Although almost all men older than 50 have some prostatic enlargement, with benign prostatic hyperplasia (BPH), the prostate gland enlarges sufficiently to compress the urethra and cause some overt urinary obstruction. It is the most common cause of obstruction of urine flow in men. The degree of enlargement determines whether or not bladder outflow obstruction occurs. As the urethra becomes obstructed, the muscle inside the bladder hypertrophies in an attempt to assist the bladder to force out the urine. BPH may also cause the formation of a bladder diverticulum that remains full of urine when the patient empties the bladder. Depending on the size of the enlarged prostate, the age and health of the patient, and the extent of obstruction, benign prostatic hyperplasia (BPH), is treated symptomatically or surgically.

Causes for Benign prostatic hyperplasia (BPH)

A link between Benign prostatic hyperplasia (BPH) and hormonal activity suggests.  As males age, production of androgenic hormones decreases, causing an imbalance in androgen and estrogen levels and high levels of dihydrotestosterone, the main prostatic intracellular androgen.

Other causes of Benign prostatic hyperplasia (BPH) include:

• Neoplasm
• Arteriosclerosis
• Inflammation
• Metabolic Imbalance
• Nutritional disturbances.

Complications for Benign prostatic hyperplasia (BPH)

• Urinary stasis
• Urinary tract infection (UTI)
• Renal calculi
• Bladder wall trabeculation
• Detrusor muscle hypertrophy
• Bladder diverticula and saccules
• Urethral stenosis
• Hydronephrosis
• Paradoxical (overflow) incontinence
• Acute renal failure or chronic renal failure
• Acute postobstructive diuresis.

Nursing Diagnosis Benign Prostatic Hyperplasia (BPH)

Nursing Diagnosis for Benign Prostatic Hyperplasia (BPH) determine by data that we collect in nursing assessment.

Nursing Assessment nursing care plans for Benign Prostatic Hyperplasia (BPH)

BPH Clinical features depend on the extent of prostatic enlargement and on the lobes affected. Patient history, generally, men with suspected BPH have a history of frequent urination, nocturia, straining to urinate, weak stream, and an incomplete emptying of the bladder. Patient usually complains of a group of symptoms known as prostatism: decreased urine stream caliber and force, an interrupted stream, urinary hesitancy, and difficulty starting urination, which results in straining and a feeling of incomplete voiding. As the obstruction increases, the patient may report frequent urination with nocturia, dribbling, urine retention, incontinence and, possibly, hematuria.

Physical examination. Inspect and palpate the bladder for distension. Physical examination reveals a visible midline mass above the symphysis pubis, which represents an incompletely emptied bladder. Palpation discloses a distended bladder, A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

Diagnostic tests Benign Prostatic Hyperplasia (BPH)

Several tests help to confirm Benign Prostatic Hyperplasia (BPH) diagnosis:

• Excretory urography may indicate urinary tract obstruction, hydronephrosis, calculi or tumors, and filling and emptying defects in the bladder.
• Elevated blood urea nitrogen
• Serum creatinine levels suggest impaired renal function.
• Urinalysis and urine culture
• Cystourethroscopy
• Intravenous pyelography (IVP)
• Transrectal prostatic ultrasound (TRUS)
• A prostate-specific antigen test may be performed to rule out prostatic cancer.

Nursing diagnosis nursing care plans for  Benign Prostatic Hyperplasia (BPH)

Primary nursing diagnosis:

Urinary retention (acute or chronic) related to bladder obstruction

Common nursing diagnosis found in patient with Benign Prostatic Hyperplasia (BPH)

• Acute pain
• Fear/Anxiety [specify level]
• Impaired urinary elimination
• deficient Knowledge regarding condition,prognosis, treatment, self-care, and discharge needs
• Risk for infection
• Risk for injury
• Sexual dysfunction
• Urinary retention

Nursing care plans Benign Prostatic Hyperplasia (BPH)

Common nursing diagnosis found in patient with Benign Prostatic Hyperplasia (BPH);  Urinary retention (acute or chronic), Acute pain,  Fear, Anxiety, Impaired urinary elimination,  deficient Knowledge,  Risk for infection, Risk for injury, Sexual dysfunction,

Nursing Priorities Nursing care plans for Benign Prostatic Hyperplasia (BPH)

• Relieve acute urinary retention.
• Promote comfort.
• Provide information about disease process, prognosis, and treatment needs.
• Prevent complications.
• Help client deal with psychosocial concerns.

Sample Nursing care plans for Benign Prostatic Hyperplasia (BPH) with nursing diagnosis Urinary retention (acute or chronic)

Benign Prostatic Hyperplasia (BPH), Patient Teaching Discharge And Home Healthcare Guidelines
Patient teaching discharge and home healthcare guidelines for patient with Benign Prostatic Hyperplasia (BPH). Patient usualy  need assistance with management of therapy and catheter. Provide instructions about all medications used. Provide instructions on the correct dosage, route, action, side effects, and potential drug interactions and when to notify these to the physician, Provide information about specific procedures and tests and what to expect afterward, such as catheter, bloody urine, and bladder irritation

• Instruct patients about the need to maintain a high fluid intake, to ensure adequate urine output.
• Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention. Teach the patient to recognize the signs of Urinary Tract Infection (UTIs). Urge him to immediately report these signs to the physician because infection can worsen the obstruction.

• After the catheter is removed, the patient may experience urinary frequency, dribbling and, occasionally, hematuria. Reassure him and family members that he’ll gradually regain urinary control
• Instruct the patient to follow the prescribed oral antibiotic regimen, and tell him the indications for using gentle laxatives.

Postoperative Patient teaching

• Provide information about sexual anatomy and function as it relates to prostatic enlargement helps client understand the implications of proposed treatments because they might affect sexual performance.
• Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors.
• Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures.
• Reinforce prescribed limits on activity. Warn the patient against lifting, performing strenuous exercises, and taking long automobile rides for at least 1 month after surgery because these activities increase bleeding tendency. Also caution him not to have sexual intercourse for at least several weeks after discharge

Prevention

Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension.

• Urge the patient to seek medical care immediately if he can’t void at all, if he passes bloody urine, or if develops a fever.
• Reinforce importance of medical follow-up for at least 6 months to 1 year, including rectal examination and urinalysis.

Tuberculosis TB is an infectious disease caused by bacteria (Mycobacterium tuberculosis) that are usually spread from person to person through the air. Tuberculosis (TB) is characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and cavitation. People living in crowded, poorly ventilated conditions are most likely to become infected. It usually infects the lung but can occur at virtually any site in the body. HIV-infected patients are especially at risk. In patients with strains that are sensitive to the usual antitubercular agents, the prognosis is excellent with correct treatment. However, in those with strains that are resistant to two or more of the major antitubercular agents, mortality is 50%.

Pathophysiology

• The bacilli of Tuberculosis TB infect the lung, forming a tubercle (lesion).
• The tubercle:  May heal, leaving scar tissue. May continue as a granuloma, then heal, or be reactivated. May eventually proceed to necrosis, liquefaction, sloughing, and cavitation.
• The initial lesion may disseminate tubercle bacilli by extension to adjacent tissues, by way of the bloodstream, by way of the lymphatic system, or through the bronchi.
• Extrapulmonary Tuberculosis TB occurs more commonly in children and immunocompromised individuals and can involve lymph nodes, bones, joints, pleural space, pericardium, CNS, GU tissue, and the peritoneum.

Transmission

1. The term Mycobacterium is descriptive of the organism, which is a bacterium that resembles a fungus. The organisms multiply at varying rates and are characterized as acid-fast aerobic organisms that can be killed by heat, sunshine, drying, and ultraviolet light.
2. Tuberculosis TB is an airborne disease transmitted by droplet nuclei, usually from within the respiratory tract of an infected person who exhales them during coughing, talking, sneezing, or singing.
3. When an uninfected susceptible person inhales the droplet-containing air, the organism is carried into the lung to the pulmonary alveoli.
4. Most people who become infected do not develop clinical illness, because the body’s immune system brings the infection under control.

The primary infectious agent of Pulmonary Tuberculosis TB is, Mycobacterium tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection.

Risk Factors for Pulmonary Tuberculosis

• Close contact with someone who has active Tuberculosis TB. Inhalation of airborne nuclei from an infected person is proportional to the amount of time spent in the same air space, the proximity of the person, and the degree of ventilation.
• Immunocompromised status (e.g. those with HIV infection, cancer, transplanted organs, and prolonged high-dose corticosteroid therapy)
• Substance abuse (IV or injection drug users and alcoholics)
• Any person without adequate health care (the homeless, impoverished, minorities, particularly children under age 15 years and young adults between ages 15 and 44 yrs)
• Preexisting medical conditions or special treatment (e.g. Diabetes Mellitus, chronic renal failure, malnourishment, selected malignancies, hemodialysis, transplanted organ, gastrectomy, or jejunoileal bypass)
• Immigration from countries with a high prevalence of Tuberculosis TB (southeastern Asia, Africa, Latin America, Caribbean)
• Institutionalization (e.g. long-term care facilities, psychiatric institutions, prisons)
• Living in overcrowded, substandard housing
• Being a health care worker performing high-risk activities: administration of aerosolized pentamidine and other medications, sputum induction procedures, Bronchoscopy, suctioning, coughing procedures, caring for the immunosuppressed patient, home care with the high-risk population, and administering anesthesia and related procedures (e.g. intubation, suctioning)

Clinical Manifestations

Patient may be asymptomatic or may have insidious symptoms that may be ignored.

• Constitutional symptoms; Fatigue, anorexia, weight loss, low-grade fever, night sweats, indigestion. Some patients have acute febrile illness, chills, and flu-like symptoms.
• Pulmonary signs and symptoms; Cough (insidious onset) progressing in frequency and producing mucoid or mucopurulent sputum. Hemoptysis; chest pain; dyspnea (indicates extensive involvement).
• Extrapulmonary Tuberculosis TB: pain, inflammation, and dysfunction in any of the tissues infected.

COMPLICATIONS

1. Pleural effusion
2. TB pneumonia; Tuberculosis TB can cause massive pulmonary tissue damage, with inflammation and tissue necrosis eventually leading to respiratory failure. Bronchopleural fistulas can develop from lung tissue damage, resulting in pneumothorax. The disease can also lead to hemorrhage, and pneumonia.
3. Other organ involvement with Tuberculosis TB; Small mycobacterial foci can infect other body organs, including the kidneys and the central nervous and skeletal systems.
4. The patient also might develop Serious reactions to drug therapy

• INH may produce asymptomatic elevation in liver enzymes, rare peripheral neurotoxicity, hepatitis that may, rarely, be fatal, CNS effects (dysarthria, irritability, seizures, dysphoria, diminished concentration), lupus-like syndrome, hypersensitivity reactions, and monoamine poisoning (rarely occurring with consumption of some wines and cheeses). Patients with pre-existing liver disease should be monitored closely.
• Ethambutol may cause retrobulbar optic neuritis with decreased visual acuity and decreased red-green discrimination in one or both eyes, although this occurs rarely with daily doses of 15 mg/kg/day. EMB may also cause peripheral neuritis and cutaneous reactions. Patients should have baseline visual acuity and color discrimination (Ishihara test) testing as well as monthly monitoring.
• Pyrazinamide may cause hepatotoxicity, GI symptoms, nongouty polyarthralgia, asymptomatic hyperuricemia, and acute gouty arthritis.
• Any anti-TB drug may cause rash. If rash occurs, withhold all medications until rash subsides. Rechallenge drugs sequentially every 3 to 4 days to find cause. Usual sequence is INH, rifampin, PZA, EMB, using the first line (most important) drug first.
• Rifampin may cause pruritus with or without rash, GI adverse effects, flu-like symptoms, hepatotoxicity, rare severe immunologic reactions, orange discoloration of body fluids, and drug interactions with hormonal contraceptives, methadone, and warfarin.

Classification of Pulmonary Tuberculosis TB
An infectious disease caused by the tubercle bacillus, Mycobacterium tuberculosis. Often involves the lungs but may involve other parts of the body as well. Data from the history, physical examination, skin test, chest x-ray, and microbiologic studies are used to classify Pulmonary Tuberculosis TB into one of five classes. A classification scheme provides public health officials with a systematic way to monitor epidemiology and treatment of the disease (American Thoracic Society, 2000).

Classification of Pulmonary Tuberculosis TB

• Class 0: no exposure; no infection
• Class 1: exposure; no evidence of infection
• Class 2: latent infection; no disease (e.g. positive PPD reaction but no clinical evidence of active TB)
• Class 3: disease; clinically active
• Class 4: disease; not clinically active
• Class 5: suspected disease; diagnosis pending

Primary tuberculosis

This stage of infection, primary tuberculosis, is usually clinically and radio graphically silent. In most persons with intact cell-mediated immunity, T cells and macrophages surround the organisms in granulomas that limit their multiplication and spread. The infection is contained but not eradicated, since viable organisms may lie dormant within granulomas for years to decades.

Latent tuberculosis infection

Individuals with this latent tuberculosis infection do not have active disease and cannot transmit the organism to others. However, reactivation of disease may occur if the host’s immune defenses are impaired. Active tuberculosis will develop in approximately 10% of individuals with latent tuberculosis infection who are not given preventive therapy; half of these cases occur in the 2 years following primary infection. Up to 50% of HIV-infected patients will develop active tuberculosis within 2 years after infection with tuberculosis. Diverse conditions such as gastrectomy, silicosis, and diabetes mellitus and disorders associated with immunosuppression (e.g. HIV infection or therapy with corticosteroids or other immunosuppressive drugs) are associated with an increased risk of reactivation.

Progressive primary tuberculosis

In approximately 5% of cases, the immune response is inadequate and the host develops progressive primary tuberculosis, accompanied by both pulmonary and constitutional symptoms that are described below. Standard teaching has held that 90% of tuberculosis in adults represents activation of latent disease. New diagnostic technologies such as DNA fingerprinting suggest that as many as one-third of new cases of tuberculosis in urban populations are primary infections resulting from person-to-person transmission.

Pulmonary Tuberculosis Treatment

Antitubercular therapy with daily oral doses of isoniazid, rifampin, and pyrazinamide for at least 6 months usually cures Tuberculosis TB. After 2 to 4 weeks, the disease is no longer infectious and the patient can resume normal activities while continuing to take medication. A longer course of treatment may be necessary if the patient is slow to respond to treatment, require extended treatment for patients with AIDS

Treatment for Pulmonary Tuberculosis

• A combination of drugs to which the organisms are susceptible is given to destroy viable bacilli as rapidly as possible and to protect against the emergence of drug-resistant organisms.
• Current recommended regimen of uncomplicated, previously untreated Pulmonary Tuberculosis TB is an initial phase of 2 months of bactericidal drugs, including isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol (EMB). This regimen should be followed until the results of drug susceptibility studies are available, unless there is little possibility of drug resistance.

1. If drug susceptibility results are known and organism is fully susceptible, EMB does not need to be included.
2. For children whose visual acuity cannot be monitored, EMB is not normally recommended except with increased likelihood of INH resistance or if the child has upper lobe infiltration and/or cavity formation Pulmonary Tuberculosis TB.
3. Due to increasing frequency of global streptomycin resistance, streptomycin is not considered interchangeable with EMB unless organism is known to be susceptible to streptomycin.
4. PZA may be withheld for severe liver disease, gout and possibly, pregnancy.
5. Adverse effects including liver injury have been noted with rifampin and pyrazinamide in a once daily or twice weekly combination, therefore this combination is not recommended for the treatment of latent Pulmonary Tuberculosis TB infection.

• Follow with 4 months of isoniazid and rifampin. Six months of therapy is usually effective for killing the three populations of bacilli: those rapidly dividing, those slowly dividing, and those only intermittently dividing.
• Sputum smears may be obtained every 2 weeks until they are negative; sputum cultures do not become negative for 3 to 5 months.
• Rifabutin (Mycobutin) is used as a substitute for rifampin if the organism is susceptible to rifabutin and for patients taking medications that may interact with rifampin.
• Second-line drugs, such as cycloserine (Seromycin), ethionamide (Trecator-SC), streptomycin, Amikacin (Amikin), kanamycin (Kantrex), capreomycin (Capastat),
  para-aminosalicylic acid, and some fluoroquinolones, are used in patients with resistance, for retreatment, and in those with intolerance to other agents. Patients taking these drugs should be monitored by health providers experienced in their use.
• For people suspected of having latent Pulmonary Tuberculosis TB infection (LTBI), treatment should begin after active TB has been ruled out.

Nursing Care Plans Pulmonary Tuberculosis TB

Common nursing diagnosis found in Nursing Care Plans Pulmonary Tuberculosis TB; Ineffective Airway Clearance, Risk for impaired Gas Exchange, Imbalanced Nutrition: Less than Body Requirements, Risk for Infection, Deficient Knowledge

Nursing Care Plans Pulmonary Tuberculosis TB

Nursing diagnosis ineffective Airway Clearance related to Thick, viscous, or bloody secretions Fatigue, poor cough effort Tracheal or pharyngeal edema

Nursing goal: Respiratory Status: Airway Patency

Nursing Intervention Nursing Care Plans Pulmonary Tuberculosis TB

Airway Management:

• Assess respiratory function, such as breath sounds, rate, rhythm, and depth, and use of accessory muscles. Rationale Diminished breath sounds may reflect Atelectasis. Rhonchi and wheezes indicate accumulation of secretions and inability to clear airways, which may lead to use of accessory muscles and increased work of breathing.
• Note ability to expectorate mucus and cough effectively; document character and amount of sputum and presence of Hemoptysis Rationale Expectoration may be difficult when secretions are very thick as a result of infection or inadequate hydration. Blood tinged or frankly bloody sputum results from tissue breakdown in the lungs and may require further evaluation and intervention
• Place client in semi- or high Fowler’s position. Assist client with coughing and deep-breathing exercises Rationale Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open Atelectasis areas and promote movement of secretions into larger airways for expectoration.
• Clear secretions from mouth and trachea, suction as necessary. Rationale Prevents obstruction and aspiration. Suctioning may be necessary if client is unable to expectorate secretions.
• Maintain fluid intake of at least 2,500 ML/day unless contraindicated Rationale High fluid intake helps thin secretions, making them easier to expectorate
• Humidify inspired oxygen Rationale Prevents drying of mucous membranes and helps thin secretions
• Administer medications, as indicated, for example: Mucolytic agents, such as acetylcysteine (Mucomyst) Rationale Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance
• Bronchodilators, such as oxtriphylline (Choledyl) and theophylline (Theo-Dur) Rationale Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery
• Corticosteroids (prednisone) Rationale May be useful in the presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening
• Be prepared for and assist with emergency intubation Rationale Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding.

Evaluation (Expected Out Come) Nursing Care Plans Pulmonary Tuberculosis TB Nursing diagnosis ineffective Airway Clearance:

• Maintain patent airway.
• Expectorate secretions without assistance.
• Demonstrate behaviors to improve or maintain airway clearance.
• Participate in treatment regimen, within the level of ability and situation.
• Identify potential complications and initiate appropriate actions.

Complete Sample Nursing Care Plans Pulmonary Tuberculosis Tb

Patient Teaching Home Health Guidance for Patient with Pulmonary Tuberculosis

Patient teaching discharge and home healthcare guidelines for Patient with Pulmonary Tuberculosis. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Instruct the patient to abstain from alcohol while on INH, and refer for eye examination after starting, then every month while taking, ethambutol. Teach the patient to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that should be reported to healthcare personnel.

Patient Teaching & Home Health Guidance for Patient with Pulmonary Tuberculosis

• Improve ventilation  by opening windows in room of affected person, and keeping bedroom door closed as much as possible.
• Instruct patient to cover mouth with fresh tissue when coughing or sneezing and to dispose of tissues promptly in plastic bags.
• Discuss Tuberculosis TB testing of people residing with patient.
• Investigate living conditions, availability of transportation, financial status, alcohol and drug abuse, and motivation, which may affect compliance with follow-up and treatment. Initiate referrals to a social worker for interventions in these areas.
• Report new cases of Tuberculosis TB to public health department for screening of close contacts and monitoring.
• Review possible complications: hemorrhage, pleurisy, symptoms of recurrence (persistent cough, fever, or Hemoptysis).
• Instruct patient on avoidance of job-related exposure to excessive amounts of silicone (working in foundry, rock quarry, sand blasting), which increases risk of reactivation.
• Encourage patient to report at specified intervals for bacteriologic (smear) examination of sputum to monitor therapeutic response and compliance.
• Instruct patient in basic hygiene practices and investigate living conditions. Crowded, poorly ventilated conditions contribute to development and spread of Tuberculosis TB.
• Encourage regular symptom screening and follow-up chest X-rays for rest of life to evaluate for recurrence.
• Show the patient and family how to perform postural drainage and chest percussion. Also teach the patient coughing and deep-breathing exercises. Instruct him to maintain each position for 10 minutes and then to perform percussion and cough.
• Instruct patient on prophylaxis with isoniazid for people infected with the tubercle bacillus without active disease to prevent disease from occurring, or to people at high risk of becoming infected.
• Educate asymptomatic people about PPD testing and treatment of latent Tuberculosis TB for positive results, based on risk grouping.

Breast cancer is a leading killer after lung cancer high incidence of age since the age of 30 years, Breast cancer is rarely found in the age below 20 years. It is most common after age 50. Early detection and treatment influences the prognosis considerably of Breast cancer. Complete history and physical examination should  be done in A woman with a new breast mass. The differential diagnosis of a breast mass can be broad, including malignancies such as primary breast cancer, lymphoma, or sarcoma, or benign breast lesions such as cysts, fibroadenoma, and fat necrosis. Even skin conditions, such as sebaceous cysts, abscesses, or thrombophlebitis may occur with a palpable mass. The history and physical will help aid in the diagnosis, but ultimately a biopsy is confirmatory of the diagnosis.

Causes for Breast Cancer

The origin of breast cancer is a complex interaction between the biologic and endocrine properties of the person and the environmental exposures that may precipitate mutation of cells to a malignancy. Despite known hereditary risk factors, the majority of breast cancers are diagnosed in women with no such risk factors. Although 10% to 20% of breast cancer patients have a family history suggestive of a hereditary susceptibility, only 5% of all breast cancers can be attributed to a known genetic defect

Risk factors for Breast Cancer:

• Family history of breast or ovarian cancer
• Age, The incidence of breast cancer increases with age and steadily after age 50. Thus, 75% of all cases of breast cancer are diagnosed in postmenopausal women Premenopausal
• Parity and lactation: long menstrual cycle, early onset of menses, late menopause. First pregnancy before age 20 or after age 31, The data on lactation are mixed but appear to indicate a decreased risk of breast cancer if women nurse for a long duration
• High-fat diet
• Endometrial or ovarian cancer
• Radiation exposure, Exposure to ionizing radiation, such as in nuclear explosions or medical therapeutics, does appear to increase the risk of breast cancer.
• Estrogen therapy
• Antihypertensive therapy
• Alcohol and tobacco, there is an irrefutable link between alcohol consumption and breast cancer risk. A pooled analysis of 322,647 women showed a positive linear relationship between incremental alcohol intake and increasing breast cancer risk.
• Breast disease, Benign breast disease, such as fibrocystic disease, do not increase the risk of breast cancer. Papillomas, sclerosing adenosis, and lobular carcinoma in situ are also known to increase the risk.

Complications for Breast Cancer

Metastasis leads to site-specific complications, bone, brain, and respiratory problems if it spreads to the lung.

Diagnostic tests Breast Cancer

• Screening and early detection:  Mammography, Breast examinations, High-risk patients
• Mammogram
• Ultrasound of the breast
• Biopsy

Treatment for Breast Cancer

Depends on the stage and type of Breast Cancer

• Stage I   size less 2 cm No node involvement, no metastasis
• Stage II Size Up to 5 cm May have axillary’s node involvement, no metastasis
• Stage III Varied (any size) Extended to skin or chest wall, nodes involved (immovable axillary node)
• Stage IV Varied Distant metastasis with ipsilateral supraclavicular nodes

Therapy may include a combination of surgery, radiation, chemotherapy, and hormone therapy

Surgical. The goal of surgery is control of cancer in the breast and the axillaries nodes

• Lumpectomy
• Partial mastectomy (also known as segmental mastectomy or quadrantectomy) removes one-quarter or more of the breast.
• Simple or total mastectomy is the removal of the breast but not the lymph nodes or pectoral muscles.
• Modified radical mastectomy is the removal of the breast and some of the axillary lymph nodes.
• Radical mastectomy is the removal of the breast, pectoralis major and minor, and axillary lymph nodes. The use of this surgery has declined.

Nursing diagnosis for breast cancer determine with data that we Collect in nursing assessment and result from Diagnostic tests for Breast Cancer

Nursing Assessment Nursing Care Plans for Breast Cancer

• Patient History. Assess the patient’s and family’s previous medical history of breast cancer or other Cancers.
• Palpation may identify a hard lump, mass, or thickening of breast tissue. Palpation of the cervical supraclavicular and axillary nodes may also disclose lumps or enlargement.
• Painless lump or mass in her breast or that she noticed a thickening of breast tissue
• Examine the axillary and supraclavicular areas for enlarged nodes. You may note the tumor is firm and immovable.
• Assess the patient for pain or tenderness at the tumor site.
• Inspect the breast skin for signs of advanced disease: the presence of inflammation, dimpling, orange peel effect, distended vessels, and nipple changes or ulceration

Diagnostic tests Breast Cancer

• Screening and early detection:  Mammography, Breast examinations, High-risk patients
• Mammogram
• Ultrasound of the breast
• Biopsy

Nursing diagnosis for breast cancer:

Common Nursing diagnosis found on Nursing Care Plans for Breast Cancer

• Acute pain
• Body image disturbance related to significance of loss of part or all of the breast
• Anxiety
• Fear
• Imbalanced nutrition: Less than body requirements
• Impaired physical mobility
• Impaired skin integrity
• Ineffective coping
• Ineffective role performance
• Risk for infection
• Risk for spiritual distress
• Bathing or hygiene self-care deficit
• Energy field disturbance

Nursing Care Plans for Breast Cancer

NCPNursing care plans for Breast Cancer. Common nursing diagnosis found in nursing care plan for patient with Breast Cancer: Acute pain, Body image disturbance related to significance of loss of part or all of the breast, Anxiety, Fear, Imbalanced nutrition: Less than body requirements, Impaired physical mobility, Impaired skin integrity, Ineffective coping, Ineffective role performance, Risk for infection,        Risk for spiritual distress, Bathing or hygiene self-care deficit, Energy field disturbance

Nursing outcomes Nursing Care Plans for Breast Cancer

Patient will:

• Communicate feelings of comfort and decreased pain.
• Express that she feels less anxious.
• Participate in her own care at the highest level possible within the limitations of her illness.
• Express positive feelings about self.
• Express increased sense of well-being.
• Use situational supports to reduce fear.
• Maintain adequate nutrition through oral intake or i.v. fluids.
• Maintain optimal muscle strength and joint range of motion.
• Patient’s surgical wounds will appear pink without signs or symptoms of complications.
• Demonstrate adequate coping behaviors.
• Recognize limitations imposed by her illness and will express feelings about these limitations.
• Free from signs and symptoms of infection.
• Express the importance of her own belief system and inner resources.

Nursing interventions Nursing Care Plans for Breast Cancer

• Nursing interventions Nursing diagnosis acute pain related to Surgical procedure; tissue trauma, interruption of nerves, dissection of muscles. 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: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
• Nursing interventions nursing diagnosis anxiety related to change of body image; scarring, loss of body part, sexual attractiveness extent of disease, impact on others; uncertainty of prognosis; denial of own mortality Situational crisis. Nursing Interventions:  Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
• Nursing interventions nursing diagnosis: impaired skin integrity related to surgical removal of skin and tissue; altered circulation, presence of edema, drainage; changes in skin elasticity, sensation; tissue destruction of radiation therapy. Nursing interventions:  Wound Care: Prevention of wound complications and promotion of wound healing. Incision Site Care: Cleansing, monitoring, and promotion of healing in a wound that is closed with sutures, clips, or staples. Pressure Ulcer Care: Facilitation of healing in pressure ulcers
• Nursing interventions Nursing diagnosis: impaired physical mobility related to neuromuscular impairment; pain, discomfort; edema formation.  Nursing Interventions:  Exercise Therapy: specify level: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement. Pain Management: Alleviation of pain or a reduction in pain to a level of comfort acceptable to the patient
• Nursing interventions nursing diagnosis: imbalanced nutrition: less than body requirements related to hyper metabolic state associated with cancer consequences of chemotherapy, radiation, surgery anorexia, gastric irritation, taste distortions, nausea emotional distress, fatigue, poorly controlled pain.  Nursing Interventions:  Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight Eating Disorders Management
• Nursing interventions nursing diagnosis risk for Infection related to Inadequate secondary defenses and immunosuppression such as bone marrow suppression dose-limiting side effect of both chemotherapy and radiation Malnutrition; chronic disease process Invasive procedure. 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

Patient Teaching and Home Healthcare Guidelines for Breast Cancer

Patient Teaching and Home Healthcare Guidelines for Breast Cancer. Clearly explain all procedures and treatments for patient with Breast Cancer. Inform the patient that she may experience phantom breast syndrome a tingling or pins and needles sensation in the area where the breast was removed. Females who have had breast cancer in one breast are at higher risk for cancer in the other breast or for recurrent cancer in the chest wall. For this reason, urge the patient to continue examining the other breast and to comply with recommended follow up treatment

Explain to the patient that she may have an incision drain or some type of suction to remove accumulated fluid, relieve tension on the suture line, and promote healing The patient can expect to return home with dressings and wound drains. Teach how to self-care wound drains, empty the drainage receptacle twice a day, record the amount on a flow sheet, and take this information along when keeping a doctor’s appointment. Teach the patient how to identified symptoms of infection report symptoms of infection or excess drainage on the dressing or the drainage device

Review pain treatment medication instructions for frequency and precautions. Show the mastectomy patient how to ease postoperative pain by lying on the affected side or by placing a hand or pillow on the incision. Point out where the incision will be. Inform the patient that after the operation, she will receive analgesics because pain relief encourages coughing and turning and promotes well-being. Explain that a small pillow placed under the arm anteriorly may provide comfort. Tell the patient that she may move about and get out of bed as soon as possible, usually as soon as the effects of the anesthetic subside or the first evening after surgery.

Teach precautions to prevent lymphedema after node dissection, to help prevent lymphedema, instructs the patient to exercise her hand and arm on the affected side regularly and to avoid activities that might allow infection of this hand or arm. Tell her that infection increases the risk of lymphedema.

• Request no blood pressure or blood samples from affected arm.
• Urge the patient to avoid activities that could injure her arm and hand on the side of her surgery. Caution her not to let blood be drawn from or allow injections into that arm. She should also refuse to have blood pressure taken or I.V. therapy administered on the affected arm.

FOLLOW UP:

• Prepare the patient and family for a variety of encounters with healthcare providers (radiologist, oncologist, and phlebotomist).
• Provide information of local community resources and support groups for emotional Support

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

Causes For  Cerebral Contusion

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

Complications for Cerebral Contusion

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

Treatment for Cerebral Contusion

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

NCP Nursing care plans for Cerebral Contusion

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

Nursing Diagnosis for Cerebral Contusion

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

Nursing Assessment Nursing care plans for Cerebral Contusion

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

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

Diagnostic tests for Cerebral Contusion

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

Nursing diagnosis Nursing care plans for Cerebral Contusion

Common Nursing diagnosis found in Nursing care plans for Cerebral Contusion

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

Nursing Intervention and Rationale Nursing Care Plan for Cerebral Contusion

Nursing diagnosis acute pain

Related factors injuring agents (Cerebral Contusion)

Nursing Interventions:

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

Nursing diagnosis Anxiety

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

Nursing Interventions:

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

Nursing diagnosis Ineffective cerebral tissue Perfusion

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

Nursing Interventions

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

Nursing diagnosis Disturbed sensory perception: Kinesthetic, tactile

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

Nursing Interventions

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

Nursing diagnosis Disturbed thought processes

Nursing diagnosis Impaired verbal communication

Related to decrease in circulation to brain, Cerebral Contusion

Nursing Interventions:

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

Nursing diagnosis Ineffective coping

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

Nursing Interventions:

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

Nursing diagnosis Risk for deficient fluid volume

Nursing Interventions:

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

Nursing diagnosis Risk for infection

Risk factor inadequate primary defenses broken skin, traumatized tissue

Nursing Interventions:

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

Nursing diagnosis Risk for injury

Nursing Interventions:

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

Nursing diagnosis Risk for post trauma syndrome

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

Nursing Interventions:

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

 Patient Teaching And Home Healthcare Guidance For Patient With Cerebral Contusion

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

Patient teaching and home healthcare guidance for patient with Cerebral Contusion

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

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

Types characteristics of thyroid cancers

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

Complications For Thyroid Cancers

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

Clinical Manifestations for Thyroid Cancers

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

Symptoms of Thyroid Cancer

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

Nursing Diagnosis for Thyroid Cancer

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

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

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

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

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

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

Diagnostic Evaluation

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

Nursing Diagnosis for Patient with Thyroid Cancer

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

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

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

Nursing Intervention and Rationale Nursing Care Plan for Thyroid Cancer

Nursing Diagnosis Fear/Anxiety

Could be related to:

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

Nursing Outcomes Evaluation Criteria, Client Will:

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

Nursing Interventions and rationale Nursing diagnosis Fear/Anxiety:

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

Nursing Diagnosis Acute pain/Chronic Pain

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

Nursing Outcomes Evaluation Criteria Client Will

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

Nursing Interventions and Rationale Nursing Diagnosis Acute/Chronic Pain

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

Nursing Diagnosis Risk for Ineffective Airway Clearance

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

Nursing Outcomes Evaluation Criteria

• Client Will Maintain patent airway, with aspiration prevented.

Nursing Interventions and Rationale Nursing Diagnosis Risk for Ineffective Airway Clearance

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

Nursing Diagnosis Impaired Verbal Communication

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

Nursing Outcomes Evaluation Criteria

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

Nursing Interventions and Rationale:

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

Nursing Diagnosis Risk For Injury

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

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

Nursing Interventions And Rationale

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

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

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

Nursing Outcomes Evaluation Criteria

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

Nursing Interventions and Rationale

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

Patient Teaching Thyroid Cancer

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

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

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

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 cancer is classified by its location:

• Supraglottis (false vocal cords)
• Glottis (true vocal cords)
• Sub glottis (rare downward extension from vocal cords).

Pathophysiology and Etiology of Laryngeal Cancer

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.

Causes for Laryngeal Cancer

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.

Nursing Diagnosis for Laryngeal Cancer. 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.

Diagnostic tests

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.

Nursing Assessment 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.

Nursing Diagnosis For Laryngeal Cancer

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

Nursing Care plan for Laryngeal Cancer. Common nursing diagnosis found in Nursing Care plan for 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

Nursing interventions and rationale Nursing Care plan for Laryngeal Cancer

Nursing Diagnosis Ineffective Airway Clearance May be related to:

• Partial or total removal of the glottis, altering ability to breathe, cough, and swallow
• Temporary or permanent change to neck breathing dependent on patent stoma
• Edema formation surgical manipulation and lymphatic accumulation
• Copious and thick secretions

Nursing Outcomes Evaluation Criteria, Client Will:

Respiratory Status: Airway Patency

• Maintain patent airway with breath sounds clear or clearing.
• Clear secretions and be free of aspiration.

Nursing Intervention and Rationale Nursing Diagnosis Ineffective Airway Clearance:

• 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.
• Elevate head of bed 30 to 45 degrees. Rationale Facilitates drainage of secretions, work of breathing, and lung expansion.
• Encourage swallowing, if client is able. Rationale reducing risk of aspiration with Prevents pooling of oral secretions
• Encourage and teach effective coughing and deep breathing. Rationale Mobilizes secretions to clear airway and helps prevent respiratory complications.
• 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.
• 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.
• 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.
• 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.
• 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.
• Resume oral intake with caution Rationale Changes in muscle mass and strength and nerve innervations increase likelihood of aspiration.
• 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.

Nursing Diagnosis Impaired Verbal Communication related to:

1. Anatomical deficit removal of vocal cords
2. Physical barrier tracheostomy tube
3. Required voice rest

Nursing Outcomes Evaluation Criteria Client Will:

• Communication Enhancement: Speech Deficit Independent
• Communicate needs in an effective manner.
• Identify and plan for appropriate alternative speech methods after healing.

Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:

• 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.
• Determine whether client has other communication impairments, such as hearing, vision, and literacy. Rationale Presence of other problems influences plan for alternative communication.
• 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.
• 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.
• 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.
• Caution client not to use voice until physician gives permission. Rationale Promotes healing of vocal cord and limits potential for permanent cord dysfunction.
• 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.

Nursing diagnosis Impaired Skin/Tissue Integrity related to:

• Surgical removal of tissues and grafting
• Radiation or chemotherapeutic agents
• Altered circulation or reduced blood supply
• Compromised nutritional status
• Edema formation
• Pooling or continuous drainage of secretions oral, lymph, or chyle

Nursing Outcomes Evaluation Criteria Client Will:

• Wound Healing: Primary Intention
• Display timely wound healing without complications.
• Demonstrate techniques to promote healing and prevent complications.

Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:

• 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.
• 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.
• 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.
• 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.
• Change dressings, as indicated. Rationale Damp dressings increase risk of tissue damage and infection.
• 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.
• 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.
• Administer oral, IV, and topical antibiotics, as indicated. Rationale Prevents or controls infection.

Nursing Diagnosis Impaired Oral Mucous Membrane related to

• Dehydration or absence of oral intake, decreased saliva production secondary to radiation  or surgical procedure
• Poor or inadequate oral hygiene
• Pathological condition oral cancer, mechanical trauma oral surgery
• Difficulty swallowing and pooling of secretions and drooling
• Nutritional deficits

Nursing Outcomes and Evaluation Criteria Client Will:

• Tissue Integrity: Skin and Mucous Membranes
• Report or demonstrate a decrease in symptoms.
• Identify specific interventions to promote healthy oral mucosa.
• Demonstrate techniques to restore and maintain mucosal integrity.
• Oral Health Restoration

Nursing Intervention and Rationale Nursing Diagnosis Impaired Oral Mucous Membrane:

• 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.
• 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.
• 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.
• Apply lubrication to lips; provide oral irrigations as indicated. Rationale Counteracts drying effects of therapeutic measures and negates erosive nature of secretions.
• Avoid alcohol based mouthwashes. Rationale: Alcohol can be drying and irritating.

Nursing Diagnosis Acute Pain related to:

• Surgical incisions
• Tissue swelling
• Presence of nasogastric or orogastric feeding tube

Nursing Outcomes and Evaluation Criteria Client Will:

• Report pain is relieved or controlled.
• Demonstrate relief of pain and discomfort by reduced tension and relaxed manner.

Nursing Intervention and Rationale Nursing Diagnosis Acute Pain:

• 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
• 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.
• 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.
• 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.
• 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.

Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer

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.

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

Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer:

• 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.
• 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).
• 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.
• 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.
• Reassure the patient that speech rehabilitation measures (including laryngeal speech, esophageal speech, an artificial larynx, and various mechanical devices) may help him communicate again.
• 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.

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.

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.

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.

Causes for Bladder cancer

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.

Complications of bladder cancer

If bladder cancer progresses, complications include bone metastases and problems resulting from tumor invasion of contiguous viscera.

Nursing diagnosis for Bladder Cancer determine from data that we collect from nursing assessment and from the test diagnostic results.

Nursing Assessment

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.

Patient’s history

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.

Physical assessment

The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures.

Psychosocial assessment

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.

Diagnostic tests for bladder cancer

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.

Nursing diagnosis bladder cancer

Common nursing diagnosis found in nursing care plans for bladder cancer

• Acute pain
• Anxiety
• Disturbed body image
• Fear
• Impaired skin integrity
• Impaired urinary elimination
• Ineffective coping
• Ineffective therapeutic regimen management
• Risk for infection
• Sexual dysfunction

Nursing Care Plans for Bladder Cancer. Common nursing diagnosis found in nursing care plans for patient with Bladder cancer; Acute pain, Anxiety , Disturbed body image , Fear, Impaired skin integrity, Impaired urinary elimination, Ineffective coping, Ineffective therapeutic regimen management, Risk for infection, Sexual dysfunction.

Nursing Interventions Nursing Care Plans for bladder cancer

Nursing Diagnosis Acute Pain related to activity of disease process (cancer)

Nursing Outcomes Evaluation Criteria:

• Client will verbalize relief or control of pain.
• Client will appear relaxed and be able to sleep and rest appropriately.

Nursing Intervention nursing diagnosis Acute Pain related to activity of disease process (cancer):

1. 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.
2. 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.
3. Encourage and maintain bed rest during acute phase, if indicated Rationale Minimizes stimulation and promotes relaxation
4. Administer analgesics, as indicated Rationale Reduce or control pain and decrease stimulation of the sympathetic nervous system

Nursing Diagnosis Anxiety related to underlying Pathophysiology response, change in health status

Nursing Outcomes Evaluation Criteria:

• Patients will verbalize awareness of feelings of anxiety and healthy ways to deal with them.
• Patients will Report that anxiety is reduced to a manageable level.
• Patients will express concerns about effect of disease on lifestyle and position within family and society.
• Patients will demonstrate problem-solving skills and effective coping strategies and Use resources/support systems effectively.

Nursing Intervention Nursing Diagnosis Anxiety

1. Observe behavior indicative of anxiety which can be a clue to the client’s level of anxiety Rationale
2. Explain purpose of tests and procedures in bladder cancer treatment Rationale Reduces anxiety attributable to fear of unknown diagnosis and prognosis.
3. Encourage family and friends to treat client as before. Rationale Reassures client that role in the family and business has not been altered.
4. Administer sedatives and tranquilizers, as indicated. Rationale May be desired to help client relax until physically able to reestablish adequate coping strategies.
5. 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

Nursing Diagnosis Impaired urinary elimination

Nursing Outcomes Evaluation Criteria

• Patients will  Display continuous flow of urine, with output adequate for individual situation
• Patients will verbalize understanding of condition.
• Patients will achieve normal elimination pattern.
• Patients will demonstrate behaviors/techniques to prevent urinary infection.
• Manage care of urinary catheter, or stoma and appliance following urinary diversion.

Patient Teaching and Home Health Guidance for Bladder Cancer

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.

Patient Teaching and Home Health Guidance for Bladder Cancer:

• Tell the patient what to expect from diagnostic tests. For example, make sure he understands that he may be anesthetized for cystoscopy.
• After the test results are known, explain the implications to the patient and his family.
• Demonstrate essential coughing and deep breathing exercises.
• 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.

Following creation of an ileal conduit, teach the patient how to care of the stoma and urinary drainage system:

• If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist.
• Tell the patient that the ileal conduit stoma should reach its permanent size about 2 to 4 months after surgery.

• 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.

• 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.
• 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.
• Instruct the patient to remeasure the stoma after he goes home in case the size changes.
• Tell the patient to empty the pouch every 2 to 3 hours or when it’s one-third full.
• Advise him to check the pouch frequently to ensure that the skin seal remains intact.
• Teach the patient to provide stoma care.
• 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.
• 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.

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.

Causes of Nephrotic syndrome

About 75% of Nephrotic syndrome cases result from primary idiopathic glomerulonephritis. Classifications include the following:

• 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.
• 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.
• Focal glomerulosclerosis can develop spontaneously at any age, follow kidney transplantation, or result from heroin abuse.
• 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.

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.

Pathophysiology of Nephrotic syndrome

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.

Clinical Manifestations of Nephrotic syndrome

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

Complications of Nephrotic syndrome

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

Nephrotic Syndrome Treatment

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

Management of Nephrotic syndrome

• 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.

Special considerations in Nephrotic syndrome Treatment

• 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.

Nursing Diagnosis For Nephrotic syndrome

Nursing Diagnosis nursing care plans for Nephrotic syndrome determine with data that nurses collect in nursing assessment, and from result of diagnostic test

Nursing Assessment of Nephrotic syndrome

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.

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.

Diagnostic Evaluation of Nephrotic syndrome

• 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

Nursing Diagnosis of Nephrotic syndrome

Common nursing diagnosis found in nursing care plans for patients with Nephrotic syndrome

• Imbalanced nutrition: Less than body requirements
• Disturbed body image
• Excess fluid volume
• Ineffective tissue perfusion: Renal
• Risk for injury
• Risk for Deficient Fluid Volume related to disease process
• Risk for Infection related to treatment with immunosuppressant

Nursing Care Plans for Nephrotic syndrome. Common Nursing diagnosis found in nursing care plans for patients with Nephrotic syndrome:  Imbalanced nutrition: Less than body requirements, Disturbed body image , Excess fluid volume, Ineffective tissue perfusion: Renal, Risk for injury Risk for Deficient Fluid Volume, Risk for Infection related to treatment with immunosuppressant

Nursing Interventions Nursing Care Plans

Nursing diagnosis Risk for Deficient Fluid Volume related to disease process

Desired Outcomes/Evaluation Criteria Client Will:

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.

Nursing Intervention nursing diagnosis Risk for Deficient Fluid Volume related to disease process:

Nursing Goal Increasing Circulating Volume and Decreasing Edema

1. 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.
2. 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.
3. Monitor serum BUN and creatinine to assess renal function. Rationale: Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction.
4. 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.
5. 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.
6. 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.
7. 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.

Nursing diagnosis Risk for Infection related to treatment with immunosuppressant

Desired Outcomes Evaluation Criteria Client Will: Immune Status, Experience no signs or symptoms of infection.

Nursing Intervention Nurse Care Plans for Nephrotic syndrome with nursing diagnosis Risk for Infection related to treatment with immunosuppressants:

Nursing Goal Preventing Infection

1. 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.
2. Monitor temperature routinely; check laboratory values for neutropenia. Rationale: A shifting of the differential to the left is indicative of infection.
3. 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.
4. Monitor effectiveness of antimicrobial therapy. Rationale: within 24 to 48 hours Signs of improvement in condition should occur.

Patient Teaching Discharge and Home Healthcare Guidelines

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.

Patient Teaching Discharge and Home Health-care Guidelines for patient with Nephrotic syndrome:

• 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
• Explain that they need to monitor the urine daily for protein and keep a diary with the results of the tests.
• Have the patient or family demonstrate the testing techniques before discharge to demonstrate their ability to perform these monitoring tasks.
• Instruct the patient and family to avoid exposure to communicable diseases and to engage in scrupulous infection control measures (e.g. frequent hand washing).
• 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.
• 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.
• 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.
• 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.
• Show the patient how to safely apply and remove anti-embolism stockings, If the physician prescribes anti-embolism stockings for home use.
• Stress the importance of adhering to the special diet or Ask the dietitian to plan a high-protein, low-sodium diet
• Encourage patients to resume normal activities as soon as possible.

Nursing diagnosis nursing care plans for Chronic Renal Failure CRF End Stage Renal Disease ESRD obtained from Nursing Assessment. Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnosis, and develop a nursing care plans for Chronic Renal Failure

Nursing Assessment for Chronic Renal Failure CRF

1. 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
2. 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).
3. 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.
4. 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.

Diagnostic Test Chronic Renal Failure CRF

• 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).
• Computed tomography scan, Renal or abdominal X-ray, magnetic resonance imaging, or Ultrasonography shows reduced kidney size.
• Kidney biopsy allows histological identification of underlying pathology

Nursing Diagnosis Chronic Renal Failure CRF

Common Nursing diagnosis that could be found in patient with Chronic Renal Failure CRF:

• Risk for decreased Cardiac Output
• Risk for ineffective Protection
• Disturbed Thought Processes
• Risk for impaired Skin Integrity
• Risk for impaired Oral Mucous Membrane
• Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
• Acute pain
• Disabled family coping
• Excess fluid volume
• Imbalanced nutrition: Less than body requirements
• Impaired gas exchange
• Impaired oral mucous membrane
• Impaired urinary elimination
• Ineffective coping
• Ineffective sexuality patterns
• Ineffective tissue perfusion: Renal
• Interrupted family processes
• Powerlessness
• Risk for infection
• Risk for injury

Common nursing diagnosis found in nursing care plans for Chronic Renal Failure CRF:  Risk for decreased Cardiac Out put, Risk for ineffective Protection, Disturbed Thought Processes, Risk for impaired Skin Integrity, Risk for impaired Oral Mucous Membrane, Deficient Knowledge [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs, Acute pain, Disabled family coping, Excess fluid volume, Imbalanced nutrition: Less than body requirements, Impaired gas exchange, Impaired oral mucous membrane, Impaired urinary elimination, Ineffective coping, Ineffective sexuality patterns, Ineffective tissue perfusion: Renal, Interrupted family processes, Powerlessness, Risk for infection, Risk for injury

Nursing Intervention Nursing Care Plans Chronic Renal Failure CRF

Nursing diagnosis Risk for decreased Cardiac Output

Risk factors may include

• Fluid imbalances affecting circulating volume, myocardial workload, and systemic vascular resistance (SVR)
• Alterations in rate, rhythm, cardiac conduction (electrolyte imbalances, hypoxia)
• Accumulation of toxins (urea), soft tissue calcification (deposition of calcium phosphate)

Desired Outcomes/Evaluation Criteria Client Will

Circulation Status: 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.

Nursing Intervention Nursing diagnosis Risk for decreased Cardiac Output:

• 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).
• 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.
• 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.
• 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.
• Assess activity level and response to activity. Rationale: Weakness can be attributed to heart failure and anemia.
• 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.
• 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.
• 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.

Nursing Diagnosis Risk for ineffective Protection

Risk factors may include:

• Abnormal blood profile decreased RBC production and survival, altered clotting factors (suppressed erythropoietin production or secretion).
• Increased capillary fragility

Desired Outcomes/Evaluation Criteria Client Will

• Experience no signs and symptoms of bleeding or hemorrhage.
• Maintain or demonstrate improvement in laboratory values.

Nursing Intervention nursing diagnosis Risk for ineffective Protection:

1. 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.
2. Monitor level of consciousness (LOC) and behavior. Rationale Anemia may cause cerebral hypoxia manifested by changes in mentation, orientation, and behavioral responses.
3. 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.
4. 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.
5. Hamates gastrointestinal (GI) secretions and stool for blood. Rationale Mucosal changes and altered platelet function due to uremia may result in gastric mucosal erosion and GI hemorrhage.
6. 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.
7. 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.
8. 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.

Nursing Diagnosis Disturbed Thought Processes

May be related to: Physiological changes accumulation of toxins, such as urea, ammonia; metabolic acidosis; hypoxia; electrolyte imbalances; calcifications in the brain

Desired Nursing Outcomes Evaluation Criteria Client Will:

• Regain or maintain optimal level of mentation.
• Identify ways to compensate for cognitive impairment and memory deficits.

Nursing Intervention nursing diagnosis Disturbed Thought Processes:

1. 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.
2. 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.
3. Reorient to surroundings, person, and so forth. Provide calendars, clocks, and outside window. Rationale Provides clues to aid in recognition of reality.
4. 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.
5. 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.
6. Establish a regular schedule for expected activities. Rationale Aids in maintaining reality orientation and may reduce fear and confusion.
7. Promote adequate rest and undisturbed periods for sleep Rationale Sleep deprivation may further impair cognitive abilities.
8. Provide supplemental oxygen (O2) as indicated. Rationale Correction of hypoxia alone can improve cognition.
9. Avoid use of barbiturates and opiates. Rationale Drugs normally detoxified in the kidneys will have increased half-life and cumulative effects, worsening confusion.

Nursing diagnosis Risk for impaired Skin Integrity

Risk factors may include:

• Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy)
• Changes in fluid status; alterations in skin turgor edema
• Reduced activity, immobility
• Accumulation of toxins in the skin

Desired Outcomes/Evaluation Criteria Client Will:

• Maintain intact skin.
• Risk Management
• Demonstrate behaviors and techniques to prevent skin breakdown or injury.

Intervention Nursing diagnosis Risk for impaired Skin Integrity:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. Keep linens dry and wrinkle free. Rationale Reduces dermal irritation and risk of skin breakdown.
7. 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.
8. 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.
9. Suggest wearing loose-fitting cotton garments. Rationale Prevents direct dermal irritation and promotes evaporation of moisture on the skin.
10. Provide foam or flotation mattress. Rationale Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia and necrosis.

Nursing Diagnosis Risk for impaired Oral Mucous Membrane

Risk factors may include

• Lack of or decreased salivation, fluid restrictions
• Chemical irritation, conversion of urea in saliva to ammonia

Desired Outcomes/Evaluation Criteria Client Will

• Oral Health
• Maintain integrity of mucous membranes.
• Identify and initiate specific interventions to promote healthy oral mucosa.

Nursing Intervention Nursing diagnosis Risk for impaired Oral Mucous Membrane:

1. Inspect oral cavity: note moistness, character of saliva, presence of inflammation, ulcerations, and leukoplakia. Rationale Provides opportunity for prompt intervention and prevention of infection.
2. Provide fluids throughout 24-hour period within prescribed limit. Rationale Prevents excessive oral dryness from prolonged period without oral intake.
3. 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.
4. 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.
5. 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.
6. Provide artificial saliva as needed, such as Oral-Lube. Rationale Prevents dryness, buffers acids, and promotes comfort.

Patient Teaching Discharge and Home Healthcare Guidelines

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.

Patient Teaching Discharge and Home Healthcare Guidelines Chronic Renal Failure CRF

• 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.
• In patient that requires dialysis, instruct him on how to adjust his medication schedule as needed in relation to dialysis care plan.
• Instruct the anemic patient to conserve energy by resting frequently.
• Tell the patient to report leg cramps or excessive muscle twitching.
• Explained to patients and family the importance of keeping follow-up appointments to have his electrolyte levels monitored.
• 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.
• Eat food before drinking fluids to alleviate dry mouth.
• If the patient requires dialysis, remember that he and family members are under extreme stress. If the facility doesn’t offer a course on dialysis nurses need to teach the patient and family members.
• 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.
• 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.
• Suggest that the patient wear a medical identification bracelet or carry pertinent information with him.
• Weigh self every morning to avoid fluid overload.
• Drink limited amounts of fluids only when thirsty.
• Measure allotted fluids, and save some for ice cubes; sucking on ice is thirst quenching.
• Use hard candy or chewing gum to moisten mouth.

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

Two primary types of Renal/kidneys dialysis

Peritoneal Dialysis

• Continuous Ambulatory Peritoneal Dialysis: Continuous ambulatory peritoneal dialysis (CAPD) is a form of intracorporeal dialysis that uses the peritoneum for the semi permeable membrane.
• 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.
• 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.

Hemodialysis

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.

Indications

1. Treatment for acute renal failure (ARF) or chronic end-stage renal disease (ESRD)
2. Emergency removal of toxins due to drug overdose, acute life-threatening hyperkalemia, severe acidosis, and uremia

Choice of dialysis is determined by three main factors.

1. Type of renal failure (acute or chronic)
2. Client’s particular physical condition
3. Access to dialysis resources

Nursing Diagnosis Renal dialysis. Primary focus is at the community level at the dialysis center, although inpatient acute stay may be required during initiation of therapy.

Nursing assessment for renal dialysis

Refer to Acute Renal Failure or Chronic Renal Failure, for assessment here

Nursing Diagnoses That Could Be Found In Patient with Renal Dialysis

• Imbalanced Nutrition: Less than Body Requirements
• Impaired physical Mobility
• Self-Care Deficit
• Risk for Constipation
• Risk for disturbed Thought Processes
• Anxiety [specify level]/Fear
• Disturbed Body Image/situational low Self-Esteem
• Deficient Knowledge  regarding condition, prognosis, treatment, self-care, and discharge needs

Nursing Care Plan for patient with Renal Dialysis. Common nursing diagnosis found in nursing Care Plan Renal Dialysis;  Imbalanced Nutrition: Less than Body Requirements, Impaired physical Mobility, Self-Care Deficit, Risk for Constipation, Risk for disturbed Thought Processes, Anxiety [specify level], Fear, Disturbed Body Image/situational low Self-Esteem, Deficient Knowledge  regarding condition, prognosis, treatment, self-care, and discharge needs.

Nursing Care Plan 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

Nursing Interventions Nursing Care Plan for patient with Renal Dialysis

1. 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
2. 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
3. Note presence of nausea and anorexia Rationale Symptoms accompany accumulation of endogenous toxins that can alter or reduce intake and require intervention
4. Encourage client to participate in menu planning Rationale May enhance oral intake and promote sense of control.
5. 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.
6. 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
7. Suggest socialization during meals Rationale Provides diversion and promotes social aspects of eating.
8. Encourage frequent mouth care Rationale Reduces discomfort of oral stomatitis and metallic taste in mouth associated with uremia, which can interfere with food intake
9. 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.
10. 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.
11. 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.
12. 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.

Complete Sample Nursing Care Plan for patient with Renal Dialysis

Patient Teaching Home Health Guidance for Patient with Renal Dialysis

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.

Lifestyle Management for Renal Dialysis

1. Dietary management involves restriction or adjustment of protein, sodium, potassium, or fluid intake.
2. Ongoing health care monitoring includes careful adjustment of medications that are normally excreted by the kidney or are dialyzable.
3. 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