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.9pt; text-align: left; text-indent: -15.9pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Help
patient understand short- and longterm goals.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Teach
the patient about disease, medications, procedures, and how and when to seek
help.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 30.05pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Refer
patient to pulmonary rehabilitation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<ol start="2" style="margin-top: 0cm;" type="a">
<li class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;"><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: AGaramond-Regular;">Give
strong message to stop smoking. Discuss smoking cessation strategies.
Provide information about resource groups<o:p></o:p></span></li>
</ol>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 127.55pt;" valign="top" width="170"><div class="MsoListParagraphCxSpFirst" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">a.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Patient
needs to be a partner in developing the plan of care and needs to know what
to expect. Teaching about the condition is one of the most important aspects
of care; it will prepare the patient to live and cope with the condition and
improve quality of life.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin-left: 13.65pt; text-align: left; text-indent: -13.65pt;">
<!--[if !supportLists]--><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">b.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif";">Smoking
causes permanent damage to the lung and diminishes the lungs’ protective
mechanisms. Air flow is obstructed and lung capacity is reduced. Smoking
increases morbidity and mortality and is also a risk factor for lung cancer.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-top-alt: solid black .5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 49.6pt;" valign="top" width="66"><div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Understands disease
and what affects it<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Verbalizes the need to
preserve existing lung function by adhering to the prescribed program<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Understands purposes
and proper administration of medications<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Stops smoking or
enrolls in a smoking cessation program <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<!--[if !supportLists]--><span style="color: #0c53a1; font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman";">5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: 'Times New Roman', serif;">Identifies when and
whom to call for assistance<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt 15.85pt; text-align: left; text-indent: -15.85pt;">
<br /></div>
</td>
</tr>
</tbody></table>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Patient Teaching & Home Health Guidance </div>
<div style="text-align: justify;">
Patient Teaching & Home Health Guidance for Patient With Bronchiectasis. Bronchiectasis is a chronic pulmonary disease characterized by permanent abnormal dilatation and destruction of the elastic and muscular components of the walls of major bronchi and bronchioles. The disease has three forms: cylindrical (fusiform), varicose and saccular (cystic). It affects people of both sexes and all ages. Chief clinical features of the disease are cough, daily mucus hypersecretion, Dyspnea, and recurrent respiratory tract infections, which may be accompanied by Hemoptysis. </div>
<div style="text-align: justify;">
Patient Teaching & Home Health Guidance for Patient with Bronchiectasis: </div>
<br />
<ul>
<li style="text-align: justify;">Instruct on early signs of pulmonary or sinus infection: change in amount or color of sputum or nasal drainage, Hemoptysis, increased Dyspnea, fever, chills, fatigue, headache, chest pain. </li>
<li style="text-align: justify;">Emphasize importance of completing full course of antimicrobial therapy to prevent relapse or development of resistant strains of organisms; include education on proper delivery of intravenous and/or aerosolized antibiotics. </li>
<li style="text-align: justify;">Teach patient and significant other effective airway clearance techniques to remove secretions and optimize ventilation. In addition to postural drainage and chest percussion, the patient may be instructed on proper use of the Flutter or PEP devices. The Vest is an alternative to chest percussion. </li>
<li style="text-align: justify;">Encourage the patient to drink plenty of fluids to thin secretions and aid expectoration </li>
<li style="text-align: justify;">Educate on avoidance of potential lung irritants: secondhand smoke, dust, noxious fumes, occupational exposures, and respiratory infections. </li>
<li style="text-align: justify;">Instruct the patient to avoid air pollutants and people with known upper respiratory tract infections. </li>
<li style="text-align: justify;">Inform patient of variety of pharmacologic and non-pharmacologic smoking cessation strategies and aids. </li>
<li style="text-align: justify;">If appropriate, advise the patient to stop smoking because it stimulates secretions and irritates the airways.</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-46183322403052512812010-07-14T22:43:00.000+07:002014-10-31T18:59:53.219+07:00Nursing Care Plan for Bone Fractures<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhaXbFJjxzcJQ-Mf8Hthe1tB7rw2hMIlyV-tC1CsTUNXBERYNMI-gP83XpiQ33Uhw1bhealOVuWEWtrnZ22xAmVaQnTup2v2LgLdHxrSZQHmWTyVcMbaA33BUHIk1XpBMkO70QI6MzpRn7l/s1600/Bone-Fractures1.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: justify;"><img alt="Bone Fractures X-ray" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhaXbFJjxzcJQ-Mf8Hthe1tB7rw2hMIlyV-tC1CsTUNXBERYNMI-gP83XpiQ33Uhw1bhealOVuWEWtrnZ22xAmVaQnTup2v2LgLdHxrSZQHmWTyVcMbaA33BUHIk1XpBMkO70QI6MzpRn7l/s1600/Bone-Fractures1.gif" height="186" title="Bone Fractures X-ray" width="200" /></a></div>
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A fracture, or discontinuity of the bone, is the most common type of bone lesion. Normal bone can withstand considerable compression and shearing forces and, to a lesser extent, tension forces. A fracture occurs when more stress is placed on the bone than it is able to absorb.</div>
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A bone fracture is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impactor stress, or trivial injury as a result of certain medical conditions that weaken the bones, such asosteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then termedpathological fracture.
(http://en.wikipedia.org/wiki/Bone_fracture)</div>
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Cause for Bone Fractures
Bone Fractures Grouped according to cause, fractures can be divided into three major categories:</div>
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<ol>
<li style="text-align: justify;"><b>Fractures caused by sudden injury</b>
The most common fractures result from major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle accident, and child, spouse, or elder abuse (shown by multiple or repeated episodes of fractures). The force causing the fracture may be direct, such as a fall, or indirect, such as a massive muscle contraction or trauma transmitted along the bone. For example, the head of the radius or clavicle can be fractured by the indirect forces that result from falling on an outstretched hand. </li>
<li style="text-align: justify;"><b>Fatigue or stress fractures</b>
A fatigue fracture results from repeated wear on a bone. Pain associated with overuse injuries of the lower extremities, especially posterior medial tibial pain, is one of the most common symptoms that physically active persons, such as runners, experience Stress fractures in the tibia. </li>
<li style="text-align: justify;"><b>Pathologic fractures</b>.
A pathologic fracture is fracture that occurs when the normal integrity and strength of bone have been compromised by invasive disease or destructive processes or tumors. Fractures of this type may occur spontaneously with little or no stress. The underlying disease state can be local, as with infections, cysts, or tumors, or it can be generalized, as in osteoporosis, Paget’s disease, or disseminated tumors. </li>
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Classification of Bone Fractures
Fractures usually are classified according to:
Location
Type
Direction or pattern of the fracture line.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwqL6pntNfut6NfIN2sJIfYd6lfbJ4CFjNnxkkzplt8Y_qw4INuCLbut45VtoOdiW2eLUffYf14LiNaVBBnxy6AlyhSo3SA52Qp3_E8JpvKmXg5fE_DKOfFIMCG6vupc-f69-1dBNao99s/s1600/Classification-of-fractures.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Classification of Bone Fractures" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgwqL6pntNfut6NfIN2sJIfYd6lfbJ4CFjNnxkkzplt8Y_qw4INuCLbut45VtoOdiW2eLUffYf14LiNaVBBnxy6AlyhSo3SA52Qp3_E8JpvKmXg5fE_DKOfFIMCG6vupc-f69-1dBNao99s/s1600/Classification-of-fractures.gif" height="253" title="Classification of Bone Fractures" width="400" /></a></div>
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Fragment position</div>
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<ul>
<li style="text-align: justify;">Angulated, Bone fragments are at an angle to each other </li>
<li style="text-align: justify;">Avulsed, Bone fragments are pulled from normal position by muscle spasms, muscle contractions, or ligament resistance </li>
<li style="text-align: justify;">Comminuted, Bone breaks into many small pieces </li>
<li style="text-align: justify;">Displaced, Bone fragments separate and are deformed
Impacted, A bone fragment is forced into another bone or bone fragment </li>
<li style="text-align: justify;">Nondisplaced, After the fracture, two sections of the bone maintain normal alignment </li>
<li style="text-align: justify;">Overriding, Bone fragments overlap, thereby shortening the total length of the bone</li>
<li style="text-align: justify;">Segmental </li>
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Fracture line</div>
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<li style="text-align: justify;">Linear Fracture line is parallel to the axis of the bone </li>
<li style="text-align: justify;">Longitudinal Fracture line extends longitudinally but not parallel to the axis of the bone </li>
<li style="text-align: justify;">Oblique Fracture line crosses the bone at a 45-degree angle to the axis of the bone </li>
<li style="text-align: justify;">Spiral Fracture line coils around the bone </li>
<li style="text-align: justify;">Transverse Fracture line forms a 90-degree angle to the axis of the bone </li>
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A fracture of the long bone is described in relation to its position in the boneproximal, midshaft, and distal. Other descriptions are used when the fracture affects the head or neck of a bone, involves a joint, or is near a prominence such as a condyle or malleolus. The type of fracture is determined by its communication with the external environment, the degree of break in continuity of the bone, and the character of the fracture pieces.10</div>
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A fracture can be classified as open or closed. When the bone fragments have broken through the skin, the fracture is called an open or compound fracture. In a closed fracture, there is no communication with the outside skin.</div>
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The degree of a fracture is described in terms of a partial or complete break in the continuity of bone. A greenstick fracture, which is seen in children, is an example of a partial break in bone continuity and resembles that seen when a young sapling is broken. This kind of break occurs because children’s bones, especially until approximately 10 years of age, are more resilient than the bones of adults.</div>
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The character of the fracture pieces may also be used to describe a fracture. A comminuted fracture has more than two pieces. A compression fracture, as occurs in the vertebral body, involves two bones that are crushed or squeezed together. A fracture is called impacted when the fracture fragments are wedged together. This type usually occurs in the humerus, often is less serious, and usually is treated without surgery. Segmental fracture Bone fractures occur in two areas next to each other with an isolated section in the center</div>
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The direction of the trauma produces a certain configuration or pattern of fracture. Reduction is the restoration of a fractured bone to its normal anatomic position. The pattern of a fracture indicates the nature of the trauma and provides information about the easiest method for reduction. Linear fractures, Fracture line is parallel to the axis of the bone Transverse fractures are caused by simple angulatory forces. A spiral fracture results from a twisting motion, or torque. A transverse fracture is not likely to become displaced</div>
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Treatment for Bone Fractures</div>
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The primary goals of treatment are to return the injured limb to maximal function, to prevent complications, and to obtain the best possible cosmetic results. Emergency treatment consists of splinting the limb above and below the suspected fracture where it lies, applying a cold pack, and elevating the limb, all of which reduce edema and pain. A severe fracture that causes blood loss calls for direct pressure to control bleeding. The patient with a severe fracture may also need fluid replacement (including blood products) to prevent or treat hypovolemic shock.</div>
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Treatment Options for Bone Fractures</div>
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Treatment Options to set a Bone Fractures depends on the location and severity of the injury. To heal a bone fractures properly, the fractured bone must be realigned. The most common realignment procedures are:
Immobilization using a cast or splint
Setting of bone through surgery. Advantages of surgery include: early mobility of injured bone and some use of the injured bone within weeks rather than months.
After the bone is realigned properly, medication and rehabilitation will help the recovery process. Medication is used to lessen the pain. Rehabilitation prevents stiffness. Rehabilitation involves light movement of the tissues surrounding the injury. It helps increase blood flow which will aid the healing process.</div>
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Nonoperative Management</div>
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Until comparatively recently, nonoperative treatment was the only method of treating fractures and severe soft tissue injuries, but the introduction of anesthesia, antibiotics, improved surgical implants, and better operative techniques has changed the treatment of many fractures. The process of change continues, and probably fewer fractures will be managed nonoperatively as the functional benefits of operative treatment become more apparent to both surgeons and patients.</div>
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TRACTION: Skeletal Traction, Spinal Traction,</div>
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CASTS Braces</div>
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Slings, Bandages, and Support Strapping
skeletal traction
skeletal traction</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgV24C-lUDnv80F8yi1hp2S_cqvaEkpxjb8weQkdycvNaOvyLBqczcGXbh0BnXf0y57jMlnGaRCC9EJpXf0-SQBhlDbprBW-U2X6KrXi_qzUbjF_45IgfKhgsVvA8fS7xNdzOI2KrhjrPeC/s1600/skeletal-traction.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="skeletal traction " border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgV24C-lUDnv80F8yi1hp2S_cqvaEkpxjb8weQkdycvNaOvyLBqczcGXbh0BnXf0y57jMlnGaRCC9EJpXf0-SQBhlDbprBW-U2X6KrXi_qzUbjF_45IgfKhgsVvA8fS7xNdzOI2KrhjrPeC/s1600/skeletal-traction.gif" height="317" title="skeletal traction " width="400" /></a></div>
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Operative Management</div>
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When closed reduction is impossible, open reduction during surgery use to reduces and immobilizes the fracture by means of rods, plates, or screws</div>
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<ul>
<li style="text-align: justify;">Plating </li>
<li style="text-align: justify;">Intramedullary Nailing </li>
<li style="text-align: justify;">Kirschner wires </li>
<li style="text-align: justify;">External Fixation </li>
<li style="text-align: justify;">Arthroplasty </li>
<li style="text-align: justify;">Amputations </li>
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Complications for Bone Fractures</div>
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Possible complications of fractures include arterial damage, nonunion, fat embolism, infection, shock, avascular necrosis, and peripheral nerve damage. Acute Compartment Syndrome Nonunions and Bone Defects
Nursing diagnosis for bone fractures</div>
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Nursing diagnosis for bone fractures determine by data that we found in nursing assessment:
Nursing Assessment nursing care plans for bone fractures</div>
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<b><i>Assessment on patient’s history</i></b> usually reveals what caused the fracture, major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle accident, or elder abuse. The patient typically reports pain that increases with movement and an inability to move the part of the arm or leg distal to the injury. The severity of the pain depends on the fracture type. The patient may also complain of a tingling sensation distal to the injury, possibly indicating nerve and vessel damage.</div>
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<b><i>Inspection</i></b> may disclose soft-tissue edema, an obvious deformity or shortening of the injured limb, and discoloration over the fracture site. Open fractures produce an obvious skin wound and bleeding. Gentle palpation usually reveals warmth, crepitus and, possibly, dislocation. Numbness distal to the injury and cool skin at the end of the extremity may indicate nerve and vessel damage.
Auscultation may reveal loss of pulses distal to the injury, an indication of possible arterial compromise or nerve damage.</div>
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<b><i>Palpation</i></b> pulses in distal of the fracture to detect injury to blood vessels, which is a surgical emergency</div>
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Diagnostic tests for Bone Fractures</div>
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Anteroposterior and lateral X-rays of the suspected fracture, as well as X-rays of the joints above and below it, confirm the diagnosis.
Angiography can reveal concurrent vascular injury.
MRI or CT Scan of spine if suspect a bone tumor or compression of spinal cord
Bone densitometry can predict an increased risk of osteoporosis usually in pathologic fractures
Blood tests</div>
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Nursing Care Plans for Bone Fractures. Common nursing diagnosis for bone fractures:</div>
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<ul>
<li style="text-align: justify;">Acute pain, </li>
<li style="text-align: justify;">Anxiety, </li>
<li style="text-align: justify;">Bathing or hygiene self-care deficit, </li>
<li style="text-align: justify;">Fear, </li>
<li style="text-align: justify;">Impaired physical mobility, </li>
<li style="text-align: justify;">Ineffective coping, </li>
<li style="text-align: justify;">Ineffective role performance, </li>
<li style="text-align: justify;">Ineffective tissue perfusion: Peripheral, </li>
<li style="text-align: justify;">Risk for deficient fluid volume, </li>
<li style="text-align: justify;">Risk for disuse syndrome, </li>
<li style="text-align: justify;">Risk for infection, </li>
<li style="text-align: justify;">Risk for injury, </li>
<li style="text-align: justify;">Risk for [additional] Trauma. </li>
</ul>
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Nursing Goals Nursing Care Plans for Bone Fractures</div>
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Pain controlled.
Prevented or minimized Complications
Fracture stabilized.
Condition, prognosis, and therapeutic regimen understood.
Plan in place to meet needs after discharge.
Nursing Care Plans for Bone Fractures with nursing diagnosis Acute pain</div>
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Sample Nursing Care Plans For bone Fracture with nursing diagnosis Pain Acute</div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">NURSING <o:p></o:p></span></b></div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">DIAGNOSIS<o:p></o:p></span></b></div>
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<b><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 10.0pt;">EVALUATION</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Acute Pain related to Muscle
spasms Movement of bone fragments, edema, and injury to the soft tissue<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Traction, immobility device<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Stress, anxiety<o:p></o:p></span></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 5.0cm;" valign="top" width="189"><div class="MsoListParagraph" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: justify; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Perform a comprehensive assessment of pain including
location, characteristics, onset/duration, frequency, quality, severity<o:p></o:p></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Maintain
immobilization of affected part<o:p></o:p></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Elevate
and support injured extremity<o:p></o:p></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Perform
and supervise passive or active ROM exercises<o:p></o:p></span></div>
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Suggest diversional
activities appropriate for client’s age, physical abilities, and personal
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</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Administer
medications, as indicated.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="color: #231f20; font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 10.0pt;">Verbalize
relief of pain.<o:p></o:p></span></div>
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<br /></div>
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prescribed pharmacologic regimen<o:p></o:p></span></div>
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<br /></div>
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<!--[if !supportLists]--><span style="color: #231f20; font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 10.0pt;">Display
relaxed manner, able to participate in activities, and sleep and rest
appropriately<o:p></o:p></span></div>
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<br /></div>
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<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 10.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 10.0pt; mso-fareast-font-family: "Times New Roman";">Demonstrate use of relaxation skills and diversional
activities, as indicated for individual situation<o:p></o:p></span></div>
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Patient Teaching Discharge and Home Healthcare Guidelines for Fractures
Patient </div>
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Teaching Discharge and Home Health care Guidelines for fractures patient. To prevent complications of prolonged immobility, encourage the patient to participate in physical and occupational therapy as prescribed. Verify that the patient has demonstrated safe use of assistive devices such as wheelchairs, crutches, walkers, and transfers. Teach the patient the purpose, dosage, schedule, precautions, and potential side effects, interactions, and adverse reactions of all prescribed medications. Review with the patient all follow-up appointments that are arranged. If home care is necessary, verify that appropriate arrangements have been completed. </div>
<br />
<ul>
<li style="text-align: justify;">Help the patient set realistic goals for recovery. </li>
<li style="text-align: justify;">Show the patient how to use his crutches properly. </li>
<li style="text-align: justify;">Tell the patient with a cast to report immediately signs of impaired circulation (skin coldness, numbness, tingling, or discoloration). </li>
<li style="text-align: justify;">Warn the patient against getting the cast wet, and instruct him not to insert foreign objects under the cast.
Teach the patient to exercise joints above and below the cast as ordered. </li>
<li style="text-align: justify;">Tell the patient not to walk on a leg cast or foot cast without the physician’s permission. </li>
<li style="text-align: justify;">Emphasize the importance of returning for follow-up care.</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-79330913009315129602010-07-10T10:44:00.000+07:002014-10-31T18:59:53.330+07:00Nursing Care Plans for Asthma<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivsUXdiTheWkb4EIg97_MOWEc1sp9_qOcUDA9OwlHA_IjEQ_Fq-Z2Copl5TQWYlwAqhiMGu3Ywdzy9bdzv3ub7eGWsjUpgMj4hRVl4irQBfM_wEIfykgBNMBIOy6KcdEOEhV-eJRlK4yHr/s1600/Asthma-inhalers.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivsUXdiTheWkb4EIg97_MOWEc1sp9_qOcUDA9OwlHA_IjEQ_Fq-Z2Copl5TQWYlwAqhiMGu3Ywdzy9bdzv3ub7eGWsjUpgMj4hRVl4irQBfM_wEIfykgBNMBIOy6KcdEOEhV-eJRlK4yHr/s1600/Asthma-inhalers.gif" height="320" width="291" /></a></div>
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Asthma is a growing health problem, the number of children with asthma has increased markedly, unfortunately, and approximately 75% of children with asthma continue to have chronic problems in adulthood. Asthma is a reversible lung disease that may resolve spontaneously or with treatment, asthma is characterized by obstruction or narrowing of the airways, which are typically inflamed and hyperresponsive to various stimuli. Signs of asthma range from mild wheezing and Dyspnea to life-threatening respiratory failure. Symptoms of bronchial airway obstruction may persist between acute episodes. </div>
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Hyper-reactivity leads to airway obstruction due to acute onset of muscle spasm in the smooth muscle of the tracheobronchial tree, thereby leading to a narrowed lumen. In addition to muscle spasm, there is swelling of the mucosa, which leads to edema. Lastly, the mucous glands increase in number, hypertrophy, and secrete thick mucus. </div>
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In asthma, the total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV) increase, but the hallmark of airway obstruction is a reduction in ratio of the forced expiratory volume in 1 second (FEV1) and the FEV1 to the forced vital capacity (FVC). </div>
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Although asthma can result from infections (especially viral) and inhaled irritants, it often is the result of an allergic response. An allergen (antigen) is introduced to the body, and sensitizing antibodies such as immunoglobulin E (IgE) are formed. IgE antibodies bind to tissue mast cells and basophils in the mucosa of the bronchioles, lung tissue, and nasopharynx. An antigen-antibody reaction releases primary mediator substances such as histamine and slow-reacting substance of anaphylaxis (SRS-A) and others. These mediators cause contraction of the smooth muscle and tissue edema. In addition, goblet cells secrete a thick mucus into the airways that causes obstruction. </div>
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<b>Extrinsic and intrinsic asthma </b></div>
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For many asthmatics, intrinsic and extrinsic asthma coexist. Intrinsic asthma results from all other causes except allergies, such as infections (especially viral), inhaled irritants, and other causes or etiologies. The parasympathetic nervous system becomes stimulated, which increases bronchomotor tone, resulting in bronchoconstriction. </div>
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Asthma that results from sensitivity to specific external allergens is referred to as extrinsic (atopic). In those cases where the allergen isn’t obvious, asthma is referred to as intrinsic (nonatopic). Allergens that cause extrinsic asthma include pollen, animal dander, house dust or mold, kapok or feather pillows, food additives containing sulfites, and any other sensitizing substance. </div>
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Extrinsic asthma usually begins in childhood and is accompanied by other manifestations of atopy (type I, immunoglobulin [Ig] E–mediated allergy), such as eczema and allergic rhinitis. </div>
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With intrinsic asthma, no extrinsic allergen can be identified. Most cases are preceded by a severe respiratory tract infection. Irritants, emotional stress, fatigue, exposure to noxious fumes, and endocrine, temperature, and humidity changes may aggravate intrinsic asthma attacks. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLUGOSxx9jAQzRQNdHipLUxFPuFpo32lNNLeZg5tkiCBO3yt_AYlCWshPTPzxHRVghKFtP4ELsT4UMK7_poDFcI3-lC5YYNHEeMbtr1NDLA497vhOrkZrQMvXPWidFVQauNQ-JDihvQeAE/s1600/Asthma.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLUGOSxx9jAQzRQNdHipLUxFPuFpo32lNNLeZg5tkiCBO3yt_AYlCWshPTPzxHRVghKFtP4ELsT4UMK7_poDFcI3-lC5YYNHEeMbtr1NDLA497vhOrkZrQMvXPWidFVQauNQ-JDihvQeAE/s1600/Asthma.gif" height="258" width="320" /></a></div>
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<b>Asthma Causes </b></div>
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Asthma also called chronic reactive airway disease, chronic inflammatory disorder episodic exacerbations of reversible inflammation and hyperreactivity and variable constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Asthma that results from sensitivity to specific external allergens is known as extrinsic. In cases in which the allergen isn’t obvious, asthma is referred to as intrinsic. </div>
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Extrinsic asthma Allergens include pollen, animal dander, house dust or mold, kapok or feather pillows, food additives containing sulfites, Genetic and environmental: household substances (such as dust mites, pets, cockroaches, mold), pollen, foods, latex, emotional upheaval, air pollution, cold weather, exercise, chemicals, medications, viral infections and any other sensitizing substance. </div>
<div style="text-align: justify;">
Extrinsic asthma usually begins in childhood and is accompanied by other manifestations such as eczema and allergic rhinitis. In patients with intrinsic (nonatopic) asthma, no extrinsic allergen can be identified. Most cases are preceded by a severe respiratory tract infection. Irritants, emotional stress, fatigue, and exposure to noxious fumes, as well as endocrine changes and changes in temperature and humidity, may aggravate intrinsic asthma attacks. In many patients with asthma, intrinsic and extrinsic asthma coexist.
Exercise may also provoke an asthma attack. In patients with exercise-induced asthma, bronchospasm may follow heat and moisture loss in the upper airways. </div>
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<div style="text-align: justify;">
<b>Treatment for Asthma </b></div>
<div style="text-align: justify;">
Treatment of acute asthma aims to decrease bronchoconstriction, reduce bronchial airway edema, and increase pulmonary ventilation. After an acute episode, treatment focuses on avoiding or removing precipitating factors, such as environmental allergens or irritants. </div>
<div style="text-align: justify;">
Drug therapy is most effective when begun soon after the onset of symptoms. A patient who doesn’t respond to this treatment, whose airways remain obstructed, and who has increasing respiratory difficulty is at risk for status asthmaticus and may require mechanical ventilation. </div>
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<b>Nursing Assessment for patients with asthma </b></div>
<div style="text-align: justify;">
An asthma attack may begin dramatically, with simultaneous onset of many severe symptoms, or insidiously, with gradually increasing respiratory distress. It typically includes progressively worsening shortness of breath, cough, wheezing, and chest tightness or some combination of these signs and symptoms. </div>
<div style="text-align: justify;">
<b>Patients history</b>, obtain history of allergies thorough description of the response to allergens or other irritants. The patient may describe a sudden onset of symptoms after exposure, with a sense of suffocation. Symptoms include dyspnea, wheezing, and a cough and also chest tightness, restlessness, anxiety, and a prolonged expiratory phase. Ask if the patient has experienced a recent viral infection. </div>
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<b>Physical examination</b>. severe shortness of breath can hardly speak, patients use their accessory muscles for breathing. Some patients have an increased anteroposterior thoracic diameter. If the patient has marked, color changes such as pallor or cyanosis or becomes confused, restless, or lethargic, increased risk of respiratory failure. </div>
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<b>Percussion</b> of the lungs usually produces hyper-resonance, and palpation may reveal vocal fremitus. </div>
<div style="text-align: justify;">
<b>Auscultation</b> high-pitched inspiratory and expiratory wheezes, prolonged expiratory phase of respiration. A rapid heart rate, mild systolic hypertension, and a paradoxic pulse may also be present. </div>
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<div style="text-align: justify;">
Diagnostic test for asthma </div>
<div style="text-align: justify;">
Pulmonary function tests
Pulse oximetry.
Arterial blood gas (ABG) analysis.
Complete blood count.
Chest X-rays.
Peak Expiratory Flow Rates (PEFR) </div>
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<div style="text-align: justify;">
<b>Nursing diagnosis for Asthma</b> </div>
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Common nursing diagnosis found in Nursing Care Plans for Asthma; </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Impaired gas exchange related to Altered oxygen supply obstruction of airways by secretions, bronchospasm, air-trapping Alveoli destruction
Ineffective airway clearance related to obstruction from narrowed lumen and thick mucus
imbalanced </li>
<li>Nutrition: Less than Body Requirements related to Dyspnea, sputum production Medication side effects; anorexia, nausea or vomiting </li>
<li>Fatigue </li>
<li>Ineffective breathing pattern </li>
<li>Anxiety </li>
<li>Deficient knowledge (treatment regimen, self-care, and discharge needs) </li>
<li>Fear </li>
</ul>
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<div style="text-align: justify;">
Sample Nursing care plans for Asthma</div>
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<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">NURSING DIAGNOSIS<o:p></o:p></span></b></div>
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<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">INTERVENTIONS<o:p></o:p></span></b></div>
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<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 113.25pt;" valign="top" width="151"><div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">RATIONALE<o:p></o:p></span></b></div>
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<b><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">EVALUATION</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
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<tr style="height: 384.2pt; mso-yfti-irow: 1;">
<td style="border-top: none; border: solid black 1.0pt; height: 384.2pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">ineffective Airway Clearance R/T Bronchospasm<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Increased production of
secretions, retained secretions, thick, viscous secretions<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Decreased energy or fatigue<o:p></o:p></span></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 384.2pt; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div class="MsoListParagraph" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">Evaluate
respiratory rate/depth and breath sounds.</span><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
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<br /></div>
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<br /></div>
<div class="MsoListParagraph" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Assist client to maintain a comfortable position.<o:p></o:p></span></div>
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<br /></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoListParagraph" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Keep environmental free from sources of allergen such as
dust, smoke, and feather pillows to a minimum according to individual
situation.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Encourage/instruct
in deep-breathing and directed coughing exercises<o:p></o:p></span></div>
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<br /></div>
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<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 384.2pt; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 113.25pt;" valign="top" width="151"><div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 8.85pt; text-indent: -12pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Tachypnea is usually present to some degree and may be
pronounced during respiratory stress.</span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 8.85pt; text-indent: -12pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">facilitates respiratory function using gravity; however,
client in severe distress will seek the position that most eases breathing<o:p></o:p></span></div>
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<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 8.85pt; text-align: left; text-indent: -12pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Precipitators of allergic type of respiratory reactions
that can trigger or exacerbate onset of acute episode.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.85pt; text-align: left; text-indent: -12pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">To maximize cough effort, lung expansion and drainage, and
reduce pain impairment.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 384.2pt; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 63.95pt;" valign="top" width="85"><div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 17.6pt; text-indent: -17.6pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Respiratory
Status: Airway Patency<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 17.6pt; text-indent: -17.6pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Maintain
patent airway with breath sounds clear or clearing.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 17.6pt; text-indent: -17.6pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Demonstrate
behaviors to improve or maintain clear airway.<o:p></o:p></span></div>
</td>
</tr>
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<td style="border-top: none; border: solid black 1.0pt; height: 91.5pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 3.0cm;" valign="top" width="113"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">impaired Gas Exchange R/T Altered
oxygen supply, obstruction of airways by secretions, bronchospasm<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 91.5pt; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 155.95pt;" valign="top" width="208"><div class="MsoListParagraph" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">monitor skin and mucous membrane color.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Monitor
vital signs<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Encourage
adequate rest and limit activities to within client tolerance.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Monitor
and graph serial ABGs and pulse oximetry.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 11.45pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Administer
medications as indicated<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 91.5pt; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 113.25pt;" valign="top" width="151"><div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 8.85pt; text-indent: -12pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Duskiness and central cyanosis indicate advanced hypoxemia<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 8.85pt; text-indent: -12pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Increased PaCO2 signals impending respiratory failure for
asthmatics.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; height: 91.5pt; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid windowtext 1.5pt; mso-border-top-alt: solid windowtext 1.5pt; padding: 0cm 5.4pt 0cm 5.4pt; width: 63.95pt;" valign="top" width="85"><div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 17.6pt; text-indent: -17.6pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Demonstrate
improved ventilation<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 17.6pt; text-indent: -17.6pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Demonstrate
adequate oxygenation of tissues by ABGs within client’s normal limits<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 17.6pt; text-indent: -17.6pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">absence
of symptoms of respiratory distress<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<br />
<b>Patient Teaching Discharge and Home Healthcare Guidelines for Asthma</b><br />
<div style="text-align: justify;">
To prevent asthma attacks, teach patients the triggers that can precipitate an attack. Teach the patient and family the correct use of medications, including the dosage, route, action, and side Effects. In rare instances, asthma can lead to respiratory failure (status asthmaticus) if patients are not treated immediately or are unresponsive to treatment. Explain that any Dyspnea unrelieved by medications, and accompanied by wheezing and accessory muscle use, needs prompt attention from a healthcare provider. </div>
<div style="text-align: justify;">
</div>
<ul>
<li>Teach the patient and his family to avoid known allergens and irritants. </li>
<li>Teach the patient about his medications, drug interactions, including proper dosages, administration instructions, and adverse effects. </li>
<li>Teach the patient how to use a metered dose inhaler. </li>
<li>Explain how to use a peak flow meter to measure the degree of airway obstruction, If the patient has moderate to severe asthma. Tell him to keep a record and Explain the importance of calling the physician at once if the peak flow drops suddenly </li>
<li>If the patient develops a fever above 100° F (37.8° C), chest pain, shortness of breath without coughing or exercising, or uncontrollable coughing. Tell the patient to notify the physician </li>
<li>Teach the patient and his family an uncontrollable asthma attack requires immediate attention. </li>
<li>Teach the patient diaphragmatic and effective coughing techniques. </li>
<li>Urge him to Increase fluid intake to help loosen secretions and maintain hydration. </li>
<li>Teach the patient and his family important of Regular medical follow-up care, when to notify healthcare professional of changes in condition, and periodic spirometry testing, chest x-rays, and sputum cultures.</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-55046467711913106452010-07-01T08:17:00.000+07:002014-10-31T18:59:53.238+07:00Nursing Care Plans for Anemia<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilW_ePDiq9ymW9LMPeOIsFAk39epVC8cXptVlpHSEkzCzLoSDRPKvAto1giNAaMSMrLzkAiyVINj-1rIIBAfhWFvMqKzPHINfRaXyzxwEdrRPCDBq_Vz4EdDH0i7LPplFaiOsOx7UIh6zb/s1600/Anemias.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: justify;"><img alt="Anemia" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilW_ePDiq9ymW9LMPeOIsFAk39epVC8cXptVlpHSEkzCzLoSDRPKvAto1giNAaMSMrLzkAiyVINj-1rIIBAfhWFvMqKzPHINfRaXyzxwEdrRPCDBq_Vz4EdDH0i7LPplFaiOsOx7UIh6zb/s1600/Anemias.gif" height="241" title="Anemia" width="320" /></a></div>
<div style="text-align: justify;">
Iron deficiency anemia, anemia of chronic disease, pernicious anemia, Aplastic anemia, hemolytic anemia. The anemias are a group of blood disorders characterized by too little hemoglobin in the blood. Hemoglobin is a substance contained in red blood cells that carries oxygen from the lungs to other body tissues. Anemia is often a sign or symptom of an underlying disease rather than a disease in its own right. There are three tests commonly used to detect anemia: the number of red blood cells can be counted; the amount of hemoglobin in the red blood cells can be measured; or the proportion of blood cells to serum (the liquid part of blood, called the hematocrit) can be assessed. </div>
<div style="text-align: justify;">
Adult anemia is usually defined as a Hemoglobin Hgb level lower than 11 g/dL, with severe anemia defined as Hemoglobin Hgb lower than 8 g/dL. Anemia Associated with many physiological complications, including dyspnea, fatigue, dizziness, decreased cognition, impaired sleep, sexual dysfunction, and significant debilitation </div>
<div style="text-align: justify;">
Anemia can develop in three ways: loss of blood through injury, diseases of the digestive tract, or heavy menstrual flow in women; rapid destruction of red blood cells (e.g. sickle cell anemia); or inadequate production of healthy red blood cells (e.g. thalassemia). The underlying causes of anemias range from poor nutrition (iron-deficiency anemia) and digestive disorders (Crohn disease, celiac disease) to colorectal cancer, parasitic diseases (e.g. hookworm), and genetic disorders (sickle cell anemia, thalassemia). </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Pathophysiology: decreased number of circulating red blood cells (RBCs), reduction in the amount of hemoglobin (Hgb) in the RBCs, or a combination of both, resulting in diminished oxygen-carrying capacity of the blood </div>
<br />
<ul>
<li style="text-align: justify;">Iron deficiency anemia inadequate iron stores, which results in insufficient Hemoglobin Hgb, causing cells to appear abnormal, unusually small (microcytic), and pale (hypochromic) </li>
<li style="text-align: justify;">Anemia of chronic disease; accompanies chronic inflammatory, infectious, or neoplastic disorders </li>
<li style="text-align: justify;">Pernicious anemia; lack of intrinsic factor in the stomach results in inability to absorb vitamin B12 causing abnormal RBC formation </li>
<li style="text-align: justify;">Aplastic anemia: failure of bone marrow to produce cells, including RBCs and white blood cells (WBCs) and platelets </li>
<li style="text-align: justify;">Hemolytic anemia: premature destruction of RBCs </li>
</ul>
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<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Causes and Complications of Anemia </div>
<div style="text-align: justify;">
Causes and Etiology for Anemia, Anemia is often a sign or symptom of an underlying disease rather than a disease in its own. Anemia goes undetected in many people, and symptoms can be minor or vague. The signs and symptoms can be related to the anemia itself, or the underlying cause. </div>
<div style="text-align: justify;">
<b>Iron deficiency anemia</b>
Causes by Lack of iron in the body due to a variety of causes, inadequate nutrition, such as not enough foods that contain iron or Malabsorption syndromes. </div>
<div style="text-align: justify;">
<b>Anemia of chronic disease</b>
Primarily due to slowed production of RBCs because of low reticulocyte production. Symptoms usually associated with the disease causing the anemia rather than the anemia itself. </div>
<div style="text-align: justify;">
<b>Pernicious anemia</b>
An autoimmune disorder Characterized by the production of auto antibodies that destruct gastric parietal cells and their secretory product leads to a lack of intrinsic factor, which is needed for vitamin B12 absorption include Crohn’s and Whipple’s diseases, gastrectomy or gastric bypass, and chemotherapeutic medications. </div>
<div style="text-align: justify;">
<b>Aplastic anemia</b>
Bone marrow failure; May be associated with conditions that affect erythropoietin production and secretion, such as certain cancers and cancer treatments, hepatic, or endocrine disorders. Exposure to chemicals, immune conditions, such as systemic lupus erythematosus, or rheumatoid arthritis. </div>
<div style="text-align: justify;">
<b>Hemolytic anemia</b>
Accelerated destruction of RBCs sickle cell anemia Causes include hereditary factors, such as sickle cell trait or disease, blood transfusion reactions, acute viral or infectious agents, certain drugs, and toxins, such as chemicals and venoms. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Complications of Anemia: </div>
<div style="text-align: justify;">
Anemia is often a sign or symptom of an underlying disease rather than a disease in its own Mild anemia does not have any significant long-term consequences. As the anemia becomes more severe, medical problems may arise:
High-output heart failure increased risk for a heart attack
The lack of iron associated with anemia can cause many complications, including hypoxemia, brittle or rigid fingernails, cold intolerance, and possible behavioral disturbances in children. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Assessment</div>
<div style="text-align: justify;">
<b>Patient’s history</b> because Anemia symptoms usually develop insidiously Patient’s history may not help to establish disease onset. The patient may report signs and symptoms of anemia (progressive weakness and fatigue, shortness of breath, and headache) or signs of thrombocytopenia (easy bruising and bleeding, especially from the mucous membranes) </div>
<div style="text-align: justify;">
<b>Inspection</b> patients with Anemia may reveal pallor if the patient is anemic, and ecchymosis, petechiae, or retinal bleeding if thrombocytopenia is present. You may note alterations in the level of consciousness and weakness if bleeding into the central nervous system has occurred. </div>
<div style="text-align: justify;">
<b>Auscultation </b>may reveal bibasilar crackles, tachycardia, and a gallop murmur if severe anemia results in heart failure.
Fever, oral and rectal ulcers and sore throat may indicate the presence of an infection but without characteristic inflammation due to leukopenia. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Diagnostic test for Anemia </div>
<div style="text-align: justify;">
Complete blood count (CBC): Hgb; hematocrit (Hct); RBC count, morphology, indices, and distribution width index; platelet count and size; and WBC count and differential.
Bone marrow biopsies </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing diagnosis for Anemia </div>
<div style="text-align: justify;">
Common nursing diagnosis found in Nursing care plans for anemia:</div>
<br />
<ul>
<li style="text-align: justify;">Activity Intolerance related to Imbalance between oxygen supply or delivery and demand </li>
<li style="text-align: justify;">Impaired oral mucous membrane </li>
<li style="text-align: justify;">Imbalanced Nutrition: Less than Body Requirements related to Failure to ingest or inability to digest food or absorb nutrients necessary for formation of normal RBCs </li>
<li style="text-align: justify;">Constipation/Diarrhea related to Decreased dietary intake, changes in digestive processes Drug therapy side effects </li>
<li style="text-align: justify;">Risk for Infection Inadequate secondary defenses—decreased Hgb, leukopenia, or decreased granulocytes (suppressed inflammatory response) Inadequate primary defenses—broken skin, stasis of body fluids, invasive procedures, chronic disease, malnutrition </li>
<li style="text-align: justify;">Risk for deficient fluid volume </li>
<li style="text-align: justify;">Deficient Knowledge regarding condition, prognosis, treatment, self-care, prevention of crisis, and discharge needs related to Lack of exposure, recall Information misinterpretation Unfamiliarity with information resource </li>
<li style="text-align: justify;">Fatigue </li>
<li style="text-align: justify;">Fear </li>
<li style="text-align: justify;">Ineffective coping</li>
<li style="text-align: justify;">Ineffective thermoregulation </li>
</ul>
<br />
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Anemia are a group of blood disorders characterized by too little hemoglobin in the blood. Hemoglobin is a substance contained in red blood cells that carries oxygen from the lungs to other body tissues. Anemia is often a sign or symptom of an underlying disease rather than a disease in its own right. There are three tests commonly used to detect anemia: the number of red blood cells can be counted; the amount of hemoglobin in the red blood cells can be measured; or the proportion of blood cells to serum (the liquid part of blood, called the hematocrit) can be assessed. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>Sample Nursing care plans for anemia</b></div>
<div style="text-align: justify;">
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<td style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 63.8pt;" valign="top" width="85"><div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">NURSING DIAGNOSIS<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 6.0cm;" valign="top" width="227"><div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">INTERVENTIONS<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180"><div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">RATIONALE<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104"><div align="center" class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="color: #231f20; font-family: "Times New Roman","serif"; font-size: 12.0pt;">EVALUATION</span></b><b><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></b></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 63.8pt;" valign="top" width="85"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Activity Intolerance related to
Imbalance between oxygen supply or delivery and demand<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 6.0cm;" valign="top" width="227"><div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Assess
patient ability to perform ADLs<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Monitor
vital sign (Blood Pressure, pulse, and respirations) during and after
activity<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Suggest
client change position slowly; monitor for dizziness.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Provide
or recommend assistance with activities and ambulation as necessary, allowing
client to be an active participant as much as possible.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Identify
and implement energy-saving techniques<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Instruct
client to stop activity if palpitations, chest pain, shortness of breath,
weakness, or dizziness occur<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt -5.4pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt -5.4pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt -5.4pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt -5.4pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin: 0cm 0cm 0.0001pt -5.4pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Collaborative<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Monitor
laboratory studies, such as Hgb/Hct, RBC count, and arterial blood gases
(ABGs).<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Provide
supplemental oxygen as indicated.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Administer
the following, as indicated: Whole blood, packed RBCs (PRCs); blood products
as indicated. <o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Monitor
closely for transfusion reactions.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 8.75pt; text-align: left; text-indent: -14.15pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;">
</span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Prepare
for surgical intervention, if indicated.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: left;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 134.65pt;" valign="top" width="180"><div class="MsoListParagraphCxSpFirst" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Influences choice of interventions and needed assistance.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Cardiopulmonary manifestations result from attempts by the
heart and lungs to supply adequate amounts of oxygen to the tissues.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Postural hypotension or cerebral hypoxia may cause
dizziness, fainting, and increased risk of injury.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Although help may be necessary, self-esteem is enhanced when
client does some things for self.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span><span style="font-family: 'Times New Roman', serif; font-size: 12pt;"> </span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Encourages client to do as much as possible, while
conserving limited energy and preventing fatigue.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Cellular ischemia potentiates risk of infarction, and
excessive cardiopulmonary strain and stress may lead to decompensation and
failure<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Identifies deficiencies in RBC components affecting oxygen
transport, treatment needs, and response to therapy.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Maximizing oxygen transport to tissues improves ability to
function<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Increases number of oxygen-carrying cells; corrects
deficiencies to reduce risk of hemorrhage in acutely compromised individuals.<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt;">
<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin: 0cm 0cm 0.0001pt 8.8pt;">
<br /></div>
<div class="MsoListParagraphCxSpLast" style="margin: 0cm 0cm 0.0001pt 8.8pt; text-indent: -14.2pt;">
<!--[if !supportLists]--><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt; font-stretch: normal;"> </span></span><!--[endif]--><span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Surgery is useful to control bleeding in clients who are
anemic because of bleeding, such as in ulcers and uterine bleeding; or to
remove spleen as treatment of autoimmune hemolytic anemia. Bone marrow and
stem cell transplantation may be done in presence of bone marrow failure aplastic
anemia.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt 0cm 5.4pt; width: 78.0pt;" valign="top" width="104"><div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Report an increase in activity
tolerance, including ADLs.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Demonstrate a decrease in
physiological signs of intolerance pulse, respirations, and BP remain within
client’s normal range.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<br /></div>
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: "Times New Roman","serif"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";">Display laboratory values (Hgb/Hct)
within acceptable range.<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<br />
Patient Teaching and Home Healthcare Guidelines for Anemia<br />
<div style="text-align: justify;">
</div>
<ul>
<li>Teach the patient to avoid contact with potential sources of infection which can harbor organisms. </li>
<li>Reassure and support the patient and his family by explaining the disease and its treatment, particularly if the patient has recurring acute episodes. </li>
<li>Explain the purpose of all prescribed drugs, and discuss possible adverse reactions, including those he should report promptly. </li>
<li>Tell the patient who does not require hospitalization that he can continue his normal lifestyle with appropriate restrictions. </li>
<li>To prevent folic acid deficiency anemia, emphasize the importance of a well balanced diet high in folic acid. Teach the patient to meet daily folic acid requirements by including a food from each food group in every meal, Advise the patient not to stop taking the supplements when he begins to feel better. </li>
<li>To help prevent exacerbation of sickle cell anemia, advise the patient to avoid tight clothing that restricts circulation. </li>
<li>Emphasize the need for prompt treatment of infection.</li>
<li>Explain the need to increase fluid intake to prevent dehydration that results from impaired ability to properly concentrate urine. Tell parents to encourage a child with sickle cell anemia to drink more fluids. </li>
<li>To encourage normal mental and social development, warn parents against being overprotective. Although the child must avoid strenuous exercise, he can enjoy most everyday activities. </li>
<li>Refer parents of children with sickle cell anemia for genetic counseling to answer their questions about the risk to future offspring. Recommend screening of other family members to determine if they are heterozygote carriers. </li>
<li>In sickle cell anemia Inform the patient and his parents that if he must be hospitalized for a vaso-occlusive crisis, I.V. fluids and a parenteral analgesic may be administered. He may also receive oxygen therapy and blood transfusions. </li>
<li>Women with sickle cell anemia Warn them that they are poor obstetric risks. </li>
<li>Emphasize the need for preventing trauma, abrasions, and breakdown of the skin. </li>
<li>Be sure the patient understands the need to maintain a good nutritional intake to enhance the immune system and resistance to infections. </li>
<li>Teach the patient the potential for bleeding and hemorrhage, and instruction to prevent bleeding. </li>
<li>Discuss the need for regular dental examinations. </li>
<li>Explain the importance of maintaining regular bowel movements to prevent straining.</li>
</ul>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-38813081496751885792010-06-18T07:58:00.000+07:002014-10-31T18:59:53.200+07:00Nursing care Plans for Thalassemia<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpQY5z27z0vLM4t64uS5Vc3ySKcWo1Gacls3H3CdXQg-W1fTqq1fdg3ySVxWD9demhnf4IHConc7HvKFnhFiSSUb5IpyliKxgBjTD3aFDMrHcUvyElE2LOfoUcPgmVK8m_kij5rViKVtk2/s1600/skull-abnormality-in-a-patient-with-thalassemia-major.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="skull abnormality in a patient with thalassemia major" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpQY5z27z0vLM4t64uS5Vc3ySKcWo1Gacls3H3CdXQg-W1fTqq1fdg3ySVxWD9demhnf4IHConc7HvKFnhFiSSUb5IpyliKxgBjTD3aFDMrHcUvyElE2LOfoUcPgmVK8m_kij5rViKVtk2/s1600/skull-abnormality-in-a-patient-with-thalassemia-major.gif" height="320" title="skull abnormality in a patient with thalassemia major" width="275" /></a></div>
<div style="text-align: justify;">
Thalassemia is a group of hereditary hemolytic anemia, which Marked by a deficit in the production of hemoglobin. Where the damage occurred in the red blood cells in the blood vessel so that the age erythrocyte be short. It is characterized by defective synthesis in one or more of the polypeptide chains necessary for hemoglobin production. Because Thalassemia affects hemoglobin production, it also impairs red blood cell (RBC) synthesis. </div>
<div style="text-align: justify;">
There are two main types of Thalassemia: ”alpha” and “beta.” The names refer to the part of the hemoglobin molecule that is missing or mutated. </div>
<div style="text-align: justify;">
Two pairs of polypeptide chains”alpha and beta chains” make up hemoglobin. In Thalassemia, diminished synthesis can affect either pair. Structurally, the chains are normal, but the genetic defect decreases their number. In alpha Thalassemia, alpha chain synthesis slows; in beta-Thalassemia, beta chain synthesis slows. Some patients with beta-Thalassemia have no normal hemoglobin only hemoglobin S and the minor hemoglobin’s. </div>
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<br /></div>
<div style="text-align: justify;">
Causes for Thalassemia </div>
<div style="text-align: justify;">
Thalassemia major Causes by homozygous inheritance of the partially dominant autosomal gene
Thalassemia intermedia Causes by homozygous inheritance of the partially dominant autosomal gene.
Thalassemia minor is caused by heterozygous inheritance of the same gene.
In All type of Thalassemia deficiency of beta polypeptide chain production impairs hemoglobin synthesis and results in continual production of fetal hemoglobin, even after the neonatal period. </div>
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<br /></div>
<div style="text-align: justify;">
Complications for Thalassemia </div>
<div style="text-align: justify;">
Pathologic fractures
Cardiac arrhythmias
Heart failure
Other complications that result from iron deposits in the heart and other tissues caused by repeated blood transfusions. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Treatment for Thalassemia </div>
<div style="text-align: justify;">
Patients with Thalassemia minor usually do not require any specific treatment. Treatment for patients with Thalassemia major includes chronic blood transfusion therapy, iron chelation, splenectomy, and allogeneic hematopoietic transplantation.
References:
http://en.wikipedia.org/wiki/Thalassemia </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Assessment</div>
<div style="text-align: justify;">
Thalassemia major: severe anemia, splenomegaly or hepatomegaly with abdominal enlargement, frequent infections, bleeding tendencies e.g. epistaxis, and anorexia, small bodies and large heads, mentally disabled, mongoloid.
Thalassemia intermediate: anemia, jaundice, and splenomegaly, hemosiderosis caused by increased intestinal absorption of iron.
Thalassemia minor: mild anemia usually with no signs or symptoms. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Diagnostic Test for Thalassemia </div>
<div style="text-align: justify;">
RBC count and hemoglobin level
X-rays of the skull and long bones </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Diagnosis</div>
<div style="text-align: justify;">
Activity intolerance
Deficient knowledge (treatment regimen)
Delayed growth and development
Disturbed body image
Ineffective tissue perfusion: Cardiopulmonary
Interrupted family processes
Risk for infection </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing care Plans for Thalassemia </div>
<div style="text-align: justify;">
Treatment of thalassemia major is essentially supportive. For example, infections require prompt treatment with the appropriate antibiotic. Transfusions of packed RBCs raise the hemoglobin level but must be used judiciously to minimize iron overload. Thalassemia intermedia and thalassemia minor generally don’t require treatment. Iron supplements are contraindicated in all forms of thalassemia. Treatment of children is more difficult. Regular blood transfusions may minimize physical and mental retardation, but transfusions increase the risk of deadly hemosiderosis and iron overload. Continuous subcutaneous infusion of an iron-chelating agent may help produce a negative overall iron balance. If rapid splenic sequestration of transfused RBCs necessitates more transfusions, a splenectomy may be performed. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing outcomes </div>
<div style="text-align: justify;">
Patient and parents will:
Verbalize the importance of balancing activity, as tolerated, with frequent rest periods.
Demonstrate age-appropriate skills and behaviors to the extent possible.
Express positive feelings about himself.
Develop no cardiac arrhythmias.
Voice feelings and concerns related to the patient’s illness.
Remain free from signs and symptoms of infection
Nursing interventions nursing care plans for Thalassemia
Watch for adverse reactions during and after RBC transfusions.
Collaborative an antibiotic, and observe the patient for adverse reactions.
Provide an adequate diet,
Encourage the patient to drink plenty of fluids.
Provide emotional support
Help the patient and his family cope for chronic nature of
Explain the need for lifelong transfusions. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Patient teaching</div>
<div style="text-align: justify;">
Explain how to prevent infection e.g. nutrition, wound care
Tell about signs of hepatitis and iron overload, which are always possible with frequent transfusions.
Explain why child must avoid strenuous athletic activity to avoid pathologic fractures.</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-18501556460727713192010-06-11T07:55:00.000+07:002014-10-31T18:59:53.131+07:00Nursing Diagnosis for Acute Pain<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikb8P0Ltxgo_bNdAtyq4k44GFTdC4YwV8kJD8HMDB5UoXXZZTQMvDoIcbWb2xqzidqWNL07GF08PFdrPgc5aPtgMiTVde8QgRjCNKNCEj9LfpNZTIGvt14aH0IifgLAAY1OnosvKckGA_M/s1600/Pain.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: justify;"><img alt="Acute Pain" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEikb8P0Ltxgo_bNdAtyq4k44GFTdC4YwV8kJD8HMDB5UoXXZZTQMvDoIcbWb2xqzidqWNL07GF08PFdrPgc5aPtgMiTVde8QgRjCNKNCEj9LfpNZTIGvt14aH0IifgLAAY1OnosvKckGA_M/s1600/Pain.jpg" height="235" title="Acute Pain" width="320" /></a></div>
<div style="text-align: justify;">
NANDA Nursing Diagnosis for Acute Pain Related factors R/T trauma, injuring agents (biological, chemical, physical, psychological) </div>
<div style="text-align: justify;">
Suggestion on using NANDA Nursing Diagnosis Acute Pain: Distinguish between acute pain Nursing diagnosis with the chronicles pain Nursing diagnosis. One of the two sets is that diagnosis of a painful time. ONSET acute pain is less than 6 months, while the painful chronicles ONSET it is more than 6 months. If you only have two diagnoses to indicate, pain is acute pain and chronic pain. Thus, there is no automatic diagnosis Crashes feel comfortable or feel comfortable painful chronic pain. </div>
<div style="text-align: justify;">
Definition Nursing Diagnosis for Acute Pain:
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Outcomes Client Will:
Report pain is relieved / controlled.
Follow prescribed pharmacological regimen.
Verbalize methods that provide relief.
Demonstrate use of relaxation skills and diversion activities as indicated for individual situation. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Priority Nursing Diagnosis for Acute Pain
To assess etiology/precipitating contributory factors:
evaluate client’s response to pain:
assist client to explore methods for alleviation/control of pain </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Sample Clinical Applications using Nursing Diagnosis for Acute Pain:
Traumatic injuries, surgical procedures, infections, cancer, burns, skin lesions, gangrene, thrombophlebitis/pulmonary embolus, neuralgia</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-57307540577688405302010-06-10T07:51:00.000+07:002014-10-31T18:59:53.267+07:00Malignant Brain Tumors<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitO2oXCQVBqTJJMZcIFTEQ7oJvwqbV2o9Q2iRg1xJRCbayQZUsceeHItP-MWM682G2xy5iaUDY8_p5dU66fZpcP1LShdA0TmdbjKwYS-X_IapwKreod-I_GchHP5M6S66YFnJTz5VFI-8O/s1600/Brain-Tumors.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Malignant Brain Tumors" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitO2oXCQVBqTJJMZcIFTEQ7oJvwqbV2o9Q2iRg1xJRCbayQZUsceeHItP-MWM682G2xy5iaUDY8_p5dU66fZpcP1LShdA0TmdbjKwYS-X_IapwKreod-I_GchHP5M6S66YFnJTz5VFI-8O/s1600/Brain-Tumors.gif" height="249" title="Malignant Brain Tumors" width="320" /></a></div>
<div style="text-align: justify;">
Primary brain tumors comprise a diverse group of neoplasm’s that are often malignant and refractory to treatment, malignant brain tumors. More common in males than in females, malignant brain tumors (gliomas, meningiomas, and schwannomas) they cause central nervous system (CNS) changes by invading and destroying tissues and by secondary effects mainly compression of the brain, cranial nerves, and cerebral vessels; cerebral edema; and increased intracranial pressure ICP. Tumors can occur at any age. In adults, incidence is highest between ages 40 and 60, and the most common tumor types are gliomas and meningiomas. They usually occur above the covering of the cerebellum (supratentorial tumors). Most tumors in children occur before age one or between ages 2 and 12. The most common are astrocytomas, medulloblastomas, ependymomas, and brain stem gliomas. Brain tumors are one of the most common causes of cancer death in children. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>Primary brain tumors classified by their siteof origin </b></div>
<div style="text-align: justify;">
</div>
<ul>
<li>CNS tumors that originate in glial tissue Gliomas, occurring in the glial, or supportive tissues around the brain: Astrocytomas
Brain-stem gliomas
Ependymomas
Oligodendrogliomas </li>
<li>CNS tumors that do not originate in glial tissue: Medulloblastoma
Craniopharyngiomas
Germinomas
Pineal-region tumors </li>
</ul>
<br />
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Causes of Brain Tumor </div>
<div style="text-align: justify;">
Brain tumors may be attributed to a familial link or to exposure to ionized radiation (a known environmental risk). Brain tumors may result from metastasis in 20% to 40% of patients with other cancers. In some cases, the cause remains unknown. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Risk Factors of Primary Brain Tumors </div>
<div style="text-align: justify;">
Hereditary syndromes (proven): tuberous sclerosis, neurofibromatosis types 1 and 2, nevoid basal cell carcinoma syndrome, Turcot’s syndrome, and Li-Fraumeni syndrome
Family History of brain tumors
History of prior cancer
Exposure to infectious agents
Allergies (possible reduced risk)
Head trauma
Drugs and medications
Dietary history: N-nitroso compounds, oxidants, antioxidants
Tobacco usage
Alcohol consumption
Ionizing radiation exposure
Cellular telephones, Power frequency electromagnetic field exposure </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Complications </div>
<div style="text-align: justify;">
In malignant brain tumors, life-threatening complications from increasing ICP include coma, respiratory or cardiac arrest, and brain herniation</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-7544685417394157482010-06-07T07:45:00.000+07:002014-10-31T18:59:53.316+07:00Nursing care plans for Cervical Cancer<div style="text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsmN_2aHjzesW6AbWJXaHZydUpti9xVK2vAxUFCs4UUpzN_BxafN_LgPZIi02NM0dgdXqPLULi5vBi2BoZcuezqDDpl1TplirCYQ4GvgxR5QogfL30GBasWr6jRP1c-iABJjOgv3BsJWlZ/s1600/female-reproductive-organs.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsmN_2aHjzesW6AbWJXaHZydUpti9xVK2vAxUFCs4UUpzN_BxafN_LgPZIi02NM0dgdXqPLULi5vBi2BoZcuezqDDpl1TplirCYQ4GvgxR5QogfL30GBasWr6jRP1c-iABJjOgv3BsJWlZ/s1600/female-reproductive-organs.gif" height="204" width="320" /></a></div>
Cervical cancer is the third most common cancer of the female reproductive system. Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third most common female pelvic cancer. The death rate from cervical cancer has steadily declined over the past 50 years owing to the increased use of the Papanicolaou exam, which detects cervical changes before cancer develops.
Three types of cervical cancer are:
Dysplasia,
Carcinoma in situ (CIS) and Invasive carcinoma </div>
<div style="text-align: justify;">
Preinvasive cancer ranges from minimal cervical dysplasia, in which the lower third of the epithelium contains abnormal cells, to carcinoma in situ, in which the full thickness of epithelium contains abnormally proliferating cells (also known as cervical intraepithelial neoplasia). Preinvasive cancer is curable in 75% to 90% of patients with early detection and proper treatment. If untreated, it may progress to invasive cervical cancer, depending on the form. </div>
<div style="text-align: justify;">
CIS is carcinoma confined to the epithelium. The full thickness of the epithelium contains abnormally proliferating cells. Both dysplasia and CIS are considered preinvasive cancers and, with early detection, have a 5-year survival rate of 73% to 92%. </div>
<div style="text-align: justify;">
In invasive disease, cancer cells penetrate the basement membrane and can spread directly to contiguous pelvic structures or disseminate to distant sites by way of lymphatic routes. In 95% of cases, the histologic type is squamous cell carcinoma, which varies from well-differentiated cells to highly anaplastic spindle cells. Only 5% of cases are adenocarcinomas. Invasive cancer typically occurs between ages 30 and 50; it rarely occurs younger than age 20. </div>
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<br /></div>
<div style="text-align: justify;">
Cervical cancer stage (source: http://en.wikipedia.org) </div>
<div style="text-align: justify;">
Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton, and cervical conization. </div>
<div style="text-align: justify;">
The TNM staging system for cervical cancer is analogous to the FIGO stage. </div>
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<b>Stage 0</b> – full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ) </div>
<div style="text-align: justify;">
<b>Stage I – limited to the cervix </b></div>
<div style="text-align: justify;">
IA – diagnosed only by microscopy; no visible lesions </div>
<div style="text-align: justify;">
IA1 – stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread </div>
<div style="text-align: justify;">
IA2 – stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less </div>
<div style="text-align: justify;">
IB – visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm </div>
<div style="text-align: justify;">
IB1 – visible lesion 4 cm or less in greatest dimension </div>
<div style="text-align: justify;">
IB2 – visible lesion more than 4 cm </div>
<div style="text-align: justify;">
<b>Stage II </b>– invades beyond cervix<br />
IIA – without parametrial invasion, but involve upper 2/3 of vagina<br />
IIB – with parametrial invasion </div>
<div style="text-align: justify;">
<b>Stage III</b> – extends to pelvic wall or lower third of the vagina<br />
IIIA – involves lower third of vagina<br />
IIIB – extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney </div>
<div style="text-align: justify;">
IVA – invades mucosa of bladder or rectum and/or extends beyond true pelvis </div>
<div style="text-align: justify;">
IVB – distant metastasis </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>Causes for Cervical cancer </b></div>
<div style="text-align: justify;">
Worldwide studies suggest that Causes for Cervical cancer is sexually transmitted human papillomaviruses (HPVs). Certain strains of HPV (16, 18, and 31) are associated with an increased risk of cervical cancer. Several predisposing factors have been related to the development of cervical cancer: intercourse at a young age), multiple sexual partners, and herpesvirus 2 and other bacterial or viral venereal infections. Genetic considerations While most risk factors for cervical cancer are environmental, some studies have found that the daughters or sisters of cervical cancer patients are more likely to get the disease. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>Complications of Cervical cancer </b></div>
<div style="text-align: justify;">
Disease progression can cause flank pain from sciatic nerve or pelvic wall invasion and hematuria and renal failure associated with bladder involvement.<br />
<br />
<ul>
<li>Ureteric obstruction </li>
<li>Intermenstrual PV bleed </li>
<li>Vesicovaginal fistula </li>
<li>Post-menopausal PV bleed </li>
<li>Uterine enlargement </li>
<li>Menorrhagia </li>
</ul>
</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Nursing Assessment</div>
<div style="text-align: justify;">
<b>Patient’s history,</b> early cervical cancer usually asymptomatic, establishes a thorough history with particular attention to the presence of the risk factors and the woman’s menstrual history. assess a history of later symptoms of cervical cancer, including abnormal bleeding or spotting between periods or after menopause, metrorrhagia or menorrhagia, dysparuenia and postcoital bleeding; leukorrhea in increasing amounts and changing over time from watery to dark and foul; and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss; abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs, or other symptoms associated with neoplasms, such as fatigue. The patient history includes abnormal vaginal bleeding, such as a persistent vaginal discharge that may be yellowish, blood-tinged, and foul-smelling; postcoital pain and bleeding; and bleeding between menstrual periods or unusually heavy menstrual periods. The patient history may suggest one or more of the predisposing factors for this disease. </div>
<div style="text-align: justify;">
<b>Physical Examination</b>. Pelvic examination. Observe the patient’s external genitalia for signs of inflammation, bleeding, discharge, or local skin or epithelial changes.
Palpate for motion tenderness of the cervix (Chandelier’s sign); a positive Chandelier’s sign (pain on movement) usually indicates an infection. Also examine the size, consistency (hardness may reflect invasion by neoplasm), shape, mobility (cervix should be freely movable), tenderness, and presence of masses of the uterus and adnexa.
If the cancer has advanced into the pelvic wall, the patient may report gradually increasing flank pain, which can indicate sciatic nerve involvement. Leakage of urine may point to metastasis into the bladder with formation of a fistula. Leakage of stool may indicate metastasis to the rectum with fistula development. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>Diagnostic test</b></div>
<div style="text-align: justify;">
Papanicolaou examination ((Pap smear)
Colposcopy followed by punch biopsy or cone biopsy
The Vira/Pap test to examination of the specimen’s deoxyribonucleic acid (DNA) structure to detect HPV </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>Nursing diagnosis</b></div>
<div style="text-align: justify;">
Common nursing diagnosis found in nursing care plans for Cervical Cancer:<br />
<br />
<ul>
<li>Pain (acute) related to postprocedure swelling and nerve damage </li>
<li>Anxiety </li>
<li>Fear </li>
<li>Impaired physical mobility </li>
<li>Impaired skin integrity </li>
<li>Ineffective coping </li>
<li>Ineffective sexuality patterns </li>
<li>Risk for infection
Sexual dysfunction </li>
</ul>
<br />
Cervical cancer is the third most common cancer of the female reproductive system. Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third most common female pelvic cancer. The death rate from cervical cancer has steadily declined over the past 50 years owing to the increased use of the Papanicolaou exam, which detects cervical changes before cancer develops.<br />
<br />
<b>Nursing Key outcomes</b><br />
Pain control; Pain: Disruptive effects; Well-being, after nursing interventions patient will
Report feeling less pain.
Report feelings of reduced anxiety.
Verbalize her concerns and fears related to her diagnosis and condition.
Maintain joint mobility and range of motion.
Free from breakdown.
Demonstrate adaptive coping behaviors.
Resume normal sexual activity patterns to the fullest extent possible.
Remain free from signs or symptoms of infection.
The patient and partner will express feelings and perceptions about changes in sexual performance.<br />
<br />
<b>Nursing interventions nursing care plans for Cervical Cancer </b><br />
Analgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application<br />
<b>Collaborative </b><br />
If you assist with a biopsy, drape and prepare the patient as for a routine Pap test and pelvic examination. Have a container of formaldehyde ready to preserve the specimen during transfer to the pathology laboratory. Assist the physician as needed, and provide support for the patient throughout the procedure.
If you assist with cryosurgery or laser therapy, drape and prepare the patient as for a routine Pap test and pelvic examination. Assist the physician as necessary, and provide support for the patient throughout the procedure.
Preinvasive lesions (CIS) can be treated by conization, cryosurgery, laser surgery, or simple hysterectomy (if the patient’s reproductive capacity is not an issue). All conservative treatments require frequent follow-up by Pap tests and colposcopy because a greater level of risk is always present for the woman who has had CIS Administer analgesics and prophylactic antibiotics, as ordered.<br />
<b>Independent </b><br />
Listen to the patient’s fears and concerns, and offer reassurance when appropriate. Encourage her to use relaxation techniques to promote comfort during diagnostic procedures.
When a patient requires surgery, prepare her mentally and physically for the surgery and the postoperative period.
After any surgery, monitor vital signs every 4 hours.
Watch for and immediately report signs of complications, such as bleeding, abdominal distention, severe pain, and wheezing or other breathing difficulties. Encourage deep breathing and coughing.
Check to see whether the radioactive source is to be inserted while the patient is in the operating room (preloaded) or at bedside (afterloaded). If the source is preloaded, the patient returns to her room hot and safety precautions begin immediately.
Remember that safety precaution time, distance, and shielding begin as soon as the radioactive source is in place. Inform the patient that she will require a private room.
Check the patient’s vital signs every 4 hours
Assist the patient with range-of-motion arm exercises.
Avoid leg exercises and other body movements that could dislodge the source. If ordered, administer a tranquilizer to help the patient relax.
Provide activities that require minimal movement.
Watch for treatment complications by listening to and observing the patient and monitoring laboratory studies and vital signs. When appropriate, perform measures to prevent or alleviate complications.<br />
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<b>Patient teaching, discharge and home healthcare guidelines for patients with Cervical Cancer: </b><br />
Be sure the patient and family understand any pain medication prescribed, including dosage, route, action, and side effects. Reassure the patient that this disease and Cervical Cancer care treatment should not radically alter her lifestyle or prohibit sexual intimacy. Tell to the patient all the post procedure complications. Ensure that the patient understands the need for ongoing Pap smears if appropriate. Vaginal cytological studies are recommended at 4-month intervals for 2 years, every 6 months for 3 years, and then annually. Explain the importance of complying with follow-up visits to the gynecologist and oncologist. Stress the value of these visits in detecting disease progression or recurrence<br />
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Biopsy<br />
Explain to the patient that she may feel pressure, minor abdominal cramps, or a pinch from the punch forceps. Reassure her that the pain will be minimal because the cervix has few nerve endings.<br />
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Cryosurgery<br />
Explain to the patient that the procedure takes about 15 minutes, during which time the physician uses refrigerant to freeze the cervix. Caution to the patients that she may experience abdominal cramps, headache, and sweating, but reassure her that she will feel little, if any, pain.<br />
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Laser surgery<br />
Explain to the patient the laser surgery procedure takes about 30 minutes and may cause abdominal cramps. After excision biopsy, cryosurgery, or laser therapy, tell the patient to expect a discharge or spotting for about 1 week. Advise her not to douche, use tampons, or engage in sexual intercourse during this time. Caution her to report signs of infection. Stress the need for a follow-up Pap test and a pelvic examination in 3 to 4 months and periodically thereafter. Also, tell her what to expect postoperatively if a hysterectomy is necessary.<br />
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Preloaded internal radiation therapy<br />
Tell to the patient that preloaded internal radiation therapy procedure requires hospital stay, bowel preparation, a povidoneiodine vaginal douche, a clear liquid diet, and nothing by mouth the night before the implantation. It also requires an indwelling urinary catheter. Inform the patient that preloaded internal radiation therapy is performed in the operating room under general anesthesia.<br />
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After loaded internal radiation therapy<br />
Explain to the patient that a member of the radiation team implants the source after the patient returns to her room from surgery. Remind the patient to watch for and report uncomfortable adverse effects, warn the patient to avoid people with obvious infections during therapy. Inform the patient that vaginal narrowing caused by scar tissue can occur after internal radiation. Describe the complications that can occur after high-dose radiation therapy.</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-33489199621177204802010-05-25T20:52:00.000+07:002014-10-31T18:59:53.177+07:00Nursing Care Plans for Abruptio Placentae (Placenta Abruption)<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1fZFW2bmMA2UvuV9NVBLJTH7EhSTsAvWja729Me7wGvAyRE14v2Moh73ycWIMlw9A0as6mWzbOhizQGez9Kjtade9m17AzjA-_UV_FuhSgRDJiOX9VmotRf9QzH2m6NYi04Z9c9QyOq2R/s1600/Abruptio-Placentae.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Abruptio Placentae (Placenta Abruption)" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1fZFW2bmMA2UvuV9NVBLJTH7EhSTsAvWja729Me7wGvAyRE14v2Moh73ycWIMlw9A0as6mWzbOhizQGez9Kjtade9m17AzjA-_UV_FuhSgRDJiOX9VmotRf9QzH2m6NYi04Z9c9QyOq2R/s1600/Abruptio-Placentae.jpg" height="132" title="Abruptio Placentae (Placenta Abruption)" width="200" /></a></div>
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Abruptio placentae also called placental abruption occur when the placenta prematurely separates from the uterine wall, usually after the 20th week of gestation, producing hemorrhage. This disorder may be classified according to the degree of placental separation and the severity of maternal and fetal symptoms. It is characterized by a triad of symptoms: vaginal bleeding, uterine hypertonus, and fetal distress. It can occur during the prenatal or intrapartum period. Abruptio placentae is most common in multigravidas usually in women older than age 35 and is a common cause of bleeding during the second half of pregnancy. On heavy maternal bleeding generally necessitates termination of the pregnancy. The fetal prognosis depends on the gestational age and amount of blood lost. The maternal prognosis is good if hemorrhage can be controlled. </div>
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Grading System for Abruptio Placentae (placenta abruption) </div>
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<ul>
<li>Grade 0 Less than 10% of the total placental surface has detached; the patient has no symptoms; however, a small retroplacental clot is noted at birth. </li>
<li>Grade I approximately 10%–20% of the total placental surface has detached; vaginal bleeding and mild uterine tenderness are noted; however, the mother and fetus are in no distress. </li>
<li>Grade II Approximately 20%–50% of the total placental surface has detached; the patient has uterine tenderness and tetany; bleeding can be concealed or is obvious; signs of fetal distress are noted; the mother is not in hypovolemic shock. </li>
<li>Grade III More than 50% of the placental surface has detached; uterine tetany is severe; bleeding can be concealed or is obvious; the mother is in shock and often experiencing coagulopathy; fetal death occurs. </li>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWm6WtIm4_tl9qcbYN93Xb-LjruPq3CsINRtgto3PC0MAYtXRV8zGsYDJ_s8VnJccj9LD-fOtAvu97hPkXoKUVNuovQdEnQ51H8Un0hpHLDel63aY-VPqDLxmaNNbh-W7TUc3Hc2umZDr5/s1600/central-placenta-abruption.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Central abruption" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWm6WtIm4_tl9qcbYN93Xb-LjruPq3CsINRtgto3PC0MAYtXRV8zGsYDJ_s8VnJccj9LD-fOtAvu97hPkXoKUVNuovQdEnQ51H8Un0hpHLDel63aY-VPqDLxmaNNbh-W7TUc3Hc2umZDr5/s1600/central-placenta-abruption.png" height="320" title="Central abruption" width="320" /></a></div>
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Central abruption, the separation occurs in the middle, and bleeding is trapped
Between the detached placenta and the uterus, concealing the hemorrhage </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhI1JKp7z2N7NZSJcMkM-yijUX3M6PmauIJzI7vzXnwpPJILH0sWyKk7l-rrACsSmG_rID40sOLaI3qliKF5XUnof1u3b6mIP6EM2gUyokNhpnwhMUeRV7kPfgXgAU-6WQ169hpJ7whLOpZ/s1600/marginal-placenta-abruption.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Marginal abruption" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhI1JKp7z2N7NZSJcMkM-yijUX3M6PmauIJzI7vzXnwpPJILH0sWyKk7l-rrACsSmG_rID40sOLaI3qliKF5XUnof1u3b6mIP6EM2gUyokNhpnwhMUeRV7kPfgXgAU-6WQ169hpJ7whLOpZ/s1600/marginal-placenta-abruption.png" height="320" title="Marginal abruption" width="320" /></a></div>
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Marginal abruption, separation begins at the periphery and bleeding accumulates between
The membranes and the uterus and eventually passes through the cervix, becoming an external hemorrhage. </div>
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Causes for Abruptio Placentae (placenta abruption) </div>
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The cause of abruptio placentae is unknown; however, any condition that causes vascular changes at the placental level may contribute to premature separation of the placenta. Predisposing factors include:
Traumatic injury.
Placental site bleeding from a needle puncture during amniocentesis,
Chronic or pregnancy-induced hypertension.
Multiparity
Short umbilical cord
Dietary deficiency
Smoking
Advanced maternal age
Pressure on the vena cava from an enlarged uterus. </div>
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The spontaneous rupture of blood vessels at the placental bed may result from a lack of resiliency or to abnormal changes in the uterine vasculature. The condition may be complicated by hypertension or by an enlarged uterus that can’t contract sufficiently to seal off the torn vessels. Consequently, bleeding continues unchecked, possibly shearing off the placenta partially or completely. </div>
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Complications for Abruptio Placentae (placenta abruption) </div>
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Hemorrhage and shock.
Renal failure,
Disseminated intravascular coagulation.
Maternal and fetal death. </div>
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Nursing Assessment</div>
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Abruptio placentae produce a wide range of clinical effects, depending on the extent of placental separation and the amount of blood lost from maternal circulation.
Obtain patient history obstetric history. Determine the date of the last menstrual period to calculate the estimated day of delivery and gestational age of the infant. Inquire about alcohol, tobacco, and drug usage, and any trauma or abuse situations during pregnancy
Mild Abruptio placentae with marginal separation usually report mild to moderate vaginal bleeding, vague lower abdominal discomfort, and mild to moderate abdominal tenderness.
Moderate Abruptio placentae are about 50% placental separation usually report continuous abdominal pain and moderate, dark red vaginal bleeding. Onset of symptoms may be gradual or abrupt. Vital signs may indicate impending shock. Palpation reveals a tender uterus that remains firm between contractions.
Severe Abruptio placentae about 70% placental separations patient usually report abrupt onset of agonizing, unremitting uterine pain (described as tearing or knifelike) and moderate vaginal bleeding. Vital signs indicate rapidly progressive shock. Palpation reveals a tender uterus with board like rigidity. Uterine size may increase in severe concealed abruptions.
Psychosocial Assessment to understanding patient’s situation and also the significant other’s degree of anxiety, coping ability, and willingness to support the patient </div>
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Diagnostic tests for Abruptio Placentae (placenta abruption) </div>
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Pelvic examination under double setup
Ultrasonography
Decreased hemoglobin level
Decreased platelet count.
Periodic assays for fibrin split products aid in monitoring the progression of abruptio placentae and in detecting DIC. </div>
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Treatment for Abruptio Placentae (placenta abruption)
Medical Treatment management goals of abruptio placentae are to assess, control, and restore the amount of blood lost and to deliver a viable infant and prevent coagulation disorders.
After determining the severity of placental abruption and appropriate fluid and blood replacement, prompt cesarean delivery is necessary if the fetus is in distress. If the fetus isn’t in distress, monitoring continues; delivery is usually performed at the first sign of fetal distress. </div>
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Nursing diagnosis</div>
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Primary nursing diagnosis fluid volume deficit related to blood loss. Common nursing diagnosis fond in Nursing Care Plans for Abruptio Placentae (placenta abruption):
Acute pain
Anxiety
Deficient fluid volume
Dysfunctional grieving
Fear
Ineffective coping
Ineffective tissue perfusion: Cardiopulmonary </div>
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Key outcomes the patient will: </div>
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Express feelings of comfort.
Express feelings of reduced anxiety.
Communicate feelings about the situation.
Discuss fears and concerns.
Use available support systems, such as family and friends, to aid in coping.
Remain hemodynamically stable.
Patient’s fluid volume will remain within normal parameters. </div>
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Nursing interventions</div>
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Monitor Vital sign; blood pressure, pulse rate, respirations, central venous pressure, intake and output, and amount of vaginal bleeding.
Monitor fetal heart rate electronically.
If vaginal delivery is elected, provide emotional support during labor.
Because of the neonate’s prematurity, the mother may not receive an analgesic during labor and may experience intense pain. Reassure the patient of her progress through labor, and keep her informed of the fetus’s condition.
Encourage the patient and her family to verbalize their feelings. Help them to develop effective coping strategies. Refer them for counseling, if necessary. </div>
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Patient teaching discharge and home healthcare guidelines</div>
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Teach the patient to identify and report signs of placental abruption, such as bleeding and cramping.
Explain procedures and treatments to allay patient’s anxiety.
Teach the patient to notify the doctor and come to the hospital immediately if she experiences any bleeding or contractions.
Prepare the patient and her family for the possibility of an emergency cesarean delivery, the delivery of a premature neonate, and the changes to expect in the postpartum period. Offer emotional support and an honest assessment of the situation.
Tactfully discuss the possibility of neonatal death. Inform the patient that the neonate’s survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive disorders.
Inform the patient that frequent monitoring and prompt management greatly reduce the risk of death. </div>
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After Postpartum Patient teaching discharge and home healthcare guidelines </div>
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Give the usual postpartum instructions for avoiding complications. Inform the patient that she is at much higher risk of developing abruptio placentae in subsequent Pregnancies. Instruct the patient on how to provide safe care of the infant. Provide a list of referrals to the patient and significant others to help them manage their loss, If the fetus has not Survived</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-50894354025631092222010-05-24T20:36:00.000+07:002014-10-31T18:59:53.229+07:00Nursing Care Plans for Bulimia Nervosa<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdyi3fhnJYXdWfTbKBOEIylooQMwF9GYq9kKTHgUfC1pPK-kyJ5E3BpNYeBLDoJZjEvaV4OVId-dxPob1iU1VpLMocNcW8ZVpdX0eP5vlXuC-nTvBowj0VyCpg8x0ecayXxRvT3CJYOYfQ/s1600/Nursing-Care-Plans-for-Bulimia-Nervosa.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Bulimia Nervosa" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdyi3fhnJYXdWfTbKBOEIylooQMwF9GYq9kKTHgUfC1pPK-kyJ5E3BpNYeBLDoJZjEvaV4OVId-dxPob1iU1VpLMocNcW8ZVpdX0eP5vlXuC-nTvBowj0VyCpg8x0ecayXxRvT3CJYOYfQ/s1600/Nursing-Care-Plans-for-Bulimia-Nervosa.gif" height="195" title="Bulimia Nervosa" width="200" /></a></div>
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Bulimia nervosa the binge and purge syndrome is an eating disorder, the essential features of bulimia nervosa include eating binges followed by feelings of guilt, humiliation, and self deprecation guilt, and anxiety over fear of weight gain. Characterized by extreme overeating, followed by self induced vomiting and abuse of laxatives, diuretics, strict dieting or fasting to overcome the effects of the binges. Unless the patient devotes an excessive amount of time to binging and purging, bulimia nervosa seldom is incapacitating. </div>
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Bulimia nervosa usually begins in adolescence or early adulthood and can occur simultaneously with anorexia nervosa. The disorder occurs predominantly in females and begins in adolescence or early adult life. Between 1% and 3% of adolescent and young females meet the diagnostic criteria for bulimia nervosa; 5% to 15% have some symptoms of the disorder. </div>
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Causes for Bulimia Nervosa </div>
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The exact cause of bulimia is unknown, but bulimia is generally attributed to a combination of psychological, genetic, and physiological causes. Such factors include family disturbance or conflict, sexual abuse, maladaptive learned behavior, struggle for control or self-identity, cultural overemphasis on physical appearance, and parental obesity. Bulimia nervosa is strongly associated with depression. </div>
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Complications for Bulimia Nervosa </div>
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Dental caries result from repetitive vomiting in bulimia nervosa.
Erosion of tooth enamel.
Parotitis
Gum infections.
Arrhythmias and even sudden death result from electrolyte imbalances.
Ipecac syrup intoxication can cause cardiac failure in patients who rely on this drug to induce vomiting.
Esophageal tears and gastric ruptures rare complications.
Mucosal damage can occur if patient with bulimia nervosa use laxatives.
Potential psychiatric complication of bulimia nervosa is suicide.
Bulimia nervosa patients are more prone to psychoactive substance use disorders. </div>
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Nursing Assessment</div>
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Patient history of bulimia nervosa is characterized by episodic binge eating that may occur up to several times per day. The patient commonly reports a binge-eating episode during which she continues eating until abdominal pain, sleep, or the presence of another person interrupts it. The preferred food usually is sweet, soft, and high in calories and carbohydrate content.
Unlike the anorexic patient bulimic patient usually can keep her eating disorder hidden, because patient’s weight frequently fluctuates, but usually stays within the normal range through the use of diuretics, laxatives, vomiting, and exercise.
The patient may complain of abdominal and epigastric, Amenorrhea, Painless swelling of the salivary glands, hoarseness, throat irritation or lacerations, and dental erosion.
In addition, the patient may exhibit calluses of the knuckles or abrasions and scars on the dorsum of the hand, resulting from tooth injury during self-induced vomiting.
A bulimic patient commonly is perceived by others as a perfect student, mother, or career woman; an adolescent may be distinguished for participation in competitive activities, such as gymnastics, sports, or ballet.
However, the patient’s psychosocial history may reveal an exaggerated sense of guilt, symptoms of depression, childhood trauma (especially sexual abuse), parental obesity, or a history of unsatisfactory sexual relationships. </div>
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Symptomatology for Bulimia Nervosa </div>
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Patients with Bulimia Nervosa usually solitary and secret and patients with Bulimia Nervosa able to consume thousands of calories in one episode.
Loss of control to stop eating After the binge has begun
Following the binge, the individual engages in inappropriate compensatory measures to avoid gaining weight (e.g., self-induced vomiting; excessive use of laxatives, diuretics, or enemas; fasting; and extreme exercising).
Eating binges may be viewed as pleasurable but are followed by intense self-criticism and depressed mood.
Individuals with bulimia are usually within normal weight range, some a few pounds underweight, some a few pounds overweight.
Obsession with body image and appearance is a predominant feature of this disorder. Individuals with bulimia display undue concern with sexual attractiveness and how they will appear to others.
Binges usually alternate with periods of normal eating and fasting.
Excessive vomiting may lead to problems with dehydration and electrolyte imbalance.
Gastric acid in the vomitus may contribute to the erosion of tooth enamel.
Treatment Bulimia Nervosa
Treatment of bulimia nervosa may continue for several years. Interrelated physical and psychological symptoms must be treated simultaneously. Merely promoting weight gain isn’t sufficient to guarantee long-term recovery. A patient whose physical status is severely compromised by inadequate or chaotic eating patterns is difficult to engage in the psychotherapeutic process.
Psychotherapy focuses on breaking the binge-purge cycle and helping the patient regain control over eating behavior. Treatment may occur in either an inpatient or outpatient setting. It includes behavior modification therapy, possibly in highly structured psychoeducational group meetings. Individual psychotherapy and family therapy, which address the eating disorder as a symptom of unresolved conflict, may help the patient understand the basis of her behavior and teach her self-control strategies. Antidepressant drugs, particularly the selective serotonin reuptake inhibitor fluoxetine, may be used to supplement psychotherapy.
The patient may also benefit from participation in self-help groups such as Overeaters Anonymous or in a drug rehabilitation program if she has a concurrent substance abuse problem. </div>
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Nursing diagnosis</div>
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<ul>
<li>Anxiety </li>
<li>Chronic low self-esteem </li>
<li>Constipation </li>
<li>Deficient fluid volume </li>
<li>Disturbed body image </li>
<li>Disturbed sleep pattern </li>
<li>Imbalanced nutrition: Less than body requirements </li>
<li>Ineffective coping </li>
<li>Social isolation </li>
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Nursing Key outcomes</div>
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The patient will:
State strategies to reduce levels of anxiety.
Express positive feelings about self.
Have regular bowel elimination patterns.
Acknowledge change in body image.
Verbalize feeling well rested.
Display appropriate eating patterns, including regular, nutritious meals.
Participate in decision-making about case.
Interact with family or friends.
Fluid balance will remain stable, with intake equal to or greater than output. </div>
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Nursing interventions</div>
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Supervise the patient during mealtimes and for a specified period after meals, usually 1 hour. Set a time limit for each meal. Provide a pleasant, relaxed environment for eating.
Using behavior modification techniques, reward the patient for satisfactory weight gain.
Establish a contract with the patient, specifying the amount and type of food to be eaten at each meal.
Encourage the patient to recognize and verbalize her feelings about her eating behavior. Provide an accepting and nonjudgmental atmosphere, controlling your reactions to her behavior and feelings.
Encourage the patient to talk about stressful issues, such as achievement, independence, socialization, sexuality, family problems, and control.
Identify the patient’s elimination patterns.
Assess the patient’s suicide potential.
Refer the patient and her family to the National Eating Disorders Association and the National Association of Anorexia Nervosa and Associated Disorders as sources of additional information and support. </div>
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Nursing interventions for bulimia nervosa base on its nursing diagnosis: </div>
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Nursing Diagnosis Imbalanced nutrition: Less than body requirements </div>
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If client is unable or unwilling to maintain adequate oral intake, physician may order a liquid diet to be administered via nasogastric tube.
Nursing care of the individual receiving tube feedings should be administered.
In collaboration with dietitian, to provide realistic (according to body structure and height) weight gain, determine number of calories required to provide adequate nutrition.
Explain to patient’s behavior modification program as outlined by physician.
Explain benefits of compliance with prandial routine and consequences for noncompliance.
Sit with client during mealtimes for support and to observe amount ingested. Give to the patient a time limit for meals.
Client should be observed for at least 1 hour following meals.
Client may need to be accompanied to bathroom.
Weigh client daily; use same scale, if possible.
Do not discuss food or eating with client. </div>
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Nursing Diagnosis Deficient fluid volume </div>
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Teach client importance of daily fluid intake of 2000 to 3000 ml. This information is required to promote client safety and plan nursing care. Keep strict record of intake and output.
Weigh client daily; use same scale, if possible.
Assess and document condition of skin turgor and any changes in skin integrity.
Hot water and soap are drying to the skin, .Discourage client from bathing every day if skin is very dry.
Monitor laboratory serum values, and notify physician of significant alterations.
Client should be observed for at least 1 hour after meals and may need to be accompanied to the bathroom if self-induced vomiting is suspected.
Assess and document moistness and color of oral mucous membranes.
To minimizing risk of tissue infection. Encourage frequent oral care to moisten mucous membranes, reducing discomfort from dry mouth, and to decrease bacterial count.
Help client identify true feelings and fears that contribute to maladaptive eating behaviors. </div>
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Nursing Diagnosis Ineffective coping </div>
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Establish a trusting relationship with.
When nutritional status has improved, begin to explore with client the feelings associated with his or her extreme fear of gaining weight,
Explore family dynamics. Help client to identify his or her role contributions and their appropriateness within the family system
Initially, allow client to maintain dependent role. To deprive the individual of this role at this time could cause his or her anxiety to rise to an unmanageable level.
Give Positive reinforcement to increases self-esteem and encourages the client to use behaviors that are more acceptable.
Explore with client ways in which he or she may feel in control within the environment, without resorting to maladaptive eating behaviors. </div>
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Patient teaching for Bulimia Nervosa </div>
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To monitor the treatment progress Teach the patient how to keep a food journal.
Teach about risks abuse of laxative, emetic, and diuretic to the patient.
To help the patient gain control over her behavior and achieve a realistic and positive self-image Provide assertiveness training.
If the patient is taking a prescribed tricyclic antidepressant, instruct her to take the drug with food. Warn her to avoid consuming alcoholic beverages; exposing herself to sunlight, heat lamps, or tanning beds; and discontinuing the medication unless she has notified the physician.</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-52864753832473704842010-05-16T20:25:00.000+07:002014-10-31T18:59:53.233+07:00Nursing Care Plans for Urinary Tract Infections (UTIs)<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3sh6qnDa2wPTwkEuetuKA7ky9Cw_Elptkk-vonDhj5jlMsrPc2Ff5oXiHwOo6uXJIsYPuUPz0hGlCF_TsfGkW4EVakZ5uzdnhkRm_XdcES51fjTv9i0QVMl_m38UZWKMZtZRjALhyphenhyphenc4zH/s1600/Kidneys-and-Urinary-Tract.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Urinary Tract" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3sh6qnDa2wPTwkEuetuKA7ky9Cw_Elptkk-vonDhj5jlMsrPc2Ff5oXiHwOo6uXJIsYPuUPz0hGlCF_TsfGkW4EVakZ5uzdnhkRm_XdcES51fjTv9i0QVMl_m38UZWKMZtZRjALhyphenhyphenc4zH/s1600/Kidneys-and-Urinary-Tract.gif" height="200" title="Urinary Tract" width="194" /></a></div>
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Urinary tract infections (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra The two forms of lower urinary tract infection (UTI) are cystitis (infection of the bladder) and urethritis (infection of the urethra). Urinary tract infection (UTI) more common in females than in males. UTI is prevalent in girls. In adult males and in children, lower UTIs typically are associated with anatomic or physiologic abnormalities and therefore need close evaluation. Most UTIs respond eadily to treatment, but recurrence and resistant bacteria flare-up during therapy are possible. </div>
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“Urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract. The main etiologic agent is Escherichia coli. Although urine contains a variety of fluids, salts, and waste products, it does not usually have bacteria in it. When bacteria get into the bladder or kidney and multiply in the urine, they may cause a UTI. “Pathogenesis </div>
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The most common organism implicated in is E. coli and Staphylococcus. The bladder wall is coated with various mannosylated proteins, such as Tamm-Horsfall proteins (THP), which interfere with the binding of bacteria to the uroepithelium. As binding is an important factor in establishing pathogenicity for these organisms, its disruption results in reduced capacity for invasion of the tissues.[clarification needed] Moreover, the unbound bacteria are more easily removed when voiding. The use of urinary catheters (or other physical trauma) may physically disturb this protective lining, thereby allowing bacteria to invade the exposed epithelium. During cystitis, uropathogenic Escherichia coli (UPEC) subvert innate defenses by invading superficial umbrella cells and rapidly increasing in numbers to form intracellular bacterial communities (IBCs). By working together, bacteria in biofilms build themselves into structures that are more firmly anchored in infected cells and are more resistant to immune system assaults and antibiotic treatments This is often the cause of chronic urinary tract infections. </div>
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Source: http://en.wikipedia.org/wiki/Urinary_tract_infection </div>
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Urinary reflux is one reason that bacteria spread in the urinary tract. Vesicourethral reflux occurs when pressure increases in the bladder from coughing or sneezing and pushes urine into the urethra. When pressure returns to normal, the urine moves back into the bladder, taking with it bacteria from the urethra. In vesicoureteral reflux, urine flows backward from the bladder into one or both of the ureters, carrying bacteria from the bladder to the ureters and widening the infection. If they are left untreated, UTIs can lead to chronic infections, pyelonephritis, and even
systemic sepsis and septic shock. If infection reaches the kidneys, permanent renal damage can occur, which leads to acute and chronic renal failure. </div>
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Causes for Urinary tract infection (UTI) </div>
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Most lower Urinary tract infection (UTI) result from ascending infection by a single gram-negative, enteric bacterium, such as Escherichia coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, and Serratia. In a patient with neurogenic bladder, an indwelling urinary catheter, or a fistula between the intestine and bladder, a lower UTI may result from simultaneous infection with multiple pathogens. </div>
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Studies suggest that infection results from a breakdown in local defense mechanisms in the bladder that allows bacteria to invade the bladder mucosa and multiply. These bacteria can’t be readily eliminated by normal urination. </div>
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The pathogen’s resistance to the prescribed antimicrobial therapy usually causes bacterial flare-up during treatment. Even a small number of bacteria in a midstream urine specimen obtained during treatment casts doubt on the effectiveness of treatment. </div>
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In almost all patients, recurrent lower Urinary tract infection (UTI) result from reinfection by the same organism or by some new pathogen. In the remaining patients, recurrence reflects persistent infection, usually from renal calculi, chronic bacterial prostatitis, or a structural anomaly that is a source of infection. The high incidence of lower UTI among females probably occurs because natural anatomic features that facilitate Urinary tract infection (UTI). </div>
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Urinary tract infections (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra </div>
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Nursing Assessment </div>
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Patients History. The patient with a UTI has a variety of symptoms that range from mild to severe. The typical complaint is of one or more of the following: frequency, burning, urgency, nocturia, blood or pus in the urine, and suprapubic fullness. The patient may complain of urinary urgency and frequency, dysuria, bladder cramps or spasms, itching, a feeling of warmth during urination, nocturia. Other complaints include low back pain, malaise, nausea, vomiting, pain or tenderness over the bladder, chills, and flank pain. Inflammation of the bladder wall also causes hematuria and fever. Ask the patient about risk factors, including recent catheterization of the urinary tract, pregnancy or recent childbirth, neurological problems, volume depletion, frequent sexual activity, and presence of a sexually transmitted infection (STI). </div>
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Physical Examination. Physical examination is often unremarkable in the patient with a UTI, although some patients have costovertebral angle tenderness in cases of pyelonephritis. On occasion, the patient has fever, chills, and signs of a systemic infection. Inspect the urine to determine its color, clarity, odor, and character. Surveillance for STIs is recommended as part of the examination. </div>
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Diagnostic tests</div>
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Several tests are used to diagnose lower UTIs:
Leukocyte esterase dip test
Clean-catch urinalysis.
Clean-catch collection is preferred to catheterization, which can reinfect the bladder with urethral bacteria.
Sensitivity testing is used to determine the appropriate antimicrobial drug.
Stained smear of urethral discharge can be used to rule out sexually transmitted disease.
Voiding cystourethrography or excretory urography </div>
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Nursing diagnosis</div>
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<ul>
<li>Acute pain </li>
<li>Deficient knowledge (prevention) </li>
<li>Disturbed sleep pattern </li>
<li>Impaired urinary elimination </li>
<li>Risk for infection </li>
<li>Risk for injury
Sexual dysfunction </li>
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Nursing Key outcomes Nursing care plans for Urinary tract infections (UTIs) </div>
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The patients will:
Report increased comfort.
Identify risk factors that exacerbate the disease process or condition and modify his lifestyle accordingly.
Verbalize feeling well rested after undisturbed periods of sleep.
Remain free from signs or symptoms of infection.
Avoid or minimize complications.
Reestablish sexual activity at the preillness level.
Patient and family will demonstrate skill in managing elimination problem. </div>
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Nursing interventions </div>
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Administer antibiotics specific to the invading organism as ordered
Watch for GI disturbances from antimicrobial therapy. If ordered, administer nitrofurantoin macrocrystals with milk or meals to prevent such distress.
If the patient experiences perineal discomfort, sitz baths to the perineum may increase comfort.
If sitz baths don’t relieve perineal discomfort, apply warm compresses sparingly to the perineum, but be careful not to burn the patient.
Apply topical antiseptics on the urethral meatus as necessary.
Collect urine specimens for culture and sensitivity testing carefully and promptly.
Encourage patients to increase fluid intake to promote frequent urination </div>
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Patient Teaching and Home Healthcare Guidelines</div>
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Teach the patient an understanding of the proposed therapy, including the medication name, dosage, route, and side effects, Emphasize the importance of completing the prescribed course of therapy or, with long-term prophylaxis, of strictly adhering to the ordered dosage.
Explain that an uncontaminated midstream urine specimen is essential for accurate diagnosis.
Teach the female patient to clean the perineum properly and to keep the labia separated during urination.
To prevent recurrent lower UTIs, teach a female patient to carefully wipe the perineum from front to back and to thoroughly clean it with soap and water after bowel movements.
Teach to the patients never to postpone urination and to empty her bladder completely.
Tell the male patient that prompt treatment of predisposing conditions such as chronic prostatitis helps prevent recurrent UTIs.
Urge the patient to drink about 2 qt (2 L) of fluid a day during treatment.</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0tag:blogger.com,1999:blog-3260502332421841616.post-64432684256759907262010-04-16T20:12:00.000+07:002014-10-31T18:59:53.281+07:00Nursing Care Plans for Gout/Gouty Arthritis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyA4NB-_sDuzBftoHpNDj4-ZbkhHuHzmWBLQYCeZNDL94w_nm7zb3pfScKtobLvWNOcbGPmNXb5HYfcGPQok3gyQrhylU7P7LwSjmRXZhXp5QBy_upMt23yantBh7jz_KiAh2cpLATLHBV/s1600/Gout_Gouty-Arthritis.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyA4NB-_sDuzBftoHpNDj4-ZbkhHuHzmWBLQYCeZNDL94w_nm7zb3pfScKtobLvWNOcbGPmNXb5HYfcGPQok3gyQrhylU7P7LwSjmRXZhXp5QBy_upMt23yantBh7jz_KiAh2cpLATLHBV/s1600/Gout_Gouty-Arthritis.gif" height="166" width="200" /></a></div>
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Gout also known as gouty arthritis is a metabolic disease marked by monosodium urate deposits that cause red, swollen, and acutely painful joints. Gout can affect any joint but mostly affects those in the feet, especially the great toe, ankle, and midfoot. Gout is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis (red, tender, hot, swollen joint). It is caused by elevated levels of uric acid in the blood. The uric acid crystallizes and deposits in joints, tendons, and surrounding tissues. Gout affects 1% of Western populations at some point in their lives. Gout is caused by an increased level of uric acid in the blood, salts of which are deposited in the joints. It mostly occurs in middle-aged men and almost always involves pain at the base of the great toe. Gout may result from a primary metabolic disturbance or may be a secondary effect of another disease, as of the kidneys.Gout is treated with drugs to suppress formation of uric acid or to increase elimination of uric acid. Patients who receive treatment for gout have a good prognosis. </div>
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The final, unremitting stage of the disease (also known as tophaceous gout) is marked by persistent painful polyarthritis. An increased concentration of uric acid leads to urate deposits in cartilage, synovial membranes, tendons, and soft tissue, called Tophi/tophus . Tophi/tophus form in the fingers, hands, knees, feet, ulnar sides of the forearms, pinna of the ear, Achilles tendon and, rarely, in such internal organs as the kidneys and myocardium. Renal involvement may adversely affect renal function. </div>
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Causes for Gout/Gouty Arthritis </div>
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Hyperuricemia is the underlying problem of gout, Although the underlying cause of primary gout is unknown, it appears to be linked to a genetic defect in purine metabolism that causes overproduction of uric acid (Hyperuricemia), retention of uric acid, or both. </div>
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Secondary gout develops during the course of another disease, such as obesity, diabetes mellitus, hypertension, polycythemia, leukemia, myeloma, sickle cell anemia, and renal disease. Secondary gout can also follow treatment with such drugs as hydrochlorothiazide or pyrazinamide. </div>
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Complications for Gout/Gouty Arthritis </div>
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Potential complications include:
Renal disorders such as renal calculi
Circulatory problems, such as atherosclerotic disease, cardiovascular lesions, stroke, coronary thrombosis, and hypertension
Infection that develops when occur tophi ruptures and nerve entrapment. </div>
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Treatment for Gout/Gouty Arthritis </div>
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Gout/Gouty Arthritis management has three goals:
Stop the acute attack.
Treat hyperuricemia to reduce urine uric acid levels.
Prevent recurrent gout and renal calculi. </div>
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Treatment for an acute attack: </div>
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Bed rest; immobilization and protection of the inflamed, painful joints; and local application of cold.
Analgesics, such as acetaminophen, relieve the pain associated with mild attacks.
Acute inflammation requires nonsteroidal anti-inflammatory drugs or intramuscular corticotropin. </div>
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Treatment for chronic gout involves </div>
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Decreasing the serum uric acid level.
Adjunctive therapy emphasizes avoidance of alcohol and sparing use of purine-rich foods.
Weight reduction program decreases uric acid levels and eases stress on painful joints.
In some cases, surgery may be necessary excised and drained tophi to improve joint function or correct deformities. </div>
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Nursing Assessment </div>
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<b>Patient history</b> Reveal that the patient has a sedentary lifestyle and a history of hypertension or renal calculi. report waking with pain in toe or another location in the foot.He may complain that initially moderate pain has grown and He may report accompanying chills and a mild fever. </div>
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<b>Inspection</b> a swollen, dusky red or purple joint with limited movement. Maybe found tophi, especially in the outer ears, hands, and feet, In chronic stage of gout, the skin over the tophi may ulcerate and release a chalky white exudate or pus. </div>
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<b>Palpation</b> may reveal warmth over the joint and extreme tenderness. The vital signs assessment may disclose fever and hypertension. If the patient has a fever, possible occult infection must be investigated. </div>
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Diagnostic tests for Gout/Gouty Arthritis </div>
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Needle aspiration of synovial fluid (arthrocentesis) or tophaceous material
Serum uric acid
X-rays </div>
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Nursing Diagnosis</div>
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Common nursing diagnosis found in Nursing care plans for Gout/Gouty Arthritis
Acute pain
Activity intolerance
Anxiety
Deficient knowledge (diagnosis and treatment)
Disturbed sleep pattern
Impaired physical mobility
Ineffective coping
Risk for injury</div>
lifenurseshttp://www.blogger.com/profile/08142043557871268387noreply@blogger.com0