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

Definition of Pneumothorax (collapsed lung), Pneumothorax is is defined as the presence of air in the pleural space. Air in the pleural space occurring spontaneously or from trauma. In patients with chest trauma, it is usually the result of a laceration to the lung parenchyma, tracheobronchial tree, or esophagus. The patient’s clinical status depends on the rate of air leakage and size of wound. The amount of air or gas trapped in the intrapleural space determines the degree of lung collapse.

Classification of Pneumothorax

• Spontaneous Pneumothorax sudden onset of air in the pleural space with deflation of the affected lung in the absence of trauma.
• Open Pneumothorax (sucking wound of chest) implies an opening in the chest wall large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration.
• Tension Pneumothorax buildup of air under pressure in the pleural space resulting in interference with filling of both the heart and lungs.
• Traumatic Pneumothorax; Traumatic Pneumothorax may result from insertion of a central venous line, thoracic surgery, or a penetrating chest injury, such as a gunshot or knife wound, or it may follow a transbronchial biopsy. It may also occur during thoracentesis or a closed pleural biopsy. When traumatic Pneumothorax follows a penetrating chest injury, hemothorax (blood in the pleural space) may also occur.

Other classification of Pneumothorax :

• Primary spontaneous Pneumothorax
• Secondary spontaneous Pneumothorax
• Iatrogenic Pneumothorax
• Traumatic Pneumothorax

Clinical Manifestations of Pneumothorax

• Hyperresonance; diminished breath sounds.
• Reduced mobility of affected half of thorax.
• Tracheal deviation away from affected side in tension pneumothorax
• Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, and cyanosis
• Mild to moderate dyspnea and chest discomfort may be present with spontaneous pneumothorax

Pneumothorax Etiology

• Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs
• Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis
• Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus
• Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries

Complications

• Acute respiratory failure.
• Cardiovascular collapse with tension Pneumothorax
• Hypoxemia

Pneumothorax Treatment. Treatment is conservative for spontaneous pneumothorax in which no signs of increased pleural pressure appear (indicating tension Pneumothorax), lung collapse is less than 30%, and the patient shows no signs of Dyspnea or other indications of physiologic compromise.  Such treatment consists of bed rest, careful monitoring of blood pressure, pulse rate, and respirations, oxygen administration, and  needle aspiration.

If more than 30% of the lung is collapsed, treatment to reexpand the lung includes placing a thoracostomy tube in the second or third intercostal space in the midclavicular line, connected to an underwater seal or low-pressure suction.

Oxygen therapy and mechanical ventilation are prescribed as needed. Surgical interventions include removing the penetrating object, exploratory thoracotomy if necessary, thoracentesis, and thoracotomy for patients with two or more episodes of spontaneous pneumothorax or patients with pneumothorax that does not resolve within 1 week.

Spontaneous Pneumothorax

• Treatment is generally nonoperative if Pneumothorax is not too extensive; Observe and allow for spontaneous resolution for less than 50% pneumothorax in otherwise healthy person, Needle aspiration or chest tube drainage may be necessary to achieve reexpansion of collapsed lung if greater than 30% pneumothorax.
• Surgical intervention by pleurodesis or thoracotomy with resection of apical blebs is advised for patients with recurrent spontaneous pneumothorax.

Tension Pneumothorax

• Immediate decompression to prevent cardiovascular collapse by thoracentesis or chest tube insertion to let air escape.
• Chest tube drainage with underwater-seal suction to allow for full lung expansion and healing

Open Pneumothorax

• Close the chest wound immediately to restore adequate ventilation and respiration. Patient is instructed to inhale and exhale gently against a closed glottis (Valsalva maneuver) as a pressure dressing (petroleum gauze secured with elastic adhesive) is applied. This maneuver helps to expand collapsed lung.
• Chest tube is inserted and water-seal drainage set up to permit evacuation of fluid/air and produce reexpansion of the lung.
• Surgical intervention may be necessary to repair trauma.

Recurring spontaneous pneumothorax treated by instilling a sclerosing agent through a thoracostomy tube or during thoracostomy. Thoracotomy and pleurectomy are other procedures that prevent recurrence by causing the lung to adhere to the parietal pleura. Traumatic and tension pneumothoraces require chest tube drainage. Traumatic Pneumothorax may also require surgical repair.

Nursing Diagnosis Pneumothorax
Nursing Assessment Pneumothorax

Patient History, Obtain history for chronic respiratory disease, trauma, and onset of symptoms. The patient history reveals sudden, sharp, pleuritic pain. The patient may report that chest movement, breathing, and coughing exacerbate the pain. He may also report shortness of breath.

Ask about chest pain; determine its onset, intensity, and location. Ask if the patient has shortness of breath or difficulty in breathing or fatigue. Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Ask if the patient smokes cigarettes

For patients who have experienced chest trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. Specify the type of trauma (blunt or penetrating).

Physical Examination

The severity of the symptoms depends on the extent of any underlying disease and the amount of air in the pleural space. Examine the patient’s chest for a visible wound that may have been caused by a penetrating object. Patients with an open Pneumothorax also exhibit a sucking sound on inspiration.

Inspection typically reveals asymmetrical chest wall movement with overexpansion and rigidity on the affected side. The patient may appear cyanotic. In tension pneumothorax, he may have distended neck veins and pallor, and he may exhibit anxiety. Observe whether the patient has a flail chest. Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe the patient carefully for pallor. Take the patient’s blood pressure and pulse rate, noting the early signs of shock or massive bleeding, such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. Continue to monitor the vital signs frequently during periods of instability to determine changes in the condition or the development of complications.

Palpation, note any tracheal deviation toward the unaffected side, subcutaneous emphysema (also known as crepitus; a dry, crackling sound caused by air trapped in the subcutaneous tissues), or decreased to absent tactile fremitus over the affected area. Percussion may elicit a hyperresonant or tympanitic sound.

Auscultation reveals decreased or absent breath sounds over the affected area and no adventitious sounds other than a possible pleural rub. Auscultate chest for diminished breath sounds and percuss for hyperresonance.

Percussion may reveals hyperresonance on the affected side

Diagnostic Test For Pneumothorax

Blood Tests

• Arterial blood gases (ABGs): Measures oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia.
• Hemoglobin/hematocrit (Hgb/Hct): Assesses relationship of red blood cells (RBCs) to fluid volume or viscosity.

Other Diagnostic Studies

• Chest x-ray: Evaluates organs or structures within the chest and is the initial study of choice in blunt force chest trauma.
• Thoracic computed tomography (CT): Enhance anatomic views of the chest and locates abnormalities. Early CT may influence therapeutic management.
• Thoracic ultrasound: Assists in determining abnormalities in the chest.
• Thoracentesis: Performed to relieve the intrathoracic pressure due to accumulation of fluid in the pleural space.

Nursing diagnosis Pneumothorax

Common Nursing Diagnosis That Could Be Found In Patient with Pneumothorax:

• Ineffective Breathing Pattern
• Risk for Trauma/Suffocation
• Deficient Knowledge [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs
• Acute pain
• Anxiety
• Fear
• Impaired gas exchange related to decreased oxygen diffusion capacity
• Ineffective coping
• Ineffective tissue perfusion: Cardiopulmonary
• Risk for infection

Common Nursing Diagnosis That Could Be Found In Nursing care plans for Pneumothorax:  Ineffective Breathing Pattern, Risk for Trauma/Suffocation, Deficient Knowledge,  Acute pain, Anxiety,  Fear, Impaired gas exchange, Ineffective coping,  Ineffective tissue perfusion: Cardiopulmonary,  Risk for infection.

Nursing diagnosis:

Ineffective Breathing Pattern related to: Decreased lung expansion due to air or fluid accumulation, musculoskeletal impairment, Pain and anxiety, inflammatory process

Nursing Interventions Nursing Diagnosis Ineffective Breathing Pattern

Respiratory Monitoring

1. Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.
2. Evaluate respiratory function, noting rapid or shallow respirations, Dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.
3. Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
4. Auscultate breath sounds.
5. Note chest excursion and position of trachea.
6. Assess fremitus.

Ventilation Assistance

1. Assist client with splinting painful area when coughing, or during deep breathing.
2. Maintain position of comfort, usually with head of bed elevated. Turn to affected side.  Encourage client to sit up as much as possible.
3. Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.

Tube Care: Chest

1. If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once.
2. After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage.

Ventilation Assistance

1. Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.
2. Administer supplemental oxygen via cannula, mask, or mechanical ventilation, as indicated.
3. Administer analgesics and sedatives, as indicated.

Complete Sample Nursing Care Plans for Pneumothorax

Patient teaching for Pneumothorax

Patient teaching Discharge and home healthcare guidance for patient with Pneumothorax; Review all follow-up appointments, which often involve chest x-rays, arterial blood gas analysis, and a physical exam. Refer for counseling, if necessary. Teach the patient when to notify the physician of complications and to report any sudden chest pain or difficulty breathing

Patient teaching Discharge and home healthcare guidance for patient with Pneumothorax

• Reassure the patient. Explain what Pneumothorax is, what causes it, and all diagnostic tests and procedures.
• If the patient is having surgery or chest tubes inserted, explain why he needs these procedures. Reassure him that the chest tubes are inserted to make him more comfortable.
• Encourage the patient to perform deep-breathing exercises every hour when awake.
• Discuss the potential for recurrent spontaneous Pneumothorax, and review its signs and symptoms. Emphasize the need for immediate medical intervention if these should occur.
• Instruct patient to continue use of the incentive spirometer at home.
• For patients with spontaneous Pneumothorax, there is an increased risk for repeat occurrence; therefore, encourage these patients to report sudden Dyspnea immediately.

Nursing Care Plans for Bone Fractures. Common nursing diagnosis for bone fractures:  Acute pain, Anxiety, Bathing or hygiene self-care deficit, Fear, Impaired physical mobility, Ineffective coping, Ineffective role performance, Ineffective tissue perfusion: Peripheral, Risk for deficient fluid volume, Risk for disuse syndrome, Risk for infection, Risk for injury, risk for [additional] Trauma.

Nursing Goals Nursing Care Plans for Bone Fractures

• Pain controlled.
• Prevented or minimized Complications
• Fracture stabilized.
• Condition, prognosis, and therapeutic regimen understood.
• Plan in place to meet needs after discharge.

Nursing Care Plans for Bone Fractures with nursing diagnosis Acute pain

Patient Teaching Discharge and Home Healthcare Guidelines for Fractures

Patient Teaching Discharge and Home Health care Guidelines for fractures patient. To prevent complications of prolonged immobility, encourage the patient to participate in physical and occupational therapy as prescribed. Verify that the patient has demonstrated safe use of assistive devices such as wheelchairs, crutches, walkers, and transfers. Teach the patient the purpose, dosage, schedule, precautions, and potential side effects, interactions, and adverse reactions of all prescribed medications. Review with the patient all follow-up appointments that are arranged. If home care is necessary, verify that appropriate arrangements have been completed.

• Help the patient set realistic goals for recovery.
• Show the patient how to use his crutches properly.
• Tell the patient with a cast to report immediately signs of impaired circulation (skin coldness, numbness, tingling, or discoloration).
• Warn the patient against getting the cast wet, and instruct him not to insert foreign objects under the cast.
• Teach the patient to exercise joints above and below the cast as ordered.
• Tell the patient not to walk on a leg cast or foot cast without the physician’s permission.
• Emphasize the importance of returning for follow-up care.

A fracture, or discontinuity of the bone, is the most common type of bone lesion. Normal bone can withstand considerable compression and shearing forces and, to a lesser extent, tension forces. A fracture occurs when more stress is placed on the bone than it is able to absorb.

A bone fracture is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impactor stress, or trivial injury as a result of certain medical conditions that weaken the bones, such asosteoporosis, bone cancer, or osteogenesis imperfecta, where the fracture is then termedpathological fracture.

(http://en.wikipedia.org/wiki/Bone_fracture)

Cause for Bone Fractures

Bone Fractures Grouped according to cause, fractures can be divided into three major categories:

• Fractures caused by sudden injury

The most common fractures result from major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle accident, and child, spouse, or elder abuse (shown by multiple or repeated episodes of fractures). The force causing the fracture may be direct, such as a fall, or indirect, such as a massive muscle contraction or trauma transmitted along the bone. For example, the head of the radius or clavicle can be fractured by the indirect forces that result from falling on an outstretched hand.

• Fatigue or stress fractures

A fatigue fracture results from repeated wear on a bone. Pain associated with overuse injuries of the lower extremities, especially posterior medial tibial pain, is one of the most common symptoms that physically active persons, such as runners, experience Stress fractures in the tibia.

• Pathologic fractures.

A pathologic fracture is fracture that occurs when the normal integrity and strength of bone have been compromised by invasive disease or destructive processes or tumors. Fractures of this type may occur spontaneously with little or no stress. The underlying disease state can be local, as with infections, cysts, or tumors, or it can be generalized, as in osteoporosis, Paget’s disease, or disseminated tumors.

Classification of Bone Fractures

Fractures usually are classified according to:

• Location
• Type
• Direction or pattern of the fracture line.

Fragment position

• Angulated, Bone fragments are at an angle to each other

• Avulsed, Bone fragments are pulled from normal position by muscle spasms, muscle contractions, or ligament resistance

• Comminuted, Bone breaks into many small pieces

• Displaced, Bone fragments separate and are deformed

• Impacted, A bone fragment is forced into another bone or bone fragment

• Nondisplaced, After the fracture, two sections of the bone maintain normal alignment

• Overriding,  Bone fragments overlap, thereby shortening the total length of the bone

• Segmental

Fracture line

• Linear Fracture line is parallel to the axis of the bone
• Longitudinal Fracture line extends longitudinally but not parallel to the axis of the bone
• Oblique Fracture line crosses the bone at a 45-degree angle to the axis of the bone
• Spiral Fracture line coils around the bone
• Transverse Fracture line forms a 90-degree angle to the axis of the bone

A fracture of the long bone is described in relation to its position in the boneproximal, midshaft, and distal. Other descriptions are used when the fracture affects the head or neck of a bone, involves a joint, or is near a prominence such as a condyle or malleolus. The type of fracture is determined by its communication with the external environment, the degree of break in continuity of the bone, and the character of the fracture pieces.10

A fracture can be classified as open or closed. When the bone fragments have broken through the skin, the fracture is called an open or compound fracture. In a closed fracture, there is no communication with the outside skin.

The degree of a fracture is described in terms of a partial or complete break in the continuity of bone. A greenstick fracture, which is seen in children, is an example of a partial break in bone continuity and resembles that seen when a young sapling is broken. This kind of break occurs because children’s bones, especially until approximately 10 years of age, are more resilient than the bones of adults.

The character of the fracture pieces may also be used to describe a fracture. A comminuted fracture has more than two pieces. A compression fracture, as occurs in the vertebral body, involves two bones that are crushed or squeezed together. A fracture is called impacted when the fracture fragments are wedged together. This type usually occurs in the humerus, often is less serious, and usually is treated without surgery. Segmental fracture Bone fractures occur in two areas next to each other with an isolated section in the center

The direction of the trauma produces a certain configuration or pattern of fracture. Reduction is the restoration of a fractured bone to its normal anatomic position. The pattern of a fracture indicates the nature of the trauma and provides information about the easiest method for reduction. Linear  fractures, Fracture line is parallel to the axis of the bone Transverse fractures are caused by simple angulatory forces. A spiral fracture results from a twisting motion, or torque. A transverse fracture is not likely to become displaced

Nursing Care Plans for Fractures

Nursing Diagnosis for Fractures

Treatment for Bone Fractures

The primary goals of treatment are to return the injured limb to maximal function, to prevent complications, and to obtain the best possible cosmetic results. Emergency treatment consists of splinting the limb above and below the suspected fracture where it lies, applying a cold pack, and elevating the limb, all of which reduce edema and pain. A severe fracture that causes blood loss calls for direct pressure to control bleeding. The patient with a severe fracture may also need fluid replacement (including blood products) to prevent or treat hypovolemic shock.

Treatment Options for Bone Fractures

Treatment Options to set a Bone Fractures depends on the location and severity of the injury. To heal a bone fractures properly, the fractured bone must be realigned. The most common realignment procedures are:

• Immobilization using a cast or splint
• Setting of bone through surgery. Advantages of surgery include: early mobility of injured bone and some use of the injured bone within weeks rather than months.

After the bone is realigned properly, medication and rehabilitation will help the recovery process. Medication is used to lessen the pain. Rehabilitation prevents stiffness. Rehabilitation involves light movement of the tissues surrounding the injury. It helps increase blood flow which will aid the healing process.

• Nonoperative Management

Until comparatively recently, nonoperative treatment was the only method of treating fractures and severe soft tissue injuries, but the introduction of anesthesia, antibiotics, improved surgical implants, and better operative techniques has changed the treatment of many fractures. The process of change continues, and probably fewer fractures will be managed nonoperatively as the functional benefits of operative treatment become more apparent to both surgeons and patients.

1. TRACTION: Skeletal Traction, Spinal Traction,
2. CASTS Braces
3. Slings, Bandages, and Support Strapping

skeletal traction

Operative Management

When closed reduction is impossible, open reduction during surgery use to reduces and immobilizes the fracture by means of rods, plates, or screws

1. Plating
2. Intramedullary Nailing
3. Kirschner wires
4. External Fixation
5. Arthroplasty
6. Amputations

Complications for Bone Fractures

Possible complications of fractures include arterial damage, nonunion, fat embolism, infection, shock, avascular necrosis, and peripheral nerve damage. Acute Compartment Syndrome Nonunions and Bone Defects

Nursing diagnosis for bone fractures

Nursing diagnosis for bone fractures determine by data that we found in nursing assessment :

Nursing Assessment nursing care plans for bone fractures

Assessment on patient’s history usually reveals what caused the fracture, major trauma, such as a fall on an outstretched arm, a skiing or motor vehicle accident, or elder abuse. The patient typically reports pain that increases with movement and an inability to move the part of the arm or leg distal to the injury. The severity of the pain depends on the fracture type. The patient may also complain of a tingling sensation distal to the injury, possibly indicating nerve and vessel damage.

Inspection may disclose soft-tissue edema, an obvious deformity or shortening of the injured limb, and discoloration over the fracture site. Open fractures produce an obvious skin wound and bleeding. Gentle palpation usually reveals warmth, crepitus and, possibly, dislocation. Numbness distal to the injury and cool skin at the end of the extremity may indicate nerve and vessel damage.

Auscultation may reveal loss of pulses distal to the injury, an indication of possible arterial compromise or nerve damage.

Palpation pulses in distal of the fracture to detect injury to blood vessels, which is a surgical emergency

Diagnostic tests for Bone Fractures

• Anteroposterior and lateral X-rays of the suspected fracture, as well as X-rays of the joints above and below it, confirm the diagnosis.
• Angiography can reveal concurrent vascular injury.
• MRI or CT Scan of spine if suspect a bone tumor or compression of spinal cord
• Bone densitometry can predict an increased risk of osteoporosis usually in pathologic fractures
• Blood tests

• Acute pain
• Anxiety
• Bathing or hygiene self-care deficit
• Fear
• Impaired physical mobility
• Ineffective coping
• Ineffective role performance
• Ineffective tissue perfusion: Peripheral
• Risk for deficient fluid volume
• Risk for disuse syndrome
• Risk for infection
• Risk for injury

Nursing Care Plans for Bone Fractures

Appendicitis

Nursing Care Plans For Appendicitis, Appendicitis is an acute inflammation of the vermiform appendix, a narrow, blind tube that extends from the inferior part of the cecum just below the ileocecal valve. Although the appendix has no known function, it does regularly fill and empty itself of food. Appendicitis occurs when the appendix becomes inflamed from ulceration of the mucosa or obstruction of the lumen. If untreated, this disease is fatal.

Causes For Appendicitis

Obstruction of the vermiform appendix. Since the appendix is a small, finger-like Appendage of the cecum, it is prone to obstruction as it regularly fills and empties with intestinal contents. obstruction caused by a fecal mass, stricture, barium ingestion, or viral infection. This obstruction sets off an inflammatory process that can lead to infection, thrombosis, necrosis, and perforation.

Complications For Appendicitis

Common complication of appendicitis:

• Appendix ruptures or Perforates.
• Peritonitis.

Other complications include:

• Appendiceal abscess
• Pyelophlebitis.

Diagnostik tes

• Complete blood count
• Abdominal ultrasound
• Abdominal computed tomography (CT) scan

Nursing Assessment Nursing Care Plans For Appendicitis

Because other disorders can mimic appendicitis in sign and symptoms, diagnosis must rule out illnesses with similar symptoms: bladder infection, gastroenteritis, ileitis, colitis, acute salpingitis, tubo-ovarian abscess, diverticulitis, gastritis, ovarian cyst, pancreatitis, renal colic, and uterine disease

• Patients history of midabdominal pain as the disease process progresses, patients usually complain of a constant epigastric or periumbilical pain that eventually localizes in the right lower quadrant of the abdomen.
• The patient may also report anorexia, nausea, one or two episodes of vomiting, and a low-grade fever. Later signs and symptoms include malaise, constipation and, rarely, diarrhea.
• Inspection typically shows a patient who walks bent over to reduce right lower quadrant pain. When sleeping or lying in a supine position, he may keep his right knee bent up to decrease pain.
• Auscultation usually reveals normal bowel sounds.
• Palpation and percussion disclose no localized abdominal findings except diffuse tenderness in the midepigastric area and around the umbilicus. Tenderness in the right lowers abdominal. There may be pain in the right lower quadrant resulting from palpating the lower left quadrant (Rovsing’s sign).

Appendicitis Treatment

1. Appendectomy
2. If peritonitis develops, treatment involves GI intubation, parenteral replacement of fluids and electrolytes, and administration of antibiotics.

Nursing diagnosis Nursing Care Plans For Appendicitis

Common nursing diagnosis found in Nursing Care Plans For Appendicitis

• Acute pain
• Imbalanced nutrition: Less than body requirements
• Impaired skin integrity
• Ineffective tissue perfusion: GI
• Risk for deficient fluid volume
• Risk for infection
• Risk for injury

Nursing Key outcomes, Interventions and patients teaching Nursing Care Plans for Appendicitis

Nursing care plans for Dementia

Nursing care plans for Dementia, Dementia is a chronic disturbance involving multiple cognitive deficits, including memory impairment. Dementia is characterized by chronicity and deterioration of selective mental functions. Onset is insidious over months to years in most cases. Dementia is usually progressive, more common in the elderly, and rarely reversible even if underlying disease can be corrected. Dementia can be classified as cortical or subcortical.

Type of Dementia

There are three types of cortical dementia:

• Primary degenerative dementia (eg, Alzheimer dementia), accounting for about 50–60% of cases.
• atherosclerotic (multi-infarct) dementia, 15–20% of cases (this figure is probably low because of the tendency to overuse the diagnosis of Alzheimer dementia)
• Mixtures of the first two types or dementia due to miscellaneous causes, 15–20% of cases . Examples of primary degenerative dementia are Alzheimer dementia (most common) and Pick, Creutzfeldt-Jakob, and Huntington dementias (less common).

In all types, loss of impulse control (sexual and language) is common. The tenuous level of functioning makes the individual most susceptible to minor physical and psychological stresses. The course depends on the underlying cause, and the general trend is steady deterioration.

Pseudodementia is a term applied to depressed patients who appear to be demented. These patients are often identifiable by their tendency to complain about memory problems vociferously rather than try to cover them up. They usually say they can’t complete cognitive tasks but with encouragement can often do so. They can be considered to have depression-induced reversible dementia that remits when the depression resolves.

Causes of dementia

• CNS pathology: head trauma, hypertensive cerebral changes, seizures, tumors
• Endocrinopathies: thyroidism, parathyroidism
• Hypoxemia
• Hypothermia or hyperthermia
• Substance intoxication or abstinence and withdrawal states
• Exposure to certain metals, toxins, or drugs
• Metabolic: diabetic acidosis, hypoglycemia, acid-base imbalances
• Hepatic encephalopathy
• Thiamine deficiency
• Postoperative states
• Psychosocial stressors: relocation stress, sensory deprivation or overload, sleep deprivation, immobilization.

Pathophysiology

Primary Dementia :

• Primary dementias are degenerative disorders that are progressive, irreversible, and not due to any other condition. Specific disorders are dementia of the Alzheimer’s type (DAT) and vascular dementia (formerly multi-infarct dementia). DAT demonstrates progression of symptoms from the initial stage, which is characterized by mild cognitive deficits in the area of short-term memory and accomplishment of goal-directed activity, to the final stage in which profound impairment occurs in the areas of cognition and self-care abilities. Research is ongoing; however, DAT is believed to have multiple causative factors.
• Genetic factors:

1. Familial Alzheimer’s disease is associated with abnormal genes on chromosomes 1, 14, and 21. In particular, with genes located on these chromosomes (1 and 14) that encode for amyloid precursor protein which leads to accumulation of the amyloid beta-peptide in plaques.
2. A specific cholesterol-bearing protein, apolipoprotein E4 (Apo E4), is found on chromosome 19 twice as often in people with DAT as in the general population.

• Biochemical and brain structural factors:

1. The neurotransmitter acetylcholine has been implicated in terms of relative deficit and/or receptor abnormalities as related to Alzheimer’s disease.
2. Autopsy findings reveal presence of brain changes, that is, the presence of amyloid plaques and neurofibrillary tangles associated with nerve cell destruction.
3. Additional areas of investigation include:

• Slow viral infection.
• Autoimmune processes.
• Head trauma.

Secondary Dementia:

Occur as a result of another pathologic process.

• Infection-related dementias
  • Acquired immunodeficiency syndrome
  • Chronic meningitis
  • Creutzfeldt-Jakob disease
  • Progressive multifocal leukoencephalopathy
  • Postencephalitic dementia syndrome
  • Syphilis
  • Subacute sclerosing panencephalitis
  • Tuberculosis
• Subcortical degenerative disorders
  • Huntington’s disease
  • Parkinson’s disease
  • Wilson’s disease
  • Thalamic dementia
• Hydrocephalic dementias
• Vascular dementias
• Traumatic conditions, such as posttraumatic encephalopathy and subdural hematoma
• Neoplastic dementias
  • Glioma
  • Meningioma
  • Meningeal carcinomatosis
  • Metastatic deposits
• Inflammatory conditions, such as sarcoidosis, systemic lupus erythematosus, and temporal arteritis
• Toxic conditions, such as alcohol-related syndrome and iatrogenic dementias (anticonvulsant, anticholinergic, antihypertensive, psychotropic drugs)
• Metabolic disorders
  • Anemias
  • Deficiency states (minerals and vitamins)
  • Cardiac or pulmonary failure
  • Hepatic encephalopathy
  • Porphyria (deficiency in enzymes involved in heme synthesis)
  • Uremia

Clinical Manifestations for dementia

Not all of these features will be present in every person, nor will every person go through every stage and phase of dementia Slow, insidious onset, Impaired long- and short-term memory, Deterioration of cognitive abilities judgment, abstract thinking, Often irreversible if untreated, Personality changes, No or slow EEG changes.

Early dementia

• Appear more apathetic, with less sparkle.
• Lose interest in hobbies or activities.
• Be unwilling to try new things.
• Be unable to adapt to change.
• Show poor judgement and make poor decisions.
• Be slower to grasp complex ideas and take longer with routine jobs.
• Blame others for ‘stealing’ lost items.
• Become more self-centred and less concerned with others and their feelings.
• Become more forgetful of details of recent events.
• Be more likely to repeat themselves or lose the thread of their conversation.
• Be more irritable or upset if they fail at something.
• Have difficulty handling money.

Moderate dementia

• Be very forgetful of recent events. Memory for the distant past seems better, but some details may be forgotten or confused.
• Be confused regarding time and place.
• Become lost if away from familiar surroundings.
• Forget names of family or friends, or confuse one family member with another.
• Forget saucepans and kettles on the stove. May leave gas unlit.
• Wander around streets, perhaps at night, sometimes becoming lost.
• Behave inappropriately – for example, going outdoors in their nightwear.
• See or hear things that are not there.
• Become very repetitive.
• Be neglectful of hygiene or eating.
• Become angry, upset or distressed through frustration.

Severe dementia

• Be unable to remember – for even a few minutes – that they have had, for example, a meal.
• Lose their ability to understand or use speech.
• Be incontinent.
• Show no recognition of friends and family.
• Need help with eating, washing, bathing, using the toilet or dressing.
• Fail to recognise everyday objects.
• Be disturbed at night.
• Be restless, perhaps looking for a long dead relative.
• Be aggressive, especially when feeling threatened or closed in.
• Have difficulty walking, eventually perhaps becoming confined to a wheelchair.
• Have uncontrolled movements.

Dementia Treatment

• Treatment is generally community focused; the goal of treatment is to maintain the quality of life as long as possible despite the progressive nature of the disease. Effective treatment is based on:
  • Diagnosis of primary illness and concurrent psychiatric disorders
  • Assessment of auditory and visual impairment
  • Measurement of the degree, nature, and progression of cognitive deficits
  • Assessment of functional capacity and ability for self-care
  • Family and social system assessment
• Environmental strategies in order to assist in maintaining the safety and functional abilities of the patient as long as possible.
• Pharmacologic therapy used for the person with DAT is directed toward the use of anticholinesterase drugs to slow the progression of the disorder by increasing the relative amount of acetylcholine. Available drugs include donepezil (Aricept), galantamine (Reminyl), rivastigmine (Exelon) and tacrine (Cognex). An NMDA-receptor antagonist memantine (Namenda) may be provided in an attempt to improve cognition. Other drugs may be used for behavioral control and symptom reduction.
  • Agitation management: neuroleptic drugs
  • Psychosis: neuroleptic drugs
  • Depression: antidepressants, ECT
• Hypertension management in vascular dementia is important in reducing the severity of symptoms.
• Family education is a treatment strategy because statistics indicate that family caregivers provide care for patients with DAT in 7 out of 10 cases. The family and the treatment team collaborate in the delivery of care.

Complications for dementia

• Without accurate diagnosis and treatment, secondary dementias may become permanent.
• Falls with serious orthopedic or cerebral injuries.
• Self-inflicted injuries.
• Aggression or violence toward self, others, or property.
• Wandering events, in which the person can get lost and potentially suffer exposure, hypothermia, injury, and even death.
• Serious depression is demonstrated in caregivers who receive inadequate support.
• Caregiver stress and burden may result in patient neglect or abuse.

Nursing Process Nursing Care Plans For Dementia

Nursing Assessment Nursing Care Plans For Dementia

• Assess the onset and characteristics of symptoms (determine type and stage of disorder).
• Establish cognitive status using standard measurement tools.
• Determine self-care abilities.
• Assess threats to physical safety (eg, wandering, poor reality testing).
• Assess affect and emotional responsiveness.
• Assess ability and level of support available to caregivers.

Nursing Diagnosis Nursing Care Plans for Dementia

• Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding
• Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs
• Risk for Injury related to cognitive impairment and wandering behavior
• Impaired Social Interaction related to cognitive impairment
• Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places

Interventions and Evaluation Nursing Care Plans For Dementia

NO	DIAGNOSIS	OUTCOME	INTERVENTION	EVALUATION
1	Impaired Communication related to cerebral impairment as demonstrated by altered memory, judgment, and word finding	Demonstrate congruent verbal and nonverbal communication.	Speak slowly and use short, simple words and phrases. Consistently identify yourself, and address the person by name at each meeting. Focus on one piece of information at a time. Review what has been discussed with patient. If patient has vision or hearing disturbances, have him wear prescription eyeglasses and/or a hearing device. Keep environment well lit. Use clocks, calendars, and familiar personal effects in the patient’s view. If patient becomes verbally aggressive, identify and acknowledge feelings. If patient becomes aggressive, shift the topic to a safer, more familiar one. If patient becomes delusional, acknowledge feelings and reinforce reality. Do not attempt to challenge the content of the delusion.	Demonstrates decreased anxiety and increased feelings of security in supportive environment
2	Bathing or Hygiene Self-Care Deficit related to cognitive impairment as demonstrated by inattention and inability to complete ADLs	Independence in Self-Care	Assess and monitor patient’s ability to perform ADLs. Encourage decision making regarding ADLs as much as possible. Label clothes with patient’s name, address, and telephone number. Use clothing with elastic and Velcro for fastenings rather than buttons or zippers, which may be too difficult for patient to manipulate. Monitor food and fluid intake. Weigh patient weekly. Provide food that patient can eat while moving. Sit with patient during meals and assist by cueing. Initiate a bowel and bladder program early in the disease process to maintain continence and prevent constipation or urine retention	Maintains maximum degree of orientation and self-care within level of ability
3	Risk for Injury related to cognitive impairment and wandering behavior	Safety appears	Discuss restriction of driving when recommended. Assess patient’s home for safety: remove throw rugs, label rooms, and keep the house well lit. Assess community for safety. Alert neighbors about the patient’s wandering behavior. Alert police and have current pictures taken. Provide patient with a MedicAlert bracelet. Install complex safety locks on doors to outside or basement. Install safety bars in bathroom. Closely observe patient while he is smoking. Encourage physical activity during the daytime. Give patient a card with simple instructions (address and phone number) should the patient get lost. Use night-lights. Install alarm and sensor devices on doors.	Safety precautions and close surveillance maintained; no injury
4	Impaired Social Interaction related to cognitive impairment	Socialization increase	Provide magazines with pictures as reading and language abilities diminish. Encourage participation in simple, familiar group activities, such as singing, reminiscing, doing puzzles, and painting. Encourage participation in simple activities that promote the exercise of large muscle groups.	Attends group activities; sings, exercises with group
5	Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places	Risk for violence is not appears	Respond calmly and do not raise your voice. Remove objects that might be used to harm self or others. Identify stressors that increase agitation. Distract patient when an upsetting situation develops.	Decreased occurrence of acting-out behaviors

]]> http://www.lifenurses.com/nursing-care-plans-for-dementia/feed/ 0