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Creatinine is created in proportion to muscle mass and usually stays stable. If they are elevated it indicates that the cardiac muscle is stressed out or injured. The provider will place a gloved finger into the rectum and needs to have feces on it when it comes out. Promote oral care The mouth is a place that can get infected easily, especially if a patient is on antibiotics, which destroys some of the good bacteria there. It is important to teach the patient and their family members the signs and symptoms of stroke. Treatment is focused on pain control, fluid resuscitation and sometimes blood transfusions.
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If you are pregnant, nursing, taking medication, or have a medical condition, please consult with your healthcare professional before using any products on this site. Sign in or Create an account. Home Supplements Thyroid IodoRx. See 1 more picture. Buy in bulk and save. Product Description Same formula as Iodoral!
New and less expensive! The benefits of a high potency Iodine supplement do not end there. This is placed under the skin and is a device that sends electrical signals to the heart to help it beat with the right rhythm and pace. Using beta blockers, calcium channel blockers and cardiac glycosides will help control the rate of the heart beat. They block beta 1 receptors from being stimulated. Stimulation of Beta 1 causes positive inotropic force of contraction and chronotropic pace of heart beat effects.
If you block beta 1 you will have decreased force of contraction and decreased heart rate. They block calcium channels… Duh. When calcium enters the cell in causes the cell to contract, thus when the channels are blocked, it decreases the production of electrical activity innately decreasing the heart rate.
This medication stimulates the Vagus nerve, which when stimulated slows the heart rate down. When it is blocked it causes increased contractility of the heart.
If your heart is beating stronger it will inherently slow down. Coumadin Aspirin Lovenox Plavix Eliquis Thinning the blood helps to disintegrate and break up the clot as well as increasing flow of blood. The most common are listed to the left. Fall education Being on a blood thinner, the patient needs to be informed of their risk of bleeding out especially if they fall and hit their head.
Make sure to go over environmental hazards such as good lighting and eliminating throw rugs. If a patient does fall and hit their head they need to go to the ER immediately, even if they are not experiencing any adverse effects.
Time to call The risk of a blood clot forming and moving to the brain is fairly high. It is important to teach the patient and their family members the signs and symptoms of stroke. Teach the patient that if they feel confused or feel weakness on one side to call for help. Troponin I Creatine Kinase MB Initial measurement of the cardiac enzymes is important because it helps with any trending information, the sooner you get this information the better.
Also getting trending results over specific periods of time is helpful. Is an enzyme that helps the interaction of myosin and actin in the cardiac muscle. When necrosis of the myocyte happens, the contents of the cell eventually will be released into the bloodstream. Troponin can become elevated hours after in ischemic cardiac event and can stay elevated for up to 14 days. This enzyme is found in the cardiac muscle cells and catalyses the conversion of ATP into ADP giving your cells energy to contract.
When the cardiac muscle cells are damaged the enzyme is eventually released into the bloodstream. CKMB levels should be checked at admission, and then every 8 hours afterwards. Etiology Any issue with the cardiovascular system could potentially cause CHF or put the patient at a much higher risk for CHF , such as myocardial infarction, coronary artery disease, hypertension, cardiomyopathy, heart arrhythmias, etc. Desired Outcome maximized cardiac functionality as well as decreased stress on the cardiovascular system.
Restrict sodium intake Water follows salt! The patient has too much fluid on board and needs to get rid of it, restricting the sodium helps with this. This means educating the patient on dietary changes that need to happen and be adhered to. Try to stay between mg of salt in a serving. Monitor BNP Normal range: Brain natriuretic peptide BNP: When the heart is stressed or working hard to pump blood, it releases BNP. Listen to breath sounds Monitor O2 saturation Fluid can back up into the lungs and cause shortness of breath, especially upon exertion.
Be careful about laying these patients flat as you can put them in respiratory distress. Place the patient on O2 as needed to help them keep their O2 levels adequate. Furosemide Lasix Bumetanide Bumex Hydrochlorothiazide Microzide Spironolactone Aldactone We need to get all this fluid out of the patient… The best way to do this is administer diuretics.
Most commonly used diuretics in congestive heart failure are loop and sometimes thiazides are used with loop diuretics: This can change per patient and per doctor recommendation, so make sure to get a goal from the physician. Cirrhosis Nursing Care Plan. Pathophysiology Liver cirrhosis is a chronic, irreversible liver disease. Desired Outcome Minimize continued liver damage, optimize nutrition, maximize hepatic circulation, minimize and prevent respiratory complications.
Nursing Interventions and Rationales Promote nutrition Many who suffer from cirrhosis have impaired nutrition and require nutritional support with specific vitamins and minerals; enteral or parenteral feedings may be ordered Assist with paracentesis, if needed Patients may require the abdominal fluid that has built up ascites to be drained.
Assist in set-up, positioning, and post-procedure site assessments, and monitoring as needed. Daily weights This indicates if fluid has been accumulating, or if patient is losing weight Dietary adjustments: Monitor for excess fluid volume assess daily weight, JVD, blood pressure Increasing values indicate vascular congestion Note and address electrolyte imbalances Fluid and electrolyte imbalances are common and can result in dysrhythmias Promote oral care Patients are at a higher risk for bleeding gums and mouth sores, which can cause a decreased appetite in an already malnourished individual Complete a careful and comprehensive respiratory assessment vitals, labs, auscultation Essential to note impaired gas exchange and compromised respiratory function early.
Pathophysiology Less air flow is able to flow into and out of the alveoli both trapping CO2 as well as restricting O2 entering. Desired Outcome Clear, even, non-labored breathing while maintaining optimal oxygenation for patient.
Nursing Interventions and Rationales Avoid irritants: Quit smoking or being around smoke Be mindful of the weather very cold can aggravate the bronchi Allergens like dust or pollen The key to avoiding a flare up of COPD is to avoid things that make it worse. If the patient is smoking still this is a priority, they need to quit smoking.
Provide education on smoking with COPD and the benefits of quitting. If the patient has been working very hard to breath for a long period of time and is getting worse, be prepared with an airway cart.
And for the love of the airway, have your respiratory therapist aware of the patient! Breathing Treatments and medications Beta-Agonists: Plan the oxygen monitoring with the physician. Give oxygen as ordered and needed. Obtain an ECG The lungs and the heart are in the same general area, if someone is having problems breathing, make sure their heart is ok.
Encourage a healthy weight Can be either overweight or underweight Having access weight on the patient decreases the space for the lungs to expand. Plus, generally those who lose weight are also moving more to lose the weight, double win.
Some patients especially those with emphysema can be very thin barrel chested and it is important to make sure they are getting the proper nutrition so their body is at optimal performance for that patient. Helping the patient move more often helps improve breathing abilities. Pathophysiology Blood clots formed from any source, lodging in the patient leg or arm, impeding blood flow. Etiology Narrowing or occlusion of the vessels in an extremity. Desired Outcome Stabilization of the blood clot or disintegration of the blood clot as well as prophylaxis treatment for future blood clots.
Subjective and Objective Data Subjective Data Painful extremity Numbness and tingling on affected extremity Potential subjective data to be concerned about and monitor for: Chest Pain CP Stroke: Objective Data Warm, red, firm and swollen leg Decreased peripheral pulse on affected extremity. Nursing Interventions and Rationales Assess a full neuro exam, assess breathing-Pulse oximetry, difficulty in breathing, chest pain, obtain an EKG.
Heparin- initial therapy to break up clot. Transition into a SubQ or oral anticoagulant to prevent future clots. This is an anticoagulant that breaks up blood clots as well as prevents them. Patient will need to have frequent blood draws to monitor their INR. Therapeutic range is between 2 and 3. Educate about avoiding vitamin K both supplements as well as food Vitamin K works to help increase clotting, this is opposite of what we are trying to do for this patient, unless of course they are bleeding out, in which case the treatment may be vitamin K with Fresh Frozen Plasma FFP Continuous monitoring: This monitors for changes in oxygenation if the clot moves to the lungs.
Nosebleeds are obvious, however, inform the patient that if they bleed through nasal packing for longer than 15 minutes they should go to the ER. Also they they feel dizzy, faint, or are losing color in their face they should go to the ER.
Diabetes Nursing Care Plan. Etiology The cause for Type I diabetes is unknown, but hypothesized to be potentially genetic or triggered by a virus. Desired Outcome Blood sugar control with minimal side effects. Nursing Interventions and Rationales Blood sugar monitoring: The physician will make a target blood glucose level. Teach the patient that they need to monitor their blood glucose. Teach the patient how to use their glucometer and record their results. Insulin administration -Rapid Acting: Each institution has guidelines and each insulin has guidelines.
Following the guidelines, make sure you know the onset, peak and duration of each type of insulin. Up to 12 hours -Intermediate Action Onset: Up to 24 hours -Long Acting Onset: Up to 24 hours To administer insulin, teach the patient to rotate injection sites and to clean the site with alcohol prior to inserting needle. Educate about nutritional changes and monitoring This would be a good time to get the dietician involved. The patient needs to learn at a minimum, how to count carbs and which foods to avoid such as beer.
If the patient is hypoglycemic, and they are able to eat or drink, give them some OJ and graham crackers with peanut butter. Increase water intake if the patient has hyperglycemia Monitor feet and educate about monitoring feet Both decreased blood flow to the feet as well as neuropathy occur to make the feet something the patient really needs to watch.
Wounds are hard to heal so if they are having a hard time feeling their feet and they become injured, the wounds will be worse than with someone without diabetes. Teach the patient to check their feet everyday. Washing their feet, cutting their toenails straight across, and scrubbing off calluses gently are a couple of points to make with the patient. The patient may have a podiatrist involved in their care as well. Placing strain on the cardiovascular system wrecks havoc on other organ systems.
Being diabetic makes the chances of that system having issues worse. A patient can lose their vision, kidney function, have a stroke or heart attack. Educate about maintaining a healthy weight and keeping active With a healthy weight, the patient is likely also implementing a healthy diet as well as implementing more movement. These three things weight, diet, exercise can help to manage or even reverse diabetes. Healthy weights are calculated based on height and sex of the patient.
Other ways to monitor the size of the patient is to use a BMI calculator or measure waist circumference. Etiology Ketoacidosis can occur when diabetic patients experience emotional or physical stress such as with bacterial infections UTI, etc , prolonged vomiting, surgery or when they miss doses of insulin. Desired Outcome Maintain blood glucose level within the target range, maintain normal fluid balance.
Blurry vision Excessive urination. Monitor glucose and intervene with prescribed insulin as appropriate to reduce glucose levels and prevent further ketone production. Monitor fluid and electrolyte balance to prevent dehydration and complications such as decreased sodium, potassium, calcium and magnesium Excess blood glucose can cause nausea and vomiting resulting in electrolyte imbalances.
These electrolyte deficiencies can lead to further complications and cardiac arrhythmias. Assess for fever and other symptoms of infection and administer antibiotics as necessary.
Administer medications as appropriate Medications may be given to lower the blood glucose level in order to prevent further production of ketones or to manage symptoms of vomiting and underlying infection. This will be evident by low blood pressure and tachycardia Prevent injury and falls; assist with ambulation Fatigue and weakness are common due to the cells inability to use glucose to produce energy, also following vomiting, and in cases of dehydration.
Nutrition and lifestyle education Maintaining a high blood glucose level, missing doses of insulin or being sick can cause ketones to form in the blood. Educate patients on healthy diet and lifestyle to prevent DKA. Emphysema Nursing Care Plan. Pathophysiology Destruction of the alveoli shapes and functionality. Etiology Exposure to lung irritants in the air: Nursing Interventions and Rationales Auscultate lung sounds If wheezy they may need a breathing treatment If you hear crackles they may have pneumonia and potentially could use suctioning.
Monitor ABGs Blood gases help to determine if the patient is in respiratory acidosis. Encourage a healthy weight Early stages of emphysema: Plus, generally those who lose weight are also moving more to lose the wieght, double win.
In later stages of emphysema, the patient can be very thin barrel chested and it is important to make sure they are getting the proper nutrition so their body is at optimal performance for that patient. Prepare for the worst: Breathing treatments and medications Beta-Agonists: Gerd Nursing Care Plan. Pathophysiology The repeated assault of stomach acid and bile into the esophagus.
Etiology A weakened esophageal sphincter allowing the acid or bile up into the esophagus from the stomach. Desired Outcome Maintain a normal amount of acid in the stomach, eliminate or decrease burning in the esophagus from acid splashing up and protect the GI tract from bleeding.
Nursing Interventions and Rationales Educate on the benefits of lifestyle changes: Quitting smoking Wear loose fitting clothing Keeping active Quitting smoking: Nicotine relaxes the esophageal sphincter. Teaching the patients about the connection helps give them another reason to quit.
Wear loose fitting clothing: Having the midsection squeezed puts pressure on the stomach-this is the same concept as being overweight. Helps the patient lose weight, which is important since excess weight pushes on the stomach. Esomeprazole Lansoprazole Omeprazole Pantoprazole Antacids: Maalox Mylanta Rolaids H2 Blockers: Cimetidine Famotidine Nizatidine Ranitidine Prokinetics: Erythromycin Proton Pump Inhibitors: Neutralizes stomach acid H2 Blockers: Decreases the amount of acid made in the stomach -Inhibits action of histamine leading to inhibition of gastric acid secretion Prokinetics: Helps to empty the stomach faster.
Helps to empty the stomach faster watch out for diarrhea though! Educate on nutritional changes Nutritional changes such as not over eating, avoiding acidic foods like orange juice or spicy foods such as salsa.
Also after eating, be sure to have the patient sitting in an upright position for at least hours. Also, having a patient sleep with their HOB greater than 30 degrees helps. Prepare the patient for a Barium Swallow Test An X-Ray tech will perform this test, your job as a nurse is to prepare the patient for this appointment.
Generally the patient has been NPO but check with the hospital policy or through the X-Ray tech as to how long they would like the patient to be NPO prior to the test. Assist with Endoscopy This procedure allows the visualization of the esophagus and the esophageal sphincter. The nurse will be administering sedative medications, maintaining the airway and monitoring vital signs. Obtain an ECG The symptoms of chest burning and pain are similar to that of a heart attack.
It is always important to eliminate the heart as a problem, and not to just assume that the patient is experiencing GERD symptoms. Encourage a healthy weight Access fat on a patient usually shows up in their abdomen and the displaces their stomach, increasing the risk of acid or bile deviously sneaking into the supposed off limits zones.
Pathophysiology Bleeding along the lining of the Gastrointestinal Tract is hard to recognize because it is not something you can see immediately, or necessarily get imaging or laboratory test work to discover the cause of bleeding right away.
Etiology The bleeding along the GI tract is from a perforation somewhere in the intestines or stomach. Desired Outcome Controlling and stopping of the bleeding, vital signs back to baseline, normal blood counts such as hemoglobin. Monitor heart rate and blood pressure When the heart is low on fluids to fill it, it will start beating faster and your pressure gets lower. If patient becomes hypotensive, put them in reverse trendelenburg, give them fluids, and get the physician.
When administering the blood, remember to have the blood product double checked with another nurse. Vital signs every Administer pantoprazole Protonix Potential surgical intervention to stop the bleeding Give pantoprazole Protonix , a proton pump inhibitor PPI that decreases the amount of acid in the GI lining. If it is not able to stop the bleeding, potential surgical intervention may be needed to stop the bleed.
Also-To be noted is the use of anticoagulants warfarin, aspirin, heparin, etc. Ask all your patients if they take an anticoagulant regardless of their issues, it is important to know. Make sure that the heart is still lub-dubbing as it should be. Assess for bleeding in stool GI bleed: Fall precautions The patient is at an increased risk for fall. This means that it is super important to educate the patient on using the call light if they need to get up and assisting with any mobilization of the patient.
Glaucoma Nursing Care Plan. Pathophysiology Glaucoma is group of diseases in which the pathophysiology is not fully understood. Etiology The exact cause of glaucoma is unknown. Desired Outcome Decrease intraocular pressure as quickly as possible, prevent further visual damage.
Nursing Interventions and Rationales Prevent further compromised vision Must report changing assessment findings to the provider promptly, especially with angle-closure glaucoma because timing is a factor in preventing permanent blindness. Remove as much clutter, cords, rugs, etc. This is especially important in the patient with sudden visual changes, as they have not slowly adapted over years as one may have with progressive loss.
Appropriately assess vision You must know the degree of visual compromise so that you are able to tell if it has changed. Educate about appropriate eye drop administration Post-procedure or during long-term management, patients are frequently on various various eye drops.
They may need additional intervention with color-coding bottles because they may not be able to clearly read labels. Ensure support systems are equally aware of regimen. Educate about importance of follow-up care Compliance is key! Patients must follow be compliant with their treatment regimen to prevent further deterioration. Manage pain Patients can have sudden pain, which will increase their intraocular pressure, making the problem even worse. Manage anxiety A sudden inability to see or the new knowledge that you will have a degree of blindness is upsetting.
Provide as much education and emotional support as possible, and if necessary, administer medications. Gout Nursing Care Plan. Pathophysiology Gout is a metabolic disorder and form of arthritis. Etiology Essentially, gout is caused by too much uric acid in the blood. Nursing Interventions and Rationales Treat pain: Hypertension Nursing Care Plan.
Pathophysiology The pathophysiology of HTN is quite complex. Etiology Primary HTN can be caused by many different factors. Desired Outcome Control blood pressure down to a safe level appropriately. You may want to speak with a pharmacist about optimal medication timing. Control pain Pain will increase blood pressure. Control as much as possible and time appropriately with activity.
Educate about disease process, treatment regimen, dietary changes Education is key because you cannot feel HTN. Patients must understand how important compliance is to prevent major events in the future.
Leukemia Nursing Care Plan. Pathophysiology Leukemia is a cancer of the blood. Etiology The exact etiology of leukemia is unknown, but there seems to be higher likelihood of it developing when certain environmental and genetic factors are present. Desired Outcome Minimize complications, resolve and recover from leukemia if possible. Nursing Interventions and Rationales Prevent infection Patients with leukemia have an impaired ability to fight infection and therefore we must be diligent in preventing infection.
This includes strict hand hygiene, which is the most effective infection prevention measure. Promote normothermia Progressive hyperthermia may occur, therefore it's essential to monitor body temp closely, especially if patient is receiving chemotherapy. Sepsis surveillance Patients undergoing leukemia treatment are at higher risk for developing sepsis, so make sure to monitor them closely and notify the MD when needed.
Educate patient and loved ones about infection prevention The patient and support system must be compliant with infection prevention measures for this to be successful, not just the health care team. They must understand its importance and be equally as diligent. Educate patient and loved ones about plan of care, symptoms to expect, and when to get concerned The more the patient and family can predict or be aware of, the better. Therefore, it is essential to take extra care to prevent breakdown Avoid procedures that would increase infection risk: Must weigh risk versus benefit, and patients with leukemia are at a much higher risk for infection, so the benefit of said procedures may not outweigh the risk.
Initiate bleeding precautions Clotting factors are impaired and therefore patients with leukemia are at an increased risk for bleeding. Cluster care and conserve energy Energy conservation is essential. We must maximize the time in which the patient is able to care for themselves. Feedings, ambulating and toileting is the priority. Therefore, do not disturb their sleep unnecessarily.
Cluster labs, vitals, and other aspects of care as clinically appropriate. Pain medications may be ordered scheduled rather than PRN. Assess appropriately type, severity, precipitating and aggravating factors, what relieves the pain, and so forth. Leverage non-pharmacological interventions to complement pharmacological interventions by timing appropriately.
Promote assistive devices to conserve energy Walkers, wheelchairs, canes, shower chairs, are all things that can help the patient conserve energy while still participating in their own care.
Make sure to educate and visualize a return demonstration before allowing independent use. Time pain medications and antimetics to be at their peak for therapy, chemo, and meals. By timing these meds to be at their peak when anticipating increased pain and nausea, you can increase intake and their ability to participate in therapy.
Patients will most likely need assistance in caring for themselves. Prioritize their activities to promote those that are involved in their own care conserve energy to feed self over walking up and down halls.
Closely monitor intake and output, assess for signs of dehydration skin turgor, mucous membranes, cap refill. Dehydration and kidney compromise is a potential complication, therefore we must watch for it diligently. Please see the quote below: It does increase cost and makes the patient feel isolated, straining their mental health unnecessarily.
Pathophysiology Cardiac muscle tissue death from lack of blood flow. Etiology Narrowing or occlusion of the cardiac vessels that perfuse the heart.
Desired Outcome Re-perfusion to cardiac muscle and return of cardiac muscle functionality, or as much as possible. Initial dose is mg IV. Evidence based research has left the use of oxygenation and its helpfulness in these situations inconclusive. Oxygen can cause vasoconstriction thus worsening the situation and decreasing blood flow. Administer oxygen when clinically relevant. This is the initial medication given, along with aspirin.
This medication dilates the blood vessels to help allow any blood flow that might be impeded. This can happen 3 times total. A total of 4 baby aspirin 81 mg each can be given for a total of mg. If the ECG is a normal sinus or otherwise non-concerning rhythm, place them on a 3 or 5 lead cardiac monitor for frequent re-assessing. Right sided 12 lead ECG shows the right side of the heart to assess for right ventricular ischemia.
You are worried about a worsening condition such as cardiac arrest. BP Monitoring The measurement is determined by the doctor, who is determining this based on evidence based research married with patient factors.
This can also be monitored by an arterial line. This is important because the higher the blood pressure, the more pressure is on a clot. Heparin This is an anticoagulant that breaks up blood clots as well as prevents them.
If they are elevated it indicates that the cardiac muscle is stressed out or injured. Troponin I is an enzyme that helps the interaction of myosin and actin in the cardiac muscle. Neutropenia Nursing Care Plan.
Pathophysiology Neutropenia is an abnormally low count of neutrophils, which is a type of white blood cell. Desired Outcome Restore neutrophil count, prevent additional destruction, prevent infection. Promote oral care The mouth is a place that can get infected easily, especially if a patient is on antibiotics, which destroys some of the good bacteria there. Brushing and flossing regularly is essential. Promote hygiene Proper hygiene reduces the risk for infection, which is our main concern with neutropenia.
Prevent skin breakdown Skin is an essential aspect of our body that prevents infection. Therefore, if it is compromised, it can be quite a problem for a patient with neutropenia.
Prevent ulcers and breakdown, as they may not be able to heal properly and prevent healing and recovery. Promote nutrition and ensure food is prepared and stored appropriately Food that is not stored or prepared properly could cause infection.
Listeria is a food-borne illness that could be quite detrimental to a neutropenic patient. Osteoporosis Nursing Care Plan. Pathophysiology Even after bone are done growing after childhood, bones are constantly being broken down and replaced. Etiology During younger years, bone is regenerated faster than old is broken down.
Desired Outcome Address any underlying causes and prevent fractures. Nursing Interventions and Rationales Prevent injury initiate fall precautions Injury can be catastrophic for patients with osteoporosis, as a fall could much more easily cause major fractures Control pain Patients with fractures typically experience pain; pain control is essential to participating in rebab Consult physical and occupational therapy as appropriate Establishing rehab needs and plan for nursing to assist with implementation; also safely evaluates their max functional level Assist with ROM activities Patients may require assistance to ensure appropriate movement occurs to prevent atrophy from immobility Try to avoid using restraints if possible A patient is much more likely to cause a fracture from restraints if they have osteoporosis and confusion.
It is especially important to avoid restraints in these patients. Assist with repositioning every 2 hours if needed Repositioning skin breakdown; assist patient with this if they are unable to do so themselves Promote appropriate bowel habits Decreased mobility, pain, medications, and so forth all contribute to constipation. Being proactive rather than reactive will safe the patient discomfort, additional pain, and increase compliance with treatment regimen.
Promote nutrition Prevents skin breakdown, promotes healing. Increasing calcium intake and supplementation as appropriate Support fracture stabilization Whether cast or splint, ensure it is on appropriately and evaluate for skin irritation and breakdown.
Assess for appropriate circulation. Monitor for fat embolism Fat embolism is a complication from a fracture respiratory insufficiency, rash. Pneumonia Nursing Care Plan. Pathophysiology Pneumonia is essentially when fluid or pus gets trapped in the alveoli of the lungs pictured below and impaired gas exchange results.
Etiology Pneumonia can be caused by a virus, bacteria, fungus, or from inhaling something a chemical, inhalant, or aspirating on food or fluid. Desired Outcome Resolve the infection, optimize gas exchange, minimize impact from impaired gas exchange.
If patient is able to clear their own airway, continue to encourage this. If not, suction frequently and consider an advanced airway to ensure a patent airway, which ultimately maximizes gas exchange. Getting phlegm out is important.
Optimize fluid balance Patients with pneumonia may not be consuming adequate oral intake due to fatigue or not feeling well, but hydration is essential to healing. Patients may need IV fluids if PO intake is inadequate.
Assess and treat pain If patients are not coughing because of pain, it will only allow fluid to continue to build.
Treat pain appropriately and encourage them to cough to clear phlegm. Providing additional oxygen supports this as much as possible. Use caution in patients with underlying lung conditions.
Patients cannot adequately participate in these important activities if they are not maximizing their time to rest. Appropriate sleep promotes healing. Also, trough levels will most likely to be ordered to assess if the patient is getting too much, too little, or just enough of the antibiotic.
The timing of these labs related to administration times are essential for accuracy. Prevent further infection Patients may have invasive lines like a internal urinary catheter, central venous catheter, endotracheal tube, and so forth. It is essential to care for these devices properly to prevent further infection. Educate patient and loved ones on the importance of energy conservation, effective airway clearance, nutrition, as well as coughing and deep breathing Patients must be aware of how these aspect of recovery are pertinent so they will be more likely to participate and remain compliant.
Pathophysiology Postpartum hemorrhage is the excessive bleeding following delivery of a baby. Etiology Normally, the uterus continues to contract after the delivery of the baby and placenta. Desired Outcome Patient will maintain optimal fluid balance and vital signs within normal limits. Nursing Interventions and Rationales Assess vital signs and monitor for signs of shock Decreased fluid volume will cause blood pressure to drop and patient will go into shock Monitor blood loss Amount of blood loss and presence of blood clots can help determine treatment.
Monitor lab values to determine need for transfusions or signs of complications Watch hematocrit and clotting levels to know if blood transfusion is necessary and for signs and severity of DIC. Administer IV fluids, medications and blood products as necessary Watch hematocrit and clotting levels to know if blood transfusion is necessary and for signs and severity of DIC. Fluid replacement may be necessary and, depending on amount of blood lost and hematocrit level, a blood transfusion may be required.
Oxytocin is sometimes given to initiate contractions that will help stop bleeding. Perform uterine massage to stimulate contractions following delivery Begin fundal massage and educate patient on how to massage abdomen to stimulate contractions. These contractions may help stop bleeding.
Respiratory failure Nursing Care Plan. Pathophysiology Essentially, at its most basic level, respiratory failure is inadequate gas exchange. There are three main types: Desired Outcome Restore oxygen levels of blood as appropriate and remove excess carbon dioxide.
Objective Data Hypoxia Hypercapnia Blue skin, lips, nail beds, etc. Use caution with COPD patients, as they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may have a lower baseline SpO2 level Ensure patient is in optimal position to decrease work of breathing Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange if clinically appropriate to be sitting up Prepare for rapid sequence intubation, if necessary Helpful to be prepared, as this can progress quickly.
Know where the necessary meds and equipment are and how to get ahold of assistive personnel. Promote a calming environment so all the patient has to worry about is breathing. The underlying cause must be treated and routinely reevaluated for the patient to progress. Assess ability to swallow safely post-intubation Vocal cords may be irritated and have edema if a patient has been intubated and if give oral intake too quickly too early, patients can easily aspirate.
Many facilities require patients to wait hrs post intubation to resume regular oral intake as well as a swallow evaluation. Rhabdomyolysis Nursing Care Plan. Pathophysiology Essentially, skeletal muscle is destroyed for various reasons and their intracellular contents in particular myoglobin leak into the bloodstream. Etiology Quite a few things can cause this.
Patients may need dialysis if oliguria is present. Insert Foley and prevent infection Enables nurse to closely and accurately monitor urine output, foley is a source of infection and must be cared for diligently Monitor labs Labs can and will dictate treatment regimens, especially because symptoms can vary widely.
CK, serum and urine pH, bicarb, and electrolytes to name a few Correct electrolytes per orders Electrolyte imbalances are common K, Ca, P are of particular importance Monitor for compartment syndrome If significant muscle injury occurred, compartment syndrome is a risk. Muscle injury is typical due to decreased perfusion. If a medication was noted to cause this, it and alternatives should be evaluated with the prescriber.
Pathophysiology The exact patho of RA is not fully understood, although there is thought to be a genetic component leading to more susceptible individuals. Chronic inflammation and degenerative changes are the hallmark aspects of RA. Etiology Like the pathophysiology, the etiology is unknown. Desired Outcome There is no cure for RA, therefore the goal is to manage symptoms and slow the disease progression.
Nursing Interventions and Rationales Manage both chronic and acute pain: Seizures Nursing Care Plan. Pathophysiology Seizures are a very complex neurological issue. Etiology The exact cause of a seizure can be extremely difficult to pinpoint. Desired Outcome Stop any current seizure activity as soon as possible, minimize damage, and prevent it from occurring in the future. Objective Data Rhythmic twitching Loss of consciousness Staring off Repetitive behavior lip smacking.
Nursing Interventions and Rationales Ensure safety and initiate seizure precautions for patients at-risk for seizures. This includes having suction set up and working, having an ambu-bag in the room, padding side rails, not restrain them or putting anything in their mouth if a seizure occurs, having all side rails up, and so forth.
Seizures frequently happen without warning, therefore we must ensure safety in case it occurs. They must receive these promptly, as ordered. Also be aware of your PRN antiepileptics and when to administer them typically for seizures lasting longer than 2 minutes Reevaluate any medications that may lower the seizure threshold some antibiotics, antidepressants, narcotics, and many more may do this We want to do all we can to prevent seizures from occurring, therefore the healthcare team must evaluate meds that may increase the seizure risk and closely look at them to decide if the benefit is worth the risk, or if an alternative is available that does not lower the seizure threshold Educate patient and family on hospital procedures, and when to notify staff Some patients with a history of seizures can tell when one is coming on, which is helpful to communicate to the nurse.
Provide emotional support Seizures are serious and upsetting to witness. The more empathy and support you can provide patients and loved ones, the better. Sepsis Nursing Care Plan. Etiology Essentially, the cause of sepsis is the original infection. Desired Outcome Lessening the immune response, prevention cellular death, resolution of infection, minimizing damage from cellular oxygen deprivation and lactic acid build up, maximizing cardiac output and resolution of the condition.
Objective Data Elevated temp over F Low temp below Nursing Interventions and Rationales Prompt lab draws Labs in sepsis diagnosis and treatment are very time sensitive. It is imperative the nurse is drawing labs promptly, as this evaluates the effectiveness of treatment and determines next steps.
Appropriate administration of IV antibiotics Baseline blood cultures must be drawn prior to the initiation of antibiotics to ensure the appropriate pathogen is identified.
Optimize fluid-volume status Patients suffering from sepsis usually require massive fluid resuscitation. Assess, monitor, and optimize cardiac output Cardiac output is typically compromised in sepsis. The nurse must communicate with the MD about this and how to treat it, as some may need more fluid, or vasopressors, or both. Assess, monitor, and support oxygen status Septic patients may need significant respiratory support, depending on severity.
Asepsis is KEY with all patient care but in particular the septic patient. Frequently septic patients will require a central venous catheter and foley catheter. These are invasive lines that can easily get infected but are necessary when a patient is that ill. Many septic patients with fluctuating body temps may have continuous temperature monitoring via foley, rectal tube, or endotracheal tube Communicate with and educate patient and loved one Sepsis is serious and scary.
Shock — Hypovolemic Nursing Care Plan. Pathophysiology Hypovolemic shock is a loss of blood volume leading to decreased oxygenation of vital organs.
Etiology Any condition causing loss of circulating blood or plasma volume. Desired Outcome The goal is to restore circulating blood volume, preserve hemodynamics, and prevent any damage to vital organs. Traumatic injuries Internal bleeding, such as a GI bleed or surgical complication Postpartum hemorrhage Fluid loss from: Burns Diarrhea Vomiting Nurses should assess their patient for the risk of developing hypovolemic shock.
Either way, the more aware the nurse is of the risk, the more likely it can be prevented or caught early. Assess and monitor VS and LOC Patient may develop tachycardia and tachypnea in the early stages, then hypotension in later stages.
Level of consciousness should be assessed because it may decrease as the patient loses oxygenation of their brain. Decreasing LOC is a sign of advancing shock. Notify the provider for: If the blood pressure continues to drop, the patient will lose perfusion to vital organs. They may also begin to have difficulty protecting their own airway - the provider needs to be notified Monitor Hemodynamics Hemodynamic measurements will tell us the severity of the shock and how well the patient is responding to treatment.
It can be calculated with a non-invasive blood pressure, but is more accurate when measured by an Arterial Line. If fluid resuscitation is effective, we will see this number return back down to normal Prepare for procedures Arterial lines are placed for invasive hemodynamic monitoring.
Patients who have severe hemorrhages may receive a large bore 12g central catheter called a Cordis so they can receive large volumes of fluids rapidly. Patients may need to be taken to the OR to repair the injury or internal bleeding that caused the hypovolemia in the first place.
This should be done with a pressure bag or rapid infuser. At this rate, 1 L of fluids takes 1 hour to infuse. Shorter and thicker catheters will provide for faster fluid administration. Administer Blood Products For patients who have lost significant amounts of blood due to trauma or hemorrhage, they should receive transfusions of blood products.
Be sure that consent is obtained and that the patient is aware of possible reactions. Verify the blood product with another nurse prior to administering and monitor per facility protocol for transfusion reactions. Usually this is q15min x 2, q30 min x 1, and q1h after that for standard infusions.
However, in hypovolemic shock, even blood products are given via rapid infusion. During massive transfusion protocol, units of plasma, platelets, and clotting factors are given at certain intervals to prevent this clotting problem.
Stroke Nursing Care Plan. Pathophysiology A stroke is essentially a neurological deficit caused by decreased blood flow to a portion of the brain. Cluster care; promote rest Maximizes time with the patient so they can rest when care is not being provided Monitor vital signs appropriately; know BP limits Closely monitoring BP is essential in managing ICP Prevent edema: Facilitate communication; promote family coping and communication Having a stroke is a major life event.
Roles within families and support systems may change, especially if the patient played a caregiving role within their family structure. Syncope Nursing Care Plan. Pathophysiology Syncope is essentially a loss of consciousness, which is typically caused by hypotension. Etiology Syncope typically has a cardiac etiology, but can also be due to many other things like a side effect from a med, neuro issue, psych issue, or lung problem.
Desired Outcome No additional syncopal events, no injury, identification of cause and treatment to prevent further episodes. Monitor appropriately and notify MD if needed, promote safety Promote adequate fluid intake Prevents worsening hypotension.
Pathophysiology Infection within the genitourinary system, which then causes inflammation. Desired Outcome Resolution of infection, restoration of normal bladder functioning.
Nursing Interventions and Rationales Assess pain, Assess urine color, clarity, odor Assess mental status Assess body temperature Must obtain baseline assessment data Discontinue indwelling catheter if applicable May be source of infection Draw appropriate labs CBC, UA Identifies infection, follow ups can show if treatment is effective Encourage increased fluids start IVF if necessary Increased urinary output helps flush out bacteria Promote routine voiding Taking the patient to the bathroom on regular intervals will help facilitate emptying the bladder completely Educate on proper perineal cleansing techniques to decrease risk of infection Improper wiping can cause infections Administer meds as ordered antibiotics, antispasmodics, analgesics Decreases discomfort and kills bacteria causing infection.