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CONSTIPATION Nursing Care Plan

Constipation is a condition in which a person cannot regularly eliminate his/her bowel or cannot even complete it's elimination due to the stool that is hard and dry cause by a diet that lacks of fiber and fluids. This condition is common and it affects all ages so it is better that you knew how to manage this condition. Here's an example of nursing care plan for constipation.

ASSESSMENT
Subjective:
"I'am having difficulty in defecation because of my dry stool," as verbalized by the patient.

Objectives:
I observed from the patient that he/she has a distended abdomen and upon palpation, the patient has a tender abdomen without palpable muscle resistance. Through percussion, I detected dullness in the abdomen. (We consider a patient that he/she had a distended abdomen when his/her belly is swelling, distended abdomen is usually called swelling of the abdomen. While tender abdomen is when you palpate the abdominal area and you feel that it is hard and had a mass.) His/her sample stool is hard-dry.

The patient's vital signs are taken and noted as follows: Body temperature is 37.2 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, pulse rate is 82 beats per minute. Respiratory rate and pulse rate is normal while the patient's body temperature is above normal. His/her blood pressure is categorized as pre-hypertention.

DIAGNOSIS
Constipation related to observed hard, formed stool as evidenced by distended abdomen and palpable abdominal mass. (Constipation is the condition of being unable to easily release solid waste from your body. Stool is a solid waste product of the body while the liquid waste is the urine. The process of removing waste products inside the body, either solid or liquid, is called excretion.)

PLANNING
After 8 hours of nursing intervention, the patient will regain normal pattern of bowel functioning. (Once a day is considered a regular bowel. One a week is considered the patient is constipated while five or more are a day is a condition which is called diarrhea.)

INTERVENTION
Review your client's dietary regimen and note if the diet is deficient in fiber. Fiber helps food to move through your digestive tract more quickly for healthy elimination. So encourage the client to have a balanced diet that rich in fiber. Fiber-rich foods are whole foods, fruits and vegetables.

Ask the client about his/her fluid intake and evaluate his/her hydration status. Encourage the client to have adequate fluid intake because this will promote passage to stool. Tell the patient to drink at least 8 glasses of water everyday.

There are other factors you should consider such as activity level and exercise, pain in defecation, and bowel obstructions. (Did you know that sedentary lifestyle may affect elimination patterns and activities beyond the body's limit reduces stimulation for contractions of intestines?) Pain in defecation is sometimes caused by hemorrhoids, it is the swelling of veins in the rectum and anus. Fecal impaction is one of the most causes of bowel obstruction.

Encourage the client for treatment of underlying medical causes of constipation where appropriate to improve organ function, including bowel. Administer enemas and/or digitally remove impacted stool and establish bowel program to include glycerin suppositories and digital simulation, as appropriate, when long-term or permanent bowel dysfunction is present.

EVALUATION
After 8 hours of nursing intervention, the patient regained the normal pattern of bowel functioning.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

ACUTE CONFUSION Nursing Care Plan

Acute confusion is a state in which a person's cognitive function is below from a previously attained baseline level of cognitive function. A person with disturbance to its thought process accompany with decrease in level of conciousness is experiencing acute confusion. We provide an example of nursing care plan for acute confusion with a 3-hour nursing care intervention. 

ASSESSMENT
Subjective:
"I hear a voice of a little boy and a ball dribbling," as verbalized by the patient.

Objectives:
I observed from the patient that he/she is experiencing restlessness; a person who doesn't able to relax or rest. The decreased in level of conciousness and inappropriate responses are clearly manifested. I also noticed that there is poor eye contact and fluctuation in his/her body movement.

The vital signs are taken and noted as follows: Body temperature is 36.8 degrees Celcius which is above normal level of 36.5, blood pressure is 110/80 mmHg which is considered normal, pulse rate of 85 bpm and respiratory rate of 18 cycle per minute. Both pulse rate and respiratory rate are normal.

DIAGNOSIS
(You may use "Acute confusion related to acoustic hallucination as manifested by strategic level of consciousness and inappropriate responses.") Acoustic hallucination refers when a person is hearing a sound or void that seems real to them but does not really exist. The patient verbally said that he/she is hearing a voice of a little boy and a ball dribbling which is actually not exist in his/her room.

PLANNING
After 3 hours of nursing intervention, the patient will regain usual reality, orientation and level of consciousness. (Why 3u hours? Actually, it depends on how much time you would take to accomplish all your actions and interventions to manage the patient's problem).

INTERVENTION
Before anything, you must first investigate the possibility of alcohol and other drug withdrawal or intake. Too much alcohol intake can make a person hallucinate and do inappropriate responses. If the patient was drunk, make a plan for acute confusion due to alcohol intake. Drug withdrawal or intake, like alcohol, could also cause hallucinations.

After investigation had done, you must evaluate vital signs for indicators of poor tissue perfusion. Lack of oxygen in the brain also cause hallucinations. You must also assess the diet and nutritional status of the patient, so that you can identify the deficiency of essential vitamins and nutrients which may cause confusion.

Orient the client to surroundings, staffs and necessary things needed, you must concisely and briefly presents reality and give only simple directions. You allow sufficient time for the client to respond, communicate and make decisions. If possible, encourage his/her family members to participate in the reorientation as well as providing out aping input. While doing this, you must maintain calm environment and eliminate extraneous stimuli to prevent exacerbation of psychiatric conditions. Note behavior that may be indicative of potential for violence and take appropriate actions. Note: Limit use of restraints because it may wooden the situation and it may increase likelihood of untoward complications.

EVALUATION
After 3 hours of nursing intervention, the patient regained usual reality, orientation and level of consciousness. (Remember that this is your goal, if the patient still experiencing the problem, try to reassess the patient again.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

BOWEL INCONTINENCE Nursing Care Plan

ASSESSMENT
Subjective:
"I'm unable to control my defecation," as verbalized.

Objectives:
I observed from the client that his/her clothing and bedding were stained by feces. The room has a fecal odor which was came from the patient. The patient had a red in his/her perianal skin and there's a soft stool protruding in his/her rectal orifice.  Vital signs were taken and noted as follows: Body temperature of 37.5 degrees Celcius, blood pressure of 130/90, respiratory rate of 18 cycles per minute and pulse rate of 98 beats per minute. Both of his/her respiratory and pulse rate are normal but his/her body temperature and blood pressure are above normal.

DIAGNOSIS
Bowel incontinence related to inability to control defecation as evidenced by fecal staining of clothing. (Defecation is a process when a person eliminates his/her own feces).

PLANNING
After 4 hours of nursing intervention, the patient will participate in therapeutic regimen to control incontinence and maintain a regular pattern of bowel function.

INTERVENTIONS

Identify pathophysiology factors present such as multiple sclerosis, acute and chronic cognitive and self-care impairments, spinal cord injury, stroke, ileus, ulcerative colitis. Rescue results of diagnostic studies such as abdominal x-ray, colon imaging, complete blood count, serum chemistries, stool for blood guaiac as appropriate. Determine historical aspects of incontinence with preceding/precipitating events. Review medication regimen that might increase potential for bowel problems. Auscultate the abdomen and look for the presence, location, and tenderness. Palpate the abdomen for distention, masses and tenderness.



Establish bowel program worth predictable time for defecation efforts, use suppositories and digital simulation when indicated. Place bedpan at specified interval to take into consideration of individual needs and incontinent patterns. Maintain daily program initially. Progress to alternate days dependent on usual pattern of amount of stool. Take client to the bathroom or place on commode or bedpan at specific intervals, taking into consideration individual needs and incontinence patterns to maximize success of program. Provide perineal care and hygiene to prevent perineal infection and excoriation. 


Promote exercise program, as individually able, to increase muscle tone and strength, including perineal muscles. Provide incontinence aid or pads until control is obtained. Note that incontinence pads should be changed frequently to reduced incidence of skin rashes or breakdown. Demonstrate techniques such as contacting abdominal muscles, leaving forward on a commode, manual compression to increase intra-abdominal pressure during defecation, and left to right abdominal massage to stimulation of peristalsis.

Refer to ND diarrhea if incontinence is due to uncontrollable diarrhea and ND constipation if incontinence is due to impaction.

Instruct the use of suppositories or stool softeners, if indicated to stimulate timed defecation. Note the stool characteristics such as color, odor, consistency, amount, shape and frequency to provide a comparative baseline. Identify foods such as daily bran muffins, prunes that promote regular bowel and encourage the client in high-fiber diet and adequate amount of warm fluids. 

Provide emotional support to client, especially when condition is long-term or chronic because it enhances coping with difficult situation.

EVALUATION
After 4 hours of nursing intervention, the patient participated in therapeutic regimen to control incontinence and maintained a regular pattern of bowel function.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

DECISIONAL CONFLICT Nursing Care Plan

Decisional conflict is when a person is uncertain about which course of action to choose when the choices have involve risk, challenge, or negative or disadvantage to personal life values. Here's a good sample of nursing care plan for decisional conflict.

ASSESSMENT
Subjective:
"I want to start my surgery but it will take 3 months before I will fully recover. My 
family depends on me and the 3-month absences in my work would cause us to much trouble," as verbalized by the patient.

Objectives:
I observed that the patient is vacillating between alternative choices. (Vacillation  is when a person cannot decide from the possible choices). Because of that, there is a delay on decision-making and self-focus. Restlessness also observed as the client can find his/her comfort and cannot stay still.

Vital signs are taken and noted as follows: Body temperature is 36.6 degrees Celcius, blood pressure is 130/80 mmHg, respiratory rate is 18 cycles per minute, and pulse rate is 112 beats per minute. The client's body temprature, blood pressure, and pulse rate are normal but his/her blood pressure is categorize as pre-hypertention.

DIAGNOSIS
Decisional conflict related to moral obligation requires performity or not performing actions as manifested by delayed decision-making. (Working for your  family and to sustain their daily needs is one kind of moral obligations).

PLANNING
After 4 hours of nursing intervention the patient will be able to make decision and express satisfaction with the choice and free of physical signs of distress. (Why 4 hours? The primary goal is to help the client make the best decision for him/her self, to decide on a short period of time but have enough time to think about his/her decision).

INTERVENTION
Before you start any intervention, try to actively listen to the reason of your client for indecisiveness because this will clarify the problem and work toward to a solution. While listening to the patient, determine usual ability to manage own affairs. Note for expressions of indecision and dependence on others. Note: Remember that accurate and clearly understood information about situation will help the client make the best decision for self. Also you must accept verbal expressions of anger or guilt but you need to set limits on maladaptive behavior to promote client safety. If you find something that your patient was misinterpreted or misconcepted, correct it and provide factual information because this will provide better decision.

Choices may have risky, uncertain outcomes and msg reflect a need to make value judgements or may generate anticipated regret over having to reject positive choice and accept negative consequences. Just support the client for decisions made, especially if consequences are unexpected or difficult to cope with. Provide positive feedback for efforts and progress noted.

EVALUATION
After 4 hours of nursing intervention the patient was able to make decision and expressed satisfaction with the choice and free of physical signs of distress. (It's okay if the patient took much more time to completely decide but if the patient is still can't decide on his/her own. Try to reassess the patient and make a nursing care plan again).

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

DECREASED CARDIAC OUTPUT Nursing Care Plan

Decreased cardiac output is a state in which inadequate blood is pumped by the heart to meet the metabolic demands of the body caused by cardiac dysfunctions, blood flow obstructions, electrolyte imbalances, and more. Before coming up with a nursing care plan, a lot of assessment, tests and monitoring will be done first to find the accurate intervention to the patient. But here is an example of a nursing care plan for decreased cardiac output.

ASSESSMENT
Subjective:
"I feel that I'm having palpitations right now," as verbalized by the patient.

Objectives:
I observed from the patient that he/she has distended neck vein and facial edema. He/she also positive in prolonged capillary refill as I press his/her fingertip (prolonged capillary refill is when it takes too much time before your fingertip return to its normal color after you press it. The patient is restlessness as he can't stay still and find his/her comfort.

Vital signs are taken and noted as follows: Body temperature is 36.8 degrees Celcius, blood pressure is 110/70 mmHg, respiratory rate is 20 cycles per minute, and pulse rate is 128 beats per minute. There's slightly above normal in his/her body temperature while blood pressure and respiratory rate are in normal range. But the patient is in tachycardia as his/her pulse rate exceeds the 80-100 beats per minute normal range.

DIAGNOSIS
Decreased cardiac output related to palpitations as evidenced by altered heart rate (tachycardia) and distended neck vein. (Palpitations is a sensation when your heart has skipped a beat or added an extra beat. You may become overly aware of your heartbeat which you felt in the neck, throat, or chest and it feels like your heart is racing, pounding, or fluttering.)

PLANNING
After 4 hours of nursing intervention, the patient's cardiac output will be normalized and his/her palpitations will be gone.

INTERVENTION
Before you start any nursing interventions, determine first his/her vital signs and  hemodynamic parameters including cognitive status. The initial vital signs taken will be the baseline for comparison to follow trends and evaluate response to interventions. Note vital signs responses to activity procedures and time required to return to baseline.

You must review diagnostic and laboratory data such as cardiac makers, complete blood count and electrolytes. These will help determine the underlying 
causes of decreased in cardiac output. After these, perform periodic hemodynamic measurements as indicated such as arterial pressures and cardiac output and monitor cardiac rhythm continously to note effectiveness of medications and assistive devices such as implanted pacemaker of defibrillator.  Maintain patency of invasive intravascular monitoring and infusion lines. Tape connections to prevent air embolus and exanguination. Also assess urine periodically; weigh daily and note total fluid balance.

You may administer high-flow oxygen via mask or ventilator as indicated because this can increase oxygen available for cardiac function and tissue perfusion. In addition, depending on the client as indicated, restrict or increase fluids. You must change linens routinely and administer antipyretics as indicated, to maintain body temperature in near-normal range.

EVALUATION
After 4 hours of nursing intervention, the patient's cardiac output normalized and his/her palpitations are gone.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Ineffective breathing pattern is a state when there is inadequate ventilation in the results of the process of breathing or respiration. inadequate ventilation may cause mild to serious complications and damage to entire body system of a person. Below is a sample of nursing care plan for patients with ineffective breathing pattern.

ASSESSMENT
Subjective:
"I can't breath well because of my chest pain," as verbalized by the patient.

Objectives:
I clearly observed to the patient his/her difficulty of breathing and shortness of breath in response to his/her altered breath depth and altered chest excursion. As I observe the timing ratio, there is a prolonged expiration phases. Nasal flaring and grunting also observe.

Vital signs are taken and noted as follows: Body temperature is 35.7 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 23 cycles per minute and pulse rate is 110 beats per minute. Only body temperature is normal, but his/her blood pressure is considered as pre-hypertension, respiratory rate is above normal also his/her pulse rate is above normal.

DIAGNOSIS
Ineffective breathing pattern related to difficulty of breathing as manifested by prolonged expiration phases than inspiration. (Remember that expiration, also called exhalation is breathing out while inspiration, also known as inhalation is breathing in.

PLANNING
After an 30 minutes of nursing intervention, the patient will able to do coping mechanisms to improve his breathing pattern. (When it comes to difficulty of breathing, nursing intervention must done in a short period of time).

INTERVENTION
You must determine if there are presence of factors and physical conditions that would cause breathing impairments. Start by auscultating the chest to evaluate the type of breathing pattern such as tachypnea, grunting, Cheyne-Stokes, and other irregular patterns. Cheyne-Stokes breathing is an abnormal pattern of very shallow breaths to alternating apnea and deep, rapid breathing which is also called as periodic respiration.

Ineffective breathing pattern may also occur when the patient is experiencing pain located in the chest, so you must assess for concomitant pain and discomfort that may restrict limit respiratory effort. Positioning may help or prevent this situation, so encourage the patient position of comfort of by elevating the head of the bed or have client to sit up in chair, as appropriate to promote physiologic ease of maximal inspiration. Note: if immobility is a factor, you need to reposition the patient atleast every two hours.

Encourage slower/deeper respirations, use purse lip technique, to assist client in taking control of the situation and if symptoms persist administer oxygen at lowest concentration in indicated and prescribed respiratory medication for management of underlying pulmonary condition. If obstruction of secretions is the cause, suction airway as needed to clear the secretions. 

Just remember to maintain calm attitude while dealing with the client to limit level of anxiety. Monitor pulse oximetry, as indicated to verify maintenance in oxygen saturation and maintain emergency equipment in readily accessible location and include age and size appropriate ET tubes when ventilatory support might be needed.

EVALUATION
After 30 minutes of nursing intervention, the patient did the coping mechanisms to improve his breathing pattern.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

READINESS FOR ENHANCED COMFORT Nursing Care Plan

ASSESSMENT
Subjective:
"I wish I could feel comfortable in this room," as verbalized by the patient.

Objectives:
The patient is irritable, restlessness, and prolonged sitting and standing than reading at be. The patient has a stressed appearance, dry skin and mouth and have enlarged eye bag. Vital signs are taken and noted noted as follows: Body temperature of 36.5 degrees Celcius, blood pressure of 110/70 mmHg, respiratory rate of 20 cycles per minute, pulse rate of 88 beats per minute. All of his/her vital signs are within the normal range.

DIAGNOSIS
Readiness for enhaced comfort related to irritability and restlessness as manifested by irritability and presense of eyebags. (Restlessness is a condition when a person can not find his/her comfort).

PLANNING
After 4 hours of nursing intervention, the patient will be able to verbalize sense of comfort or contentment.

INTERVENTION

Physical


Verify that the client is managing pain and pain components effectively. Success in this area usually address other issues or emotions such as far, loneliness, anxiety and anger. Ascertain what is used for comfort to rest such as head of bed up or down, music on or off, white noise, rocking motion, certain person thing.



Collaborate in treating medical conditions including oxygenation, elimination, mobility, cognitive abilities, electrolyte balance, thermoregulation, hydration, to promote physical stability. Work with client to prevent pain, nausea, itching, thirst and other physical comfort. Suggest patent to be present during procedures to comfort child. Provide age-appropriate comfort measures such as back rub, change position, cuddling, use of heat or cold to provide non-pharmacological pain management.

Promote overall health measures such as nutrition, adequate flood intake, appropriate vitamin or iron supplement. Discuss potential complication and possible need for median follow-up care or alternative therapies. Timely recognition and intervention can prime wellness. Assist client to identify and acquire necessary equipment such as lift, chair, safety grab bars, personal hygiene supplies to meet individual needs.

Environmental

Provide quiet environment and calm activities. Provide for periodic changes in personal surroundings when client is confined. Use the individual's input in creating the changes such as seasonal bulletin boards, color changes, rearranging furnitures and pictures. Determine that client's environmental respects privacy and provides natural lighting and readily accessible view outdoors which an aspect that can be manipulated to enhance comfort. Create compassionate, supportive, and therapeutic environment incorporating client's cultural and age or developmental factors. correct environmental hazards that could influence safety or negatively affect comfort. Arrange for home visit or evaluation as needed. Discuss long-term plan for taking care of needs.



Sociocultural


Ascertain meaning of comfort in context of interpersonal, family cultural values, and societal relationships. Validate client understanding of client's diagnosis or prognosis and ongoing methods of managing condition, as appropriate and desired by client. Encourage age-appropriate diversionary activities such as TV,  radio, or playtime. Avoid over stimulation and understimulation.

EVALUATION
After 4 hours of nursing intervention, the patient was verbalized sense of comfort or contentment.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

INEFFECTIVE BREASTFEEDING Nursing Care Plan

Exclusive breastfeeding is called when an infant has received only breastmilk from his/her mother or a wet nurse, or expressed breastmilk, and no other liquids or solids, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines.

ASSESSMENT
Subjective:
"I have difficulty every time I have to breastfeed my first baby," as verbalized by the patient.

Objectives:
I observed from the patient that she had a swollen and sore nipples. Red rashes around the nipple area are present. Vital signs are taken and noted as follows: Body temperature is 36.5 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 17 cycles per minute, and pulse rate  of 88 beats per minute.
DIAGNOSIS:
 Ineffective breastfeeding related to nipple sores secondary to red rashes around the nipple area.

PLANNING
After 8 hours of nursing intervention, the patient will be able to breastfeed her baby effectively and nipple sores and rashes will be diminished.

INTERVENTION

Established rapport to the patient to provide trust and quality nurse-client interaction since the affected body part is considered a private part. Assess mother's knowledge and previous experience with breastfeeding. Identify cultural beliefs and practices regarding lactation, let down techniques, and maternal preferences. Provide emotional support to mother and instruct the mother the proper breastfeeding. Note incorrect myths/misunderstandings especially in teenage mothers who are more likely to have limited knowledge and concerns about body image issues.


Determine whether lactation failure is primary like maternal prolactin deficiency, inadequate mammary gland tissues, breast surgery that has damage the nipples, areola enervation. Perform physical assessment, noting appearance of breast and nipples, minimal or no breast enlargement during pregnancy. Note prematurity and infant anomaly such as cleft lift or cleft palate to determine special equipment or feeding needs. Review feeding schedule to note increased demand for feeding at least 8 times/day, taking both breasts at each feeding for more than 15 minutes on each side of use of supplements with artificial nipple.

Provide health teachings such as, wear 100% cotton fabrics, avoid nipple shields or nursing pads that contains plastics. Don't use soap, alcohol, or dying agents on nipples. Apply ice before nursing and soak warm water before attaching to infant to soften nipple and remove dried milk. Apply ice before nursing and begin with least sore side to established let-down reflex. Recommend  using a variety of nursing positions because it helps to provide support with the mother as well as the baby.

Inform mother about early infant feeding cuts like rooting, lip smacking, sucking fingers or hand versus late cues of crying. Early recognition of infant hunger promotes ring timely and more rewarding feeding experience for infant and mother. Recommend avoidance or overuse of supplemental feedings and pacifiers unless specially indicated because it can lessen infant's desire to breastfeed and increase risk of early weaning. Schedule follow up visit with health care provider 48 hours after hospital discharge and 2 weeks after birth for evaluation of milk intake and breastfeeding process.

EVALUATION
After 8  hours of nursing intervention, the patient was breastfed her baby effectively and nipple sores and rashes was diminished.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

DISTURBED BODY IMAGE Nursing Care Plan

Disturbed body image is when a person distress his/her appearance that is actually divergent to which is considered normal. Below is a sample of nursing care plan for disturbed body image patients.

ASSESSMENT
Subjective:
"How could I go to school in this situation, my classmates would probably laugh at me," as verbalized by the patient.

Objectives:
I observed from the patient that he/she had damages in facial structure, his/her face was sad and no eye contact when I was taking to him/her. He/she only used non-verbal response to communication and he/she skipped meals. Vital signs was taken and noted as follows: Body temperature is 36.6 degrees Celcius, blood pressure is 110/80 mmHg, respiratory rate is 16 cycles per minut,  and pulse rate of 72 beats per minute.
DIAGNOSIS
Disturbed body image related to change in facial structure secondary to negative eye contact and using only non-verbal communication. (Non-verbal communication is when a person only uses facial expressions, gestures, and hands to communicate with others).

PLANNING
After 8 hours of nursing intervention, the patient will able to verbalize acceptance to body changes and incorporate body image change into self-concept.

INTERVENTION
Establishment rapport to the patient because this will increase the nurse-patient relationship. Note withdrawn  behavior and use of denial. Discuss pathophysiology present and situation affecting the individual. For example, when alteration of the body image is related to neurological deficit such as cerebrovascular accident, refer to unilateral neglect.

Assess mental and physical influence of illness or conflict on the client's emotional state such as disease of the endocrine system or use of thyroid therapy. Recognize behavior indicative of overconcern with body and its processes. Have client describe self, noting what is positive and what is negative. Be aware of how client believes others see self.  

Discuss meaning of loss or change in client. A small loss may have a bid impact such as the use of a urinary catheter or enema for incontinence. A change in function such as immobility in elderly may be more difficult for some to deal with than a change in appearance. Permanent facial scaring of child may be difficult for parents to accept. Note signs of grieving or indicators of severe or prolonged depression to evaluate need for counseling and medication.

Listen to client's comments and responses to the situation. Different situations are upsetting to different people, depending on individual coping skills and past experiences. Note use of addictive substances or alcohol because it may reflect dysfunctional coping.

Alert staff to monitor own facial expressions and other non-verbal behaviors because they need to convey acceptance and not revulsion when the client's appearance is affected. Encourage family members to treat client normally and not as invalid. Help client to select and use clothing and make up to minimize body changes and enhance appearance. Provide information at client's level of acceptance and in small pieces to allow easier assimilation. Clarify misconception. Reinforce explanations given by other health team members. Offer positive reinforcement for efforts made such as wearing make up, using prosthetic device.

EVALUATION
After 8 hours of nursing intervention, the patient had verbalized acceptance to body changes and intervention body image change into self-concept.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

RISK-PRONE HEALTH BEHAVIOR Nursing Care Plan

Risk-prone health behavior is a state when a person cannot modify his/her behavior in a consistent manner with a change of his/her health. Below is a sample of nursing care plan for patients with risk-prone behavior.

ASSESSMENT
Subjective:
"I still kept on smoking, even though I know I had my emphysema," as verbalized by the patient.

Objectives:
The patient have productive cough and he/she is positive to barrel chest. Rapid breathing and wheezing also manifested. Vital signs are taken and noted as follows: Body temperature is 36.8 degrees Celcius, blood pressure is 130/90 mmHg, respiratory rate of 25 cycles per minute, and pulse rate of 72 beats per minute. All of his/her vital signs are above normal except pulse rate which is on the other hand, below normal. That means he/she had an abnormal vital signs.

DIAGNOSIS
Risk-prone health behavior related to continuous smoking secondary to respiratory condition.

PLANNING
After 2 hours of nursing intervention, the patient will initiate lifestyle changes that will permit adaptations to current life situation.

INTERVENTION
Review previous life situations and role changes with the client to determine coping skills used it any. Explain the disease process, causative factors and prognosis to enhance understanding. Perform a physical and psychological assessment to determine the extent of the limitations of the current condition. Listen to the client's perception of inability and reluctant to adapt to situations that are currently occurring. Survey with the client past and present significant support systems such as family, church, groups, and organizations to identify helpful resources. Explore the expressions of emotions signifying impaired adjustment by client such as overwhelming anxiety, fear, anger, worry, passive and active denial. Note child's interaction with parent because development of coping behaviors is limited at this age, and primary caregivers provide support for the child and serve as role models. Determine whether child displays problems with school performance, withdraws from family or peers, or demonstrates aggressiveness behavior toward others or self.

Listen to client's perception of the factors leading to the present dilemma, noting onset, duration, presence or absence of physical complaints, and social withdrawal. Determine lack of inability to use available resources. Review available documentation and resources to determine actual life experiences such as medical records or consultant's notes. In situations of great stress, physical and emotional, the client may not accurately assess occurrences leading to the present situation.

Organize a team conference including client and ancillary services to focus on contributing factors effecting adjustment and plan for management of the situation. Acknowledge client's efforts to adjust because these can lessen feelings of blame or guilt and defensive response. Share information with adolescent's peers as indicated when illness affects body image. Peers are primary support for this age group. Provide an open environment encouraging communication so that expression of feelings concerning impaired function can be dealt with realistic and openly. Use therapeutic communication skills such as active listening, acknowledgement, silence and statements.

EVALUATION
After 2 hours of nursing intervention, the patient initiated lifestyle changes that would permit adaptations to current life situation.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

RISK FOR ASPIRATION Nursing Care Plan

Aspiration is the medical term for inhaling small particles of food or drops of liquid into the lungs which is commonly caused by depressed level of conciousness. Here is an example of nursing care plan for patients with risk for aspiration.

ASSESSMENT
Subjective:
(for the risk for aspiration, we don't have any subjective data
as we assume that the patient is unconscious.)

Objective:
The patient is sleepy, unconscious and coherent. His/her eyes are only respond to painful stimuli. The client utters inappropriate words and no body movements. I used Gaslow's Coma scale and the result of my observation is 5, eye response 2, verbal response 3, and motor response 0.
DIAGNOSIS
Risk for aspiration related to unconciousness as manifested by GCS of 5.

PLANNING
 - After an hour of nursing intervention, risk for aspiration will be gone.

INTERVENTION
Identify at risk client according to condition or disease process to determine when observation and interventions may be required. Note client's level of consciousness, awareness of surroundings, and cognitive function, as impairments in these areas increase client's risk of aspiration. Determine presence of neuromuscular disorders, noting muscle groups involved, degree of impairment, and whether they are of an acute or progressive nature such as stroke, Parkinson's disease, Guillain-Barre syndrome, or amyotropic lateral sclerosis.

Assess the client's ability to swallow and strength of gag reflex and evaluate amount/consistency of secretions to determine presence/effectiveness of protective mechanisms. Observe for neck and facial edema particularly risk for airway obstruction and inability to handle secretions. Remove oral dentures to prevent foreign aspiration. Suction as needed but avoid triggering of gag mechanic.

Note administration of enteral feedings because of potential for regurgitation and misplacement of the tube. Ascertain lifestyle habits for example, use of alcohol, tobacco, and other CNS-suppresants which can affect awareness and muscles of gag and swallow. Assist with diagnostic studies such as fiber optic endoscopy which may be done to assess for presence or degree of secretions. Assist in postural drainage to mobilize thickened secretions that may interfere with swallowing 
Monitor use of oxygen masks in clients at risk for vomiting. Refrain from using oxygen masks for comatose individuals. Keep wire cutters with client at all times when jaws are wired or banded to facilitate clearing airway in emergency situations. Maintain operational suction equipment at bedside or chair side. Avoid keeping client supine when on mechanical ventilation especially when also receiving enteral feedings. Supine positioning and enteral feedings have been shown to be independent risk factors for the development of aspiration pneumonia. Ascultate lung sounds frequently, especially in client who is coughing frequently or not coughing at all, or in client on ventilator being tube-fed, to determine presence of secretions. Elevate client to highest or best possible position or sitting upright position in chair for eating and drinking and during the feedings. Provide a rest period prior to feeding time. The rested client may have less difficulty with swallowing. 

EVALUATION
After an hour of nursing intervention, the risk for aspiration had gone.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!