Sunday, May 14, 2006

RADICAL VULVECTOMY

Extensive surgery, radical vulvecvtomy involves removing the labia majora, labia minor, glans clitoris, perivascular skin and lymph glands. Often the area is reconstructed using skin grafts. This surgery is indicated for invasive cancer of the vulva.

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety related to insufficient knowledge of preoperative and postoperative routines and perceived negative effects on life style.

POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Hemorrhage/shock
  • Urinary retention
  • Sepsis
  • Pulmonary embolism
  • Thrombophlebitis
  • Lymphedema
  • Vaginal stenosis
  • Wound dehiscence

Nursing Diagnosis

  • Acute pain related to effects of surgery and immobility
  • Grieving related to loss of body function and its effects on life style
  • High risk for altered sexuality patterns related to impact of surgery on sexual functioning and changes in body image
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of home care, wound care, self-catheterization, and follow-up care

Related Care Plan

  • General surgery generic care plan
  • Anticoagulant therapy

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

RENAL SURGERY (Nephrostomy, Nephrectomy, Extracorporeal, Ureteral Stents)

The term renal surgery encompasses various procedures. Nephrostomy involves an opening into the kidney with placement of a permanent or temporary drainage tube. Nephrectomy is the surgical removal of a kidney owing to disease or malfunction or for donation. Insertion of ureteral stents is done to maintain urinary flow in cases or ureteral obstruction. Extracorporeal renal surgery involves removing the kidney, preserving it by continuous flushing with a cold solution, surgically repairing it, and them reimplanting it. This surgery is indicated to remove obstructions (tumors, calculi) and to repair vascular lesions.

PREPROCEDURE PERIOD
Collaborative Problems

Potential Complications

  • Hemorrhage/shock
  • Paralytic ileus
  • Renal insufficiency
  • Pyelonephritis
  • Ureteral stent dislodgement
  • Pneumothorax secondary to thoracic approach

Nursing Diagnosis

  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of hydration requirements, nephrostomy care, and signs and symptoms of complications
  • Impaired physical mobility related to distention of renal capsule and incision
  • High risk for altered respiratory function related to pain on breathing and coughing secondary to location of incision

Related Care Plan

  • General surgery generic care plan

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

RENAL TRANSPLANT

Renal transplantation has become the treatment of choice for many clients with end-stage renal disease. Renal transplantation provides an improved quality of life and a more cost-effective method of treatment of end-stage renal disease than dialysis. Improved surgical techniques and improved pharmacologic immunosuppression have improved both client and graft survival greatly.

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Fear related to diagnosis and anticipated surgical experience
  • Anxiety related to the wait for a donor kidney to become available

POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Hemodynamic instability
  • Hypervolemia/hypovolemia
  • Hypertension/hypotension
  • Renal failure (donor kidney)
  • Excessive immunosuppression
  • Electrolyte imbalances
  • Deep vein thrombosis
  • Sepsis

Nursing Diagnosis

  • High risk for infection related to altered immune system secondary to immunosuppressant medications
  • High risk for altered oral mucous membrane related to increased susceptibility to infection secondary to immunosuppression
  • High risk for self-concept disturbance related to transplant experience, potential for rejection, and side effects of medications
  • High risk for noncompliance related to complexity of treatment regimen and euphoria
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of prevention of infection, activity progression, dietary management, daily record keeping, pharmacologic therapy, signs and symptoms of infection and rejection, effective birth control measures/pregnancy recommendations, follow-up care, and community resources.

Related Care Plan

  • General surgery generic care plan
  • Corticosteroid therapy care plan

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

THORACIC SURGERY

A term encompassing various procedures involving a surgical opening into the chest cavity, thoracic surgery may be a pneumonectomy (removal of entire lung), lobectomy (removal of a lobe), segmentectomy (removal of a segment), wedge resection (removal of a lesion), or exploratory thoracotomy (diagnostic).

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety related to impending surgery and insufficient knowledge of preoperative routines, intra-operative activities, and postoperative self-care activities

POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Mediastinal shift
  • Subcutaneous emphysema
  • Acute Pulmonary Edema
  • Respiratory Insufficiency
  • Pneumothorax, hemothorax
  • Pulmonary embolism
  • Thrombophlebitis

Nursing Diagnosis

  • Ineffective airway clearance related to increased secretions and diminished cough secondary to pain and fatigue
  • Impaired physical mobility related to restricted arm and shoulder movement secondary to pain and muscle dissection and imposed position restrictions
  • Acute pain related to surgical incision, hest tube sites, and immobility secondary to lengthy surgery
  • Grieving related to loss of body part and its perceived effects on life style

Related Care Plan

  • General surgery generic care plan

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

TOTAL JOINT REPLACEMENT (Hip, Knee, Shoulder)

Prosthetic replacement may be indicated for joint degenerations caused by rheumatoid arthritis, osteoarthritis, trauma, tumors or congenital deformities. joint prosthesis of metal or high-density polyethylene are implanted into the prepared bone using cement, or a porous, coated prosthesis is implanted that allows bone growth into the implant.

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety related to scheduled surgery and lack of knowledge of preoperative and postoperative routines, postoperative sensations, and use of assistive devices

POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Dislocation/subluxation of joint
  • Neurovascular compromise
  • Fat emboli
  • Hemorrhage/hematoma formation
  • Sepsis
  • Thromboemboli

Nursing Diagnosis

  • Impaired physical mobility related to pain, stiffness, fatigue, restrictive equipment and prescribed activity restriction
  • High risk for impaired skin integrity related to pressure and decreased mobility secondary to pain and temporary restrictions
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of activity restrictions, use of assistive devices, signs of complications, and follow-up care
  • High risk for injury related to altered gait and use of assistive devices

Related Care Plan

  • General surgery generic care plan
  • Anticoagulant therapy

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

UROSTOMY

In urostomy, the surgeon diverts the ureters external to the abdomen (ureterostomy) or to a resected segment of bowel, then brings the bowel segment to the abdominal surface as a urinary stoma (ileal or colon conduit) the Kock continent urostomy pouch, an internal low-pressure urinary reservoir constructed of ileum contains two nipple valves, one on the loop of ileum entering the pouch and one directly behind the abdominal stoma. The ureters are anastomosed to this loop; the valves prevent reflux of urine into the renal collecting system. The client, if able, can learn to perform periodic ileal bladder emptying via intermittent self-catheterization. Ileocecal pouches are gaining popularity. The reservoir can be positioned in the pelvis or in the abdomen

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety related to lack of knowledge of urostomy care and perceived negative effects on life style.

POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Internal Urine leakage
  • Urinary tract infection/urinary calculi
  • Peristomal ulceration/herniation
  • Stomal necrosis, retraction, prolapse, stenosis, obstruction

Nursing Diagnosis

  • High risk for altered sexuality patterns related to erectile dysfunction (male) or inadequate lubrication (female)
  • High risk for social isolation related to anxiety over possible odor or leakage from appliance
  • High risk for ineffective management of therapeutic regimen related to related to insufficient knowledge of stoma pouching procedure, colostomy irrigation, peristomal skin care, perineal wound care, and incorporation of ostomy care into activity of daily living (ADL)
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of intermittent self-catheterization of continent urostomy
  • High risk for self-concept disturbance related to effects of ostomy on body image
  • High risk for altered sexuality patterns related to perceived negative impact of ostomy on sexual functioning and attractiveness

Related Care Plan

  • General surgery generic care plan

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

Friday, May 12, 2006

ARTERIOGRAPHY

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Fear related to potential negative findings of arteriogram and insufficient knowledge of routines and expected sensations

POSTPROCEDURE PERIOD
Collaborative Problems

Potential complications

  • Hematoma
  • Hemorrhage
  • Paresthesia
  • Embolism
  • Thrombosis (arterial site)
  • Renal failure
  • Urinary retention
  • Allergic reaction

Nursing Diagnosis

  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of activity restrictions and signs and symptoms of complications

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition


CARDIAC CATHETERIZATION

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety related to impending cardiac catheterization

POSTPROCEDURE PERIOD
Collaborative Problems

Potential complications

  • Systemic (allergic reaction)
  • Cardiac (dysrhythmias, myocardial infarction, congestive heart failure, and pulmonary edema)
  • Circulatory (hematoma formation or hemorrhage at entry site, hypovolemia, and thromboembolic phenomenon)

Nursing Diagnosis

  • Anxiety related to cardiac catheterization results
  • Impaired physical mobility related to prescribed bed rest and restricted movement of affected extremity
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of site care, sings and symptoms of complications, and follow-up care

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

CASTS

Collaborative Problems
Potential complications

  • Compartmental syndrome
  • Infection

Nursing Diagnosis

  • High risk for impaired skin integrity related to pressure of cast on skin surface
  • (Specify) Self-care deficit related to limitation of movement secondary to cast
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of cast care, sings and symptoms of complications, use of assistive devices, and hazards

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

CESIUM IMPLANT

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety related to scheduled internal radiation insertion and the effects of internal radiation and insufficient knowledge of post procedure restrictions

POSTPROCEDURE PERIOD
Collaborative Problems

Potential complications

  • Bleeding
  • Infection
  • Pulmonary complications
  • Vaginal stenosis
  • Radiation cystitis
  • Displacement of radioactive source
  • Thrombophlebitis
  • Bowel dysfunction

Nursing Diagnosis

  • Anxiety related to fear of radiation and its effects, uncertainty of outcome, feelings of isolation, and pain or discomfort
  • Self-care deficit: bathing, toileting related to activity restriction and isolation
  • High risk for impaired skin integrity related to immobility secondary to prescribed activity restrictions
  • High risk for altered sexuality patterns related to radiation-induced vaginal stenosis
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of home care, reportable signs and symptoms, activity restrictions, and follow-up care
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

CHEMOTHERAPY

Collaborative Problems
Potential complications

  • Anaphylactic reaction
  • Cardiotoxicity
  • Electrolyte imbalance
  • Extravasations of vesicant drugs
  • Hemorrhagic cystitis
  • Bone marrow depression
  • Renal insufficiency
  • Pulmonary toxicity
  • Neurotoxicity
  • Renal calculi

Nursing Diagnosis

  • Anxiety related to prescribed chemotherapy, insufficient knowledge of chemotherapy, and self-care measures
  • Altered comfort related to gastrointestinal cell damage, stimulation of vomiting center, fear, and anxiety
  • Altered nutrition: less than body requirements related to anorexia, taste changes, persistent nausea/vomiting, and increased intestinal mobility
  • Altered oral mucous membrane related to dryness and epithelial cell damage secondary to chemotherapy
  • Fatigue related to effects of anemia, malnutrition, persistent vomiting, and sleep pattern disturbance
  • High risk for colonic constipation related to autonomic nerve dysfunction secondary to Vinca alkaloid administration and inactivity
  • Diarrhea related to intestinal cell damage, inflammation, and increased intestinal mobility
  • High risk for impaired skin integrity related to persistent diarrhea, malnutrition, prolonged sedation, and fatigue
  • Self-concept disturbance related to change in lifestyle, role, alopecia, and weight loss or gain

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

CORTICOSTEROID THERAPY

Collaborative Problems
Potential complications

  • Steroid-induced diabetes
  • Hypertension
  • Osteoporosis
  • Peptic ulcer
  • Thromboembolism
  • Hypokalemia
  • Pseudotumor cerebri

Nursing Diagnosis

  • High risk for fluid volume excess related to sodium and water retention
  • High risk for altered nutrition: more than body requirements related to increased appetite
  • High risk for infection related to immunosuppression
  • High risk for body image disturbance related to changes in appearance
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of administration schedule, adverse reactions, signs and symptoms of complications, hazards of adrenal insufficiency, and potential causes of adrenal insufficiency

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

ENTERAL NUTRITION

Collaborative Problems
Potential complications

  • Hypoglycemia/hyperglycemia
  • Hypervolemia
  • Hypertonic dehydration
  • Electrolyte and trace mineral imbalances
  • Mucosal erosion

Nursing Diagnosis

  • High risk for infection related to gastrostomy incision and enzymatic action of gastric juices on skin
  • Altered comfort: cramping, distention, nausea, vomiting related to type of formula, administration rate, route, or formula temperature
  • Diarrhea related to adverse response to formula, rate, or temperature
  • High risk for aspiration related to position of tube and individual
  • High risk for self-concept disturbance related to inability to taste or swallow food and fluids
  • High risk for ineffective management of therapeutic regimen related to lack of knowledge of nutritional indications/requirements, home care, and signs and symptoms of complications
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

EXTERNAL ARTERIOVENOUS SHUNTING

Collaborative Problems
Potential complications

  • Thrombosis
  • Bleeding

Nursing Diagnosis

  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of catheter care, precautions, emergency measures, prevention of infection, and activity limitations
  • Anxiety related to upcoming shunt insertion

Related Care Plans

  • Acute or chronic renal failure
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

HEMODIALYSIS

Collaborative Problems
Potential complications

  • Electrolyte imbalance (potassium, sodium)
  • Nausea/vomiting
  • Transfusion reaction
  • Hemorrhage
  • Seizures
  • Dialysis disequilibrium syndrome
  • Dialysate leakage
  • Clotting
  • Air embolism
  • Sepsis
  • Hyperthermia
  • Fluid imbalances
  • Hypertension/hypotension
  • Anemia

Nursing Diagnosis

  • High risk for infection transmission related to frequent contacts with blood and high risk of hepatitis B
  • Powerlessness related to need for treatments to live despite effects on lifestyle
  • Altered family processes related to the interruption of role responsibilities caused by the treatment schedule

Related Care Plans

  • Chronic or acute renal failure
  • External arteriovenous shunting
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

HEMODYNAMIC MONITORING

Collaborative Problems
Potential complications

  • Monitoring system problems
  • Hemorrhage
  • Thrombosis/thrombophlebitis
  • Pulmonary embolism and Air embolism
  • Arterial spasms

Nursing Diagnosis

  • High risk for infection related to invasive lines
  • Impaired physical mobility related to position restrictions secondary to hemodynamic monitoring
  • Anxiety related to impending procedure, loss of control, and unpredictable outcome
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

LONG-TERM VENOUS ACCESS DEVICE

Collaborative Problems
Potential complications

  • Pneumothorax (except PICC)
  • Hemorrhage
  • Embolism/thrombosis
  • Sepsis


Nursing Diagnosis

  • Anxiety related to upcoming insertion of catheter port and insufficient knowledge of procedure
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of home care, signs and symptoms of complications, and community resources
  • High risk for infection related to catheter’s direct access to bloodstream

Related Care Plans

  • Cancer (Initial diagnosis)
  • Chemotherapy
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

MECHANICAL VENTILATION

Collaborative Problems
Potential complications

  • Respiratory Insufficiency
  • Atelectasis
  • Oxygen toxicity
  • Decreased Cardiac output
  • GI bleeding

Nursing Diagnosis

  • High risk for dysfunctional weaning response related to weaning attempts, respiratory muscle fatigue secondary to mechanical ventilation, increased work of breathing, supine position, protein-calorie malnutrition, inactivity, and fatigue
  • Disuse syndrome
  • Fear related to the nature of the situation, uncertain prognosis of ventilator dependence, weaning
  • impaired verbal communication related to effects of intubations on ability to speak
  • High risk for infection related to disruption of skin layer secondary to tracheostomy
  • Powerlessness related to dependency on respirator, inability to talk, and loss of mobility
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

PACEMAKER INSERTION

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety related to impending pacemaker insertion and prognosis

POSTPROCEDURE PERIOD
Collaborative Problems

Potential complications

  • Cardiac dysrhythmias
  • Pacemaker malfunction (failure to sense, failure to fire, or failure to capture)
  • Infection
  • Necrosis over Pulse Generator
  • Perforation of the right ventricle
  • Pneumothorax

Nursing Diagnosis

  • Impaired physical mobility related to incisional site pain activity restrictions, and fear of lead displacements
  • Self-concept disturbance related to perceived loss of health and dependence on pacemaker
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of activity restrictions, precautions, sings and symptoms of complications, and follow-up care
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

PREPROCEDURE PERIOD
Nursing Diagnosis

  • Anxiety/fear (individual, family) related to the health status, angioplasty procedure , routines, outcome, and possible need for cardiac surgery

POSTPROCEDURE PERIOD
Collaborative Problems

Potential complications

  • Dysrhythmias
  • Acute coronary occlusion (clot, spasm, collapse)
  • Myocardial infarction
  • arterial dissection or rupture
  • hemorrhage/hematoma at Angioplasty site

Nursing Diagnosis

  • Impaired physical mobility related to prescribed bed rest and restricted movement of involved extremity
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of care of insertion site, discharge activities, diet, medications, signs and symptoms of complications, exercise, and follow-up care
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

PERITONEAL DIALYSIS

Collaborative Problems
Potential Complications

  • Hypovolemia/Hypervolemia
  • Electrolyte imbalances
  • Uremia
  • Hemorrhage
  • Hyperglycemia
  • Bladder/Bowel Perforation
  • Inflow/Outflow problems

Nursing Diagnosis

  • High risk for infections related to access to peritoneal cavity, and use of high dextrose concentration in dialysis solution
  • High risk for ineffective breathing pattern related to immobility, pressure, and pain
  • Altered comfort related to catheter insertion, instillation of dialysis solution, outflow, suction, and chemical irritation of peritoneum
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of rationale or treatment, medications, home dialysis procedure, signs and symptoms of complications, community resources, and follow-up care
  • Altered family processes related to the effects of interruptions of the treatment schedule on role responsibilities
  • Powerlessness related to chronic illness and the need for continuous treatment
  • Altered nutrition: less than body requirements related to anorexia
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

RADIATION THERAPY

Collaborative Problems
Potential Complications

  • Myelosuppression
  • Malabsorption
  • Pleural effusion
  • Cerebral edema
  • Cystitis, urethritis, and tenesmus
  • Myelitis and parotitis
  • Renal calculi
  • Fluid and electrolyte imbalance

Nursing Diagnosis

  • Anxiety related to prescribed radiation therapy and insufficient knowledge of treatments and self-care measures
  • High risk of altered oral mucous membrane related to dry mouth or inadequate oral hygiene
  • Impaired skin integrity related to effects of radiation on epithelial and basal cells and effects of diarrhea on perineal area
  • altered comfort related to stimulation of the vomiting center and damage to the gastrointestinal mucosa cells secondary to radiation
  • Fatigue related to systemic effects of radiation therapy
  • altered comfort related to damage to sebaceous and sweat glands secondary to radiation
  • Self-concept disturbance related to alopecia, skin changes, weight loss, sterility, and changes in role relationships and life styles
  • Grieving related to changes in life style, role, finances, functional capacity, body image, and health losses
  • Altered family processes related to imposed changes in family roles, relationships, and responsibilities.
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

TRACHEOSTOMY

PREOPERATIVE PERIOD
Nursing Diagnosis

  • Anxiety related to lack of knowledge of impending surgery and implication of condition on life style (chronic)

POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Hypoxia
  • Hemorrhage
  • Tracheal edema
  • Subcutaneous emphysema
  • Pheumothorax
  • Tracheoesophageal fistula
  • Displaced tracheostomy tube
  • Accidental extubation

Nursing Diagnosis

  • High risk for ineffective airway clearance related to increased secretions secondary to tracheostomy, obstruction of inner cannula, or displacement or tracheostomy tube
  • High risk for infection related to excessive pooling of secretions and bypassing of upper respiratory defenses
  • Impaired verbal communication related to inability to produce speech secondary to tracheostomy
  • High risk for altered nutrition: less than body requirements related to postoperative NPO status, dysphagia, odynophagia, anorexia, aspiration
  • High risk for altered sexuality patterns related to change in appearance or fear of rejection
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of tracheostomy care, precautions, signs and symptoms of complications, emergency care, and follow-up care
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

TOTAL PARENTERAL NUTRITION

Collaborative Problems
Potential Complications

  • Pneumothorax, Hemothorax, or hydrothorax
  • Air embolism
  • Sepsis
  • Hyperglycemia

Nursing Diagnosis

  • High risk for infections related to catheter’s direct access to bloodstream
  • High risk for self-concept disturbance related to inability to ingest food
  • High risk for activity intolerance related to deconditioning
  • High risk for ineffective management of therapeutic regimen related to insufficient knowledge of home care, signs and symptoms of complications, catheter care, and follow-up care (laboratory studies)
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd

HOSPITALIZED CLIENTS

Collaborative Problems
Potential Complications
  • cardiovascular
  • Respiratory

Nursing Diagnosis

  • Anxiety related to unfamiliar environment, routines, diagnostic tests, treatments, and loss of control
  • Risk for injury related to unfamiliar environment and physical and mental limitations secondary to condition, medications, therapies, and diagnostic tests
  • Risk for infections related to increased microorganisms in environment, the risk of person-to-person transmission, and invasive tests and therapies
  • (Specify) Self-care deficit related to sensory, cognitive, mobility, endurance, or motivation problems
  • Risk for altered nutrition: Less than body requirements related to decreased appetite secondary to treatments, fatigue, environment, and changes in usual diet; and to increased protein and vitamin requirements for healing
  • Risk for constipation related to change in fluid and food intake, routine, and activity level; effects of medications; and emotional stress
  • Sleep pattern disturbance related to unfamiliar, noisy environment, change in bedtime ritual, emotional stress
  • Risk for spiritual distress related to separation from religious support system, lack of privacy, or inability to practice spiritual rituals
  • Altered family process related to disruption of routines, change in role responsibilities, and fatigue associated with increased workload and visiting hour requirements

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

SURGICAL CLIENTS

PREOPERATIVE PERIOD
Nursing Diagnosis

  • Anxiety/fear related to surgical experience, loss of control, unpredictable outcome, and insufficient knowledge of preoperative exercises and activities, and postoperative changes and sensations


POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Hemorrhage
  • Hypovolemia/shock
  • Evisceration
  • Dehiscence
  • Infection (Peritonitis)
  • Urinary Retention
  • Thrombophlebitis
  • Paralytic ileus

Nursing Diagnosis

  • Risk for altered Respiratory function related to immobility secondary to post-anesthesia state and pain
  • Risk for infection related to increased susceptibility to bacteria secondary to wound
  • Pain related to surgical interruption of body structure, flatus, and immobility
  • Risk for altered nutrition: less than body requirements related to increased protein and vitamin requirements for wound healing and decreased intake secondary to pin, nausea, vomiting, and diet restrictions
  • Risk for colonic constipation related to decreased peristalsis secondary to immobility and effects of anesthesia and narcotics
  • Activity intolerance related to pain and weakness secondary to anesthesia, tissue hypoxia, and insufficient fluid and nutrient intake
  • Risk for ineffective management of therapeutic regimen related to insufficient knowledge of care of operative site, restrictions (diet, activity), medications, signs an symptoms of complications, and follow-up care
Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

AMBULATORY SURGICAL CLIENTS

PREOPERATIVE PERIOD
Nursing Diagnosis
  • Fear related to scheduled outpatient surgery and insufficient knowledge of preparation, routines, and postoperative condition


POSTOPERATIVE PERIOD
Collaborative Problems

Potential Complications

  • Hemorrhage
  • Hypovolemia/Shock

Nursing diagnosis

  • Risk for altered Respiratory function related to immobility secondary to post-anesthesia state and pain
  • Risk for infection related to increased susceptibility to bacteria invasion of wound
  • Pain relate to surgical interruption of body structures, flatus, and immobility
  • Risk for ineffective management of therapeutic regimen related to insufficient knowledge of operative site care, diet and activity restrictions, medications, sings and symptoms of complications, and follow-up care

Lynda Juall Carpenito
NURSING CARE PLANS AND DOCUMENTATION, 2nd Edition

RISK FOR ACTIVITY INTOLERANCE related to immobility

DEFINITION

state of being at risk for extreme fatigue or other physical symptoms following simple activity.

ASSESSMENT

  • History of present illness
  • age
  • past experience with immobility or prescribed bed rest
  • Cardiovascular status, including blood pressure, heart rate and rhythm at rest and with activity, CBC, skin temperature and color, edema, chest pin or discomfort
  • Respiratory status, including arterial blood gases, pulmonary function studies, and respiratory rate, depth, and patterns both at rest and activity
  • Neurologic status, including level or conciousness, orientation, mental status, sensory status, motor status
  • Musculoskeletal status, icluding range of motion, muscle size, strength, tone, and functional mobility as follows:

0 = completely independent

1 = requires use of equipment or device

2 = requires help, supervision, or teaching from another person

3 = requires help from another person and equipment or device

4 = dependent, does not participate in activity

RISK FACTORS

  • Altered level of consciousness
  • Imposed restriction of movement, including mechanical (traction or cast), medical protocol
  • Inactivity
  • Prolonged bed rest
  • Severe pain

ASSOCIATED MEDICAL DIAGNOSIS

  • Cerebrovascular accident
  • Congestive heart failure
  • Fractures (with traction or cast)
  • Guillain-Barrè syndrome
  • Multiple sclerosis, severe head injury, spinal cord injury

EXPECTED OUTCOMES

  • Patient maintains muscle strength and joint range of motion. (1, 2, 3, 4, 5, 6, 7)
  • Patient carries out isometric exercise regimen. (4, 5, 6)
  • Patient understands rationale for maintaining activity level and avoids risk factors that may lead to activity intolerance. (11)
  • Patient performs self-care activities to tolerance level. (7, 8, 9, 10, 12)
  • BP and pulse and respiratory rates remain within prescribed range during periods of activity (specify). (10)

INTERVENTIONS AND RATIONALES

  1. Position patient to maintain proper body alignment. use assistive devices as needed to maintain joint function and prevent musculoskeletal deformities.
  2. Turn and position at least evry 2 hours. establish a turning schedule for dependent patients. post at bedside and monitor frequency. Turning helps prevent skin breakdown by relieving pressure.
  3. Assess patient’s level of functioning using the functional mobility scale. Communicate level to all staff. communication among staff members ensures continuity of care and preserves identified level of independence.
  4. Unless contraindicated, perform range-of-motion exercise every 2-4 hours. Progress from passive to active, according to patient tolerance. Range-of-motion exercises prevent joint contractures and muscular atrophy.
  5. Encourage active movement by helping patient use trapeze or other assistive device to improve muscle tone and enhance self-esteem
  6. Teach patient how to perform isometric exercises to maintain and improve muscle tone and joint mobility
  7. Assist patient in carrying out self-care, as tolerated, to foster independence and improve mobility.
  8. Encourage patient involvement in care planning and decision making to enhance compliance.
  9. Teach patient, family member, or partner methods to maximize patient’s participation in self-care. informed caregivers can encourage patient to become more independent.
  10. Assess patient’s physiologic response to increased activity (BP, respirations, heart rate and rhythm). Teach patient symptoms of overexertion, such as dizziness, chest pain, and dyspnea. Monitoring vital signs helps to assess tolerance for increased exertion and activity.
  11. Explain rationale for maintaining or improving activity level. Discuss factors that increase risk of activity intolerance. Education will help patient avoid activity intolerance.
  12. encourage patient to carry out activities of daily living by offering emotional support and positive feedback. this will enhance patient’s self-esteem and motivation.

DOCUMENTATION

  • Patient’s statements indicating motivation to maintain maximum activity level within restrictions imposed by illness
  • Activities performed by patient , family, or partner
  • Patient’s physiologic response to increased activity
  • teaching instructions provided to patient, family, or partner
  • Evaluations for each expected outcome
NURSING DIAGNOSIS CARDS 8th Edition
SPRINGHOUSE

ACTIVITY INTOLERANCE related to imbalance between oxygen supply and demand

DEFINITION

Extreme fatigue or other physical symptoms caused by simple activity.

ASSESSMENT

  • History of circulatory disease, respiratory disease, or both
  • Patient’s perception of tolerance for activity
  • Respiratory status, including arterial blood gases, pulmonary function studies, and respiratory rate, depth, and patterns both at rest and activity
  • Cardiovascular status, including BP, CBC, exercise ECG results, and heart rate and rhythm both at rest and with activity
  • Knowledge, including understanding of present condition, perception of need to maintain or restore an activity level consistent with capabilities, and physical, mental, and emotional readiness to learn.

DEFINING CHARACTERISTICS

  • Circulatory problems, respiratory problems, or both, including abnormal heart rate or blood pressure in response to activity, arrhythmia or ischemic changes on ECG, and exertional discomfort, dyspnea, tachypnea, or hyperpnea
  • Verbal report of fatigue or weakness

ASSOCIATED MEDICAL DIAGNOSIS

  • Acute myocardial infarction
  • Anemias
  • Asthma, bronchitis, COPD
  • Congenital and valvular disorders, congestive heart failure
  • Interstitial lung disease
  • Peripheral vascular disorders
  • Pulmonary edema, pulmonary embolus, respiratory failure, respiratory infections, respiratory neoplasms

EXPECTED OUTCOMES (numbers following to each outcome correspond to numbered interventions)

  • Patient states desire to increase activity level (1, 2, 3, 7)
  • Patient states understanding of the need to increase activity level gradually (1, 4, 5, 6, 7, 9)
  • Patient identifies controllable factors that cause fatigue (5, 7, 8, 9)
  • Blood pressure and pulse and respiratory rates remain within prescribed limits during activity (4, 6, 7, 8, 10)
  • Patient states sense of satisfaction with each new level of activity attained (2, 3, 7, 8, 9)
  • Patient demonstrates skill in conserving energy while carrying out daily activities to tolerance level (7)
  • Patient explains illness and connects symptoms of activity intolerance with deficit in oxygen supply or use (4, 5, 7, 8, 9, 10)

INTERVENTIONS AND RATIONALES

  1. Discuss with patient the need for activity to communicate to patient that activity will improve physical and psychosocial well-being.
  2. Identify activities patient considers desirable and meaningful to enhance his motivation to become more active.
  3. Encourage patient to help plan activity progression, being sure to include activities the patient considers essential. Participation in planning helps ensure patient compliance.
  4. Instruct and help patient to alternate periods of rest and activity to reduce the body’s oxygen demand and prevent fatigue.
  5. Identify and minimize factors that decrease the patient’s exercise tolerance to help increase the activity level.
  6. Monitor physiologic response to increased activity (including respirations, hear rate and rhythm, BP) to ensure return to normal a few minutes after exercising.
  7. Teach patient how to conserve energy while performing activities of daily living- for example, sitting in a chair while dressing, wearing lightweight clothing that fastens with Velcro or a few large buttons, and wearing slip-on shoes. These measures reduce cellular metabolism and oxygen demand.
  8. Teach patient exercises for increasing strength and endurance, which will improve breathing and gradually increase activity level.
  9. Support and encourage activity to patient’s level of tolerance to help patient develop independence.
  10. Before discharge, formulate a plan with patient and caregivers that will enable the patient either to continue functioning at maximum activity tolerance or to gradually increase activity tolerance. For example, teach patient and caregivers to monitor patient’s pulse during activities; to recognize need for oxygen, if prescribed; and to use oxygen equipment properly. Participation in planning encourages patient satisfaction and compliance.

DOCUMENTATION

  • Patient’s perception of need of activity
  • Patient’s priorities in performing selected activities
  • Patient’s priorities in performing selected activities
  • Patient’s description of physical effects of various activities
  • Observations made while the patient performs activities
  • Skills demonstrated by patient in conserving energy during activity
  • New activities patient was able to perform
  • Evaluations for each expected outcome
NURSING DIAGNOSIS CARDS 8th Edition
SPRINGHOUSE

ACTIVITY INTOLERANCE related to functional changes accompanying aging

DEFINITION

Insufficient physiologic pr psychological energy to complete or endure required or desired daily activities

ASSESSMENT

  • usual activity level, including self-care (dressing, feeding, toileting), transfer, walking, stair climbing, and aids for ambulation
  • pain
  • Cardiovascular status, including blood pressure, heart rate and rhythm (at rest and with activity), skin temperature and color, edema, and chest pain
  • respiratory status, including arterial blood gas levels, auscultation for breath sounds, rate, rhythm, depth, and pattern of respirations at rest and with activity
  • musculoskeletal status, including range of motion, muscle size, strength, tone, and functional mobility as follows:

0 = completely independent

1 = requires use of equipment or device

2 = requires help, supervision, or teaching from another person

3 = requires help from another person and equipment or device

4 = dependent, does not participate in activity

  • laboratory studies, including complete blood count
  • environmental factors, including safety hazards
  • history of chronic illnesses
  • sensory deficits, including hearing, vision, and touch
  • psychosocial status, including cognitive and mental status, mood, affect, behavior, family support, coping style
  • economic status
  • medication history, including prescribed and over-the-counter medications

DEFINING CHARACTERISTICS

  • cognitive impairment
  • decreased mobility caused by chronic illness, contracture or stiffness or muscles or joints, pain on movement, or an unsafe environment
  • depression
  • feelings of isolation
  • inability to manage one or more activities of daily living, such as shopping, housekeeping, laundry, and cooking
  • inability to perform one or more self-care activities

ASSOCIATED MEDICAL DIAGNOSES

  • Advanced cardiopulmonary illness
  • advanced dementia
  • cataracts
  • chronic obstructive pulmonary disease
  • glaucoma
  • macular degeneration
  • osteoarthritis
  • Parkinsonism
  • rheumatoid arthritis

EXPECTED OUTCOMES (numbers following to each outcome correspond to numbered interventions)

  • Patient uses assistive devices to carry out activities (1,2,7)
  • Members of the interdisciplinary health care team coordinate to develop an activity regimen for the patient (3,5,7,9,10)
  • patient identifies meaningful activities and develops a plan to incorporate them into is daily routine (4,6,7,8)
  • Patient participates in exercise and social activities to the extent possible (8)
  • Patient’s pulse, respirations, and blood pressure remain within established parameters during periods of activity. (9,10)
  • patient discusses importance of good nutrition and adequate rest (11)
  • patient describes plans to use support services (12)

INTERVENTIONS AND RATIONALES

  1. establish realistic goals for improving patient’s activity level, considering his physical limitations and energy level, to help improve his quality of life
  2. Demonstrate use of assistive devices, such as a cane, walker, or trapeze, to teach methods of conserving energy and independence.
  3. Coordinate patient’s activity regimen. For example, balance medical treatment, exercise program, nutrition plan, and referrals (such as home health services) to address the patient’s physical and psychosocial needs.
  4. encourage patient to express feelings about decreased energy levels to enhance acceptance
  5. Monitor patient’s medication to identify drugs that may impair activity tolerance.
  6. Help patient identify meaningful activities and incorporate them into his daily routine to heighten satisfaction with energy expenditure.
  7. Modify the environment to aid independent activity. for example, place bed on the first floor of the home, near a bathroom, and tell patient about energy –saving devices, such as an elevated toilet seat, a trapeze bar on the bed, and a chair that rise him to a standing position to promote independence.
  8. Encourage patient to become involved in exercise and social activities to increase stamina and decrease social isolation.
  9. Perform periodic health assessments and monitor complaints of weakness or fatigue to assess whether acute idleness or exacerbation of a chronic condition is causing activity intolerance.
  10. Establish progressive goals to increase ambulation. Since older patient may tire easily, his activity should increase gradually. Monitor vital signs before and after ambulation to detect cardiovascular insufficiency.
  11. Teach patient bout good nutrition and adequate rest to improve health practices.
  12. Refer patient to a home care agency for follow-up. discuss the impact on self-esteem of getting help from people or devices, and encourage patient to interview and select home health personnel to maintain independence

DOCUMENTATION

  • observations of patient’s response to activity
  • patient’s statements regarding need for activity
  • observations of the patient’s skill in modifying activity level and use of support services to adjust to activity intolerance
  • patient’s statements indicating willingness to adapt to activity limitations
  • evaluations for each expected outcome

NURSING DIAGNOSIS CARDS 8th Edition
SPRINGHOUSE