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
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.
corticosteroid use. Encourage ambulation immediately after surgery.
Encourage the patient to express any concerns he may have about having a chronic
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
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
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
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.
If the patient has acute bacterial pharyngitis, emphasize the importance of completing
the full course of antibiotic therapy. Tell him to call the physician if he experiences any
subsides in 3 to 10
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
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,
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-
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.
The patient will maintain joint
breathing Institute seizure precautions if you suspect CNS involvement.
mobility and range of motion.
Risk for infection
The patient will maintain skin Warm and protect the patient's hands and feet if she has Raynaud's phenomenon.
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
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.
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
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-
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
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
1. Musculoskeletal Problems
Arising before or at birth, congenital disorders of the musculoskeletal system include clubfoot, developmental dysplasia of the hip, muscular dystrophy, and
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
Disorders affecting bone structure and function include hallux valgus, herniated disk, kyphosis, Legg-CalvÂ´-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.
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
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
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
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
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.
Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale
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
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.
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
Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale
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.
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;
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.
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
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
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
Emphasize the importance of avoiding factors that precipitate acute pancreatitis,
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.
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.
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
Urge the patient to inform all sexual partners of the infection so that they can seek
To prevent gonorrhea, provide the following patient teaching:
Tell the patient to avoid sexual contact until cultures prove negative and infection is
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.
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.
immunodeficiency Nursing Diagnoses Objectives of Care Nursing Interventions and Rationale
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
Disturbed body activity, as tolerated, with financial security as well as the support of family and friends. Coping with an altered
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
failure of the immune feelings about a changed body Monitor the patient for fever, noting any pattern, and for signs of skin breakdown,
system. Although it's image. cough, sore throat, and diarrhea. Assess him for swollen, tender lymph nodes, and
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
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.
immunity and even The patient will maintain a Ensure adequate fluid intake during episodes of diarrhea.
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.
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.
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
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
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 slowlyâ€”by gravityâ€”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
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 surgeryâ€”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
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
Advise the patient to rest between activities and to stop activity that tires him or
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
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.
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.
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.
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
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.
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.
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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