Custom Search

Acute Pain - Nursing Care Plan for Glaucoma

Nursing Diagnosis : Acute Pain r / t Increase in intraocular pressure (IOP)


Definition

Glaucoma is a group of eye disorders characterized by increased intraocular pressure. (Long Barbara, 1996)

Glaucoma often occurs in both eyes, but extra fluid pressure first begins to build up in one eye. If you don't seek treatment for glaucoma and can't control it, your peripheral vision will decrease by time and subsequent eye damage may easily lead to blindness.



Etiology

There are different types of glaucoma. Most occur when pressure in the eye (intraocular) increases, damaging the optic nerve but sometimes optic nerve damage can occur even when intraocular pressure is normal.

Other types of glaucoma are rare and are caused by abnormal eye development, drugs, eye infections or inflammatory conditions, interruption of blood supply to the eye, systemic diseases and trauma.


Symptoms:
  • Headaches.
  • Sensitivity to light.
  • Blurred vision.
  • Decreased peripheral vision- gradual loss.
  • Nausea and vomiting.
  • Severe pain in the eyes.
  • Reddening of the eyes.
  • One eye becoming bigger than the other.
  • Seeing rainbows around the lights at night.
  • Visual disturbance in low light.
  • Adjustment issues entering a dark room.
  • Excessive tearing.
  • Swollen eyes.



Nursing Care Plan for Glaucoma

Assessment

a) Activity / Rest:
Change usually activities / hobbies in connection with visual impairment.

b) Food / Fluids:
Nausea, vomiting (acute glaucoma)

c) Neuro-sensory:
Visual disturbances (blurred / unclear), bright lights glare caused by the gradual loss of peripheral vision, feeling in the dark room (cataracts).
Cloudy vision / blurring, halos appear / rainbows around lights, loss of peripheral vision, photophobia (acute glaucoma).
Changes glasses / treatment not improve vision.
Signs:
Papil narrowed and red / hard eyes with cornea cloudy.
Increased tear.

d) Pain / Leisure:
Mild discomfort / watery eyes (chronic glaucoma)
Sudden pain / weight or pressure settled on and around the eyes, headache (acute glaucoma).

e) Guidance / Learning
Family history of glaucoma, diabetes, impaired vascular system.
Stress history, allergies, vasomotor disturbances (eg, an increase in venous pressure), endocrine imbalance.
Exposed to radiation, steroids / toxicity of phenothiazines.



Nursing Diagnosis for Glaucoma

Acute Pain r / t Increase in intraocular pressure (IOP)

Goal: Pain is lost or diminished.

Outcomes:
  • The patient demonstrates knowledge of assessment of pain control.
  • The patient said that the pain is reduced / lost.
  • Relaxed facial expression.

Intervention:
  • Assess the type and location of pain intensity.
  • Assess the level of pain scale to determine the analgesic dose.
  • Encourage rest in bed in a quiet room.
  • Set Fowler position of 30 degrees or in a comfortable position.
  • Avoid nausea, vomiting as this will increase the IOP.
  • Divert attention to the fun stuff.
  • Give analgesics as recommended.

Constipation and Deficient Fluid Volume - NCP for Hirschsprung's Disease

Nursing Care Plan for Hirschsprung's Disease

Symptoms and signs can vary based on the severity of their condition sometimes appear soon after birth. At other times they may not appear until the baby grows into a teenager or adult.

In the new birth signs may include :
  • Failure to issue a stool in the first day or two of birth.
  • Vomiting : include vomit green liquid called bile - digestive fluid produced in the liver.
  • Constipation or gas.
  • Diarrhea.

In children older, signs may include :
  • Distended abdomen.
  • Slight weight gain.
  • Problems in the absorption of nutrients, which leads to weight loss, diarrhea or keduanyadan delay or slow growth.
  • Infection of the colon, especially newborn child or young ones, which can include enterocolitis, a serious infection with diarrhea, fever and vomiting and sometimes dangerous colonic dilatation. In children or older adults, symptoms may include constipation and low values ​​of red blood cells (anemia) due to blood loss in the stool.

Nursing Diagnosis for Hirschsprung's Disease

1. Risk for constipation related to narrowing of the colon, secondary, mechanical obstruction.

Goal: normal defecation pattern

Outcomes: the patient does not experience constipation, maintain a patient's defecation every day.


Interventions:
  1. Observations bowel sounds, and check the patient for abdominal distention. Monitor and record the frequency and stool characteristics.
  2. Record intake and output accurately.
  3. Encourage the patient to consume 2.5 L of fluid every day, if there are no contraindications.
  4. Perform defecation program. Patients in the upper chamber pot or commode at certain times each day, as close as possible to time the usual defecation (if known).
  5. Provide a laxative, enema, or suppository according to instructions.

Rational:
  1. To plan an effective treatment in preventing constipation and faecal impaction.
  2. To assure hydration and fluid replacement therapy.
  3. To improve hydration and fluid replacement therapy.
  4. To assist adaptation to the normal physiological function.
  5. To increase the elimination of solid stool or gas from the digestive tract, monitor effectiveness.


Nursing Diagnosis for Hirschsprung's Disease

2. Risk for Deficient Fluid Volume related to discharge fluid from vomiting, inability absorps water by instentinal.

Goal: fluid requirements are met

Outcomes: elastic and normal skin turgor, CRT less than < 3 seconds

Interventions:
  1. Measure the patient's body weight each day before breakfast.
  2. Measure fluid intake and urine output to fluid status.
  3. Monitor urine specific gravity.
  4. Check the mucous membranes in the mouth every day.
  5. Determine what is the preferred fluid of patients and save the liquid in a patient's bedside, as instructed.
  6. Monitor serum electrolyte levels.
Rational:
  1. To help detect changes in fluid balance.
  2. Decrease intake or increased fluid output increase deficits.
  3. Increased specific gravity of urine indicates dehydration. Low urine specific gravity, indicating excess fluid volume.
  4. Dry mucous membranes is an indication of dehydration.
  5. To increase intake.
  6. Changes in electrolyte values ​​may indicate the onset of fluid imbalance.

Risk for Fluid Volume Deficit related to Peptic Ulcer

Nursing Care Plan for Peptic Ulcer

Peptic ulcer is an erosion of gastrointestinal mucosa caused by too much hydrochloric acid and pepsin. Although ulcers can occur in the esophagus, the most common location is the duodenum and stomach (Wardell, 1990).

Chronic ulcers can penetrate the muscular wall. Recovery resulted in the formation of fibrous tissue and eventually permanent scarring. Ulcers can be recovered or recovered several times throughout one's life.

Peptic ulcers are sores on the mucous membranes of the esophagus, stomach and duodenum, which is caused by gastric work.

The main complications related to peptic ulcer disease, in general, are:
  1. Hemorrhage, evidenced by hematemesis and guaiac positive fesses.
  2. Perforation, evidenced by the sudden onset of severe pain accompanied by abdominal stiff as a board and symptoms of shock.
  3. Obstruction. This complication is more common in duodenal ulcer that is located near the pylorus. It is caused by constriction of gastric outlet as a result of edema and scar tissue from recurrent ulcers.
Etiology
  1. Increased production of stomach acid.
  2. Stress.
  3. Blood type.
  4. Cigarette smoke.
  5. Resistance of the lower hull.
  6. H. pylori infection. H. pylori bacteria can injure the mucous membranes and mucous membranes lose durability. In addition, the body will form antibodies to fight bacterial inflammatory reactions such as side effects but will cause damage to mucous membranes.
  7. Non-steroidal antiinflamatory drugs (NSAIDs) Drugs NSAIDs will lead to an increase in gastric acid spending, and reducing the protection of the mucous membrane of the stomach acid.
Both of the above causes are the most common cause of peptic ulcers. The second addition is the cause of the other causes of severe illness such as severe burns or following major surgery; Zollinger-Ellison syndrome; and others.

Signs and Symptoms
  1. Pain is felt after eating.
  2. Pain midnight.
  3. Disappear after eating.
  4. Bleeding, ulcers when active.
  5. Heartburn sore, commonly occurs 2-3 hours after eating, it gets better when filled with food or an antacid medication was given.
  6. Patients often wake up at night because of the pain.
  7. Pain may spread to the waist.
  8. Nausea.
  9. Vomiting.
  10. Discomfort in the pit of the stomach, accompanied by belching, bloating and not resistant to fatty foods.
  11. Burning feeling in the chest and discomfort in the chest.
  12. Loss of appetite, weight loss.
  13. On inspection dirt can be found occult blood.
  14. Vomiting blood.

Nursing Diagnosis : Risk for Fluid Volume Deficit

related to excessive blood loss secondary to peptic ulcer disease.

Defining characteristics :
  • Stool guaiac positive,
  • Black stool passage,
  • Coffee ground vomiting,
  • Drop in blood pressure accompanied by tachycardia, tachypnea, wet moist skin, stating thirst, decreased urine output.

Goal : Demonstrate no signs of acute inflammation.

Outcomes: soft brown stool passage, hemoglobin and hematocrit within normal limits.

Intervention:
  • Vital signs every 4 hours, when the stool guaiac positive.
  • The color and consistency of stool (fecal guaiac all if bleeding does not appear)
  • Coffee ground vomiting.
  • Tell your doctor about Coffee ground vomiting, black stool, emesis or stool bright red, a decrease in blood pressure accompanied by tachycardia and tachypnea, cool moist skin, or hemoglobin and hematocrit values below the normal range. Give blood transfusion according to program and monitor adverse reactions.
  • Evaluate the effectiveness of the drug. Use infusion pump when giving this medicine with a continuous drip.
  • Attach the hose NGT, and connect on intermittent suction according to the program if there is a bright red emesis. Maintain patency irritate the hose with cold normal saline.
  • Maintain fasting to order in case of vomiting. Provide appropriate intravenous therapy programs. Use the 18-G needle to start an intravenous infusion when blood transfusion is needed.
  • If the patient has weakness and dizziness, place bedpan beside the bed and toileting aids as needed. Instruct the patient to signal for help when getting out of bed.
  • Maintain bed rest if active bleeding occurs.
  • Prepare patients for surgery or sclerosing to order.
Rationalization:
  • To evaluate the effectiveness of therapy.
  • Emesis coffee color indicates blood mixed with gastric. Black stool (melena) indicates the gastro intestinal bleeding. Emesis or stool red light indicates active bleeding. Excessive blood loss can cause anemia, evidenced by the low hemoglobin and hematocrit and symptoms of shock.
  • NGT intubation route to give gastric lavage. Cold solution and vasopressin causes vasoconstriction.
  • Hypovolemia cause rapid blood loss. Intravenous fluids help improve intravascular volume until the bleeding can be controlled. Blood transfusion should be administered through a large-diameter needle because of high viscosity.
  • Bed rest reduces energy use and activity of the gastrointestinal tract.
  • Surgery is required when drug therapy is not effective in controlling severe bleeding after 24 hours.

3 Nursing Diagnosis and Interventions for Cystic Fibrosis


Cystic fibrosis (CF) is an inherited disease of the mucus glands and sweat . Cystic fibrosis (CF) affects mostly the lungs, pancreas, liver, intestines, sinuses, and sex organs.

Normally , mucus is watery / runny. Maintaining the layers of certain organs moist and prevents drying out or getting infected. But in CF, an abnormal gene causes mucus to become thick and sticky.

Mucus formed in the lungs and block the airways. It makes it easier for bacteria to grow and leads to repeated lung infections are serious. Over time, these infections can cause serious damage to the lungs.

Thick and sticky mucus can also block tubes, or ducts of the pancreas. As a result, the digestive enzymes produced by the pancreas is not able to reach the small intestine. These enzymes help break down food. Without them, the intestines can not absorb fats and proteins fully.

As a result:
  • Nutrients leave the body unused, and can become malnourished.
  • Stools become very large.
  • May not get enough vitamins A, D, E, and K.
  • May have gas in the intestines, the stomach is swollen, and pain or discomfort.
Abnormal genes also cause sweat to become very salty. As a result, when sweating, the body loses salt amounts are large. This can upset the balance of minerals in the blood. The imbalance may lead to getting heat emergency.

Nursing Care Plan for Cystic Fibrosis

Nursing Diagnosis I:

Ineffective airway clearance related to thick mucus secretions and effort and a lot of bad cough.

Goal: Not experiencing aspiration.

Outcomes: Shows an effective cough and increased air exchange in the lungs.

Interventions :

1. Auscultation of breath sounds. Note the example of wheezing breath sounds, crackles, rhonchi.
R /: Some degree of spasm of the bronchial obstruction with airway obstruction and may / not indicated the presence of abnormal breath sounds or crackles eg absence of breath sounds.

2. Perform physiotherapy to issue secret and give the patient a comfortable position, eg, elevation of the head of the bed, sitting on the back of the bed (position semi-Fowler / Fowler).
R /: head of bed elevation facilitate respiratory function using gravity.

3. Assist clients to dilute sputum, with the collaboration expectorant administration to improve airway clearance.
R /: Giving expectorants may help thin the secret, that secret is more easily removed.

4. Provide nebulizer with a solution and in accordance with the right tools.
R /: Nebulization can help spending viscous secretions.

5. Observations clients closely after aerosol therapy and chest physiotherapy to prevent aspiration due to many sputum suddenly become watery.
R /: To prevent aspiration.

6. Provide postural drainage (adjust the area where there is a buildup of mucus) as prescribed to reduce the viscosity of mucus.
R /: Postural drainage aids in the excretion of mucus is thick.


Nursing Diagnosis II :

Impaired gas exchange related to airway obstruction by nasal obstruction.

Goal: Maintaining adequate oxygenation or ventilation.

Outcomes:
The patient showed respiratory rate effectively.
Free of respiratory distress.
Arterial blood gas within the normal range.

Interventions :

1. Maintain a patent airway.
R /: Preventing complications of respiratory failure.

2. Position the patient to obtain maximum efficiency ventilators, such as a high Fowler's position or sitting, leaning forward.
R /: Position Fowler / semi-Fowler can facilitate respiratory function and can reduce airway collapse, dyspnoea, and breath work by using gravity.

3. Monitor vital signs, arterial blood gases (ABGs), and pulse oximetry to detect / prevent hypoxemia.
R /: increased PaCO2 indicates impending respiratory failure during asthmatic. Tachycardia, dysrhythmias, and changes in BP may indicate systemic hypoxemia effects on cardiac function.

4. Provide supplemental oxygen according to the provisions / requirements. Monitor patients closely for carbon dioxide narcosis due to oxygen is danger of oxygen therapy in patients with chronic lung disease.
R /: Occurrence / respiratory failure that would require effort dating lifesaving action. Supplemental oxygen administration can fix / prevent worsening hypoxia.

5. Motivation exercise appropriate physical condition of the patient.
R /: Physical exercise is often effective to clear accumulated lung secretions and to improve endurance exercise capacity before experiencing dyspnea



Nursing Diagnosis III

Ineffective breathing pattern related to tracheobronchial obstruction.

Goal:
Repairing or maintaining a normal breathing pattern.
Patients achieving lung function maximum.

Outcomes:
Patients showed an effective respiratory frequency with the frequency and depth within the normal range and lungs clear / clean.
Patients free of dyspnea, cyanosis, or other signs of respiratory distress.


Interventions :

1. Provide position Fowler or semi-Fowler.
R /: Position Fowler / semi-Fowler enables lung expansion and ease breathing. Changing position and ambulation improve air charging different lung segments which improves gas diffusion.

2. Teach deep breathing techniques, and or lip breathing or diaphragmatic breathing abdominal exercises when indicated and effective cough.
R /: to help spending sputum.

3. Observation vital signs (RR or frequency per minute).
R /: Tachycardia, dysrhythmias, and changes in BP may indicate the effect of systemic hypoxemia pad cardiac function.