Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Imbalanced Nutrition, Less Than Body Requirements related to anorexia and vomiting.

Imbalanced Nutrition, Less Than Body Requirements NANDA Definition: Intake of nutrients insufficient to meet metabolic needs.

Characteristics :

• Loss of weight
• Lack of interest in food
• Pale conjunctiva and mucous membranes
• Poor muscle tone
• Amenorrhea
• Poor skin turgor
• Edema of extremities
• Electrolyte imbalances
• Weakness
• Constipation
• Anemias

Goals

• Client will gain 2 pounds per week for the next 3 weeks.
• Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; constipation will be corrected; client will exhibit increased energy in participation in activities).

Nursing Interventions Imbalanced Nutrition, Less Than Body Requirements for Peritonitis

Independent:

1. Monitor bow NG tube, and note the presence of vomiting or diarrhea.
Rational: The large number of gastric aspiration and vomiting or diarrhea is suspected bowel obstruction, requiring further evaluation.

2. Measure body weight each day.
Rationale: Loss of or increase in early showed further changes in hydration but loss is suspected nutritional deficit.

3. Auscultation bowel sounds, record sounds nothing or hyperactive.
Rationale: Although there is no frequent bowel sounds, bowel inflammation or irritation may accompany intestinal hyperactivity, decreased water absorption, and diarrhea.

4. Record the required calorie needs.
Rational: The calories (energy sources) will accelerate the healing process.

5. Monitor Hb and albumin
Rational: Indications adequate protein to the immune system.

6. Assess abdomen with frequent return to the gentle sound, the appearance of normal bowel sounds, flatus smooth dam.
Rationale: Indicates the return to normal bowel function.

Collaboration:

1. Collaborative installation NGT if the client can not eat and drink orally.
Rational: In order to keep the client nutrients are met.

2. Collaboration with a dietitian in your diet.
Rational: A healthy body is not easy for infection (inflammation).

3. Provide information about the food substances which are very important to balance the body's metabolism
Rationale: Clients can strive to meet the needs of eating nutritious food.

Care Plan Nursing Read more »

Risk for Infection Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Risk for Infection related to tissue trauma

Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

Goal: Reduce infections, improve patient comfort.


Expected outcomes:

• Increased healing in time, free of purulent drainage or erythema, no fever.
• Stated understanding of the causes of individual / risk factors.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.


Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

Care Plan Nursing Read more »

Nursing Care Plan for Mitral Stenosis

Mitral stenosis (MS) is a blockage of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral stenosis typically have mitral valve leaflets are thickened, komisura are fused, and the chordae tendineae are thickened and shortened. Transverse diameter of the heart are usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen. Here is a picture of mitral valve stenosis.

Mitral stenosis causes a change in shape of heart and changes in blood vessels of the lungs according to severity of Mitral Stenosis and heart conditions. Convexity left border of the heart indicates that the prominent stenosis. In most cases there are two disorders that mitral stenosis and mitral insufficiency, generally one of them stand out. Also very dilated left ventricle when the mitral insufficiency involved are very significant. Classical radiological signs of patients with Mitral stenosis is a double contour (double contour) which leads to an enlarged left atrium, and the presence of septum lines are localized.

This condition makes the pulmonary venous pressure increases, causing diversion of blood, chest X-ray look at the relative dilation of blood vessels compared to the top of the pulmonary blood vessels below the lungs. Narrowing of the mitral valve causes the valve does not open properly and blocks the flow of blood between the left heart chambers. When the mitral valve narrowing (stenosis), blood can not efficiently pass through the heart. This condition causes a person to become weak and become short of breath and other symptoms.

Mitral stenosis, a valve disorder most often caused by rheumatic heart disease. It is estimated that 99% mitral stenosis based on rheumatic heart disease. However, approximately 30% of patients with mitral stenosis can not find any previous history of the disease.

In all valvular heart disease, mitral stenosis most commonly found, namely ± 40% of all rheumatic heart disease, and affects women more than men, with a ratio of approximately 4: 1.

Myxoma (benign tumor in the left atrium) or blood clots can block blood flow as it passes through the mitral valve and cause the same effect as mitral valve stenosis.


Nursing Assessment - Nursing Care Plan for Mitral Stenosis

Anamnesa

1. Demographic Data
   
   • Name
   • Age
   • Gender
   • Interest / nation
   • Religion
   • Education
   • Works
   • Address
2. Main Complaints: patients with mitral stenosis is usually complain of shortness, cyanosis and coughing.
3. History of Disease Now: The client is usually taken to hospital after shortness of breath, cyanosis or coughing is accompanied by high fever / no.
4. History of past illness: The client had suffered from rheumatic fever disease, SLE (Systemic Lupus Erithematosus), RA (Rhemautoid arthritis), myxoma (benign tumor in the left atrium).
5. Family History of Disease: there are no hereditary factors that influence the occurrence of mitral stenosis.

ROS (Review of Systems) 

B1 (Breath): Shortness / increased respiration, low tones at the apex by using a bell on his side to the left, shortness of breath and fatigue, cough, orthopnea in venous congestion there.

B2 (Blood): an increase in the jugular vein, odema leg, in the form of atrial arrhythmia atrial fibrillation (rapid heart rate and irregular), hemoptysis, embolism and thrombus, strength weakened pulse, tachycardia, peripheral edema (started happening right heart failure), BJ 1 harsh systolic murmur, palpitations, hemoptysis, apical diastolic murmurs.

B3 (Brain): chest pain and abdominal

B4 (Bladder): excess fluid imbalance, oliguria

B5 (Bowel): Dysphagia, nausea, vomiting, no appetite B6 (Bone): weakness, sweating, rapid fatigue.


Psychosocial assessment

1. Shortness of breath affects the interaction
2. Activities limited
3. Fear of facing surgery
4. Stress due to disease condition with a poor prognosis

Nursing Diagnosis Nursing Care Plan for Mitral Stenosis

1. Impaired tissue perfusion
2. Risk for excess fluid volume
3. Ineffective breathing pattern
4. Impaired gas exchange
5. Activity intolerance

Nursing Care Plan for Mitral Stenosis

Nursing Diagnosis and Interventions for Mitral Stenosis

Care Plan Nursing Read more »