Circumstances where an individual experiencing or at risk of decreased body temperature constantly below 35, 5 º C per-rectal because of the increased vulnerability to external factors.
Related factors:
Situational (personal, environmental)
related to the heat, rain, wind
related to clothes that do not fit with the climate
related to decreased circulation: extreme weight loss
related to alcohol consumption
related to dehydration
related to inactivity
Mayor data:
Temperatures below 35.5 º C per-rectal
Cold skin
Pallor (medium)
Chills (mild)
Minor data :
Mental disorder / sleepy / restless
Decrease in pulse and respiration
Cachexia / malnutrition
Expected outcomes are:
Individuals will:
Identifying risk factors for hypothermia.
Connecting method of maintaining the warmth / heat loss prevention.
Maintain body temperature within normal limits.
Nursing Interventions - Nursing Care Plan for Hypothermia :
Teach clients to reduce exposure to the cold environment of the old.
Explain to family members that neonates, infants and the elderly are more susceptible to heat loss.
Teach early signs of hypothermia: skin cold, pale, shivering.
Explain the need to drink 8-10 glasses of water each day
Explain the need to avoid alcohol in very cold weather.
Diabetes mellitus is a disorder in which the level of blood glucose is persistently raised above the normal range. Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes mellitus occurs in two primary forms: type 1, characterized by absolute insufficiency, and the more prevalent type 2, characterized by insulin resistance with varying degrees of insulin secretory defects. Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both (ADA], Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003.
Nursing Intervention for Diabetes
Nursing Diagnosis
Impaired nutrition: less than body requirements related to the reduction of oral input, anorexia, nausea, increased metabolism of protein, fat.
Nursing Intervention
Objective : The patient's nutritional needs are met
Result Criteria : Patients can digest the amount of calories or nutrients appropriate Stable weight or additions to the range usually
Intervention :
Weigh the body weight per day or according to the indication.
Determine the diet and eating patterns of patients and compare it with foods that can be spent on patients.
Auscultation bowel sounds, record the existence of abdominal pain / abdominal bloating, nausea, vomit that has not had time to digest food, maintain a state of fasting according to the indication.
Give the liquid diet containing foods (nutrients) and the electrolyte immediately if the patient has to tolerate it orally.
Involve the patient's family at this meal digestion according to the indication.
Observation of the signs of hypoglycemia, such as changes in level of consciousness, skin moist / cold, rapid pulse, hunger, sensitive to stimuli, anxiety, headaches.
Nursing Diagnosis for Diabetes Mellitus 1. Nursing Diagnosis : Fluid Volume Deficit related to osmotic diuresis.
Goal: Demonstrate adequate hydration evidenced by stable vital signs, palpable peripheral pulse, skin turgor and capillary refill well, individually appropriate urinary output, and electrolyte levels within normal limits.
Nursing Intervention: 1.) Monitor vital signs. Rational: hypovolemia can be manifested by hypotension and tachycardia. 2.) Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes. Rational: This is an indicator of the level of dehydration, or an adequate circulating volume. 3.) Monitor input and output, record the specific gravity of urine. Rational: To provide estimates of the need for fluid replacement, renal function, and effectiveness of the therapy given. 4.) Measure weight every day. Rational: To provide the best assessment of fluid status of ongoing and further to provide a replacement fluid. 5.) Provide fluid therapy as indicated. Rational: The type and amount of liquid depends on the degree of lack of fluids and the response of individual patients.
2. Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirments related to insufficiency of insulin, decreased oral input.
Goal: Digest the amount of calories / nutrients right Shows the energy level is usually Stable or increasing weight.
Nursing Intervention: 1.) Determine the patient's diet and eating patterns and compared with food that can be spent by the patient. Rationale: Identify deficiencies and deviations from the therapeutic needs. 2.) Weigh weight per day or as indicated. Rational: Assessing an adequate food intake (including absorption and utilization). 3.) Identification of preferred food / desired include the needs of ethnic / cultural. Rational: If the patient's food preferences can be included in meal planning, this cooperation can be pursued after discharge. 4.) Involve patients in planning the family meal as indicated. Rationale: Increase the sense of involvement; provide information on the family to understand the patient's nutrition. 5.) Give regular insulin treatment as indicated. Rational: regular insulin has a rapid onset and quickly and therefore can help move glucose into cells.
c. Nursing Diagnosis : Risk for Infection related to hyperglikemia.
Goal: Identify interventions to prevent / reduce the risk of infection. Demonstrate techniques, lifestyle changes to prevent infection.
Nursing Intervention: 1). Observed signs of infection and inflammation. Rationale: Patients may be entered with an infection that usually has sparked a state of ketoacidosis or may have nosocomial infections. 2). Improve efforts to prevention by good hand washing for all people in contact with patients including the patients themselves. Rationale: Prevents cross infection. 3). Maintain aseptic technique in invasive procedures. Rational: high glucose levels in blood would be the best medium for the growth of germs. 4). Give your skin with regular care and earnest. Rational: the peripheral circulation may be disturbed that puts patients at increased risk of damage to the skin / skin irritation and infection. 5). Make changes to the position, effective coughing and encourage deep breathing. Rational: memventilasi Assist in all areas and mobilize pulmonary secretions.
Nursing Diagnosis: Impaired Urinary Elimination related to mechanical obstruction: enlargement of the prostate, decompensated detrusor muscle, bladder's inability to contract
characterized by:
inability to empty the bladder,
incontinence,
bladder distention,
presence of residual urine.
Goals:
Urinate smoothly, without any bladder distention.
Residues less than 50 ml of urine without any overflow.
Nursing Interventions for Prostate Cancer - Impaired Urinary Elimination:
Instruct the patient to urinate every 2-4 hours and when it is full
Inform patients about stress incontinence
Observation of the emission of urine, observe the size and strength
Monitor and record the time and amount of urination.
Observe the decrease in urine output and changes in emission
Percussion / palpation of the suprapubic area
Encourage take up to 3000 ml per day when there is no heart intolenransi
Monitor vital signs. Observation of hypertension, peripheral / dependent edema. Body weight was measured every day and keep intake and output accurately
Give cateter and perineal care
Give the bath seat as indicated
Collaborative
Give the medication as indicated
Antispasmodics such as oxybutynin chloride, rectal suppositories, antibiotics and antimicrobials, phenoxybenzamine.
Urinary catheterization or Foley catheter pairs as indicated
Monitor lab results just as BUN, creatinine, Elektrolite, urinalysis and culture.
After nursing actions during 2x24 hours expected of patients with expected outcomes: (161 102) Position the patient to improve eyesight. (161 103) Instruct family members to use the techniques improve eyesight (161 107) Use visual aids (161 105) Use goggles
NOC criteria:
Not done at all
Rarely do
Are underway
Often performed
Always do
Cataract Nursing Interventions Classification NIC : EYE CARE (1650)
Monitor the redness and the presence of exudate
Determine the degree of decrease in vision or sharp eyesight test
Instruct patient not to touch eyes
Monitor corneal reflex
Instruct the patient to use glasses cataract
Take action to help patients deal with limited vision.
Encourage the patient to express feelings about the loss of vision.
2. Anxiety related to changes in health status
NOC : Anxiety Control (1402)
After nursing actions during 2x24 hours expected of patients with expected outcomes: (140 206) The use of effective coping strategies (140 207) Respiratory Rate within the normal range (140 211) There is an increasing social relationships (140 214) patients feel as comfortable with the situation (1402170) The patient was calm
NOC criteria:
Not done at all
Rarely do
Are underway
Often performed
Always do
NIC: Anxiety Reduction (5820)
Trying to understand the client's circumstances
Give information about the diagnosis and action
Use a calm approach
Identify the level of anxiety
Help patients recognize situations that indicate anxiety
Encourage patients to express feelings and fears
Give the drug to reduce anxiety
Assess the level of anxiety and physical reactions at the level of anxiety
Instruct the patient to reduce anxiety with relaxation techniques
Coping Enhancement (5830)
Use a calm approach and provide assurance
Appreciate and discuss alternative responses to situations
Support the involvement of families in an appropriate manner
Respect the patient's understanding of disease processes
Supports the use of appropriate defensive mechanisms
Provide a realistic choices about aspects of current treatments
3. Low self esteem related to Impaired self-image
NOC: Body Image (1200)
After nursing actions performed in 3 x 24 hours the patient is expected to receive him, with the expected outcomes:
Receive the body have been affected
Satisfied with the appearance of the body
Satisfied with body functions
NOC criteria:
Not done at all
Rarely do
Are underway
Often performed
Always do
NIC: Self estem enhancement (5400)
Monitor the patient statement about himself
Help the patient to improve the assessment itself to award him
Help the patient to increase her confidence
Provide a strong impetus for patients
Encourage eye contact in communication with everyone
Provide health education to families
Provide health education to clients about the disease
NANDA Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.
Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks.
NANDA Definition:Inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child
Defining Characteristics:
Infant/child
Poor academic performance; frequent illness; runaway; incidence of physical and psychological trauma or abuse; frequent accidents; lack of attachment; failure to thrive; behavioral disorders; poor social competence; lack of separation anxiety; poor cognitive development
Parental
Inappropriate child care arrangements; rejection of or hostility to child; statements of inability to meet child's needs; inflexibility in meeting needs of child or situation; poor or inappropriate caretaking skills; regularly punitive; inconsistent care; child abuse; inadequate child health maintenance; unsafe home environment; verbalization of inability to control child; negative statements about child; verbalization of role inadequacy or frustration; inappropriate visual, tactile, auditory stimulation; abandonment; insecure or lack of attachment to infant; inconsistent behavior management; child neglect; little cuddling; maternal-child interaction deficit; poor parent-child interaction
Related Factors:
Social
Lack of access to resources; social isolation; lack of resources; poor home environment; lack of family cohesiveness; inadequate child care arrangements; lack of transportation; unemployment or job problems; role strain or overload; marital conflict, declining satisfaction; lack of value of parenthood; change in family unit; low socioeconomic class; unplanned or unwanted pregnancy; presence of stress (e.g., financial, legal, recent crisis, cultural move); lack of or poor parental role model; single parent; lack of social support network; father of child not involved; history of being abusive; history of being abused; financial difficulties; maladaptive coping strategies; poverty; poor problem-solving skills; inability to put child's needs before own; low self-esteem; relocations; legal difficulties
Knowledge
Lack of knowledge about child health maintenance; lack of knowledge about parenting skills; unrealistic expectations for self, infant, partner; limited cognitive functioning; lack of knowledge about child development; inability to recognize and act on infant cues; low educational level or attainment; poor communication skills; lack of cognitive readiness for parenthood; preference for physical punishment
Physiological
Physical illness
Infant/child
Premature birth; illness; prolonged separation from parent; not desired gender; attention deficit hyperactivity disorder; difficult temperament; separation from parent at birth; lack of goodness of fit (temperament) with parental expectations; unplanned or unwanted child; handicapping condition or developmental delay; multiple births; altered perceptual abilities
Psychological
History of substance abuse or dependencies; disability; depression; difficult labor and/or delivery; young age, especially adolescent; history of mental illness; high number of or closely spaced pregnancies; sleep derivation or disruption; lack of or late prenatal care; separation from infant/child
NOTE: It is important to reaffirm that adjustment to parenting in general is a normal maturational process that elicits nursing behaviors to prevent potential problems and to promote health.
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·Child Development: 2 Months
·4 Months
·6 Months
·2 Years
·3 Years
·4 Years
·5 Years
·Middle Childhood (6 - 11 Years)
·Adolescence (12 - 17 Years)
·Parent-Infant Attachment
·Parenting
·Parenting: Social Safety
·Role Performance
·Safety Behavior: Home Physical Environment
·Social Support
Client Outcomes
·Affirms desire to develop constructive parenting skills to support infant/child growth and development
·Initiates appropriate measures to develop a safe, nurturing environment
·Acquires and displays attentive, supportive parenting behaviors
·Identifies strategies to protect child from harm and/or neglect and initiates action when indicated
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·Abuse Protection: Child
·Attachment Promotion
·Developmental Enhancement
·Family Integrity Promotion
·Parenting Promotion
Nursing Interventions and Rationales
·Use active listening to explore parent's understanding of developmental needs and expectations of child and self within the context of cultural perspectives and influences. Interviewing with empathy while reserving judgment allows parent to more freely express frustrations and disappointments regarding negative feelings, needs, and parenting skills. Unrealistic expectations may be present when parent does not discern what is normal for the child (Denehy, 1992; Herman-Staab, 1994; Mrazek, Mrazek, Klinnert, 1995).
·Examine characteristics of parenting style and behaviors, including the following:
oEmotional climate at home
oAttribution of negative traits to child
oFailure to support child's increases in autonomy
oType of interaction with infant/child
oCompetition with child for spousal/significant other attention
oLack of knowledge/concern about health maintenance or behavioral problems
oOther behaviors or concerns
Children are at risk for neglect, abuse, and other negative psychosocial outcomes in families with dysfunctions (Mrazek, Mrazek, Klinnert, 1995).
·Institute abuse/neglect protection measures if evidence of inability to cope with family stressors or crisis, signs of parental substance abuse, or significant level of social isolation apparent. Risk of abuse/neglect is higher in families with high levels of stress, substance abuse, or lack of social support systems (Devlin, Reynolds, 1994).
·For mothers with toddlers, assess maternal depression, perceptions of difficult temperament in toddler, and low maternal self-efficacy. Self-efficacy is defined as one's judgment of how effectively one can execute a task or manage a situation that may contain novel, unpredictable, and stressful elements. A cyclic relationship among depression, perceived difficult temperament, and self-efficacy has been identified. Negative feelings about oneself and one's child are likely to negatively influence the parent-child relationship (Gross et al, 1994).
·Appraise parent's resources and availability of social support systems. Determine single mother's particular sources of support, especially availability of her own mother and partner. Encourage use of healthy, strong support systems. Before adequate interventions and education can be initiated, understanding of the current support system and concerns must occur. The mother's partner and her mother are often important sources of support (Zacharia, 1994).
·Model age- and cognitively appropriate caregiver skills by doing the following:
oCommunicating with child at an appropriate cognitive level of development
oGiving child tasks and responsibilities appropriate to age or functional age/level
oInstituting safety considerations such as assistive equipment
oEncouraging child to perform activities of daily living (ADLs) as appropriate
These activities illustrate parenting and child-rearing skills and behaviors for parents and family (McCloskey, Bulechek, 1992).
Multicultural
·Assess for the influence of cultural beliefs, norms, and values on the client's perception of parenting. What the client considers normal parenting may be based on cultural perceptions (Leininger, 1996).
·Acknowledge racial/ethnic differences at the onset of care. Acknowledgement of racial/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D'Avanzo et al, 2001).
·Approach individuals of color with respect, warmth, and professional courtesy. Instances of disrespect have special significance for individuals of color (D'Avanzo et al, 2001).
·Give rationale when assessing black individuals about sensitive issues. Blacks may expect white caregivers to hold negative and preconceived ideas about them. Giving rationale for questions will help alleviate this perception (D'Avanzo et al, 2001).
·Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety and significant conflict with children. Challenges to traditional beliefs and values are anxiety provoking (Charron, 1998). Less acculturated parents may experience conflict with their more acculturated children as the children demand greater independence and freedom (True, 1995).
·Use a neutral, indirect style when addressing areas where improvement is needed (such as a need for verbal stimulation) when working with Native American clients. Using indirect statements such as "Other mothers have tried..." or "I had a client who tried 'X' and it seemed to work very well" will help to avoid resentment from the parent (Seiderman et al, 1996).
·Acknowledge and praise parenting strengths noted. This will increase trust and foster a working relationship with the parent (Seiderman et al, 1996).
·Validate the client's feelings regarding parenting. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).
·Facilitate modeling and role-playing to help family improve parenting skills. It is helpful for families and the client to practice parenting skills in a safe environment before trying them in real-life situations (Rivera-Andino, Lopez, 2000).
Client/Family Teaching
·Explain individual differences in child temperaments and compare and contrast with reality of parents' expectations. Help parents determine and understand the implications of their child's temperament. Promoting parental understanding of temperament facilitates development of more realistic expectations (McClowry, 1992; Melvin, 1995).
·Discuss sound disciplinary techniques, which include catching children being good, active listening, conveying positive regard, ignoring minor transgressions, giving good directions, use of praise, and use of time-out. Disciplinary methods are subject to a variety of opinions. Proper discipline provides children with security, and clearly enforced rules help them learn self-control and social standards. Parenting classes can be beneficial when parent has had little formal or informal preparation (Herman-Staab, 1994).
·Foster acquisition of positive parenting skills. Parents may feel powerless. Helping them develop necessary skills or gain knowledge maintains the integrity of the parental role, and parents are then unlikely to use maladaptive coping styles (Baker, 1994).
·Plan parental education directed toward the following age-related parental concerns:
oBirth to 2 years Transition, sleep, aggression
o3 to 5 years Transition, parent-child relationship, sleep
o6 to 10 years School, parent-child relationship, divorce
o11 to 18 years Parent-child relationship, divorce, school
Parents with children of any age may seek basic information about a variety of concerns, which can be anticipated and addressed by providing ongoing information and support (Jones, Maestri, McCoy, 1993).
·Initiate referrals to community agencies, parent education opportunities, stress management training, and social support groups. The parent needs support to manage angry or inappropriate behaviors. Use of support systems and social services can provide an opportunity to decrease feelings of inadequacy (Campbell, 1992; Baker, 1994).
·Provide information regarding available telephone counseling services. Telephone counseling services can provide confidential advice and support to families who might not otherwise have access to help in dealing with behavioral problems and parenting concerns (Jones, Maestri, McCoy, 1993).
·Refer to care plan for Delayed Growth and development for additional teaching interventions.
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