NCP Nursing care plans for Cerebral Contusion

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

Causes For Cerebral Contusion

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

Complications for Cerebral Contusion

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

Treatment for Cerebral Contusion

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

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

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

Diagnostic tests for Cerebral Contusion
Cerebral angiography outlines vasculature, and a Computed tomography (CT) scan CT scan MRI (magnetic resonance imaging)

Nursing diagnosis
Common Nursing diagnosis found in Nursing care plans for Cerebral Contusion

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

Nursing Intervention and Rationale

Acute pain Related factors injuring agents (Cerebral Contusion)

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

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

Nursing Interventions:

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

Nursing diagnosis Ineffective cerebral tissue Perfusion Related to Interruption of blood flow by space-occupying lesions (hemorrhage, hematoma), cerebral edema

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

Nursing diagnosis Disturbed sensory perception: Kinesthetic, tactile Related to Altered sensory reception, transmission, and/or integration: Neurologic disease, trauma

Nursing Interventions

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

Nursing diagnosis Disturbed thought processes 

Nursing diagnosis Impaired verbal communication Related to decrease in circulation to brain, Cerebral Contusion 

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

Nursing diagnosis 

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

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

Nursing diagnosis 

Risk for deficient fluid volume 

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

Nursing diagnosis 

Risk for infection Risk factor inadequate primary defenses broken skin, traumatized tissue 

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

Nursing diagnosis

Risk for injury 

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

Nursing diagnosis 

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

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

Patient Teaching And Home Healthcare Guidance For Patient With Cerebral Contusion

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

Patient teaching and home healthcare guidance for patient with Cerebral Contusion 

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

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Nursing Care Plan for Thyroid Cancer

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

Types characteristics of thyroid cancers 

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

Complications For Thyroid Cancers

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

Clinical Manifestations for Thyroid Cancers 

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

Symptoms of Thyroid Cancer 

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

Nursing . Assessment

Focused Nursing Assessment for Thyroid CancerExplore patient’s feelings and concerns regarding the diagnosis, treatment, and prognosis. The first indication of disease may be a painless nodule discovered incidentally or detected during physical examination.If the tumor grows large enough to destroy the thyroid gland. Patient’s history may include sensitivity to cold and mental apathy (hypothyroidism). If the tumor triggers excess thyroid hormone production, the patient may report sensitivity to heat, restlessness, and overactivity (hyperthyroidism). The patient may also complain of diarrhea, dysphagia, anorexia, irritability, and ear pain. When speaking with the patient, you may hear hoarseness and vocal stridor. On inspection, you may detect a disfiguring thyroid mass, especially if the patient is in the later stages of anaplastic thyroid cancer. (See Anaplastic thyroid cancer.) Palpation may disclose a hard nodule in an enlarged thyroid gland or palpable lymph nodes with thyroid enlargement. By auscultation, you may discover bruits if thyroid enlargement results from an increase in TSH, which increases thyroid vascularity. 

Diagnostic Evaluation 

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

Nursing Diagnosis 

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

Nursing Intervention and Rationale Nursing Care Plan for Thyroid Cancer Nursing Diagnosis Fear/Anxiety Could be related to: 

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

Nursing Outcomes Evaluation Criteria, Client Will: 

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

Nursing Interventions and rationale Nursing diagnosis Fear/Anxiety: 

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

Nursing Diagnosis Acute pain/Chronic Pain Related to: 

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

Nursing Outcomes Evaluation Criteria Client Will 

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

Nursing Interventions and Rationale Nursing Diagnosis Acute/Chronic Pain 

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

Nursing Diagnosis Risk for Ineffective Airway Clearance Related to 

• Tracheal obstruction, swelling, bleeding, laryngeal spasms. 

Nursing Outcomes Evaluation Criteria Client Will 

• Maintain patent airway, with aspiration prevented. 

Nursing Interventions and Rationale Nursing Diagnosis Risk for Ineffective Airway Clearance 

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

Nursing Diagnosis Impaired Verbal Communication Related to: 

• Vocal cord injury, laryngeal nerve damage. Tissue edema; pain and discomfort 

Nursing Outcomes Evaluation Criteria Client Will 

• Establish method of communication in which needs can be understood. 

Nursing Interventions and Rationale: 

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

Nursing Diagnosis Risk For Injury Related to: 

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

Nursing Outcomes Evaluation Criteria Client Will 

• Demonstrate absence of injury with complications minimized or controlled. 

Nursing Interventions And Rationale 

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

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

• Lack of exposure and recall; misinterpretation, Unfamiliarity with information resources 

Nursing Outcomes Evaluation Criteria Client Will 

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

Nursing Interventions and Rationale 

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

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

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

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

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Nursing Care Plan for Laryngeal Cancer

Cancer of the larynx is a malignant tumor in the larynx (voice box). It is potentially curable if detected early. It represents less than 1% of all cancers and occurs about four times more frequently in men than in women, and most commonly in persons 50 to 70 years of age. Squamous cell carcinoma constitutes about 95% of laryngeal cancers. Rare laryngeal cancer forms adenocarcinoma and sarcoma account for the rest. An intrinsic tumor is on the true vocal cords and tends not to spread because underlying connective tissues lack lymph nodes. An extrinsic tumor is on some other part of the larynx and tends to spread easily. Laryngeal 

Cancer is classified by its location: 

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

Pathophysiology and Etiology of Laryngeal Cancer 

Occurs predominantly in men older than age 60. Most patients have a history of smoking; those with Supraglottis laryngeal cancer frequently have a history of smoking and a high alcohol intake. Other risk factors include vocal straining, chronic laryngitis, industrial exposure, nutritional deficiency, and family predisposition. About two-thirds of carcinomas of the larynx arise in the glottis, almost one-third arise in the Supraglottis region, and about 3% arise in the subglottic region of the larynx. When limited to the vocal cords (intrinsic), spread is slow because of lessened blood supply. When cancer involves the epiglottis (extrinsic), cancer spreads more rapidly because of abundant supply of blood and lymph and soon involves the lymph nodes of the neck. A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords), Supraglottis area (area above the glottis or vocal cords, including epiglottis and false cords), and sub glottis (area below the glottis or vocal cords to the cricoid). Two thirds of laryngeal cancers are in the glottis area. Supraglottis cancers account for approximately one third of the cases, subglottic tumors for less than 1%. Glottic tumors seldom spread if found early because of the limited lymph vessels found in the vocal. 

Causes for Laryngeal Cancer 

The cause of laryngeal cancer is unknown. Major risk factors include smoking and alcoholism. Minor risk factors include chronic inhalation of noxious fumes and familial disposition. An initial assessment includes a complete history and physical examination of the head and neck. This will include assessment of risk factors, family history, and any underlying medical conditions. Varied assessment findings in laryngeal cancer depend on the tumor’s location and its stage. With stage I disease, the patient may complain of local throat irritation or hoarseness that lasts about 2 weeks. In stages II and III, he usually reports hoarseness. He may also have a sore throat, and his voice volume may be reduced to a whisper. In stage IV, he typically reports pain radiating to his ear, dysphagia, and dyspnea. In advanced (stage IV) disease, palpation may detect a neck mass or enlarged cervical lymph nodes. 

Diagnostic tests 

The usual workup includes laryngoscopy, xeroradiography, biopsy, laryngeal tomography and computed tomography scans, and laryngography to visualize and define the tumor and its borders. Chest X-ray findings can help detect metastases. An indirect laryngoscopy, using a flexible endoscope, is initially performed in the otolaryngologist’s office to visually evaluate the pharynx, larynx, and possible tumor. Mobility of the vocal cords is assessed; if normal movement is limited, the growth may affect muscle, other tissue, and even the airway. The lymph nodes of the neck and the thyroid gland are palpated to determine spread of the malignancy. If a tumor of the larynx is suspected on an initial examination, a direct laryngoscopic examination is scheduled. This examination is done under local or general anesthesia and allows evaluation of all areas of the larynx. Samples of the suspicious tissue are obtained for histologic evaluation. The tumor may involve any of the three areas of the larynx and may vary in appearance. Computed tomography and magnetic resonance imaging (MRI) are used to assess regional adenopathy and soft tissue and to help stage and determine the extent of a tumor. MRI is also helpful in post-treatment follow-up in order to detect a recurrence. Positron emission tomography (PET scan) may also be used to detect recurrence of a laryngeal tumor after treatment. 

Treatment Management For Laryngeal Cancer Depends on sites and stages of cancer. Early malignancy may be removed endoscopically. Early lesions may respond to laser surgery or radiation therapy; advanced lesions to laser surgery, radiation therapy, and chemotherapy. Treatment aims to eliminate cancer and preserve speech. If speech preservation isn’t possible, speech rehabilitation may include esophageal speech or prosthetic devices. Other surgical procedures vary with tumor size and include cordectomy, partial or total laryngectomy, Supraglottic laryngectomy, and total laryngectomy with laryngoplasty. 

Risk Factors for Laryngeal Cancer Carcinogens: Tobacco (smoke, smokeless), Combined effects of alcohol and tobacco, Asbestos, Second-hand smoke, Paint fumes, Wood dust, Cement dust, Chemicals, Tar products, Mustard gas, Leather and metals. Other Factors: Straining the voice, chronic laryngitis, Nutritional deficiencies (riboflavin), History of alcohol abuse Familial predisposition, Age (higher incidence after 60 years of age), Gender (more common in men), Race (more prevalent in African Americans), weakened immune system. 

Clinical Manifestations for Laryngeal Cancer Varied assessment findings in laryngeal cancer Depend on tumor location and its stage; sequence in appearance related to pattern and extent of tumor growth. Supraglottic Cancer: Tickling sensation in throat Dryness and fullness (lump) in throat Painful swallowing (odynophagia) associated with invasion of extra laryngeal musculature Coughing on swallowing Pain radiating to ear (late symptom) Glottic Cancer (Cancer of the Vocal Cord): Most common cancer of the larynx Hoarseness or voice change Aphonia (loss of voice) Dyspnea Pain (in later stages) Subglottic Cancer (Uncommon): Coughing Short periods of difficulty in breathing Hemoptysis; fetid odor, which results from ulceration and disintegration of tumor With stage I disease Hoarseness of more than 2 weeks’ duration is noted early in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Affected voice sounds are not early signs of subglottic or supraglottic cancer. In stages II and III, he usually reports hoarseness. He may also have a sore throat that does not go away, and his voice volume may be reduced to a whisper and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms In stage IV typically reports pain radiating to his ear dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis. palpation may detect a neck mass or enlarged cervical lymph nodes. 

Treatment Management For Laryngeal Cancer 

Radiation therapy: Singly or in combination with surgery. Complications of radiation including airway obstruction, edema of larynx, soft tissue and cartilage necrosis, chondritis, pain, and loss of taste (xerostomia). Surgery therapy: Carbon dioxide laser for early-stage disease. Partial laryngectomy removal of small lesion on true cord, along with a substantial margin of healthy tissue. Supraglottic laryngectomy removal of hyoid bone, epiglottis, and false vocal cords, tracheostomy may be done to maintain adequate airway, radical neck dissection may be done. Hemilaryngectomy removal of one true vocal cord, false cord, one half of thyroid cartilage, arytenoid cartilage. Total laryngectomy removal of entire larynx (epiglottis, false or true cords, cricoid cartilage, hyoid bone; two or three tracheal rings are usually removed when there is extrinsic cancer of the larynx [extension beyond the vocal cords]). A radical neck dissection may also be done because of metastasis to cervical lymph nodes. Total laryngectomy with laryngoplasty voice rehabilitation may be attempted through the Asai operation: A dermal tube is made from the upper end of the trachea into the hypo pharynx. The tracheostomy opening is closed off with a finger. The patient expires air up the dermal tube into the pharyngeal cavity. The sound produced is transformed into almost normal speech. 

Complications of Surgery therapy 

• Salivary fistula may develop after any surgical procedure that involves entering the pharynx or esophagus. (Monitor for saliva collecting beneath the skin flaps or leaking through suture line or drain site. Management NG tube feeding, meticulous local wound care with frequent dressing changes, promotion of drainage) 
• Hemorrhage (carotid artery rupture) or hematoma formation. A major postoperative complication (e.g. skin necrosis or salivary fistula) usually precedes carotid artery rupture. Management immediate wound exploration in operating room. 
• Stomas stenosis. 
• Aspiration. 
• Long-term complications: Chest infections (from repeated aspiration), Recurrence of cancer in stoma 

Nursing Assessment for Laryngeal Cancer The nurse assesses the patient for the following symptoms: hoarseness, sore throat, dyspnea, dysphagia, or pain and burning in the throat. The neck is palpated for swelling. If treatment includes surgery, the nurse must know the nature of the surgery to plan appropriate care. If the patient is expected to have no voice, a preoperative evaluation by the speech therapist is indicated. The patient’s ability to hear, see, read, and write is assessed. Visual impairment and functional illiteracy may create additional problems with communication and require creative approaches to ensure that the patient is able to communicate any needs. In addition, the nurse determines the psychological readiness of the patient and family. The idea of cancer is terrifying to most people. Fear is compounded by the possibility of permanently losing voice and, in some cases, of having some degree of disfigurement. The nurse evaluates the patient’s and family’s coping methods to support them effectively both preoperatively and postoperatively.

Nursing Diagnosis
Common Nursing Diagnosis found in patient with Laryngeal Cancer Ineffective airway clearance Impaired verbal communication Impaired skin/tissue integrity Impaired oral mucous membrane Acute pain Imbalanced nutrition: less than body requirements Disturbed body image/ineffective role performance deficient knowledge [learning need] regarding prognosis, treatment, self-care, and discharge needs Impaired swallowing Risk for infection

Nursing interventions
Ineffective Airway Clearance May be related to: 

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

Nursing Outcomes Evaluation Criteria, Client Will:

• Respiratory Status: Airway Patency Maintain patent airway with breath sounds clear or clearing. 
• Clear secretions and be free of aspiration. 

Nursing Intervention and Rationale Nursing Diagnosis Ineffective Airway Clearance:

• Monitor vital sign respiratory rate and depth note ease of breathing. Auscultate breath sounds. Investigate restlessness, Dyspnea, and development of cyanosis. Rationale Changes in respirations, use of accessory muscles, and presence of crackles or wheezes suggest retention of secretions. Airway obstruction can lead to ineffective breathing patterns even partial Airway obstruction and impaired gas exchange, resulting in complications, such as pneumonia and respiratory arrest. 
• Elevate head of bed 30 to 45 degrees. Rationale Facilitates drainage of secretions, work of breathing, and lung expansion. 
• Encourage swallowing, if client is able. Rationale reducing risk of aspiration with Prevents pooling of oral secretions 
• Encourage and teach effective coughing and deep breathing. Rationale Mobilizes secretions to clear airway and helps prevent respiratory complications. 
• Suction laryngectomy and tracheostomy tube and oral and nasal cavities. Note amount, color, and consistency of secretions. Rationale Changes in character of secretions may indicate developing problems, such as dehydration and infection, and need for further evaluation and treatment. Prevents secretions from obstructing airway, especially when swallowing ability is impaired. 
• Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. Rationale Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. 
• Maintain proper position of laryngectomy or tracheostomy tube. Check and adjust ties as indicated. Rationale As edema develops or subsides, tube can be displaced, compromising airway. Ties should be snug but not constrictive to surrounding tissue or major blood vessels. 
• Observe tissues surrounding tube for bleeding. Change client’s position to check for pooling of blood behind neck or on posterior dressings. Rationale bleeding or sudden eruption of uncontrolled hemorrhage presents a sudden and real possibility of airway obstruction and suffocation. 
• Provide supplemental humidification Rationale: Normal physiological on nasal passages means of filtering and humidifying air are bypassed. Supplemental humidity decreases mucous crusting and facilitates coughing or suctioning of secretions through stoma. 
• Resume oral intake with caution Rationale Changes in muscle mass and strength and nerve innervations increase likelihood of aspiration. 
• Monitor serial ABGs or pulse oximetry and chest x-ray. Rationale Pooling of secretions or presence of atelectasis may lead to pneumonia, requiring more aggressive therapeutic measures. 

Nursing Diagnosis Impaired Verbal Communication related to: 

• Anatomical deficit removal of vocal cords 
• Physical barrier tracheostomy tube 
• Required voice rest 

Nursing Outcomes Evaluation Criteria Client Will:

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

Nursing Diagnosis Impaired Verbal Communication:

• Review preoperative instructions and discussion of why speech and breathing are altered, Rationale Reinforces teaching at a time when fear of surviving surgery is past. 
• Determine whether client has other communication impairments, such as hearing, vision, and literacy. Rationale Presence of other problems influences plan for alternative communication. 
• Provide immediate and continual means to summon nurse Prearrange signals for obtaining immediate help Rationale Client needs assurance that nurse is vigilant and will respond to summons. May decrease client’s anxiety about inability to speak. 
• Allow sufficient time for communication. Rationale Loss of speech and stress of alternative communication can cause frustration and block expression, especially when caregivers seem “too busy” or preoccupied. 
• Encourage ongoing communication with “outside world,” such as newspapers, television, radio, calendar, and clock. Rationale Maintains contact with “normal lifestyle” and continued communication through other avenues. 
• Caution client not to use voice until physician gives permission. Rationale Promotes healing of vocal cord and limits potential for permanent cord dysfunction. 
• Consult or refer with appropriate healthcare team members, therapists, speech pathologist, and social services. Refer to hospital-based rehabilitation, and community resources, such as Lost Chord or New Voice Club, International Association of Laryngectomees, and American Cancer Society. Rationale Ability to use alternative voice and speech methods, such as electrolarynx, TEP, voice prosthesis, and esophageal speech. Rehabilitation time may be lengthy and require a number of agencies and resources to facilitate or support learning process. 

Nursing diagnosis Impaired Skin/Tissue Integrity related to: 

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

Nursing Outcomes Evaluation Criteria Client Will:

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

Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:

• Assess skin color, temperature, and capillary refill in operative and skin graft areas. Rationale Cyanosis and slow refill may indicate venous congestion, which can lead to tissue ischemia and necrosis. 
• Protect skin flaps and suture lines from tension or pressure. Provide pillow or rolls and instruct client to support head and neck during activity. Rationale Pressure from tubing and tracheostomy tapes or tension on suture lines can alter circulation and cause tissue injury. 
• Monitor bloody drainage from surgical sites, suture lines, and drains Rationale Bloody drainage usually declines steadily after first 24 hours. Steady oozing or frank bleeding indicates problem requiring medical attention. 
• Note and report any milky-appearing drainage. Rationale Milky drainage may indicate thoracic lymph duct leakage, which can result in depletion of body fluids and electrolytes. Such a leak may heal spontaneously or require surgical closure. 
• Change dressings, as indicated. Rationale Damp dressings increase risk of tissue damage and infection. 
• Cleanse thoroughly around stoma and neck tubes (if in place), avoiding soap or alcohol. Show client how to do self-care of stoma and tube with clean water and peroxide, using soft, lint-free cloth, not tissue or cotton. Rationale Keeping area clean promotes healing and comfort. Soap and other drying agents can lead to stomal irritation and possible inflammation. Materials other than cloth may leave fibers in stoma that can irritate or be inhaled into lungs. 
• Monitor all sites for signs of wound infection, such as unusual redness; increasing edema, pain, exudates; and temperature elevation. Rationale Impedes healing, which may already be slow because of changes induced by cancer, cancer therapies, or malnutrition. 
• Administer oral, IV, and topical antibiotics, as indicated. Rationale Prevents or controls infection. 

Nursing Diagnosis Impaired Oral Mucous Membrane related to 

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

Nursing Outcomes and Evaluation Criteria Client Will:

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

Nursing Intervention and Rationale Nursing Diagnosis Impaired Oral Mucous Membrane:

• Inspect oral cavity, Tongue, Lips Teeth and gums and Mucous membranes note changes in: Saliva Rationale Surgery or Damage to salivary glands Tongue, Lips Teeth and gums and Mucous membranes may decrease production of saliva, resulting in dry mouth. Pooling and drooling of saliva may occur because of compromised swallowing capability or pain in throat and mouth. 
• Suction oral cavity frequently. Have client perform self-suctioning when possible or use gauze wick to drain secretions. Rationale Saliva contains digestive enzymes that may be erosive to exposed tissues. 
• Show client how to brush inside of mouth, palate, tongue, and teeth. Rationale Frequent oral care reduces bacteria and risk of infection and promotes tissue healing and comfort. 
• Apply lubrication to lips; provide oral irrigations as indicated. Rationale Counteracts drying effects of therapeutic measures and negates erosive nature of secretions. 
• Avoid alcohol based mouthwashes. Rationale: Alcohol can be drying and irritating. 

Nursing Diagnosis Acute Pain related to: 

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

Nursing Outcomes and Evaluation Criteria Client Will:

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

Nursing Diagnosis Acute Pain:

• Evaluate pain level frequently. Rationale : Pain is a major concern for clients undergoing laryngectomy and it is believed as many as 32% still suffer severe distress, with the administered dosing less than needed to obtain optimal pain relief 
• Investigate changes in characteristics of pain. Check mouth and throat suture lines for fresh trauma. Rationale May reflect developing complications requiring further evaluation or intervention. 
• Provide comfort measures, such as back rub and position change, and Diversional activities, such as television, visiting, and reading. Rationale Promotes relaxation and helps client refocus attention on something beside pain. 
• Schedule care activities to balance with adequate periods of sleep or rest. Rationale Prevents fatigue or exhaustion and may enhance coping with stress or discomfort. 
• Administer analgesics such as on a scheduled basis or via patient-controlled analgesia; adjust dosages according to pain level per protocols. Rationale Degree of pain is related to extent and psychological impact of surgery as well as general body condition. 

Patient Teaching Discharge and Home Healthcare Guidelines
Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer. Teach the patient signs and symptoms of potential complications and the appropriate actions to be taken. Complications include infection (wound drainage, poor wound healing, fever, achiness, chills), airway obstruction and tracheostomy stenosis (noisy respirations, difficulty breathing, restlessness, confusion, increased respiratory rate), vocal straining; fistula formation (redness, swelling, secretions along a suture line), and ruptured carotid artery (bleeding, hypotension).Teach the patient the name, purpose, dosage, schedule, common side effects, and importance of taking all medications.
Teach the patient the appropriate devices and techniques to ensure a patent airway and prevent complications. Explore methods of communication that work effectively. Encourage the patient to wear a Medic Alert bracelet or necklace, which identifies her or him as a mouth breather. Provide the patient with a list of referrals and support groups, such as visiting nurses, American Cancer Society, American Speech-Learning-Hearing Association, International Association of Laryngectomees, and the Lost Cord Club

• Before partial or total laryngectomy, instruct the patient in good oral hygiene practices. If appropriate, instruct a male patient to shave off his beard to facilitate postoperative care. 
• Explain postoperative procedures, such as suctioning, NG tube feeding, and laryngectomy tube care. Carefully discuss the effects of these procedures (breathing through the neck and speech alteration, for example). 
• After surgery Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. To Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. 
• Also, prepare the patient for other functional losses. Forewarn him that he won’t be able to smell aromas, blow his nose, whistle, gargle, sip, or suck on a straw. 
• Reassure the patient that speech rehabilitation measures (including laryngeal speech, esophageal speech, an artificial larynx, and various mechanical devices) may help him communicate again. 
• Encourage the patient to take advantage of services and information offered by the American Speech-Language-Hearing Association, the International Association of Laryngectomees, the American Cancer Society, or the local chapter of the Lost Chord Club.

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Nursing Care Plans for Bladder Cancer

Benign or malignant tumors may develop on the bladder. Bladder tumors can develop on the surface of the bladder wall (benign or malignant papillomas) or grow within the bladder wall (usually more virulent) and quickly invade underlying muscles. 

Most bladder tumors are transitional cell carcinomas, arising from the transitional epithelium of mucous membranes. Less common are adenocarcinomas, epidermoid carcinomas, squamous cell carcinomas, sarcomas, tumors in bladder diverticula, and carcinoma in situ. Bladder tumors are most prevalent in men older than age 50 and are more common in densely populated industrial areas, but women are diagnosed at more advanced stages. 

The most common presenting symptom of bladder cancer is hematuria. Gross hematuria obviously warrants a thorough evaluation of the genitourinary system. When gross hematuria is painless and total (present during the entirety of the urinary stream), it especially causes concern for bleeding from the bladder or upper tracts. Irritative urinary symptoms are relatively common at presentation, including frequency, urgency, and dysuria. The combination of these symptoms with hematuria is very suggestive and warrants full urologic evaluation. Depending on the location of their tumors, patients may have symptoms of bladder-outlet obstruction or ureteral obstruction. A small subset, 5% to 10% of patients, have symptoms related to metastatic disease. 

Causes for Bladder cancer 

Environmental carcinogens are known to predispose a person to transitional cell tumors such as 2-naphthylamine, benzidine, tobacco, coffee, and nitrates.Thus, workers in certain industries (rubber workers, weavers, leather finishers, aniline dye workers, hairdressers, petroleum workers, and spray painters) are at high risk for such tumors. The period between exposure to the carcinogen and development of symptoms is about 18 years. Squamous cell carcinoma of the bladder is common in geographic areas where schistosomiasis is endemic, such as Egypt. What is more, it’s also associated with chronic bladder irritation and infection in people with renal calculi, indwelling urinary catheters, chemical cystitis caused by cyclophosphamide, and pelvic irradiation. 

Complications of bladder cancer

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

Nursing Assessment 

The patient typically reports gross, painless, intermittent hematuria and often with clots. Patients may complain of suprapubic pain after voiding, and also complain of bladder irritability, urinary frequency, nocturia, and dribbling. If he reports flank pain, he may have an obstructed ureter. 

Patient’s history Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occurs. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia. 

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

Psychosocial assessment Diagnosis of cancer and treatment of cancer with radical cystectomy and creation of a urinary diversion system can threaten sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido. 

Diagnostic tests for bladder cancer 

To confirm a bladder cancer diagnosis, the patient typically undergoes Cystoscopy should be performed when hematuria first appears. Biopsy (If the test results show cancer cells, further studies will determine the cancer stage and treatment). Excretory urography can identify a large, early-stage tumor or an infiltrating tumor; delineate functional problems in the upper urinary tract; assess hydronephrosis; and detect rigid deformity of the bladder wall. Urinalysis can detect blood and malignant cells in the urine. Retrograde cystography evaluates bladder structure and integrity. Test results also help confirm a bladder cancer diagnosis. A bone scan can detect metastases. A computed tomography scan can define the thickness of the involved bladder wall and disclose enlarged retroperitoneal lymph nodes. Ultrasonography can find metastases in tissues beyond the bladder and can distinguish a bladder cyst from a bladder tumor. Laboratory tests, such as a complete blood count and chemistry profile, may be ordered to evaluate conditions such as anemia that are associated with bladder cancer. 

Nursing diagnosis 

Common nursing diagnosis found in nursing care plans for bladder cancer 

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

Nursing Interventions 

Acute Pain related to activity of disease process (cancer) 

Nursing Outcomes Evaluation Criteria: Client will 

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

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

1. Assess pain level, location, characteristics, and intensity Rationale Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Pains in Surgical causes usually subside gradually as healing begins. Continued or increasing pain may be a sign of infection. 
2. Listen to the patient’s fears and concerns. Stay with him during periods of severe stress and anxiety, and provide psychological support Rationale Reduction of anxiety and fear can promote relaxation and comfort. 
3. Encourage and maintain bed rest during acute phase, if indicated Rationale Minimizes stimulation and promotes relaxation 
4. Administer analgesics, as indicated Rationale Reduce or control pain and decrease stimulation of the sympathetic nervous system 

Anxiety related to underlying Pathophysiology response, change in health status 

Nursing Outcomes

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

Nursing Intervention Anxiety 

• Observe behavior indicative of anxiety which can be a clue to the client’s level of anxiety Rationale 
• Explain purpose of tests and procedures in bladder cancer treatment Rationale Reduces anxiety attributable to fear of unknown diagnosis and prognosis. 
• Encourage family and friends to treat client as before. Rationale Reassures client that role in the family and business has not been altered. 
• Administer sedatives and tranquilizers, as indicated. Rationale May be desired to help client relax until physically able to reestablish adequate coping strategies. 
• Review coping skills used in past and Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, lack of problem solving. Rationale These may be useful for the moment, but may eventually interfere with resolution of current situation 

Nursing Diagnosis Impaired urinary elimination 

Nursing Outcomes Evaluation Criteria 

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

Patient Teaching and Home Health Guidance for Bladder Cancer 

Patient teaching, discharge and home healthcare guidelines for patient with Bladder Cancer. In early stages, bladders Cancer have no symptoms. Commonly, the first sign is gross, painless, intermittent hematuria. Patients with invasive lesions often have suprapubic pain after voiding. Other symptoms include bladder irritability, urinary frequency, nocturia, and dribbling. Provide complete information about disease, disease process and treatment. Provide complete preoperative teaching. Include an explanation of the operation the patient is to undergo. Discuss equipment and procedures that the patient can expect postoperatively. Teach the patient the specific procedure to catheterize the continent coetaneous pouch or reservoir. 

Patient Teaching and Home Health Guidance for Bladder Cancer: 

• Tell the patient what to expect from diagnostic tests. For example, make sure he understands that he may be anesthetized for cystoscopy. 
• After the test results are known, explain the implications to the patient and his family. 
• Demonstrate essential coughing and deep breathing exercises. 
• In patient with orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding. 

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

• If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist. 
• Tell the patient that the ileal conduit stoma should reach its permanent size about 2 to 4 months after surgery. 
• Teach the patient how to care for his urinary stoma. Instruction usually begins 4 to 6 days after surgery. Encourage appropriate relatives or other caregivers to attend the teaching session. Advise them beforehand that a negative reaction to the stoma can impede the patient’s adjustment. 
• If the patient is to wear a urine collection pouch, teach him how to prepare and apply it. First, find out whether he will wear a reusable pouch or a disposable pouch. If he chooses a reusable pouch, he needs at least two to wear alternately. 
• Teach the patient to select the right-sized pouch by measuring the stoma and choosing a pouch with an opening that leaves a (0.3 cm) margin of skin around the stoma. 
• Instruct the patient to remeasure the stoma after he goes home in case the size changes. 
• Tell the patient to empty the pouch every 2 to 3 hours or when it’s one-third full. 
• Advise him to check the pouch frequently to ensure that the skin seal remains intact. 
• Teach the patient to provide stoma care. 
• To ensure a better seal and minimize skin breakdown, teach the patient how to use various products to level uneven abdominal surfaces, such as gullies, scars, and wedges. 
• Postoperatively, tell the patient with a urinary stoma to avoid heavy lifting and contact sports. Encourage him to participate in his usual athletic and physical activities.

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Nursing Care Plans For Nephrotic Syndrome

Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia), edema, and excess lipids in the blood (hyperlipidemia). These occur as a consequence of excessive leakage of plasma proteins into the urine because of increased permeability of the Glomerular capillary membrane. Nephrotic syndrome essentials of Diagnosis: Edema, Hypertension, Hematuria with or without dysmorphic red cells, red blood cell casts. The Nephrotic syndrome is marked by massive proteinuria greater than 3.5 g/d, low levels of serum albumin, high levels of serum lipids, and pronounced edema. Acute onset of the disorder can occur in instances of circulatory disruption producing systemic shock that decrease the pressure and flow of blood to the kidney. Progression to the Nephrotic syndrome may also occur as a complication of the previously discussed forms of glomerulonephritis. 

Causes of Nephrotic syndrome 

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

• With minimal change disease (lipid nephrosis or nil disease) in children it’s the main cause of Nephrotic syndrome the glomeruli appear normal by light microscopy. Some tubules may contain increased lipid deposits. 
• Membraneous glomerulonephritis the most common lesion in patients with adult idiopathic Nephrotic syndrome is characterized by uniform thickening of the Glomerular basement membrane containing dense deposits. It can eventually progress to renal failure. 
• Focal glomerulosclerosis can develop spontaneously at any age, follow kidney transplantation, or result from heroin abuse. 
• With membranoproliferative glomerulonephritis, slowly progressive lesions develop in the subendothelial region of the basement membrane. These lesions may follow infection, particularly streptococcal infection. This disease occurs primarily in children and young adults. 

Other causes of Nephrotic syndrome include All of diseases that increase glomerular protein permeability, which leads to increased urinary excretion of protein, especially albumin, and subsequent hypoalbuminemia. Include metabolic diseases such as diabetes mellitus; collagen-vascular disorders, such as systemic lupus erythematosus and periarteritis nodosa; circulatory diseases, such as heart failure, sickle cell anemia, and renal vein thrombosis; nephrotoxins, such as mercury, gold, and bismuth; infections, such as tuberculosis and enteritis; allergic reactions; pregnancy; hereditary nephritis; and certain neoplastic diseases such as multiple myeloma. 

Pathophysiology of Nephrotic syndrome 

Increased permeability of the Glomerular membrane is attributed to damage to the membrane and changes in the electrical charges in the basal lamina and podocytes, producing a less tightly connected barrier. This facilitates the passage of high-molecular-weight proteins and lipids into the urine. Albumin is the primary protein depleted from the circulation. The ensuing hypoalbuminemia appears to stimulate the increased production of lipids by the liver. The lower oncotic pressure in the capillaries resulting from the depletion of plasma albumin increases the loss of fluid into the interstitial spaces, which, accompanied by sodium retention, produces the edema. Depletion of immunoglobulin’s and coagulation factors places patients at an increased risk of infection and coagulation disorders. Tubular damage, in addition to Glomerular damage, occurs, and the Nephrotic syndrome may progress to chronic renal failure. 

Clinical Manifestations of Nephrotic syndrome 

The dominant Clinical Manifestations of Nephrotic syndrome is mild to severe dependent edema of the ankles or sacrum, or periorbital edema, especially in children. Such edema may lead to ascites, pleural effusion, weight gain, and high blood pressure. Insidious onset of pitting dependent edema, periorbital edema, and ascites, weight gain Fatigue, headache, malaise, irritability Marked proteinuria leading to depletion of body proteins Hyperlipidemia may lead to accelerated atherosclerosis 

Complications of Nephrotic syndrome 

Major complications include malnutrition, infection, coagulation disorders, and accelerated atherosclerosis. Thromboembolic complications renal vein thrombosis, venous and arterial thrombosis in extremities, pulmonary embolism, coronary artery thrombosis, cerebral artery thrombosis (especially in the lungs and legs). Hypovolemia. Hypochromic anemia can develop from excessive urinary excretion of transferrin. Opportunistic infections, hypertension, pleural effusion, and pericardial effusion may occur. Acute renal failure may occur. Altered drug metabolism due to decrease in plasma proteins. Progression to end stage renal failure 

Nephrotic Syndrome Treatment 

Nephrotic Syndrome Treatment. Correction of the underlying cause if possible is requires for effective treatment of Nephrotic syndrome. If it is caused by another disease, that underlying disease is treated. Supportive treatment consists of a nutritious, with restricted sodium intake, diuretics for edema, and antibiotics for infection. All nephrotoxins should be avoided. Some patients respond to an 8-week course of a corticosteroid such as prednisone followed by maintenance therapy. Others respond better to a combination of prednisone and azathioprine or cyclophosphamide. Treatment for hyperlipidemia frequently is unsuccessful. Immunosuppressant, antihypertensive, and diuretics can also help control symptoms. Angiotension converting enzyme inhibitors can decrease protein loss in urine. Some patients respond to a course of corticosteroid therapy, followed by a maintenance dose. Patients with chronic Nephrotic syndrome that’s unresponsive to therapy may require vitamin D replacement 

Management of Nephrotic syndrome 

Treatment of causative Glomerular disease Diuretics (used cautiously) and angiotensin converting enzyme inhibitors to control proteinuria Corticosteroids or immunosuppressant agents to decrease proteinuria General management of edema: Sodium and fluid restriction, Infusion of salt-poor albumin, Dietary protein supplements Low-saturated-fat diet If the kidneys lose their ability to function, dialysis may be necessary. 

Special considerations in Nephrotic syndrome Treatment 

Frequently check urine protein levels. Measure blood pressure while the patient is in a supine position and also while he’s standing, be alert for a drop in blood pressure that exceeds 20 mm Hg. If the patient has had a kidney biopsy, watch for bleeding and shock. Monitor intake and output, and check weight at the same time each morning after the patient voids and before he eats and while he’s wearing the same kind of clothing. Ask the dietitian to plan a high protein, low sodium diet. Provide good skin care because the patient with Nephrotic syndrome usually has edema, if needed provide antiembolism stockings To avoid thrombophlebitis, encourage activity and exercise Offer the patient and family reassurance and support, especially during the acute phase, when edema is severe and the patient’s body image changes. 

Nursing Assessment of Nephrotic syndrome 

Patient’s history, Patients may report no illness before the onset of symptoms some patient have a history of systemic multisystem disease, such as lupus erythematosus, diabetes mellitus, amyloidosis, or multiple myeloma or have a history of an insect sting or venomous animal bite.The patient may complain of lethargy and depression. Your assessment may reveal two common problems: periorbital edema, which occurs primarily in the morning and is more common in children, and mild to severe dependent edema of the ankles or sacrum. Nurses should note orthostatic hypotension, ascites, and swollen external genitalia, signs of pleural effusion, anorexia, and pallor. Obtain history of onset of symptoms including changes in characteristics of urine and onset of edema. 

Physical examination, Perform physical examination looking for evidence of edema and hypovolemic. Assess vital signs, daily weights, intake and output, and laboratory values. In later stages, inspect the patient for massive generalized edema of the scrotum, labia, and abdomen. Pitting edema is usually present in dependent areas. The patient’s skin appears extremely pale and fragile. You may note areas of skin erosion and breakdown. Often, urine output is decreased from normal and may appear characteristically dark, frothy, or opalescent. Some patients have hematuria as well. 

Diagnostic Evaluation of Nephrotic syndrome 

Urinalysis marked proteinuria, microscopic hematuria, urinary casts, appears foamy 24-hour urine for protein (increased) and creatinine clearance (decreased) Protein electrophoresis and immunoelectrophoresis of the urine to categorize the proteinuria Needle biopsy of kidney for histological examination of renal tissue to confirm diagnosis Serum chemistry decreased total protein and albumin, normal or increased creatinine, increased triglycerides, and altered lipid profile 

Nursing Diagnosis of Nephrotic syndrome 

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

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

Nursing Interventions 

Risk for Deficient Fluid Volume related to disease process 

Desired Outcomes/Evaluation Criteria Client Will: 

Hydration, Maintain adequate fluid balance as evidenced by vital signs and weight within client’s normal range, palpable peripheral pulses, moist mucous membranes, and good skin turgor. 

Risk for Deficient Fluid Volume related to disease process: 

Nursing Goal Increasing Circulating Volume and Decreasing Edema 

• Monitor daily weight, intake and output, and urine specific gravity. Rationale: Comparing actual and anticipated output may aid in evaluating presence and degree of renal stasis or impairment. 
• Monitor CVP (if indicated), vital signs, orthostatic blood pressure, and heart rate to detect hypovolemic. Rationale: Indicators of hydration and circulating volume and need for intervention. 
• Monitor serum BUN and creatinine to assess renal function. Rationale: Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction. 
• Administer diuretics or immunosuppressant as prescribed, and evaluate patient’s response. Rationale: May be used short-term to reduce tissue edema to facilitate movement of stone. 
• Infuse I.V. albumin as ordered. Rationale: NS is associated with significant protein loss. Serum albumin levels below 3.4 g/dL suggest need for IDPN infusions. 
• Encourage bed rest for a few days to help mobilize edema; however, some ambulation is necessary to reduce risk of Thromboembolic complications. Rationale: Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation. 
• Enforce mild to moderate sodium and fluid restriction if edema is severe; provide a high-protein diet. Rationale: As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia. 

Risk for Infection related to treatment with immunosuppressant 

Desired Outcomes Evaluation Criteria Client Will: 

Immune Status, Experience no signs or symptoms of infection. 

Nursing Intervention : 

Nursing Goal Preventing Infection 

• Monitor for signs and symptoms of infection. Rationale: Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response. 
• Monitor temperature routinely; check laboratory values for neutropenia. Rationale: A shifting of the differential to the left is indicative of infection. 
• Use aseptic technique for all invasive procedures and strict hand washing by patient and all contacts; prevent contact by patient with persons who may transmit infection. Rationale: Reduces risk of cross-contamination. 
• Monitor effectiveness of antimicrobial therapy. Rationale: within 24 to 48 hours Signs of improvement in condition should occur. 

Patient Teaching Discharge and Home Healthcare Guidelines 

Patient Teaching Discharge and Home Healthcare Guidelines for patient with Nephrotic syndrome. The most common sign of Nephrotic syndrome is mild to severe edema of the ankles or sacrum, and periorbital edema, especially in children. Edema may lead to ascites, pleural effusion, weight gain, and high blood pressure. Accompanying signs and symptoms include orthostatic hypotension, lethargy, anorexia, depression, and pallor. Major complications are malnutrition, infection, coagulation disorders, Thromboembolic vascular occlusion, and accelerated atherosclerosis. 

• Patient Teaching Discharge and Home Health-care Guidelines for patient with Nephrotic syndrome: 
• Teach the patient and family about the disease process, prognosis, and treatment plan for Nephrotic Syndrome. Teach the patient and family the purpose, dosage, route, desired effects, and side effects for all prescribed medications 
• Explain that they need to monitor the urine daily for protein and keep a diary with the results of the tests. 
• Have the patient or family demonstrate the testing techniques before discharge to demonstrate their ability to perform these monitoring tasks. 
• Instruct the patient and family to avoid exposure to communicable diseases and to engage in scrupulous infection control measures (e.g. frequent hand washing). 
• Encourage patients with hypercoagulability to maintain hydration and mobility and to follow the medication regimen. Inform patients on anticoagulant therapy of the need for laboratory monitoring of activated partial thromboplastin time or prothrombin time. 
• Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as GI bleeding, stunted growth (children), bone fractures, and immunosuppressant. 
• If the patient is taking immunosuppressant, teach him and family members to report even mild signs of infection. If he’s undergoing long-term corticosteroid therapy, teach him and family members to report muscle weakness and mental changes, Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as Gastrointestinal GI bleeding, stunted growth (children), bone fractures, and immunosuppressant. 
• Suggest to the patient that he take steroids with an antacid or with cimetidine or ranitidine, to prevent Gastrointestinal GI complications, explain that the adverse effects of steroids subside when therapy stops, but warn the patient not to discontinue the drug abruptly or without a physician’s consent. 
• Show the patient how to safely apply and remove anti-embolism stockings, If the physician prescribes anti-embolism stockings for home use. 
• Stress the importance of adhering to the special diet or Ask the dietitian to plan a high-protein, low-sodium diet 
• Encourage patients to resume normal activities as soon as possible.

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