Nursing Diagnosis and Interventions for Pediatric GERD

Gastroesophageal reflux disease (GERD) is a chronic digestive disease. GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid content of the stomach backs up into the esophagus.

The cause of GERD is complex and may involve multiple causes.

Like in adults with the condition, gastroesophageal reflux is the upward movement of stomach contents into the esophagus and sometimes into or out of the mouth.

According to the National Digestive Disease Information Clearinghouse, a child's immature digestive system is usually to blame. They add that most infants grow out of GERD by the time they are 1 year old.


Symptoms of Acid Reflux in Infants and Children

• Frequent or persistent cough
• Crying with feeding or after feeding
• Heartburn, gas, or abdominal pain
• Frequent or recurrent vomiting
• Refusing to eat or difficulty eating (choking or gagging with feeding)

Nursing Diagnosis for Gastroesophageal Reflux Disease (GERD)

1. Deficient Fluid Volume related to input, nausea and vomiting / excessive spending.
2. Acute pain related to inflammation of the esophagus lining.
3. Imbalanced Nutrition: less than body requirements related to anorexia, nausea, vomiting.
4. Risk for Impaired Gas Exchange
5. Risk for Impaired Home Maintenance
6. Risk for Aspiration related to barriers to swallow, decreased reflux larynx and glottis to liquid reflux.
7. Ineffective airway clearance related to fluid reflux into the larynx and throat.
8. Impaired swallowing related to narrowing / stricture of the esophagus due to gastroesophageal reflux disease.
9. Anxiety related to the disease process.

Nursing Interventions for Gastroesophageal Reflux Disease (GERD)

1. Increase fluid intake and adequate nutrition.

• Keep head of bed at a position 60 degrees for 30 minutes to 40 minutes.
• Give food a little but often 2 to 3 hours.
• Thicken the milk with cereal.
• Give dinner.
• Measure weight each morning.
• Monitor intake and output.

2. Observe and report any signs of respiratory distress, assess for changes in respiratory status.

3. Before the surgery is done to prepare the client and family for surgery.

4. Monitor the operating side to wholeness.

5. Prevent abdominal distension.

• Maintain patency of a nasogastric tube (NG) or gastrostomy, if installed.
• Check hose NG position.
• Auscultation bowel sounds.

6. Monitor for signs and symptoms of postoperative hemorrhage.

• Decreased blood pressure and increased pulse apex.
• Blood in NG drainage.
• Drainage like coffee grounds would exist in the first 24 hours.

7. Help the parents to express feelings or frustration because they feel responsible or not enough help.

8. Give the stimulation activity.

• Discharge planning and home care.
• Encourage parents about drug administration.
• Encourage parents about feeding.
• Encourage parents to report any vomiting or presence of fresh blood.

Care Plan Nursing Read more »

Anemia - Assessment and 4 Nursing Diagnosis

Nursing Care Plan for Anemia

Assessment

1. Activity / Rest

• Fatigue, weakness, general malaise.
• Loss of productivity, reduction in the passion for work.
• Low tolerance for exercise.
• The need for rest and sleep more.

2. Circulation

• A history of chronic blood loss.
• A history of chronic infective endocarditis.
• Palpitations.

3. Integrity ego

• Religious or cultural beliefs influence the selection of treatment, for example: rejection of blood transfusions.

4. Elimination

• A history of pyelonephritis, kidney failure.
• Flatulence, malabsobsi syndrome.
• Hematemesis, Melana.
• Diarrhea or constipation

5. Food / liquids

• Decreased appetite.
• Nausea / vomit.
• Body weight decreased.

6. Pain / comfort

• The location of pain, especially in the abdomen and head.

7. Breathing

• Shortness of breath at rest or activity

8. Seyuality

• Menstrual changes, for example; menorrhagia, amenorrhea
• Decreased sexual function.
• Impotence.

Nursing Diagnosis

1. Impaired tissue perfusion related to a decrease in the supply of oxygen / nutrients to the cells.

Characterized by:

• Palpitations,
• Pale skin, mucous membranes dry, brittle nails and hair,
• Cold extremities,
• Changes in blood pressure, slow capillary refill,
• Inability to concentrate, disorientation.

2. Activity intolerance related to imbalance of oxygen supply

Characterized by:

• Weakness and fatigue,
• Complained decrease in activity / exercise,
• More need of rest / sleep,
• Palpitations, tachycardia, increased blood pressure.

3. Imbalanced Nutrition: less than body requirements related to failure to digest, absorption of food

Characterized by:

• Weight loss is normal,
• Decrease skin turgor, oral mucosal changes,
• Decreased appetite, nausea,
• Loss of muscle tone.

4. Constipation or diarrhea related to a decrease in the amount of food, change the digestive process, adverse effects of drug use

Characterized by:

• Any changes in the frequency, characteristics, and the amount of feces,
• Nausea, vomiting, decreased appetite,
• Abdominal pain,
• Peristaltic disorders.

Care Plan Nursing Read more »

Nursing Diagnosis for Diabetic Foot Ulcers

Diabetic foot ulcers are one of the complications that are often found in people with diabetes mellitus (DM). It is estimated that 5-10% of people with diabetes found any ulceration of the legs, and about 1% of them will undergo amputation. Four of the five non-traumatic amputation in adults caused by diabetic foot. Besides being a problem for people, also be costs for patients or the government.

The cause of diabetic foot ulcers multifactorial, however there are three things that are most important as the pathogenesis of diabetic foot are:

• neuropathy (sensory, motor and autonomic).
• impaired circulation (microcirculation and makrosirkulasi), and
• infection.

Socio-economic factors and the level of knowledge is an important factor to poor people with diabetic foot ulcers circumstances. Lack of understanding of the patient regarding the prevention of diabetic foot and leg hygiene factors heighten the incidence of diabetic foot ulcers. In addition, both of these factors are often a cause of diabetic foot infections with broad.

Factors that influence the occurrence of diabetic ulcers are divided into endogenous factors and ekstrogen.
1) Endogenous factors

• Genetic, metabolic.
• Diabetic angiopathy.
• Diabetic neuropathy.

2) Exogenous factors

• Trauma.
• Infection.
• Drug.

Nursing Diagnosis for Diabetic Foot Ulcer

1. Impaired tissue perfusion related to the weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels.
2. Impaired tissue integrity related to the presence of gangrene in the extremities.
3. Impaired sense of comfort (pain) related to ischemic tissue.
4. Impaired physical mobility related to pain in the wound.
5. Risk for Infection (sepsis) related to high blood sugar levels.
6. Disturbed Sleep Pattern related to pain in the wound in the leg.

Care Plan Nursing Read more »

NCP Cholera - 6 Nursing Diagnosis and Interventions

Nursing Care Plan for Cholera

Cholera, a severe diarrheal disease caused by the bacterium Vibrio cholerae, has plagued human populations for centuries. This waterborne illness poses significant public health challenges, particularly in regions with inadequate sanitation and limited access to clean water. This article explores the causes, symptoms, transmission, and global efforts in the prevention and management of cholera.

Causes and Transmission:

1. Vibrio cholerae, the bacterium responsible for cholera, typically thrives in contaminated water and food sources. The primary mode of transmission is through the ingestion of contaminated water or food, often via the consumption of raw or undercooked seafood, or contaminated fruits and vegetables.
2. Once ingested, the bacterium releases a toxin that affects the small intestine, leading to rapid and profuse watery diarrhea—a hallmark symptom of cholera. The severity of the disease can range from mild to severe, with severe cases potentially progressing to life-threatening dehydration without prompt intervention.

Symptoms:

1. Watery Diarrhea: Cholera is characterized by the sudden onset of profuse, painless, and watery diarrhea, often described as "rice-water stool."
2. Vomiting: Individuals with cholera may experience vomiting, contributing to fluid loss and dehydration.
3. Dehydration: Rapid fluid loss can lead to severe dehydration, accompanied by symptoms such as sunken eyes, dry mucous membranes, lethargy, and a rapid heart rate.
4. Muscle Cramps: Dehydration can cause muscle cramps and weakness.

Nursing Assessment for Cholera

1. Assess the status of dehydration (skin color, temperature, acral, skin turgor, mucous membranes, eyes, crown, body temperature, pulse, respiration, behavior, weight loss).
2. Observe for manifestations of acute diarrhea
   • A sudden attack of diarrhea
   • Fever
   • Anorexia, nausea, vomiting
   • Weight loss
   • Pain and abdominal cramps, abdominal distension
   • Increased bowel sounds / hyper-peristaltic
   • Malaise
   • Bowel movements more than 3 times a day, liquid stool consistency, with / or without mucus and blood
3. Assess the psychosocial status of families
4. Assess the level of knowledge of family
   • Knowledge of diarrhea at home
   • Knowledge of dietary
   • Knowledge about the prevention of recurrent diarrhea

Nursing Diagnosis for Cholera

1. Deficient fluid volume related to excessive fluid loss through the stool or emesis
2. Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake
3. Risk for infection related to microorganisms that penetrate the gastrointestinal tract.
4. Impaired Skin Integrity: perianal, related to irritation from diarrhea
5. Anxiety related to separation from parents, unfamiliar environment, a stressful procedure.
6. Interrupted Family Processes related to crisis situations, lack of knowledge about diseases, treatment of clients.

Nursing Interventions for Cholera


Deficient fluid volume related to excessive fluid loss through the stool or emesis

Goal :

• Maintain adequate hydration

Expected outcomes:

No signs of dehydration: elastic skin turgor, sunken fontanel not, the patient is not agitated, mucous membranes moist, no weight loss.

Nursing Interventions and Rational:
1) Record Intake Output every 24 hours.
R / Knowing the status of dehydration and evaluate the effectiveness of interventions.

2) Measure the child's weight every day.
R / observe dehydration.

3) Measure vital signs and evaluation of skin turgor, mucous membranes, mental status.
R / observe dehydration.
4) Tell the family to give the child a drink gradually.
R / improve hydration.

collaboration:
5) Give oral rehydration solution (ORS).
R / rehydration and replacement of fluid loss through the stool.

6) Provide and monitor IV fluids as indicated (collaboration).
R / replacement fluid loss.

7) Observe the results of the electrolyte.
R / know the level of hydration and the effectiveness of interventions.


Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake

Goal :

• consume adequate nutrition intake.

Expected outcomes:

• No weight loss (weight stable)
• Eating out 1 serving.
• No nausea, vomiting.

Nursing Interventions and Rational:

1) Evaluation of nutritional status and weight loss
R / Identifying the need for further intervention.

2) Notify and motivation of mothers / families to continue breast-feeding.
R / breast milk reduces the severity and duration of disease and provide additional nutrients.

3) Tell the mother to give the child to eat small meals but often
R / increase food intake.

4) Observe and record the response to feeding.
R / know the tolerance of feeding.

 

 

Bibliography:

1. Ali, M., Nelson, A. R., Lopez, A. L., & Sack, D. A. (2015). Updated global burden of cholera in endemic countries. PLoS Neglected Tropical Diseases, 9(6), e0003832. doi: 10.1371/journal.pntd.0003832
2. Clemens, J. D., Nair, G. B., Ahmed, T., Qadri, F., Holmgren, J., & Cholera Symposium Participants. (2017). Cholera. The Lancet, 390(10101), 1539-1549. doi: 10.1016/S0140-6736(17)30559-7

Care Plan Nursing Read more »

Bladder Cancer - Nursing Diagnosis : Imbalanced Nutrition and Deficient Knowledge

Nursing Care Plan for Bladder Cancer

1. Imbalanced Nutrition: Less Than Body Requirements
related to:

hyper-metabolic-related cancer, the consequences of chemotherapy, radiation, surgery (anorexia, gastric irritation, lack of sense of taste, nausea), emotional distress, fatigue, inability to control pain


characterized by:

• inadequate intake,
• loss of sense of taste,
• loss of appetite,
• weight down to 20% or more below the ideal,
• decreased muscle mass and subcutaneous fat,
• constipation,
• abdominal cramping.

Goal:

• Showed a stable weight, normal laboratory results and no sign of malnutrition.
• Stated understanding of the need for adequate intake.
• Participate in the management of diet-related illness.

Interventions :

• Monitor food intake every day, whether eating in accordance with the needs of the client.
• Measure weight, triceps size and observed weight loss.
• Assess pale, slow wound healing and parotid gland enlargement.
• Encourage clients to consume high-calorie foods with adequate fluid intake. Instruct too little food to clients.
• Control of environmental factors such as foul odors or noise. Avoid foods that are too sweet, fatty and spicy.
• Create a pleasant dining atmosphere for example, a meal with friends or family.
• Encourage relaxation techniques, visualization, moderate exercise before eating.
• Encourage open communication about anorexia problems experienced by clients.

Collaboration:

• Observe laboratory studies such as total lymphocytes, serum transferrin and albumin.
• Give treatment as indicated.
• Attach a nasogastric tube for enteral feeding, balanced with infusion.

Rational:

• Provide information about nutritional status.
• Provides information about the addition and weight loss.
• Showed very poor nutritional state.
• Calories are energy sources.
• Prevent nausea and vomiting, excessive distension, dyspepsia which causes a decrease in appetite and reduce harmful stimulus which can increase anxiety.
• In order for the client to feel like being at home alone.
• To induce a feeling of wanting to eat / arouse appetite.
• In order to overcome together (with a dietitian, nurse and client).
• To determine / establish the occurrence of nutritional deficiencies as a result of the course of disease, treatment and care of the client.
• Facilitate the intake of food and beverages with maximum results and right as needed.

2. Deficient Knowledge about the disease, prognosis and treatment
related to:

• lack of information,
• misinterpretation,
• cognitive limitations.

characterized by:

• often asked,
• stating the problem,
• statement misconceptions, is not accurate in mengikiuti instruction / prevention of complications.

Goal:

• Can accurately say about diagnosis and treatment at the level of proximity ready.
• Following the procedure well and explain the reasons to follow those procedures.
• Having the initiative of changing lifestyles and participate in treatment.
• In cooperation with the furnisher.

Interventions:

• Review understanding of the client and family about the diagnosis, treatment and consequences.
• Determine the client's perception about cancer and its treatment, tell the client about the experience of other clients who have cancer.
• Give accurate and factual information. Answer the questions specifically, avoid unnecessary information.
• Provide guidance to client / family before following the treatment procedure, the old therapy, complications. Be honest with the client.
• Encourage clients to provide verbal feedback and correct misconceptions about the disease.
• Review client / family about the importance of optimal nutrition status.
• Encourage clients to assess the oral mucous membranes regularly, note the presence of erythema, ulceration.
• Encourage clients to maintain the cleanliness of the skin and hair.

Rational:

• Avoid duplication and repetition of the client's knowledge.
• Lets do justification to errors as well as errors of perception and conception of understanding.
• Assist the client in understanding the disease process.
• Assist clients and families in making treatment decisions.
• Knowing the extent of understanding the client and client's family about the disease.
• Increasing knowledge of the client and family regarding adequate nutrition.
• Reviewing the development of the processes of healing and signs of infection and problems with oral health can affect the intake of food and beverages.
• Improving the integrity of the skin and head.

Source : http://nursing-care-plan.blogspot.com/2014/01/imbalanced-nutrition-and-knowledge.html

Imbalanced Nutrition Less Than Body Requirements - NCP for Typhoid Fever

Care Plan Nursing Read more »

Lynda Juall Carpenito : Handbook of Nursing Diagnosis

Handbook of Nursing Diagnosis

Lynda Juall Carpenito RN MSN CRNP (Author)

Book Description

The ideal quick reference, this handbook offers practical guidance on nursing diagnoses and associated care. Sections cover Nursing Diagnoses, Health Promotion/Wellness Nursing Diagnoses, and Diagnostic Clusters—medical conditions with relevant collaborative problems and nursing diagnoses.

NEW! The newest nursing diagnoses approved by NANDA International for 2012–2014 are included in this edition.
NEW! Free eBook available on thePoint.
NEW! New resources such as medical and surgical care plans

Care Plan Nursing Read more »

Disturbed Body Image - Nursing Diagnosis for Scoliosis

Nursing Care Plan for Scoliosis - Nursing Diagnosis and Interventions for Scoliosis

Scoliosis is an abnormal curving of the spine. Your spine is your backbone. It runs straight down your back. Everyone's spine curves naturally a tiny bit. But people with scoliosis have a spine That curves too much. The spine Might look like the letter "C" or "S."


Symptoms

Usually there are no symptoms. But symptoms can include:

• Backache or low-back pain
• Tired feeling in the spine after sitting or standing for a long time
• Uneven hips or shoulders (one shoulder may be higher than the other)
• Spine curves more to one side.

Nursing Diagnosis for Scoliosis : Disturbed Body Image related to a posture that is tilted laterally.

Purpose: Improve the image of the body.

Nursing Interventions for Scoliosis:

1. Suggest to express their feelings and problems.
Rational: The expression of emotion helps the patient begin to accept reality

2. Give realistic expectations and goals for the short term to facilitate the achievement.
Rational: unrealistic expectations lead to patients experiencing failure and reinforces feelings of helplessness.

3. Give rewards for tasks done.
Rational: Strengthening Positive self-esteem and encourages repetition of behavior that is expected.

4. Give a boost to take care of the appropriate tolerances.
Rationale: Increasing self-reliance.

Care Plan Nursing Read more »

12 Nursing Diagnosis for Diabetes Mellitus

Diabetes Mellitus

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.
www.medicinenet.com


12 Nursing Diagnosis for Diabetes Mellitus

1. Imbalanced Nutrition: Less/More than Body Requirements

2. Ineffective Tissue Perfusion: Renal, cardiopulmonary, peripheral

3. Impaired Urinary Elimination

4. Disturbed sensory perception: Visual, tactile

5. Activity Intolerance

6. Ineffective Coping

7. Sexual Dysfunction

8. Fear

9. Deficient Knowledge

10. Risk for Impaired Skin Integrity

11. Risk for Injury

12. Risk for Infection

Nursing Care Plan for Diabetes Mellitus

Care Plan Nursing Read more »

Nursing Diagnosis and Interventions for Sinusitis

Nursing Diagnosis for Sinusitis

1 Acute Pain: head, throat, sinus related to inflammation of the nose

Goal : Pain is reduced or lost

Expected outcomes are:

• Clients express the pain diminished or disappeared
• Clients do not grimace in pain

Interventions:
1. Assess client's level of pain
R :/ Knowing the client's level of pain in determining further action

2. Explain the causes and effects of pain on the client and family
R :/ With the causes and consequences of pain the client is expected to participate in treatment to reduce pain

3. Teach relaxation techniques and distractions
R :/ The client knows the distraction and relaxation techniques can be practiced so as if in pain

4. Observation of vital signs and client complaints
R :/ Knowing the general state and development of the client's condition.


2. Anxiety related to lack of client knowledge about diseases and medical procedures (sinus irrigation / operation)

Goal: Anxiety is reduced / lost

Expected outcomes are:

• Clients will describe the level of anxiety and coping patterns.
• The client knows and understands about his illness and its treatment.

Interventions:
1. Assess client's level of anxiety
R :/ Determining the next action

2. Give comfort and ketentaman on the client:

• Show empathy (it comes with a touch client)

R :/ Facilitate client's receipt of the information provided

3. Give an explanation to clients about the illness slowly, quietly and use of clear sentences, short easy to understand
R :/ Increase client understanding about the disease and therapies for the disease so that the client more cooperative

4. Get rid of excessive stimulation such as:

• Place the room quieter client
• Limit contact with others / other clients are likely to experience anxiety

R :/ By removing the stimulus that will enhance the peace of the client concerned.

3. Ineffective Airway Clearance related to the obstruction (nasal secret buildup) secondary to inflammation of the sinuses

Goal: Effective airway, after a secret (seous, purulent) issued

Expected outcomes are:

• Clients no longer breathe through the mouth
• Airway back to normal, especially the nose

Interventions:
1. Assess the existing build-secret
R :/ Knowing the severity and subsequent action

2. Observation of vital signs
R :/ Knowing the client's development prior to surgery

3. Collaboration with the medical team for cleaning discharge
R :/ cooperation to eliminate the buildup of secret / problem

Care Plan Nursing Read more »

3 Nursing Diagnosis Interventions for Hemophilia

Nursing Diagnosis and Nursing Interventions for Hemophilia

1. Nursing Diagnosis: Ineffective Tissue Perfusion related to active bleeding
characterized by decreased consciousness, bleeding.

Objectives / Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved

Nursing Interventions

1. Assess the cause of bleeding
2. Assess skin color, hematoma, cyanosis
3. Collaboration in the provision of adequate IVFD
4. Collaboration in the provision of blood transfusion.

Rational:

1. By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
2. Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
3. Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
4. Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion.

2. Nursing Diagnosis: Deficient Fluid volume related to loss due to bleeding
characterized by: a dry oral mucosa, skin turgor is slow again.

Objectives / Expected outcomes: Indicates repairs fluid balance, moist oral mucosa, skin turgor quickly returned less than 2 seconds

Nursing Interventions:

1. Monitor vital signs
2. Monitor output and income
3. Estimate the wound drainage and the loss of a visible
4. Collaboration in the provision of adequate fluid

Rational

1. Changes in vital signs may indicate the direction of abnormal fluid loss due to an increase in bleeding / dehydration
2. Need to determine kidney function, fluid replacement needs and to help evaluate the fluid status
3. Provide information about the degree of hypovolemia and help determine intervention
4. Maintain fluid balance due to bleeding

3. Nursing Diagnosis : Risk for Injury related to weakness of the defense secondary to hemophilia
characterized by frequent injuries

Objectives / Expected outcomes: injury and complications can be avoided / did not happen.

Nursing Interventions

1. Maintain security of client's bed, put a safety on the bed
2. Avoid injury, light - weight
3. Keep an eye on every move that allows the occurrence of injury
4. Encourage the parents to bring children to the hospital immediately in case of injury
5. Explain to parents the importance of avoiding injury.

Rational

1. Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma
2. Patients with hemophilia are at risk of spontaneous bleeding was controlled so that the required monitoring every move that allows the occurrence of injury
3. Early identification and treatment can limit the severity of complications
4. Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications.
5. Lower the risk of injury / trauma.

Care Plan Nursing Read more »

Self-Care Deficit Nanda Nursing Diagnosis

Self-care deficits

When an individual is very unable to meet their own self-care requisites, a "self-care deficit" occurs. It is the job of the Registered Nurse to determine these deficits, and define a support modality.

Self-care deficit nursing theory is a grand nursing theory that was developed between 1959 and 2001 by Dorothea Orem. It is also known as the Orem model of nursing. It is particularly used in rehabilitation and primary care settings where the patient is encouraged to be as independent as possible.

Self-Care Deficit

Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

Defining Characteristics:

• Inability to feed self independently
• Inability to dress self independently
• Inability to bathe and groom self independently
• Inability to perform toileting tasks independently
• Inability to transfer from bed to wheelchair
• Inability to ambulate independently
• Inability to perform miscellaneous common tasks such as telephoning and writing

Related Factors :

• Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
• Musculoskeletal disorder such as rheumatoid arthritis
• Cognitive impairment
• Energy deficit
• Pain
• Severe anxiety
• Decreased motivation
• Environmental barriers
• Impaired mobility or transfer ability

Expected Outcomes

• Patient safely performs (to maximum ability) self-care activities.
• Resources are identified which are useful in optimizing the autonomy and independence of the patient.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Self-Care: Eating
• Self-Care: Bathing
• Self-Care: Dressing
• Self-Care: Grooming
• Self-Care: Hygiene
• Self-Care: Toileting

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Self-Care Assistance: Bathing/Hygiene
• Self-Care Assistance
• Dressing/Grooming
• Self-Care Assistance: Feeding
• Self-Care Assistance: Toileting
• Environment Management

Care Plan Nursing Read more »

Nursing Care Plan - Assessment, Diagnosis and Interventions for Acute Myocardial Infarction

Acute Myocardial Infarction (AMI)

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation).

Every year, several million people in North America are diagnosed with an AMI, and approximately one-third of these patients die during the acute phase. Health Canada has identified cardiovascular disease or heart diseases as the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national healthcare system.

Clinical Manifestations of Myocardial Infarction

Pain

1. Chest pain that occurs suddenly and constantly not subside, usually above the sternal region and upper abdomen, this is the main symptom.
2. The severity of pain can increase settled until unbearable pain.
3. Pain is very ill, such as punctured-pin that can spread to the shoulder and continued down to the arm (usually the left arm).
4. The pain started spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and do not disappear with the help of rest or nitroglycerin (NTG).
5. Pain may spread to the jaw and neck.
6. Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.
7. Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompany diabetes can interfere neuroreseptor (collect the experience of pain).

Laboratory examination Examination of cardiac enzymes :

1. CPK-MB/CPK
   Isoenzymes found in heart muscle increased by between 4-6 hours, peaks in 12-24 hours, returned to normal within 36-48 hours.
2. LDH / HBDH
   Increases in the 12-24 hour time-consuming dams to return to normal
3. AST
   Increases (less real / special) occurred within 6-12 hours, culminating in 24 hours, returning to normal within 3 or 4 days

ECG ECG changes that occur in the early phase of T wave height and symmetrical. After this there is ST segment elevation. Changes that occur later are the presence of a wave of Q / QS which indicate the presence of necrosis.


Pain scores according to White:

1. = Do not experience pain
2. = Pain on one side without disturbing activities
3. = More pain at one place and resulted in disruption of activities, such as difficulty getting out of bed, hard to bend the head and others.

Primary Assessment for Acute Myocardial Infarction Nursing Care Plan (AMI) :

Airways

1. Blockage or accumulation of secretions
2. Wheezing or crackles

Breathing

1. Shortness of breath with mild activity or rest
2. Respiration more than 24 x / min, irregular rhythm shallow
3. Ronchi, crackles
4. The expansion of the chest is not full
5. Use of auxiliary respiratory muscles

Circulation

1. Weak pulse, irregular
2. Tachycardia
3. Blood pressure increase / decrease
4. Edema
5. Nervous
6. Acral cold
7. Pale skin, cyanosis
8. Decreased urine output

Secondary Assessment Acute Myocardial Infarction (AMI) :

1. Activities
   • Symptoms:
     
     • Weakness
     • Fatigue
     • Can not sleep
     • Settled lifestyle
     • No regular exercise schedule
   • Signs:
     • Tachycardia
     • Dyspnea at rest or activity
2. Circulation
   • Symptoms:
     
     • History of Acute Myocardial Infarction (AMI)
     • Coronary artery disease
     • Blood pressure problems
     • Diabetes mellitus.
   • Signs:
     
     • Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or stand
     • Pulse: normal, full or not strong or weak / strong quality with slow capillary filling, irregular (dysrhythmias)
     • Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased contractility / complaints ventricle
     • Murmur: If there are shows valve failure or dysfunction of heart muscle
     • Friction: suspected pericarditis
     • Heart rhythm can be regular or irregular
     • Edema: juguler venous distention, edema dependent, peripheral, general edema, cracles may exist with heart failure or ventricular
     • Color: Pale or cyanotic, flat nail, on mucous membranes or lips
3. Ego integrity
   • Symptoms: an important symptom or deny the existence of conditions of fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family
   • Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain
4. Elimination
   • Signs: normal, decreased bowel sounds.
5. Food or fluid
   • Symptoms: nausea, anorexia, belching, heartburn, or burning
   • Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes
6. Hygiene
   • Symptoms or signs: difficulty perform maintenance tasks
7. Neuro Sensory
   • Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)
   • Signs: mental changes, weakness
8. Pain or discomfort
   • Symptoms:
     
     • Sudden onset of chest pain (may or may not relate to activities), not relieved by rest or nitroglycerin (although most deep and visceral pain)
     • Location: Typical on the anterior chest, Substernal, precordial, can spread to the hands, jaw, face. No specific location such as epigastric, elbow, jaw, abdomen, back, neck.
     • Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.
     • Intensity: Usually 10 (on a scale of 1-10), may experience the worst pain ever experienced.
     • Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly
9. Respiratory:
   • Symptoms:
     
     • Dyspnea with or without job
     • Nocturnal dyspnea
     • Cough with or without sputum production
     • History of smoking, chronic respiratory disease.
   • Signs:
     
     • Increased respiratory rate
     • Shortness of breath / strong
     • Pallor, cyanosis
     • Breath sounds (clean, cracles, wheezing), sputum
10. Social interactions
    • Symptoms:
      • Stress
      • Difficulty coping with the stressors that exist eg illness, treatment in hospital
    • Signs:
      • Difficulty rest - sleep
      • Response too emotional (angry constantly, fear)
      • Withdraw

Nursing Diagnosis for Acute Myocardial Infarction (AMI)

1. Acute Pain
2. Decreased Cardiac Output
3. Activity Intolerance
4. Imbalanced Nutrition: Less than Body Requirements
5. Ineffective Tissue Perfusion
6. Anxiety
7. Ineffective Coping
8. Ineffective Sexuality Patterns

Care Plan Nursing Read more »