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Advance Medical – Surgical Nrsg. II0
a.) Enumerate the diff. problems involving each system assigned and describe each.


b.) Select one problem in each system and make a NCP using format:
                Nursing Dx. – Objectives of care – Nrsg. Intervention - Rationale


Group I
1.  Eye Problems

        Disorders of the eyelids and lacrimal ducts are commonly apparent on examination. Such disorders are caused by a range of factors, from infection to congenital
         deformity. They include blepharitis, chalazion, dacryocystitis, orbital cellulitis, ptosis, and stye.
        Conjunctival disorders typically cause obvious inflammation. Although some are self-limiting, others may lead to blindness if left untreated.
        Some corneal disorders, such as abrasions, may be mild and seldom cause complications. Others, such as keratitis, can lead to blindness if untreated.
        Disorders of the uveal tract, retina, and lens may be acute or chronic and may cause visual disturbances or even vision loss. They include age-related macular
         degeneration, cataract, retinal detachment, retinitis pigmentosa, uveitis, and vascular retinopathies.
        Miscellaneous disorders include extraocular motor nerve palsies, glaucoma, and strabismus.

        Glaucoma           Nursing Diagnoses           Objectives of Care                                   Nursing Interventions and Rationale

Glaucoma is a group        Acute pain            The patient will         express  For the patient with angle-closure glaucoma, give medications, as ordered, and
of           disorders     Anxiety                feelings of comfort.               prepare him physically and psychologically for laser iridotomy or surgery.
characterized by high      Disturbed
                                                The patient will identify  Remember to administer cycloplegic eyedrops in the affected eye only. In the
intraocular pressure        sensory
                                                 strategies to reduce anxiety.    unaffected eye, these drops may precipitate an attack of angle-closure glaucoma and
(IOP) that damages          perception:
                                                                                  threaten the patient's residual vision.
the    optic    nerve.      Visual              The patient will regain normal
Glaucoma may occur         Fear                 visual functioning.             After trabeculectomy, give medications, as ordered, to dilate the pupil. Also apply a
as a primary or            Risk for injury     The patient and family will
                                                                                  topical corticosteroid, as ordered, to reduce inflammation.
congenital disease or                            express their feelings and  After surgery, protect the affected eye by applying an eye patch and shield,
secondary to other                               concerns.                        positioning the patient on his back or unaffected side, and following general safety
causes, such as injury,                                                           measures.
                                                The patient will avoid injury.
infection, surgery, or
                                                                                              Administer pain medication as ordered.
prolonged       topical
corticosteroid use.                                                                           Encourage ambulation immediately after surgery.
                                                                                              Encourage the patient to express any concerns he may have about having a chronic
                                                                                               condition.
                                                                                              Stress the importance of strictly adhering to the prescribed drug therapy to maintain
                                                                                               low IOP and prevent optic disk changes that cause vision loss.
                                                                                              Explain all procedures and treatments, especially surgery, to help reduce the patient's
                                                                                               anxiety.
                                                                                              Inform the patient that lost vision can't be restored but that treatment can usually
                                                                                               prevent further loss.
                                                                                              Instruct the patient's family how to modify his environment for safety. For example,
                                                                                               suggest keeping pathways clear and reorienting the patient to room layouts, if
                                                                                               necessary.
                                                                                              Teach the patient signs and symptoms that require immediate medical attention, such
                                                                                               as sudden vision change or eye pain.
                                                                                              Discuss the importance of glaucoma screening for early detection and prevention.
                                                                                               Point out that all people older than age 35, especially those with a family history of
                                                                                               glaucoma, should have an annual tonometric examination.


2.       Throat Problems

          Throat disorders, characterized by a sore throat, dysphagia, hoarseness, and airway obstruction, may be caused by bacterial, fungal, or viral infections; an aneurysm;
           surgical trauma; cancer; smoking; and overuse of the vocal cords. These disorders include juvenile angiofibroma, laryngitis, pharyngitis, tonsillitis, vocal cord nodules and
           polyps, and vocal cord paralysis.



         Pharyngitis          Nursing Diagnoses                Objectives of Care                                      Nursing Interventions and Rationale

Pharyngitis, the most  Acute pain                      The     patient   will     express  Administer an analgesic and warm saline gargles as ordered and as appropriate.
common            throat     Fatigue              feelings of comfort.
                                                                                         Encourage the patient to drink plenty of fluids (up to 2½ qt [2.5 L] per day). Monitor
disorder, is an acute or     Imbalanced
                                                  The patient will verbalize the         intake and output scrupulously, and watch for signs of dehydration (cracked lips, dry
chronic inflammation          nutrition:    Less
                                                   importance of adequate rest            mucous membranes, low urine output, poor skin turgor). Provide meticulous mouth
of the pharynx. It's          than         body
                                                   periods.                               care to prevent dry lips and oral pyoderma and maintain a restful environment.
widespread       among        requirements
adults who live or           Impaired      oral  The patient will take in an           Obtain throat cultures, and administer an antibiotic as ordered.
work in dusty or dry          mucous               adequate number of calories
                                                                                         Maintain a restful environment, especially if the patient is febrile, to conserve energy.
environments,        use      membrane             every day.
their             voices     Risk for deficient  The                                   Encourage a soft, light diet with plenty of liquids to combat the commonly
                                                             patient's   mucous
excessively, habitually       fluid volume                                                experienced anorexia. An antiemetic can be given before eating if ordered.
                                                   membranes will remain intact.
use      tobacco      or                                                                 Examine the skin twice a day for possible drug sensitivity rashes or for rashes
alcohol, or suffer from                              The patient's fluid volume will
                                                                                          indicating a communicable disease.
chronic        sinusitis,                             remain within normal range.
persistent coughs, or                                                                    Administer an antitussive, as ordered, if the patient has a cough.
allergies.                                                                               Administer an analgesic as ordered.
Uncomplicated
                                                                                         If the patient has acute bacterial pharyngitis, emphasize the importance of completing
pharyngitis      usually
                                                                                          the full course of antibiotic therapy. Tell him to call the physician if he experiences any
subsides in 3 to 10
                                                                                          adverse reactions.
days.
                                                                                         Advise the patient with chronic pharyngitis how to minimize sources of throat
                                                                                          irritation in the environment, by using a bedside humidifier, for example. Refer him to
                                                                                          a self-help group, if appropriate, to stop smoking.
                                                                                         Inform the patient and his family that in the case of a positive streptococcal infection,
                                                                                          all of his family should undergo throat cultures, regardless of the presence or absence
                                                                                          of symptoms. Individuals with positive cultures require penicillin therapy.
                                                                                         Teach the patient to avoid using irritatants, such as alcohol, which may exacerbate
                                                                                          symptoms.


3.       Problems that involve Immune System

         Characterized by a harmful reaction to extrinsic materials or allergens, allergic disorders include allergic rhinitis, anaphylaxis, asthma, atopic dermatitis, blood
          transfusion reaction, latex allergy, and urticaria and angioedema.
   Autoimmune disorders are marked by an abnormal immune response to oneself. Autoimmunity leads to a sequence of tissue reactions and damage that may produce
        diffuse, systemic signs and symptoms. Among the autoimmune disorders are ankylosing spondylitis, fibromyalgia syndrome, Goodpasture's syndrome, graft rejection
        syndrome, juvenile rheumatoid arthritis, lupus erythematosus, polymyositis and dermatomyositis, Reiter's syndrome, rheumatoid arthritis, scleroderma, SjÃgren's
        syndrome, and vasculitis.



Lupus erythematosus          Nursing Diagnoses            Objectives of Care                                     Nursing Interventions and Rationale

Lupus erythematosus          Acute pain              The patient will express  Continually assess the patient for signs and symptoms of organ involvement, while
is      a        chronic     Constipation             feelings of comfort and           offering encouragement, emotional support, and thorough patient teaching.
inflammatory                 Decreased                decreased pain.
                                                                                        Monitor the patient for hypertension, weight gain, and other signs of renal
autoimmune disorder           cardiac output
                                                      The patient will pass soft,       involvement.
that     affects      the    Diarrhea
                                                       regular       stool    without
connective       tissues.    Disturbed body                                            Evaluate the patient for possible neurologic damage signaled by personality changes,
                                                       straining.
Lupus erythematosus           image                                                      paranoid or psychotic behavior, depression, ptosis, and diplopia.
takes two forms:             Fatigue                 The patient will maintain
                                                                                        Check urine, stools, and GI secretions for blood. Check the scalp for hair loss and the
discoid             lupus    Imbalanced               adequate cardiac output.
                                                                                         skin and mucous membranes for petechiae, bleeding, ulceration, pallor, and bruising.
erythematosus (DLE)           nutrition:    Less      The patient will resume a
and systemic lupus            than         body                                         Provide a balanced diet. Foods high in protein, vitamins, and iron help maintain
                                                       normal bowel elimination
erythematosus (SLE).          requirements                                               optimum nutrition and prevent anemia. Renal involvement may mandate a low-
                                                       pattern.
DLE affects only the         Impaired      oral                                         sodium, low-protein diet. Provide bland, cool foods if the patient has a sore mouth.
skin;    SLE      affects     mucous                  The patient will verbalize
                                                                                        Urge the patient to get plenty of rest. Schedule diagnostic tests and procedures to
multiple          organs      membrane                 feelings about a changed body
                                                                                         allow adequate rest.
(including the skin)         Impaired physical        image.
and can be fatal.             mobility                                                  Describe all tests and procedures to the patient. Explain that several blood samples
                                                      The patient will express
                             Impaired      skin                                         are needed initially and then periodically to monitor progress.
                                                       feelings of increased energy.
                              integrity                                                 Apply heat packs to relieve joint pain and stiffness. Encourage regular exercise to
                             Impaired tissue         The patient will show no signs
                                                                                         maintain full range of motion and to prevent contractures.
                              integrity                of malnutrition.
                                                                                        Explain to the patient the expected benefit of prescribed medications, and watch for
                             Impaired urinary        The patient's oral mucous
                                                                                         adverse effects, especially when administering high doses of corticosteroids or
                              elimination              membrane will remain intact.
                                                                                         NSAIDs.
                             Ineffective
                                                      The patient will maintain joint
                              breathing                                                 Institute seizure precautions if you suspect CNS involvement.
                                                       mobility and range of motion.
                              pattern
 Risk for infection
                       The patient will maintain skin        Warm and protect the patient's hands and feet if she has Raynaud's phenomenon.
 Risk            for
                        integrity.
  peripheral                                                  If musculoskeletal involvement compromises the patient's mobility, arrange for a
  neurovascular        The site of impaired tissue will       physical therapy and occupational therapy consultation.
  dysfunction           have reduced pain, redness,
                                                              Support the patient's self-image. Offer female patients helpful tips. Suggest
                        and swelling.
                                                               hypoallergenic cosmetics. As needed, refer her to a hairdresser who specializes in
                         The patient will maintain fluid      scalp disorders. Offer male patients similar advice, suggesting hypoallergenic hair care
                          balance; intake will equal           and shaving products.
                          output.
                                                      Teach range-of-motion exercises and body alignment and postural techniques.
                       The patient will maintain a
                                                      Be sure the patient understands ways to avoid infection. Direct her to avoid crowds
                        respiratory rate within five
                                                       and people with known infections.
                        breaths of baseline.
                                                      Advise the patient to notify the physician if fever, cough, or rash occurs or if chest,
                       The patient will remain free
                                                       abdominal, muscle, or joint pain worsens.
                        from signs and symptoms of
                        infection.                    Teach the importance of eating a balanced diet and the restrictions associated with
                                                       medications.
                       The     patient will report
                        alterations in sensation or  Teach the patient and her family about prescribed medications. Include such
                        pain in the extremities.       information as adverse effects, whether the medication needs to be taken with food,
                                                       and correct administration techniques.
                                                             Teach the importance of good skin care, avoiding dryness and the use of irritating
                                                              soaps, hair dryers, hair coloring, and permanent wave solutions.
                                                             Encourage exercise, such as aerobics, swimming, walking, bicycling, and range-of-
                                                              motion exercises.
                                                             Stress the importance of keeping regular follow-up appointments and contacting the
                                                              physician if flare-ups occur.
                                                             Instruct the photosensitive patient to wear protective clothing (hat, sunglasses, long-
                                                              sleeved shirts or sweaters, and slacks) and to use a sunscreen when outdoors.
                                                             Teach the patient to perform meticulous mouth care to relieve discomfort and
                                                              prevent infection.
                                                             Because SLE usually affects women of childbearing age, questions associated with
pregnancy commonly arise. The best evidence available indicates that a woman with
                                                                                           SLE can have a safe, successful pregnancy if she sustains no serious renal or
                                                                                           neurologic impairment. Advise her to seek additional medical care from a
                                                                                           rheumatologist during her pregnancy. As indicated, explain that her physicians may
                                                                                           order low-dose aspirin to reduce the risk of thrombosis during pregnancy.
                                                                                        Warn the patient against trying unproven miracle drugs to relieve arthritis symptoms.
                                                                                        Refer the patient to the Lupus Foundation of America and the Arthritis Foundation, as
                                                                                         necessary.



Group II
1.   Musculoskeletal Problems

      Arising before or at birth, congenital disorders of the musculoskeletal system include clubfoot, developmental dysplasia of the hip, muscular dystrophy, and
       osteogenesis imperfecta.
      Joint disorders, which attack the body's centers of mobility, are painful and disabling. Causes of joint disorders may range from chronic conditions to acute infections. No
       matter what the cause, they all need a team treatment approach that emphasizes patient participation. This includes gout, neurogenic arthropathy, osteoarthritis, and
       septic arthritis.
      Disorders affecting bone structure and function include hallux valgus, herniated disk, kyphosis, Legg-Calv´-Perthes disease, Osgood-Schlatter disease, osteomyelitis,
       osteoporosis, Paget's disease, and scoliosis.
      Diseases that affect the skeletal muscles and connective tissues invariably cause discomfort and restrict movement. Common among these disorders are Achilles tendon
       contracture, carpal tunnel syndrome, rhabdomyolysis, tendinitis and bursitis, and torticollis.


   Herniated disk         Nursing Diagnoses              Objectives of Care                                       Nursing Interventions and Rationale

A herniated disk (also    Activity                 The patient will perform  Assess the patient's pain. With the patient and the physician, plan a pain-control
known as a herniated       intolerance               activities without excessive    regimen using such methods as relaxation, transcutaneous electrical nerve
nucleus pulposus or a     Anxiety                   fatigue or pain.                stimulation, distraction, heat or ice application, traction, bracing, or positioning in
ruptured or slipped       Chronic pain                                              addition to analgesics and muscle relaxants. Give pain medications as ordered and
                                                    The patient will identify
disk) occurs when all     Dressing       or                                         assess the patient's response.
                                                     strategies to reduce anxiety.
or part of the nucleus     grooming     self-
                                                                                    Offer supportive care, careful patient teaching, and encouragement to help the
pulposus,           an     care deficit             The patient will express
intervertebral disk's  Fear                  feelings of comfort and                 patient cope with the discomfort and frustration of chronic back pain and impaired
gelatinous      center,  Impaired physical   decreased pain.                         mobility. Include the patient and his family in all phases of his care.
extrudes through the      mobility
                                             The patient will perform             Encourage the patient to verbalize his concerns about his disorder. Answer questions
disk's weakened or  Risk for injury
                                              activities of daily living within     the patient has as honestly as you can.
torn outer ring (anulus
                                              the confines of the disorder.
fibrosus).          The                                                            Encourage the patient to perform as much self-care as his immobility and pain allow.
resultant pressure on                        The patient will discuss fears        Provide him with adequate time to perform these activities at his own pace.
spinal nerve roots or                         and concerns.
                                                                                   Help the patient identify and perform activities that promote rest and relaxation.
on the spinal cord                           The patient will achieve the
itself causes back pain                                                            If the patient is to undergo myelography, question him carefully about allergies to
                                              highest level of mobility
and other symptoms                                                                  iodides, iodine-containing substances, or seafood because such allergies may indicate
                                              possible within the confines of
of       nerve     root                                                             sensitivity to a radiopaque contrast agent used in the test. Monitor intake and output.
                                              the disease.
irritation.                                                                         Watch for seizures and an allergic reaction.
                                             The patient will demonstrate
                                                                                   If the patient is in traction, ensure that the pelvic straps are properly positioned and
                                              methods to prevent injury to
                                                                                    that the weights are suspended. Periodically remove the traction to inspect skin. Also
                                              himself.
                                                                                    remember to monitor for deep vein thrombosis.
                                                                                   After laminectomy, microdiskectomy, or spinal fusion, enforce bed rest as ordered. If
                                                                                    the patient has a blood drainage system (Hemovac) in use, check the tubing
                                                                                    frequently for patency and a secure vacuum seal. Empty the system at the end of each
                                                                                    shift as ordered, and record the amount and color of drainage. Report colorless
                                                                                    moisture on dressings (possible cerebrospinal fluid leakage) or excessive drainage
                                                                                    immediately. Check the neurovascular status of the patient's legs (color, motion,
                                                                                    temperature, and sensation).
                                                                                   Monitor vital signs, and check for bowel sounds and abdominal distention. Use the
                                                                                    logrolling technique to turn the patient. Administer analgesics as ordered, especially
                                                                                    about 30 minutes before initial attempts to sit or walk. Assist the patient during his
                                                                                    first attempt to walk. Provide a straight-backed chair, and allow him to sit in it briefly.
                                                                                   Teach the patient about treatments, which may include bed rest and pelvic traction;
                                                                                    heat application to the area to decrease pain; an exercise program; medications to
                                                                                    decrease pain, inflammation, and muscle spasms; and surgery.
                                                                                   Before myelography, reinforce previous explanations of the need for this test, and tell
                                                                                    the patient to expect some pain. Assure him that he'll receive a sedative before the
test, if needed, to keep him as calm and comfortable as possible. After the test, urge
                                                                                           the patient to remain in bed with his head elevated (especially if metrizamide was
                                                                                           used) and to drink plenty of fluids.
                                                                                        If surgery is required, explain all preoperative and postoperative procedures and
                                                                                         treatments to the patient and his family.
                                                                                        Prepare the patient for discharge.


2.       Breast Problems

          Some breast disorders, such as mastitis, result from infection and usually affect lactating women. Others, such as galactorrhea, result from hormonal dysfunction
           unrelated to lactation.


          Mastitis           Nursing Diagnoses            Objectives of Care                                      Nursing Interventions and Rationale

Parenchymatous               Acute pain          The patient will express               Give an analgesic as needed.
inflammation of the          Ineffective          feelings of comfort.
                                                                                          Provide comfort measures such as warm soaks.
mammary glands, or            breast-feeding
                                                  The patient will resume
mastitis,        occurs      Risk for impaired                                           Use meticulous hand-washing technique and provide good skin care.
                                                   breast-feeding with no further
postpartum in about           skin integrity                                              Tell the patient to take the antibiotic exactly as prescribed, even if her symptoms
                                                   complications.
1%      of     lactating     Risk for infection                                           subside.
women, mainly in                                  The patient's skin integrity will
primiparas who are                                 remain intact.                         Reassure the mother that breast-feeding won't harm her infant because he's the
breast-feeding.        It                                                                  source of the infection. If only one breast is affected, advise the patient to offer the
                                                     The patient will remain free
occurs occasionally in                                                                     infant that breast first to promote complete emptying and prevent clogged ducts.
                                                      from signs and symptoms of
nonlactating women                                                                         However, if an open abscess develops, she must stop breast-feeding with this breast
                                                      infection.
and rarely in men. The                                                                     and use a breast pump until the abscess heals. She should continue to breast-feed on
prognosis is good.                                                                         the unaffected side.
                                                                                          Show how to position the infant properly to prevent cracked nipples.
                                                                                          Stress the importance of emptying the breasts completely, because milk stasis can
                                                                                           cause infection and mastitis.
                                                                                          Teach the patient to alternate feeding positions and to rotate pressure areas on the
nipples.
                                                                                           Remind the patient to position the infant properly on the breast with the entire areola
                                                                                            in his mouth.
                                                                                           Advise the patient to expose sore nipples to the air as often as possible.
                                                                                           Teach the patient proper hand-washing technique and personal hygiene.
                                                                                           Instruct the patient to get plenty of rest and consume sufficient fluids and a balanced
                                                                                            diet to enhance breast-feeding.
                                                                                           Suggest applying a warm, wet towel to the affected breast or taking a warm shower
                                                                                            to relax and improve breast-feeding.


3.       Reproductive Health Problems

          Common gynecologic complaints may arise from menstrual problems, such as premenstrual syndrome, and infections, such as vulvovaginitis and pelvic inflammatory
           disease. Hormonal dysfunction can lead to other gynecologic disorders such as endometriosis and infertility. The development of benign tumors can account for such
           disorders as ovarian cysts and uterine leiomyomas.
          Male reproductive disorders affect the testes, prostate, and epididymis. Examples of male reproductive disorders include benign prostatic hyperplasia, epididymitis,
           male infertility, prostatitis, testicular torsion, and undescended testes.


 Pelvic inflammatory
                             Nursing Diagnoses             Objectives of Care                                      Nursing Interventions and Rationale
        disease
                                                     The patient will express
Pelvic inflammatory         Acute pain                                                  After establishing that the patient has no drug allergies, administer an antibiotic and
                                                      feelings of comfort.
disease (PID) is an         Anxiety                                                      an analgesic as ordered.
                                                     The patient will identify
umbrella term that          Deficient      fluid
                                                      strategies to reduce anxiety.      Monitor vital signs for fever and fluid intake and output for signs of dehydration.
refers to any acute,         volume
                                                     The patient's fluid volume will     Watch for abdominal rigidity and distention, possible signs of developing peritonitis.
subacute, recurrent,        Ineffective
                                                      remain       within     normal     Provide frequent perineal care if vaginal drainage occurs.
or chronic infection of      coping
                                                      parameters.
the    oviducts    and      Ineffective                                                 Use meticulous hand-washing technique; institute wound and skin precautions, if
                                                     The patient will demonstrate
ovaries, with adjacent       sexuality                                                    necessary.
                                                      adaptive coping behaviors.
tissue involvement. It       patterns
                                                     The patient will express           Encourage the patient to discuss her feelings. Also, offer emotional support, and help
includes inflammation       Risk of infection
of       the       cervix                          feelings about her current     her develop effective coping strategies.
(cervicitis),      uterus                          condition.
                                                                                 To prevent recurrence, encourage compliance with treatment and explain the disease
(endometritis),                                   The patient will remain free
                                                                                  and its severity.
fallopian           tubes                          from signs and symptoms of
(salpingitis),        and                          infection.                    Stress the need for the patient's sexual partner to be examined and, if necessary,
ovaries (oophoritis),                                                             treated for infection.
which can extend to                                                                     Discuss the use of condoms to prevent the spread of sexually transmitted diseases.
the connective tissue
lying between the                                                                       Because PID may cause dyspareunia, advise the patient to check with her physician
broad          ligaments                                                                 about sexual activity.
(parametritis).                                                                         To prevent infection after minor gynecologic procedures, such as dilatation and
                                                                                         curettage, tell the patient to immediately report fever, increased vaginal discharge, or
                                                                                         pain. After such procedures, instruct her to avoid douching or having intercourse for
                                                                                         at least 7 days.



Group III
1. Urinary system (Prostate) Problems

       Congenital renal disorders are present at birth but may not cause signs and symptoms until much later in life. These disorders include medullary sponge kidney and
        polycystic kidney disease.
       Acute renal disorders have a sudden onset. They include acute poststreptococcal glomerulonephritis, acute pyelonephritis, acute renal failure, acute tubular necrosis,
        renal calculi, and renal vein thrombosis.
       Chronic renal disorders develop slowly and persist for a long time. They include chronic glomerulonephritis, chronic renal failure, cystinuria, hydronephrosis, nephrotic
        syndrome, renal tubular acidosis, and renovascular hypertension.
       Lower urinary tract disorders include congenital anomalies of the ureter, bladder, and urethra; lower urinary tract infection; neurogenic bladder; and vesicoureteral
        reflux.


   Benign prostatic
                            Nursing Diagnoses            Objectives of Care                                      Nursing Interventions and Rationale
     hyperplasia
Although most males  Acute pain     The patient will                        express  Prepare the patient for diagnostic tests and surgery as appropriate.
over age 50 have  Impaired urinary   feelings of comfort.
some            prostatic       elimination
                                                        The patient and family will  Monitor and record the patient's vital signs, intake and output, and daily weight.
enlargement,           in      Risk for infection
                                                         demonstrate skill in managing  Watch closely for signs of postobstructive diuresis (such as increased urine output and
benign          prostatic      Risk for injury
                                                         the    urinary     elimination hypotension), which may lead to dehydration, lowered blood volume, shock,
hyperplasia (BPH) the          Sexual
                                                         problem.                       electrolyte losses, and anuria.
prostate           gland        dysfunction
enlarges sufficiently to       Urinary retention     The patient will remain free  Administer antibiotics as ordered for UTI, urethral procedures that involve
compress the urethra                                   from signs or symptoms of      instruments, and cystoscopy.
and cause some overt                                   infection.
                                                                                     If urine retention occurs, try to insert an indwelling urinary catheter. If the catheter
urinary obstruction.                                  The patient will minimize      can't be passed transurethrally, assist with suprapubic cystostomy. Watch for rapid
BPH      begins     with                               complications.                 bladder decompression.
changes                in
periurethral glandular                                The patient will express  Avoid giving a patient with BPH decongestants, tranquilizers, alcohol, antidepressants,
tissue. As the prostate                                feelings about potential or         or anticholinergics because these drugs can worsen the obstruction.
enlarges,     it    may                                actual changes in sexual
                                                                                       After prostatic surgery
extend      into     the                               activity.
bladder and obstruct                                                                    Maintain the patient's comfort, and watch for and prevent postoperative
                                                      The patient will regain ability
urine     outflow     by                                                                   complications. Observe for signs of shock and hemorrhage. Check the catheter
                                                       to completely evacuate the
compressing           or                                                                   frequently (every 15 minutes for the first 2 to 3 hours) for patency and urine color;
                                                       bladder.
distorting the prostatic                                                                   check the dressings for bleeding.
urethra. BPH may also                                                                      Postoperatively, many urologists insert a three-way catheter and establish continuous
cause a diverticulum                                                                        bladder irrigation. Keep the solution flowing at a rate sufficient to maintain patency
musculature         that                                                                    and ensure that returns are clear and light pink. Watch for fluid overload from
retains urine when the                                                                      absorption of the irrigating fluid into the systemic circulation. If a regular catheter is
rest of the bladder                                                                         used, observe it closely. If drainage stops because of clots, irrigate the catheter as
empties. Depending                                                                          ordered, usually with 80 to 100 ml of normal saline solution, while maintaining aseptic
on the size of the                                                                          technique.
enlarged prostate, the
                                                                                           Administer belladonna and opium suppositories or other anticholinergics, as ordered,
age and health of the
                                                                                            to relieve bladder spasms that can occur after transurethral resection.
patient,     and     the
extent       of      the                                                                   Make the patient comfortable after an open procedure: Administer suppositories
obstruction, BPH may                                                                        (except after perineal prostatectomy), and give analgesics to control incisional pain.
be treated surgically                                                                       Change dressings frequently.
or symptomatically.
                                                                                           Continue infusing I.V. fluids until the patient can drink enough on his own (2 to 3 qt [2
                                                                                            to 3 L]/day) to maintain adequate hydration.
   Administer stool softeners and laxatives, as ordered, to prevent straining. Don't check
                                                                                             for fecal impaction because a rectal examination can cause bleeding.


2.       Biliary & Pancreatic Problems

          Diseases of the gallbladder and biliary tract are common and often painful conditions that usually require surgery and may be life-threatening. They are often associated
           with inflammation and deposition of calculi.
          Acute or chronic inflammation is commonly associated with disorders of the stomach, intestines, and pancreas. In addition, ulceration, herniation, or the development
           of diverticula may damage the GI mucosa lining the stomach and intestines.



         Pancreatitis        Nursing Diagnoses               Objectives of Care                                     Nursing Interventions and Rationale

Inflammation of the          Acute pain                The patient will        express  Assess the patient's level of pain. As ordered, administer meperidine or other
pancreas,              or    Deficient      fluid       feelings of comfort.              analgesics. Evaluate and document effectiveness of pain medications; watch for
pancreatitis, occurs in       volume                                                       adverse reactions.
                                                        The patient's fluid volume will
acute and chronic            Disturbed body
                                                         remain       within     normal  Maintain the NG tube for drainage or suctioning.
forms. It's associated        image
                                                         parameters.
with     biliary    tract    Hopelessness                                                Restrict the patient to bed rest, and provide a quiet and restful environment.
disease, alcoholism,         Imbalanced                The patient will express
                                                                                          Place the patient in a comfortable position that also allows maximal chest expansion,
trauma, and certain           nutrition:     Less        positive      feelings   about
                                                                                           such as Fowler's position.
drugs, and it can be          than          body         himself.
idiopathic.        Acute      requirements                                                Assess pulmonary status at least every 4 hours to detect early signs of respiratory
                                                        The patient will participate in
pancreatitis generally       Ineffective                                                  complications.
                                                         decisions about care.
resolves clinically and       breathing                                                   Monitor fluid and electrolyte balance and report any abnormalities. Maintain an
histologically but is         pattern                   The patient will achieve
                                                                                           accurate record of intake and output. Weigh the patient daily and record his weight.
serious in nature and        Risk for impaired          adequate        caloric    and
has a 10% mortality.          skin integrity             nutritional intake.              Evaluate the patient's present nutritional status and metabolic requirements.
Chronic pancreatitis         Risk for injury         The     patient's     breathing  Provide I.V. fluids and parenteral nutrition as ordered. As soon as the patient can
causes       irreversible                              pattern will remain within five     tolerate it, provide a diet high in carbohydrates, low in protein, and low in fat.
tissue damage and                                      breaths of baseline.               Monitor serum glucose levels and administer insulin as ordered.
tends to progress to
significant loss of                                   The patient's skin integrity will  Don't confuse thirst due to hyperglycemia (indicated by serum glucose levels up to
pancreatic function.                                     remain intact.                      350 mg/dl and glucose and acetone in the urine) with dry mouth due to NG intubation
                                                                                             and anticholinergics.
                                                        The patient      will    avoid
                                                         complications.                    If the patient has chronic pancreatitis, allow him to express feelings of anger,
                                                                                            depression, and sadness related to his condition, and help him to cope with these
                                                                                            feelings. Encourage him to use appropriate physical outlets to express his emotions,
                                                                                            such as pounding a punching bag and throwing pillows.
                                                                                           Counsel the patient to contact a self-help group, such as Alcoholics Anonymous, if
                                                                                            needed.
                                                                                           Emphasize the importance of avoiding factors that precipitate acute pancreatitis,
                                                                                            especially alcohol.
                                                                                           Refer the patient and family members to the dietitian. Stress the need for a diet high
                                                                                            in carbohydrates and low in protein and fats. Caution the patient to avoid beverages
                                                                                            with caffeine and irritating foods.
                                                                                           Point out the need to comply with pancreatic enzyme replacement therapy. Instruct
                                                                                            the patient to take the enzymes with meals or snacks to help digest food and to
                                                                                            promote fat and protein absorption. Advise him to watch for and report any of the
                                                                                            following signs and symptoms: fatty, frothy, foul-smelling stools; abdominal
                                                                                            distention; cramping; and skin excoriation.


3.       Problems of sexually transmitted diseases

          Sexually transmitted diseases (STDs) are some of the most common infections in the United States. STDs include chancroid, chlamydial infections, genital warts,
           gonorrhea, herpes simplex virus, syphilis, and trichomoniasis.



         Gonorrhea           Nursing Diagnoses               Objectives of Care                                     Nursing Interventions and Rationale

Gonorrhea      is    a  Acute pain          The patient will remain free  Before treatment, determine if the patient has any drug sensitivities. During
common        sexually  Ineffective sexual   from pain.                     treatment, watch closely for signs of a drug reaction.
transmitted    disease   patterns
                                             The patient will voice his  Use standard precautions when obtaining specimens for laboratory examination and
that usually starts as  Risk for infection
an infection of the  Situational low   feelings about potential or            when caring for the patient. Carefully place all soiled articles in containers, and
genitourinary      tract, self-esteem   actual changes in sexual               dispose of them according to facility policy.
especially the urethra                  activity.
                                                                              Monitor the patient for complications.
and cervix. It also can
                                       The patient will state infection
begin in the rectum,                                                          Isolate the patient with an eye infection.
                                        risk factors.
pharynx, or eyes. Left                                                        If the patient has gonococcal arthritis, apply moist heat to ease pain in affected joints.
untreated, gonorrhea                   The patient will identify signs
                                                                               Administer analgesics as ordered.
spreads through the                     and symptoms of infection.
blood to the joints,                                                          If the physician or laboratory hasn't already done so, report all cases of gonorrhea to
                                       The patient will experience no
tendons,     meninges,                                                         the local public health authorities so that they can follow up with the patient's sexual
                                        further signs or symptoms of
and endocardium; in                                                            partners. Examine and test all people exposed to gonorrhea.
                                        infection.
females, it also can                                                          Report all cases of gonorrhea in children to child abuse authorities.
lead to chronic pelvic                 The patient will express
inflammatory disease                    concern about self-concept,           Routinely instill prophylactic medications, according to facility protocol, in the eyes of
(PID) and sterility.                    esteem, and body image.                all neonates on admission to the nursery. Check the neonate of an infected mother
                                                                               for any signs of infection. Obtain specimens for culture from his eyes, pharynx, and
                                                                               rectum.
                                                                              Urge the patient to inform all sexual partners of the infection so that they can seek
                                                                               treatment.
                                                                           To prevent gonorrhea, provide the following patient teaching:
                                                                              Tell the patient to avoid sexual contact until cultures prove negative and infection is
                                                                               eradicated.
                                                                              Advise the partner of an infected person to receive treatment even if the partner
                                                                               doesn't have a positive culture. Recommend that the partner avoid sexual contact
                                                                               with anyone until treatment is complete because reinfection is extremely common.
                                                                              Counsel the patient and all sexual partners to be tested for human immunodeficiency
                                                                               virus and hepatitis B infection.
                                                                              Instruct the patient to be careful when coming into contact with any bodily discharges
                                                                               to avoid contaminating the eyes.
                                                                              Tell the patient to take anti-infective drugs for the length of time prescribed.
                                                                              To prevent reinfection, tell the patient to avoid sexual contact with anyone suspected
of being infected, to use condoms during intercourse, to wash genitalia with soap and
                                                                                        water before and after intercourse, and to avoid sharing washcloths or using douches.
                                                                                       Advise the patient to return for follow-up testing.



Group IV
1.   HIV and Aids infection

       Immunodeficiency disorders are caused by an absent or a depressed immune response and manifest in various forms. Immunodeficiency disorders include acquired
        immunodeficiency syndrome, chronic fatigue and immune dysfunction syndrome, chronic mucocutaneous candidiasis, common variable immunodeficiency,
        complement deficiencies, DiGeorge syndrome, selective IgA deficiency, and severe combined immunodeficiency disease.

        Acquired
  immunodeficiency          Nursing Diagnoses           Objectives of Care                                     Nursing Interventions and Rationale
       syndrome
Currently one of the
                            Activity             The patient will verbalize the  Recognize that a diagnosis of AIDS is profoundly distressing because of the disease's
most widely publicized
                             intolerance           importance      of   balancing   social impact and the discouraging prognosis. The patient may lose his job and
diseases,      acquired
                            Disturbed body        activity, as tolerated, with     financial security as well as the support of family and friends. Coping with an altered
immunodeficiency
                             image                 rest.                            body image, the emotional burden of serious illness, and the threat of death may
syndrome (AIDS) is
                            Fatigue                                                overwhelm the patient.
marked by progressive                             The patient will verbalize
                            Hopelessness
failure of the immune                              feelings about a changed body  Monitor the patient for fever, noting any pattern, and for signs of skin breakdown,
                            Hyperthermia
system. Although it's                              image.                           cough, sore throat, and diarrhea. Assess him for swollen, tender lymph nodes, and
                            Imbalanced
characterized        by                                                             check laboratory values regularly.
                             nutrition:   Less    The patient will express that
gradual destruction of                             he has more energy.             Avoid glycerine swabs for mucous membranes. Try normal saline or bicarbonate
                             than        body
cell-mediated (T-cell)                                                              mouthwash for daily oral rinsing.
                             requirements         The patient will make
immunity, it also
                            Impaired     oral     decisions on his own behalf.    Record the patient's caloric intake.
affects        humoral
                             mucous
immunity and even                                 The patient will maintain a  Ensure adequate fluid intake during episodes of diarrhea.
                             membrane
autoimmunity                                       normal body temperature.
                            Impaired     skin                                  Provide meticulous skin care, especially if the patient is debilitated.
because of the central
                             integrity            The patient will maintain
role of the CD4+ T                                                              Encourage the patient to maintain as much physical activity as he can tolerate. Make
                            Impaired tissue       current weight or achieve
lymphocyte            in                                                         sure his schedule includes time for both exercise and rest.
                             integrity
immune       reactions.    Ineffective              ideal weight.
                                                                                     If the patient develops Kaposi's sarcoma, monitor the progression of lesions.
The           resultant     coping
                                                  The patient's oral mucous
immunodeficiency           Ineffective health                                       Monitor opportunistic infections or signs of disease progression, and treat infections
                                                   membranes will remain intact.
makes the patient           maintenance                                                 as ordered.
susceptible          to    Ineffective           The patient's wounds and
                                                                                     Combination antiretroviral therapy is used to maximally suppress HIV replication,
opportunistic               protection             lesions will heal without
                                                                                        thereby improving survival. Poor drug compliance may lead to resistance and
infections,    unusual     Ineffective            complications.
                                                                                        treatment failure. Patients must understand that medication regimens must be
cancers, and other          sexuality             The site of impaired tissue will     followed closely and may be required for many years, if not throughout life.
abnormalities      that     patterns               have      reduced      redness,
define AIDS.               Interrupted                                              Urge the patient to inform potential sexual partners and health care workers that he
                                                   swelling, and pain.
                            family processes                                            has HIV infection.
                           Noncompliance         The patient will use support
                                                                                     Teach the patient how to identify the signs of impending infection, and stress the
                            (treatment             systems to assist with coping.
                                                                                        importance of seeking immediate medical attention.
                            regimen)              The patient will perform
                           Powerlessness                                            Involve the patient with hospice care early in treatment so he can establish a
                                                   health maintenance activities
                           Risk for deficient                                          relationship.
                                                   according to the level of his
                            fluid volume           ability.                          If the patient develops AIDS dementia in stages, help him understand the progression
                           Risk for infection                                          of this symptom.
                           Social isolation      The patient will demonstrate
                                                   use of protective measures,  Keep in mind that cultures that traditionally rely on extended family, churches, and
                                                   including conserving energy,         ministers for social and emotional support, such as Blacks and Hispanics, may feel
                                                   maintaining a balanced diet,         particularly isolated if they're reluctant to disclose their HIV illness to anyone other
                                                   and getting plenty of rest.          than immediate family. With several major support systems unavailable to them, they
                                                                                        may need support and assistance in tapping their internal resources as well as in using
                                                  The patient will voice feelings
                                                                                        other external resources that may be available to them.
                                                   about changes in sexual
                                                   identity.                                   Health care workers and the public are advised to use precautions in all
                                                                                    situations that risk exposure to blood, body fluids, and secretions. Diligently practicing
                                                  The family will state ways to
                                                                                    standard precautions can prevent the inadvertent transmission of acquired
                                                   support and assist the patient.
                                                                                    immunodeficiency syndrome (AIDS), hepatitis B, and other infectious diseases that are
                                                  The patient will comply with transmitted by similar routes. In addition:
                                                   the treatment regimen.
                                                                                     Educate the patient and his family, sexual partners, and friends about disease
                                                  The patient will express             transmission and prevention of extending the disease to others.
                                                   feelings of control over his
                                                                                     Inform the patient not to donate blood, blood products, organs, tissue, or sperm.
                                                   condition and situation.
 The patient will maintain  If the patient uses I.V. drugs, caution him not to share needles.
                                                     adequate fluid balance.
                                                                                       Inform the patient that high-risk sexual practices for AIDS transmission are those that
                                                    The patient will experience no     exchange body fluids, such as vaginal or anal intercourse without a condom.
                                                     fever, chills, or other signs or
                                                                                       Discuss safer sexual practices, such as hugging, petting, mutual masturbation, and
                                                     symptoms of illness.
                                                                                        protected sexual intercourse. Abstaining is also the most protective method of not
                                                    The patient will maintain peer     transmitting the disease.
                                                     and family relationships.
                                                                                       Advise female patients of childbearing age to avoid pregnancy. Explain that an infant
                                                                                        may become infected before birth, during delivery, or during breast-feeding.


2.        Cancer

          Cancers in the head, neck, and spine are among the deadliest and most disfiguring. Involvement of speech and sense organs, as well as the central nervous system, can
           have an enormous impact on the patient's quality of life.
          The lung and breast are the most common sites for thoracic cancer. Although rare, soft-tissue sarcomas may also develop in the chest region.
          Cancers in the abdominal and pelvic region of the body can obstruct the affected organ or disrupt its secretory or absorptive functions and obstruct the flow of GI
           contents.
          Besides their impact on physiologic function, cancers of the reproductive system have profound implications for the patient's body image and self-esteem.
          Cancer in bone, skin, and soft tissue can be just as serious as cancer in some major organs. Both primary malignant tumors and metastatic lesions may afflict these
           structures.
          When cancer affects the circulatory systems, the entire body may become rapidly involved in the disease.



     Esophageal cancer       Nursing Diagnoses             Objectives of Care                                    Nursing Interventions and Rationale

Esophageal cancer is        Acute pain        The patient will express  Monitor the patient's nutritional and fluid status, and provide him with high-calorie,
most common in              Anxiety            feelings of comfort and           high-protein foods. If he's having trouble swallowing solids, puree or liquefy his food,
males older than age        Deficient  fluid   decreased pain.                   and offer a commercially available nutritional supplement. As ordered, provide tube
60 and is nearly             volume                                               feedings, and prepare him for supplementary parenteral nutrition.
                                               The patient will express that
always fatal. The           Fatigue
                                                he feels less anxious.           To prevent food aspiration, place the patient in Fowler's position for meals and allow
disease        occurs       Fear
                                                                                  plenty of time to eat. If he regurgitates food after eating, provide mouth care.
worldwide,        but       Imbalanced        The patient will maintain fluid
incidence        varies   nutrition:     Less   volumes within normal range.
                                                                               If the patient has a gastrostomy tube, give food slowly—by gravity—in prescribed
geographically. It is     than          body
                                               The patient will express that   amounts (usually 200 to 500 ml). Offer him something to chew before each feeding.
most commonly found       requirements
                                                he has more energy.             This promotes gastric secretions and provides some semblance of normal eating.
in    Japan,    Russia,  Impaired
China, the Middle         swallowing           The patient will express  Administer ordered analgesics for pain relief as necessary. Provide comfort measures,
East, and the Transkei  Risk             for   concerns and fears related to   such as repositioning and distractions.
region of South Africa.   aspiration            his diagnosis and condition.
                                                                               After surgery, monitor the patient's vital signs, fluid and electrolyte balance, and
                         Risk for infection  The patient will maintain        intake and output. Immediately report unexpected changes in the patient's condition.
                                                weight within an acceptable     Monitor him for such complications as infection, fistula formation, pneumonia,
                                                range.                          empyema, and malnutrition.
                                                The patient will swallow  If an anastomosis to the esophagus was performed, position the patient flat on his
                                                 without coughing or choking. back to prevent tension on the suture line. Watch for signs of an anastomotic leak.
                                                                        If the patient had a prosthetic tube inserted, make sure it doesn't become blocked or
                                                 The patient won't aspirate.
                                                                          dislodged. This could cause a perforation of the mediastinum or precipitate tumor
                                              The patient will show no
                                                                          erosion.
                                               evidence of infection.
                                                                         After radiation therapy, monitor the patient for such complications as esophageal
                                                                          perforation, pneumonitis and fibrosis of the lungs, and myelitis of the spinal cord.
                                                                                 After chemotherapy, take steps to decrease adverse effects, such as providing normal
                                                                                  saline mouthwash to help prevent mouth ulcers. Allow the patient plenty of rest, and
                                                                                  administer medications as ordered to reduce adverse effects.
                                                                                 Protect the patient from infection.
                                                                                 Throughout therapy, answer the patient's questions and tell him what to expect from
                                                                                  surgery and other therapies. Listen to his fears and concerns, and stay with him during
                                                                                  periods of severe anxiety.
                                                                                 Encourage the patient to identify actions and care measures that promote his comfort
                                                                                  and relaxation. Try to perform these measures, and encourage the patient and family
                                                                                  to do so as well.
                                                                                 Whenever possible, include the patient in care decisions.
                                                                                 Explain the procedures the patient is to undergo after surgery—closed chest
                                                                                  drainage, nasogastric suctioning, and placement of gastrostomy tubes.
 If appropriate, instruct family members in gastrostomy tube care. This includes
                                                                                        checking tube patency before each feeding, providing skin care around the tube, and
                                                                                        keeping the patient upright during and after feeding.
                                                                                       Stress the need to maintain adequate nutrition. Ask a dietitian to instruct the patient
                                                                                        and family. If the patient has difficulty swallowing solids, instruct him to puree or
                                                                                        liquefy his food and to follow a high-calorie, high-protein diet to minimize weight loss.
                                                                                        Also, recommend that he add a commercially available, high-calorie supplement to his
                                                                                        diet.
                                                                                       Encourage the patient to follow as normal a routine as possible after recovery from
                                                                                        surgery and during radiation therapy and chemotherapy. Tell him that this will help
                                                                                        him maintain a sense of control and reduce the complications associated with
                                                                                        immobility.
                                                                                       Advise the patient to rest between activities and to stop activity that tires him or
                                                                                        causes pain.



Group V
1.   Cardiovascular Disorders

      Abnormalities during fetal development may cause structural defects of the heart and great arteries. These defects may increase pulmonary blood flow (such as atrial
       septal defect, patent ductus arteriosus, and ventricular septal defect), obstruct the flow of blood out of the heart (such as coarctation of the aorta), cause a mixing of
       oxygenated and deoxygenated blood in the heart or great vessels (such as transposition of the great arteries), or decrease pulmonary blood flow (such as Tetralogy of
       Fallot).
      Valvular heart disease
      Acquired inflammatory heart disease
      Degenerative cardiovascular disorders
      Vascular disorders can affect the arteries, the veins, or both types of vessels. Arterial disorders include aneurysms, which result from a weakening of the arterial wall;
       arterial occlusive disease, which commonly results from atherosclerotic narrowing of the artery's lumen; and Raynaud's disease, which may be linked to immunologic
       dysfunction. Thrombophlebitis, a venous disorder, results from inflammation or occlusion of the affected vessel.


    Hypertension         Nursing Diagnoses              Objectives of Care                                      Nursing Interventions and Rationale
Hypertension is an  Deficient                 The patient will identify        If a patient is hospitalized with hypertension, find out if he was taking his prescribed
intermittent         or    knowledge            appropriate food choices.         antihypertensive. If he wasn't, ask why. If he can't afford the medication, refer him to
sustained elevation of     (lifestyle                                             the appropriate social service department.
                                               The patient will express that
diastolic or systolic      modifications)
                                                he has more energy.              When routine blood pressure screening reveals elevated pressure, make sure the
blood pressure. Serial     Fatigue
                                                                                  sphygmomanometer cuff size is appropriate for the patient's upper arm
blood         pressure  Ineffective           The patient will demonstrate
                                                                                  circumference. Take the pressure in both arms in lying, sitting, and standing positions.
measurements        are    coping               adaptive coping behaviors.
                                                                                  Ask the patient if he smoked, drank a beverage containing caffeine, or was
used     to     classify  Ineffective tissue  The patient will maintain
                                                                                  emotionally upset before the test. Advise him to return for blood pressure testing at
hypertension:              perfusion:           adequate cardiac output and       frequent and regular intervals.
                           Cardiopulmonary      hemodynamic stability.
 Prehypertension:
                          Noncompliance:                                        To help identify hypertension and prevent untreated hypertension, participate in
    systolic      blood                        The patient will comply with
                           Therapeutic                                            public education programs dealing with hypertension and ways to reduce risk factors.
    pressure greater                            his therapy regimen.
                           regimen                                                Encourage public participation in blood pressure screening programs. Routinely
    than 120 but less
                          Risk for injury     The patient will remain free      screen all patients, especially those at risk (blacks and those with family histories of
    than 140 mm Hg
                                                from complications.               hypertension, stroke, or heart attack).
    or diastolic blood
    pressure greater                                                             Teach the patient to use a self-monitoring blood pressure cuff and to record the
    than 80 but less                                                              reading at least twice weekly in a journal for review by the physician at every office
    than 90 mm Hg                                                                 appointment. Tell the patient to take his blood pressure at the same hour each time
                                                                                  with relatively the same type of activity preceding the measurement.
   Stage            1
    hypertension:                                                                Tell the patient and family to keep a record of drugs used in the past, noting especially
    systolic     blood                                                            which ones are or aren't effective. Suggest recording this information on a card so the
    pressure greater                                                              patient can show it to his physician.
    than 139 but less                                                            To encourage compliance with antihypertensive therapy, suggest establishing a daily
    than 160 mm Hg                                                                routine for taking medication. Warn the patient that uncontrolled hypertension may
    or diastolic blood                                                            cause stroke and heart attack. Tell him to report any adverse reactions to prescribed
    pressure greater                                                              drugs. Advise him to avoid high-sodium antacids and over-the-counter cold and sinus
    than 89 but less                                                              medications containing harmful vasoconstrictors.
    than 100 mm Hg
                                                                                 Help the patient examine and modify his lifestyle. Suggest stress-reduction groups,
   Stage           2                                                             dietary changes, and an exercise program, particularly aerobic walking, to improve
    hypertension:                                                                 cardiac status and reduce obesity and serum cholesterol levels.
    systolic    blood
    pressure greater                                                             Encourage a change in dietary habits. Help the obese patient plan a reducing diet. Tell
                                                                                  him to avoid high-sodium foods (such as pickles, potato chips, canned soups, and cold
than 159 mm Hg                                                                        cuts), table salt, and foods high in cholesterol and saturated fat.
     or diastolic blood
     pressure greater
     than 99 mm Hg


2.       Pulmonary Disorders

          Pediatric disorders include croup, a severe inflammation of the upper airway, and epiglottiditis, an acute inflammation of the epiglottis that affects mainly young
           children. They also include respiratory distress syndrome, which is marked by widespread alveolar collapse and occurs mainly in premature infants, and sudden infant
           death syndrome, which strikes apparently healthy infants.
          Acute respiratory disorders require prompt treatment and nursing care. They range from acute respiratory distress syndrome to sarcoidosis.
          Several factors can lead to chronic respiratory disorders. For instance, a genetic defect leads to cystic fibrosis, whereas damage to the bronchial wall results in
           bronchiectasis. Environmental factors cause chronic obstructive pulmonary disease, infection causes pulmonary tuberculosis, and occupational hazards lead to such
           disorders as asbestosis, berylliosis, coal worker's pneumoconiosis, and silicosis.


         Atelectasis         Nursing Diagnoses             Objectives of Care                                     Nursing Interventions and Rationale

In atelectasis, alveolar    Acute pain             The patient will express  Encourage the patient recovering from surgery (or other patients at high risk for
clusters (lobules) or       Anxiety                 feelings of comfort, either       atelectasis) to perform coughing and deep-breathing exercises every 1 to 2 hours. To
lung segments that          Deficient               verbally or through behavior.     minimize pain during these exercises, hold a pillow tightly over the patient's incisional
expand incompletely          knowledge                                                 area. Teach the patient how to do this for himself. Gently reposition the patient often,
                                                    The patient will use support
may produce a partial        (prevention)                                              and help him walk as soon as possible. Administer adequate analgesics to control
                                                     systems to assist with anxiety.
or complete lung            Fear                                                      pain.
collapse.           This    Impaired        gas    The patient will express an
                                                                                      Monitor mechanical ventilation. Maintain tidal volume at 10 to 15 ml/kg of the
phenomenon                   exchange                understanding of techniques
                                                                                       patient's body weight to ensure adequate lung expansion. Use the sigh mechanism on
effectively    removes      Ineffective             to prevent atelectasis, such as
                                                                                       the ventilator, if appropriate, to intermittently increase tidal volume at the rate of 3
certain regions of the       airway clearance        incentive spirometry and deep
                                                                                       to 4 sighs/hour.
lung      from       gas    Ineffective             breathing.
exchange. This allows        breathing                                                Monitor pulse oximetry for decreases in oxygenation.
                                                    The patient will discuss fears
unoxygenated blood           pattern                 and concerns.                    Help the patient use an incentive spirometer to encourage deep breathing.
to pass unchanged           Risk for infection
through these regions                                 The patient will maintain  Humidify inspired air, and encourage adequate fluid intake to mobilize secretions. Use
and produces hypoxia.                                  adequate ventilation and    postural drainage and chest percussion to remove secretions.
oxygenation.
                                   For the intubated or uncooperative patient, provide suctioning as needed. Administer
   The patient will maintain a     sedatives with care because these medications depress respirations and the cough
    patent airway.                  reflex. They also suppress sighs. Keep in mind that the patient is able to cooperate
                                    minimally (or not at all) with treatment if he has pain.
 The patient will maintain a
  respiratory rate within five      Assess breath sounds and respiratory status frequently. Report changes immediately.
  breaths of baseline.
                                    Offer ample reassurance and emotional support because the patient's limited
 The patient will remain free       breathing capacity may frighten him.
  from signs and symptoms of
                                    Teach the patient how to use the spirometer. Urge him to use it every 1 to 2 hours.
  infection.
                                    Show the patient and family members how to perform postural drainage and
                                     percussion. Instruct the patient to maintain each position for 10 minutes and then
                                     perform chest percussion. Let him know when to cough. Teach coughing and deep-
                                     breathing exercises to promote ventilation and mobilize secretions.
                                   Encourage the patient to stop smoking, lose weight, or both, if needed. Refer him to
                                    appropriate support groups for help.
                                   Demonstrate comfort measures to promote relaxation and conserve energy. Advise
                                    the patient and family members to alternate periods of rest and activity to promote
                                    energy and prevent fatigue.

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Nursing care plans

  • 1. Advance Medical – Surgical Nrsg. II0
  • 2. a.) Enumerate the diff. problems involving each system assigned and describe each. b.) Select one problem in each system and make a NCP using format: Nursing Dx. – Objectives of care – Nrsg. Intervention - Rationale Group I 1. Eye Problems  Disorders of the eyelids and lacrimal ducts are commonly apparent on examination. Such disorders are caused by a range of factors, from infection to congenital deformity. They include blepharitis, chalazion, dacryocystitis, orbital cellulitis, ptosis, and stye.  Conjunctival disorders typically cause obvious inflammation. Although some are self-limiting, others may lead to blindness if left untreated.  Some corneal disorders, such as abrasions, may be mild and seldom cause complications. Others, such as keratitis, can lead to blindness if untreated.  Disorders of the uveal tract, retina, and lens may be acute or chronic and may cause visual disturbances or even vision loss. They include age-related macular degeneration, cataract, retinal detachment, retinitis pigmentosa, uveitis, and vascular retinopathies.  Miscellaneous disorders include extraocular motor nerve palsies, glaucoma, and strabismus. Glaucoma Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale Glaucoma is a group  Acute pain  The patient will express  For the patient with angle-closure glaucoma, give medications, as ordered, and of disorders  Anxiety feelings of comfort. prepare him physically and psychologically for laser iridotomy or surgery. characterized by high  Disturbed  The patient will identify  Remember to administer cycloplegic eyedrops in the affected eye only. In the intraocular pressure sensory strategies to reduce anxiety. unaffected eye, these drops may precipitate an attack of angle-closure glaucoma and (IOP) that damages perception: threaten the patient's residual vision. the optic nerve. Visual  The patient will regain normal Glaucoma may occur  Fear visual functioning.  After trabeculectomy, give medications, as ordered, to dilate the pupil. Also apply a as a primary or  Risk for injury  The patient and family will topical corticosteroid, as ordered, to reduce inflammation. congenital disease or express their feelings and  After surgery, protect the affected eye by applying an eye patch and shield, secondary to other concerns. positioning the patient on his back or unaffected side, and following general safety causes, such as injury, measures.  The patient will avoid injury.
  • 3. infection, surgery, or  Administer pain medication as ordered. prolonged topical corticosteroid use.  Encourage ambulation immediately after surgery.  Encourage the patient to express any concerns he may have about having a chronic condition.  Stress the importance of strictly adhering to the prescribed drug therapy to maintain low IOP and prevent optic disk changes that cause vision loss.  Explain all procedures and treatments, especially surgery, to help reduce the patient's anxiety.  Inform the patient that lost vision can't be restored but that treatment can usually prevent further loss.  Instruct the patient's family how to modify his environment for safety. For example, suggest keeping pathways clear and reorienting the patient to room layouts, if necessary.  Teach the patient signs and symptoms that require immediate medical attention, such as sudden vision change or eye pain.  Discuss the importance of glaucoma screening for early detection and prevention. Point out that all people older than age 35, especially those with a family history of glaucoma, should have an annual tonometric examination. 2. Throat Problems  Throat disorders, characterized by a sore throat, dysphagia, hoarseness, and airway obstruction, may be caused by bacterial, fungal, or viral infections; an aneurysm; surgical trauma; cancer; smoking; and overuse of the vocal cords. These disorders include juvenile angiofibroma, laryngitis, pharyngitis, tonsillitis, vocal cord nodules and polyps, and vocal cord paralysis. Pharyngitis Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale Pharyngitis, the most  Acute pain  The patient will express  Administer an analgesic and warm saline gargles as ordered and as appropriate.
  • 4. common throat  Fatigue feelings of comfort.  Encourage the patient to drink plenty of fluids (up to 2½ qt [2.5 L] per day). Monitor disorder, is an acute or  Imbalanced  The patient will verbalize the intake and output scrupulously, and watch for signs of dehydration (cracked lips, dry chronic inflammation nutrition: Less importance of adequate rest mucous membranes, low urine output, poor skin turgor). Provide meticulous mouth of the pharynx. It's than body periods. care to prevent dry lips and oral pyoderma and maintain a restful environment. widespread among requirements adults who live or  Impaired oral  The patient will take in an  Obtain throat cultures, and administer an antibiotic as ordered. work in dusty or dry mucous adequate number of calories  Maintain a restful environment, especially if the patient is febrile, to conserve energy. environments, use membrane every day. their voices  Risk for deficient  The  Encourage a soft, light diet with plenty of liquids to combat the commonly patient's mucous excessively, habitually fluid volume experienced anorexia. An antiemetic can be given before eating if ordered. membranes will remain intact. use tobacco or  Examine the skin twice a day for possible drug sensitivity rashes or for rashes alcohol, or suffer from  The patient's fluid volume will indicating a communicable disease. chronic sinusitis, remain within normal range. persistent coughs, or  Administer an antitussive, as ordered, if the patient has a cough. allergies.  Administer an analgesic as ordered. Uncomplicated  If the patient has acute bacterial pharyngitis, emphasize the importance of completing pharyngitis usually the full course of antibiotic therapy. Tell him to call the physician if he experiences any subsides in 3 to 10 adverse reactions. days.  Advise the patient with chronic pharyngitis how to minimize sources of throat irritation in the environment, by using a bedside humidifier, for example. Refer him to a self-help group, if appropriate, to stop smoking.  Inform the patient and his family that in the case of a positive streptococcal infection, all of his family should undergo throat cultures, regardless of the presence or absence of symptoms. Individuals with positive cultures require penicillin therapy.  Teach the patient to avoid using irritatants, such as alcohol, which may exacerbate symptoms. 3. Problems that involve Immune System  Characterized by a harmful reaction to extrinsic materials or allergens, allergic disorders include allergic rhinitis, anaphylaxis, asthma, atopic dermatitis, blood transfusion reaction, latex allergy, and urticaria and angioedema.
  • 5. Autoimmune disorders are marked by an abnormal immune response to oneself. Autoimmunity leads to a sequence of tissue reactions and damage that may produce diffuse, systemic signs and symptoms. Among the autoimmune disorders are ankylosing spondylitis, fibromyalgia syndrome, Goodpasture's syndrome, graft rejection syndrome, juvenile rheumatoid arthritis, lupus erythematosus, polymyositis and dermatomyositis, Reiter's syndrome, rheumatoid arthritis, scleroderma, SjÃgren's syndrome, and vasculitis. Lupus erythematosus Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale Lupus erythematosus  Acute pain  The patient will express  Continually assess the patient for signs and symptoms of organ involvement, while is a chronic  Constipation feelings of comfort and offering encouragement, emotional support, and thorough patient teaching. inflammatory  Decreased decreased pain.  Monitor the patient for hypertension, weight gain, and other signs of renal autoimmune disorder cardiac output  The patient will pass soft, involvement. that affects the  Diarrhea regular stool without connective tissues.  Disturbed body  Evaluate the patient for possible neurologic damage signaled by personality changes, straining. Lupus erythematosus image paranoid or psychotic behavior, depression, ptosis, and diplopia. takes two forms:  Fatigue  The patient will maintain  Check urine, stools, and GI secretions for blood. Check the scalp for hair loss and the discoid lupus  Imbalanced adequate cardiac output. skin and mucous membranes for petechiae, bleeding, ulceration, pallor, and bruising. erythematosus (DLE) nutrition: Less  The patient will resume a and systemic lupus than body  Provide a balanced diet. Foods high in protein, vitamins, and iron help maintain normal bowel elimination erythematosus (SLE). requirements optimum nutrition and prevent anemia. Renal involvement may mandate a low- pattern. DLE affects only the  Impaired oral sodium, low-protein diet. Provide bland, cool foods if the patient has a sore mouth. skin; SLE affects mucous  The patient will verbalize  Urge the patient to get plenty of rest. Schedule diagnostic tests and procedures to multiple organs membrane feelings about a changed body allow adequate rest. (including the skin)  Impaired physical image. and can be fatal. mobility  Describe all tests and procedures to the patient. Explain that several blood samples  The patient will express  Impaired skin are needed initially and then periodically to monitor progress. feelings of increased energy. integrity  Apply heat packs to relieve joint pain and stiffness. Encourage regular exercise to  Impaired tissue  The patient will show no signs maintain full range of motion and to prevent contractures. integrity of malnutrition.  Explain to the patient the expected benefit of prescribed medications, and watch for  Impaired urinary  The patient's oral mucous adverse effects, especially when administering high doses of corticosteroids or elimination membrane will remain intact. NSAIDs.  Ineffective  The patient will maintain joint breathing  Institute seizure precautions if you suspect CNS involvement. mobility and range of motion. pattern
  • 6.  Risk for infection  The patient will maintain skin  Warm and protect the patient's hands and feet if she has Raynaud's phenomenon.  Risk for integrity. peripheral  If musculoskeletal involvement compromises the patient's mobility, arrange for a neurovascular  The site of impaired tissue will physical therapy and occupational therapy consultation. dysfunction have reduced pain, redness,  Support the patient's self-image. Offer female patients helpful tips. Suggest and swelling. hypoallergenic cosmetics. As needed, refer her to a hairdresser who specializes in  The patient will maintain fluid scalp disorders. Offer male patients similar advice, suggesting hypoallergenic hair care balance; intake will equal and shaving products. output.  Teach range-of-motion exercises and body alignment and postural techniques.  The patient will maintain a  Be sure the patient understands ways to avoid infection. Direct her to avoid crowds respiratory rate within five and people with known infections. breaths of baseline.  Advise the patient to notify the physician if fever, cough, or rash occurs or if chest,  The patient will remain free abdominal, muscle, or joint pain worsens. from signs and symptoms of infection.  Teach the importance of eating a balanced diet and the restrictions associated with medications.  The patient will report alterations in sensation or  Teach the patient and her family about prescribed medications. Include such pain in the extremities. information as adverse effects, whether the medication needs to be taken with food, and correct administration techniques.  Teach the importance of good skin care, avoiding dryness and the use of irritating soaps, hair dryers, hair coloring, and permanent wave solutions.  Encourage exercise, such as aerobics, swimming, walking, bicycling, and range-of- motion exercises.  Stress the importance of keeping regular follow-up appointments and contacting the physician if flare-ups occur.  Instruct the photosensitive patient to wear protective clothing (hat, sunglasses, long- sleeved shirts or sweaters, and slacks) and to use a sunscreen when outdoors.  Teach the patient to perform meticulous mouth care to relieve discomfort and prevent infection.  Because SLE usually affects women of childbearing age, questions associated with
  • 7. pregnancy commonly arise. The best evidence available indicates that a woman with SLE can have a safe, successful pregnancy if she sustains no serious renal or neurologic impairment. Advise her to seek additional medical care from a rheumatologist during her pregnancy. As indicated, explain that her physicians may order low-dose aspirin to reduce the risk of thrombosis during pregnancy.  Warn the patient against trying unproven miracle drugs to relieve arthritis symptoms.  Refer the patient to the Lupus Foundation of America and the Arthritis Foundation, as necessary. Group II 1. Musculoskeletal Problems  Arising before or at birth, congenital disorders of the musculoskeletal system include clubfoot, developmental dysplasia of the hip, muscular dystrophy, and osteogenesis imperfecta.  Joint disorders, which attack the body's centers of mobility, are painful and disabling. Causes of joint disorders may range from chronic conditions to acute infections. No matter what the cause, they all need a team treatment approach that emphasizes patient participation. This includes gout, neurogenic arthropathy, osteoarthritis, and septic arthritis.  Disorders affecting bone structure and function include hallux valgus, herniated disk, kyphosis, Legg-Calv´-Perthes disease, Osgood-Schlatter disease, osteomyelitis, osteoporosis, Paget's disease, and scoliosis.  Diseases that affect the skeletal muscles and connective tissues invariably cause discomfort and restrict movement. Common among these disorders are Achilles tendon contracture, carpal tunnel syndrome, rhabdomyolysis, tendinitis and bursitis, and torticollis. Herniated disk Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale A herniated disk (also  Activity  The patient will perform  Assess the patient's pain. With the patient and the physician, plan a pain-control known as a herniated intolerance activities without excessive regimen using such methods as relaxation, transcutaneous electrical nerve nucleus pulposus or a  Anxiety fatigue or pain. stimulation, distraction, heat or ice application, traction, bracing, or positioning in ruptured or slipped  Chronic pain addition to analgesics and muscle relaxants. Give pain medications as ordered and  The patient will identify disk) occurs when all  Dressing or assess the patient's response. strategies to reduce anxiety. or part of the nucleus grooming self-  Offer supportive care, careful patient teaching, and encouragement to help the pulposus, an care deficit  The patient will express
  • 8. intervertebral disk's  Fear feelings of comfort and patient cope with the discomfort and frustration of chronic back pain and impaired gelatinous center,  Impaired physical decreased pain. mobility. Include the patient and his family in all phases of his care. extrudes through the mobility  The patient will perform  Encourage the patient to verbalize his concerns about his disorder. Answer questions disk's weakened or  Risk for injury activities of daily living within the patient has as honestly as you can. torn outer ring (anulus the confines of the disorder. fibrosus). The  Encourage the patient to perform as much self-care as his immobility and pain allow. resultant pressure on  The patient will discuss fears Provide him with adequate time to perform these activities at his own pace. spinal nerve roots or and concerns.  Help the patient identify and perform activities that promote rest and relaxation. on the spinal cord  The patient will achieve the itself causes back pain  If the patient is to undergo myelography, question him carefully about allergies to highest level of mobility and other symptoms iodides, iodine-containing substances, or seafood because such allergies may indicate possible within the confines of of nerve root sensitivity to a radiopaque contrast agent used in the test. Monitor intake and output. the disease. irritation. Watch for seizures and an allergic reaction.  The patient will demonstrate  If the patient is in traction, ensure that the pelvic straps are properly positioned and methods to prevent injury to that the weights are suspended. Periodically remove the traction to inspect skin. Also himself. remember to monitor for deep vein thrombosis.  After laminectomy, microdiskectomy, or spinal fusion, enforce bed rest as ordered. If the patient has a blood drainage system (Hemovac) in use, check the tubing frequently for patency and a secure vacuum seal. Empty the system at the end of each shift as ordered, and record the amount and color of drainage. Report colorless moisture on dressings (possible cerebrospinal fluid leakage) or excessive drainage immediately. Check the neurovascular status of the patient's legs (color, motion, temperature, and sensation).  Monitor vital signs, and check for bowel sounds and abdominal distention. Use the logrolling technique to turn the patient. Administer analgesics as ordered, especially about 30 minutes before initial attempts to sit or walk. Assist the patient during his first attempt to walk. Provide a straight-backed chair, and allow him to sit in it briefly.  Teach the patient about treatments, which may include bed rest and pelvic traction; heat application to the area to decrease pain; an exercise program; medications to decrease pain, inflammation, and muscle spasms; and surgery.  Before myelography, reinforce previous explanations of the need for this test, and tell the patient to expect some pain. Assure him that he'll receive a sedative before the
  • 9. test, if needed, to keep him as calm and comfortable as possible. After the test, urge the patient to remain in bed with his head elevated (especially if metrizamide was used) and to drink plenty of fluids.  If surgery is required, explain all preoperative and postoperative procedures and treatments to the patient and his family.  Prepare the patient for discharge. 2. Breast Problems  Some breast disorders, such as mastitis, result from infection and usually affect lactating women. Others, such as galactorrhea, result from hormonal dysfunction unrelated to lactation. Mastitis Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale Parenchymatous  Acute pain  The patient will express  Give an analgesic as needed. inflammation of the  Ineffective feelings of comfort.  Provide comfort measures such as warm soaks. mammary glands, or breast-feeding  The patient will resume mastitis, occurs  Risk for impaired  Use meticulous hand-washing technique and provide good skin care. breast-feeding with no further postpartum in about skin integrity  Tell the patient to take the antibiotic exactly as prescribed, even if her symptoms complications. 1% of lactating  Risk for infection subside. women, mainly in  The patient's skin integrity will primiparas who are remain intact.  Reassure the mother that breast-feeding won't harm her infant because he's the breast-feeding. It source of the infection. If only one breast is affected, advise the patient to offer the  The patient will remain free occurs occasionally in infant that breast first to promote complete emptying and prevent clogged ducts. from signs and symptoms of nonlactating women However, if an open abscess develops, she must stop breast-feeding with this breast infection. and rarely in men. The and use a breast pump until the abscess heals. She should continue to breast-feed on prognosis is good. the unaffected side.  Show how to position the infant properly to prevent cracked nipples.  Stress the importance of emptying the breasts completely, because milk stasis can cause infection and mastitis.  Teach the patient to alternate feeding positions and to rotate pressure areas on the
  • 10. nipples.  Remind the patient to position the infant properly on the breast with the entire areola in his mouth.  Advise the patient to expose sore nipples to the air as often as possible.  Teach the patient proper hand-washing technique and personal hygiene.  Instruct the patient to get plenty of rest and consume sufficient fluids and a balanced diet to enhance breast-feeding.  Suggest applying a warm, wet towel to the affected breast or taking a warm shower to relax and improve breast-feeding. 3. Reproductive Health Problems  Common gynecologic complaints may arise from menstrual problems, such as premenstrual syndrome, and infections, such as vulvovaginitis and pelvic inflammatory disease. Hormonal dysfunction can lead to other gynecologic disorders such as endometriosis and infertility. The development of benign tumors can account for such disorders as ovarian cysts and uterine leiomyomas.  Male reproductive disorders affect the testes, prostate, and epididymis. Examples of male reproductive disorders include benign prostatic hyperplasia, epididymitis, male infertility, prostatitis, testicular torsion, and undescended testes. Pelvic inflammatory Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale disease  The patient will express Pelvic inflammatory  Acute pain  After establishing that the patient has no drug allergies, administer an antibiotic and feelings of comfort. disease (PID) is an  Anxiety an analgesic as ordered.  The patient will identify umbrella term that  Deficient fluid strategies to reduce anxiety.  Monitor vital signs for fever and fluid intake and output for signs of dehydration. refers to any acute, volume  The patient's fluid volume will Watch for abdominal rigidity and distention, possible signs of developing peritonitis. subacute, recurrent,  Ineffective remain within normal  Provide frequent perineal care if vaginal drainage occurs. or chronic infection of coping parameters. the oviducts and  Ineffective  Use meticulous hand-washing technique; institute wound and skin precautions, if  The patient will demonstrate ovaries, with adjacent sexuality necessary. adaptive coping behaviors. tissue involvement. It patterns  The patient will express  Encourage the patient to discuss her feelings. Also, offer emotional support, and help includes inflammation  Risk of infection
  • 11. of the cervix feelings about her current her develop effective coping strategies. (cervicitis), uterus condition.  To prevent recurrence, encourage compliance with treatment and explain the disease (endometritis),  The patient will remain free and its severity. fallopian tubes from signs and symptoms of (salpingitis), and infection.  Stress the need for the patient's sexual partner to be examined and, if necessary, ovaries (oophoritis), treated for infection. which can extend to  Discuss the use of condoms to prevent the spread of sexually transmitted diseases. the connective tissue lying between the  Because PID may cause dyspareunia, advise the patient to check with her physician broad ligaments about sexual activity. (parametritis).  To prevent infection after minor gynecologic procedures, such as dilatation and curettage, tell the patient to immediately report fever, increased vaginal discharge, or pain. After such procedures, instruct her to avoid douching or having intercourse for at least 7 days. Group III 1. Urinary system (Prostate) Problems  Congenital renal disorders are present at birth but may not cause signs and symptoms until much later in life. These disorders include medullary sponge kidney and polycystic kidney disease.  Acute renal disorders have a sudden onset. They include acute poststreptococcal glomerulonephritis, acute pyelonephritis, acute renal failure, acute tubular necrosis, renal calculi, and renal vein thrombosis.  Chronic renal disorders develop slowly and persist for a long time. They include chronic glomerulonephritis, chronic renal failure, cystinuria, hydronephrosis, nephrotic syndrome, renal tubular acidosis, and renovascular hypertension.  Lower urinary tract disorders include congenital anomalies of the ureter, bladder, and urethra; lower urinary tract infection; neurogenic bladder; and vesicoureteral reflux. Benign prostatic Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale hyperplasia Although most males  Acute pain  The patient will express  Prepare the patient for diagnostic tests and surgery as appropriate. over age 50 have  Impaired urinary feelings of comfort.
  • 12. some prostatic elimination  The patient and family will  Monitor and record the patient's vital signs, intake and output, and daily weight. enlargement, in  Risk for infection demonstrate skill in managing Watch closely for signs of postobstructive diuresis (such as increased urine output and benign prostatic  Risk for injury the urinary elimination hypotension), which may lead to dehydration, lowered blood volume, shock, hyperplasia (BPH) the  Sexual problem. electrolyte losses, and anuria. prostate gland dysfunction enlarges sufficiently to  Urinary retention  The patient will remain free  Administer antibiotics as ordered for UTI, urethral procedures that involve compress the urethra from signs or symptoms of instruments, and cystoscopy. and cause some overt infection.  If urine retention occurs, try to insert an indwelling urinary catheter. If the catheter urinary obstruction.  The patient will minimize can't be passed transurethrally, assist with suprapubic cystostomy. Watch for rapid BPH begins with complications. bladder decompression. changes in periurethral glandular  The patient will express  Avoid giving a patient with BPH decongestants, tranquilizers, alcohol, antidepressants, tissue. As the prostate feelings about potential or or anticholinergics because these drugs can worsen the obstruction. enlarges, it may actual changes in sexual After prostatic surgery extend into the activity. bladder and obstruct  Maintain the patient's comfort, and watch for and prevent postoperative  The patient will regain ability urine outflow by complications. Observe for signs of shock and hemorrhage. Check the catheter to completely evacuate the compressing or frequently (every 15 minutes for the first 2 to 3 hours) for patency and urine color; bladder. distorting the prostatic check the dressings for bleeding. urethra. BPH may also  Postoperatively, many urologists insert a three-way catheter and establish continuous cause a diverticulum bladder irrigation. Keep the solution flowing at a rate sufficient to maintain patency musculature that and ensure that returns are clear and light pink. Watch for fluid overload from retains urine when the absorption of the irrigating fluid into the systemic circulation. If a regular catheter is rest of the bladder used, observe it closely. If drainage stops because of clots, irrigate the catheter as empties. Depending ordered, usually with 80 to 100 ml of normal saline solution, while maintaining aseptic on the size of the technique. enlarged prostate, the  Administer belladonna and opium suppositories or other anticholinergics, as ordered, age and health of the to relieve bladder spasms that can occur after transurethral resection. patient, and the extent of the  Make the patient comfortable after an open procedure: Administer suppositories obstruction, BPH may (except after perineal prostatectomy), and give analgesics to control incisional pain. be treated surgically Change dressings frequently. or symptomatically.  Continue infusing I.V. fluids until the patient can drink enough on his own (2 to 3 qt [2 to 3 L]/day) to maintain adequate hydration.
  • 13. Administer stool softeners and laxatives, as ordered, to prevent straining. Don't check for fecal impaction because a rectal examination can cause bleeding. 2. Biliary & Pancreatic Problems  Diseases of the gallbladder and biliary tract are common and often painful conditions that usually require surgery and may be life-threatening. They are often associated with inflammation and deposition of calculi.  Acute or chronic inflammation is commonly associated with disorders of the stomach, intestines, and pancreas. In addition, ulceration, herniation, or the development of diverticula may damage the GI mucosa lining the stomach and intestines. Pancreatitis Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale Inflammation of the  Acute pain  The patient will express  Assess the patient's level of pain. As ordered, administer meperidine or other pancreas, or  Deficient fluid feelings of comfort. analgesics. Evaluate and document effectiveness of pain medications; watch for pancreatitis, occurs in volume adverse reactions.  The patient's fluid volume will acute and chronic  Disturbed body remain within normal  Maintain the NG tube for drainage or suctioning. forms. It's associated image parameters. with biliary tract  Hopelessness  Restrict the patient to bed rest, and provide a quiet and restful environment. disease, alcoholism,  Imbalanced  The patient will express  Place the patient in a comfortable position that also allows maximal chest expansion, trauma, and certain nutrition: Less positive feelings about such as Fowler's position. drugs, and it can be than body himself. idiopathic. Acute requirements  Assess pulmonary status at least every 4 hours to detect early signs of respiratory  The patient will participate in pancreatitis generally  Ineffective complications. decisions about care. resolves clinically and breathing  Monitor fluid and electrolyte balance and report any abnormalities. Maintain an histologically but is pattern  The patient will achieve accurate record of intake and output. Weigh the patient daily and record his weight. serious in nature and  Risk for impaired adequate caloric and has a 10% mortality. skin integrity nutritional intake.  Evaluate the patient's present nutritional status and metabolic requirements. Chronic pancreatitis  Risk for injury  The patient's breathing  Provide I.V. fluids and parenteral nutrition as ordered. As soon as the patient can causes irreversible pattern will remain within five tolerate it, provide a diet high in carbohydrates, low in protein, and low in fat. tissue damage and breaths of baseline.  Monitor serum glucose levels and administer insulin as ordered. tends to progress to significant loss of  The patient's skin integrity will  Don't confuse thirst due to hyperglycemia (indicated by serum glucose levels up to
  • 14. pancreatic function. remain intact. 350 mg/dl and glucose and acetone in the urine) with dry mouth due to NG intubation and anticholinergics.  The patient will avoid complications.  If the patient has chronic pancreatitis, allow him to express feelings of anger, depression, and sadness related to his condition, and help him to cope with these feelings. Encourage him to use appropriate physical outlets to express his emotions, such as pounding a punching bag and throwing pillows.  Counsel the patient to contact a self-help group, such as Alcoholics Anonymous, if needed.  Emphasize the importance of avoiding factors that precipitate acute pancreatitis, especially alcohol.  Refer the patient and family members to the dietitian. Stress the need for a diet high in carbohydrates and low in protein and fats. Caution the patient to avoid beverages with caffeine and irritating foods.  Point out the need to comply with pancreatic enzyme replacement therapy. Instruct the patient to take the enzymes with meals or snacks to help digest food and to promote fat and protein absorption. Advise him to watch for and report any of the following signs and symptoms: fatty, frothy, foul-smelling stools; abdominal distention; cramping; and skin excoriation. 3. Problems of sexually transmitted diseases  Sexually transmitted diseases (STDs) are some of the most common infections in the United States. STDs include chancroid, chlamydial infections, genital warts, gonorrhea, herpes simplex virus, syphilis, and trichomoniasis. Gonorrhea Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale Gonorrhea is a  Acute pain  The patient will remain free  Before treatment, determine if the patient has any drug sensitivities. During common sexually  Ineffective sexual from pain. treatment, watch closely for signs of a drug reaction. transmitted disease patterns  The patient will voice his  Use standard precautions when obtaining specimens for laboratory examination and that usually starts as  Risk for infection
  • 15. an infection of the  Situational low feelings about potential or when caring for the patient. Carefully place all soiled articles in containers, and genitourinary tract, self-esteem actual changes in sexual dispose of them according to facility policy. especially the urethra activity.  Monitor the patient for complications. and cervix. It also can  The patient will state infection begin in the rectum,  Isolate the patient with an eye infection. risk factors. pharynx, or eyes. Left  If the patient has gonococcal arthritis, apply moist heat to ease pain in affected joints. untreated, gonorrhea  The patient will identify signs Administer analgesics as ordered. spreads through the and symptoms of infection. blood to the joints,  If the physician or laboratory hasn't already done so, report all cases of gonorrhea to  The patient will experience no tendons, meninges, the local public health authorities so that they can follow up with the patient's sexual further signs or symptoms of and endocardium; in partners. Examine and test all people exposed to gonorrhea. infection. females, it also can  Report all cases of gonorrhea in children to child abuse authorities. lead to chronic pelvic  The patient will express inflammatory disease concern about self-concept,  Routinely instill prophylactic medications, according to facility protocol, in the eyes of (PID) and sterility. esteem, and body image. all neonates on admission to the nursery. Check the neonate of an infected mother for any signs of infection. Obtain specimens for culture from his eyes, pharynx, and rectum.  Urge the patient to inform all sexual partners of the infection so that they can seek treatment. To prevent gonorrhea, provide the following patient teaching:  Tell the patient to avoid sexual contact until cultures prove negative and infection is eradicated.  Advise the partner of an infected person to receive treatment even if the partner doesn't have a positive culture. Recommend that the partner avoid sexual contact with anyone until treatment is complete because reinfection is extremely common.  Counsel the patient and all sexual partners to be tested for human immunodeficiency virus and hepatitis B infection.  Instruct the patient to be careful when coming into contact with any bodily discharges to avoid contaminating the eyes.  Tell the patient to take anti-infective drugs for the length of time prescribed.  To prevent reinfection, tell the patient to avoid sexual contact with anyone suspected
  • 16. of being infected, to use condoms during intercourse, to wash genitalia with soap and water before and after intercourse, and to avoid sharing washcloths or using douches.  Advise the patient to return for follow-up testing. Group IV 1. HIV and Aids infection  Immunodeficiency disorders are caused by an absent or a depressed immune response and manifest in various forms. Immunodeficiency disorders include acquired immunodeficiency syndrome, chronic fatigue and immune dysfunction syndrome, chronic mucocutaneous candidiasis, common variable immunodeficiency, complement deficiencies, DiGeorge syndrome, selective IgA deficiency, and severe combined immunodeficiency disease. Acquired immunodeficiency Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale syndrome Currently one of the  Activity  The patient will verbalize the  Recognize that a diagnosis of AIDS is profoundly distressing because of the disease's most widely publicized intolerance importance of balancing social impact and the discouraging prognosis. The patient may lose his job and diseases, acquired  Disturbed body activity, as tolerated, with financial security as well as the support of family and friends. Coping with an altered immunodeficiency image rest. body image, the emotional burden of serious illness, and the threat of death may syndrome (AIDS) is  Fatigue overwhelm the patient. marked by progressive  The patient will verbalize  Hopelessness failure of the immune feelings about a changed body  Monitor the patient for fever, noting any pattern, and for signs of skin breakdown,  Hyperthermia system. Although it's image. cough, sore throat, and diarrhea. Assess him for swollen, tender lymph nodes, and  Imbalanced characterized by check laboratory values regularly. nutrition: Less  The patient will express that gradual destruction of he has more energy.  Avoid glycerine swabs for mucous membranes. Try normal saline or bicarbonate than body cell-mediated (T-cell) mouthwash for daily oral rinsing. requirements  The patient will make immunity, it also  Impaired oral decisions on his own behalf.  Record the patient's caloric intake. affects humoral mucous immunity and even  The patient will maintain a  Ensure adequate fluid intake during episodes of diarrhea. membrane autoimmunity normal body temperature.  Impaired skin  Provide meticulous skin care, especially if the patient is debilitated. because of the central integrity  The patient will maintain role of the CD4+ T  Encourage the patient to maintain as much physical activity as he can tolerate. Make  Impaired tissue current weight or achieve lymphocyte in sure his schedule includes time for both exercise and rest. integrity
  • 17. immune reactions.  Ineffective ideal weight.  If the patient develops Kaposi's sarcoma, monitor the progression of lesions. The resultant coping  The patient's oral mucous immunodeficiency  Ineffective health  Monitor opportunistic infections or signs of disease progression, and treat infections membranes will remain intact. makes the patient maintenance as ordered. susceptible to  Ineffective  The patient's wounds and  Combination antiretroviral therapy is used to maximally suppress HIV replication, opportunistic protection lesions will heal without thereby improving survival. Poor drug compliance may lead to resistance and infections, unusual  Ineffective complications. treatment failure. Patients must understand that medication regimens must be cancers, and other sexuality  The site of impaired tissue will followed closely and may be required for many years, if not throughout life. abnormalities that patterns have reduced redness, define AIDS.  Interrupted  Urge the patient to inform potential sexual partners and health care workers that he swelling, and pain. family processes has HIV infection.  Noncompliance  The patient will use support  Teach the patient how to identify the signs of impending infection, and stress the (treatment systems to assist with coping. importance of seeking immediate medical attention. regimen)  The patient will perform  Powerlessness  Involve the patient with hospice care early in treatment so he can establish a health maintenance activities  Risk for deficient relationship. according to the level of his fluid volume ability.  If the patient develops AIDS dementia in stages, help him understand the progression  Risk for infection of this symptom.  Social isolation  The patient will demonstrate use of protective measures,  Keep in mind that cultures that traditionally rely on extended family, churches, and including conserving energy, ministers for social and emotional support, such as Blacks and Hispanics, may feel maintaining a balanced diet, particularly isolated if they're reluctant to disclose their HIV illness to anyone other and getting plenty of rest. than immediate family. With several major support systems unavailable to them, they may need support and assistance in tapping their internal resources as well as in using  The patient will voice feelings other external resources that may be available to them. about changes in sexual identity. Health care workers and the public are advised to use precautions in all situations that risk exposure to blood, body fluids, and secretions. Diligently practicing  The family will state ways to standard precautions can prevent the inadvertent transmission of acquired support and assist the patient. immunodeficiency syndrome (AIDS), hepatitis B, and other infectious diseases that are  The patient will comply with transmitted by similar routes. In addition: the treatment regimen.  Educate the patient and his family, sexual partners, and friends about disease  The patient will express transmission and prevention of extending the disease to others. feelings of control over his  Inform the patient not to donate blood, blood products, organs, tissue, or sperm. condition and situation.
  • 18.  The patient will maintain  If the patient uses I.V. drugs, caution him not to share needles. adequate fluid balance.  Inform the patient that high-risk sexual practices for AIDS transmission are those that  The patient will experience no exchange body fluids, such as vaginal or anal intercourse without a condom. fever, chills, or other signs or  Discuss safer sexual practices, such as hugging, petting, mutual masturbation, and symptoms of illness. protected sexual intercourse. Abstaining is also the most protective method of not  The patient will maintain peer transmitting the disease. and family relationships.  Advise female patients of childbearing age to avoid pregnancy. Explain that an infant may become infected before birth, during delivery, or during breast-feeding. 2. Cancer  Cancers in the head, neck, and spine are among the deadliest and most disfiguring. Involvement of speech and sense organs, as well as the central nervous system, can have an enormous impact on the patient's quality of life.  The lung and breast are the most common sites for thoracic cancer. Although rare, soft-tissue sarcomas may also develop in the chest region.  Cancers in the abdominal and pelvic region of the body can obstruct the affected organ or disrupt its secretory or absorptive functions and obstruct the flow of GI contents.  Besides their impact on physiologic function, cancers of the reproductive system have profound implications for the patient's body image and self-esteem.  Cancer in bone, skin, and soft tissue can be just as serious as cancer in some major organs. Both primary malignant tumors and metastatic lesions may afflict these structures.  When cancer affects the circulatory systems, the entire body may become rapidly involved in the disease. Esophageal cancer Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale Esophageal cancer is  Acute pain  The patient will express  Monitor the patient's nutritional and fluid status, and provide him with high-calorie, most common in  Anxiety feelings of comfort and high-protein foods. If he's having trouble swallowing solids, puree or liquefy his food, males older than age  Deficient fluid decreased pain. and offer a commercially available nutritional supplement. As ordered, provide tube 60 and is nearly volume feedings, and prepare him for supplementary parenteral nutrition.  The patient will express that always fatal. The  Fatigue he feels less anxious.  To prevent food aspiration, place the patient in Fowler's position for meals and allow disease occurs  Fear plenty of time to eat. If he regurgitates food after eating, provide mouth care. worldwide, but  Imbalanced  The patient will maintain fluid
  • 19. incidence varies nutrition: Less volumes within normal range.  If the patient has a gastrostomy tube, give food slowly—by gravity—in prescribed geographically. It is than body  The patient will express that amounts (usually 200 to 500 ml). Offer him something to chew before each feeding. most commonly found requirements he has more energy. This promotes gastric secretions and provides some semblance of normal eating. in Japan, Russia,  Impaired China, the Middle swallowing  The patient will express  Administer ordered analgesics for pain relief as necessary. Provide comfort measures, East, and the Transkei  Risk for concerns and fears related to such as repositioning and distractions. region of South Africa. aspiration his diagnosis and condition.  After surgery, monitor the patient's vital signs, fluid and electrolyte balance, and  Risk for infection  The patient will maintain intake and output. Immediately report unexpected changes in the patient's condition. weight within an acceptable Monitor him for such complications as infection, fistula formation, pneumonia, range. empyema, and malnutrition.  The patient will swallow  If an anastomosis to the esophagus was performed, position the patient flat on his without coughing or choking. back to prevent tension on the suture line. Watch for signs of an anastomotic leak.   If the patient had a prosthetic tube inserted, make sure it doesn't become blocked or The patient won't aspirate. dislodged. This could cause a perforation of the mediastinum or precipitate tumor  The patient will show no erosion. evidence of infection.  After radiation therapy, monitor the patient for such complications as esophageal perforation, pneumonitis and fibrosis of the lungs, and myelitis of the spinal cord.  After chemotherapy, take steps to decrease adverse effects, such as providing normal saline mouthwash to help prevent mouth ulcers. Allow the patient plenty of rest, and administer medications as ordered to reduce adverse effects.  Protect the patient from infection.  Throughout therapy, answer the patient's questions and tell him what to expect from surgery and other therapies. Listen to his fears and concerns, and stay with him during periods of severe anxiety.  Encourage the patient to identify actions and care measures that promote his comfort and relaxation. Try to perform these measures, and encourage the patient and family to do so as well.  Whenever possible, include the patient in care decisions.  Explain the procedures the patient is to undergo after surgery—closed chest drainage, nasogastric suctioning, and placement of gastrostomy tubes.
  • 20.  If appropriate, instruct family members in gastrostomy tube care. This includes checking tube patency before each feeding, providing skin care around the tube, and keeping the patient upright during and after feeding.  Stress the need to maintain adequate nutrition. Ask a dietitian to instruct the patient and family. If the patient has difficulty swallowing solids, instruct him to puree or liquefy his food and to follow a high-calorie, high-protein diet to minimize weight loss. Also, recommend that he add a commercially available, high-calorie supplement to his diet.  Encourage the patient to follow as normal a routine as possible after recovery from surgery and during radiation therapy and chemotherapy. Tell him that this will help him maintain a sense of control and reduce the complications associated with immobility.  Advise the patient to rest between activities and to stop activity that tires him or causes pain. Group V 1. Cardiovascular Disorders  Abnormalities during fetal development may cause structural defects of the heart and great arteries. These defects may increase pulmonary blood flow (such as atrial septal defect, patent ductus arteriosus, and ventricular septal defect), obstruct the flow of blood out of the heart (such as coarctation of the aorta), cause a mixing of oxygenated and deoxygenated blood in the heart or great vessels (such as transposition of the great arteries), or decrease pulmonary blood flow (such as Tetralogy of Fallot).  Valvular heart disease  Acquired inflammatory heart disease  Degenerative cardiovascular disorders  Vascular disorders can affect the arteries, the veins, or both types of vessels. Arterial disorders include aneurysms, which result from a weakening of the arterial wall; arterial occlusive disease, which commonly results from atherosclerotic narrowing of the artery's lumen; and Raynaud's disease, which may be linked to immunologic dysfunction. Thrombophlebitis, a venous disorder, results from inflammation or occlusion of the affected vessel. Hypertension Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale
  • 21. Hypertension is an  Deficient  The patient will identify  If a patient is hospitalized with hypertension, find out if he was taking his prescribed intermittent or knowledge appropriate food choices. antihypertensive. If he wasn't, ask why. If he can't afford the medication, refer him to sustained elevation of (lifestyle the appropriate social service department.  The patient will express that diastolic or systolic modifications) he has more energy.  When routine blood pressure screening reveals elevated pressure, make sure the blood pressure. Serial Fatigue sphygmomanometer cuff size is appropriate for the patient's upper arm blood pressure  Ineffective  The patient will demonstrate circumference. Take the pressure in both arms in lying, sitting, and standing positions. measurements are coping adaptive coping behaviors. Ask the patient if he smoked, drank a beverage containing caffeine, or was used to classify  Ineffective tissue  The patient will maintain emotionally upset before the test. Advise him to return for blood pressure testing at hypertension: perfusion: adequate cardiac output and frequent and regular intervals. Cardiopulmonary hemodynamic stability.  Prehypertension:  Noncompliance:  To help identify hypertension and prevent untreated hypertension, participate in systolic blood  The patient will comply with Therapeutic public education programs dealing with hypertension and ways to reduce risk factors. pressure greater his therapy regimen. regimen Encourage public participation in blood pressure screening programs. Routinely than 120 but less  Risk for injury  The patient will remain free screen all patients, especially those at risk (blacks and those with family histories of than 140 mm Hg from complications. hypertension, stroke, or heart attack). or diastolic blood pressure greater  Teach the patient to use a self-monitoring blood pressure cuff and to record the than 80 but less reading at least twice weekly in a journal for review by the physician at every office than 90 mm Hg appointment. Tell the patient to take his blood pressure at the same hour each time with relatively the same type of activity preceding the measurement.  Stage 1 hypertension:  Tell the patient and family to keep a record of drugs used in the past, noting especially systolic blood which ones are or aren't effective. Suggest recording this information on a card so the pressure greater patient can show it to his physician. than 139 but less  To encourage compliance with antihypertensive therapy, suggest establishing a daily than 160 mm Hg routine for taking medication. Warn the patient that uncontrolled hypertension may or diastolic blood cause stroke and heart attack. Tell him to report any adverse reactions to prescribed pressure greater drugs. Advise him to avoid high-sodium antacids and over-the-counter cold and sinus than 89 but less medications containing harmful vasoconstrictors. than 100 mm Hg  Help the patient examine and modify his lifestyle. Suggest stress-reduction groups,  Stage 2 dietary changes, and an exercise program, particularly aerobic walking, to improve hypertension: cardiac status and reduce obesity and serum cholesterol levels. systolic blood pressure greater  Encourage a change in dietary habits. Help the obese patient plan a reducing diet. Tell him to avoid high-sodium foods (such as pickles, potato chips, canned soups, and cold
  • 22. than 159 mm Hg cuts), table salt, and foods high in cholesterol and saturated fat. or diastolic blood pressure greater than 99 mm Hg 2. Pulmonary Disorders  Pediatric disorders include croup, a severe inflammation of the upper airway, and epiglottiditis, an acute inflammation of the epiglottis that affects mainly young children. They also include respiratory distress syndrome, which is marked by widespread alveolar collapse and occurs mainly in premature infants, and sudden infant death syndrome, which strikes apparently healthy infants.  Acute respiratory disorders require prompt treatment and nursing care. They range from acute respiratory distress syndrome to sarcoidosis.  Several factors can lead to chronic respiratory disorders. For instance, a genetic defect leads to cystic fibrosis, whereas damage to the bronchial wall results in bronchiectasis. Environmental factors cause chronic obstructive pulmonary disease, infection causes pulmonary tuberculosis, and occupational hazards lead to such disorders as asbestosis, berylliosis, coal worker's pneumoconiosis, and silicosis. Atelectasis Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale In atelectasis, alveolar  Acute pain  The patient will express  Encourage the patient recovering from surgery (or other patients at high risk for clusters (lobules) or  Anxiety feelings of comfort, either atelectasis) to perform coughing and deep-breathing exercises every 1 to 2 hours. To lung segments that  Deficient verbally or through behavior. minimize pain during these exercises, hold a pillow tightly over the patient's incisional expand incompletely knowledge area. Teach the patient how to do this for himself. Gently reposition the patient often,  The patient will use support may produce a partial (prevention) and help him walk as soon as possible. Administer adequate analgesics to control systems to assist with anxiety. or complete lung  Fear pain. collapse. This  Impaired gas  The patient will express an  Monitor mechanical ventilation. Maintain tidal volume at 10 to 15 ml/kg of the phenomenon exchange understanding of techniques patient's body weight to ensure adequate lung expansion. Use the sigh mechanism on effectively removes  Ineffective to prevent atelectasis, such as the ventilator, if appropriate, to intermittently increase tidal volume at the rate of 3 certain regions of the airway clearance incentive spirometry and deep to 4 sighs/hour. lung from gas  Ineffective breathing. exchange. This allows breathing  Monitor pulse oximetry for decreases in oxygenation.  The patient will discuss fears unoxygenated blood pattern and concerns.  Help the patient use an incentive spirometer to encourage deep breathing. to pass unchanged  Risk for infection through these regions  The patient will maintain  Humidify inspired air, and encourage adequate fluid intake to mobilize secretions. Use and produces hypoxia. adequate ventilation and postural drainage and chest percussion to remove secretions.
  • 23. oxygenation.  For the intubated or uncooperative patient, provide suctioning as needed. Administer  The patient will maintain a sedatives with care because these medications depress respirations and the cough patent airway. reflex. They also suppress sighs. Keep in mind that the patient is able to cooperate minimally (or not at all) with treatment if he has pain.  The patient will maintain a respiratory rate within five  Assess breath sounds and respiratory status frequently. Report changes immediately. breaths of baseline.  Offer ample reassurance and emotional support because the patient's limited  The patient will remain free breathing capacity may frighten him. from signs and symptoms of  Teach the patient how to use the spirometer. Urge him to use it every 1 to 2 hours. infection.  Show the patient and family members how to perform postural drainage and percussion. Instruct the patient to maintain each position for 10 minutes and then perform chest percussion. Let him know when to cough. Teach coughing and deep- breathing exercises to promote ventilation and mobilize secretions.  Encourage the patient to stop smoking, lose weight, or both, if needed. Refer him to appropriate support groups for help.  Demonstrate comfort measures to promote relaxation and conserve energy. Advise the patient and family members to alternate periods of rest and activity to promote energy and prevent fatigue.