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Hyperemesis Gravidarum Case Study, Assessment and Nursing Care Plan

Sunday, 21 September 2014

Hyperemesis gravidarum is severe and unremitting nausea or vomiting associated with pregnancy that can persist past the first trimester. In contrast, morning sickness is transient nausea or vomiting that generally occurs during only the first trimester. Women with multiple gestations, family history of the disorder, transient hyperthyroidism, or abnormally elevated human chorionic gonadotropin levels are at increased risk for hyperemesis gravidarum. The prognosis for mother and fetus is usually good when treatment is initiated before significant complications develop and the woman can gain more than 7 lb (3.2 kg) throughout the pregnancy.

Hyperemesis Gravidarum Case Study, Assessment and Nursing Care Plan

Duodenal Ulcer Nursing Case Studies with Pathophysiology and NCP

Sunday, 10 August 2014

A duodenal ulcer is a circumscribed lesion in the mucosal membranes of the proximal part of the small intestines. It follows a chronic course characterized by remission and exacerbation, commonly requiring surgery.

Pathophysiology
With a duodenal ulcer, Helicobacter pylori releases a toxin that promotes mucosal inflammation and ulceration. Ulceration stems from the inhibition of prostaglandin synthesis, increased gastric acid and pepsin secretion, reduced gastric mucosal blood flow, or decreased cryoprotective mucus production.

Complications
■ GI hemorrhage
Abdominal or intestinal infarction
■ Ulcer penetration into attached structures
■ Duodenal obstruction



Assessment (only potential abnormalities listed)

Nursing history by Functional health pattern

Colostomy Nursing Case Study with NCP Pathophysiology

Wednesday, 23 July 2014

colostomy is an opening (stoma) in the abdominal wall that allows for the defection of stool. It's created surgically in response to a GI problem caused by trauma, infection, inflammation, obstruction, malignancy, or a non-functioning bowel. A colostomy may be a temporary measure used to allow the bowel to heal.

Complications
■ Bleeding
■ Obstruction
■ Tissue necrosis



Cleft Lip and Cleft Palate Nursing Case Study w/ NCP

Monday, 16 June 2014

Cleft lip and cleft palate are abnormalities in closure of the lip or palatine shelf that may occur separately or in combination. Cleft lip deformities can occur unilaterally, bilaterally or rarely, in the midline. Only the lip may be involved, or the defect may extend into the upper jaw or nasal cavity. Incidence is highest in children with a family history of cleft defects, those exposed to teratogens during fetal development, or those with various chromosomal abnormality syndromes.



Alzheimer's Disease and its Assessment: Nursing Case Study with NCP

Sunday, 11 May 2014

Alzheimer's disease is an acquired syndrome of decline in short- and long-term memory and other cognitive functions. It's progressive and disabling; no cure or definitive treatment exists. It accounts for 60% to 80% of all cases of dementia and isn't an inherent aspect of aging. Memory loss is associated with impairment in abstract thinking and judgment. Alzheimer's disease is diagnosed by clinical findings and confirmed by autopsy.

Alzheimer's disease

Pathophysiology
Neuropathological findings of Alzheimer's disease include extracellular deposition of amyloid-beta protein, intracellular neurofibrillary tangles, and loss of neurons. Amyloid-beta protein is thought to interfere with neuronal function by stimulating free radical production, which can result in neuronal cell death. Hyperphosphorylated neurofibrillary tangles deposit in neurons, leading to cell death. Neuronal cell death and synapse loss affect neurotransmitter pathways; deficient production of acetylcholine, serotonin, and norepinephrine occurs.

Complications
Injury secondary to violent behavior or wandering
Pneumonia and other infections
Malnutrition
Dehydration
Aspiration
Death
Assessment
Health perception and management
Confusion, disorientation, and memory loss attributed to another reason such as aging
Family reports of the patient's mental decline

Nutrition and metabolism
Anorexia
Omission of meals
Weight loss
Fatigue and malaise
Dysphagia (in later stages)

Elimination
Constipation
Urinary and fecal incontinence (in later stages)

Activity and exercise
Limits activity to familiar environments
Increasing inability to perform activities of daily living
Deterioration in personal hygiene and appearance
Increasing difficulty performing complex tasks
Demonstrates wandering behavior or loss of locomotion

Cognition and perception
Progressively impaired judgment
Progressively impaired ability to orient self in the environment
Loss of immediate, recent, and remote memory, including episodic (events) and semantic (knowledge) memory
Incongruent, inconsistent, often depressed affect
Progressively reduced conceptualization, attention, arousal, concentration, and abstract thinking
Progressively impaired expressive language and increased receptive aphasia
Repetitive actions or perseveration

Sleep and rest
Nocturnal restlessness with insomnia
Altered sleep‑wake cycle
Growing difficulty in awakening as the disease progresses

Self-perception and self-concept
Attempt to sustain an internal center of control, dignity, and self‑esteem
Sexuality and reproduction
Rejection of intimate contact

Roles and relationships
Altered family dynamics resulting from role reversals and increased patient dysfunction
Increased social withdrawal (isolationism)

Coping and stress management
Defense mechanisms, such as rationalization, denial, and projection
Apathy, depression, and helplessness
Primary emotional lability, characterized by irritability, anger, fear, and agitation
Symptoms of ego disintegration, including hallucinations, illusions, and suicidal ideation

Values and beliefs
Altered value system resulting from defective mental faculties
Physical Examination

General appearance and nutrition
Unkempt
Poor personal hygiene
Malnourished
Dehydrated

Mental status and behavior
Confusion
Disorientation
Labile affect
Irritability
Clinical depression

Integumentary
Poor skin turgor

Gastrointestinal
Fecal incontinence

Neurologic
Cognitive dysfunction
Memory loss
Language disintegration

Musculoskeletal
Decreased activity tolerance
Lack of coordination
Immobility
Limited range of motion

Renal and urinary
Urine retention
Urinary incontinence

Diagnostic studies
Postmortem brain biopsy is the only definitive diagnostic test, which rules out other differential diagnoses. Diagnosis is made on clinical assessment.
Nursing care plan
Nursing diagnosis
Nursing priorities

Chronic confusion related to degenerative loss of cerebral tissue
     Provide a safe, structured environment.
     Promote an optimum level of functioning.
     Establish effective communication patterns.

Imbalanced nutrition: Less than body requirements related to memory loss, difficulty swallowing, and inadequate food intake
     Stabilize and improve nutritional status.


Risk for injury related to wandering behavior or decline in judgment
     Prevent injury while maximizing independence.


Risk for constipation related to memory loss about toileting behavior, inadequate diet, or inadequate fluid intake
     Establish an effective elimination pattern.


Risk for caregiver role strain related to progressive needs of the Alzheimer's disease patient
     Provide support and assistance from community agencies.


Other potential nursing diagnoses: Bathing or hygiene self-care deficit: bathing/hygiene related to disease progression ■ Dressing/grooming self-care deficit related to disease progression ■ Toileting self-care deficit related to disease progression ■ Feeding self-care deficit related to disease progression ■ Anxiety related to situational crisis ■ Interrupted family processes related to disease ■ Ineffective health maintenance related to perceptual or cognitive impairment ■ Impaired memory related to the disease process ■ Grieving related to change in health status ■ Wandering related to disease progression




Chronic confusion related to degenerative loss of cerebral tissue
Expected outcome
The patient will remain free from injury, communicate needs as clearly as possible, and wear identification jewelry.
Suggested NOC Outcomes
Cognition; Cognitive orientation; Concentration; Decision-making; Distorted thought self-control; Identity; Information processing; Memory; Neurological status: Consciousness
Nursing interventions
Intervention type
Intervention
Rationale
Collaborative
Assess the patient's level of cognitive functioning using a functional rating scale for symptoms of dementia or a Mini–Mental Status Examination.
Prepare the patient for psychological testing.
Information obtained from the patient and his family provides a guide for planning care.
Psychological testing provides information necessary to structure a therapeutic regimen.
Independent
Assign the patient to a room close to the nursing station or with surveillance for frequent observation.
Close observation allows for improved patient safety.
Independent
Minimize hazards in the environment.
Decreasing possible hazards helps prevent possible injury.
Independent
Maintain consistency in nursing routines.

Consistency in routines provides structure in an unfamiliar environment and may help minimize confusion.
Independent
Promote self‑care within the scope of the patient's abilities; assist when necessary. Identify specific needs in the care plan.
Allowing the patient to provide self-care preserves self-esteem. Identifying needs in the care plan promotes consistency with appropriate care.
Independent
Establish and maintain a therapeutic relationship by communicating with the patient in a calm, reassuring, affirming, and nonthreatening manner.
Trust must be established to achieve any goal because of the patient's suspicions and increasing paranoia.

Independent
Give simple, specific directions for accomplishing tasks; use eye contact and unobtrusive guidance.
The effects of memory loss and a reduced attention span can be minimized with clear directions and appropriate guidance.
Independent
Orient the patient to reality frequently and repetitively.
Although repetitive reorientation may not reduce disorientation, it may reduce the patient's anxiety.
Independent
Administer and document medications as ordered. Evaluate their effect, and observe for adverse reactions.
Medication may improve the patient's status. Noting adverse reactions prompts appropriate adjustments to treatment.
Independent
Use aids to improve language skills, and use verbal repetition and pictures to improve recall.
Both methods may assist the patient with word recall.
Independent
Minimize communication barriers. Be aware that anxiety, cultural influences, spiritual beliefs, and language difficulties may contribute to paranoia and withdrawal.
Knowing and understanding the patient's cultural background and beliefs can enhance communication.
Independent
Encourage social interaction by including the patient in unit activities when possible, allowing maximum flexibility in visiting hours, and providing occupational therapy referrals.
Continued social interaction reinforces reality and contributes to a sense of self‑worth and identity.

Independent
Prevent excessive stimulation and promote a regular sleep‑wake pattern.

Moderate stimulation helps orient the patient; excessive stimulation and sleep deprivation contribute to confusion.
Independent
Be attentive. Keep your verbal and nonverbal responses to the patient consistent.
Consistent verbal and nonverbal responses reduce cognitive dissonance.
Independent
When talking with the patient, encourage reminiscences.

Remembering past events helps the patient maintain self‑identity. Distant memory may remain even when recent memory is impaired.

[Additional individualized interventions]

Suggested NIC Interventions
Anxiety reduction; Calming technique; Cognitive stimulation; Dementia management; Family involvement promotion; Mood management
Imbalanced nutrition: Less than body requirements related to memory loss, difficulty swallowing, and inadequate food intake
Expected outcome
The patient will attain or maintain optimal weight.
Suggested NOC Outcomes
Nutritional status: Food & fluid intake; Nutritional status: Nutrient intake; Weight control
Nursing interventions
Intervention type
Intervention
Rationale
Collaborative
Assess present nutritional status: Weigh the patient and record customary dietary intake on admission.
Assessing the patient's nutritional status provides necessary information for determining actual deficits; an appropriate dietary regimen may then be formulated.
Independent
Offer a balanced diet consisting of small meals at regular intervals and nutritious snacks between meals.


Provide finger foods when possible.

Regularly scheduled meals help maintain a structured environment. Small quantities may appeal to the patient and provide a sense of achievement when all the food is consumed.
Finger foods are easier to handle than food that must be eaten with a utensil.
Independent
Prepare the tray in advance—cut the meat, provide a spoon, open containers, and so forth—with appropriate portions of food arranged so that the patient may eat unassisted.

The patient may develop coordination difficulties, which impairs his ability to use utensils. Preparing food servings in advance decreases the patient's frustration and prevents the humiliation of being unable to provide self‑care.
Independent
Provide time and privacy for meals.
The patient who has difficulty chewing or swallowing will need more time to eat. Lack of coordination may result in socially unacceptable eating habits.
Independent
Monitor and record daily weight and intake, including the amount and type of food. Adjust the dietary plan accordingly.
Evaluating weight and intake provides guidelines for modifying the dietary plan.

Independent
Provide dietary information to the home caregiver.

The patient will probably continue to need assistance in menu selection, cooking, and eating after discharge. The person shopping, cooking, and offering meals to the patient may need instruction in the patient's specific dietary needs.

[Additional individualized interventions]

Suggested NIC Interventions
Diet staging; Fluid monitoring; Nutrition management; Nutritional monitoring; Weight gain assistance
Risk for injury related to wandering behavior or decline in judgment
Expected outcome
The patient will be appropriately dressed for the temperature, walk about only when attended, and avoid injury.
Suggested NOC Outcomes
Fall prevention behavior; Personal safety behavior; Risk control; Safe home environment
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Consider alarms or other audible signal to monitor patient activity.

An alarm or signal alerts the staff to patient activity and may minimize injury. If unattended, the patient may become lost, even in familiar surroundings.
Independent
Prepare an identity card, a bracelet, necklace, or a name tag for the patient. Include his name, address, phone number, medical problem, and other pertinent information.
Should the patient wander, identification information can help in the patient's prompt return.

Independent
Ensure that the patient is dressed appropriately for the temperature.


Provide shoes that fit well.

The patient may not make appropriate choices about dress and may have a reduced ability to identify or verbalize discomfort. Loose shoes may be lost or may contribute to injuries from falls.
Independent
Avoid using restraints.

Restraints increase the patient's agitation and paranoia and may contribute to injury.
Independent
Review the patient's home environment with the family. Recommend specific safety measures to prepare for home care.
An unprepared home environment may contribute to injuries.
Independent
Encourage a regular exercise program as tolerated.

Regular exercise decreases restlessness and agitation, promotes muscle tone, and contributes to a sense of well-being. Overactivity, however, may contribute to fatigue and confusion.

Watch for nonverbal cues to injury, such as grimacing, rubbing, panting, or protecting an injured area, and note repetitive use of words or seemingly inappropriate statements. Alert the family to cues observed.

The patient may be unable to identify or express discomfort but may reveal illness or injury through nonverbal cues.
Because aphasia may make expressions of discomfort convoluted, such words as cold or hurt, especially if repeated, may warrant investigation.

[Additional individualized interventions]

Suggested NIC Interventions
Environmental management; Fall prevention; Surveillance: Safety
Risk for constipation related to memory loss about toileting behavior, inadequate diet, or inadequate fluid intake
Expected outcome
The patient will demonstrate knowledge of bathroom location and will regularly eliminate soft, formed stools.
Suggested NOC Outcomes
Bowel elimination; Hydration; Symptom control
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Place the patient in a bed close to the bathroom. Identify the bathroom clearly—symbols or color codes may be helpful. Frequently remind the patient of its location.
A patient with Alzheimer's disease may forget the location of the bathroom.

Independent
Prompt the patient at regular intervals to use the toilet. With an incontinent patient, use standard precautions.

The patient may neglect toileting because of memory loss. Reminders, with assistance at regular intervals, promote a regular elimination pattern and help prevent accidents.
Independent
Encourage a therapeutic diet with ample fluid and fiber intake.
Proper diet promotes effective elimination. Ample fluids and fiber help prevent constipation.
Independent
Observe the patient for nonverbal clues that signal the need for elimination.
Nonverbal clues can alert the nurse or caregiver to toileting needs and help prevent accidents, especially if the patient is unable to verbalize the need to eliminate.
Independent
Administer and document use of elimination aids (stool softener, laxative, or cathartic) as ordered.
Evaluate their effect and observe for adverse effects.

Such aids may help promote regular elimination. Noting the effects of medication prompts appropriate actions if treatment isn't effective or causes adverse effects.
Independent
Monitor and document the frequency of elimination.

Noting the frequency of elimination helps identify a regular bowel pattern and minimizes problems.

[Additional individualized interventions]

Suggested NIC Interventions
Bowel management; Constipation/impaction management; Fluid management
Risk for caregiver role strain related to progressive needs of the Alzheimer's disease patient
Expected outcome
The caregiver will be involved in teaching and providing care, will arrange a plan for care and mutual support, and will identify community support resources.
Suggested NOC Outcomes
Caregiver emotional health; Caregiver lifestyle disruption; Role performance
Nursing interventions
Intervention type
Intervention
Rationale
Independent
Involve the caregiver and available family members in all teaching. Assess family roles, resources, and coping behaviors.

Teaching the caregiver and family about the patient's needs promotes understanding of the patient's condition and helps them cope with the situation.
Independent
Offer support, understanding, and reassurance to the family. Support efforts to provide care for the patient in the home setting. Provide examples of caregiving schedules.
Encourage family members to give each other breaks and "holidays." Encourage the use of adult day-care programs.
Maintaining a stable home environment with familiar caregivers helps give the patient a sense of worth, reduces isolation, and may minimize disorientation.
Frequent breaks from caregiving help increase family cohesiveness and prevent burnout.
Collaborative
Involve a social worker or discharge planner in decisions regarding home care or nursing home placement.
If appropriate, encourage family members to express their feelings about the decision to place the patient in a nursing home.
The social worker or discharge planner may offer special expertise in answering questions about long‑term care.
Family members may feel guilt, relief, anguish, or other conflicting emotions and will need support if this decision becomes necessary.
Independent
Provide information about community resources, such as home care, financial and legal assistance, and an Alzheimer's support group. Encourage use of all available resources.
Community support may help lessen the family's burden and promote healthy adaptations to change. A social service referral may decrease inappropriate use of resources and help avert family crises.

[Additional individualized interventions]

Suggested NIC Interventions
Caregiver support; Counseling; Respite care; Role enhancement; Support group
Teaching checklist
Diagnosis and disease process and treatment plan
Minimization of environmental hazards and prevent injury
Recommendations for promoting self‑care and maintaining independence
Identification devices
Wandering prevention
Purpose, dosage, administration schedule, and adverse effects of prescribed medications
Techniques for maintaining or improving language skills
Recommendations for meeting nutrition and elimination needs
Available community resources
Date, time, and location of follow-up appointments

Transient Tachypnea of the Newborn: Nursing Case Study

Tuesday, 29 April 2014

Transient tachypnea of the newborn (TTN) is a mild respiratory problem. It begins after birth and generally lasts about 3 days. TTN is also known as wet lungs or type II respiratory distress syndrome.

Pathophysiology
TTN results from the delayed absorption of fetal lung fluid after birth. Before birth, the fetus doesn't use his lungs to breathe. Instead, the fetal lungs are filled with fluid. All of the fetus' nutrients and oxygen come from the mother through the placenta. During the birth process, some of the neonate's lung fluid is squeezed out as he passes through the birth canal. After birth, the remaining fluid is pushed out of the lungs as the lungs fill with air. Fluid that remains is later coughed out or absorbed into the bloodstream. TTN results when fluid remains in the lungs, forcing the neonate to breathe harder and faster to get adequate oxygen.


Complications
■ Infection

Assessment
Nursing history by functional health pattern (mother)
Health perception and management

■ History of cesarean delivery

Physical examination
Respiratory

■ Persistently high respiratory rate usually greater than 60 breaths/minute
■ Mild retractions
■ Nasal flaring
■ Expiratory grunting

Gastrointestinal
■ Difficulty feeding because of fast respiratory rate

Diagnostic studies
■ Chest X‑ray reveals hyperinflation, fluid in fissures, costophrenic angles, and a flattened diaphragm; patches of collapse may be seen.

■ Arterial blood gas (ABG) analysis may reveal slight hypoxemia and decreased partial pressure of carbon dioxide.

Teaching checklist
■ Purpose, dosage, administration schedule, and adverse effects of discharge medications
■ Feeding guidelines
■ Signs and symptoms requiring medical intervention
■ Date, time, and location of follow‑up appointments
■ Reasons to call the pediatrician and contact information

Image credit: Kidshealth.org

Pregnancy Complicated by Cardiac Disease and Its Assessment: Nursing Case Study

Sunday, 13 April 2014

Women with cardiac disease who otherwise may not have thought of becoming pregnant are now choosing pregnancy because of medical improvements in cardiac care. The two main cardiac dysfunctions affecting pregnancy are congenital and rheumatic heart diseases. Congenital heart diseases include atrial septal defect, ventricular septal defect, pulmonary stenosis, and coarctation of the aorta. The risks for women with rheumatic heart disease are related to endocarditis that has caused heart valve stenosis or regurgitation. Women with mitral valve prolapse may require prophylactic antibiotic therapy during labor to prevent endocarditis.

The issue facing women of childbearing age and their cardiologists is whether a woman with cardiac disease can complete a pregnancy successfully, based on the type and extent of her disease. The New York State Heart Association has established four classes to describe cardiac status, regardless of the etiology of the dysfunction. Women with class I or II disease usually can have a normal pregnancy and delivery. Class III disease poses moderate to marked limitation on activity, with the woman becoming symptomatic during less than ordinary activity and, thus, needing to be on complete bed rest throughout her pregnancy to deliver successfully. A woman with class IV disease is symptomatic at rest and isn't a good candidate for having a successful pregnancy.

Pathophysiology
The underlying problem depends on the location and severity of the cardiac defect. Valvular stenosis decreases blood flow through the valve, increasing the workload on heart chambers located before the stenotic valve. Regurgitation permits blood to leak through an incompletely closed valve, increasing the workload on heart chambers on either side of the affected valve. A normal heart can compensate for increased demands; however, if myocardial or valvular disease develops or if the patient has a congenital heart defect, cardiac decompensation can occur. A patient with a cardiac disorder is at greatest risk when hemodynamic changes reach their maximum, from 28 to 32 weeks' gestation.

Complications
■ Maternal cardiac decompensation, including myocardial failure and cardiomyopathy
■ Intrauterine growth retardation
■ Fetal distress
■ Prematurity

Assessment
Health perception and management
■ Care provided by a cardiologist

Activity and exercise
■ Palpitations
■ Feeling of smothering
■ Shortness of breath with exercise
■ Chest pain related to exertion

Sleep and rest
■ Fatigue

Self-perception and self-concept
■ Fear
■ Anxiety

Coping and stress management
■ Inadequate support system
■ Inadequate coping measures for stress

Physical examination
Integumentary
■ Cyanosis
■ Clubbing

Respiratory
■ Dyspnea
■ Orthopnea
■ Cough, with or without hemoptysis
■ Basilar crackles
■ Paroxysmal nocturnal dyspnea

Cardiovascular
■ Vertigo
■ Syncope
■ Tachycardia
■ Pulse irregularities
■ Progressive generalized edema
■ Diastolic, presystolic, or continuous murmur
■ Loud, harsh, systolic murmur, especially if associated with a thrill
■ Arrhythmias
■ Unequivocal cardiac enlargement

Diagnostic studies
■ X-rays reveal abnormalities in cardiac or vessel size, contour, outline, position, or density; unequivocal cardiac enlargement confirms a diagnosis of cardiovascular disease in pregnancy. (Note: The need for X-rays must be carefully evaluated; if they're performed, a lead shield should cover the abdomen and pelvis; avoidance during the first trimester should be a priority.)

■ Electrocardiography reveals hypertrophy, arrhythmias, ischemia, conduction defects, heart block, pericarditis, and electrolyte abnormalities.

■ Echocardiography reveals valvular abnormalities, ventricular dysfunction, or other cardiac disorders.

■ Hemoglobin (Hb) level and hematocrit (HCT) decrease in response to expansion of blood volume (normal ranges from 12 to 15 g/dl and 35% to 45%, respectively); HCT may increase from constant hypoxia.

■ White blood cell count increases (normal ranges from 5,000 to 10,000/mm3 in first trimester; 10,000 to 12,000/mm3 by term).

■ Clotting factors decrease because depression of fibrinolytic activity occurs during normal pregnancy and the postpartum period.

■ Serum electrolyte levels increase (normal range of sodium level is 136 to 145 mEq/L and potassium level is 3.5 to 5 mEq/L).

Teaching checklist
■ Preconception counseling
■ Medications that are safe to use during pregnancy
■ Maternal and fetal risks
■ Long-term maternal morbidity and mortality
■ Signs and symptoms of heart failure
■ Labor and delivery plan
■ Nutrition
■ Limitations to physical activity
■ Fetal echocardiography
■ Fetal monitoring