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Lemetria Whitehurst posted an education article in Nursing Education Excellence: Your Academic Roadmap
According to the SAMHSA 2024 National Survey on Drug Use and Health (NSDUH) Key Findings, an estimated 23.4% of Americans are affected by mental illness and substance abuse disorders, which lead to significant morbidity and mortality. By identifying psychosocial factors, nurses can create a more comprehensive and patient-centered plan of care that addresses the whole person, leading to better outcomes and an improved quality of life. Quick Glance: Mastering Psychosocial DiagnosisWhat It Is: A clinical judgment about a patient's mental, emotional, social, and spiritual responses to their health. Why It's Important: It enables holistic, patient-centered care, addressing issues like anxiety or poor coping that can hinder physical recovery. Care Plan Components: Assessment, Diagnosis, Expected Outcomes, and Interventions with Rationale. Common Diagnoses: Ineffective Coping, Situational Low Self-Esteem, Grieving, Social Isolation, Anxiety. 2026 NCLEX Relevance: Psychosocial Integrity makes up approximately 9-15% of the NCLEX-RN exam. What is a Psychosocial Nursing Diagnosis?A psychosocial nursing diagnosis is a formal judgment about an individual's, family's, or community's responses to actual or potential health problems and life processes from a mental, emotional, social, and spiritual standpoint. Unlike a medical diagnosis that identifies a disease, a nursing diagnosis identifies the human response to that disease. For example, a medical diagnosis might be "Myocardial Infarction," while a related psychosocial nursing diagnosis could be "Anxiety related to fear of death." This focus allows nurses to create interventions that directly target the patient's emotional distress, which can significantly influence their physical recovery. The Importance of a Holistic Approach in Patient CareA holistic approach recognizes that a patient's mind and body are connected. Stressors, relationships, coping strategies, and self-perception can all contribute to or worsen physical conditions. By using a psychosocial diagnosis, nurses can: Identify underlying emotional and social stressors. Create targeted interventions to improve coping and resilience. Improve communication and build a stronger therapeutic relationship. Empower patients to take an active role in their recovery. This patient-centered method leads to more effective treatment, as it helps patients achieve both physical health and a higher quality of life. -
I have to do a care plan based on a psychosocial nursing diagnosis for a 75 year-old man with Alzheimer's. I have no idea where to start. He is unable to verbally communicate and is combative at times. He is also a retired colonel and at one time was very active in his church. As I said I am lost! Our instructors have not really gone into how to do care plans so we are learning as we go. Any help would be appreciated. (from Nursing Diagnosis - Psychosocial) To write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. What else do you know about this patient? Does he have any other comorbidities? The biggest thing about a care plan is the assessment, of the patient. The second is knowledge about the disease process. The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. The nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse. Think of them as a recipe to caring for your patient. Your plan of care. Care plans must be chosen from the "approved" script....NANDA. You need to let what the patient says, does and feels (the assessment) dictate what you do next. You need a care plan book. I prefer Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Every single nursing diagnosis has its own set of symptoms, or defining characteristics. They are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. There are currently 188 nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. What you need to do is get this information to help you in writing care plans so you diagnose your patients correctly. Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. 5 Step Nursing Process Assessment Collect data from medical record, do a physical assessment of the patient, assess ADLs, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology Determination of the patient's problem(s)/nursing diagnosis Make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use Planning Write measurable goals/outcomes and nursing interventions Implementation Initiate the care plan Evaluation Determine if goals/outcomes have been met. A dear friend to allnurses, daytonite (RIP) always had the best advice....check out this link: Nursing Diagnosis What Is A Care Plan? A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. The nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. One of the main goals every nursing school wants its RNs to learn by graduation is how to use the nursing process to solve patient problems. Care Plan RealityThe foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be a medical disease, a physical condition, a failure to be able to perform ADLs (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be a detective and always be on the alert and lookout for clues. At all times. and that is within the spirit of step #1 of this whole nursing process. Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers. Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. In order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Care plan reality: Is actually a shorthand label for the patient problem. The patient problem is more accurately described in the definition of this nursing diagnosis (every Nanda nursing diagnosis has a definition). Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLs (because that's what we nurses shine at). What I would suggest you do is to work the nursing process from step #1. The ADLs are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. And, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. Did you miss any of the signs and symptoms in the patient? If so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. But, you have to have those signs, symptoms and patient responses to back it all up. You need to know what alzheimer's is....what the symptoms are, what treatments are available...if any. Does this patient have any other comorbidities? So your patient, from what you tell me has... Impaired Verbal Communication NANDA-I definition: decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols Chronic Confusion NANDA-I definition: An irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior Impaired Memory NANDA-I definition: inability to remember or recall bits of information or behavioral skills Risk for Falls NANDA-I definition: increased susceptibility to falling that may cause physical harm Psychosocial Interventions Learn more about psychosocial interventions by reading it at Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards.
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Over 17,000 people sustain spinal cord injuries yearly in the United States. This severe and often life-changing condition happens when a sudden, traumatic event injures the tightly-packed bundle of neurons and nerves of the spinal column. Severe spinal injuries can cause spinal shock and may permanently change strength, sensation, and other bodily functions depending on the level of the damage. Proper nursing diagnosis and care plans are essential for providing quality patient care for those with spinal cord injuries. In addition, nursing care plans give patients and their caregivers the knowledge and resources necessary for navigating the changes to their physical, mental, and social abilities associated with spinal cord injuries. Table of Contents Diagnosis Causes Assessment At-Risk Populations Complications Treatments Nurse's Role Nursing Care Plans Ineffective Breathing Pattern Autonomic Dysreflexia Impaired Skin Integrity Impaired Physical Mobility Acute Pain Constipation Impaired Urinary Elimination Anticipatory Grieving Situational Low Self-Esteem Disturbed Sensory Perception Deficient Knowledge Self-Care Deficit More Diagnoses NCLEX Test Questions Readings and Resources Wrapping Up Diagnosis of Spinal Cord Injury The care of the patient varies depending on the timing of the injury. A patient with acute spinal cord injury needs immediate care focused on diagnosing the severity of the damage. Once the patient stabilizes, care must change to address the longevity of the condition, and the care team must focus on helping the patient live a full and long life. During the acute phase, determining the severity and level of the injury is of utmost importance to providing proper medical and nursing care. Determining the level of the injury drives acute care. The American Spinal Injury Association Impairment Scale categorizes the extent of a spinal cord injury. This tool compares motor and sensory function severity before and after injury. Healthcare providers use this scale and other diagnostic tools to determine the type and severity of the injury. Types of Spinal Cord Injuries Types of spinal injuries can be broken down in two ways, by the level of the damage and if the injury is complete or incomplete. Let's explore both of these categorizations. Level of Injury There are four types of spinal cord injuries based on the location of the impact: cervical, thoracic, lumbar, and sacral. Cervical injuries: Cervical spinal cord injuries are the most severe type of spinal cord injury because they affect a more extensive body area. This type of injury may result in paralysis of all four limbs, quadriplegia, or tetraplegia. Thoracic injuries: Thoracic spinal cord injuries can cause partial paralysis in the legs and arms. They may result in paraplegia or paralysis of the lower body below the injury site. Lumbar injuries: Lumbar spinal cord injuries may result in effects similar to thoracic spinal cord injuries, depending on where the injury occurred. Lumbosacral injuries: Lumbosacral spinal cord injuries may result in incomplete or complete paralysis of the upper and lower extremities. Complete vs. Incomplete The main differences between a complete and incomplete injury are seen in the type of remaining function the patient experiences. Complete injuries result in total paralysis below the injured spinal cord on both sides of the body. Incomplete injuries result in function remaining on one or both sides of the body because the body and brain can still communicate along intact pathways. Causes of Spinal Cord Injury Spinal cord injuries are usually the result of traumatic events. However, they may be related to long-term conditions too. Common causes include: Car accidents Falls Sports injuries Acts of violence Non-traumatic incidents or conditions Traumatic injuries can damage the spinal cord in one of three ways. First, the trauma may damage one or more physical structures, like the vertebrae, bones, ligaments, or discs. Another cause may be extreme pressure on the vertebrae, which can compress and damage the nerves within the cord. Finally, penetrating injuries, such as those seen with gunshots, can sever or severely damage the spinal cord. For nontraumatic incidents, patients can experience arthritis, degenerative disc disease, cancer, or infection in the CNS. In addition, a virus or injury can cause an immune response that causes a spinal cord injury. When this happens, the body's immune system attacks the nerve cells, causing neuroinflammation. Assessment The most common signs of spinal cord injury are paralysis, weakness, loss of feeling, and difficulty with movement. To assess these symptoms, healthcare professionals may ask questions about the person's medical history or do a physical exam to see how well they can move or feel different body parts. They may also examine how well the individual breathes and their responsiveness to external stimulation. The following tests may be run to check for damage to the spine. Magnetic resonance imaging, or MRI, creates 3D pictures of the body, including organs, tissues, bones, and nerves. It is a valuable tool for uncovering brain or spine trauma from an accident, observing herniated discs between vertebrae parts, and vascular issues such as bleeding and inflammation that can compress the spinal cord area. Computerized tomography (CT) scans are invaluable in diagnosing various medical conditions, providing clinicians with clear two-dimensional images of bones, organs, and tissues. X-rays provide comprehensive views of body parts, such as joints and organs. Within minutes, an X-ray can detect misalignments or fractures in the spine. At-Risk Populations Multiple populations have an increased risk of sustaining a spinal cord injury. Risk factors include the following: Motor vehicle accidents account for almost half of all spinal cord injuries, the vast majority from car accidents. People who drive often or engage in reckless behaviors while driving are at an increased risk of spinal injury. Falls account for about one-quarter of spinal cord injuries, and the risk increases with age. Individuals over 65 with chronic diseases that cause mobility limitations are at risk for a spinal cord injury due to falls. Violence or assaults account for about 15 percent of spinal cord injuries. Anyone engaging in potentially risky behaviors is at risk of sustaining a spinal cord injury. Athletes are likely to suffer from an incomplete traumatic spinal cord injury. Those that play contact sports, such as football and rugby, are especially at risk. Complications Since the spine plays a significant role in bodily functions, a spinal cord injury can lead to various health complications. It is the basis for nerve signals that control body movements and reflexes. If the spinal cord is damaged, it can interfere with coordination and muscle movements. The most common complications of a spinal cord injury include: Respiratory problems: If the spine gets damaged in the thoracic or cervical region, it can interfere with one's breathing ability and lead to complications such as pneumonia and atelectasis. Urinary tract infections: With a spinal cord injury, the bladder may lose its ability to empty completely, leading to urinary tract infections. The patient may also experience bladder spams that can be uncomfortable and cause incontinence. Muscle and joint pain: The muscles may weaken, leading to reduced muscle tone, contractures, and joint and muscle pain. While the patient may not fully feel their extremities, they may still feel sensations, pain, and discomfort. Autonomic dysreflexia occurs when the nervous system overreacts to specific triggers, increasing blood pressure, lowering pulse, and causing flushing and headaches. Stimulation as simple as a full bladder, constipation, a sunburn, or an ingrown toenail can be enough to trigger this response. Pressure sores: Patients with an absent or limited ability to change position may develop pressure sores due to the lack of sensation and decreased mobility. If not properly cared for, pressure sores can lead to mild or severe infections. Sexual dysfunction: Patients may experience erectile dysfunction or difficulty in achieving orgasm. This complication can be challenging for the patient to deal with psychologically. Increased risk of heart problems: Heart problems can onset other issues like an increased risk of stroke or heart attack due to decreased physical activity. Inability to control blood pressure: Patients experience fluctuations in blood pressure, experiencing both hypotension and hypertension, leading to potential health risks. Treatments Many treatments for spinal cord injuries exist. The goal of treatments after a spinal cord injury is to help the patient achieve the highest level of independence possible and minimize the risk of complications. Therefore, a multidisciplinary approach to care is essential to provide holistic treatment modalities. Examples of common treatments include the following: Surgery: If the injury is severe, surgery may be necessary to stabilize and reduce spinal deformity. Physical therapy: Physical therapists will work with individuals who have sustained a spinal cord injury to help them regain strength, balance, and coordination. Long-term physical therapy can help reduce pain and minimize the risk of contractures through splinting and other devices. Occupational therapy: Occupational therapists teach patients new ways of performing activities of daily living, such as dressing, bathing, and cooking. Medications: Medications may help manage pain, spasticity, and other complications of spinal cord injury. Assistive devices: Assistive devices can help with mobility and daily activities. Such devices may include wheelchairs, walkers, or scooters. Nurse's Role Caring for a Patient With Spinal Cord Injury A nursing diagnosis for spinal cord injury aims to do more than address medical needs. It focuses on the patient's overall well-being and seeks to improve the quality of life for the patient and their caregivers. Nurses assist with activities of daily living, manage pain, provide psychological support, and help the patient to adjust to their new life. As a nurse, you'll work as part of an interdisciplinary team to provide care. In addition, you'll play a significant role in educating the patient and their caregivers on self-care strategies so they can return home. Nursing Protocols for Spinal Cord Injury Nurses follow established protocols to assess and provide evidence-based spinal cord injury care. These protocols may include monitoring vital signs, assessing neurological status, providing skin care and pressure ulcer prevention, evaluating the patient's dietary needs, and providing emotional support. Nursing Care Plans Related to Spinal Cord Injury A nursing diagnosis for spinal cord injury is the basis for creating a personalized care plan for each patient. The plan's goals should focus on improving the quality of life and providing emotional and psychological support. The care plan must include individualized interventions to manage pain, improve mobility, promote wound healing, and prevent further complications. This section provides several care plans for spinal cord injury. Though these are not exhaustive, they can provide a starting point when developing individualized patient care plans. Risk for Ineffective Breathing Pattern Care Plan An ineffective breathing pattern for patients with spinal cord injuries may occur due to damage to the respiratory muscles that can lead to reduced oxygenation and ventilation. Respiratory failure causes alterations in normal respiratory functions such as rate, depth, timing, rhythm, and pattern. An inefficient breathing system hinders the body from supplying cells with vital oxygen. Changes in both abdominal and thoracic patterns can indicate imminent respiratory failure. Nursing Diagnosis: Risk for Ineffective Breathing Potentially Related to Partial or complete loss of intercostal muscle function Impairment of nerve innervation to the diaphragm (lesions at or above C-5) Gastric distension Reflexive abdominal spasms Evidenced By Bradypnea Dyspnea Nasal flaring Accessory muscle use Orthopnea Shortness of breath The abnormal or dysfunctional rhythm of breathing Desired Outcomes The patient will report more comfort in breathing. The patient demonstrates an adequate oxygen saturation level. The patient maintains a breathing pattern within normal limits, characterized by normal rate, depth, and rhythm. Risk for Ineffective Breathing Assessment Assess the patient's respiratory rate periodically. Auscultate lung sounds in all fields frequently. Monitor the patient's breathing pattern for apnea, ataxic, or Cheyne-Stokes respiration abnormalities. Assess for an effective cough to move secretions. Monitor for cyanosis or dusky skin tones. Observe for abdominal distension or muscle spasms. Monitor pulse oximetry and serial ABGs. Risk for Ineffective Breathing Nursing Interventions Encourage the patient to breathe slowly and deeply when experiencing dyspnea. Rationale: Helps to open the airways and reduce shortness of breath. Provide oxygen therapy as prescribed. Rationale: Helps to improve oxygen saturation levels. Educate on breathing exercises, such as pursed lip breathing, diaphragmatic breathing, and abdominal breathing, as indicated. Rationale: Slows the breathing down, eases effort, and increases oxygenation. Refer to respiratory and physical therapy as needed. Rationale: Specialized therapists can educate on exercises to strengthen muscles and the effort needed to mobilize secretions. Assist with positioning techniques that are comfortable for the patient and promote relaxation. Rationale: Allows for optimal air entry and expansion of all lung fields. Encourage the patient to cough and perform the "quad cough" as needed. Rationale: Mobilizes secretions so they can be suctioned. Suction as needed. Rationale: Removes secretions and improves oxygenation. Risk for Autonomic Dysreflexia Care Plan Autonomic dysreflexia is the result of the autonomic nervous system getting disrupted. The autonomic nervous system regulates involuntary functions such as breathing, heart rate, and digestion. Stimuli, such as a full bladder, can cause the body to be unable to regulate itself properly. Autonomic dysreflexia is a severe condition that can cause complications such as high blood pressure, stroke, and even death. Nurses must assess for signs of autonomic dysreflexia and administer treatment quickly. Swift actions can prevent stroke, seizures, or cardiac arrest. Nursing Diagnosis: Risk for Autonomic Dysreflexia Potentially Related to Distention of the bladder Urinary tract infection Pressure sores Fecal impaction Bladder spasms Constipation Digital stimulation Hemorrhoids Tight or lumpy clothing Ingrown toenails Evidenced By High blood pressure Bradycardia Redness or flushing above the level of the injury Pale skin below the level of the injury Headache Nasal Congestion Nausea Vomiting Blurred vision Feelings of anxiety or impending doom Desired Outcomes The patient reports no symptoms of autonomic dysreflexia. The patient will understand the triggers of autonomic dysreflexia. The patient will verbalize three preventative measures to prevent autonomic dysreflexia. The patient will verbalize three corrective measures. Risk for Autonomic Dysreflexia Assessment Assess for the presence of triggers of autonomic dysreflexia. Monitor for signs of autonomic dysreflexia, such as high blood pressure, rapid heart rate, redness of the face and neck, flushing, enlarged pupils, headache, or nasal congestion. Obtain blood pressure every 3-5 mins during an episode. Obtain a urine culture if a UTI is suspected. Risk for Autonomic Dysreflexia Nursing Interventions Provide education about the condition and triggers of autonomic dysreflexia. Rationale: Promotes self-care and prevention. Administer medications as indicated for high blood pressure, bradycardia, and other conditions. Rationale: Treats condition and minimizes complications Eliminate any known stimulus. Rationale: Helps to stop the episode. Stay with the patient during the episode. Rationale: Reduces complications, allows quick treatment, and helps calm the patient. Place the patient in a sitting position or raise the head of the bed as tolerated. Rationale: Reduces blood pressure and prevents seizures, stroke, and intracranial hemorrhage. Risk for Impaired Skin Integrity Care Plan The skin is a delicate yet important organ. It acts as a protective barrier that helps keep harmful substances and bacteria out. Unfortunately, spinal cord injuries cause limitations to mobility and impaired sensation, which can impact the integrity of the skin. Nursing Diagnosis: Risk for Impaired Skin Integrity Potentially Related to Paralysis Immobility Pressure on the skin Edema Poor circulation Altered metabolic state Evidenced By Pressure sore or ulcers Redness of the skin Pain or discomfort Warmth Color changes to the skin Desired Outcomes The patient will verbalize the risk factors of pressure ulcers. The patient will verbalize strategies to prevent pressure ulcers. The patient will understand the importance of proper skincare and how to prevent further damage. Risk for Impaired Skin Integrity Assessment Assess skin integrity of paralyzed areas regularly, noting redness, warmth, swelling, and discoloration. Monitor areas at risk of developing pressure ulcers more frequently, including the back of the head, skin folds, and bony prominences. Risk for Impaired Skin Integrity Interventions Provide education about proper skin care and prevention of pressure ulcers. Rationale: Promotes self-care and prevention. Turn the patient at least every two hours. Rationale: Reduces pressure and promotes circulation to affected areas. Use positioning devices, such as pillows or foam wedges, as indicated. Rationale: Relieves the pressure on bony regions and minimizes skin breakdown. Assist the patient in keeping the skin clean, dry, and moisturized. Rationale: Promotes skin health and reduces the risk of breakdown. Assess the skin routinely for signs of infection, redness, open areas, and warmth. Rationale: Provides an opportunity to address any skin issues quickly. Educate the patient on the importance of proper nutrition and hydration. Rationale: Keeps the skin hydrated and healthy, reducing the breakdown risk. Use specialized mattresses as indicated. Rationale: Reduces pressure points and minimizes the risk of skin breakdown. Impaired Physical Mobility Care Plan Physical mobility is essential for overall health and well-being, so addressing any limitations should be captured as part of a holistic nursing care plan. Being unable to move freely can take an emotional and psychological toll on a person. Spinal cord injuries can also cause health problems due to limited movements, such as blood clots or skin ulcers. Nursing Diagnosis: Impaired Physical Mobility Potentially Related to Impaired neuromuscular function Immobilization from splinting, traction, or recent surgery Evidenced By Unable to move Paralysis Decreased range of motion Contractures Atrophy of muscles Desired Outcomes The patient will maintain proper body alignment, evidenced by an absence of foot-drop or contractures. The patient will maintain strength within normal limits in all non-involved body parts or extremities. The patient will achieve an increased level of independence. Impaired Physical Mobility Assessment Assess the patient's motor function for appropriateness related to the level of injury. Assess the patient's skin integrity daily. Observe the patient's range of motion and ability to complete daily tasks independently. Assess for signs of pulmonary emboli, such as dyspnea or cyanosis. Assess for signs of peripheral blood clots, such as redness or warmth in the lower extremities. Impaired Physical Mobility Nursing Interventions Encourage patients to be as active and involved in their care as possible. Rationale: Promotes independence and positive mental health. Encourage the use of adaptive equipment as needed. Rationale: Promotes independence. Initiate referrals for physical and occupational therapy if needed. Rationale: Utilizes specialized therapists to promote physical movement and independence. Provide a method for the patient to signal when they need help. Rationale: Promotes independence while reducing fears about being unable to move or care for oneself alone. Assist with ROM and physical therapy exercises as needed. Rationale: Enhances circulation and prevents contractures and muscle atrophy. Apply splints and other positioning devices as indicated. Rationale: Maintains proper joint alignment and reduces the risk of contractures. Reposition the patient often. Rationale: Reduces the risk of pressure ulcers. Encourage respiratory health, such as deep breathing, suctioning, and coughing. Rationale: Reduces the risk of respiratory infection caused by immobility. Apply sequential compression devices or compression stockings as needed. Rationale: Reduces the risk of blood clots by improving leg vasomotor tone. Acute Pain Care Plan Acute pain is a common symptom of spinal cord injury related to tissue damage and trauma. Patients may experience pain at the spinal cord injury site, or it may be referred to other body parts. Depending on the nature of the trauma, the patient may have other injuries causing pain too. The healthcare team must provide as much pain relief as possible. Adequate relief depends upon a thorough physical assessment and using a validated pain tool if the patient is coherent and able to rate their pain. Including pain in the nursing care plan is crucial to overall care during the acute phase of a spinal cord injury. Nursing Diagnosis: Acute Pain Potentially Related to Trauma or physical injury Evidenced By Self-reporting of pain Increased heart rate and blood pressure Increased sensitivity to stimulation above the injury Reports of burning pain below the level of injury Muscle tension Muscle spasms Phantom pain Headaches Desired Outcomes The patient will report a decrease in pain intensity. The patient will demonstrate the ability to self-manage pain adequately. The patient will demonstrate relaxation and other non-drug strategies to manage pain. The patient will participate in activities of daily living with minimal pain interference. Acute Pain Assessment Assess the patient's level of pain using a 0-10 scale frequently. Observe the patient's behavior for signs of pain, such as increased muscle spasms, restlessness, irritability, or change in vital signs. Evaluate the patient's response to analgesics and non-pharmacologic pain relief strategies. Assess the patient's ability to function in activities of daily living. Acute Pain Nursing Interventions Encourage the patient to rest as needed. Rationale: Getting rest can help reduce the intensity of pain. Provide pain relief medications as needed. Rationale: Reduces pain levels. Provide education about proper body mechanics, splinting, and positioning to relieve pressure on affected areas. Rationale: Reduces pressure and maintains proper body alignment, thereby reducing pain. Implement non-pharmacological strategies, such as massage and warm/cold compresses. Rationale: Reduces pain levels without the use of medications. Educate the patient on relaxation techniques, such as meditation and deep breathing. Rationale: Promotes pain relief without the use of medications. Risk for Constipation Care Plan Constipation is a common complication of spinal cord injury, as it can lead to impaired motility and difficulty perceiving the need for a bowel movement. Slower than usual bowel motility can create the perfect condition for constipation and fecal impaction. Monitoring the patient's bowel patterns and managing any related symptoms is essential. Nurses also play an integral part in educating patients on preventing constipation with strategies like increasing fluids, fiber intake, and activity. Left untreated, constipation can worsen and cause other problems like nausea, vomiting, abdominal pain, or rectal bleeding. So, the nurse must continually assess and treat the signs and symptoms of constipation. Nursing Diagnosis: Risk for Constipation Potentially Related to Immobility and decreased physical activity Lack of nerve innervation to the bowel and rectum Perceived impairment Poor diets, such as inadequate fluid or fiber intake Evidenced By Fewer bowel movements than usual Difficulty in passing stool Abdominal cramps Nausea and vomiting Anorexia Inability to expel stool voluntarily Ileus Desired Outcomes The patient will have sufficient elimination without difficulty. The patient will participate in a bowel program. The patient will demonstrate proper bowel care techniques. The patient will report decreased pain and discomfort related to constipation. Risk for Constipation Assessment Assess for pain related to constipation. Record the frequency, amount, and consistency of bowel movements. Observe the patient's behavior and response to constipation. Assess for medications that may contribute to constipation. Auscultate the location and characteristics of bowel sounds. Assess for abdominal distension, especially in the presence of decreased or absent bowel sounds. Assess for nausea and vomiting. Assess for blood in vomit, gastric secretions, and stool. Monitor for the signs of impaction, such as the absence of stools for several days, semiliquid stools, abdominal distension, restlessness, or reports of abdominal pressure or pain. Risk for Constipation Nursing Interventions Create and administer a daily bowel program that may include stool softeners, prune juice, digital stimulation, or suppositories. Rationale: Assists with bowel evacuation when the patient can't perform voluntarily. Educate the patient on a high-fiber diet and increased fluid intake. Rationale: Improves the consistency of the stool and movement through the bowel. Encourage the patient to change positions as tolerated, including sitting up in a chair and increasing activity. Rationale: Help to move stool through the bowel. Insert an NG tube and attach it to suction, as necessary. Rationale: Reduces bowel distension and prevents nausea and vomiting. Insert a rectal tube as needed. Rationale: Reduces bowel distension. Administer medications, such as laxatives, stool softeners, and antacids, if indicated. Rationale: Alleviates symptoms of constipation and promotes defecation. Impaired Urinary Elimination Care Plan It's common for patients with spinal cord injury to experience impaired urinary elimination related to impaired nerve innervation. Common signs include urinary retention, incontinence, and urinary tract infections. It is crucial to assess the patient's bladder and kidney functions, monitor changes in urine output, and encourage preventive and management strategies to reduce the likelihood of infections and other complications. Nursing Diagnosis: Impaired Urinary Elimination Potentially Related to Bladder atony Disruption in nerve innervation to the bladder Evidenced By Bladder distension Incontinence or overflow Urinary retention Bladder or kidney stones Renal dysfunction Urinary tract infections Desired Outcomes The patient will participate in a daily bladder program. The patient will verbalize/demonstrate how to prevent urinary retention. The patient will verbalize/demonstrate how to prevent urinary tract infections. Impaired Urinary Elimination Assessment Assess for bladder distention. Observe for bladder overflow. Observe the signs of urinary tract infection, such as bloody or cloudy urine, foul odor, or sediment in the urine. Check the urine for the presence of bacteria. Assess the patient's urinary patterns, such as frequency and amount. Monitor urinary tract health laboratory values, such as BUN and creatinine. Assess residual urine amounts via postvoid ultrasound or catheterization. Impaired Urinary Elimination Nursing Interventions Implement bladder retraining techniques, such as fluid management, timed voiding, and bladder stretching exercises. Rationale: Improves urinary control. Encourage the patient to drink between 2 and 4 liters of fluid daily, if not contraindicated. Rationale: Promotes urine production and reduces the risk of a urinary tract infection. Provide urinary catheter care per protocols. Rationale: Reduces the risk of urinary tract infection. Teach the patient or family members how to perform intermittent catheterization as needed. Rationale: Promotes self-care and decreases the risk of urinary tract infection. Educate on the importance of increased mobility. Rationale: Reduces urine retention and improves bladder muscle strength. Anticipatory Grieving Care Plan Patients with spinal cord injuries may experience grief related to the significant changes in their life before and after the injury. Grief is a natural yet normal response to loss, and anticipatory grief is the process of mourning the losses associated with impending death or other sudden tragic life changes. These patients may experience extreme loss of function, changes in their professional and social life, and alterations in their relationships, just to name of few of the many possible changes. These changes can lead to feelings of loss, sadness, and grief. Nursing Diagnosis: Anticipatory Grieving Potentially Related to Loss of physical abilities Unfamiliar environment Fear of the unknown Forced changes in lifestyle due to spinal cord injury Impact on relationships Evidenced By Sadness Feelings of hopelessness Withdrawal from activities and social contacts Increased anxiety or fear Depression Anger Bereavement Changes in sleep patterns Desired Outcomes The patient will verbalize an understanding of anticipatory grief. The patient will demonstrate effective coping strategies to manage grief reactions. The patient will be able to express feelings openly. Anticipatory Grieving Assessment Assess the patient's knowledge and understanding of their spinal cord injury. Observe signs or symptoms of anticipatory grief, such as depression, anxiety, and sadness. Assess for signs of grieving (shock, denial, anger, depression) Anticipatory Grieving Interventions Provide a safe space for the patient to talk about their feelings. Rationale: Promotes self-expression of feelings. Educate the patient and family regarding anticipatory grief and the available resources to help cope. Rationale: Increases knowledge that this is considered normal and provides help. Refer the patient to a psychologist, psychiatrist, or other mental health professional, if needed. Rationale: Provides specialized mental health and grief counseling care. Administer anti-anxiety and antidepressants as prescribed. Rationale: Treats anxiety and depression. Situational Low Self-Esteem Care Plan Low self-esteem can be a common side effect of spinal cord injury related to the injury's substantial impact on their emotional, physical, and overall well-being. For example, they may face challenges like feeling reliant on others, struggling with the changes to their body and its ability to function independently, or how they perceive themselves as a person, in their relationships, and as a worker. Nurses are often the closest healthcare professionals to the patient because they spend much time with the patient providing care. This closeness you'll experience with the patient can provide cues as to their feelings about their situation and if their self-esteem is low. Therefore, it's crucial to be observant and to allow the patient to talk freely about their feelings. Nursing Diagnosis: Situational Low Self-Esteem Potentially Related to Loss of physical abilities Changes in appearance and physical function Needing help to perform activities of daily living Impact on relationships Evidenced By Reduced or negative self-talk Anxiety Lack of motivation Lack of resilience Focusing on their past abilities Feelings of hopelessness or helplessness Withdrawing from social interactions Verbalization of confusion about the purpose of their life Desired Outcomes The patient will verbalize an improved sense of self-worth. The patient will demonstrate positive and realistic thoughts about themselves. The patient will engage in activities that are meaningful and enjoyable. The patient will actively participate in therapy and other activities to boost self-esteem and morale. Situational Low Self-Esteem Assessment Assess the patient's knowledge and understanding of their spinal cord injury. Observe for any signs of low self-esteem, such as reduced or negative self-talk, lack of motivation, or avoidance of activities. Assess the patient's emotional state, including signs of anxiety or depression. Review any prior medical history, such as psychiatric diagnoses, previous mental health treatments, and use of medications for mental health. Actively listen to the patient's statements about their situation and feelings. Assess how the patient interacts with their family and close friends. Observe for inappropriate sexual comments or behaviors. Situational Low Self-Esteem Nursing Interventions Provide patient and family with education regarding low self-esteem and the available resources to help cope. Rationale: Promotes self-care and knowledge of the condition. Refer the patient and family to counseling or support groups as needed. Rationale: Establishes community support. Educate the patient and family on healthy expression and understanding. Rationale: Promotes self-care and realistic coping strategies. Provide accurate information about their prognosis, treatment, and chronicity of the condition. Rationale: Provides education and allows them to set realistic goals for the future. Talk with the patient about the changes in their relationships and roles. Rationale: Allows for an open, honest conversation with support. Find another person with a spinal cord injury willing to speak to the patient about coping with the changes. Rationale: Provides hope and gives them a role model for the future. Disturbed Sensory Perception Care Plan When the spinal cord injury is damaged, it disrupts the normal functioning of the nerves and sensory pathways. This damage may cause altered sensations like tingling and numbness. These alterations to their sensory function can make it challenging for patients to perceive changes to their body movement and positioning. Patients may fear falling out of bed or not realize when their arms or legs are in an unnatural position. This new sensory deficit status can take time to get accustomed to for many patients. Nurses can help by educating patients and providing extra support during routine care activities. Nursing Diagnosis: Disturbed Sensory Perception Potentially Related to Changes to sensory reception secondary to the spinal cord injury Evidenced By Changes in proprioception Changes to sensory acuity Uncoordinated motor movements Desired Outcomes The patient will demonstrate improved sensory perception. The patient will communicate an understanding of their environment, situation, and feelings of security. The patient will verbalize strategies to compensate for their sensory changes. Disturbed Sensory Perception Assessment Assess the patient's sensory function by asking when they feel touch, hot/cold, or pinprick sensations. Assess the patient's knowledge and understanding of their spinal cord injury. Observe for any signs or symptoms of disturbed sensory perception, such as confusion and disorientation. Assess the patient's current emotional state, including signs of anxiety or depression. Review any medical history, such as psychiatric diagnoses, previous mental health treatments, environment, and stimulation level. Ask the patient if they are experiencing any difficulties with sensory perception. Disturbed Sensory Perception Nursing Interventions Provide patient and family with education regarding disturbed sensory perception and the available resources to help cope. Rationale: Promotes self-care and provides support. Encourage the patient to engage in meaningful and enjoyable activities. Rationale: Provides normal activities and reality orientation. Incorporate relaxation techniques, such as deep breathing and meditation, into the care plan. Rationale: Promotes relaxation and reduces sensory overload. Protect from falls, burns, and improper positioning of extremities. Rationale: Provides safety measures the patient may be unable to provide themselves. Deficient Knowledge Care Plan Patients with a new spinal cord injury will likely not fully understand the condition, treatment, and prognosis. The complexity of a spinal cord injury can be challenging to grasp just following the initial trauma, as there may still be many unknowns. As the patient's condition stabilizes, they'll have to learn many new self-care treatments and require lots of education to perform their care independently. Nurses play a primary role in patient education. They will teach about the injury, prescribed treatments, and any new self-care activities the patient must perform. Nurses also play an essential role in teaching family members and other caregivers how to appropriately provide care for the patient when they return home. Nursing Diagnosis: Deficient Knowledge Potentially Related to Lack of access to information Cognitive deficits related to the injury New information Misinterpretation of information Evidenced By Expressing uncertainty or misconceptions Inability to answer questions related to injury/treatment Questions or requests for information Inappropriate behaviors, such as agitation or apathy Desired Outcomes The patient will demonstrate an understanding of information related to the injury and treatments. The patient will express increased comfort in discussing the injury/treatment. The patient will apply strategies to manage changes caused by the injury. Deficient Knowledge Assessment Assess the patient's understanding of their injury/treatment. Identify any gaps in knowledge or confusion the patient may have regarding the injury/treatment. Assess the patient's understanding of the mental and physical changes caused by the injury. Deficient Knowledge Nursing Interventions Educate the patient and family about the injury, treatment, and self-care needs. Rationale: Provides knowledge for self-care. Engage in self-directed and designed learning. Rationale: Empowers the patient to be an active participant in their care. Teach the patient self-care activities and use the teach-back method for activities such as positioning, splint application, or catheterization. Rationale: Provides knowledge for self-care and tests retention and understanding. Educate the patient on the importance of participating in daily exercises or therapies, such as physical therapy or occupational therapy. Rationale: Provides knowledge for self-care. Educate on the use, dose, and side effects of all medications. Rationale: Provides knowledge for self-care. Instruct on proper skin care routines, such as skin assessment, keeping skin clean and dry, and using specialized skin devices such as foam or silicone gel. Rationale: Provides knowledge for self-care. Provide a call system and other emergency assistance or e equipment as needed. Rationale: Promotes safety and provides access to emergency assistance when needed. Coordinate care with community-based providers and programs as needed. Rationale: Promotes self-care and acclimation back into the community. Educate the patient on the need to notify their electric company and other utilities if being without power causes significant health problems, as seen with ventilator support. Rationale: Provides access to emergency assistance. Self-Care Deficit Care Plan Self-care deficit happens when the patient cannot engage in activities of daily living, including bathing, grooming, dressing, and eating. This nursing problem occurs because of the impaired muscles and nerves from the spinal cord injury. Coping with a self-care deficit can be overwhelming and frustrating for the patient, especially if they were once independent, because now they may need to rely on others for a significant amount of care. While the self-care deficit is related to the physical nature of the injury, it's crucial to understand that there is a psychological component to this nursing diagnosis for the patient. Nurses, nursing aides, and therapists will provide hands-on care for patients with spinal cord injuries, but it's critical not to treat the patient as though they are a child. Patients should be given as much freedom to choose how and when care is provided so they continue to feel in control. Nursing Diagnosis: Self-Care Deficit Potentially Related to Physical limitations; immobility Paralysis Weakness of muscles Impaired or absent nerve transmission Evidenced By Inability to perform activities of daily living Verbal and nonverbal expressions of frustration or fatigue Physical limitations that interfere with self-care Desired Outcomes The patient will demonstrate how to safely perform self-care activities with or without using adaptive equipment. The patient will actively participate in determining what activities they need help with and what they can perform independently. The patient will verbalize all steps they must take to perform a self-care task safely and independently. Self-Care Deficit Assessment Assess the patient's current abilities to perform self-care activities. Identify any physical or cognitive limitations that may interfere with self-care. Assess the patient's current support system and their willingness and ability to help with personal care needs. Self-Care Deficit Nursing Interventions Educate the patient on strategies they can use to be as independent as possible during care activities. Rationale: Teaches new ways of tackling care activities that promote self-care and independence. Encourage the patient to perform self-care activities when possible. Rationale: Promotes independence. Give the patient as much time as needed to perform care themselves. Rationale: Promotes independence and provides time so they don't get frustrated or feel rushed. Encourage the patient to make decisions about their care. Rationale: Promotes independence and a strong sense of self. Ask for a referral to occupational therapy for a home assessment to make suggestions on modifications that can be made to allow the patient to remain independent in their care. Rationale: Promotes self-care and independence. Request a referral to home care services for personal care assistance. Rationale: Provides assistance and promotes safety. Encourage the patient and their family to understand their needs for independence and dependence. Rationale: Promotes self-care and promotes self-esteem. More Spinal Cord Injury Diagnoses The care plan for spinal cord injury can vary depending on the resulting damage and individual patient needs. Other nursing diagnoses to consider may include the following: Risk for Trauma Risk for infection related to compromised skin Grieving Constipation Risk for disuse syndrome Lack of caregiver knowledge Spinal Cord Injury NCLEX Test Questions If you're a student, it's never too early to practice taking NCLEX questions. The care of patients after spinal cord injury will likely be on your test, so practice with the below questions so you can be prepared for the big day! Q1: What is the most common cause of spinal cord injury? A1: The most common cause of spinal cord injuries is motor vehicle accidents. Other causes include falls, violence, and sports-related injuries. Q2: What are the signs and symptoms of spinal cord injury? A2: Signs and symptoms of spinal cord injuries may include loss of sensation or movement in affected areas, changes in skin color, pain or tingling sensations in hands and feet, difficulty breathing, weakness or lack of coordination, dizziness, and blurred vision. Q3: How is a spinal cord injury diagnosed? A3: Spinal cord injuries are typically diagnosed with imaging tests such as MRI, CT scan, and X-rays. Other diagnostic tests may include physical examinations, neurological tests, and laboratory tests. Q4: What is the treatment for spinal cord injury? A4: Treatment for spinal cord injuries depends on many factors, such as the location and severity of the injury, and may include surgery, medication, physical therapy, occupational therapy, and lifestyle modifications. Q5: What is the prognosis for someone with a spinal cord injury? A5: The prognosis for someone with a spinal cord injury depends on the location and severity of the injury. In some cases, some level of recovery is possible. However, in other cases, the damage may be permanent. Additional Readings and Resources Want more information about caring for patients with spinal cord injuries? Check out these posts on AllNurses: Care plan advice - Nursing Student Assistance Please check my priority of RN Dx??? - Nursing Student Assistance Paraplegia patient diagnoses help Spastic quadriplegia Wrapping Up Spinal Cord Injury Care Plans Spinal cord injuries require an extreme amount of physical and psychological care. The nurse may be busy performing high-acuity hands-on care during the acute phase. As the patient stabilizes, they'll need holistic psychological and social support. These spinal cord injury nursing diagnoses can help you create comprehensive care plans for your patients. References Spinal Cord Injury Facts and Figures at a Glance Classifications In Brief: American Spinal Injury Association (ASIA) Impairment Scale Cervical Injury Neurological and Functional Recovery After Thoracic Spinal Cord Injury Lumbar Spine Injuries in Sports: Review of the Literature and Current Treatment Recommendations Lumbosacral Spine Acute Bony Injuries Spinal Cord Injuries MRI Scans Computed Tomography (CT) Spinal Cord Injury Autonomic dysreflexia Cheyne Stokes Respirations Autonomic dysreflexia IASP Terminology Spinal Shock (Nursing) Spinal cord Injury
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According to a 2021 study, abdominal pain is the most common gastrointestinal symptom that brings patients to ambulatory clinics in the U.S. It's critical that nurses understand this condition's complexity to assess it thoroughly. Although abdominal pain can indicate a less critical condition like indigestion or constipation, it can signal something more serious—like an inflamed appendix. Appendicitis, which involves acute inflammation of the appendix, affects roughly 8.6% of men and 6.7% of women globally. Thus, healthcare professionals, like nurses and doctors, need to recognize and treat appendicitis appropriately by creating tailored care plans for each patient. This guide will assist you in developing a nursing diagnosis, care plan, and other relevant information for patients with appendicitis. Table of Contents Diagnoses Assessment At-Risk Populations Treatments Complications Caring for Appendicitis Protocols Acute Care Plan Risk for Infection Care Plan Risk for Deficient Fluid Care Plan Knowledge Deficit Care Plan Surgical Procedure Anxiety Care Plan Risk for Constipation Care Plan Activity Intolerance Care Plan Impaired Skin Integrity Care Plan Appendicitis NCLEX Questions More Readings Diagnosis of Appendicitis Appendicitis is a serious medical condition characterized by inflammation of the appendix – a narrow, finger-like pouch near the colon. Without immediate surgical removal of the appendix, it can rupture and lead to severe complications like an abscess or peritonitis. Nurses must understand the condition's pathophysiology to perform a though nursing assessment. Several symptoms of appendicitis must be identified to assist the provider in making an accurate diagnosis. These symptoms include: Periumbilical pain that travels to the lower-right quadrant of the abdomen Severe pain in the right lower quadrant of the abdomen upon palpation (known as McBurney's point) Fever Malaise Constipation or diarrhea Abdominal bloating Urinary frequency or urgency Nausea and vomiting Fecaliths - hardening of feces in varying sizes seen on X-ray Feelings of urgency and frequency of the need to urinate Flatulence Loss of appetite As symptoms progress, patients may experience the following: Distention in the abdomen Rigid abdomen Increased pain with movement or coughing Pain exacerbated by palpitation Abdominal rebound When a patient presents to an acute care setting with abdominal pain, it is critical to diagnose appendicitis quickly to ensure patient safety. Delay in diagnosis can increase the risk of appendix rupture, which occurs in about 2% of cases within 36 hours and rises by 5% every 12 hours if symptoms are left untreated. In cases where a diagnosis is inconclusive based on physical examination and symptoms, a healthcare provider may order imaging tests to identify signs of inflammation of the appendix or fecaliths that could indicate appendicitis. Assessment In almost all cases, appendicitis requires prompt medical attention and surgical intervention. A thorough nursing assessment is critical in identifying signs of appendicitis and getting prompt treatment when a patient presents with abdominal pain. A nursing assessment should include the following: Physical Exam and History: Perform a thorough head-to-toe assessment and obtain a history from the patient about their symptoms. The nursing assessment should include assessing for the following: Loss of appetite Nausea/vomiting Characteristics of the abdominal pain, including signs of abdominal distention, rebound tenderness, periumbilical pain, and McBurney's point pain Fever Chills Constipation or diarrhea Difficulty passing gas Reports of generalized malaise Reports of urinary urgency or frequency Risk factors such as age between 10 and 30 and a family history of appendicitis Related: RN Case Manager: Job Description, Salary, and How to Become One Determine Vital Abnormalities: Check for common vital abnormalities associated with appendicitis, such as tachycardia, diaphoresis, and fever. Listen for unusual bowel sounds. Assess Pain: Determine the location of the patient's pain, note its significant characteristics, determine its severity, and track it over time. Increasing pain may suggest appendicitis and the need for surgery. Conduct Blood Test and Urinalysis: Look for an elevated white blood cell count and any other abnormal lab values. Labs can also be used to rule out the presence of kidney stones or a urinary tract infection. However, it's important to note that pyuria, hematuria, and proteinuria are common in appendicitis. Imaging: Imaging may reveal abdominal inflammation and fecaliths, both signs of appendicitis. Common imaging used to diagnose appendicitis include: X-rays to rule out other reasons for the abdominal pain Ultrasound to evaluate the right lower quadrant pain Barium enema to evaluate changes or abnormalities of the colon CT scan or MRI (depending on the patient's other conditions) to inspect the size and other characteristics of the appendix At-Risk Populations Appendicitis can affect people of all ages, but some populations and subgroups are more susceptible to the condition than others. Consider the list of at-risk populations below when conducting your nursing assessment: Pediatric patients as young as ten and young adults patients up to 30 Patients with cystic fibrosis Patients with periumbilical injuries Patients with pre-existing inflammatory bowel disease and digestive tract infections Post-op patients with surgical incisions near the appendix Although this list represents the most at-risk populations, anyone can experience appendicitis, so each patient presenting with acute or chronic onset of abdominal pain should be assessed thoroughly. Treatments There are various medical treatments available for appendicitis, including: Appendectomy: This is the surgical removal of the appendix and is the most common course of treatment. There are two types of appendectomies: Open appendectomy (Laparotomy): This is an open surgery where the surgeon creates an incision of 5-10 centimeters to remove the appendix and clean the area. Laparoscopic appendectomy: This minimally invasive surgery uses several small incisions on the abdomen and a video camera to remove the appendix. Abscess Drainage: If the appendix ruptures, the doctor may need to drain the abdomen before surgery. This procedure typically takes two weeks and involves antibiotic therapy. Complications Appendicitis carries a primary risk of rupture, with 2% of patients experiencing it within 36 hours if symptoms are left untreated. The risk of rupture significantly increases after that, making it necessary for the patient to receive an appendectomy as soon as possible. The most common complications of appendicitis are: Perforation of the appendix Peritonitis Abdominal Abscess Death While not having an appendectomy will cause complications, it's critical to note that the surgery does come with minor risks. The most common complications of appendectomy include: Wound infection Bleeding Peritonitis, if the appendix ruptures during surgery Injury to other abdominal organs Ileus Nurse's Role Caring for Appendicitis Whether the nurse encounters a patient with appendicitis in an urgent care setting, emergency department, or medical surgical nursing unit, they are crucial to the patient's care. They play a vital role in ensuring patient comfort and safety while maintaining treatment efficacy across all phases of the condition. In the diagnosis process, nurses provide assessments, help diagnose the condition, and provide relief from pain. During treatment, they manage and treat complications and co-occurring disorders while delivering post-operative care. Nurses also work to minimize the risk of complications from appendicitis and appendectomy by carefully managing care plans. Nursing Protocols for Appendicitis The care provided by nurses to patients with appendicitis is crucial. During the preoperative phase, nurses are responsible for ensuring that patients maintain NPO status, receive fluids to address dehydration, and monitor them for any changes in pain or signs of rupture of the appendix. They also help to position the patient comfortably in a right-side-lying position and monitor bowel sounds. Additionally, nurses may administer pain medications and non-pharmacologic pain interventions such as relaxation, positioning, and meditation modalities. Antibiotics may be prescribed and administered orally or through an IV to address the infection. After the appendectomy, nurses continue to monitor the patient's condition closely. They regularly check the patient's temperature to detect any signs of rupture or infection, access and clean the abdominal incision, manage the patient's diet, and monitor the color, amount, and other characteristics of drainage at the surgical site. Nursing Care Plans Related to Appendicitis It's crucial to create nursing care plans that guide the care of the nursing team. It's important to note that the below list is not all-encompassing. Care plans must be individualized to each patient's unique needs. Here are some of the most common nursing care plans with nursing interventions for patients with appendicitis. Acute Pain Care Plan Acute pain is a common symptom experienced by patients with appendicitis. This pain typically originates in the periumbilical area and then spreads to the lower-right quadrant of the abdomen. Potentially Related to: Bloating Inflammation Infection Ruptured appendix Evidenced By: Complaints of abdominal pain Non-verbal demonstration of pain such, as movement, crying, or moaning Diaphoresis Abdominal rebound pain Desired Outcomes: The patient will report no pain upon discharge. The patient will display nonverbal signs of comfort. The patient will verbalize understanding of their prescribed treatments and pharmacologic regimens to control pain. Acute Pain Assessment Follow these steps to complete an assessment for acute pain. Assess the Pain: Begin by assessing the pain in the abdomen. Ask the patient to rate the pain on the 0/10 scale and obtain a thorough history of onset, duration, and characteristics of the pain. Assess Non-Verbal Signs: Look for non-verbal signs of pain such as moaning, grimacing, or guarding. Patients may also appear to be in more discomfort with moving. Palpate the Abdomen: The patient will report tenderness and pain when you palpate the abdomen. During the assessment, they may report rebound tenderness upon removing pressure to the right lower quadrant of the abdomen. The abdomen may appear rigid and distended upon observation. Related: Wound Care Nurse: Job Description, Salary, and How to Become One Acute Pain Interventions The most common intervention for acute pain are: Administration of Analgesics: Pain medication, such as opioids or acetaminophen, may help control pain. NSAIDs can help reduce inflammation and mitigate pain. Make the Patient Comfortable: Many patients find lying on their right side or in a semi-fowler position increases comfort. To mitigate pain, offer other non-pharmacologic comfort interventions, such as warm blankets or ice packs. Offer Distractions: Many patients experience anxiety with severe pain. Offer distractions, such as meditation, relaxation techniques, and a quiet and dimly lit room to ease any anxieties and increase comfort. Maintain NPO: Prevent the patient from eating or drinking to reduce discomfort and risk during surgery. Instruct on Discharge Medications: Some patients may require pain medication at discharge. Ensure the patient understands the risks and instructions associated with the drugs including when to take it, how to taper off the drug, and signs of complications that should be reported to their physician. Risk for Infection Care Plan Infection is a common complication of appendicitis. It can also happen after surgical intervention and may present as a wound infection. As a result, one of the most crucial responsibilities of nursing staff is to assess for any signs of infection. Use the following care plan to help prevent infections in your appendicitis patients: Potentially Related to: Appendix rupture Post-operative infections in surgical incisions Abscess formation Evidenced By: While tenderness, fever, and inflammation indicate the presence of infection, this care plan is designed to prevent infection and minimize its associated risk. Desired Outcomes: The patient's vital signs and white blood count are within normal range. The surgical incision is free of signs of infection, such as drainage, redness, and warmth. The patient verbalizes understanding of post-hospital antibiotic regimen. Risk for Infection Assessment Follow the steps to assess for risk of infection: Evaluate Lab Work: Begin by checking for high WBC and CRP levels, which are common in appendicitis patients. If the appendix has ruptured, levels will increase. Request Imaging: You can request a CT scan and other imaging modalities to determine if the patient has appendicitis. An ultrasound may also be performed to determine free-flowing abdominal fluid in the event of a rupture. Check Vital Signs: Signs of an infection may include tachycardia, fever, and hypotension. If infection is left untreated, it can spread throughout the body, causing sepsis. Risk for Infection Interventions The following interventions are best for preventing infection: Handwashing: Handwashing is the best preventive measure against infection in healthcare. Wash hands carefully whenever handling the patient or performing tasks. Administer Antibiotics: The patient may receive antibiotics orally or prophylactically before surgery. You may also treat rupture with IV antibiotics. Perform Decolonization: Perform decolonization by carefully washing the skin with antiseptic soap, such as chlorhexidine, and removing any body hair. This procedure helps to decrease the risk of infection. Instruct on Surgical Care: Before the patient is discharged home, they'll need thorough instructions on wound care, including how to clean the skin and when to change the dressing. You must also educate on the signs of infection to watch for and when to report any abnormalities to the physician. Risk for Deficient Fluid Volume Care Plan Use the following care plan to address the risk of deficient fluid volume in patients with appendicitis. This condition can cause a lack of appetite and dehydration in patients. Potentially Related to: Loss of appetite NPO status Diarrhea and vomiting NPO status Fever Healing process Inflammation in the abdomen with the build-up of fluid Evidenced By: Although patients may exhibit traditional signs of dehydration, including fatigue and discoloration of urine, this plan aims to prevent the risk of dehydration before symptoms develop. Desired Outcomes: The patient will demonstrate a fluid balance within normal limits, including stable vital signs, adequate urine output, and signs of normal skin hydration, such as moist mucus membranes and normal skin turgor throughout treatment. The patient is free of vomiting or diarrhea upon discharge. Risk for Deficient Fluid Volume Assessment Use the following steps to assess the risk of deficient fluid volume: Assess Skin Turgor and Mucous Membranes: Dry membranes and abnormal skin turgor may indicate dehydration. Check Lab Values: Dehydration can manifest as an electrolyte imbalance, so check labs frequently and track them over time to assess for trends. Monitor Fluid Intake to Urinary Output: Compare fluid intake and urinary output each shift. Look for other urinary signs of dehydration, such as dark or concentrated urine with increased specific gravity. Assess intestinal activity by auscultating bowel sounds: Ensure bowel sounds are active before beginning oral intake. Risk for Deficient Fluid Volume Interventions Deploy the following interventions for deficient fluid intake: Administer IV Fluids with electrolytes as prescribed: IV fluids are the best way to replace lost fluids. Additionally, if the patient is pre-op with NPO status, they won't be able to drink water. Offer clear liquids as prescribed post-op and advance diet as tolerated: Once bowel sounds are active, clear liquids should be offered, and the diet should be advanced as tolerated to achieve and maintain normal fluid balance. Administer Antiemetics: Because vomiting is a common side effect of appendicitis, you can treat it with antiemetics to prevent nausea and promote fluid retention. Provide oral care: Mucus membranes dry quickly if the patient is unable to take fluids orally. Apply a moisturizer to the lips and offer mouth swabs to keep the oral cavity moist. Knowledge Deficit Care Plan Most patients won't fully understand the surgical and medical interventions necessary to treat appendicitis. Use the following care plan to address the potential knowledge deficiencies. This plan aims to educate patients on the signs and symptoms of appendicitis, post-operative care, and other relevant information related to their condition. Potentially Related to: Lack of exposure to a friend or family member who has had appendicitis in the past Misinformation or misinterpretation of information Unfamiliarity with informational resources Inability to understand the information presented Evidenced By: Verbalization of concerns Questions and requests for information Suspicion of the treatment plan Statements of misconception Inaccurate follow-through of instructions Desired Outcomes: The patient will participate in the treatment regimen according to the instructions. The patent will verbalize understanding and ask any questions they have before discharge. The patient will self-advocate throughout the process. The patient will verbalize when to contact the physician or other care provider with ongoing questions after discharge. Related: Nurse Educator: Job Description, Salary, and How to Become One Knowledge Deficient Assessment Follow these steps to conduct an assessment of possible knowledge deficiency: Inquire: Ask the patient to explain their degree of familiarity with the condition and request any information needed. Assess Non-Verbal Cues: Determine the presence of confusion by assessing body language and facial expressions. Knowledge Deficit Interventions Conduct the following interventions to address knowledge deficiency: Explain Procedures: Take the time to explain each treatment step to the patient. Review Post-Operative Instructions: Ensure patients understand their pharmacological regimen and post-op instructions. Encourage Questions: Encourage the patient to ask for clarification when confused. Use the Teach-Back Method: Use the teach-back method by asking the patient to answer a few questions about the information you provide them about their condition. This ensures they comprehend the information you teach them about appendicitis, appendectomy, medications, and other prescribed treatments. Anxiety Related to Surgical Procedure Care Plan Many patients experience anxiety related to impending surgical procedures for acute appendicitis. With the following care plan, you can mitigate the patient's concern and, in doing so, minimize the risk potential. Potentially Related to: Impending surgical procedure Deficient knowledge Fear of hospitalization, healthcare providers, or other aspects of the visit Pain Evidenced By: Rapid heart rate, tachycardia Excessive sweating Verbalization of fear Crying or non-verbal expressions of fear Desired Outcomes: The patient will freely discuss fears and concerns throughout the process. The patient will display regular vital signs. The patient will experience no anxiety by discharge. Anxiety Related to Surgical Procedure Assessment Follow the steps below to assess stress related to surgical procedures: Request Verbal Confirmation: Ask the patient to share their fears with you and rate their anxiety on a 0-10 scale. Observe Non-Verbal Signals: Pay attention to the patient's speech patterns and other physiological symptoms of anxiety, such as fidgeting or crying. Conduct Head-to-Assessment: Note any physical signs of anxiety, such as heart palpitations or high blood pressure. Assess Vital Signs: Determine the presence of tachycardia or tachypnea in patients with anxiety. Conduct a Thorough Medical History: Ask the patient about underlying mental health conditions, such as anxiety or depression. Anxiety Related to Surgical Procedure Interventions Offer the following interventions to prevent stress related to surgical procedures: Acknowledge the Presence of Anxiety: Begin by addressing and validating the patient's feelings. Administer Medication as Appropriate: You may be able to administer anti-anxiety medication to help the patient manage their anxiety if prescribed. Provide Active Listening and Distractions: Depending on the patient's needs, provide active listening and distract them throughout the procedure. Offer Soothing Coping Mechanisms: Help patients manage anxiety by guiding them through healthy coping mechanisms such as mindfulness and visualization. Allow Family or Friends to Stay with the Patient if Possible: Having a solid support system can help the patient feel safe. Allow loved ones to stay with the patient as much as possible. Request Consults from Mental Healthcare Providers as Needed: If the patient's anxiety isn't reduced by other modalities, consider requesting a consult from a mental healthcare provider who can order treatments as necessary. Risk for Constipation Care Plan Patients diagnosed with appendicitis are at a greater risk of experiencing constipation. Use the following care plan to prevent constipation and mitigate the risks linked to infrequent bowel movements. Potentially Related to: Insufficient fluid intake Irregular eating patterns Abdominal sensitivity Medications like NSAIDs and antibiotics Reduced postoperative intestinal motility Evidenced By: Although constipation presents as few bowel movements and hard, dry stools, this care plan aims to prevent constipation before it occurs. Desired Outcomes: The patient will have regular bowel movements by discharge. The patient will understand the treatment plan and post-operative care for constipation symptoms. Risk for Constipation Assessment To assess the risk of constipation, follow the steps below: Assess Abdominal Pain: Although the patient is likely in pain, you can ask for the location, duration, and severity of pain to determine if it is due to constipation. Ask About Bowel Habits: Ask the patient about their bowel movements, including frequency, consistency, and effort to pass stool. Assess Stool Characteristics: If the patient has a bowel movement, be sure to assess the color, consistency, and amount of stool and document it in the chart. Risk for Constipation Interventions The following interventions help reduce the symptoms of constipation: Treat Pain and Discomfort: Treat the patient's pain with pain medication if necessary. However, remember that many pain medications can further cause constipation, so assess the risk of constipation before administering pain medications. Administer Stool Softeners: Provide laxatives or softeners to help the patient pass stools. Increase Hydration: Use IV hydration or ask the patient to drink more water if appropriate. Prescribe High-Fiber Diet: Once the patient is cleared, you can prescribe a high-fiber diet to aid constipation. Increase Activity: Have the patient sit up in a chair or take a walk once able to aid in intestinal motility. Activity Intolerance Care plan Activity intolerance could arise from fatigue, pain, or anxiety associated with appendicitis treatment. To treat activity intolerance, consider the following care plan. Potentially Related to: Abdominal pain Constipation Dehydration Post-op fatigue General malaise Evidenced By: Expressed desire to remain immobile Reports of weakness or fatigue Altered physiological response to movement Inability to perform specific movements Changes in vital signs with movement Desired Outcomes: The patient will return to regular activities as normal following discharge. The patient will display improvement in movement intolerance by discharge. The patient will take one walk per shift around the unit while hospitalized without signs of pain or discomfort. Related: Best Registered Nurse (RN) Jobs and Salaries in 2023 Activity Intolerance Assessment Use the following steps to conduct an activity intolerance assessment: Consult the Patient: Ask the patient to report any instances of activity intolerance. Monitor Vital Signs: Take the patient's resting pulse, blood pressure, and respiratory data. Monitor throughout and after movement or activity. Determine Level of Activity Intolerance: Track the patient's progress across different activities, determine the level of intolerance, and ask the patient to investigate the perceived causes. Assess Hydration and Nutritional Status: Determine the patient's hydration levels to rule out dehydration. Activity Intolerance Interventions Follow these steps to provide interventions for activity intolerance: Establish Goals of Activity with the Patient: Work with the patient to set activity goals each shift. Increase Fluid Intake: Provide IV fluids or urge the patient to drink water if applicable. Provide Emotional Support: Encourage the patient as they attempt movement or activity. Gradually Increase Activity: Set realistic but progressively larger activity goals. Provide Support: Offer support such as a bedside commode or assistance with ADLs until the patient can safely perform activities alone. Impaired Skin Integrity Care Plan In the course of or after treatment for appendicitis, the patient might encounter skin damage caused by surgical incision or excessive fluid accumulation in the abdomen. Follow this care plan to tackle impaired skin integrity. Potentially Related to: Appendix perforation Surgical incision Fluid excess in the abdomen Inflammation Evidenced By: Tissue damage Surgical incision Changes in the appearance of the affected area Desired Outcomes: The patient will maintain intact tissue integrity following discharge. The patient will understand post-op care for the surgical incision. The patient will experience reduced pain or no pain by discharge. Impaired Skin Integrity Assessment To conduct a deficient skin integrity assessment, follow the steps below: Perform a Skin Assessment: Perform regular skin checks to determine changes in skin integrity over time. If the patient isn't as active as usual, be sure to check for signs of skin breakdown and assess the surgical site. Assess the Affected Area: Check the surgical site at least every shift and more frequently according to protocols or if the patient has an increase in pain, drainage, or other concerning signs. Assess the length of the incision and ensure the edges are well-approximated. Look for redness, swelling, and drainage. Document the skin assessment per the hospital protocol. Monitor Metrics such as WBCs, albumin, prealbumin, and total protein to determine complications in healing. You can also monitor body temperature for signs of infection. Impaired Skin Interventions To improve impaired skin integrity, the following steps can be taken: Change dressings frequently and as per the recommended protocol. Educate the patient on proper wound care and post-operative care, including when and how to change the dressing and what types of changes to report to the physician. Administer fluids to help with a speedy recovery. Monitor the patient's intake to ensure they are eating a healthy diet to promote healing. Teach the patient to turn and reposition at least every two hours. If they are unable to do this on their own, provide assistance. Assist the patient to get out of bed to promote circulation and healing. More Appendicitis Diagnoses The following diagnoses may also co-occur with appendicitis: Anorexia Fecaliths Fever Lethargy and fatigue Resistance to treatment Agitation Appendicitis NCLEX Test Questions If you plan to take the NCLEX test anytime soon, you might need sample test questions related to appendicitis. Consider the following. Which of the following complications of appendicitis might happen if the patient doesn't seek treatment within 24-36 hours of symptom onset? Constipation Perforation Peritonitis Seizure A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location. Left lower quadrant Left upper quadrant Right upper quadrant Right lower quadrant A patient presents with a suspected appendicitis. What clinical manifestations do you expect the patient to have? High fever Rebound tenderness Nausea and vomiting Pain relieved by lying on either side Additional Readings and Resources Looking for more information about caring for patients with appendicitis? Check out the allnurses resources below: For further information on appendicitis, refer to the following resources: Appendicitis Guide Ruptured Appendix Guide For additional information on care plans and the NCLEX exam, consult: An NCLEX Study Guide A Guide to Care Plans
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Table of Contents Diagnosis At-Risk Populations Complications Treatments Nurse's Role Nursing Care Plans Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing Pattern Risk for Infection Risk for Imbalanced Nutrition Potentially Related to Acute Pain Decreased Activity Tolerance Deficient Knowledge Anxiety More Pneumonia Diagnosis NCLEX Readings and Resources Wrapping Up Citations This respiratory infection can vary in severity, ranging from mild to severe, and can worsen over time and even become life-threatening if not treated. Specific populations, such as older adults, those with chronic lung conditions, or young children, are more vulnerable to the infection and often experience the most severe consequences of the disease. Many people with pneumonia require acute treatment with antibiotics and other modalities, and some even require emergency room visits or hospitalization. The CDC reports that 1.5 million Americans needed emergent care for pneumonia in 2020 and that pneumonia accounted for more than 41,000 deaths in 2021 alone. This article provides general nursing diagnoses and care plans for patients with pneumonia you can use to create patient-centered nursing care plans for those you care for during nursing school and beyond. Diagnosis Healthcare providers use the presence of specific symptoms to confirm the diagnosis of pneumonia. For example, the physician may perform a physical exam, including auscultating lung sounds, and review the patient's medical history. If pneumonia is suspected, the healthcare provider may order the following tests: Chest x-ray - visualizes the location and severity of the pneumonia Blood tests - looks for increased WBCs and other indicators of infection and cultures to determine the pathogen causing the pneumonia Sputum test - determines the cause of the infection Pulse oximetry - measures the blood's oxygen level CT scan - to obtain detailed images of the lungs, common in hard-to-treat or worsening pneumonia Pleural fluid culture - analyzes fluid from the lungs to determine the cause of the infection in hard-to-treat or worsening pneumonia Diagnosing pneumonia in patients with atypical symptoms, such as children, is challenging. Pediatric patients don't have the respiratory drive of adults, so it's crucial to observe the patient closely and start treatments quickly before the situation becomes life-threatening. Types of Pneumonia There are a few different ways to classify pneumonia. Classifications are done by determining where the patient acquired the disease and by the organism that caused it. First, pneumonia may be classified by where the patient acquired the condition. The two classifications include: Hospital-acquired pneumonia happens in patients who have recently stayed in a hospital or healthcare setting. These patients may experience complications because the microorganism causing the infection may resist antibiotics. Patients at increased risk include patients who: Require oxygen support Have difficulty coughing and deep breathing to remove mucus from their lungs Have a tracheostomy Have a weakened immune system. Community-Acquired Pneumonia captures pneumonia outside of the hospital or healthcare setting. People with chronic lung conditions are at an increased risk of acquiring this condition. The second way to classify pneumonia is based on the organism causing it. This includes: Bacterial Pneumonia is the most common type of community-acquired pneumonia in adults. Streptococcus pneumoniae is the most common cause of bacterial pneumonia. Viral Pneumonia is the second most common type. The following viruses commonly cause viral pneumonia: Respiratory syncytial virus (RSV) (common in children under the age of five) Influenza virus Parainfluenza virus Adenovirus Fungal Pneumonia is the least common cause of pneumonia but can lead to a severe illness if left untreated. This type of pneumonia is most common in vulnerable populations, such as those with an organ transplant, undergoing chemotherapy, or taking medications used to treat autoimmune conditions. Symptoms of Pneumonia Nurses must be aware of the most common signs and symptoms of pneumonia. Hospitalized patients and those at high risk for contracting the condition should be monitored closely. Report new or worsening signs to the healthcare provider for further assessment and treatment. Some of the most common symptoms of pneumonia include the following: Fever, shaking, and chills Wet cough that produces yellow, green, or bloody mucus Pleuritic chest pain that may worsen with deep breathing or coughing Dyspnea Fatigue and general malaise Lack of appetite Shallow breathing in young adults, children, and babies Nasal flaring and accessory muscle use in young children Nausea and vomiting in young children Confusion in older adults Low body temperature in adults over 65 and those with chronic lung conditions At-Risk Populations Some individuals are at a higher risk of contracting pneumonia. We'll review each group below. Older Adults As we age, our immunity decreases, increasing our risk of infections like pneumonia. In addition, many older people also have comorbidities, such as COPD, asthma, or heart disease, that compound their risk further. Older adults may also be less likely to engage in physical activity, which can help clear their lungs and reduce the risk of pneumonia and other lung infections. Young Children Some children may be at an increased risk of developing pneumonia because of other health conditions, such as: Chronic lung conditions, like cystic fibrosis or asthma Diseases causing the patient to be immunocompromised, such as cancer Structural or genetic problems within the respiratory system A child's environment can also place them at an increased risk. This includes: Children who are underfed or lack the essential vitamins, nutrients, and minerals to help them fight infections Children exposed to secondhand smoke Children exposed to mold, water damage, or indoor air pollution People with Comorbid Conditions Adults with specific comorbid conditions are at an increased risk of developing pneumonia. People at increased risk include those with the following: COPD increases the risk of pneumonia 16 times in the first year after the diagnosis Chronic heart disease increases the risk of developing pneumonia by more than three times Diabetes causes hyperglycemia, which in turn places the patient at a higher risk of pneumonia Complications Unfortunately, sometimes pneumonia worsens, even when treated. It can cause severe dyspnea and breathing difficulties in the patient that can become life-threatening and lead to long-term complications or even death. Common complications of pneumonia include: Pleural effusion Lung abscess Bacteremia Treatments The healthcare provider will order treatments to cure the infection, reduce symptoms and discomfort, and prevent potential complications. Common treatments include: Antibiotics to treat bacterial infections Antifungals to treat fungal infections Cough suppressants and expectorants to loosen mucus and help expectorate it from the lungs Fever reducers to lower body temperature and associated discomfort Oxygen therapy for comfort and to increase blood oxygen Diet rich in vitamins and minerals Rest to allow the body to fight the infection Patients with severe pneumonia may require hospitalization. Although this is less common, it may be necessary for those immunocompromised patients due to chronic health conditions, age, and other factors. It is also essential for patients whose symptoms have worsened dramatically, such as those with very shallow breathing, who require mechanical ventilation, or who have bradycardia. Nurse's Role Caring for a Patient With Pneumonia Nurses play a crucial role in caring for a patient with pneumonia and performing routine assessments to monitor for new or worsening symptoms. A comprehensive nursing assessment includes auscultating lung sounds, assessing blood oxygen levels and respiratory effort, and assessing for fever. Nurses also administer treatments as ordered by the physician, including antibiotics, IV fluids, antipyretics, breathing treatments, and oxygen therapy. Education is another critical task nurses perform when caring for patients with pneumonia. Patients must understand self-care, including how and when to take antibiotics, how to use home oxygen, and when to call the healthcare provider or seek emergency medical treatment. Nursing Protocols for Pneumonia In-depth respiratory assessment to auscultate lung sounds, monitor respiratory effort, including respiratory rate and depth, assess for purulent sputum and use of accessory muscles during breathing Head-to-assessment to watch for fever, tachycardia, bradycardia, pleuritic chest pain, and other physical symptoms Risk Assessment to identify at-risk populations such as seniors and children Nursing Care Plans Related to Pneumonia A well-written nursing care plan establishes essential assessments, interventions, and patient outcomes. Below, you will find pneumonia nursing care plans you can use as a basis for patients in your care. This list of nursing care plans is not exhaustive, and, of course, all nursing care plans must be individualized to the patient's specific care needs. Nursing Care Plan: Impaired Gas Exchange Impaired gas exchange occurs when the exchange of oxygen and carbon dioxide across the alveolar-capillary barrier is impaired. Certain conditions, such as pneumonia, can cause changes in lung function and alveolar collapse, negatively affecting ventilation. In addition, impaired gas exchange can lead to hypoxemia, fluid shifting into interstitial spaces, and pulmonary edema. Potentially Related To Impaired gas exchange may be related to the following factors: Fluid-filled alveoli Excess mucus in the airways Inflammation of the alveoli and other airway structures Hypoventilation Changes in the alveolar-capillary membrane Disruption to the oxygen-carrying capacity of the blood Evidenced By The most common symptoms of impaired gas exchange include: Tachypnea and dyspnea Cyanosis Dusky and pale skin color Tachycardia Restlessness Changes in the level of consciousness Hypotension Hypoxemia Confusion Desired Outcomes Possible desired outcomes for an impaired gas exchange nursing diagnosis include: The patient will maintain gas exchange within normal limits. The patient's ABGs will be maintained within an acceptable range for them. The patient will experience improved oxygenation and ventilation. The patient will maintain blood oxygen levels above 90%. Impaired Gas Exchange Nursing Assessment A thorough nursing assessment helps you determine the baseline and ongoing status of the patient's condition. Your nursing assessment may include the following: Perform a thorough respiratory assessment, noting respirations' rate, rhythm, and depth and using accessory muscles and nasal flaring. Assess for abnormal lung sounds, such as crackles or rhonchi. Assess for peripheral and central cyanosis related to impaired perfusion and oxygenation. Monitor for changes in mental status and consciousness. Assess cardiac health, including heart rate, rhythm, and blood pressure. Monitor pulse oximetry and ABGs. Assess blood pH electrolytes. Impaired Gas Exchange Nursing Interventions and Rationales Common nursing interventions for impaired gas exchange include: Assist the patient in finding a comfortable position by elevating the head of the bed, sitting in a chair, or sitting up while leaning forward onto a table or other surface. Rationale: Maximizes chest expansion and comfort. Encourage coughing and deep breathing exercises. Rationale: Improves ventilation by mobilizing secretions. Institute energy conservation techniques, such as planned rest periods and clustering care activities. Rationale: Reduces oxygen demands and prevents over-exhaustion. Administer oxygen therapy as indicated. (Note: Use caution in patients with chronic lung disease.) Rationale: Maintains PaO2 within normal limits. Nursing Care Plan: Ineffective Airway Clearance Ineffective airway clearance commonly occurs in patients with pneumonia. The patient's ability to clear their airway may be related to a weak or non-producing cough or excessive lung mucus build-up. In severe cases of infective airway clearance, the patient may require an artificial airway or ventilatory support. Potentially Related To Ineffective airways clearance may be related to the following: Pleuritic chest pain Extreme fatigue and low-energy Aspiration Inflammation in the trachea, bronchi, or other areas of the respiratory tract Lung edema Excessive mucus Airway spasms Evidenced By Ineffective airway clearance may produce the following symptoms: Orthopnea Hypoxemia Hypercapnia Dyspnea Tachypnea Cyanosis Dusky skin color Hypotension Confusion Abnormal ABGs Accessory muscle use Desired Outcomes Possible desired outcomes for a patient with ineffective airway clearance include the following: The patient maintains clear airways with normal breath sounds, respiratory rate, and effort. The patient experiences improved gas exchange. The patient demonstrates signs of improving respiratory status. Ineffective Airways Clearance Nursing Assessment Common nursing assessment strategies to include in a pneumonia nursing care plan include: Assess the respiratory rate, rhythm, depth, and accessory muscle use. Auscultate the lungs for decreased breath sounds, wheezing, rales, rhonchi, stridor, crackles, or grunts. Monitor for confusion, restlessness, or anxiety. Assess for signs of atelectasis, including crackles, impaired diaphragmatic excursion, tracheal shift, or tubular breath sounds. Monitor for changes in cardiac status, including heart rate and blood pressure. Assess the strength of the cough, bronchospasms, and secretions. Assess the amount, texture, and color of the sputum. Track and trend oxygen saturations. Monitor ABGs and chest x-ray reports. Assess the patient's nutritional status. Evaluate hydration status. Ineffective Airway Clearance Nursing Interventions and Rationales Nursing interventions for ineffective airways clearance include: Assist the patient in a comfortable position with the head raised. Rationale: Allows chest expansion and maximizes oxygen exchange. Assist the patient in repositioning every two hours if on bed rest. Rationale: Increases oxygen exchange and movement of mucus. Encourage ambulation if indicated. Rationale: Assists in loosening mucus and maintaining overall body strength. Maintain oxygen saturation at 90% or higher. Rationale: Improves oxygenation and reduces complications. Suction as necessary. Rationale: Assists removing mucus if the patient cannot do it independently. Encourage coughing and deep breathing. Rationale: Assists with oxygenation and mucus removal. Administer oxygen, antibiotics, and other medications as ordered. Rationale: Treats pneumonia and improves oxygenation. Educate the patient on proper positioning, coughing and deep breathing exercises, and the importance of movement. Rationale: Promotes self-care to improve oxygenation and expectoration of mucus. Educate the patient on increasing fluid intake. Rationale: Promotes self-care to thin mucus. Educate the patient on understanding medications, therapies, and inhalers. Rationale: Promotes self-care strategies to cure pneumonia and treat symptoms. Nursing Care Plan: Ineffective Breathing Pattern Symptoms of pneumonia, such as fever and chest pain, can change the patient's breathing patterns. These changes lead to compensatory tachypnea to meet the body's metabolic demands. The ineffective breathing pattern happens because affected alveoli are impaired and cannot effectively exchange oxygen and carbon dioxide. Potentially Related To Possible related factors for ineffective breathing pattern includes the following: Hypoxia Anxiety Pleuritic chest pain O2/CO2 ratio alterations Decreased lung expansion Inflammation in the lungs Evidenced By The most frequent signs and symptoms of an ineffective breathing pattern include the following: Tachypnea Dyspnea Orthopnea Use of accessory muscles or nasal flaring Changes in respiratory patterns, such as rate and depth Abnormal breath sounds, such as rhonchi, bronchial lung sounds, and egophony Decreased breath sounds over affected areas of the lungs Productive cough Non-productive cough Reduced vital capacity Purulent sputum Hypoxemia Cyanosis Presence of infiltrates on chest x-ray Desired Outcomes The desired outcomes of an ineffective breathing pattern are: The patient maintains respiratory rate and rhythm within normal limits. The patient maintains an oxygen blood saturation above 90%. Ineffective Breathing Pattern Nursing Assessment Appropriate nursing assessments for ineffective breathing patterns may include: Assess and record respiratory rate every 2-4 hours as indicated. Monitor breathing patterns for abnormalities. Monitor for paradoxical motion. Monitor ABG levels. Auscultate breath sounds. Assess for nasal flaring and accessory muscle use. Evaluate oxygen levels in the blood. Observe and record sputum characteristics, such as color, amount, and consistency. Evaluate the nutrition and activity levels of the patient. Monitor vital signs for fever and tachycardia. Ineffective Breathing Pattern Nursing Interventions and Rationales Appropriate nursing interventions may include: Assist the patient to an upright position. Rationale: Improves chest expansion and oxygenation. Encourage deep breathing exercises. Rationale: Promotes chest expansion and reduces the risk of atelectasis. Administer medications and supplemental oxygen as needed. Rationale: Treats symptoms of underlying pneumonia and improves oxygenation. Encourage coughing and expectoration of mucus. Rationale: Maintain a clear airway. Encourage ambulation and light activity as tolerated. Rationale: Promotes mobility and movement of fluid in the lungs. Request a dietary consult. Rationale: Provides specialized assessment of patient's dietary needs. Encourage the patient to take frequent rest periods and to cluster activities. Rationale: Promotes energy conservation. Educate the patient on the medication regimen, energy conservation, breathing techniques, and when to seek additional treatment before discharge from the hospital setting. Rationale: Promotes self-care. Nursing Care Plan: Risk for Infection While pneumonia is typically not a life-threatening condition, it can lead to a secondary infection or sepsis, especially in immunocompromised patient populations. Sepsis and other severe secondary infections can lead to respiratory failure and even death if left untreated. Potentially Related To The risk for infection may be related to the following: Presence of existing pneumonia Suctioning, intubation, and other invasive procedures Ineffective lung function caused by mucus Secondary problems, such as immobility or malnutrition Evidenced By The common signs of infection are: Fever Chills Body sweats Muscle aches Cough Increased white blood cells Desired Outcomes The common signs of infection are: Fever Chills Body sweats Muscle aches Cough Increased white blood cells Desired Outcomes The most common desired outcomes are: The patient is free of the primary infection, and it does not create a secondary infection. Risk for Infection Nursing Assessment Appropriate nursing assessments include: Monitor for signs of a secondary infection. Monitor the patient's vital signs and laboratory values for signs of a worsening condition. Risk for Infection Nursing Interventions and Rationales Disinfect and sterilize any equipment. Rationale: Reduces the spread of infection and re-infection. Teach patients how to wash their hands and perform adequate hygiene. Rationale: Reduces the spread of infection and re-infection. Restrict visitors per hospital protocols. Rationale: Reduces the spread of infection. Educate the patient about disinfecting items at home. Rationale: Reduces the spread of infection in the community setting. Institute isolation protocols as needed. Rationale: Protects healthcare workers and visitors from infection. Administer medications, such as antibiotics and oxygen, per orders. Rationale: Treats pneumonia and side effects. Monitor the effectiveness of all drug therapies. Rationale: Identifies the need for medication adjustments. Teach the patient about a nutrient-rich diet. Rationale: Promotes self-care and a healing diet. Remove waste, clean the room, and wear gloves and other PPE as indicated. Rationale: Prevents the spread of infection. Increase the patient's fluid intake as indicated. Rationale: Thins mucus in the lungs to assist with mobilization and expectoration. Educate the patient regarding breathing and physical activity exercises. Rationale: Promotes activity, chest expansion, and oxygenation. Encourage frequent rest periods and necessary clustering activities. Rationale: Assists with energy conservation. Assess for changes in condition. Rationale: Identifies signs of worsening infection. Nursing Care Plan: Risk for Imbalanced Nutrition: Less Than Body Requirements The risk for imbalanced nutrition is when a person does not consume the proper nutrients or calories required to maintain a healthy weight. For example, patients with pneumonia may not have much of an appetite from the illness or might not feel they can eat, related to their dyspnea and labored breathing. Potentially Related To Patients with the following conditions are at higher risk of developing imbalanced nutrition while they have pneumonia: Difficulty breathing Excessive coughing Increased metabolic needs secondary to infection and fever Swallowing air that leads to abdominal distention and discomfort Evidenced By The most common signs of imbalanced nutrition include: Weight loss Physical weakness Swollen mucus membranes Confusion Pale skin Fatigue Desired Outcomes The desired outcomes for the patient include the following: The patient maintains a healthy appetite, food consumption, and weight. Risk for Imbalanced Nutrition Nursing Assessment Assess the patient's weight regularly. Monitor intake and output. Risk for Imbalanced Nutrition Nursing Interventions and Rationales Request a nutritional consult. Rationale: Provides a specialized assessment of the patient's nutritional needs. Schedule respiratory treatments and medications that cause stomach upset at least an hour after meals. Rationale: Reduces side effects such as nausea just before meals. Provide small frequent meals and snacks. Rationale: Improves oxygenation and chest expansion. Consider a high-calorie, high-protein diet if not contraindicated. Rationale: Promotes healing and provides needed nutrients. Keep the patient's area clean and remove any secretions or waste before meals. Rationale: Provides a pleasant environment during mealtime. Educate the patient on the prescribed diet after discharge. Rationale: Promotes weight gain. Encourage oral hygiene. Rationale: Reduces mouth sores and dryness to increase food intake. Provide supplements as ordered. Rationale: Provides additional calories and nutrients. Nursing Care Plan: Acute Pain Pleuritic chest pain is a common side effect of pneumonia. This condition can cause sharp or stabbing pain with coughing or deep breathing. In addition, pleuritic chest pain can cause the patient to avoid coughing, causing an increase in mucus in the lungs and creating more pain. This vicious cycle can be challenging to treat. Potentially Related to Acute pain is caused by the following: Pleuritic chest pain Excessive coughing Evidenced By Signs of acute pain include: Verbalization of chest pain Avoiding coughing and deep breathing Changes in behavior or personality Changes in sleep patterns Grimacing with movement or coughing Desired Outcomes The patient will be pain-free within 2 hours after administration of pain medications. The patient will demonstrate non-pharmacologic methods to control pain, such as frequent position changes and meditation. Acute Pain Nursing Assessment Ask the patient about the pain's location, intensity, rating, and duration. Use the FACES Scale to evaluate the intensity of the pain. Observe for grimacing, crying, or other signs of pain. Evaluate the patient's mental ability to perform a multimodal approach to pain relief. Assess the patient's response to pain management strategies. Acute Pain Nursing Interventions and Rationales Provide pain relief measures per the facility protocol. Rationale: Treats the pain appropriately. Educate the patient on non-pharmacologic pain relief strategies. Rationale: Reduces pain and allows for self-care. Encourage the patient to change positions frequently. Rationale: Reduces pain and increases chest expansion. Evaluate the effectiveness of pain management techniques. Rationale: Indicates the need for new treatment modalities. Nursing Care Plan: Decreased Activity Tolerance Pneumonia may cause the patient to experience decreased activity tolerated due to poor oxygenation and increased metabolic demands. As a result, the condition may deplete the patient's energy reserves and reduce the intake of adequate nutrients. Potentially Related To Common factors that cause activity intolerance in those with pneumonia include: Exhaustion General weakness Decreased oxygenation The most common risk factors are: Decreased oxygenation Evidenced By Signs of decreased activity tolerance may be: Weakness and fatigue Poor activity tolerance Dyspnea and tachypnea Change in vital signs during activity Desired Outcomes The patient will report improved tolerance to activity. The patient will be free of signs of respiratory distress. Decreased Activity Tolerance Nursing Assessment Assess the patient's response to physical activity. Decreased Activity Tolerance Nursing Interventions and Rationales Encourage coughing and deep breathing. Rationale: Mobilizes mucus and improves oxygenation. Encourage rest and monitor the patient's sleep pattern. Rationale: Promotes sleep and healing. Educate on the importance of pacing oneself and clustering activities. Rationale: Promotes energy conservation. Assist with care tasks that cause the patient to tire quickly. Ratonale: Reduces exhaustion. Nursing Care Plan: Deficient Knowledge Some patients may be unfamiliar with pneumonia and common treatments. Educating the patient on the condition and self-care techniques can aid full recovery. Potentially Related To Deficient knowledge can be caused by the following: Lack of exposure to the condition Inability to comprehend information Inability to learn Refusal to learn Lack of access to learning protocols or educational resources Evidenced By Common signs of deficient knowledge of pneumonia care include: Lack of remembering of information Requesting information or asking questions Stating misconceptions Worsening or recurrent pneumonia Confusion about pneumonia treatments Non-compliance with prescribed treatment regimens Desired Outcomes The patient verbalizes the cause, side effects, and treatments of pneumonia. The patient and caregiver verbalize understanding of the treatment regimen. The patient participates in the treatment program. The patient's pneumonia resolves, and no secondary infection occur. Deficient Knowledge Nursing Assessment Assess the person's ability to comprehend new information and desire to learn. Ask the patient about previous healthcare experiences and note any misconceptions or poor experiences that may inhibit learning. Assess self-care and home caregiver needs. Deficient Knowledge Nursing Interventions and Rationales Educate on the signs, symptoms, and treatment of pneumonia. Rationale: Establishes a baseline understanding. Create a peaceful mental and physical atmosphere for the patient. Rationale: Provides a positive learning environment. Educate on the need to follow up with a care provider. Rationale: Establishes the need for ongoing care. Utilize the teach-back method. Rationale: Promotes learning and retention. Keep the informational sessions short and easy to understand. Rationale: Promotes learning and retention. Slowly progress the complexity of the material over time. Rationale: Promotes a natural progression to more challenging information Educate on signs and symptoms that require the patient to notify the healthcare provider. Rationale: Ensures timely follow-up for worsening or recurrent infection. Anxiety Dyspnea and other signs of impaired breathing can evoke anxiety in patients. The patient's care team must treat the anxiety holistically so the patient can relax and rest. Potentially Related To Anxiety can be caused by the following: Shortness of breath Feelings of not being able to breathe deeply Pain during breathing General feelings of illness Evidenced By The most common signs of anxiety include: Nervous feeling Hyperventilation Excessive worrying Increased difficulty breathing Desired Outcomes The patient will experience reduced anxiety symptoms after using anxiety-reducing strategies, such as medications or relaxation. Anxiety Nursing Assessment Ask the patient if they feel anxious or nervous. Observe for signs of anxiety, such as nervousness, inability to sleep or rest, or poor concentration. Anxiety Nursing Interventions and Rationale Administer medications as prescribed. Rationale: Reduces anxiety symptoms. Educate on using relaxation techniques, such as meditation and deep breathing. Rationale: Reduces symptoms of anxiety. Play soft music and keep the lighting in the room low. Rationale: Improves relaxation. Educate the patient on the signs and symptoms of anxiety and strategies to reduce symptoms. Rationale: Promotes recognition of anxiety and self-care strategies. More Pneumonia Diagnosis Risk for Deficient Fluid Volume Deficient Fluid Volume Pneumonia NCLEX Test Questions Nursing students often wonder what kind of questions might be on the NCLEX. There is a good chance you'll encounter questions about caring for patients with pneumonia. Below are sample questions you might see on the NCLEX. Aminophylline is prescribed for a patient with acute bronchitis. The nurse knows the primary purpose of this medication is to: a. Suppress the patient's cough b. Relax the bronchial airway I. Rationale: Aminophylline inhibits isoenzymes and soothes the lungs, vessels, and throat muscles. c. Prevent infection d. Enhance expectoration Dr. Smith prescribes Proventil for a patient with asthma. While teaching the patient about the side effects of this drug, the nurse should explain how this drug may cause: a. Congestion b. Anxiety I. Rationale: Proventil/Albuterol can cause anxiety, nervousness, tremors, headaches, and palpitations. c. Lethargy d. Hyperkalemia Sally, a student with acute rhinitis, sees the on-campus nurse due to excessive nasal passage drainage. The nurse asks Sally about the color of the nasal drainage to diagnose the patient. Typically, the color of acute rhinitis drainage is: a. Brown b. Yellow c. Clear I. Rationale: Acute rhinitis presents with clear secretions, mouth breathing, dark eye circles, and sniffling. d. Gray A senior client with pneumonia usually has _____ as their first symptom. a. Altered mental status I. Rationale: Lower mental acuity, confusion, dehydration, and loss of appetite are the first symptoms in elderly patients. b. Fever c. Hemoptysis d. Cough _____ is a pathophysiological mechanism that facilitates pneumonia development. a. Efusion b. Inflammation I. Rationale: Macrophages cause lung inflammation. c. Bronchiectasis d. Malnutrition Additional Readings and Resources If you need more information about pneumonia, check out these great articles on AllNurses: Help needed for a Pneumonia nursing dx, including pathophysiology. Thorough Assessment Is it okay to falsify respiratory rates? Wrapping Up Pneumonia Nursing Care Plans While pneumonia is a common illness, it's critical to understand that it can become life-threatening without proper diagnosis and treatment. Use these nursing care plans as a basis for your nursing assessments and interventions to provide holistic and comprehensive care for your patients or clients. Citations https://www.CDC.gov/nchs/fastats/pneumonia.htm https://pubmed.ncbi.nlm.nih.gov/22621820/ New evidence of risk factors for community-acquired pneumonia: a population-based study Identification of new risk factors for pneumonia: population-based case-control study https://onlinelibrary.wiley.com/doi/10.1002/dmrr.682 COPD and Pneumonia: The Dangers of COPD and Pneumonia Together (copdhealth.today) Hospital-acquired and ventilator-associated pneumonia: Diagnosis, management, and prevention | Cleveland Clinic Journal of Medicine (ccjm.org) Bacterial Pneumonia: Symptoms, Causes, and Treatment (healthline.com) RSV (Respiratory Syncytial Virus) | CDC Pneumonia in Adults With Asthma: Impact on Subsequent Asthma Exacerbations | Open Forum Infectious Diseases | Oxford Academic (oup.com)
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Table of Contents Signs & Symptoms Assessment Factors Affecting Causes Treatments Complications Nurse's Role Nursing Care Plans Hypernatremia Hyponatremia Hypercalcemia Hypocalcemia Hypermagnesemia Hypomagnesemia Hyperkalemia Hypokalemia Alkalosis Acidosis Electrolyte Imbalance Nursing Diagnosis NCLEX Test Questions Readings and Resources Wrapping Up Citations If not treated promptly and correctly, some imbalanced electrolytes have life-threatening consequences and can even lead to cardiac arrest. When electrolytes become imbalanced, they can impair many of the body's critical functions, including blood acidity and pressure regulation, hydration levels, nerve and muscle coordination, and tissue repair. Losing body fluids caused by diarrhea, sweating, vomiting, medications, conditions, or extensive burns often lead to electrolyte imbalances that must be treated medically and with a nursing care plan for hands-on care and nursing interventions. This article offers ten electrolyte imbalance nursing diagnoses and care plans to help you care for your patients. We'll focus on acid-base, sodium, calcium, magnesium, and potassium imbalances. Signs and Symptoms of Electrolyte Imbalance Different types of electrolyte imbalances cause various signs and symptoms. The signs depend on which electrolyte is affected, the severity of the imbalance, and the presence of comorbidities. However, there are common signs you might observe with most types of imbalances. Many patients experience no noticeable symptoms if the imbalance is mild or occurs gradually. Common signs and symptoms of electrolyte imbalance include: Fatigue Muscle weakness, cramps, or spasms Confusion and irritability Cardiac dysrhythmias Tachycardia Nausea and vomiting Diarrhea or constipation Dyspnea Headaches Dizziness Delirium Numbness of limbs, fingers, and toes Assessment of Electrolyte Imbalance The nursing assessment is vital to the identification of electrolyte imbalances. Registered nurses or practical nurses must take a comprehensive history and perform a physical exam, paying particular attention to the patient's skin turgor to assess for dehydration. In addition, you should ask about any recent changes in medication and inquire about the patient's dietary habits. It is also vital to obtain laboratory tests for electrolytes such as sodium, potassium, chloride, and bicarbonate. Abnormal electrolyte levels should be promptly reported to the healthcare provider so treatment can begin. Factors Affecting the Occurrence of Electrolyte Imbalance Many factors can lead to electrolyte imbalance, including: Dehydration - may be caused by excessive sweating, vomiting, diarrhea, or inadequate fluid intake Kidney disease - impaired kidney function affects the regulation of electrolyte levels in the body Diabetes - many diabetic patients have imbalances in sodium and potassium Dietary changes - inadequate or excessive intake of electrolyte-containing foods such as dairy and fruits can lead to an imbalance, and a high protein diet may lead to hypernatremia Parenteral nutrition - may cause loss of electrolytes Medications - certain medications, such as diuretics and laxatives, can interfere with electrolyte levels Trauma - physical trauma or injury can disrupt electrolyte balance Hypertension - can cause too much sodium and potassium in the body Diuretics -promote the release of sodium through the urine, which may lead to a decrease in electrolyte levels High aldosterone levels - can cause hypernatremia or hypokalemia Heart disease - can cause an imbalance in electrolytes, specifically potassium, and sodium Excessive vomiting or diarrhea - can cause loss of electrolytes Congestive heart failure - may cause irregular sodium and potassium levels Surgery - can cause post-operative imbalances due to fluid volume changes (hypovolemia/hypervolemia), blood transfusion, the body's stress response related to the procedures, or an underlying condition or disease Causes of Electrolyte Imbalance More than half of the body's weight consists of water. Blood and fluid in and around the cells hold most of the water found in the body. In addition, electrolytes move throughout the body due to the function of the liver, kidneys, and other organs. Because electrolytes are needed for overall health and wellness, many changes in the body or organ function can create imbalances that require treatment. The most common causes of electrolyte imbalance include: Electrolyte Poor Diets Vomiting or Diarrhea Medications (example: diuretics and laxatives) Medical Conditions (example: diabetes, kidney disease, congestive heart failure) Hypovolemia or Hypervolemia Treatments However, if the imbalance is severe or related to an acute medical condition, surgery, or trauma, the patient may need hospitalization and treatment with IV fluids and other medications. In addition, patients with kidney failure or severe kidney damage may require hemodialysis to remove waste and fluids from the body to achieve electrolyte balance. Complications Untreated or significant electrolyte imbalances can be life-threatening and cause the following complications: Seizures Coma Cardiac arrest Death Nurse's Role Caring for a Patient with Electrolyte Imbalance Nurses are integral in caring for acutely ill patients experiencing an electrolyte imbalance. Thorough head-to-toe assessments to check for new or worsening signs of specific imbalances and monitoring and reporting any critical lab values ensure that changes in the patient's condition are addressed quickly. In the home or outpatient setting, nurses perform similar assessments for signs and symptoms of electrolyte imbalances. In addition, medication and condition education is essential to the long-term management of any imbalances and the underlying conditions that cause them. Teaching patients self-care strategies can prevent acute exacerbations and hospitalizations. Nursing Protocols for Electrolyte Imbalance Nurses must know the protocols for electrolyte imbalance. They must recognize the signs of each type of imbalance, evaluate and monitor electrolyte levels, and create individualized nursing care plans to address their findings. They should also be familiar with treatments for electrolyte imbalances, like rehydration therapy and medications. Each protocol starts with assessing the patient's symptoms with planned interventions and desired outcomes. Nurses treating a patient for electrolyte imbalances will perform the following tasks to ensure the patient's safety and well-being: Monitor electrolyte levels in the patient and adjust treatment plans accordingly Teach the patient and family about electrolyte imbalances, potential complications, and treatment options Provide education on lifestyle changes that can help maintain balanced electrolytes Administer IV fluids, oral medications, and supplements as ordered Weigh the patient daily and review any changes in body weight, if indicated Provide emotional support to the patient and their family Refer the patient to other healthcare professionals as needed Record and document all treatments, medications, and patient condition changes Administer oxygen therapy and other treatments as needed Monitor the patient for dehydration, shock, or any other complications associated with electrolyte imbalance Nursing Care Plans Related to Electrolyte Imbalance Now, let's review some nursing care plans you can use when caring for patients with common electrolyte imbalances. The below nursing care plans are not exhaustive or individualized to a patient but can provide an overview of how to address these conditions. It's also important to note that lab values are not included in these nursing care plans as each laboratory establishes normal and abnormal values. Therefore, always refer to your institution's laboratory value norms and protocols when determining when to report electrolyte imbalance values to the healthcare provider. Risk for Hypernatremia Care Plan Hypernatremia occurs when the level of sodium in the body is abnormally high. It can cause serious problems, such as seizures and confusion. Nursing Diagnosis: Risk for Hypernatremia Potentially Related To Dehydration Severe diarrhea Fever Vomiting Poorly controlled diabetes Certain medications Kidney disease Diabetes insipidus Extensive burns Evidenced By Extreme thirst Fatigue Headache Nausea Lethargy Confusion Muscle twitching or spasms Seizures Coma Desired Outcomes The patient will maintain a normal fluid balance The patient will maintain normal serum sodium and intravascular volume levels. The patient will maintain normal electrolyte levels. The patient's heart rate and blood pressure will be within normal limits. The patient will verbalize an understanding of the cause of hypernatremia and how to self-manage the condition. The patient will be free of neuromuscular irritability. Risk for Hypernatremia Nursing Assessment Assess sodium levels. Ask the patient if they have extreme thirst. Assess mental status for new-onset confusion. Monitor fluid intake and output. Risk for Hypernatremia Nursing Interventions and Rationales Increase the patient's fluid intake or provide free water to patients receiving enteral feedings. Rationale: May prevent hypernatremia if the patient cannot perceive or respond to thirst. Encourage increased oral and IV fluid intake. Rationale: Gradually restores the balance of sodium and water. Educate patients to avoid foods high in sodium, such as processed foods or canned vegetables and vegetable juice. Rationale: Minimizes the risk of too much sodium intake through diet and reduces the risk of heart disease and heart failure. Provide regular oral care and avoid mouthwashes containing alcohol. Rationale: Prevents further drying and promotes comfort. Restrict a diet high in sodium and administer diuretics as ordered. Rationale: Decreases sodium levels while there is extracellular fluid excess. Monitor laboratory values for electrolyte levels as ordered. Rationale: Detects changes in the patient's fluid and electrolyte balance. Administer intravenous fluids as ordered. Provide seizure precautions such as lowering the height of the bed and using padding on side rails. Rationale: Protects against injury during seizures. Risk for Hyponatremia Care Plan Hyponatremia occurs when the level of sodium in the body becomes abnormally low. In this case, excessive water excretes in the kidneys. It can cause seizures and confusion. Nursing Diagnosis: Risk for Hyponatremia Potentially Related To Water intoxication Vomiting Diarrhea Side effects of gastric suctioning, medication, or electrolyte-free IV fluids Kidney dysfunction Evidenced By Confusion Nausea and vomiting Drowsiness or fatigue Restlessness Muscle weakness or spasms Seizures Coma Desired Outcomes The patient will maintain a normal heart rate and blood pressure. The patient will maintain normal serum sodium levels. Risk for Hyponatremia Nursing Assessment Monitor fluid intake and output. Evaluate sodium levels. Assess the patient's neurological and neuromuscular status. Monitor urine and serum osmolality and electrolytes. Risk for Hyponatremia Nursing Interventions and Rationales Provide seizure precautions such as lowering the height of the bed and using padding on side rails. Rationale: Protects against injury during seizures. Irrigate nasogastric tubes with normal saline. Rationale: Isotonic solutions reduce electrolyte loss in gastrointestinal fluids. Encourage foods and fluids high in sodium, such as eggs, milk, and meat. Rationale: Provides a slow replacement of dietary sodium. Risk for Hypercalcemia Care Plan Hypercalcemia occurs when the level of calcium in the body is abnormally high. It can cause serious problems, such as an increased risk of cardiac arrest, confusion, muscle weakness, and pain. Nursing Diagnosis: Risk for Hypercalcemia Potentially Related To Kidney problems Hyperparathyroidism Hyperthyroidism Side effects of certain medications, such as theophylline, thiazide diuretics, and antineoplastics Evidenced By Nausea and vomiting Constipation Excessive thirst Frequent urination Bone pain and muscle weakness Cardiac dysrhythmias Confusion Lethargy Depression Desired Outcomes The patient will be free of ECG changes, such as tachycardia and bradycardia. The patient will maintain normal calcium levels. The patient will maintain a normal cognitive status. Risk for Hypercalcemia Nursing Assessment Monitor blood calcium, phosphate, and magnesium levels. Assess the patient's level of consciousness and neuromuscular status. Assess bowel sounds. Monitor cardiac rhythm and rate. Review the medication regimen for drugs that can elevate calcium levels, such as phenytoin and heparin. Risk for Hypercalcemia Nursing Interventions and Rationales Increase the use of safety measures when moving the patient. Rationale: Decreases the risk of injury, including pathological fractures related to weakened bones. Promote a diet high in bulk. Rationale: Decreases the risk of constipation related to impaired gastrointestinal tone. Assess for urinary stones by straining the urine. Rationale: High calcium levels increase the risk of stone formation. Encourage up to four liters of fluid intake daily and include fluids containing sodium if signs of cardiac tolerance are present. Rationale: Increases urinary flow and removal of calcium to minimize the risk of stone formation and improves hydration. Administer sodium sulfate and isotonic saline as ordered. Rationale: Increases urinary excretion by diluting extracellular calcium concentrations and reducing tubular reabsorption of calcium. Risk for Hypocalcemia Care Plan Hypocalcemia occurs when calcium levels in the blood are abnormally low. Chronic laxative use, diarrhea, and certain medications can cause hypocalcemia. Low calcium levels can disrupt the body's magnesium and phosphorous levels, causing an electrolyte imbalance. Nursing Diagnosis: Risk for Hypocalcemia Potentially Related to Diarrhea Chronic laxative use Renal failure Side effects of certain medications, such as anticonvulsants, diuretics, and antibiotics Evidenced By Muscle twitches, cramps Dry, scaly skin Brittle nails Depression Confusion Irritability Hallucinations Muscle aches Laryngospasms Tetany Seizures Cardiac arrhythmias Congestive heart failure Desired Outcomes The patient will maintain cardiac rhythms within normal limits. The patient will maintain serum calcium levels within normal limits. The patient will be free of respiratory distress. The patient will be free of neuromuscular irritability. Risk for Hypocalcemia Nursing Assessment Monitor laboratory results. Monitor the patient's respiratory status, including rate, rhythm, and signs of dyspnea. Monitor heart rate and rhythm. Assess for petechiae and ecchymosis, and other signs of bleeding. Perform a medication regimen review. Risk for Hypocalcemia Nursing Interventions and Rationales Educate the patient on the chronic and excessive use of laxatives and antacids. Rationale: Medications containing phosphorous can reduce serum calcium levels. Encourage the patient to use antacids containing calcium, such as Tums, if needed. Rationale: Assists with oral replacement of calcium levels. Educate the patient on the importance of meeting dietary calcium needs. Rationale: Diets including calcium-rich foods reduce the risk of tooth decay, osteoporosis, and eczema. Administer medications as ordered. Rationale: Certain medications can increase serum calcium levels. Risk for Hypermagnesemia Care Plan Magnesium regulation happens in the renal and gastrointestinal systems. The nutrient is absorbed in the GI tract and excreted through urine. If an excess of magnesium exists, it's stored in the bones. Hypermagnesemia happens when magnesium levels in the blood are abnormally high. Magnesium is a vital nutrient in the body and is needed to maintain nerve and muscle function, blood pressure, and blood glucose levels. Nursing Diagnosis: Risk for Hypermagnesemia Potentially Related To Chronic diarrhea Renal dysfunction Diabetic ketoacidosis Side effects of medications containing magnesium Diuretic overuse or abuse Evidenced By Nausea Mental impairment Headache Vomiting Flushing Hypotension Respiratory depression Decreased or absent reflex response Desired Outcomes The patient will maintain normal serum magnesium levels. The patient will maintain normal blood pressure values. The patient will maintain respiratory functions within normal limits. Risk for Hypermagnesemia Nursing Assessment Assess renal function. Renal impairment can affect the body's ability to regulate magnesium levels. Check serum Magnesium levels. Use a corrected magnesium level to get an accurate reading. Assess respiratory rate and rhythm. Monitor heart rate and rhythm. Monitor blood pressure. Monitor urinary output and 24-hour fluid balance. Assess the level of consciousness and neuromuscular status, including muscle tone, strength, and reflexes. Risk for Hypermagnesemia Nursing Interventions and Rationales Encourage bed rest and use safety precautions during movement. Rationale: Promotes safety if the patient experiences neurological depression or muscle weakness. Encourage increased fluid intake. Rationale: Promotes excretion of magnesium through the kidneys. Educate on avoiding antacids with magnesium, such as Mylanta or Maaylox. Rationale: Minimizes risk of hypermagnesemia related to increased oral intake. Administer diuretics and IV fluids. Rationale: Promotes excretion of magnesium through the kidneys. Administer calcium gluconate or 10% calcium chloride. Rationale: Reverses symptoms of too much magnesium in the blood. Prepare and educate the patient on dialysis. Rationale: Lowers magnesium levels quickly. Risk for Hypomagnesemia Care Plan Hypomagnesemia occurs when the magnesium levels in the blood are abnormally low. Magnesium is found in the intracellular fluid. The body needs magnesium for normal nerve and muscle function, protein synthesis, contraction of skeletal and cardiac muscles, and blood pressure regulation. Nursing Diagnosis: Risk for Hypomagnesemia Potentially Related To Gastrointestinal losses Renal disease Diabetic ketoacidosis Hyperaldonsteonism Malnutrition Side effects of certain medications, including chemotherapeutics and diuretics Evidenced By Weakness Irritability Torsades de pointes Tetany Cardiac dysrhythmias Hypertension Hyperreflexia Nausea Involuntary movements Decreased GI function, including mobility and bowel sounds Death Desired Outcomes The patient will maintain normal serum magnesium levels. The patient will display normal cardiac function. The patient will display normal mental and neuromuscular function. Risk for Hypomagnesemia Nursing Assessment Assess for the presence of slowed GI mobility, such as reduced bowel sounds or the presence of an ileus. Assess for laryngeal stridor and dysphagia. Monitor cardiac function, including heart rate, rhythm, and ECG changes. Assess the level of consciousness and neuromuscular tone, movement, and reflexes. Observe for signs of digoxin toxicity if part of the patient's medication regimen, including vomiting, nausea, blurred vision, and heart block. Assess magnesium, phosphate, and calcium levels. Assess renal function, which can affect the body's ability to regulate magnesium levels. Risk for Hypomagnesemia Nursing Interventions and Rationales Educate on the proper use of laxatives and diuretics. Rationale: Overuse or abuse can lower magnesium levels. Provide seizure and safety precautions. Rationale: Protects against injury related to seizure or changes in mental status. Utilize a cradle or footboard on the hospital bed. Rationale: Keeping linens off of feet and legs may reduce muscle spasms. Keep the environment calm, quiet, and dim. Rationale: Promotes rest and minimizes stimulation. Encourage ROM exercises. Rationale: Minimizes effects of muscle changes, including spasticity and weakness. Increase magnesium-rich foods, including dairy, green leafy vegetables, and meat. Rationale: Promotes replacement of magnesium through the diet for mild electrolyte imbalance. Administer oral or IV magnesium supplements as indicated. Rationale: Replaces magnesium for moderate to severe hypomagnesemia. Risk for Hyperkalemia Care Plan Potassium is critical to normal body function, including the operation of the heart, kidneys, muscles, and nervous system. In addition, this essential macromineral regulates the osmolarity of extracellular fluid by exchanging it with sodium. It also helps to keep the transmembrane electrical potential between the intracellular and extracellular fluid within normal limits. Hyperkalemia happens when the potassium levels in the blood are abnormally high. This condition is common in patients with abnormal kidney function affecting the ability to remove potassium from the body, such as in patients with renal disease. In addition, other treatment modalities can affect the potassium levels in the body and place the patient at an elevated risk of hyperkalemia. Nursing Diagnosis: Risk for Hyperkalemia Potentially Related To Renal disease Certain medications, including NSAIDs, diuretics, and cytotoxic drugs Large transfusion with banked blood Too much potassium in the diet Rhabdomyolysis Burns, tissue injuries, or trauma Evidenced By Heart palpitations Abnormal heart rhythms Nausea Desired Outcomes The patient will not experience life-threatening cardiac conduction or neuromuscular disturbance. The patient will maintain normal serum potassium levels. The patient will remain free of signs and symptoms of hyperkalemia. Risk for Hyperkalemia Nursing Assessment Assess urine and serum electrolytes. Use a 12-lead ECG to identify signs of cardiac conduction abnormality. Monitor cardiac status, including heart rate and rhythm. Monitor respiratory status, including rate and depth. Assess the level of consciousness and neuromuscular function, including movement and strength. Monitor serum potassium levels. Monitor urinary output. Risk for Hyperkalemia Nursing Interventions and Rationales Administer diuretics as indicated. Rationale: Promotes potassium excretion and renal clearance. Instruct on needed dietary changes, such as increasing the intake of fats and low-potassium foods. Rationale: Reduces dietary sources of potassium. Educate on limiting salt or salt substitutes containing potassium. Rationale: Reduces dietary sources of potassium. Educate on the use of potassium supplements, if indicated. Rationale: Correct administration can reduce the risk of misuse or overuse. Perform a medication review for medications containing potassium or those that affect potassium excretion. Rationale: Indicates the need for regular monitoring of potassium levels and may require the healthcare provider to consider alternate drug therapies. Monitor BUN and creatinine levels. Rationale: Indicates patients at high risk of kidney problems, which may affect potassium excretion. Encourage frequent rest and the need to participate in ROM exercises as tolerated. Rationale: Reduces muscle weakness and cramping and improves muscle tone. Risk for Hypokalemia Care Plan Hypokalemia is when the potassium levels in the blood are abnormally low, which can cause serious problems such as muscle weakness, paralysis, and cardiac arrest. This condition may happen due to inadequate potassium intake or absorption, too much potassium loss, or potassium shifting into the cells from the extracellular fluid. Nursing Diagnosis: Risk for Hypokalemia Potentially Related to Severe diarrhea or vomiting Diets high in sodium Profuse sweating Diabetic acidosis Renal failure Side effects of some diuretics and antibiotics Evidenced By Lightheadedness Excessive urination and thirst Hypotension Muscle twitches and cramps Muscle weakness Tingling and numbness Heart palpitations Constipation Fatigue Desired Outcomes The patient will maintain potassium levels within normal limits. The patient will maintain a normal heart rhythm. The patient will maintain normal cognitive and neuromuscular function. Risk for Hypokalemia Care Plan Nursing Assessment Assess for excessive wound, gastric, or urinary output. Monitor heart rate and rhythm. Assess for signs of metabolic alkalosis, including cardiac dysrhythmias, tachycardia, tetany, and changes in mental status. Auscultate bowel sounds for changes in motility. Monitor serum potassium levels and arterial blood gases as indicated. Risk for Hypokalemia Care Plan Nursing Interventions and Rationales Educate on the use of laxatives and the importance of avoiding overuse. Rationale: Prevent the recurrence of potassium depletion due to laxative use. Carefully administer IV potassium using an infusion pump or micro drip set. Rationale: Ensures safe administration and safeguards against overdose. Observe for signs of hyperkalemia when administering potassium supplements. Rationale: Promotes safe usage of potassium supplements. Monitor blood pressure and electrocardiogram. Rationale: Detects early signs of the condition. Perform a medication review to assess for potassium-wasting drugs, such as Lasix or gentamicin. Rationale: Identifies patients at increased risk of the condition. Risk for Alkalosis Care Plan Metabolic Alkalosis is an acid-base imbalance always related to an underlying condition. Alkalosis happens when there is either too much bicarbonate or too little acid in the body. Symptoms of the disease are seen in the respiratory, metabolic, and renal systems. If left untreated, metabolic alkalosis can be life-threatening and progress to coma or seizures. Nursing Diagnosis: Risk for Alkalosis Potentially Related To Severe vomiting NG tube drainage without electrolyte replacement Fistulas Steroid or diuretic use Excessive intake of baking soda or milk (alkali) Excessive use of antacids Evidenced By Dry skin Altered skin turgor Dry mucous membranes Hypotension Tachycardia Fever Decreased urine output Concentrated urine Confusion Thirst Weakness Dehydration Desired Outcomes The patient will maintain a normal acid-base balance. The patient will be free of signs of dehydration. The patient's vital signs will remain within normal ranges. The patient's fluid loss will be corrected. Risk for Alkalosis Nursing Assessment Assess for signs of dehydration. Determine the cause of fluid loss. Ask the patient about excessive antacid use. Monitor serum pH and bicarbonate levels. Monitor urine pH. Monitor intake and output. Risk for Alkalosis Nursing Interventions and Rationales Educate on the use of laxatives and the importance of avoiding overuse. Rationale: Prevent the recurrence of potassium depletion due to laxative use. Carefully administer IV potassium using an infusion pump or micro drip set. Rationale: Ensures safe administration and safeguards against overdose. Observe for signs of hyperkalemia when administering potassium supplements. Rationale: Promotes safe usage of potassium supplements. Encourage increased intake of potassium-rich foods, such as bananas, oranges, and potatoes. Rationale: Promotes management of the condition through dietary sources. Monitor blood pressure and electrocardiogram. Rationale: Detects early signs of the condition. Perform a medication review to assess for potassium-wasting drugs, such as Lasix or gentamicin. Rationale: Identifies patients at increased risk of the condition. Risk for Alkalosis Care Plan Metabolic Alkalosis is an acid-base imbalance always related to an underlying condition. Alkalosis happens when there is either too much bicarbonate or too little acid in the body. Symptoms of the disease are seen in the respiratory, metabolic, and renal systems. If left untreated, metabolic alkalosis can be life-threatening and progress to coma or seizures. Nursing Diagnosis: Risk for Alkalosis Potentially Related To Severe vomiting NG tube drainage without electrolyte replacement Fistulas Steroid or diuretic use Excessive intake of baking soda or milk (alkali) Excessive use of antacids Evidenced By Dry skin Altered skin turgor Dry mucous membranes Hypotension Tachycardia Fever Decreased urine output Concentrated urine Confusion Thirst Weakness Dehydration Desired Outcomes The patient will maintain a normal acid-base balance. The patient will be free of signs of dehydration. The patient's vital signs will remain within normal ranges. The patient's fluid loss will be corrected. Risk for Alkalosis Nursing Assessment Assess for signs of dehydration. Determine the cause of fluid loss. Ask the patient about excessive antacid use. Monitor serum pH and bicarbonate levels. Monitor urine pH. Monitor intake and output. Risk for Alkalosis Nursing Interventions and Rationales Administer oral or IV fluid replacement therapy. Rationale: Replaces the fluid loss and restores normal electrolyte levels. Evaluate electrolyte levels. Rationale: Establishes causes of alkalosis, such as hypokalemia and hypochloremia, to allow for treatment. Administer medications to treat symptoms of alkalosis, including antiemetics or antidiarrheals. Rationale: Treats the underlying cause of hypovolemia, including vomiting or diarrhea. Risk for Acidosis Care Plan Metabolic acidosis is when the blood pH is abnormally low, resulting in an electrolyte imbalance. As a result, bicarbonate levels are so low that the body's acid-base balance is affected, leading to various symptoms such as nausea, confusion, and drowsiness. If left untreated metabolic acidosis may lead to the following complications: Chronic kidney problems Bone disease Delayed growth Renal stones It's vital to understand that metabolic acidosis is almost always due to an underlying condition that must be treated to reduce morbidity and mortality in the patient. Nursing Diagnosis: Risk for Acidosis Potentially Related To Poorly controlled diabetes Loss of bicarbonate Chronic alcohol use Heart disease Liver disease Cancer Low blood sugar Prolonged oxygen deprivation Poor kidney function Evidenced By Tachycardia Tachypnea Drowsiness Confusion Weakness Loss of appetite Nausea and vomiting Sweet or fruity-smelling breath Desired Outcomes The patient will maintain normal serum electrolyte and bicarbonate levels. The patient will no longer experience confusion. The patient's vital signs will be within normal limits. The patient will not exhibit complications of metabolic acidosis. Risk for Acidosis Nursing Assessment Monitor skin temperature. Assess skin turgor, color, and capillary refill. Assess the patient's neurological status and level of consciousness. Assess for underlying conditions, such as kidney failure or diabetes. Assess for hypotension. Assess for altered respiratory status. Listen to bowel sounds. Monitor intake and output. Evaluate serum and blood pH. Risk for Acidosis Nursing Interventions and Rationales Provide oral hygiene with sodium bicarbonate mouthwashes or lemon glycerin swabs. Rationale: Protectively lubricates the mouth and neutralizes acids. Administer oral or IV fluids as indicated. Rationale: Helps to treat the underlying cause of acidosis. Implement seizure and coma precautions, like placing the bed in a low position or using side rail padding. Rationale: Promotes safety and minimizes injury from advanced neurological Complications. Administer sodium bicarbonate, lactate, or saline IV as indicated. Rationale: Corrects the bicarbonate deficiency. Educate on a low-protein, high-carbohydrate diet. Rationale: Helps to correct acid-base imbalances. More Electrolyte Imbalance Nursing Diagnosis Below are more nursing diagnoses for electrolyte imbalances: Hypervolemia Hypovolemia Hyperphosphatemia Hypophosphatemia Hyperchloremia Hypochloremia Electrolyte Imbalance NCLEX Test Questions As a nursing student, you must study for the NCLEX-RN or NCLEX-PN. Therefore, you may encounter questions about electrolyte imbalances. Below are sample test questions and answers to help registered nurse students pass the exam. Let's test your knowledge. Q. What is the cause of hypochloremia? A. Hypochloremia can be caused by loss of fluids from vomiting, diarrhea, and sweating. Q. What are the signs and symptoms of hypervolemia? A. The signs and symptoms of hypervolemia are edema, weight gain, shortness of breath, rapid heart rate, confusion, and fatigue. Q: How can dehydration lead to an electrolyte imbalance? A: Dehydration can lead to an electrolyte imbalance due to a decreased concentration of ions in the blood, which disrupts normal bodily functions. Q: How is hypophosphatemia treated? A: Treatment for hypophosphatemia includes oral supplements, intravenous phosphate, and dietary changes. Additional Readings and Resources Need more information about electrolyte imbalances? AllNurses has you covered! Check out these other articles below: Question about the nursing diagnosis: Risk for fluid electrolyte imbalance - Nursing Student Assistance Dialysis Nurses! Help me; I'm painfully new and have no experience Nocturnal Muscle Cramps Understanding Delirium in the Hospitalized Older Adult Wrapping Up Electrolyte Imbalance Nursing Care Plans Electrolytes perform vital body functions. An imbalance can cause systemic symptoms that require prompt assessment and treatment. Nurses are essential to the care, treatment, and resolution of all types of electrolyte imbalances and must be skilled in their care. These nursing diagnoses and care plans provide a solid basis of understanding and can be referenced when creating individualized care plans for patients. If you have other questions or suggestions for other assessments or interventions, please comment below to begin the conversation and receive further support from the AllNurses community. Citations https://pubmed.ncbi.nlm.nih.gov/3684705/ https://www.cancer.gov/publications/dictionaries/cancer-terms/def/diuretic https://www.healthline.com/health/electrolyte-disorders https://www.ncbi.nlm.nih.gov/books/NBK441960/ https://www.ncbi.nlm.nih.gov/books/NBK441960/ https://www.uptodate.com/contents/overview-of-the-treatment-of-hyponatremia-in-adults https://www.ncbi.nlm.nih.gov/books/NBK430714/ https://www.ncbi.nlm.nih.gov/books/NBK549811/ https://www.ncbi.nlm.nih.gov/books/NBK470284/ https://www.ncbi.nlm.nih.gov/books/NBK545269/ Overview of postoperative electrolyte abnormalities - UpToDate
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Table of Contents Signs and Symptoms At-Risk Populations Treatments Caring For Seizure Patients Care Plans for Seizures Additional Nursing Diagnosis for Seizures Seizures NCLEX Questions Conclusion Approximately 1 in every 100 US adults has had at least one unprovoked seizure in their lifetime or was diagnosed with epilepsy. A seizure occurs when there is abnormal electrical activity in the brain and can cause physical symptoms and changes in awareness, behavior, and emotions, depending on which part of the brain is affected. While most seizures don't cause severe or long-term side effects, it's important to note that untreated seizures can be life-threatening. Therefore, seizure care must be swift, accurate, and safety-focused. As a nurse, you must develop a seizure nursing diagnosis care plan tailored to your patient's specific needs to address and prevent seizure activity. In addition, the care plan should educate patients on what to do before and after a seizure, how to minimize triggers and cover all prescribed medical modalities. This guide will teach you some seizure nursing diagnoses and interventions you can include in your care plans for patients with seizures. Signs and Symptoms of Seizure The first step healthcare providers take to diagnose a seizure disorder is identifying the signs and symptoms. Depending on the situation, many patients will experience seizures at home and may even seek emergent medical care. Others will be in a care setting when the seizure happens. In both of the above scenarios, it's critical the physician and other healthcare providers receive an accurate description of what happened during the seizure activity to make the diagnosis. This information must often come from family, friends, or other witnesses because the patient might not remember anything from a few minutes before the seizure begins until a short time after it stops. Signs of seizures can include: Loss of consciousness Uncontrollable movements, such as jerking or shaking Confusion Dazed expressions on the face Difficulty breathing Bladder incontinence It's critical to know that the symptoms may vary from seizure to seizure in the same patient and from one type to another. Because of this, be sure to report any symptoms consistent with a seizure for further diagnosis by a physician. Types of Seizures Understanding the pathophysiology of seizures is crucial to care. It's helpful to be familiar with the different types of seizures when making a seizure nursing diagnosis care plan. Furthermore, understanding the different seizure types will help you identify seizure triggers and have a better chance of preventing a seizure from happening. Below are the most common seizure types. Generalized Seizure This seizure type affects both sides of the brain and is mainly characterized by loss of consciousness or convulsions. There are two types of generalized seizures: tonic-clonic (formerly known as grand mal or convulsive) and absence (formerly known as petit mal). A person with a tonic-clonic seizure may suddenly fall, and their body stiffens. Jerking motions follow in rapid succession. Finally, the individual may lose consciousness or cry out. They may experience confusion or altered consciousness for up to 30 minutes following the seizure. This period is called a postictal state. A person with an absence seizure may experience staring spells and small muscle twitches, such as rapid blinking, lip smacking, or eyelid fluttering. They may or may not lose consciousness or awareness. This type of seizure can be mistaken for daydreaming because the seizure activity is short, usually lasting 15 seconds or less. Absence seizures resolve independently, but the patient might not remember what happened during that period. Focal Seizure A focal seizure, also called a partial seizure, affects one part of the brain and tends to be less severe than a generalized seizure. Where in the brain the seizure happens dictates the symptoms, so it's critical to know that two patients having a focal seizure may have seizures that look quite different. There are three categories of focal seizures: Simple focal seizure - the patient experiences momentary changes in motor or sensory functions, such as losing their sense of smell or taste without loss of consciousness Complex focal seizure - the patient experiences repetitive movements known as automatisms and impaired consciousness and may or may not remember details of the seizure Secondary generalized seizure - the patient experiences a seizure that begins in one part of the brain but moves to another, eventually turning into a generalized seizure At-Risk Populations Anyone, regardless of gender and age, can develop seizures. Nonetheless, some individuals are more prone to them than others. For example, pediatric patients and people over 55 are at an increased risk of seizure disorders. Other groups that may be at a high risk of seizures include individuals with: A brain tumor A brain injury related to head trauma Certain genetic conditions or neurological disorders A family history of seizure disorders Dementia A history of prolonged drug use A history of stroke Acute infection and high fever Changes inside or outside the body often trigger seizures. Therefore, it's essential to know the most common triggers to reduce the likelihood of a patient with a seizure disorder having another seizure. Common triggers include: Dehydration Fevers, especially in pediatric patients Sleep deprivation Menstrual cycle Loud music Flickering lights Severe hypoglycemia Treatments There is a range of seizure treatment options based on seizure type. Below is an overview of the most common treatments. Of course, treatments must be individualized to the patient and the underlying cause of the seizure disorder to be most effective. Medication Anti-seizure medications are the first line of seizure treatment and can help control seizure activity. These include benzodiazepines and antiepileptic drugs, which either stop the seizure from occurring or decrease its duration and severity. However, as with any medications, drugs to treat seizures can have side effects, so be sure to monitor for and report any new complaints by the patient. Some of the most common drugs used to treat seizures include: Phenytoin (Dilantin) Lamotrigine (Lamictal) Levetiracetam (Keppra, Spritam) Carbamazepine (Tegretol) Topiramate (Topamax) Lorazepam (Ativan) Surgery Surgery may be recommended to remove structural abnormalities that cause seizures. This treatment is most effective if the seizures always originate in the same part of the brain. Surgery isn't a first-line treatment but may be used when medications fail to control the seizures. Surgery may also help to identify and treat tumors or lesions that cause seizures. Physicians may perform the following types of surgeries to treat seizure disorders, including: Thermal ablation Lobectomy Hemispherectomy Corpus callosotomy Electrical Stimulation Electrical stimulation may be an effective treatment for seizures with one area of origin that a physician can't safely remove through surgical intervention. Several types of electrical stimulation devices can be used, depending on the type of seizures the patient experiences. These types include vagus nerve stimulation, deep brain stimulation, and responsive neurostimulation. Nurse's Role in Caring For Seizure Patients As a nurse, seizure prevention and management are integral to your practice. You must thoroughly understand seizure types, risk factors, triggers, and treatments to care for seizure patients properly. In addition, educating the patient and their family about seizure precautions and prevention strategies they can utilize at home is also critical. If you work in a pediatric institution or a community setting where you see pediatric patients, you'll play a unique role when caring for those with seizures. Not only will you care for the patient, but you'll also need to educate and support the parents and other family members who may be scared and stressed with worries about their child's health. Nursing Protocols For Seizures Knowing and understanding your facility's seizure protocols is essential. Always work fast to secure a safe environment and monitor the patient during the seizure. Call for assistance from the nursing team and others as needed. General nursing interventions you can use to ensure safety include: Assist the patient to the floor if they are standing or sitting when the seizure happens to ensure safety Place a pillow under their head for protection and to reduce the risk of injury Remove furniture or other objects to allow the patient to move free of injury Turn the patient onto their side to reduce the risk of choking Loosen tight clothing around the neck, chest, and abdomen to allow for easy expansion of the chest during breathing Administer supplemental oxygen if you observe signs of respiratory distress Administer ordered medications to control and stop seizure activity and monitor for side effects Closely monitor the patient once seizure activity stops to ensure safety and assess for needed interventions Nursing Care Plans Related to Seizures Now that you understand the basics of seizure management, you can begin developing nursing care plans for seizure care. Below are some nursing diagnoses and interventions you can use when caring for patients with a seizure disorder. However, it's important to note that care plans must be individualized to the patient and that the below list is not exhaustive. Seizure Nursing Care Plan: Risk For Ineffective Airway Clearance Maintaining a patent airway during a seizure is crucial. Thorough assessment and prompt interventions can minimize lift-threatening situations where the patient can't keep a clear airway unassisted. Patients may be at risk of ineffective airway clearance related to cognitive and neuromuscular impairment. A clear airway reduces the risk of aspiration and minimizes the risk of potential long-term effects of the seizure. Nursing Diagnosis: Risk for Ineffective Airway Clearance Potentially Related to Neuromuscular impairment Cognitive impairment Muscular rigidity in the neck and chest Evidenced by Difficulty breathing Increased respiratory rate Abnormal breathing pattern Desired Outcomes The patient will maintain a patent airway to prevent aspiration during the seizure. The patient will verbalize strategies they can use at home to maintain an open airway during a seizure. Risk for Ineffective Airway Clearance Care Plan Assessment Observe the patient for signs of an obstructed airway. Evaluate the patient's ability to expectorate secretions. Monitor the patient's respiratory rate and breathing pattern. Assess for the need for supplemental oxygen to ease breathing difficulty. Risk for Ineffective Airway Clearance Interventions and Rationales Use padded side rails and place the bed in the lowest position. Rationale: Reduces the risk of injury during a seizure. Evaluate the need for protective headgear and educate the patient on its use. Rationale: Protects against head injuries. Educate on the risk of burns related to cigarette smoking and the need to only smoke with supervision. Rationale: Reduces the risk of burns during the seizure. Stay with the patient during and after the seizure. Rationale: Allows for continuous assessment of injury risk. Support and protect the patient's head and extremities during the seizure. Do not restrain them. Rationale: Reduces the risk of injury and allows the body to move freely. Reorient the patient after seizure activity. Rationale: Allows the patient to recover from disorientation, confusion, or anxiety to limit the risk of injury. Administer medications to stop the seizure according to the treatment regimen. Rationale: Stops convulsions and reduces the risk of injury. Seizure Nursing Care Plan: Risk for Injury The Epilepsy Foundation reports that statistics about seizure-related injuries aren't readily available because many aren't reported or recorded. However, patients are at a heightened risk of injury before, during, and after seizures related to muscle and neurological changes. Therefore, prevention and observation are vital to reducing the patient's risk of injury. Nursing Diagnosis: Risk of Injury Potentially Related to Loss of Consciousness Muscle Rigidity Convulsions Loss of sensations Evidenced by Falls Head trauma Unexplained bruises, lacerations, skin tears, or other injuries Desired Outcomes The patient will be free of injuries during seizure activity. The patient will verbalize at-home strategies they can use to reduce the risk of injury during seizures. The patient will perform a home risk assessment and correct environmental risk factors. The patient will follow the treatment plan to manage seizure activity to reduce the risk of seizure-related injuries. Risk of Injury Care Plan Assessment Assess for seizure triggers and patterns. Assess for caregiver availability. Assess drug-regimen compliance. Note the patient's age, gender, developmental age, and decision-making abilities. Assess the patient's surroundings and remove dangerous objects to minimize seizure-related injuries. Risk for Injury Care Plan Interventions and Rationales Use padded side rails and place the bed in the lowest position. Rationale: Reduces the risk of injury during a seizure. Evaluate the need for protective headgear and educate the patient on its use. Rationale: Protects against head injuries. Educate on the risk of burns related to cigarette smoking and the need to only smoke with supervision. Rationale: Reduces the risk of burns during the seizure. Stay with the patient during and after the seizure. Rationale: Allows for continuous assessment of injury risk. Support and protect the patient's head and extremities during the seizure. Do not restrain them. Rationale: Reduces the risk of injury and allows the body to move freely. Reorient the patient after seizure activity. Rationale: Allows the patient to recover from disorientation, confusion, or anxiety to limit the risk of injury. Administer medications to stop the seizure according to the treatment regimen. Rationale: Stops convulsions and reduces the risk of injury. Seizure Nursing Care Plan: Deficient Knowledge Arming the patient with knowledge about their seizure condition is the best way to reduce the risk of long-term and life-threatening sequelae. Patients with a newly diagnosed seizure disorder will need education about seizure triggers, symptoms, and medications to minimize the frequency and seizure-related risks. In addition, ongoing education is necessary anytime the treatment plan changes or the patient experiences new signs or symptoms. Nursing Diagnosis: Deficient Knowledge Potentially Related to Inadequate knowledge about seizure triggers Poor knowledge about seizure causes Lack of interest in seizure education Inability to remember seizure information Evidenced by Inability to identify seizure triggers Failure to adhere to seizure medications and treatments Increase in seizures Injuries resulting from seizures Desired Outcomes The patient will demonstrate seizure management techniques and measures. The patient will verbalize triggers and strategies to avoid them. The patient will verbalize seizure information, including seizure types and medications. The patient will adhere to their medication and seizure management plan. The patient will have no missed seizure medication doses for 30 days. Deficient Knowledge Care Plan Assessment Assess what the patient knows about their seizure disorder. Assess the level of compliance with the treatment plan. Assess the patient's medication compliance. Deficient Knowledge Interventions and Rationales Review potential triggers. Rationale: Educate the patient on potential triggers so they can limit their exposure to reduce the frequency of seizures. Educate on seizure warning signs. Rationale: Provides information the patient can use to recognize an impending seizure so they can get to a safe place. Instruct the patient to keep a seizure diary. Rationale: Establishes patterns, triggers, and warning signs so the patient can actively participate in their care and seizure management protocols. Educate on the treatment plan. Rationale: Provides information and interventions the patient must use daily to live with the condition safely. Seizure Nursing Care Plan: Caregiver Role Strain Nearly one million adults 55 or older and 470,000 children live with seizures. People in these age groups commonly receive care from others, even without a chronic condition like epilepsy. Caregivers may experience role strain when caring for someone with seizures and trying to juggle other commitments, such as work, caring for other family members, and social involvement. Nursing Diagnosis: Caregiver Role Strain Potentially Related to Stress due to seizure caretaking activities Lack of knowledge about seizure caretaking Ineffective coping strategies Chronic seizures Unpredictability of seizures Inadequate support from family and loved ones Lack of resources like transportation Pediatric patients with new or worsening seizures Evidenced by Physical and emotional exhaustion of the caregiver Inability to meet the seizure management needs of the patient Increase in stress levels Anxiety and depression Isolation from loved ones Failure to care for the patient with seizures Disturbed sleep Inability to maintain employment Desired Outcomes Caregiver voices their own needs and takes actions that support those needs. Caregiver implements effective coping strategies, including relaxation techniques. Caregiver identifies needed community and family resources. Patient reports a decrease in seizure activity which lessens caregiver stress. Patient actively participates in their care as much as possible to relieve the caregiver's burden. Caregiver Role Strain Care Plan Assessment Assess the caregiver's roles and responsibilities. Assess the patient's ability to manage their seizures. Assess the caregiver's support system. Caregiver Role Strain Care Plan Interventions and Rationales Encourage the caregiver to set up respite care and other care coordination support. Rationale: Provides support and rest for the caregiver so they can recover and employ self-care activities. Offer community-based resources. Rationale: Provides the caregiver with information about support groups for education and funds to help with medical, transportation, or housing expenses. Recommend a specialist or epilepsy center. Rationale: Establishes a relationship with a healthcare provider that offers expanded services and support for patients with seizures and those who care for them. Refer to a nurse case manager. Rationale: Provides additional support and resources to ensure the caregiver receives the help they need to provide comprehensive at-home care to the patient with seizures. Seizure Nursing Care Plan: Risk for Falls Seizure patients may experience a seizure type that causes muscular rigidity and jerky movements, resulting in a fall. Sudden falls are evident in seizure patients with both primary and secondary seizure types. It is important to note that falls can cause severe injuries or even death. However, the type of injuries after a fall differs based on the age and gender of the patient. Nursing Diagnosis: Risk for Falls Potentially Related to Muscular contraction and jerking seizure episodes Poor balance Decreased muscle strength Confusion or changes in neurological status Evidenced by Observation of a fall during s seizure Loss of balance during a seizure New bruises, cuts, scrapes, or other injuries following a seizure Desired Outcome The patient will be free of falls during seizures. The patient will be free of injuries during seizures. The patient will verbalize ways to prevent falls during seizures. The patient will demonstrate compliance with medication regimens to prevent seizures, thereby reducing the risk of falls during seizures. The patient recognizes warning signs of a seizure and how to get to a safe place before the seizure happens. The patient reduces exposure to seizure triggers to prevent seizures. Risk for Falls Care Plan Assessment Assess for the occurrence of falls during past seizures. Assess for bruises, scrapes, cuts, and other injuries after a seizure. Assess the patient's location during a seizure if no one witnessed it. Risk for Falls Interventions and Rationales Educate the patient on warning signs and to lie down on the floor or another safe place if they feel a seizure starting. Rationale: Recognition of the start of a seizure and relocation to a safe place reduces the risk of injury. Recommend headgear and educate on its use. Rationale: Using headgear for patients who fall often reduces the risk and severity of injuries. Educate caregivers to assist the patient to the floor before or during the seizure. Rationale: Placing the patient on the floor before the fall or assisting them to the floor during a seizure reduces the risk of injury related to unassisted falls. Seizure Nursing Care Plan: Acute Confusion Seizures may cause disorientation, leading to acute confusion. Seizure patients may show changes in brain activity that cause confusion, delusion, and disorientation just after the seizure stops. Patients with seizures that start in the brain's temporal lobe may have long-term effects that cause confusion and memory problems. It's common for patients with temporal lobe involvement also to experience difficulty finding words. Nursing Diagnosis: Acute Confusion Potentially Related to Changes in brain activity Secondary seizure types Origination of the seizure in the temporal lobe Evidenced by Delusions and disorientation Confused thought process Agitation or restlessness Memory problems Inability to answer questions Inability to find the right words Desired Outcome The patient will be free of confusion after seizures. The patient will reorient quickly after seizures. The patient will recognize the memory or word identification issues and use strategies to help them communicate effectively. Acute Confusion Seizure Care Plan Assessment Reorient the patient after a seizure. Rationale: Assists the patient in understanding they had a seizure and lets them know where they are. Perform neuro-checks on the patient after a seizure. Rationale: Establishes a baseline and ongoing assessment of the patient's neurological status and any changes that may occur. Educate caregivers to assess the patient's neurological status following seizures. Rationale: Provides consistent at-home care for the patient and helps to establish patterns of seizures that may need further treatment. More Seizure Diagnosis Other nursing seizure diagnoses you may need to consider when caring for someone with seizures include: Non-compliance Anxiety Low self-esteem Ineffective seizure control Hyperthermia Risk for trauma Sleep disturbances Depression Seizure NCLEX Test Questions Here are some seizure-related NCLEX test questions to assess your understanding of seizure nursing diagnosis and care plans: True or false, a patient with a tonic-clonic seizure should be placed on their side. A. True B. Fales Answer: A - True You are assessing your patients to determine who has a higher seizure risk. Which of the following patients is most at risk? A. A patient with COPD B. patient with a history of stroke C. patient with a leg fracture D. patient with congestive heart failure Answer: B - A history of stroke places the patient at an increased risk of seizure. You are developing a seizure nursing diagnosis plan for a patient with a seizure disorder. How often should the care plan be updated? A. Daily B. Every two weeks C. Monthly D. As needed Answer: D - As needed, seizure care plans should be updated according to the frequency and severity of the seizure disorder. You are monitoring a patient when they suddenly start seizing. What should you do? A. Stay with the patient until the seizure activity stops B. Restrain the patient for their safety C. Turn them onto their abdomen D. Stimulate the patient's limbs Answer: A - Stay with the patient until the seizure stops; keeping seizure patients safe while seizure activity occurs is vital. Wrapping up Seizure Nursing Diagnoses and Care Plans Caring for patients with seizure disorders requires a holistic and comprehensive nursing care plan. Self-management, with or without the help of caregivers, is crucial to long-term management for those living with seizures. Nurses must actively participate in the care plan and delivery of all treatment modalities to understand knowledge gaps and educate the patient and family accordingly.
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Table of Contents Full-term vs. Preterm Infants Newborn Assessment Nursing Diagnosis and Care Plans Gas Exchange Nursing Assessment Rationales Newborn Diagnoses NCLEX Readings and Resources Wrapping Up Infant delivery is commonplace in the U.S., with more than 3.6 million births annually. Most pregnancies and births happen without adverse events. However, the risk is always there, so nurses must be prepared to intervene quickly. Healthcare providers and nurses are the first professionals that come in contact with neonates and are responsible for ensuring safe delivery and assessing for any life-threatening abnormalities. While newborns have exceptional abilities to adapt to their new environment, it does not rule out the risks of potential problems in the first hours and days of life. The neonatal period is the first 28 days following delivery and is marked by growth and adaptation to breathing, suckling, digestion, and elimination. Unfortunately, it is the most fragile period of life. The World Health Organization reports that death during this period happens due to inadequate or substandard care worldwide. While modern medicine reduces deaths, the CDC reported 5.4 deaths per 1,000 live births in the U.S. in 2020 alone. This article provides an overview of full-term newborn nursing care. Once we establish baseline information, we'll provide common newborn care plans you can use in your practice. Full-term vs. Preterm Infants This article focuses on caring for full-term infants and their parents or caregivers. It's critical to understand the difference between a preterm and full-term pregnancy to establish your baseline understanding. The CDC defines preterm birth as babies born before 37 weeks gestation. About one in every ten births in the U.S. meet this definition. The last few months in utero are when critical growth and development of the lungs, liver, and brain happens. So, babies born before they reach full-term (39 weeks gestation) may experience life-threatening conditions. Importance of the Newborn Assessment Nurses must begin their assessment the minute the baby is delivered. It's important to note that the assessment for preterm and full-term infants is essentially the same. However, care strategies and interventions vary significantly and must be individualized to the newborn's gestational age and the presence or absence of normal body functions. While a head-to-assessment is needed, nurses typically use one or more evidence-based assessments to establish the newborn's baseline function and overall well-being. Below are the most common assessments done during the nursing process at birth. Definitions of normal and abnormal findings are provided too. Size Parameters Healthy newborns come in all sizes. Standard size measurements obtained at birth include weight, length, and head circumference. Average newborns weigh between 7 and 7.5 pounds—however, a baby weighing between 5 pounds, 11 ounces and 8 pounds, 6 ounces is within normal limits. Low birth weight is any weight under 5 pounds, 8 ounces, and larger than average babies weigh over 8 pounds 13 ounces. Many factors can impact the newborn's weight, such as Maternal health and nutritional status - Poor nutrition or overall health can affect the baby's growth and development Gestation - preterm newborns are typically smaller, and babies born past their due date may be larger at birth Maternal smoking - mothers who smoke often have smaller-than-average babies Gender - boys usually weigh more than girls at birth Family history - size and weight at birth may run in families Gestational diabetes - mothers who have diabetes during pregnancy commonly deliver larger-than-average newborns Multiples - pregnancies with more than one baby typically have lower birth weight infants The average length of an infant at birth is between 19 to 20 inches. Full-term babies between 18.5 and 21 inches long are within normal length limits. The last measurement obtained at birth is the frontal-occipital or head circumference. This standard nursing assessment indicates normal brain development and ranges between 13 and 14 inches at birth. Wrap a measuring tape around the broadest part of the infant's head to perform this measurement. The tape measure should be just above the eyebrows and ears and wrap around the back of the head where it slopes to the neck. Vital Sign Measurement Nurses obtain complete vital signs immediately after birth as part of a thorough nursing assessment. Normal vital sign ranges include: Temperature: 97.7 - 99.4 Fahrenheit (36.5 - 37.5 Celsius) Pulse: 120-160 beats per minute Respirations: 30-60 breaths per minute Blood pressure: 75-50/45-30 mm Hg at birth APGAR Scoring The APGAR scoring happens at the first and fifth minutes of life and is a good predictor of neonatal mortality. This standard assessment is divided into five categories, each represented in the acronym: Activity, Pulse, Grimace, Appearance, Respiration/breathing. If the one-minute score is low, the nurse and healthcare provider will administer the appropriate interventions and treatments, such as oxygen or stimulation. Most babies improve by the five-minute assessment. However, if the baby's status has not improved at this time point, the nurse obtains a third APGAR score 10 minutes after birth. Scores between 7 and 10 are within normal limits. A score between 4 and 6 is moderately abnormal, and scores of 3 or below are concerning. Suppose the child's condition does not improve with standard interventions. In that case, the baby may require a higher level of care and be transferred to the neonatal intensive care unit for assessment by the pediatric nursing team. Each assessment category receives a score of 0 to 2 points, with the highest possible overall score of 10. It's normal for most babies to get a score lower than 10 during the first few moments of life because their hands and feet may appear blue as they learn to breathe outside the womb. Below is the rubric used during the APGAR scoring: Activity/muscle tone 0 points - limp or floppy 1 point - limbs flexed 2 points - actively moving Pulse/heart rate 0 points - absent pulse 1 point - pulse below 100 beats per minute 2 points - pulse over 100 beats per minute Grimace 0 points: absent response to stimulation, such as suctioning of nares 1 point: facial movement or grimacing with stimulation 2 points: crying, coughing, sneezing, or withdrawing feet to stimulation Appearance 0 points: full-body paleness, blue or bluish-gray skin color 1 point: pink body, but blue extremities 2 points: pink skin color all over Respiration/breathing 0 points: absent breathing 1 point: weak cry, irregular breathing 2 points: strong cry There is some hesitancy within the medical community regarding APGAR scoring. However, observing the baby holistically helps determine the nursing care plan and interventions. A low APGAR score may be related to the following: Complicated deliveries Preterm infants Cesarean delivery Standard Head-to-Toe Nursing Care Standard newborn nursing care includes: Looking for signs of respiratory distress, such as wheezing, labored breathing, or apnea Assessing overall cardiovascular status, including heart rate and rhythm, and providing stimulation or positive pressure ventilation as needed Monitoring body temperature and drying and swaddling the infant to reduce heat escaping Performing APGAR scoring Administering Hepatitis B and Vitamin K vaccination within 1 hour of delivery Measuring weight, length, and head circumference Obtaining routine newborn blood tests via heel stick Initiating breastfeeding early Promoting skin-to-skin contact Assessing parent-child bonding Nursing Diagnosis and Care Plans for Parents of Newborns The nursing process, assessment, and interventions play a crucial role in the care of the newborn at birth. Nurses also provide care and support to the mother during the postpartum phase and provide education to help the new caregivers bond with and provide care to their infant. A delicate balance of skilled nursing care, empathy, and compassion can create a holistic and comprehensive care environment for everyone. Below are some of the most common nursing diagnoses for newborns. Nursing Diagnosis: Risk for Hypothermia Keeping the newborn warm immediately following birth is essential. A high surface area to volume ratio makes losing too much heat easy. Low birth weight infants are at an increased risk and may experience rapid heat loss and hypothermia if nursing interventions to combat the problem are not instituted quickly. Potentially Related To High surface area to volume ratio Pre-term birth Low birth weight Presence of infectious disease Thin skin that allows heat loss Lack of shiver response to increase warmth Inadequate subcutaneous fat stores Inadequate thermoregulation function Cesarean delivery Evidenced By Low body temperature Desired Outcomes The patient will maintain a body temperature within normal limits. The parents/caregivers will demonstrate proper dressing and swaddling techniques. The parents/caregivers will verbalize normal body temperature and ways to prevent heat loss. Risk for Hypothermia Nursing Assessment 1. Assess the body temperature. 2. Monitor for risk factors, such as preterm birth, low birth weight, and infection. 3. Assess for signs of cold stress. Risk for Hypothermia Interventions and Rationales 1. Dry the newborn, dress, and swaddle in a warm blanket. Rationale: Wet skin from birth increases heat loss and feelings of coldness. Swaddling helps to hold in warmth and maintain body temperature. 2. Utilize isolettes and radiant warmers as needed. Rationale: Provides external warming to combat heat loss. 3. Cover the head with a cap. Rationale: Prevents heat from escaping from the head, which is a large percentage of the newborn's body surface. 4. Educate the parents/caregivers on keeping the newborn warm. Rationale: Assists in the successful transition to parenting and helps with thermal regulation after birth. Nursing Diagnosis: Risk for Impaired Gas Exchange Newborns must adapt to their new environment quickly. This adaptation relies heavily on the lung's ability to breathe normally outside the uterus. Unfortunately, prematurity, congenital disabilities, and acquired infections can impair the lung's ability to maintain gas exchange within normal limits. Because a newborn's respiratory status can lead to heart failure, nurses must promptly perform a thorough respiratory assessment and provide needed interventions. Potentially Related To Increased metabolic rate due to change of environment at birth Poor lung function Reduced functional residual capacity Cold stress at birth Excess mucus secretions in the respiratory tract Evidenced By Abnormal breathing Nasal flaring Cyanosis Hypoxemia Retractions Desired Outcomes The patient will maintain ABGs within normal limits. The patient will maintain oxygen saturation within normal limits. The patient will maintain respiratory patterns and effort within normal limits. Risk for Impaired Gas Exchange Nursing Assessment Conduct a thorough respiratory assessment. Monitor ABGs, pulse oxygenation, and other blood tests for signs of circulatory, respiratory, or metabolic problems. Monitor for nasal flaring, retractions, grunting, and other signs of labored breathing. Assess the parent's understanding of the infant's respiratory status. Assess the parent's understanding of signs of respiratory distress. Risk for Impaired Gas Exchange Nursing Interventions and Rationales 1. Suction the airway. Rationale: Removes secretions to allow for easier breathing 2. Administer oxygen. Rationale: Improves gas exchange. 3. Stimulate the infant. Rationale: Wakes the baby up and stimulates breathing. 4. Assess the need for mechanical ventilation. Rationale: Provides external breathing mechanism if the child lacks respiratory drive. Nursing Diagnosis: Risk for Infection A newborn's immune system is immature for the first few months of life. This immaturity increases the risk of contracting infections and may allow infectious processes to become life-threatening quickly. Therefore, the nurse must assess for signs and symptoms of infection and educate parents and caregivers on ways to keep the infant safe while the immune system continues to develop. Potentially Related To Inadequate immunity Exposure to pathogens in the environment Traumatized tissues Decreased action of the cilia in the lungs Inadequate immune response in the blood system Trauma at delivery Congenital anomalies Prematurity at birth Evidenced By Increased WBCs Fever Localized signs of infection related to the primary site Desired Outcomes The patient will be free of signs and symptoms of infection. The parents/caregivers will verbalize three ways to prevent infection. The parents/caregivers will demonstrate infection prevention strategies. The parents/caregivers will demonstrate proper hand hygiene before discharge home. Risk for Infection Nursing Assessment Assess the body temperature for signs of fever. Assess for congenital anomalies, prematurity, and delivery trauma. Monitor for signs of infection. Assess for signs of immunity. Assess the parent/caregiver's knowledge of infection control strategies. Assess for early signs of sepsis or septic shock. Risk for Infection Nursing Interventions and Rationales 1. Encourage breastfeeding. Rationale: Provides immunoglobulins to build up the newborn's immune system. 2. Follow infection control and hand hygiene protocols Rationale: Decreases the risk of exposure to pathogens. 3. Educate the parents/caregivers on infection control and hand hygiene protocols. Rationale: Decreases the risk of exposure to pathogens. 4. Administer antibiotics and other medications as prescribed for an actual infection. Rationale: Treats causative pathogens. Nursing Diagnosis: Risk for Unstable Blood Glucose Levels While infants must adapt to life outside the uterus, their time inside may still affect them for the first hours or days after birth. Blood glucose levels may be unstable just after delivery and can cause adverse effects on the child. Monitoring blood glucose levels and other signs and administering prescribed interventions is a critical role of the nurse. Potentially Related To Inadequate maternal nutrition during pregnancy Poorly controlled maternal diabetes Pancreatic tumors at birth Congenital metabolic diseases or disabilities Birth asphyxia Infection Evidenced By Cyanosis Shakiness Apnea Hypothermia Lethargy Poor muscle tone Seizures Lack of interest in breast or bottle feeding Desired Outcomes The patient will maintain a blood glucose level within normal limits. Risk for Unstable Blood Glucose Levels Nursing Assessment 1. Educate the mother and other caregivers on maternal risk factors and the need for blood glucose instability monitoring at birth. Rationale: Promotes understanding and involvement in the newborn's care. 2. Encourage early breast or bottle feeding. Rationale: Prevents and treats hypoglycemia. 3. Administer glucose supplements as ordered. Rationale: Prevents and treats hypoglycemia. 4. Educate parents/caregivers on signs of low blood glucose. Rationale: Promotes care of the newborn and caregiver-child bonding. Nursing Diagnosis: Ineffective Breastfeeding Breastfeeding benefits both the mother and the newborn. Breast milk provides needed nutrients and antibodies, protects against infant illnesses, and reduces the mother's risk of high blood pressure and ovarian cancer. It's essential to honor each family's decision about breastfeeding while educating them on the benefits. Some mothers may struggle to produce milk or experience mastitis and other complications that can make breastfeeding challenging. Be sure to provide support, empathy, and education together because other factors may outweigh the desire to breastfeed. Potentially Related To Poor or weak suck reflex Preterm infant History of maternal breast surgery Congenital anomaly prohibiting sucking or swallowing Lack of knowledge about the importance and benefits of breastfeeding Lack of family or partner support Evidenced By Newborn crying during breastfeeding attempts Newborn pulling away or arching away from the breast during feeding Newborn crying or rooting within one hour of feeding Inadequate breast milk production Poor or resistant latching Insufficient weight gain Too few wet and dirty diapers Sore nipples past the first week of life Desired Outcomes The infant will achieve effective breastfeeding. The mother will verbalize breastfeeding difficulties and seek assistance. The mother will be free of signs of mastitis or other infections. The infant will be satisfied after breastfeeding. The mother will verbalize feeling comfortable with breastfeeding techniques. Ineffective Breastfeeding Nursing Assessment Assess the structure of the mother's breast and nipples for abnormalities. Assess the mother's knowledge of lactation and breastfeeding. Assess the mother's milk flow. Assess for family or significant other support. Assess the infant's ability to latch onto the breast. Assess the infant's suckling reflex. Assess for newborn abnormalities that impact feeding, such as cleft lip or palate. Ineffective Breastfeeding Nursing Interventions and Rationales 1. Educate parents/caregivers on lactation and breastfeeding. Rationale: Promotes understanding and sets realistic expectations. 2. Educate parents/caregivers on the correct infant positioning during breastfeeding. Rationale: Promotes successful breastfeeding. 3. Provide a calm and quiet atmosphere during breastfeeding. Rationale: Reduces distractions and helps the mother relax, which assists with releasing breast milk. 4. Educate parents/caregivers on burping the infant after every breastfeeding session. Rationale: Prevents reflux and feeding-related discomfort in the infant. Nursing Diagnosis: Ineffective Infant Feeding Pattern The nurse in the labor and delivery room plays an integral role in the timing of the first breastfeeding session, which should be within the first few minutes of life. Initial breast milk, called colostrum, is packed full of disease-fighting nutrients which help the newborn's immune response. As the nurse, you might notice difficulty with this first feeding. However, most of the time, ineffective feeding patterns take hours or days to appear. The newborn may have trouble coordinating their suck/swallow responses, leading to poor oral intake that doesn't meet metabolic needs. Early detection of ineffective feeding patterns reduces the risk of poor weight gain and often prevents the parent/caregiver's decision to stop breastfeeding prematurely. Potentially Related To Defects of the soft palate Prematurity Neurological impairment or delay NPO status of the infant Evidenced By Maternal reports of poor latch and feeding schedule Infant weight loss Desired Outcomes The infant and mother will establish a feeding routine within normal limits. The mother will demonstrate strategies to deal with an ineffective feeding pattern. The infant will gain weight. Ineffective Feeding Pattern Nursing Assessment Observe breastfeeding sessions for difficulty. Assess for defects of the soft palate. Monitor the number of wet and dirty diapers. Monitor for weight loss. Ask the parents/caregivers about feeding patterns. Ineffective Feeding Pattern Nursing Interventions and Rationales 1. Minimize stimulation during breastfeeding sessions. Rationale: Reduces stimuli that can interrupt the infant's feeding. 2. Offer alternative methods of feeding as needed. Rationale: Maintains infant weight. 3. Educate the parents/caregivers on alternate feeding positions. Rationale: Provides knowledge of alternate positions that may ease the stress on the parents and infant. 4. Instruct the parents/caregivers to keep a feeding journal. Rationale: Provides information about the feeding patterns over time. Nursing Diagnosis: Risk for Neonatal Jaundice Many infants experience hyperbilirubinemia at birth due to the immaturity of the liver. Usually, the liver filters bilirubin from the blood and gets rid of it through the intestines. However, a newborn's immature liver cannot perform this function, which causes excess bilirubin in the blood. As a result, hyperbilirubinemia causes a distinct yellowing of the skin that usually appears within the first few days of life. Jaundice in the newborn usually resolves independently or with at-home treatments, such as placing the baby in direct sunlight. However, in rare cases, neonatal jaundice is caused by an underlying disease or congenital anomaly that cannot resolve without surgery, medications, or other interventions. Potentially Related To Hyperbilirubinemia Rh incompatibility Prematurity Breastfeeding Immature liver Neonatal sepsis Liver disease Biliary atresia Abnormal red blood cell function Evidenced By Yellow skin tone Yellowing of the whites of the eyes Dark yellow urine Pale colored stools Lethargy Poor feeding Inadequate weight gain Desired Outcomes The infant will be free of signs of hyperbilirubinemia. Risk for Neonatal Jaundice Nursing Assessment Examine infant skin color in a well-lit room. Blanch the skin to assess the color. Monitor bilirubin blood levels and Coomb's test lab values. Educate on the need for liver and bile duct ultrasound, if indicated. Risk for Neonatal Jaundice Nursing Interventions and Rationales Administer phototherapy as ordered. Rationale: Special lighting that produces blue-green light alters the structure of the bilirubin molecules and promotes excretion, lowering blood levels. Administer IVIG as prescribed. Rationale: Alleviates jaundice in Rh incompatibility. Administer blood transfusions as prescribed. Rationale: Dilutes bilirubin levels in the blood. Educate the parents/caregivers on the condition and interventions to take at home. Rationale: Promotes parent/caregiver's ability to care for the child at home independently. Encourage frequent feeding sessions. Rationale: Lowers bilirubin levels by flushing it out of the infant's system. Nursing Diagnosis: Impaired Parent/Newborn Attachment While most parents bond quickly with their newborn, some experience a disruption of the interaction between the parent or caregiver and the infant. This disruption can lead to impaired attachment and a limited or absent bond between the two. In addition, a lack of connection between the caregivers and the infant at birth can create problems in the newborn, such as poor feeding patterns, weight loss, and feelings of abandonment that can have long-lasting effects. The nurse has a frontline view of the parent/child connection at birth. It's critical to observe this connection closely, provide support, and educate the parents as needed. Potentially Related To First-time parenting Knowledge deficit of newborn care Parent/caregiver anxiety Psychological or cognitive impairment of the parent/caregiver Post-partum depression Poor health of the parent or child at birth Evidenced By Inadequate infant soothing offered by the parent/caregiver Lack of bond between the two Physical distance between the parent/caregiver and child Poor feeding, weight loss, or infant failure to thrive Desired Outcomes The parent/caregiver will demonstrate acceptable parenting behaviors. The parent/caregiver will provide a secure environment for the child. The parent/caregiver will attempt skin-to-skin contact and other strategies to connect with the child. Impaired Parent/Newborn Attachment Nursing Assessment Observe the parent/child connection. Assess the parent/caregiver's response to the infant. Asses the infant for signs of overall well-being, such as weight gain. Impaired Parent/Newborn Attachment Nursing Interventions and Rationales Provide time for the parent/caregiver to discuss any fears, worries, or needs about the relationship with their newborn. Rationale: Encourages open and honest conversation so you can create a holistic plan for the parent/caregiver and child. Offer praise and support when you observe a parent/child bond. Rationale: Offers support and encouragement for acceptable behaviors. Encourage skin-to-skin contact at birth and continuing throughout the first few weeks or months of life. Rationale: Promotes parent/child bonding. Offer community-based classes on parenting as needed. Rationale: Provides ongoing education and support and positive parent/child bonding examples. Educate the parents/caregivers on routine care of the newborn. Rationale: Bridges any potential knowledge gap regarding infant care. Educate parents/caregivers on normal newborn development. Rationale: Provides knowledge of normal and abnormal development and when to seek additional support or treatment. More Newborn Diagnoses Other nursing care plans that may be appropriate for newborn care include: Risk for hyperthermia Imbalanced nutrition: less than body requirements Compromised family coping Risk for injury Deficient fluid volume Failure to thrive Newborn NCLEX Test Questions It's never too early to take practice NCLEX test questions. A few questions about newborn care you practice with are below. Which option below best describes how to assess an infant's palmar grasp reflex? a. Gently stroke the infant's cheek and assess if the head turns. b. Stimulate the sole of the foot by stroking from the heel upward. c. Stroke the inside of the infant's hand, assessing if the fingers close around the object, providing stimulation. d. Assess if the infant moves the legs in a stepping motion when held upright with the feet touching a surface. An average heart rate at birth is: a. 120 beats per minute b. 60 beats per minute c. 220 beats per minute d. 75 beats per minute Which statement below best represents how to obtain an infant head circumference measurement? a. Wrap the tape measure around the infant's head at the level of the eyebrows. b. Place a tape measure just under the ears and wrap it around the head. c. Wrap a measuring tape around the broadest part of the infant's head, just above the eyebrows, ears, and around the back of the head where it slopes to the neck. d. Place the tape measure at the mid-point of the ears, above the eyes, and at the base of the skull. Additional Readings and Resources Did you know AllNurses has more content on newborns and related topics? Check out these great articles below: Tips for Newborn Screenings Assessing a newborn being held by mom NICU Nurse's Guide to Respiratory Distress Syndrome Wrapping Up Newborn care is an exciting area of nursing care. You get to witness the miracle of life repeatedly and support parents and caregivers when they need it most. We hope these newborn nursing care plans help you in your nursing care journey! References: https://www.CDC.gov/nchs/fastats/births.htm https://www.who.int/europe/news-room/fact-sheets/item/newborn-health https://www.CDC.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm https://www.CDC.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm https://onlinelibrary.wiley.com/doi/abs/10.1111/PPE.12360 https://www.sciencedirect.com/science/article/abs/pii/S0300957220302136 https://my.clevelandclinic.org/health/diseases/21053-rh-factor https://med.stanford.edu/newborns/professional-education/jaundice-and-phototherapy/the-coombs--test.html
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Table of Contents Understanding Obesity Nursing Care Plans More Nursing Diagnoses Obesity NCLEX Questions Readings and Resources Additionally, 50 percent of people surveyed by Harvard University in January 2022 reported weight gain since the beginning of the COVID-19 pandemic, making this condition even more complex today. Obesity puts individuals at risk of severe health issues, including heart disease, stroke, and diabetes. In addition, those living with obesity can experience social and psychological problems along with physical health issues. Therefore, proper assessment of obese patients is essential to determine the best course of treatment. This article provides six obesity nursing diagnoses and care plans nurses can use when caring for patients living with obesity. Understanding Obesity Obesity occurs when one's body stores excess body fat. It happens over time and can be caused by other underlying conditions or illnesses if not treated. Managing obesity is a complex process that requires a comprehensive, multidisciplinary approach. Obesity doesn't just constitute a physical condition but also has psychological, emotional, and social aspects. For example, shorter sleep durations of less than seven hours can cause metabolic and hormonal changes, leading to weight gain. And weight gain can negatively impact a person's body image, causing severe psychological and social problems. This continuous cycle might leave the patient dealing with physical, social, and psychological conditions that must be treated individually while also treating the underlying obesity. Diagnosing Obesity A medical provider diagnoses obesity by examining several factors during a physical exam. A thorough health history may reveal healthy and unhealthy habits concerning weight gain, weight loss, exercise, medications, stress, and appetite. The physician will ask about other conditions that may have caused the obesity before developing a treatment plan. This includes high blood pressure, diabetes, underactive thyroid disease, and high cholesterol. The patient's height, weight, and waist circumference provide data to diagnose obesity. One tool commonly used is the body mass index (BMI). This calculation is done by taking the patient's weight in kilograms or pounds and dividing it by the square of their height in meters or feet. An individual with a BMI of 30 or higher is considered obese, and 40 or higher is categorized as severely obese. Obesity can onset due to genetic, behavioral, environmental, and medical factors. It's essential to understand that BMI isn't interpreted in the same manner for children and teens, even though the same calculation is used. Causes of Obesity Obesity is caused by several factors, including: Eating more calories than the number burned Lack of physical activity or exercise Genetic predisposition Medications Medical condition Risk Factors of Obesity A patient's behaviors may place them at a heightened risk for obesity. Factors that put a person at a higher risk include: Unhealthy eating habits, such as overeating or eating high-calorie, low-nutrient foods Sedentary lifestyle Over 45 years of age Sleep deprivation High or uncontrolled stress levels Complications Being obese is directly related to several comorbid conditions, including: Asthma Sleep apnea Stroke Heart disease Diabetes type 2 Gout Osteoarthritis Gastroesophageal reflux Fatty liver Treatment and Prevention The best treatment plan for obesity is to prevent it from happening. Preventative measures include establishing healthy habits such as a well-balanced diet, regular exercise, managing stress, and getting adequate sleep. Once obesity happens, it usually takes a multidisciplinary approach to treat the root cause of the disease. In addition, the treatment plan must include lifestyle changes such as improving eating habits, increasing exercise or physical activity, and learning how to manage stress levels. For some patients, behavioral changes alone won't be enough to treat obesity. In these situations, the patient might require medications or surgery. However, both treatment modalities have potentially serious risks, so this treatment regimen is usually reserved for severe cases only. Nursing Care Plans for Obesity Now that we've covered the basics of obesity let's dive into six obesity nursing diagnoses and care plans. It's essential to note that many care plans could be related to obesity based on the patient's specific situation. Therefore, this is not an all-encompassing list. Here are six obesity nursing diagnoses. Imbalanced Nutrition: More Than Body Requirements Overeating isn't the only reason people gain weight. Many people eat average amounts of food but gain weight because of the kinds of foods they consume. A healthy diet must consist of the right types and amounts of food combined with a healthy exercise regimen. Potentially Related to: Excess food intake Lack of nutritious food due to socioeconomic status Psychosocial factors, such as depression Evidenced By BMI of 30 or higher Weighing 20% or more over ideal body weight Excess body fat Observed or reported dysfunctional eating habits Desired Outcomes: Patient's calorie intake meets metabolic needs, which leads to weight loss. Patient will make healthy food choices. Patient will actively participate in their meal planning. Assessment: Ask the patient about their diet and exercise habits. This question establishes if they have unhealthy habits contributing to obesity. Instruct the patient to keep a daily food diary noting caloric intake and the amounts and types of foods consumed. Then, review the food diary weekly with the patient. This activity provides clarity around poor eating habits. Obtain the patient's height, weight, and abdominal circumference to evaluate the degree of fat by using the BMI calculation. Interventions with Rationale Educate the patient about emotional eating. Talk to them about what triggers overeating or other poor eating habits. Rationale: Establishes if the patient eats to satisfy an emotional need rather than physiological hunger. Create a simple eating plan with the patient that considers their current weight and eating habits and patterns. Rationale: Involving the patient in creating the eating plan helps with compliance. Instruct the patient to include craved foods in their eating plan. Rationale: The patient shouldn't feel that any foods are off-limits. This strategy helps them create healthy limits on foods while knowing they still get to eat the foods they enjoy the most. Establish realistic weekly weight loss goals. Rationale: Losing a few pounds each week helps the patient see progressive improvement. This type of weight loss usually has a lasting effect. Create an exercise plan that increases the time and difficulty of the activities weekly. Rationale: Exercise goals must be realistic to avoid feelings of defeat and premature quitting. Starting slowing and building a longer or more intense workout weekly increases the likelihood of success. Sedentary Lifestyle According to the American Psychological Association, 50 million Americans live sedentary lifestyles. This means they sit or lean most of the day. A sedentary life increases individuals' risk of obesity and other health conditions. Potentially Related to: Lack of motivation or interest Lack of resources for classes or memberships Inadequate knowledge about the importance of activity Fear of injury Comorbid conditions that limit activity levels Safety concerns related to exercise Evidenced By Poor overall health and condition Observed or reported a sedentary lifestyle Desired Outcomes: Patient will verbalize the importance of regular physical activity to obtain a healthy weight. Patient will verbalize any needed safety precautions and monitoring techniques to ensure safety. Patient will set realistic exercise goals that gradually increase activity. Patient will participate in at least 30 minutes of physical activity per day. Assessment Ask the patient about their current activity level. Ask the patient about their desired activity level. Ask the patient about perceived or actual barriers to exercise. Observe the patient's daily routine for activity or exercise. Interventions with Rationale Educate the patient on the health benefits of regular exercise. Rationale: Educating the patient about the benefits increases compliance and motivation. Provide ideas of ways to combat a sedentary lifestyle. Rationale: Patients may feel that leading an active lifestyle isn't possible if they work a desk job or have underlying conditions that make exercise challenging. Providing creative ways to increase activity slowly helps them see it's possible and adopt these practices. Educate on an exercise plan, including any needed equipment. Rationale: By providing education on an exercise plan and working with the patient, you'll have the opportunity to answer any questions they might have and be able to demonstrate how to use exercise equipment. Ask for a physical, occupational, or exercise therapy consult to help develop a progressive exercise plan. Rationale: A multidisciplinary approach to a sedentary lifestyle helps educate and implement a successful plan. The therapy team can provide exercises and parameters to ensure the patient's safety while increasing activity. Disturbed Body Image Body image is how a person thinks and feels about their body. It may or may not relate to what they look like. The people around them and societal standards can affect a person's body image. Research shows that a person living with obesity may be dissatisfied with their body even after losing weight. The most significant body image issues are seen in those with child or adolescent-onset obesity, females, and people with binge eating disorders. Potentially Related to: Societal norms around weight Family or peers encouragement about the need to change eating habits Evidenced By Verbalizing a negative body image Fear of others rejecting or reacting to one's body Preoccupation with weight and the need to change or "fix" it Verbalizing feelings of powerlessness or hopelessness related to their body or eating habits Desired Outcomes: Patient will verbalize a realistic self-image. Patient will accept their body as is. Patient will participate in a healthy exercise regimen and diet plan that helps them lose appropriate weight. Assessment Ask the patient how they feel about their weight to determine their body image. Observe how the patient interacts with others concerning their body image. Interventions with Rationale Provide privacy during care. Rationale: Patients who are sensitive or self-conscious about their bodies may need more privacy to feel safe and comfortable. Providing privacy shows respect and builds trust between the nurse and the patient. Promote open communication about their feelings and behaviors free of judgment. Rationale: This supports the patient and helps develop a trusting relationship to get to the root cause of their obesity. Graph weight loss weekly. Rationale: Providing a visual account of weight loss based on data helps orient the patient to reality so they can set realistic and achievable goals. Educate on types of fitness, including those the patient can build up to. Rationale: Offering a variety of fitness ideas helps the patient stay engaged and motivated. You can offer weight training, mobility exercises, stretching, yoga, and endurance and strength training. Impaired Social Interaction Obesity often comes with significant or severe psychological and social burdens. One study found that individuals living with obesity experience more discrimination in healthcare, are less likely to get married and earn less money compared to peers without obesity. Being treated differently can change the desire to be around others and even cause the person with obesity to resist relationships of all kinds and socially isolate to avoid being hurt. Addressing impaired social interactions in patients with obesity is a critical task that the nurse must do with care. Potentially Related to: Verbalization or observed discomfort when in social situations Disturbance of self-esteem or self-concept Evidenced By Reluctance or refusal to participate in social interactions Verbalization of discomfort being around others in social settings Desired Outcomes: Patient will verbalize awareness of feeling uncomfortable in social situations. Patient will verbalize possible actions to help feel more comfortable in social gatherings. Patient will demonstrate improved interactions and behaviors when in social situations. Assessment Assess for social stigmas around obesity in the patient's culture to better understand their feelings. Assess for the presence of psychological illnesses that could be an underlying cause of obesity. Assess the patient's defense mechanisms and coping skills used in social interactions that could be the cause of social isolation. Interventions with Rationale Suggest using positive self-talk such as "I enjoy life" or "I enjoy social interactions" before attending social gatherings. Rationale: Positive self-talk promotes confidence and helps patients embrace the changes they need to take. Refer the patient and family for therapy. Rationale: Impaired social interaction may be a long-standing behavior that takes time and special care. A licensed counselor can help patients create support systems and plans to help them feel better in social settings. Help the patient set motivational goals. Rationale: Helping the patient develop reasons to keep them on track with goals can increase compliance. Examples of motivational goals include feeling confident in a new outfit or swimsuit or being comfortable during intimacy. Deficient Knowledge Some patients may not fully understand the risks of being obese. Nurses help bridge the knowledge gap by educating the patient and giving them all the needed information to make informed decisions. Potentially Related to: Lack of information Misinterpretation of information Lack of interest in learning needed information Lack of receiving accurate or complete information Evidenced By: Verbalization of inability to lose weight Requesting information about nutritional needs, obesity, and diet Past inabilities to achieve diet and exercise modification Desired Outcomes: The patient will verbalize two to three lifestyle changes they can make to lose weight. The patient will seek information about healthy nutrition and exercise regimens. The patient will create a weight loss plan and accompanying goals. Assessment: Assess the patient's understanding of healthy eating and the need for exercise. Ask the patient what resources they use when making diet and exercise choices. Interventions with Rationale Educate the patient on healthy eating and exercise habits to create a healthy lifestyle. Rationale: Helping the patient focus on wellness instead of weight loss may increase the likelihood of losing and keeping it off. Provide a list of resources for books, community classes, online websites, and groups. Rationale: Providing various resources helps the patient explore options to choose the right resources for themselves. Educate on a variety of non-food rewards the patient can use for accomplishments. Rationale: This intervention helps reduce the likelihood of emotional eating. Encourage the patient to get involved in non-food-related activities, such as hiking or walking. Rationale: This strategy allows the patient to have fun in a controlled environment without the risk of being tempted by poor food choices. Impaired Physical Mobility Patients living with obesity may struggle to make independent and purposeful physical movements. This limitation can place them at a higher risk of continued weight gain, making losing weight more challenging. Therefore, the nurse must address this problem with practical ways the patient can increase physical mobility, even if it's small incremental changes. Potentially Related to: Sedentary lifestyle Comorbid conditions Poor overall health Evidenced By Verbalization or observation of the lack of ability to move independently and purposefully Desired Outcomes: The patient will increase mobility, as evidenced by increased daily activity and weight loss. The patient will participate in 10 minutes of physical activity daily for one week and then increase the movement by 5 minutes daily up to a maximum of 60 minutes. The patient will lose at least three pounds each week for four weeks. Assessment Assess the patient's mobility to establish a baseline for treatment. Assess the patient's motivation and willingness to increase mobility to lose weight. Interventions with Rationale Create an individualized plan that considers the patient's baseline mobility status. Rationale: Tailoring a plan to the patient makes the goals realistic and attainable, which will help with compliance. Educate the patient on the importance of starting with a low-intensity, short-interval exercise plan. Rationale: It's critical to consider that the patient may be deconditioned due to lack of movement. Short and easy exercises will improve endurance over time. Educate the patient on the possible complications of obesity. Rationale: A sedentary lifestyle puts the patient at a higher risk of high blood pressure, diabetes mellitus type 2, and heart disease. More Obesity Diagnoses Hopelessness related to the inability to lose weight Fatigue related to deconditioning and excess weight Obesity NCLEX Test Questions You may encounter questions on the NCLEX about obesity. Below is a sample question to help you prepare. Which nursing action should the nurse take when coaching obese adults enrolled in a behavior modification program? a. Ask the adults about situations that usually increase their appetites b. Instruct the adults to write the caloric intake of every meal in a food diary c. Encourage the adults to eat small frequent meals d. Encourage the adults to reward themselves with sugarless candy to achieve goals Correct Answer: A Rationale: Behavior modification programs help the patient identify the cause of negative behaviors. By asking the adults to tell you about situations that increase their appetites, you are identifying behaviors they can modify. Additional Readings and Resources: Obesity in the Digital Age Tricks for hearing heart sounds in patients with obesity Wrapping Up Nursing Diagnosis for Obesity Care Plans for Obesity Obesity is a significant health issue affecting millions of people worldwide. It can disrupt the patient's quality of life, increase the risk of serious conditions, and cause emotional and psychological distress. Nurses can make a difference in the lives of patients living with obesity by providing education, setting realistic goals, and helping them develop healthy behaviors. With proper care and support, patients can set realistic weight loss, exercise, and diet goals that they can achieve.
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Table of Contents Overview of Risk for Falls Risk Factors Expected Outcomes Nursing Assessment Interventions and Rationale Risk for Falls Overview A fall is defined (1) as a patient coming to rest on the floor and can be described as an assisted or unassisted fall. An assisted fall is described as a patient being lowered to the ground by another person and is a controlled descent. An unassisted fall is a patient that falls without the assistance of someone else. About 1/4th of patients (2) aged 65 and older report falling yearly. Falls are the most reported safety event in the inpatient setting (3). Recent studies show that 1/4th of falls that occur inpatient are injurious, costing more than $7,000 per injury (4). Patient safety is a priority in the hospital setting, but nurses must be able to identify which patient is at an increased risk and put it on the nursing care plan. Risk Factors Preventing falls is fundamental in reducing incidence of falls with injury. Many fall risk factors place a patient at a higher risk for falls. Age Adults 65 years and older Physiological Impaired gait and mobility: paralysis, weakness, etc. Sensory impairment Use of assistive devices: cane, walker, wheelchairs, etc. Neurological deficit: stroke (current or previous), dementia, brain tumors, delirium, confusion, etc. Incontinence and urgency History of falls (both at home and inpatient) Vision and hearing impairment Post-operative patients Medications Antihypertensives Diuretics Pain medications Sedatives Environmental Wet floor Clutter Height of bed Cords: IV pumps, sequential compression device IVs Inadequate footwear Lifestyle Work environment Lack of fall prevention equipment: safety harness, etc Alcohol and recreational drugs Expected Outcomes The patient will remain free from falls during their hospital stay. The patient will demonstrate the use of call light. The patient will demonstrate a clutter-free environment. The patient will verbalize understanding of the risk for falls. What Is the Nursing Assessment for Risk for Falls? Before providing a nursing diagnosis, a nursing assessment for risk for falls must be completed. It is important that a thorough assessment is completed upon admission and anytime there is a patient condition change (post fall, each shift, environmental changes, etc.). An important note is that the care setting (progressive, acute care, etc.) can affect how much you can assess. Physical Assessment: Medical conditions and vitals can indicate that the patient is not at baseline. Example: A hypotensive patient is at an increased risk for a fall. Caregivers can provide information on the patient's baseline status at home to compare. Evaluation and Assessment of Primary Medical History: Note the chronic conditions that the patient may have that impact their ability to walk, see, or hear. Other evaluations to consider during the medical history review are the patient's use of recreational drugs and alcohol. Skin Assessment: Ensure that the patient's skin is intact and that there are no wounds on the ankles, feet, or heels that could impact the patient's ability to ambulate. Mobility Assessment: How the patient moves to the bed, in the bed, and what kind of assistance the patient will need is important to be mindful of. There is a potential for loss of muscle strength and an impaired gait making it difficult for the patient to be independent in their activities of daily living. Neurological Assessment: If the patient is hallucinating or confused, they are at an increased risk of overestimating their abilities and may be more impulsive in their actions. Fall Assessment Tools: The Morse Fall Scale is a fall risk assessment used to identify risk factors for falls in hospitalized patients (5). This fall scale considers the patient's history of falls, secondary diagnosis, ambulatory aid, IV therapy, gait, and mental status. A score is then provided, determining if the patient has a low, moderate, or high fall risk. Review of Medications: A thorough review of what medications the patient takes at home and what they receive in the hospital is important as many medications can cause changes in blood pressure resulting in hypotension (6) and lowered heart rate. Other medication side effects causing an increased risk for falls are dizziness, blurred vision, impaired cognition, and altered gait and balance. Collaborating with providers to reduce the medication the patient takes can be beneficial. Assessment of Environment: The environment should remain free of clutter, cords, and spills. Extra clutter and cords create trip hazards if the patient were to get up by themselves, putting them at an increased risk for falls. Interventions and Rationale Nursing interventions and safety measures vary depending on the nursing assessment and the associated nursing diagnosis. Each intervention should be selected based on the patient's fall risk (low risk, moderate risk, or high risk) using the Morse Fall Scale. Once specific nursing interventions are selected, they should be placed on the nursing care plan. Non-Skid Socks or Proper Footwear Provides safe ambulation practices for the patient, ensuring there is little room for the patient to slip on the floor. Fall Risk Identification Wristbands can remind patients to seek assistance when getting out of bed independently. Signs placed in the patient's room to remind patients to use the call light. Provide a Safe Environment A clean and clutter-free environment allows for safe ambulation if the patient gets up independently. Encourage the Use of Call Light The use of a call light can be an important factor in reducing falls, as patients can ask for items to be moved closer or for assistance with mobilization. Personal Items and Possessions Within Reach Having all items within reach of the patient can reduce the number of times the patient may attempt to get out of bed and ultimately reduce the risk of falling. Encourage Assistance When Ambulating and Toileting Ensuring that patients are assisted can improve safety and the prevention of falls. Call Light Responsiveness Promptly answering the call light and assisting the patient will prevent the patient from getting out of bed unassisted. Hourly Rounding Patients have the opportunity to bring up things they need each hour and seek assistance with ambulation and toileting with a decreased need to use the call light. The nurse can ensure that each patient has everything they need. Bed Wheels Locked Ensuring that the environment is ready for the patient and is safe is a top priority in preventing equipment from malfunctioning or moving when the patient is trying to sit in the bed. Orient the Patient to the Environment Being in an unfamiliar environment places the patient at an increased risk for falls. When a patient has been shown where things are and how to use certain features (such as bed controls and TV controls), the patient is less likely to trip over something. Provide Assistive Devices Patients that use assistive devices should have one within reach, allowing them to use it to ambulate when needed. Physical and Occupational Therapy Plans An evaluation and treatment plan is created for each individual to help them progress and strengthen, reducing the risk of falls with gait and assistive device training. Physical therapists can design an exercise program based on each patient's functional ability and mobility challenges (6). Encourage Participation in Activities of Daily Living Patients who actively participate in daily activities will improve their fine motor skills and allow them to do as much as possible without great assistance. Chair Alarm/Bed Alarm Alarms can notify healthcare staff that a patient is up or attempting to get up. Bed in Lowest Position If a patient were to fall out of bed, they would be closer to the ground, reducing the risk of injury. Original Allnurses Post Citations https://www.who.int/news-room/fact-sheets/detail/falls https://www.CDC.gov/falls/data/falls-by-state.html https://ojin.nursingworld.org/table-of-contents/volume-18-2013/number-2-may-2013/fall-program-measurement/ https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1368-8. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/
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Table of Contents What is SOB? Diagnostic Considerations Case Study Care Plans for SBO Anecdotal Experience with Small Bowel Obstruction What is Small Bowel Obstruction (SBO)? SBO is a potentially life-threatening condition where the small intestine is blocked, preventing the normal passage of food, air, and fluid. This blockage causes a painful build-up of undigested food, gas, and fluid proximal to the intestinal obstruction(7). In layperson's terms, this is a severe case of backed-up plumbing. SBOs can be complete. incomplete (or partial). non-strangulated. strangulated (medical emergency). SBO occurs when the small intestine is either: mechanically blocked (mechanical ileus) or non-mechanically blocked (functional ileus). Causes The leading cause of mechanical ileus is intra-abdominal adhesions from prior abdominal surgery (65%), followed by hernias (15%)(7). Mechanical ileus from intra-abdominal adhesions occurs when a patient had surgery some time ago, and the intra-abdominal adhesions from that surgery are causing pressure on the small intestine. The leading cause of functional ileus is post-operative ileus(7). Post-operative functional ileus occurs 3-5 days post-abdominal surgery. The bowel responds to manipulation by temporarily shutting down(7). You will encounter both mechanical and functional ileus in medical-surgical nursing. Symptoms for both mechanical ileus and functional ileus are the same and typically have an acute onset. The acute onset of symptoms helps differentiate small and lower bowel obstructions(7). Signs and Symptoms The classic signs and symptoms of SBO are(7): abdominal distension. abdominal pain. nausea with vomiting. SBOs are diagnosed using: abdominal X-ray, ultrasound, and abdominal CT scan with contrast (gold standard)(7, 6). Diagnostic Considerations The differential diagnoses for SBO include the following conditions and diseases (not exhaustive): inflammatory bowel disease (IBD) obstruction of the large intestine pancreatitis acute appendicitis intussusception Physical Examination Initially, patients may have intensified bowel sounds due to increased motility-as the bowel is trying to overcome the obstruction by increased peristalsis(7). The abdomen is typically tender and distended. Early on in SBO, patients can pass gas and have a bowel movement, or they may have diarrhea(6). Nursing Tip: A common misconception is that bowel sounds are absent in bowel obstructions. That's not true! In the pathophysiology of SBO, bowel sounds can be hyperactive or absent. Hyperactive bowel sounds are common in early SBO. You'll hear high-pitched tinkly sounds in the upper quadrants(2). Treatment The blockage's severity, location, and underlying causes dictate treatment. Treatment for mechanical ileus may include surgery, while treatment for functional ileus is supportive and rarely requires surgery(7). Treatment typically includes: nasogastric tube (NGT) to decompress the bowel for vomiting patients(7). NPO to rest the bowel. intravenous fluid and electrolyte replacement to replace volume and to correct electrolyte or acid-base disturbances(7). surgery if indicated(6). antibiotics if suspicion of infection or ischemia(7). Delaying operative treatment (when indicated) beyond three days after hospital admission results in increased morbidity rates and longer postoperative hospitalization(5). A serious complication of SBO is peritonitis. Case Study This case study, while shorter and simpler, is similar to NCLEX NGN case studies in that it evolves over time. Thelma is a 55-year-old female who is three days post abdominal hysterectomy. She has a history of hypertension treated with metoprolol and depression treated with Prozac. Her history includes knee replacement and cholecystectomy. Thelma is complaining of abdominal cramping and nausea. She has no known allergies. She has a 20 gauge IV heplock in her left forearm. Vital signs are: Temp 98.4, HR 96, B/P 140/90 mmHg, RR 18, O2 sat 97% on room air, and pain level of 6 out of 10. Nursing Assessment Thelma is sitting on a gurney, and you assist her in lying supine to better assess her abdomen. Place a folded towel under her knees for comfort and to relax the abdominal muscles(2). Nursing Tip: Always put your eyes on your patient, front and back! Patients may forget they had surgery or think it's not significant enough to mention. You will be surprised at what you discover, from incidental pacemakers to body piercings to old incisions. Inspect, auscultate, palpate, and percuss all four abdominal quadrants, as there can be different findings in each quadrant. Perform auscultation before palpation and percussion because palpation and percussion can falsely increase bowel sounds(2). These are your findings. On inspection, her abdomen appears distended and taut. You take note of the scars on her abdomen from her prior open cholecystectomy. Her surgical incision is clean and approximated. On auscultation, you hear high-pitched bowel sounds in the upper quadrants. On palpation, her abdomen is tender, and she demonstrates guarding (voluntary protective contraction of the abdomen)(2). On percussion, you discover the abdomen is tympanic, which indicates gas(2). Note: If bowel sounds had been absent, listen for a full 3 minutes before confirming their absence(2). Based on your assessment, you immediately remove her water pitcher, anticipating an NPO order as soon as you call the provider. What is the significance of the tympanic abdomen? A tympanic abdomen is like a drum with a tight drumskin. Trapped air causes distention and tympany. What is the significance of the high-pitched bowel sounds in the upper quadrants? High-pitched bowel sounds can be normal, but if they are high-pitched, hyperactive, and found in combination with abdominal tenderness and distention, there is pathology. What is causing the elevated heart rate and blood pressure? Most likely pain and anxiety. Nursing Tip: Always compare symptoms and vital signs to the patient's baseline! A patient's variance from baseline drives appropriate, individualized treatment. You need to call the provider, who was planning to discharge, but you need to have all pertinent information. Review the chart, anticipating what the provider may ask. Review chart You reviewed this morning's resulted labs. Labs come back with an abnormal white blood cell count of 12,000/mm3, slightly elevated but non-specific. While you're reviewing the chart, Thelma suddenly projectile vomits a large amount of bilious fluid and undigested food. Nursing Tip: Emesis that is fecal in odor suggests a more distal obstruction while emesis that is bilious with undigested food suggests a more proximal obstruction. Thelma's vomitus does not have a fecal odor. The first order of business in suspected SBO is to keep a sufficient number of emesis bags or basins close by within your patient's reach. Vomiting in SBO is sudden and forceful. Nursing Hack: Put a dab of Mentholatum in your nose under your mask when you're going into a room where you'll be exposed to noxious odors. If you don't have Mentholatum, you can sandwich toothpaste between 2 cloth masks. What's your assessment at this point? At three days post-op, Thelma is at risk for a functional ileus. With her history of cholecystectomy and possible adhesions, she also has a risk factor for mechanical ileus. What's your first priority? When prioritizing, always think airway, breathing, and circulation first. In this case airway, breathing, and circulation are good, so you continue to prioritize the problems at hand. Knowing that SBOs can be a medical emergency, you prioritize contacting the provider. Alleviating pain is also a priority, and a colleague or charge nurse can help you. Thelma has PRN pain medication already ordered in the chart from her surgery. Before calling, gather all your information, anticipate questions, and have the electronic medical record open. Nursing Tip: Know what orders to expect so you'll know if you don't get them. You call and reach the on-call surgeon, Dr. Jones, as the operating surgeon is out of town. Using Situation-Background-Assessment-Recommendation (SBAR)(4), you give the following information: S: Patient vomited a large amount of undigested food. Her abdomen is tender, distended, and tympanic with guarding.2 She has hyperactive, high-pitched bowel sounds in the upper quadrants. She is afebrile with temp 98.4, HR 96, B/P 140/90, RR 18, and O2 sat 97%. B: She's post-op day three total abdominal hysterectomy performed by Dr. Out-of-Town. She has a history of cholecystectomy and no known allergies. A: My assessment is that she possibly has an SBO. R: Would you like me to place an NG tube to low intermittent suction and start IV fluids? Dr. Jones starts dictating the following orders: Stat CT scan with contrast Basic metabolic panel (BMP) CBC Ondansetron (Zofran) 8 mg twice daily IV as needed for nausea Lactated Ringers at 125 mL an hour Cefazolin 1 gm IV every 8 hrs NPO NG tube to low intermittent suction. You ask Dr. Jones if she will be entering the orders electronically herself, as your facility prohibits telephone and verbal orders unless it's an emergency. She says yes and that she will be in to see the patient soon. Note: If you must take a telephone order, be sure and conduct a read-back(4). NG tube NG suction removes the content closest to the obstruction in patients who are vomiting or distended. Note: The use of an NG tube is common, although there is no evidence to support its routine placement in the lack of emesis(7,3,6). NG suction is intermittent, not continuous. Nursing Tip: Be sure to set your wall suction to intermittent and not continuous. You don't want the NG tube sticking to the stomach mucosa! Patients typically feel a great deal of relief once the NG tube is placed. Now it's time to document your assessment and formulate a care plan. There are always several nursing diagnoses and interventions to choose from, and most electronic documentation platforms make it easy to associate interventions with diagnoses. In addition, there are different formats for writing a nursing care plan. Nursing students should be aware of what their institution and instructors require. Nursing Care Plans (NCP) for SBO The examples below are typical of the detailed kind of handwritten care plan required of a nursing student using NANDA-I approved nursing diagnoses. When creating your care plan, use the nursing process. Risk of Deficient Fluid Volume Care Plan Nursing Diagnosis: Risk of deficient fluid volume as evidenced by NPO status, gastrointestinal losses, nausea and vomiting Assessment: Pt has nausea and vomiting Pt is NPO Goals & Outcomes: Pt will be free of nausea and vomiting Pt will be able to take sufficient fluids by mouth Patient will be normovolemic Nursing Interventions & Rationales: Administer IV fluids Administer anti-emetics Monitor I&O Rationale: Fluid imbalance must be corrected immediately to mitigate severe hypovolemia. Risk of Electrolyte Imbalance Care Plan Nursing Diagnosis: Risk of electrolyte imbalance as evidenced by gastrointestinal losses. Assessment: Pt has NG suction Goals & Outcomes: Serum electrolytes will be within normal range within 24 hrs Nursing Interventions & Rationales: Monitor serum electrolytes Administer IV electrolyte replacement as needed Rationale: To mitigate severe electrolyte imbalance, electrolyte imbalance must be corrected immediately. Gastrointestinal losses, such as vomiting or NG suctioning, can result in hypokalemia(7). Acute Pain Care Plan Nursing Diagnosis: Acute abdominal pain r/t pressure, abdominal distention as evidenced by ℅ pain. Assessment: Pt ℅ acute pain 7/10 HR 98, B/P 145/90 Facial grimacing Goals & Outcomes: Pt will describe satisfactory pain control at an acceptable level of 3 or below after PRN pain medication Nursing Interventions & Rationales: Administer PRN pain medication Assess for pain and after PRN pain meds document Decompress bowel with NG suction Rationale: NG tube provides symptomatic relief. Abdominal pressure caused by trapped air is painful. Dysfunctional Gastrointestinal Motility Care Plan Nursing Diagnosis: Dysfunctional gastrointestinal motility r/t effects of surgery. Assessment: Abdomen distended tender Intermittent hyperactive bowel sounds in upper quadrants Goals & Outcomes: Pt will pass flatus freely Pt will have normoactive bowel sounds Pt will be free of abdominal distention and pain Nursing Interventions & Rationales: Ambulate at least twice daily Encourage patient to pass flatus Monitor for abdominal distention, nausea, and vomiting, tympanny Provide chewing gum Rationale: Exercise increases motility. Pt may be reluctant to pass gas due to embarrassment. Ambulation and gum chewing increase peristalsis(7). Risk for Ineffective Coping Care Plan Nursing Diagnosis: Risk for ineffective coping related to prolonged hospital stay. Goals & Outcomes: Patient will express any concerns, fears, and feelings r/t SBO complication Nursing Interventions & Rationales: Provide opportunity to express concerns, fears, and feelings Rationale: Verbalization of concerns helps reduce anxiety. Additional Nursing Diagnoses Other nursing diagnoses could include imbalanced nutrition and knowledge deficit. Anecdotal This is about a rule I routinely broke as an experienced nurse. Disclaimer- I don't recommend breaking the rules, at least until you gain experience and can defend your own nursing practice decisions. Once nausea and abdominal pain caused by gas are relieved by the NG tube, the most discomfort by far is from parched mouths and chapped lips. Lemon glycerin swabs leave the mouth sticky and coated and are terrible. Oral swabs and sponges just aren't effective. I couldn't stand to see patients in so much discomfort for no reason. So I would put a few ice chips in the center of a washcloth, fold the washcloth over the ice, and pinch right under the ice to make a lollipop. The portion with ice chips resembles the head of a lollipop. The patient can suck on the washcloth lollipop. Is this technically allowed if your patient is NPO? No. Is it going to harm your patient? No. Gas is a good thing Nursing Tip: Have your patient walk and chew gum! Chewing gum increases peristalsis(7). Patients often apologize for passing gas. Praise them, encourage them, and tell them it's a good sign! To help pass gas, have them pull up their knees while in bed, turn side to side, bend over frontwards and walk, walk, walk! STAFF NOTE: Original Community Post This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post: References 1. Ackley, B. J., Ladwig, G. B., Makic, M. Beth Flynn, Martinez-Kratz, M. Reyna, & Zanotti, M. (2020). Nursing diagnosis handbook : an evidence-based guide to planning care. Twelfth edition. St. Louis, Missouri: Elsevier. 2. Ferguson CM. Inspection, Auscultation, Palpation, and Percussion of the Abdomen. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 93. Available from: https://www.ncbi.nlm.nih.gov/books/NBK420/ 3. Fonseca, A. L., Schuster, K. M., Maung, A. A., Kaplan, L. J., & Davis, K. A. (2013). Routine nasogastric decompression in small bowel obstruction: is it really necessary?. The American Surgeon, 79(4), 422-428.https://journals.sagepub.com/doi/abs/10.1177/000313481307900433 4. Friesen MA, White SV, Byers JF. Handoffs: Implications for Nurses. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 34. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2649/ 5. Keenan, Jeffrey E. MD; Turley, Ryan S. MD; McCoy, Christopher Cameron MD; Migaly, John MD; Shapiro, Mark L. MD; Scarborough, John E. MD. Trials of nonoperative management exceeding 3 days are associated with increased morbidity in patients undergoing surgery for uncomplicated adhesive small bowel obstruction. Journal of Trauma and Acute Care Surgery 76(6):p 1367-1372, June 2014. | DOI: 10.1097/TA.0000000000000246 6. Long, B., Robertson, J., & Koyfman, A. (2019). Emergency medicine evaluation and management of small bowel obstruction: evidence-based recommendations. The Journal of Emergency Medicine, 56(2), 166-176.https://www.sciencedirect.com/science/article/abs/pii/S0736467918310503 7. Vilz, T. O., Stoffels, B., Strassburg, C., Schild, H. H., & Kalff, J. C. (2017). Ileus in Adults. Deutsches Arzteblatt international, 114(29-30), 508–518. https://doi.org/10.3238/arztebl.2017.0508
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For new mothers, the postpartum period comes with significant changes as they adapt to their new role and heal from giving birth. Potential mental health challenges exist as hormonal changes and other factors cause postpartum depression in 6.5% to 20% of women. Many new mothers also experience anxiety around bonding with their babies or breastfeeding. One study reported that up to 50% of mothers stop breastfeeding their infants due to insufficient milk supply. Complications can also appear following birth, resulting in severe health concerns and even deaths. The number of maternal deaths sharply increased to 1,178 per 100,000 live births in 2021 due to COVID-19, prompting birth centers to adopt new safety measures. As a nurse, you can have a significant impact during the postpartum period. Frequent interactions with the new mother put you in a unique position to listen to her concerns and guide her as she enters a new chapter in her life. Your role also encompasses watching out for symptoms that could indicate physical or psychological complications to address these issues early and improve the outcome with a relevant treatment plan. As a nurse, you can also make a difference by developing a personalized care plan that reflects each patient's unique health history. When creating a care plan and delivering holistic care, one factor to consider is any existing health disparities in outcomes related to ethnicities and social backgrounds. 1. Impaired Parenting Care Plan Unfortunately, some parents aren't ready to provide their babies a safe and healthy environment. As a nurse, you're usually one of the first healthcare professionals who are in a position to notice difficulties with bonding. Nursing Diagnosis Impaired parenting Potentially Related To A history of childhood abuse Unwanted pregnancy Socioeconomic challenges Lack of maturity Knowledge deficit Physical illness in the mother or child Psychological conditions of the parents Evidenced By Dissociation, rejection, or aggressive behavior toward the baby Lack of caretaking skills Voicing inability to care for the child Inappropriate childcare arrangements or unsafe home environment Desired Outcomes Parent will gain access to resources to develop the right skills and build a support network. Parent will learn about parenting styles and healthy bonding. Parent will learn about options like guardianship or adoption. Parent will initiate measures to create a safe and nurturing environment. Impaired Parenting Care Plan Assessment Communicate with the patient: Use active listening to understand the parents' frustrations and concerns better. Identify challenges: Ask about barriers that hinder providing an environment where the child can thrive. Consider psychological health: Assess to which extent depression and other health challenges play a part in feelings of inadequacy as a parent. Put the child first: Assess the child's safety and consider whether to contact social services. Impaired Parenting Care Plan Interventions Teach and demonstrate: Set an example by showing how to interact and bond with the infant. Educate the parents on normal development and typical behaviors to expect from their child at different milestones to boost their confidence. Communication is vital: Encourage open communication and connect parents with relevant resources to address socioeconomic challenges. Address the stigma linked to parenting expectations and asking for help. 2. Readiness for Enhanced Parenting Care Plan Becoming a good parent takes time. Readiness for enhanced parenting refers to the will to become a better parent. The average age at which women have their first child is 23 years old, meaning that many new mothers face economic and social challenges on their way to becoming successful parents. Nursing Diagnosis Readiness for enhanced parenting Potentially Related To Single parenthood Socioeconomic challenges Lack of support network Physical or psychological health challenges Knowledge deficit Evidenced By Anxiety regarding one's ability to care for the child Lack of knowledge about parenting Lack of concrete plans regarding supporting and caring for the child Verbalizing inability to care for the child Desired Outcomes Parents verbalize necessary changes to create a healthy environment. Parents learn about resources they can use. Parents establish a concrete plan to reach personal or professional goals to better care for the child. Readiness for Enhanced Parenting Care Plan Assessment Assess knowledge: Communicate with the parents to better understand how much they know about parenting skills, normal newborn behaviors, and safety measures they should take, such as how to ensure safe infant sleep. Discuss the mother's feelings: Be a compassionate listener. Ask how the mother or father feels about their new role and encourage them to voice anxiety and other concerns. Teach about the importance of outside help: Find out how much the parents know about the community resources available to them. Ask about other support systems, such as extended family and friends. Inquire if they feel comfortable asking others for help. Readiness for Enhanced Parenting Interventions Teach caretaking skills: Demonstrate how to care for the baby, including feeding, holding, or changing diapers. Ask the parents to provide a return demonstration to assess their knowledge and build comfort with each task. Teach the new mother to recognize feeding cues and other signs the newborn uses to communicate. Help with planning for the future: Encourage open communication and questions to address anxiety. Discuss the future with the parents and encourage them to formulate a concrete plan, including community classes or resources, to keep improving their parenting skills. 3. Ineffective Breastfeeding Care Plan The CDC reports that breastfeeding exclusively drops significantly over the first six months of life for many infants. While 83.2% of all infants start out receiving some breast milk, by six months, only 24.9% of infants receive breast milk exclusively. One explanation for this decrease in breastfeeding is that families who breastfeed lack the support systems needed to reach long-term breastfeeding goals. This research supports the need for care plan development for families who experience ineffective breastfeeding. Nursing Diagnosis Ineffective breastfeeding Potentially Related To Inadequate knowledge about breastfeeding techniques or its importance Inadequate support systems Ineffective suck-swallow response in the infant Maternal breast pain Insufficient breast milk production Maternal ambivalence to breastfeeding Evidenced By Infant is unable to latch to the breast Infant crying or fussing within one hour of breastfeeding Inadequate weight gain in the infant Sustained weight loss in the infant Painful or sore nipples persisting beyond the first week of breastfeeding Perceived insufficient milk production Insufficient emptying of each breast during a breastfeeding session Desired Outcomes Patient will achieve effective breastfeeding with adequate milk production. Patient demonstrates proper breastfeeding techniques, including positioning and latching. Ineffective Breastfeeding Care Plan Assessment Assess risks for ineffective breastfeeding: Assess for modifiable risk factors to provide adequate information and support to the mother to develop effective breastfeeding techniques. Assess patient's breastfeeding knowledge: Assess the patient's knowledge, understanding, and beliefs about breastfeeding to correct any inaccuracies or myths. Perform a breast assessment: Assess for barriers such as nipple soreness, breast engorgement, history of breast surgery, or poor enlargement of the breasts during pregnancy. Assess infant's sucking reflex: It's critical to begin interventions for infant sucking issues early to correct any problems. Ineffective Breastfeeding Care Plan Interventions Educate the mother about breastfeeding: Provide education regarding breastfeeding techniques and encourage questions. Make sure the mother understands producing milk and getting an infant to latch on properly can take time. Establish a breastfeeding plan: Refer the mother to a lactation consultant. You can also present bottle feeding as an alternative and assist with proper breastfeeding positioning. Encourage skin-to-skin contact immediately after delivery. This technique promotes breastfeeding initiation and improves the mother's milk supply. Promote comfort and relaxation during breastfeeding. Being uncomfortable can lead to poor let-down reflexes and the mother stopping breastfeeding too soon. 4. Infection Care Plan Infections are a reasonably common nursing diagnosis for postpartum women since this complication affects 5% to 7% of women who give birth. It's a severe complication that significantly increases the risk of maternal death and can cause additional anxiety for the new mother. Nursing Diagnosis Infection care Potentially Related To Trauma sustained during childbirth Retained placental fragments (RTF) Cesarean section Mastitis Evidenced By Pain Fever Rapid heart rate Localized swelling and tenderness Desired Outcomes Patient is without signs or symptoms of infection. Vital signs return to normal. Infection Care Plan Assessment Perform a physical exam: Look for common signs of infection, such as swelling, tenderness, and pain at the site of the infection (breast, perineal area, abdomen). Discuss the patient's symptoms to rule out other possible causes of pain. Lab work: Use blood tests to confirm the presence of infection. An elevated white blood cell count will indicate an infection. Infection Care Plan Interventions Seek medical care: Refer the patient to a doctor immediately for further assessment and possible antibiotic therapy. Assess Surgical Incisions for signs of infection: Keep the incision site clean and assess for signs of infection, such as odor, redness, swelling, and purulent drainage. Educate the patient: Teach the patient the signs and symptoms of infection and when to report them to the nursing staff or their healthcare provider. 5. Risk for Pain Care Plan A study conducted in Finland found that 83% of women giving birth for the first time used an epidural. While pain management is a crucial goal during labor and delivery, many mothers also need a pain management plan in the weeks that follow. Nursing Diagnosis Risk for pain Potentially Related To Multiple births Cesarean birth Trauma sustained during birth Prolonged labor Evidenced By Patient voicing pain or discomfort lady partsl tears Uterine rupture Nerve injury Desired Outcomes Patient reports pain is 4/10 or less within 2 hours of nursing interventions. Patient verbalizes an improvement in pain and discomfort. Risk for Pain Care Plan Assessment Identify the patient's risk for pain: Assess the patient's birth experience and potential for painful injuries. Communicate with the labor and delivery team regarding birth trauma or any C-section complications. Listen to the patient: Assess the patient's pain levels and self-reported symptoms regularly. Using a 0-10 scale will help you track pain levels. Risk for Pain Care Plan Interventions Administer analgesics as prescribed: Providing analgesics per the physician's order helps control exacerbation of pain. Monitor for side effects and effectiveness of the intervention and report any changes or further needs to the physician. Monitor the healing process: Beyond managing pain, this nursing diagnosis for postpartum calls for monitoring the healing process closely to observe for any signs of possible complications, such as infection. Utilize distraction to reduce pain: Encourage activities that help distract the mother from the pain while she is not caring for the newborn. Examples include meditation, position changes, or breathing exercises. Provide plenty of support and reassurance since recovering from a physical injury can make parenting difficult. 6. Caregiver Role Strain Care Plan More than 50% of Americans over 40 find themselves caring for aging parents and children. Welcoming a new addition to the family can be a source of stress that results in caregiver role strain for those who already have obligations. Nursing Diagnosis Caregiver role strain Potentially Related To Acting as a caregiver to an aging or sick relative Acting as a caregiver to multiple children A history of burnout Evidenced By Lack of energy Feelings of hopelessness Neglecting one's needs Desired Outcomes Parent verbalizes strategies to use to improve feelings of burnout or overwhelm. Parent demonstrates ability to care for infant without physical or emotional side effects. Parent verbalizes hope and confidence in their ability to perform in their new role. Caregiver Role Strain Care Plan Assessment Learn more about the caregiver's situation: Ask the parent about their home situation and other caregiving obligations. Letting new parents open up about their anxieties and concerns can reveal they juggle many roles at home. Caregiver Role Strain Care Plan Interventions Help create realistic expectations: Discuss healthy expectations for a new parent and encourage the patient to set boundaries if they struggle with their other roles. Provide support: Demonstrate proper infant caregiving skills to help the patient feel more confident about their ability to care for their newborn. 7. Fatigue Care Plan Research shows that mothers of children under the age of two experience higher levels of fatigue, independently from the amount of sleep they get. Fatigue typically includes a lack of motivation, frequent drowsiness, and low energy levels. Nursing Diagnosis Fatigue Potentially Related To An underlying health problem Undiagnosed postpartum depression A history of fatigue or burnout Evidenced By Feelings of tiredness Lack of energy Change in mood Desired Outcomes Patient verbalizes adequate energy levels. Patient utilizes tools and resources to prevent fatigue as they settle into their role as a parent. Fatigue Care Plan Assessment Ask about sleep and energy: Identify new mothers at risk for fatigue by asking about their sleep schedule and overall energy levels. Identify underlying causes: Assess vital signs and lab values to rule out physical causes of reported symptoms. Encourage open communication with the patient to identify potential signs of postpartum depression. Fatigue Care Plan Interventions Provide assistance: Help the patient perform tasks as needed, including caring for the newborn. Treat underlying causes: Treat abnormal lab values or let the patient rest to recover after giving birth. Educate the patient: Provide information about diet, exercise, or sleep hygiene to help the patient manage fatigue in the future. 8. Self-Esteem, Situational Low Care Plan Research shows that as many as 23% of teen girls suffer from low self-esteem. For many women, these feelings persist into adulthood and can lead to a severe situational low during the transition to parenthood. Nursing Diagnosis Self-esteem, situational low Potentially Related To Difficult childhood Disapproval from relatives regarding the pregnancy A history of depression and low self-esteem Evidenced By Being overly critical of oneself Focusing on negative things Withdrawing from activities they once enjoyed Decreased desire to care for the newborn Desired Outcomes Patient verbalizes their understanding of the self-esteem issues. Patient verbalizes feeling more confident about fulfilling their role as a parent. Self-Esteem, Situational Low Care Plan Assessment Assess the patient's mental state: Ask questions and encourage open communication to identify negative feelings. Listen for statements that reflect low self-esteem and feelings of doubt or hopelessness. Identify whether negative feelings affect the patient's ability to care for the child: Ask the patient if they are experiencing difficulty bonding or if they lack confidence in their ability to provide care to the infant. Observe for evidence of these feelings, such as not soothing the infant when it cries. Self-Esteem, Situational Low Care Plan Interventions Focus on the positive: Help the patient reframe the situation by highlighting their achievements. Consider asking the physician for a referral to a counselor or psychologist if ongoing support is needed. Educate the patient: Discuss the adverse effects of deprecating statements. Encourage the patient to seek help to deal with their self-esteem issues. 9. Deficient Fluid Volume Care Plan Postpartum hemorrhage, or an excessive loss of blood when giving birth, is a condition that affects 14 million women globally each year. Excessive blood loss can result in a deficient fluid volume diagnosis, a condition where the patient loses water and electrolytes. Nursing Diagnosis Deficient fluid volume Potentially Related To Uterine atony Postpartum hemorrhage Evidenced By Blood loss of 500ml or more Hypotension Weakness Dehydration Changes in mental status Tachycardia Decreased urine output Desired Outcomes Patient maintains a blood pressure above 90/60 mm Hg. Patient's hemoglobin levels are within normal limits. Deficient Fluid Volume Care Plan Assessment Monitor vital signs: Postnatal hemorrhage is a leading cause of maternal death. Monitor for signs of hypotension, confusion, faintness, weakness, and tachycardia. Identify signs of dehydration: Assess the patient's degree of dehydration by looking for signs like urine concentration or loss of skin elasticity. Assess the uterus: If there are signs the patient is bleeding, a thorough assessment of the uterus must be completed. Assess for a "boggy" or soft uterus, which can indicate it isn't contracting after the birth of the infant. Monitor lochia: Bleeding after delivery is expected. However, the amount of bleeding should decrease after a few hours and should not contain large clots. Watch closely for serious bleeding beyond and extended bleeding and report to the physician immediately should there be concerns. Deficient Fluid Volume Care Plan Interventions Manage postpartum bleeding: Use blood-absorbing products, uterine massage, and uterotonic agents to stop the bleeding. Increase fluid intake: Drinking more fluid may be sufficient in mild cases, but administering intravenous hydration is a common treatment for this nursing diagnosis for postpartum women. Replace electrolytes: Follow electrolyte replacement protocols and administer potassium and phosphorus replacement products if ordered. Continue monitoring vitals: Monitor the patient's vitals until they return to normal. Report any significant changes or concerning values to the physician. Maintain bedrest. Encourage bed rest to prevent falls, dizziness, and orthostatic hypotension. If not contraindicated, consider elevating the patient's legs to promote venous return. Administer blood products. If the blood loss requires blood products, administer them per the facility's protocol. 10. Ineffective Tissue Perfusion Care Plan Ineffective tissue perfusion is a potential complication that stems from postpartum hemorrhage. In some cases, severe blood loss results in a lack of oxygenated blood flow. Tissues and organs can die. Nursing Diagnosis Ineffective tissue perfusion Potentially Related To Postpartum hemorrhage Low hemoglobin Evidenced By Irregular heart rhythm Altered respiratory rate Abnormal arterial blood gasses Nausea Vomiting High or low blood pressure Elevated BUN/creatinine Decreased urine output Altered mental state Restlessness Desired Outcomes Patient will maintain cardiopulmonary perfusion as evidenced by normal heart rate and rhythm, and the absence of shortness of breath. Patient will maintain adequate peripheral perfusion as evidenced by warm skin. temperature, intact skin, strong pedal pulses, and no signs of edema. Ineffective Tissue Perfusion Care Plan Assessment Monitor vitals closely: Look for changes in heart rate and rhythm, and respirations. Assess the severity of the situation: Lab work can provide insights into perfusion issues. Compare results over time to assess for changes. Obtain a complete health history: Ask the patient or their family member if they have a history of conditions that affect perfusion. This might include having a history of myocardial infarction, congestive heart failure, blood clots, vascular diseases, diabetes, or organ failure. Ineffective Tissue Perfusion Care Plan Interventions Manage symptoms: Symptom management becomes a primary nursing action. Conduct frequent and thorough assessments to identify and report any significant changes in the patient's condition. Improve blood flow: Administer vasodilators, if ordered, to open blood vessels and improve blood flow. Keep monitoring vitals: Watch vitals closely for any changes. Ineffective tissue perfusion can result in a heart attack or organ failure. 11. Imbalance in Mood and Behavior Care Plan An imbalance in mood and behavior can occur during the postpartum period. The pressure of assuming a new role can cause mood changes, but shifting hormonal levels and other physical symptoms can exacerbate these changes. Nursing Diagnosis Imbalance in mood and behavior Potentially Related To Pain Undiagnosed postpartum depression Feelings of anxiety Underlying mood disorder Evidenced By Change in mood Withdrawal Extreme fatigue Inability to stop crying Increased anxiety Desired Outcomes Patient returns to a stable mental state. Patient has a clear path forward for managing future mood changes. Patient recognizes the need for counseling and attends per the counselor's recommendations. Patient engages in social activities. Imbalance in Mood and Behavior Care Plan Assessment Rule out physical issues: Pain and fatigue can cause highs and lows. Rule out a postpartum hemorrhage by monitoring blood pressure and other vitals. An increase in body temperature beyond the third day after giving birth can indicate an infection. Gather more information: Ask the patient if they have a history of anxiety, depression, or mood disorders before having the infant. Imbalance in Mood and Behavior Care Plan Interventions Educate the patient: Educate the patient about hormonal changes and other postpartum changes to make these symptoms easier to navigate. Manage physical symptoms: Keep the patient comfortable by alleviating pain and addressing other physical symptoms. Provide support: Offer plenty of reassurance by modeling good caretaking behavior and encouraging the patient to bond with the infant. Connect the patient to appropriate resources: Discuss mental health and encourage the patient to seek help from their support network or community resources to treat underlying mood disorders. FAQ Read on to learn more about common postpartum diagnoses. What are normal postpartum symptoms? It's normal for women to experience lady partsl discharge, incontinence, and changes in bowel movements after giving birth. Hormonal changes can lead to mood changes, breast tenderness, and other symptoms. What are three nursing diagnoses related to postpartum hemorrhage? Three other nursing diagnoses you might use for a patient with postpartum hemorrhage include deficient fluid volume, risk for imbalanced fluid volume, and ineffective tissue perfusion. Which factors put a woman at risk of experiencing postpartum complications? A pre-existing health condition increases a new mother's risk of experiencing complications. Factors like age, weight, ethnicity and socioeconomic status can also play a role. Additional Readings and Resources Learn more about postpartum diagnoses and nursing plans with these resources: Postpartum care plan with C-section and epidural anesthesia Postpartum diagnosis for mother/baby couplet Postpartum diagnosis for mother with high fundus Example of a comprehensive postpartum care plan Postpartum plan for C-section Postpartum care plan with surgery and risk of decisional conflict regarding adoption Postpartum care plan with emergency surgery References https://www.ncbi.nlm.nih.gov/books/NBK519070/ https://www.ncbi.nlm.nih.gov/books/NBK52688/ https://www.gao.gov/assets/gao-23-105871.pdf https://www.CDC.gov/breastfeeding/data/reportcard.htm https://pubmed.ncbi.nlm.nih.gov/32809639/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9086622/ https://www.pewresearch.org/fact-tank/2022/04/08/more-than-half-of-americans-in-their-40s-are-sandwiched-between-an-aging-parent-and-their-own-children/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8296457/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914631/ https://www.who.int/publications/m/item/who-postpartum-haemorrhage-(pph)-summit https://www.ncbi.nlm.nih.gov/books/NBK555904/
