Acute Pain NCP for Appendicitis

Appendicitis is a condition characterized by inflammation of the appendix. The appendix is a small pouch attached to the beginning of your large intestine. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy.

The main symptom of appendicitis is abdominal pain. Symptoms of appendicitis may take 4-48 hours to develop. Other symptoms include:

• loss of appetite,
• nausea,
• vomiting,
• lack of appetite, and
• fever.

Diagnosis is based on patient history (symptoms) and physical examination backed by an elevation of neutrophilic white blood cells. Histories fall into two categories, typical and atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles" into the right lower quadrant (or the left lower quadrant in patients with situs inversus totalis), where tenderness develops. The combination of pain, anorexia, leukocytosis, and fever is classic. Atypical histories lack this typical progression and may include pain in the right lower quadrant as an initial symptom. Atypical histories often require imaging with ultrasound and/or CT scanning.

Nursing Diagnosis for Appendicitis: Acute Pain related to distention of the intestinal tissue.

Goal: Pain will be solved
Expected outcomes: normal breathing. normal circulation.

Intervention:

1) Assess the level of pain, location and characteristics of pain.
Rationale: To determine the extent of pain and is an indicator of early to be able to give further action.

2) Encourage deep breathing.
Rationale: deep breathing, can breathe oxygen adequately, so that the muscles into relaxation so as to reduce pain.

3) Perform gate control.
Rationale: The gate control large diameter nerve stimulating small-diameter nerve so that pain stimuli are not forwarded to the hypothalamus.

4) Give analgesics.
Rationale: As a prophylactic in order to relieve pain (if already know the symptoms for sure).

Anxiety - NCP for Pulmonary Edema

Pulmonary edema is an abnormal buildup of fluid in the air sacs of the lungs, which leads to shortness of breath.

Early symptoms of pulmonary edema include:

• shortness of breath upon exertion
• sudden respiratory distress after sleep
• difficulty breathing, except when sitting upright
• coughing

In cases of severe pulmonary edema, these symptoms will worsen to:

• labored and rapid breathing
• frothy, bloody fluid containing pus coughed from the lungs (sputum)
• a fast pulse and possibly serious disturbances in the heart's rhythm (atrial fibrillation, for example)
• cold, clammy, sweaty, and bluish skin
• a drop in blood pressure resulting in a thready pulse

The health care provider will perform a physical exam and use a stethoscope to listen to your lungs and heart. The following may be detected:

• Abnormal heart sounds
• Crackles in your lungs, called rales
• Increased heart rate (tachycardia)
• Pale or blue skin color (pallor or cyanosis)
• Rapid breathing (tachypnea)

Nursing Diagnosis : Anxiety related to Threat / Change in Health Status

Goal: Anxiety can be overcome

Expected outcomes:

• Reported fear / anxiety disappear or decrease to the level that can be handled, looks relaxed and resting / sleeping properly.

Nursing Intervention :

1) Record the degree of anxiety and fear. Inform the patient / person close to the patient, the normal feelings and push expressing feelings.
Rational:
Understanding that feelings (which are based plus oxygen imbalances that threaten) normal can help patients improve some sense of emotional control.

2) Explain the disease process and procedures in the level of the patient's ability to understand and handle information. Assess the current situation and the measures taken to address the problem.
Rational:
Eliminate anxiety as insecurity and reduce fear about personal safety. In the early phase of explanation needs to be repeated with frequent and short because the patient has decreased the scope of attention.

3) Provide comfort measures, ie, back massage, change of positions.
Rational:
Tool to reduce stress and indirect care to enhance relaxation and coping skills.

4) Help patients to identify behavioral help, eg a comfortable position, focus on breathing, relaxation techniques.
Rational:
Giving patients control measures to reduce anxiety and muscle tension.

5) Support the patient / significant other in accepting the reality of the situation, especially the plan for a long period of recuperation. Involve patients in planning and participation in care.
Rational:
Coping mechanisms and participation in treatment programs may improve learning patients to receive the expected result of the disease and improve some sense of control.

6) Watch out for out of control behavior or increased cardiopulmonary dysfunction, eg worsening dyspnea and tachycardia.
Rational:
Developing the capacity of anxiety requires further evaluation and possible intervention with anti-anxiety medication.

Activity Intolerance - NCP Pneumonia

Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites.

Risk factors that increase your chances of getting pneumonia include:

• Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)
• Cigarette smoking
• Dementia, stroke, brain injury, cerebral palsy, or other brain disorders
• Immune system problem (during cancer treatment or due to HIV/AIDS or organ transplant)
• Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus
• Recent surgery or trauma
• Surgery to treat cancer of the mouth, throat, or neck.

The most common symptoms of pneumonia are:

• Cough (with some pneumonias you may cough up greenish or yellow mucus, or even bloody mucus)
• Fever, which may be mild or high
• Shaking chills
• Shortness of breath, which may only occur when you climb stairs

Additional symptoms include:

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• Sharp or stabbing chest pain that gets worse when you breathe deeply or cough
• Headache
• Excessive sweating and clammy skin
• Loss of appetite, low energy, and fatigue
• Confusion, especially in older people.

Nursing Diagnosis for Pneumonia : Activity Intolerance

May be related to Imbalance between oxygen supply and demand. General weakness. Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea.

Desired Outcomes Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range.

1. Assist with self-care activities as necessary. Provide for progressive increase in activities during recovery phase and demand.
Rational : Minimizes exhaustion and helps balance oxygen supply and demand.

2. Assist patient to assume comfortable position for rest/sleep.
Rational : Patient may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on overbed table with pillow support.

3. Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.
Rational : Reduces stress and excess stimulation, promoting rest.

4. Explain importance of rest in treatment plan and necessity for balancing activities with rest.
Rational : Bedrest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual patient response to activity and resolution of respiratory insufficiency.

5. Evaluate patient’s response to activity. Note reports of dyspnea, increased weakness/fatigue, and changes in vital signs during and after activities.
Rational : Establishes patient’s capabilities/needs and facilitates choice of interventions.

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NCP COPD - Ineffective Airway Clearance

Chronic obstructive pulmonary disease (COPD) also known as emphysema and chronic bronchitis is a very serious disease. COPD is one of the most common lung diseases.

There are two main forms of COPD:
Chronic bronchitis, which involves a long-term cough with mucus
Emphysema, which involves destruction of the lungs over time

Symptoms of COPD
Cough, with or without mucus
Fatigue
Many respiratory infections
Shortness of breath (dyspnea) that gets worse with mild activity
Trouble catching one's breath
Wheezing

In COPD, less air flows in and out of the airways because of one or more of the following:

The airways and air sacs lose their elastic quality.
The walls between many of the air sacs are destroyed.
The walls of the airways become thick and inflamed.
The airways make more mucus than usual, which can clog them.

Nursing Care Plan for COPD

Nursing Diagnosis : Ineffective Airway Clearance related to the disruption of production increased secretions, retained secretions

Goal : Ventilation / oxygenation to the needs of clients.

Expected outcome : Maintain a patent airway and breath sounds clean

Interventions :

Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress.
Help the abdominal breathing exercises or lip.
Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).
Increase fluid intake to 3000 ml / day according to tolerance of the heart.

Impaired Physical Mobility NCP Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory arthritis and an autoimmune disease. This is where the body’s immune system attacks healthy tissues in the body, particularly the synovium the membrane joining the joints. The joints fill with fluid, due to this process and cause pain and systematic inflammation.

Rheumatoid arthritis is not only a condition linked with joints. It causes innumerable problems in other organs also such as eyes, lungs, skin and heart. Almost all of these problems are uncommon nevertheless they are crucial too, when they make their presence. Basically rheumatoid arthritis comes under the group of autoimmune diseases and hence it can make its presence in any part of the body once it catches hold of joints.

Rheumatoid arthritis is a chronic disease that may have periods of intense activity followed by a period of inactivity. Some patients may go through continuous activity that becomes worse with time. Organ damage and disability can occur with continuous rheumatoid arthritis.

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission).

When the disease is active, symptoms can include fatigue, loss of energy, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity.

Nursing Diagnosis: Impaired Physical Mobility

Related to:

• Skeletal deformity
• Painful
• Discomfort
• Activity intolerance
• Decreased muscle strength.

Can be evidenced by:

• Reluctance to try moving / inability to move in with their own physical environment.
• Limiting the range of motion, coordination imbalances, decreased muscle strength / control and mass (advanced stage).

The expected outcomes / evaluation criteria, patients will:

• Maintaining a function of position in the absence / restrictions contractures.
• Maintain or improve strength and function of and / or compensation of the body.
• Demonstrate techniques / behaviors enabling activities

Nursing Intervention Impaired Physical Mobility - Nursing Care Plan for Rheumatoid Arthritis

1. Evaluation / continue monitoring the level of inflammation / pain in the joints
Rationale: The level of activity / exercise depends on the development / resolution of the inflammatory process.

2. Keep the rest - bed rest / activity schedule sit down if necessary to provide a continuous period and nighttime sleep uninterrupted.
Rationale: Systemic Rest is recommended during acute exacerbations, and all phases of the disease is important to prevent exhaustion maintain strength

3. Assist with range of motion active / passive, and resistive exercise also demikiqan isometris if possible
Rationale: Maintain / improve joint function, muscle strength and general stamina.

4. Change positions frequently with sufficient amount of personnel. Demonstrate / removal of technical aids and mobility aid use, eg, trapeze
Rationale: Eliminates stress on the network and improves circulation. Facilitate patient self-care and independence. Proper removal techniques to prevent tearing skin abrasion.

5. Position with pillows, sandbags, rolls trokanter, splint, brace
Rationale: Increase stability (reducing the risk of injury) and maintain the necessary joint position and body alignment, reducing contractor.

6. Use a small pillow / thin below the neck.
Rationale: Preventing neck flexion.

7. Encourage the patient to maintain an upright posture and sitting height, standing, and walking.
Rationale: To maximize joint function and maintain mobility

8. Provide a safe environment, such as raising the chair, using the toilet railings, wheelchair use.
Rationale: Avoiding injury due to accidents / falls

9. Collaboration: consul with physiotherapy.
Rationale: Useful in formulating training programs / activities based on individual needs and identifying tools.

10. Collaboration: Provide foam mat / converter pressure.
Rationale: Reducing the pressure on the fragile tissue to reduce the risk of immobility.

Nursing Interventions Fluid Volume Deficit - NCP Diabetic Ulcer

Nursing Diagnosis for Diabetic Ulcer : Fluid Volume Deficit related to osmotic diuresis

Characterized by: decreased skin turgor and dry mucous membranes.

Goal: fluids or hydration needs are met.

With the expected outcomes:
Patients showed adequate hydration evidenced by stable vital signs, peripheral pulses can be palpated, skin turgor and capillary refill is good, proper urine output of individual and electrolyte levels within normal limits.
Nursing Interventions Fluid Volume Deficit - Nursing Care Plan for Diabetic Ulcer:

Independent:

1. Assess the client's history with respect to the duration or intensity of symptoms such as vomiting and excessive spending urine.
Rational:
Help estimate the total volume deficits. The process of infection resulting in fever and hypermetabolic conditions that increase water loss.

2. Monitor vital signs, note any changes in orthostatic blood pressure.
Rational:
Hypovolemia manifested by hypotension and tachycardia. Estimate the severity of hypovolemia as systolic blood pressure ≥ 10 mmHg fall from a lying position to a sitting or standing.

3. Monitor your breathing pattern as the Kussmaul breathing or breathing that smell ketones.
Rational:
Need to remove the carbonic acid produced by respiratory alkalosis respiratoris compensation to the state of ketoacidosis. Acetone breath odor caused asetoasetat acid solution and should be dropped when ketosis corrected.

4. Monitor the frequency and quality of breathing, use of accessory muscles breathing, periods of apnea and cyanosis.
Rational:
Hyperglycemia and acidosis causes normal breathing pattern and frequency. However, increased work of breathing, and rapid shallow breathing and cyanosis is indicative of respiratory fatigue or loss of capacity through compensation in acidosis. '

5. Monitor temperature, skin color, or moisture.
Rational:
Fever, chills, and diaphoresis are common in the infection process, fever with rash, dry is a sign of dehydration.

6. Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rational:
An indicator of the level of dehydration or adequate circulating volume.

7. Monitor input and output.
Rational:
Estimating the need for fluid replacement, renal function, and the effectiveness of a given therapy.

8. Measure weight every day.
Rational:
Provides the best assessment of the fluid status of ongoing and further in giving replacement fluids.

9. Maintain a minimum of 2500 ml of fluid / day.
Rational:
Maintaining hydration or circulating volume.

10. Improve the environment that cause a sense of comfort. Cover the client with a thin cloth.
Rational:
Avoid excessive heating of the client can further lead to loss of fluid.

11. Assess mental or sensory changes.
Rational:
Mental changes associated with hyperglycemia or hypoglycemia, electrolyte abnormalities, acidosis, decreased cerebral perfusion, and hypoxia. Cause untreated, the disorder predisposing to aspiration awareness on the client.

12. Observation nausea, abdominal pain, vomiting, and stomach distention.
Rational:
Lack of fluids and electrolytes alter gastrointestinal motility sehinnga often cause vomiting and potentially lead to lack of fluids and electrolytes.

13. Observation of an increased sense of fatigue, edema, weight gain, irregular pulse, and vascular distension.
Rational:
Fluid for rapid improvement potential fluid overload and chronic heart failure.

Collaboration

14. Give fluid therapy as indicated:
Rasiona:
The type and amount of liquids depends on the degree of lack of fluids and individual client response.

15. Normal saline or half normal saline with or without dextrose.
Rational:
Plasma expanders (replacement) is required if a life-threatening blood pressure was not able to return to normal with rehydration efforts that have been made.

16. Insert the catheter urine.
Rationale: Provides precise measurements of the expenditure urine, especially if autonomic neuropathy causing retention or incontinence.