What is a nursing diagnosis? Definition of Nursing Diagnosis A nursing diagnosis is the part of the nursing process, is clinical judgment about individual, family, or community responses to actual or potential health/life processes.  Nursing diagnosis are developed based on data obtained during nursing assessment. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

 Nursing Diagnosis Have two related meanings:

• Nursing diagnosis is an action: the process of analyzing assessment data to arrive at a nursing diagnosis!
• Nursing diagnosis is a label that describes the patient’s response to an actual or potential health problem

How do nurses make a Nursing Diagnosis?

1. Analyze collected data
2. Identify the client’s strengths
3. Identify the client’s normal functional level and indicators of actual or potential dysfunction
4. Formulate a diagnostic statement in relations to this synthesis

Benefits of Nursing Diagnosis

• Gives nurses a common language
• Promotes identification of appropriate expected outcomes
• Provides acuity information
• Can create a standard for nursing practice
• Provide a quality improvement base
• Promotes improved communication among nurses, other healthcare providers, and alternate care settings

Nursing Diagnosis VS Medical Diagnosis

Steps of Developing Nursing Diagnosis

Identify patterns

• Review data and look for cues
• Cluster cues (signs and symptoms)
• Synthesizing the cue clusters
• Three questions to ask self  (What are my concerns about this client, Can I or am I doing something about it, Can the overall risk be decreased by nursing interventions)

Synthesis the data

Look at all data as a whole to provide a comprehensive picture of the client in relation to past, present, and future health status

Validate the diagnosis

Test for a fit, Refer to the NANDA Diagnosis and defining characteristics. Then, compare the assessed possible ETIOLOGY with NANDA’s RELATED FACTORS or RISK FACTORS. Next, compare the assessed client cues with NANDA’s Defining Characteristics, which are used to support and provide an increased level of confidence in your selected nursing diagnosis.

Formulate the nursing diagnosis statement using nursing language

NANDA

Types of Nursing Diagnosis

• Actual Nursing Diagnosis

A client problem that is present at the time of the nursing assessment. It is based on the presence of signs and symptoms. Can be documented from assessment

• Risk Nursing Diagnosis

Risk Nursing diagnosis, a clinical judgment that the client is more vulnerable to develop this problem than others in the same or similar situation. A clinical judgment that a problem does not exist, therefore no S/S are present. This diagnosis indicates from the data, a strong likelihood that it will occur if actions are not taken by the nurses.  The Risk diagnosis only has 2 parts.  It can be used with any NANDA diagnosis

• Potential Nursing Diagnosis

This is also known as a collaborative diagnosis. one in which evidence about a health problem is incomplete or unclear therefore requires more data to support or reject it, or the causative factors are unknown but a problem is only considered possible to occur. This is a problem the nurse cannot treat independently. Nursing care will focus on monitoring and preventing the problem. A collaborative diagnosis can be written as a one or two part statement.

• Wellness Nursing Diagnosis

Potential for enhancement of current well state, this diagnosis involves a judgment about an individual, family or community in transition from one level of wellness to a higher level of wellness.

• Syndrome Nursing Diagnosis

Associated with a cluster of other diagnoses

Components of Nursing Diagnosis

Diagnostic Label

• P  Problem, Name of the nursing diagnosis as listed in the taxonomy, describes the problem using as few words as possible. DO NOT use the medical diagnosis. Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation

• Qualifier, Used to give additional meaning to the Nursing Diagnosis. words added to the diagnostic label/problem statement to gain additional meaning

• E Etiology. This is the “related to, R/T” portion of the diagnosis. What caused the client to have the problem listed? Do Not use the medical diagnosis, Must be a problem the nurse and/or client can change to do something about
• S Symptom. These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis. Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the Nursing Diagnosis

 Problems to avoid in writing Nursing Diagnosis

• Don’t confuse the etiology with the problem
• Do not use the medical diagnosis.
• Must be a problem the nurse and/or client can change to do something about. Relating the problem to an unchangeable situation
• Focus on the human responses to the problem
• Avoid the use of one piece of assessment data as a Nursing Diagnosis(EDEMA)
• Be specific
• Don’t combine NDX
• Don’t relate one Nursing Diagnosis to another.  There is a different related to factor if this is a valid Nursing Diagnosis
• Nursing interventions should not be included in the Nursing Diagnosis
• Keep your language non-judgmental
• Don’t make assumptions or statements you can’t prove with assessment data
• Be sure your statement is legally advisable

NANDA Nursing Diagnosis for Acute Pain Related factors R/T trauma, injuring agents (biological, chemical, physical, psychological)

Suggestion on using NANDA Nursing Diagnosis Acute Pain: Distinguish between acute pain Nursing diagnosis with the chronicles pain Nursing diagnosis. One of the two sets is that diagnosis of a painful time. ONSET acute pain is less than 6 months, while the painful chronicles ONSET it is more than 6 months.  If you only have two diagnoses to indicate, pain is acute pain and chronic pain. Thus, there is no automatic diagnosis Crashes feel comfortable or feel comfortable painful chronic pain.

Definition Nursing Diagnosis for Acute Pain:

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Nursing Outcomes Client Will:

• Report pain is relieved / controlled.
• Follow prescribed pharmacological regimen.
• Verbalize methods that provide relief.
• Demonstrate use of relaxation skills and diversion activities as indicated for individual situation.

Nursing Priority Nursing Diagnosis for Acute Pain

• To assess etiology/precipitating contributory factors:
• evaluate client’s response to pain:
• assist client to explore methods for alleviation/control of pain

Sample Clinical Applications using Nursing Diagnosis for Acute Pain:

Traumatic injuries, surgical procedures, infections, cancer, burns, skin lesions, gangrene, thrombophlebitis/pulmonary embolus, neuralgia

Gout/Gouty Arthritis

Gout also known as gouty arthritis is a metabolic disease marked by monosodium urate deposits that cause red, swollen, and acutely painful joints. Gout can affect any joint but mostly affects those in the feet, especially the great toe, ankle, and midfoot. Gout is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis (red, tender, hot, swollen joint). It is caused by elevated levels of uric acid in the blood. The uric acid crystallizes and deposits in joints, tendons, and surrounding tissues. Gout affects 1% of Western populations at some point in their lives. Gout is caused by an increased level of uric acid in the blood, salts of which are deposited in the joints. It mostly occurs in middle-aged men and almost always involves pain at the base of the great toe. Gout may result from a primary metabolic disturbance or may be a secondary effect of another disease, as of the kidneys.Gout is treated with drugs to suppress formation of uric acid or to increase elimination of uric acid. Patients who receive treatment for gout have a good prognosis.

The final, unremitting stage of the disease (also known as tophaceous gout) is marked by persistent painful polyarthritis. An increased concentration of uric acid leads to urate deposits in cartilage, synovial membranes, tendons, and soft tissue, called Tophi/tophus . Tophi/tophus form in the fingers, hands, knees, feet, ulnar sides of the forearms, pinna of the ear, Achilles tendon and, rarely, in such internal organs as the kidneys and myocardium. Renal involvement may adversely affect renal function.

Causes for Gout/Gouty Arthritis

Hyperuricemia is the underlying problem of gout, Although the underlying cause of primary gout is unknown, it appears to be linked to a genetic defect in purine metabolism that causes overproduction of uric acid (Hyperuricemia), retention of uric acid, or both.

Secondary gout develops during the course of another disease, such as obesity, diabetes mellitus, hypertension, polycythemia, leukemia, myeloma, sickle cell anemia, and renal disease. Secondary gout can also follow treatment with such drugs as hydrochlorothiazide or pyrazinamide.

Complications for Gout/Gouty Arthritis

Potential complications include:

• Renal disorders such as renal calculi
• Circulatory problems, such as atherosclerotic disease, cardiovascular lesions, stroke, coronary thrombosis, and hypertension
• Infection that develops when occur tophi ruptures and nerve entrapment.

Treatment for Gout/Gouty Arthritis

Gout/Gouty Arthritis management has three goals:

• Stop the acute attack.
• Treat hyperuricemia to reduce urine uric acid levels.
• Prevent recurrent gout and renal calculi.

Treatment for an acute attack:

• Bed rest; immobilization and protection of the inflamed, painful joints; and local application of cold.
• Analgesics, such as acetaminophen, relieve the pain associated with mild attacks.
• Acute inflammation requires nonsteroidal anti-inflammatory drugs or intramuscular corticotropin.

Treatment for chronic gout involves

• Decreasing the serum uric acid level.
• Adjunctive therapy emphasizes avoidance of alcohol and sparing use of purine-rich foods.
• Weight reduction program decreases uric acid levels and eases stress on painful joints.
• In some cases, surgery may be necessary excised and drained tophi to improve joint function or correct deformities.

Nursing care plans for Gout/Gouty Arthritis

Nursing Diagnosis for Gout/Gouty Arthritis

Patients teaching and home health guide for Gout/Gouty Arthritis

Nursing Diagnosis for Gout/Gouty Arthritis

Nursing Assessment Nursing care plans for Gout/Gouty Arthritis

Patient history Reveal that the patient has a sedentary lifestyle and a history of hypertension or renal calculi. report waking with pain in toe or another location in the foot.He may complain that initially moderate pain has grown and He may report accompanying chills and a mild fever.

Inspection a swollen, dusky red or purple joint with limited movement. Maybe found tophi, especially in the outer ears, hands, and feet, In  chronic stage of gout, the skin over the tophi may ulcerate and release a chalky white exudate or pus.

Palpation may reveal warmth over the joint and extreme tenderness. The vital signs assessment may disclose fever and hypertension. If the patient has a fever, possible occult infection must be investigated.

Diagnostic tests for Gout/Gouty Arthritis

• Needle aspiration of synovial fluid (arthrocentesis) or  tophaceous material
• Serum uric acid
• X-rays

Nursing Diagnosis Nursing Care Plans For Gout/Gouty Arthritis

Common nursing diagnosis found in Nursing care plans for Gout/Gouty Arthritis

• Acute pain
• Activity intolerance
• Anxiety
• Deficient knowledge (diagnosis and treatment)
• Disturbed sleep pattern
• Impaired physical mobility
• Ineffective coping
• Risk for injury

Nursing diagnosis Diabetes mellitus. Diabetes mellitus is a disorder in which the level of blood glucose is persistently raised above the normal range. Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes mellitus occurs in two primary forms: type 1, characterized by absolute insufficiency, and the more prevalent type 2, characterized by insulin resistance with varying degrees of insulin secretory defects.

Focused Nursing assessment For Diabetes Mellitus

• Patient history Patients with type 2 diabetes generally report a family history of diabetes mellitus, gestational diabetes
• Skin changes, especially on the legs and feet, may represent impaired peripheral circulation
• Ask if the patient has experienced excessive thirst (polydipsia), excessive urination (polyuria), or excessive hunger (polyphagia).
• In diagnostic test at least two occasions where the fasting plasma glucose level has been greater than or equal to 126 mg/dl, random blood glucose level greater than or equal to 200 mg/dl, blood glucose level greater than or equal to 200 mg/dl 2 hours after ingestion of 75 g of oral dextrose.

Common nursing diagnosis found in Diabetes Mellitus care plans

Imbalanced Nutrition: More than Body Requirements, Fear, Risk for Injury, Activity Intolerance, Deficient Knowledge, Risk for Impaired Skin Integrity, Ineffective Coping, Deficient knowledge (diagnosis and treatment), Disturbed sensory perception: Visual, tactile, Imbalanced nutrition: Less than body requirements, Impaired urinary elimination, Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral, Risk for infection, Sexual dysfunction

Nursing diagnosis Diabetes Mellitus by nursing priority

1. Imbalanced Nutrition: Less/More than Body Requirements
2. Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral
3. Impaired urinary elimination
4. Disturbed sensory perception: Visual, tactile
5. Activity Intolerance
6. Ineffective Coping
7. Sexual dysfunction
8. Fear
9. Deficient Knowledge
10. Deficient knowledge (diagnosis and treatment)
11. Risk for Impaired Skin Integrity
12. Risk for Injury
13. Risk for infection

Respiratory System

Nursing diagnosis pneumonia. Pneumonia, acute infection of the lung parenchyma that often impairs gas exchange. Pneumonia is an inflammatory condition of the interstitial lung tissue in which fluid and blood cells escape into the alveoli. The inflammatory process causes the lung tissue to stiffen, thus resulting in a decrease in lung compliance and an increase in the work of breathing. The fluid-filled alveoli cause a physiological shunt, and venous blood passes  unventilated portions of lung tissue and returns to the left atrium unoxygenated, patient begins to exhibit the signs and symptoms of hypoxemi

Focused Nursing assessment in  pneumonia care plans

• Vital sign: blood pressure,  body temperature, the pulse or rate of heartbeats, the respiration or rate of breathing
• Crackles, wheezing, or rhonchi over the affected lung area
• Dullness when you percuss
• Presence of cyanosis, and presence of dyspnea or tachypnea

Common nursing diagnosis found in pneumonia

Impaired gas exchange, Ineffective coping, Risk for deficient fluid Volume, Risk for infection Ineffective airway clearance, Acute pain, Anxiety, Hyperthermia, Imbalanced nutrition: Less than body requirements,

Nursing diagnosis for pneumonia base in nursing priority

1. Ineffective airway clearance
2. Impaired gas exchange
3. Imbalanced nutrition: Less than body requirements
4. Acute pain
5. Hyperthermia
6. Anxiety
7. Ineffective coping
8. Risk for deficient fluid volume
9. Risk for infection

Nursing care plans for Myocardial infarction (MI)

Nursing care plans for Myocardial infarction (MI). Myocardial infarction (MI) or acute Myocardial infarction is an acute coronary syndrome, results from reduced blood flow through one or more coronary arteries, which causes myocardial ischemia and necrosis. Myocardial infarction (MI) results when myocardial tissue becomes necrotic because of absent or diminished blood supply. When myocardial tissue is deprived of oxygenated blood supply for a period of time, an area of myocardial necrosis develops, this necrosis is surrounded by injured and ischemic tissue.

The infarction site depends on the vessels involved. For instance:

• Occlusion of the circumflex coronary artery causes a lateral Myocardial infarction (MI).
• Occlusion of the left anterior coronary artery causes an anterior Myocardial infarction (MI).
• Occlusion of the right coronary artery or one of its branches causes True posterior and inferior Myocardial infarction (MI)
• Right ventricular infarctions can also result from right coronary artery occlusion, can accompany inferior MI, and may cause right-sided heart failure.
• If a thrombus partially occludes a coronary vessel, distal microthrombi may cause necrosis in some myocytes, leading to a non-ST-segment elevation MI (NSTEMI).
• If a thrombus fully occludes the vessel for a prolonged time, an ST-segment elevation MI (STEMI) usually develops.

Men are more susceptible to Myocardial infarction (MI) than premenopausal women, although incidence is rising among women who smoke and take a hormonal contraceptive. The incidence in postmenopausal women resembles that in men.

Causes for Myocardial Infarction (MI)

A Myocardial infarction (MI) results from occlusion of one of the coronary arteries. The occlusion can stem from atherosclerosis, thrombosis, platelet aggregation, or coronary artery stenosis or spasm. Predisposing risk factors include:

• Aging
• Diabetes Mellitus
• Elevated serum triglyceride, low-density lipoprotein, and cholesterol levels, and decreased serum high-density lipoprotein levels
• Excessive intake of saturated fats, carbohydrates, or salt
• Hypertension
• Obesity
• Positive family history of coronary artery disease
• Sedentary lifestyle
• Smoking
• Stress or a type a personality (aggressive, competitive attitude, addiction to work, chronic impatience).
• In addition, use of such drugs as amphetamines or cocaine can cause a Myocardial infarction (MI).

Complications for Myocardial Infarction (MI)

Cardiac complications of Acute Myocardial infarction (MI)

• Arrhythmia.
• Cardiogenic shock.
• Heart failure.
• Pulmonary edema
• Pericarditis.

Other complications for Myocardial Infarction (MI) include

• Rupture of the atrial or
• Ventricular septum,
• Ventricular wall, or valves;
• Ventricular aneurysms
• Cerebral or pulmonary emboli.
• Dressler’s syndrome can occur days to weeks after an Myocardial infarction (MI) and cause residual pain, malaise, and fever.

Typically, elderly patients are more prone to complications and death. Psychological problems can also occur, either from the patient’s fear of another Myocardial infarction (MI) or from an organic brain disorder caused by tissue hypoxia. Occasionally, a patient may have a personality change.

Nursing Assessment nursing care plans for Myocardial infarction (MI)

PATIENT HISTORY

Symptomatology is very important in diagnosing Myocardial infarction (MI). Ask about chest, jaw, arm, and epigastric pain. Remember that not all people have the “typical” chest pain; evaluate the whole clinical picture because some people may experience no pain at all. Ask about shortness of breath, racing heart rate, diaphoresis, clammy skin, dizziness, nausea, and vomiting. Note that sudden death and full cardiac arrest may be the first indication of Myocardial infarction (MI).

Patients with coronary artery disease may report increasing anginal frequency, severity, or duration (especially when not precipitated by exertion, a heavy meal, or cold and wind). The patient may also report a feeling of impending doom, fatigue, nausea, vomiting, and shortness of breath. Sudden death, however, may be the first and only indication of an Myocardial infarction (MI).

Physical Examination

• Inspection may reveal an extremely anxious and restless patient with dyspnea and diaphoresis.
• If right-sided heart failure is present, you may note jugular vein distention.
• anterior Myocardial infarction (MI), patients exhibit sympathetic nervous system hyperactivity, such as tachycardia and hypertension.
• Patients with an inferior Myocardial infarction (MI) exhibit parasympathetic nervous system hyperactivity, such as bradycardia and hypotension.
• In patients who develop ventricular dysfunction, auscultation may disclose an S4, an S3, paradoxical splitting of S2, and decreased heart sounds.
• A systolic murmur of mitral insufficiency may be heard with papillary muscle dysfunction secondary to infarction.
• A pericardial friction rub may also be heard, especially in patients who have a transmural Myocardial infarction (MI) or have developed pericarditis.
• Fever is unusual at the onset of MI, but a low-grade fever may develop during the next few days.

Diagnostic tests for Myocardial infarction (MI)

Persistent chest pain, ST-segment changes on ECG, and elevated levels of total creatine kinase (CK) and the CK-MB isoenzyme over a 72-hour period usually confirm Myocardial infarction (MI). Cardiac troponins are useful in differentiating MI from skeletal muscle injury, or when CK-MB measurements are low and a small MI has actually occurred.

Diagnostic Highlights

• Electrocardiogram
• Creatine kinase isoenzyme (MB-CK)
• Cardiac troponin I (cTnI)
• cardiac troponin T (cTnT)

Elevated homocysteine and C-reactive protein levels have been found incidentally in patients with Myocardial infarction (MI) and may indicate a newer risk factor. The practical value of these tests remains unknown. Folic acid supplementation is used as treatment for elevated homocysteine levels

Nursing diagnosis Nursing Care Plans For Myocardial Infarction (MI).

Primary Nursing Diagnosis: Altered tissue perfusion (myocardial) related to narrowing of the coronary arteryies associated with atherosclerosis, spasm, or thrombosis

Common nursing diagnosis found on Myocardial infarction (MI).

• Activity intolerance
• Acute pain
• Anxiety
• Decreased cardiac output
• Excess fluid volume
• Fatigue
• Imbalanced nutrition: Less than body requirements
• Ineffective coping
• Ineffective denial
• Ineffective sexuality patterns
• Ineffective tissue perfusion: Cardiopulmonary

Nursing outcomes for Myocardial Infarction (MI), Patients will

• Perform activities of daily living without excessive fatigue or exhaustion.
• Express feelings of comfort and decreased pain.
• Verbalize strategies to reduce anxiety and stress.
• Maintain adequate cardiac output.
• Develop no complications of fluid volume excess.
• Verbalize the importance of balancing activities, as tolerated, with adequate rest periods.
• Achieve ideal weight.
• Develop adequate coping skills.
• The patient will recognize his acute condition and accept the lifestyle changes he needs to make.
• Express feelings about changes in sexual patterns.
• Maintain hemodynamic stability and develop no arrhythmias.

Nursing interventions Nursing Care Plans for Myocardial Infarction (MI)

• Nursing Care for patients who have suffered a Myocardial Infarction (MI), Most most of them receive treatment in the coronary care unit (CCU), where they’re under constant observation for complications.
• On admission to the CCU, monitor and record the patient’s ECG readings, blood pressure, temperature, and heart and breath sounds.
• Assess pain and give an analgesic as ordered.
• Record the severity of pain, location, type, and duration of pain.
• Check the patient’s blood pressure before and after giving nitroglycerin, especially the first dose.
• Frequently monitor ECG rhythm strips to detect rate changes and arrhythmias. if any new arrhythmias are documented, if chest pain occurs, or at least every shift change or according to facility protocol.
• Obtain ECG readings and blood pressure and pulmonary artery catheter measurements, if applicable, to determine changes. During episodes of chest pain
• Watch for crackles, cough, tachypnea, and edema, which may indicate impending left-sided heart failure.
• Monitor daily weight, intake and output, respiratory rate, serum enzyme levels, ECG readings, and blood pressure.
• Organize patient care and activities to maximize periods of uninterrupted rest.
• Provide a clear liquid diet dietary until nausea subsides. A low-cholesterol, low-sodium diet, without caffeine-containing beverages, may be ordered.
• Provide a stool softener to prevent straining during defecation, which causes vagal stimulation and may slow heart rate.
• Allow the patient to use a bedside commode, and provide as much privacy as possible.
• Assist with ROM exercises.
• If the patient is immobilized by a severe Myocardial Infarction (MI), turn him often.
• Give Antiembolism stockings to prevent venostasis and thrombophlebitis.
• Provide emotional support, and help reduce stress and anxiety .
• If the patient has undergone PTCA, sheath care is necessary. Keep the sheath line open with a heparin drip. Observe the patient for generalized and site bleeding. Keep the leg with the sheath insertion site immobile. Maintain strict bed rest. Check peripheral pulses in the affected leg frequently. Provide an analgesic for back pain if needed.
• After thrombolytic therapy, administer continuous heparin as ordered. Monitor the partial thromboplastin time every 6 hours, and monitor the patient for evidence of bleeding.

Patient Teaching and Home Healthcare Guide for Patients with Myocardial Infarction (MI)

Explain procedures and answer questions for both the patient and family. Explain the CCU environment and routine. Remember that you may need to repeat explanations after the emergency situation has resolved.

• To promote compliance with the prescribed medication regimen and other treatment measures, thoroughly explain dosages and therapy. Inform the patient of the drug’s adverse reactions, and advise him to watch for and report signs and symptoms of toxicity (for example, anorexia, nausea, vomiting, mental depression, vertigo, blurred vision, and yellow vision, if the patient is receiving a cardiac glycoside).
• Explain the need to treat recurrent chest pain or Myocardial Infarction (MI) discomfort with sublingual nitroglycerin every 5 minutes for three doses. If the pain persists for 20 minutes, teach the patient to seek medical attention. If the patient has severe pain or becomes short of breath with chest pain, teach the patient to take nitroglycerin and seek medical attention right away
• Review dietary restrictions with the patient. If he must follow a low-sodium, low-fat, or low-cholesterol diet, provide a list of foods to avoid. Ask the dietitian to speak to the patient and family.
• Explore mechanisms to implement diet control, an exercise program, and smoking cessation if appropriate.
• Encourage the patient to participate in a cardiac rehabilitation exercise program. The physician and the exercise physiologist should determine the level of exercise and then discuss it with the patient and secure his agreement to a stepped-care program.
• Counsel the patient to resume sexual activity progressively. He may need to take nitroglycerin before sexual intercourse to prevent chest pain from the increased activity.
• Advise the patient about appropriate responses to new or recurrent symptoms.
• Advise the patient to report typical or atypical chest pain. Post Myocardial Infarction (MI) syndrome may develop, producing chest pain that must be differentiated from a recurrent MI, pulmonary infarction, and heart failure.
• Stress the need to stop smoking. If necessary, refer the patient to a support group.
• Be sure the patient understands all the medications, including the dosage, route, action, and adverse effects.
• Instruct the patient to keep the nitroglycerin bottle sealed and away from heat.
• The medication may lose patients potency.

Nursing Care Plans for Acute Renal Failure; Acute renal failure is a syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria (less than 500 ml urine/24 hours), hyperkalemia, and sodium retention (Williams & Wilkins, 2006).

Acute renal failure (ARF) is a sudden and almost complete loss of kidney function (decreased Glomerular filtration rate GFR) over a period of hours to days. Acute Renal Failure ARF manifests with oliguria, anuria, or normal urine volume. Oliguria (less than 400 ml/day of urine) is the most common clinical situation seen in Acute Renal Failure ARF; anuria (less than 50 ml/day of urine) and normal urine output are not as common. Regardless of the volume of urine excreted, the patient with ARF experiences rising serum creatinine and BUN levels and retention of other metabolic waste products (azotemia) normally excreted by the kidneys (Brunner and Suddarth,2003 ).

Acute renal failure (ARF) is the abrupt deterioration of renal function that results in the accumulation of fluids, electrolytes, and metabolic waste products. The sudden interruption of renal function resulting from obstruction, reduced circulation, or renal parenchymal disease. This condition is classified as prerenal, intrarenal, or postrenal and normally passes through three distinct phases: oliguric, diuretic, and recovery. It’s usually reversible with medical treatment. If not treated, it may progress to end-stage renal disease, uremia, and death.

Causes for Acute Renal Failure

Prerenal Failure

Prerenal conditions occur as a result of impaired blood flow that leads to hypoperfusion of the kidney and a drop in the Glomerular filtration rate GFR.

• Volume depletion resulting from:

1. Hemorrhage
2. Renal losses (diuretics, osmotic diuresis)
3. Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)

• Impaired cardiac efficiency resulting from:

1. Myocardial infarction
2. Heart failure
3. Dysrhythmias
4. Cardiogenic shock

• Vasodilation resulting from:

1. Sepsis
2. Anaphylaxis
3. Antihypertensive medications or other medications that cause
4. Vasodilation

Intrarenal Failure

Intrarenal causes of ARF are the result of actual parenchymal damage to the glomeruli or kidney tubules. Intrarenal causes result from injury to renal tissue and are usually associated with intrarenal ischemia, toxins, immunologic processes, systemic and vascular disorders.

• Prolonged renal ischemia resulting from:

1. Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures)
2. Myoglobinuria (trauma, crush injuries, burns)
3. Hemoglobinuria (transfusion reaction, hemolytic anemia)

• Nephrotoxic agents such as:

1. Aminoglycoside antibiotics (gentamicin, tobramycin)
2. Radiopaque contrast agents
3. Heavy metals (lead, mercury)
4. Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
5. Nonsteroidal anti-inflammatory drugs (NSAIDs)
6. Angiotensin-converting enzyme inhibitors (ACE inhibitors)

• Infectious processes such as:

1. Acute pyelonephritis
2. Acute glomerulonephritis

Postrenal Failure

Postrenal causes of ARF are usually the result of an obstruction somewhere distal to the kidney. Pressure raises in the kidney tubules eventually, the Glomerular filtration rate GFR decreases.

• Urinary tract obstruction, including:

1. Calculi (stones)
2. Tumors
3. Benign prostatic hyperplasia
4. Strictures
5. Blood clots

Pathophysiology of Acute Renal Failure

There are four clinical phases of Acute Renal Failure ARF:

Pathophysiology of Acute Renal Failure

1. The initiation period begins with the initial insult and ends when oliguria develops.
2. The oliguria period is accompanied by a rise in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 ml. In this phase uremic symptoms first appear life-threatening conditions such as hyperkalemia develop.
3. The diuresis period, the third phase, the patient experiences gradually increasing urine output which signals that Glomerular filtration has started to recover. Laboratory values stop rising and eventually decrease. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing management continues.
4. The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory values return to the patient’s normal level. Although a permanent 1% to reduction in the GFR is common, it is not clinically significant.

Clinical Manifestations

• Prerenal decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia
• Postrenal obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis
• Intrarenal presentation based on cause; edema usually present
• Changes in urine volume and serum concentrations of BUN, creatinine, potassium, and so forth, as described above

Assessment and Diagnostic Findings Nursing Care Plans for Acute Renal Failure:

• Changes in urine
• Change in kidney contour
• Increased bun and creatinine levels (azotemia)
• Hyperkalemia
• Metabolic acidosis
• Calcium and phosphorus abnormalities
• Anemia

Complications

• Infection
• Arrhythmias due to hyperkalemia
• Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities
• GI bleeding due to stress ulcers
• Multiple organ systems failure

Nursing Process

Nursing Assessment Nursing Care Plans for Acute Renal Failure

• Determine if there is a history of cardiac disease, malignancy, sepsis, or intercurrent illness.
• Determine if patient has been exposed to potentially nephrotoxic drugs (antibiotics, NSAIDs, contrast agents, solvents).
• Conduct an ongoing physical examination for tissue turgor, pallor, alteration in mucous membranes, blood pressure, heart rate changes, pulmonary edema, and peripheral edema.
• Monitor intake and output

Nursing Diagnosis Nursing Care Plans for Acute Renal Failure

Common nursing diagnosis found in Nursing Care Plans for  Acute renal failure:

1. Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention
2. Risk for Infection related to alterations in the immune system and host defenses
3. Imbalanced Nutrition: Less Than Body Requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure
4. Risk for Injury related to GI bleeding
5. Disturbed Thought Processes related to the effects of uremic toxins on the central nervous system (CNS)

Gordon’s Functional Health Patterns is a method develops By Marjorie Gordon in 1987 proposed functional health patterns as a guide for establishing a comprehensive nursing data base. By using these categories it’s possible to create a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:

11 Gordon’s Functional Health Patterns

1. Health Perception Health Management Pattern
2. Nutritional Metabolic Pattern
3. Elimination Pattern
4. Activity Exercise Pattern
5. Sleep Rest Pattern
6. Cognitive-Perceptual Pattern
7. Self-Perception-Self-Concept Pattern
8. Role-Relationship Pattern
9. Sexuality-Reproductive
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern

Health Perception and Health Management. It’s focused on the person’s perceived level of health and well-being, and on practices for maintaining health. Also evaluated Habits including smoking and alcohol or drug use.

• Contamination
• Disturbed energy field
• Effective therapeutic regimen management
• Health-seeking behaviors (specify)
• Ineffective community therapeutic regimen management
• Ineffective family therapeutic regimen management
• Ineffective health maintenance
• Ineffective protection
• Ineffective therapeutic regimen management
• Noncompliance (ineffective Adherence)
• Readiness for enhanced immunization status
• Readiness for enhanced therapeutic regimen management
• Risk for contamination
• Risk for infection
• Risk for injury
• Risk for perioperative positioning injury
• Risk for poisoning
• Risk for sudden infant death syndrome
• Risk for suffocation
• Risk for trauma
• Risk-prone health behavior

Nutritional Metabolic Pattern it’s focused on the pattern of food and fluid consumption relative to metabolic need. Is evaluated the adequacy of local nutrient supplies.  Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system.

• Adult failure to thrive
• Deficient fluid volume: [isotonic]
• [Deficient fluid volume: hyper/hypotonic]
• Effective breastfeeding [Learning Need]
• Excess fluid volume
• Hyperthermia
• Hypothermia
• Imbalanced nutrition: more than body requirements
• Imbalanced nutrition: less than body requirements
• Imbalanced nutrition: risk for more than body requirements
• Impaired dentition
• Impaired oral mucous membrane
• Impaired skin integrity
• Impaired swallowing
• Impaired tissue integrity
• Ineffective breastfeeding
• Ineffective infant feeding pattern
• Ineffective thermoregulation
• Interrupted breastfeeding
• Latex allergy response
• Nausea
• Readiness for enhanced fluid balance
• Readiness for enhanced nutrition
• Risk for aspiration
• Risk for deficient fluid volume
• Risk for imbalanced fluid volume
• Risk for imbalanced body temperature
• Risk for impaired liver function
• Risk for impaired skin integrity
• Risk for latex allergy response
• Risk for unstable blood glucose

Elimination Pattern. It’s focused on excretory patterns (bowel, bladder, skin).

• Bowel incontinence
• Constipation
• Diarrhea
• Functional urinary incontinence
• Impaired urinary elimination
• Overflow urinary incontinence
• Perceived constipation
• Readiness for enhanced urinary elimination,
• Reflex urinary incontinence
• Risk for constipation
• Risk for urge urinary incontinence
• Stress urinary incontinence
• Total urinary incontinence
• Urge urinary incontinence
• [acute/chronic] Urinary retention

Activity and Exercise Pattern. It’s focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities.

• Activity intolerance
• Autonomic dysreflexia
• Decreased cardiac output
• Decreased intracranial adaptive capacity
• Deficient diversonal activity
• Delayed growth and development
• Delayed surgical recovery
• Disorganized infant behavior
• Dysfunctional ventilatory weaning response
• Fatigue
• Impaired spontaneous ventilation
• Impaired bed mobility
• Impaired gas exchange
• Impaired home maintenance
• Impaired physical mobility
• Impaired transfer ability
• Impaired walking
• Impaired wheelchair mobility
• Ineffective airway clearance
• Ineffective breathing pattern
• Ineffective tissue perfusion
• Readiness for enhanced organized infant behavior
• Readiness for enhanced self care
• Risk for delayed development
• Risk for disorganized infant behavior
• Risk for disproportionate growth
• Risk for activity intolerance
• Risk for autonomic dysreflexia
• Risk for disuse syndrome
• Sedentary lifestyle
• Self-care deficit
• Wandering

Cognitive-Perceptual Pattern. It’s focused on the ability to comprehend and use information and on the sensory functions. Neurologic functions, Sensory experiences such as pain and altered sensory input.

• Acute confusion
• Acute pain
• Chronic confusion
• Chronic pain
• Decisional conflict
• Deficient knowledge
• Disturbed sensory perception
• Disturbed thought processes
• Impaired environmental interpretation syndrome
• Impaired memory
• Readiness for enhanced comfort
• Readiness for enhanced decision making
• Readiness for enhanced knowledge
• Risk for acute confusion
• Unilateral neglect

Sleep Rest Pattern. It’s focused on the person’s sleep, rest, and relaxation practices. To identified dysfunctional sleep patterns, fatigue, and responses to sleep deprivation.

• Insomnia
• Readiness for enhanced sleep
• Sleep deprivation

Self-Perception-Self-Concept Pattern its focused on the person’s attitudes toward self, including identity, body image, and sense of self-worth.

• Anxiety
• disturbed Body image
• Chronic low self-esteem
• Death anxiety
• Disturbed personal identity
• Fear
• Hopelessness
• Powerlessness
• Readiness for enhanced hope
• Readiness for enhanced power
• Readiness for enhanced self-concept
• Risk for compromised human dignity
• Risk for loneliness
• Risk for powerlessness
• Risk for situational low self-esteem
• Risk for [/actual] other-directed violence
• Risk for [actual/] self-directed violence
• Situational low self-esteem

Role-Relationship Pattern. It’s focused on the person’s roles in the world and relationships with others. Evaluated Satisfaction with roles, role strain, or dysfunctional relationships.

• Caregiver role strain
• Chronic sorrow
• Complicated grieving
• Dysfunctional family processes: alcoholism (substance abuse)
• Grieving
• Impaired social interaction
• Impaired verbal communication
• Ineffective role performance
• Interrupted family processes
• Parental role conflict
• Readiness for enhanced communication
• Readiness for enhanced family processes
• Readiness for enhanced parenting
• Relocation stress syndrome
• Risk for caregiver role strain
• Risk for complicated grieving
• Risk for impaired parent/infant/child attachment
• Risk for relocation stress syndrome
• Social isolation

Sexuality and Reproduction. It’s focused on the person’s satisfaction or dissatisfaction with sexuality patterns and reproductive functions.

• Ineffective sexuality patterns
• Rape-trauma syndrome
• Sexual dysfunction

Coping-Stress Tolerance Pattern. its focused on the person’s perception of stress and coping strategies Support systems, evaluated symptoms of stress, effectiveness of a person’s coping strategies.

• Compromised family coping
• Defensive coping
• Disabled family coping
• Impaired adjustment
• Ineffective community coping
• Ineffective coping
• Ineffective denial
• Post-trauma syndrome
• Readiness for enhanced community coping
• Readiness for enhanced coping
• Readiness for enhanced family coping
• Risk for self-mutilation
• Risk for suicide
• Risk for post-trauma syndrome
• Self-mutilation
• Stress overload

Value-Belief Pattern it’s focused on the person’s values and beliefs.

• Impaired religiosity
• Moral distress
• Readiness for enhanced religiosity
• Readiness for enhanced spiritual well-being
• Risk for impaired religiosity
• Risk for spiritual distress
• Spiritual distress

]]> http://www.lifenurses.com/nursing-diagnosis-and-11-gordons-functional-health-patterns/feed/ 15 http://www.lifenurses.com/nursing-outcome-and-nursing-interventions-nursing-care-plans-for-hypertension/ http://www.lifenurses.com/nursing-outcome-and-nursing-interventions-nursing-care-plans-for-hypertension/#comments Mon, 23 Nov 2009 16:43:02 +0000 lifenurses http://www.lifenurses.com/?p=80

Common nursing diagnosis found in Nursing care plans for Hypertension; Deficient Knowledge, Ineffective Therapeutic Regimen Management, Deficient knowledge (lifestyle modifications), Fatigue, Ineffective coping, Ineffective tissue perfusion: Cardiopulmonary, Noncompliance: Therapeutic regimen, Risk for injury

Key outcomes nursing care plans for Hypertension Patient will:

• Remain free from complications.
• Identify appropriate food choices.
• Express that he has more energy.
• Maintain adequate cardiac output and hemodynamic stability.
• Demonstrate adaptive coping behaviors
• Comply with his therapy regimen.
• Demonstrates increased knowledge about high blood pressure , medication effects, and prescribed therapeutic activities
• Takes medications, keeps follow-up appointments

Nursing Interventions nursing care plans for Hypertension

Nursing Interventions nursing care plans for Hypertension with nursing diagnosis; Deficient Knowledge regarding the relationship between the treatment regimen and control of the disease process

Nursing Interventions Providing Basic Education:

• Explain the meaning of high blood pressure, risk factors, and
• Explain the influences of high blood pressure on the cardiovascular, cerebral, and renal systems.
• Stresses that Hypertension can never be total cure, only control, of essential hypertension; emphasize the consequences of uncontrolled hypertension.
• Stress the fact that there may be no correlation between high blood pressure  and symptoms; the patient cannot tell by the way he feels whether blood pressure  is normal or elevated.
• Have the patient recognize that hypertension is chronic and requires persistent therapy and periodic evaluation.
• Present a coordinated and complementary plan of guidance.
  • Inform the patient of the meaning of the various diagnostic and therapeutic activities to minimize anxiety and to obtain cooperation.
  • Solicit the assistance of the patient’s spouse, family, and friends provide information regarding the total treatment plan.
  • Be aware of the dietary plan developed for this particular patient.
• Explain the pharmacologic control of hypertension.
  • Explain that the drugs used for effective control of elevated blood pressure will likely produce adverse effects.
  • Warn the patient of the possibility that orthostatic hypotension may occur initially with some drug therapy:  Instruct the patient to get up slowly to offset the feeling of dizziness, Encourage the patient to sit or lie down immediately if he feels faint
  • Alert the patient to expect initial effects, such as anorexia, light-headedness, and fatigue, with many medications.
  • Inform the patient that the goal of treatment is to control blood pressure, reduce the possibility of complications, and use the minimum number of drugs with the lowest dosage necessary to accomplish this.

• Educate the patient to be aware of serious adverse effects and report them immediately so that adjustments can be made in individual pharmacotherapy.
• Note that dosages are individualized; therefore, they may need to be adjusted because it is often impossible to predict reactions.
• Warn the patient on vasodilating drugs to use caution in certain circumstances that produce vasodilation a hot bath, hot weather, febrile illness, consumption of alcohol which may exacerbate blood pressure reduction.
• Warn patients that blood pressure is often decreased when circulating blood volume is reduced as in dehydration, diarrhea, and hemorrhage so blood pressure should be monitored closely and treatment adjusted.

Nursing care plans for Hypertension; hypertension, high blood pressure, is the most common of all health problems in adults and is the leading risk factor for cardiovascular disorders. Hypertension is a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg over a sustained period, based on the average of two or more blood pressure measurements taken in two or more.

There are two kinds of hypertension; they are primary hypertension, meaning that the reason for the elevation in blood pressure cannot be identified.  Also known as essential hypertension. These terms mean simply that the hypertension is of unknown origin. In some patients with primary hypertension, there is a strong hereditary tendency.

And, Secondary hypertension or malignant hypertension is the term used to signify high blood pressure from an identified cause. The elevation of blood pressure results from some other disorder Such as kidney disease, renal artery stenosis.

Cause for Hypertension

Although the precise cause for most cases of hypertension cannot be identified, it is understood that hypertension is a multifactorial condition. Because hypertension is a sign, it is most likely to have many causes, just like fever has many causes. For hypertension to occur there must be a change in one or more factors affecting peripheral resistance or cardiac output. In addition, there must also be a problem with the control systems that monitor or regulate pressure.

1. Primary hypertension or essential hypertension (90% to 95% of Cases) Precise cause unknown
2. Secondary Hypertension or malignant hypertension causes by:

RENAL:  Acute glomerulonephritis, Chronic renal disease, Polycystic disease, Renal artery stenosis, Renal vasculitis,Renin-producing tumors.

CARDIOVASCULAR: Coarctation of aorta , Increased intravascular volume , Increased cardiac output, Rigidity of the aorta

ENDOCRINE:  Adrenocortical hyperfunction, Exogenous hormones e.g (glucocorticoids, estrogen including pregnancy-induced and oral contraceptives), Pheochromocytoma, Hypothyroidism, Hyperthyroidism, Pregnancy-induced

NEUROLOGIC:  Psychogenic, Increased intracranial pressure, Sleep apnea, Acute stress, including surgery

Complications for Hypertension

Hypertension is a major cause of stroke, cardiac disease, and renal failure. Complications occur late in the disease and can attack any organ system.

Cardiac complications include

• Coronary artery disease
• Angina
• Myocardial infarction
• Heart failure
• Arrhythmias
• Sudden death.

Neurologic complications:

• Cerebral infarctions and
• Hypertensive encephalopathy can cause blindness.
• Renovascular hypertension can lead to renal failure.

Treatment of Hypertension

Although essential hypertension has no cure, drug therapy and diet and lifestyle modifications can control it. Current guidelines for treating hypertension recommend, as a first step, lifestyle modifications that are aimed at increasing physical activity and weight loss in most patients. Unfortunately, many patients are unable to lose weight, and pharmacological treatment with antihypertensive drugs must be initiated.

Two general classes of drugs are used to treat hypertension:

• Vasodilator drugs that increase renal blood flow
• Natriuretic or diuretic drugs that decrease tubular reabsorption of salt and water.

Nursing Assessment Nursing care plans for Hypertension

Nursing History

• Family history of high Blood Pressure
• Previous episodes of high Blood Pressure
• Dietary habits and salt intake
• Target organ disease or other disease processes that may place the patient in a high-risk group  diabetes, CAD, kidney disease
• Cigarette smoking
• Episodes of headache, weakness, muscle cramp, tingling, palpitations, sweating, vision disturbances
• Medication that could elevate Blood Pressure:
  • Hormonal contraceptives, steroids
  • NSAIDs
  • Nasal decongestants, appetite suppressants, tricyclic antidepressants
• Other disease processes, such as gout, migraines, asthma, heart failure, and benign prostatic hyperplasia, which may be helped or worsened by particular hypertension drugs.

Physical Examination

• Auscultate heart rate and palpate peripheral pulses; determine respirations.
• If skilled in doing so, perform funduscopic examination of the eyes for the purpose of noting vascular changes. Look for edema, spasm, and hemorrhage of the eye vessels. Refer to ophthalmologist for definitive diagnosis.
• Examine the heart for a shift of the point of maximal impulse to the left, which occurs in heart enlargement.
• Auscultate for bruits over peripheral arteries to determine the presence of atherosclerosis, which may be manifested as obstructed blood flow.
• Determine mentation status by asking patient about memory, ability to concentrate, and ability to perform simple mathematical calculations.

• Blood Pressure Determination, Auscultate and record precisely the systolic and diastolic.

Nursing Diagnoses Nursing care plans for Hypertension

Common nursing diagnosis found in patient with hypertension

• Deficient Knowledge regarding the relationship between the treatment regimen and control of the disease process
• Ineffective Therapeutic Regimen Management related to medication adverse effects and difficult lifestyle adjustments

• Deficient knowledge (lifestyle modifications)
• Fatigue
• Ineffective coping
• Ineffective tissue perfusion: Cardiopulmonary
• Noncompliance: Therapeutic regimen
• Risk for injury

Nursing outcome nursing interventions and patients teaching Nursing care plans for Hypertension