97-Portal Systemic Encephalopathy

About

A result of cirrhosis or liver failure, major neurological changes occur including changes in level of consciousness, impaired thinking and memory, and even coma. This can be reversible if caught in the earlier stages.

Assess

• Elevated ammonia, confusion, lethargy, changes in level of consciousness, coma, twitching, asterixis, fetor hepaticus, muscle rigidity, seizures

Complications

• End stage liver disease, coma, death

Diagnosis

Chronic confusion related to increased ammonia retention

Risk for injury related to altered mental state

Goals

• The client will be free from injury.
• The client will exhibit signs of improved cognition and orientation.

Interventions

• Monitor vitals, liver enzymes, electrolytes, ammonia levels.
• Monitor neurological checks every two hours.
• Monitor for hypokalemia as a result of medication therapy.
• Assess for signs and symptoms of worsening ( asterixis, fetor hepaticus, decline in neuro status).
• Maintain a safe environment; monitor for cognitive changes or weakness associated with imbalance.
• Administer medications ( lactulose, etc.) as ordered.
• Teach client about continuing medications at home to maintain two to three stools daily.
• Include family members in care and teaching if client unable to remember instructions.
• Teach to avoid alcohol and over the counter medications.
• Monitor for signs/ symptoms of complications.

96-Paracentesis

About

Procedure to remove accumulated fluid in the peritoneal cavity as a result of liver disease and ascites.

Assess

Blood Pressure, vital signs, intake and output, daily weights, respiratory status including difficulty in breathing, pain

Complications

Severe hypotension, encephalopathy, infection, bleeding, pain

Diagnosis

• Fluid volume excess related to ascites.
• Risk for injury related to procedure.
• Risk for infection related to procedure.
• Ineffective breathing pattern related to pain and decreased intrathoracic space

Goals

• The client will maintain adequate fluid balance.
• The client will remain free from injury.
• The client will identify activities to minimize complication pre- and post-operatively.
• The client will have an acceptable blood pressure measurement reading.

Interventions

• Assess and monitor blood pressure and other vital signs frequently.
• Assess client's comfort level and respiratory status before during and after procedure.
• Monitor amount, color and clarity of drainage from procedure.
• Monitor for signs and symptoms of infection.
• Assess puncture site frequently for signs and symptoms of bleeding or infection.
• Assist client to comfortable position.
• Encourage client to call for assistance with any movement.
• Monitor orthostatic changes and assist client with ambulation.
• Monitor electrolytes, fluid-volume status, weight, and neurological status post-procedure.
• Teach client signs and symptoms of infection to report to health care provider.
• Teach client and family that slow position changes are necessary to prevent syncope or fainting.

95-pincriasitis

About

Inflammation of the pancreas that can be life-threatening.

Assess

Epigastric or Left upper quadrant abdomen pain, nausea, vomiting, Elevated amylase and lipase, abdomen tenderness and rigidity, jaundice

Complications

Pancreatic pseudocyst; abscess; re-occurrence of pancreatitis

Diagnosis

• Acute pain related to inflammatory changes of the pancreas
• Imbalanced nutrition: less than body requirements related to NPO status, malnutrition
• Deficient fluid volume related to emesis, diarrhea, decreased fluid intake, fever
• Ineffective coping related to denial of alcohol use

Goals

• The client will state a decrease in pain.
• The client will have pancreatic enzymes returning to normal.

Interventions

• Monitor pain levels and utilize prn medications if elevated.
• Monitor bowel sounds, nausea.
• Maintain client NPO as indicated.
• Administer medications ( antiemetics, antibiotics, enzymes, etc.) as ordered.
• Administer TPN and IV hydration as ordered.
• Teach client other pain relieving measures ( positioning, relaxation, distraction, etc).
• Teach client it may be necessary to abstain from alcohol to prevent reoccurrence.
• Monitor for signs/ symptoms of complications.

94-pencrias cancer

About

Malignancy of the pancreas; poor prognosis

Assess

Pain, jaundice, weight loss, mid-abdomen pain, ascites, hyperglycemia

Complications

Metastasis, diabetes, death

Diagnosis

• Risk for infection related to immunodeficiency secondary to treatment.
• Risk for injury related to impaired immune defenses secondary to treatment.
• Fear related to threat of death.
• Disturbed body image related to changes in physical appearance secondary to treatment.
• Nutrition less than body requirements related to impaired oral intake.
• Impaired mucous membranes related to stomatitis secondary to treatment.
• Fatigue related to immune system compromise secondary to treatment.
• Knowledge deficit related to disease management and treatment options.
• Impaired skin integrity related to surgical intervention.

Goals

• The client will be able to express concerns and fears related to diagnosis.
• The client will identify treatment options and choices.
• The client will identify post-procedure complications and ways to minimize complication.
• The client will remain free from complications.

Interventions

• Assess and monitor vitals, pain levels, intake and output.
• Encourage small, frequent meals.
• Administer medications for pain as indicated.
• Encourage client to discuss feelings related to  diagnosis.
• Teach client about treatment options, including pre- intra-, and post-care interventions.
• Monitor for complications related to diagnosis and treatment.
• Provide opportunities to discuss end-of-life care and wishes.

93-liver transplant

About

Either partial or full liver transplanted from one donor to another recipient via surgery.

Assess

VS, wound, Alk phos, Bilirubin, drainage characteristics, urine output; assess pain

Complications

• Acute Graft rejection- immunosuppressive therapy increased, s/s include tachy, fever, jaundice, changes in biliary drainage, elevated bilirubin, alk phosphatase.
• Infection- fever, foul smelling drainage from incision, t-tube, urine.
• Abscess; acute renal failure
• Transplant rejection; infection

Diagnosis

Ineffective protection related to induced immunosuppression

Decisional conflict related to acceptance of a donor liver

Goals

The client will be free from infection.

The client will be free from s/s indicating rejection of new organ.

Interventions

• Monitor for s/s of rejection.
• Monitor VS post-operatively every 15 minutes X 2, every 30 minutes X 2, every hour X 2, than every four hours ( may have different guidelines for each clinical agency).
• Monitor for complications associated with non-functioning liver ( bleeding, encephalopathy, etc).
• Monitor for s/s of infection and peritonitis ( abdomen rigidity, pain, and distention).
• Administer immunosuppressive medications as ordered.
• Teach client about medication regimen, including when to take, how often, potential side-effects, reasons to seek additional medical attention.
• Monitor for signs/ symptoms of complications.

92-liver cancer

About

Malignancy of the liver; can be primary or secondary ( metastatic).

Assess

Weight loss, pain in right upper quadrant, back pain, hepatomegaly, fatigue, weight loss, weakness, anemia, loss of appetite, jaundice, ascites, elevated CEA, elevated alkaline phosphatase, lactic dehydrogenase, AST, WBC's, RBC's. Hypercalcemia, decreased blood sugar, history of alcohol and/or smoking, history of hepatitis or cirrhosis.

Complications

Metastasis, death

Diagnosis

• Risk for infection related to immunodeficiency secondary to treatment.
• Risk for injury related to impaired immune defenses secondary to treatment.
• Fear related to threat of death.
• Disturbed body image related to changes in physical appearance secondary to treatment.
• Nutrition less than body requirements related to impaired oral intake.
• Impaired mucous membranes related to stomatitis secondary to treatment.
• Fatigue related to immune system compromise secondary to treatment.
• Knowledge deficit related to disease management and treatment options.
• Impaired skin integrity related to surgical intervention.

Goals

• The client will be able to express concerns and fears related to diagnosis.
• The client will identify treatment options and choices.
• The client will identify post-procedure complications and ways to minimize complication.
• The client will remain free from complications.

Interventions

• Assess and monitor vitals, pain levels, intake and output.
• Encourage small, frequent meals.
• Administer medications for pain as indicated.
• Encourage client to discuss feelings related to  diagnosis.
• Teach client about treatment options, including pre- intra-, and post-care interventions.
• Monitor for complications related to diagnosis and treatment.

91-hepititis C

About

Viral hepatitis spread from blood to blood transmission.

Assess

Major flu-like symptoms, blood transmission, may require rest and hospitalization during acute illness

Complications

Disease transmission, liver cancer, cirrhosis

Diagnosis

• Activity intolerance related to weakness or fatigue
• Fatigue related to infectious process
• Ineffective health maintenance related to disease process

Goals

The client will remain free from injury.

Interventions

• Balance rest with activity. Encourage client to rest.
• Monitor liver enzymes, vital signs, and appetite changes.
• Encourage small, frequent high caloric meals to ensure adequate nutrition.
• Teach client methods to prevent transmission ( standard precautions; safe sex, prevent needle contamination, cover wounds/sores).
• Teach client to avoid alcohol and over the counter medications to promote liver healing.
• Teach client to increase activity gradually, being sure to rest when feeling fatigued.
• Monitor for signs/ symptoms of complications.

90-heptitis B

About

Viral hepatitis  spread by blood contamination.

Assess

Blood transmission; IV drug use, sexual contact; fatigue, nausea, appetite loss, elevated AST and ALT, muscle aches, rashes, enlarged tender liver, jaundice, dark urine

Complications

Disease transmission, liver cancer, cirrhosis

Diagnosis

• Activity intolerance related to weakness or fatigue
• Fatigue related to infectious process
• Ineffective health maintenance related to disease process

Goals

The client will remain free from injury.

Interventions

• Balance rest with activity. Encourage client to rest.
• Monitor liver enzymes, vital signs, and appetite changes.
• Encourage small, frequent high caloric meals to ensure adequate nutrition.
• Teach client methods to prevent transmission ( standard precautions; safe sex, prevent needle contamination, cover wounds/sores).
• Teach client to avoid alcohol and over the counter medications to promote liver healing.
• Teach client to increase activity gradually, being sure to rest when feeling fatigued.
• Monitor for signs/ symptoms of complications.

89-Hepatitis A

About

Viral hepatitis caused by ingestion of feces via the oral route.

Assess

Oral fecal transmission; flu-like symptoms

Complications

Disease transmission, liver cancer, cirrhosis

Diagnosis

• Activity intolerance related to weakness or fatigue
• Fatigue related to infectious process
• Ineffective health maintenance related to disease process

Goals

The client will be free from injury.

Interventions

• Balance rest with activity. Encourage client to rest.
• Monitor liver enzymes, vital signs, and appetite changes.
• Encourage small, frequent high caloric meals to ensure adequate nutrition.
• Teach client methods to prevent transmission ( hand-washing).
• Teach client to avoid alcohol and over the counter medications to promote liver healing.
• Teach client to increase activity gradually, being sure to rest when feeling fatigued.
• Monitor for signs/ symptoms of complications.

88-Esophageal Varices

About

Varicosities with or without bleeding that develop in the esophagus secondary to cirrhosis and increased pressure on the portal systemic veins.

Assess

• Hematemesis, blood in the stool, history of alcoholism, fatigue, tachycardia, hypotension

Complications

• Bleeding, hepatic encephalopathy, alcohol withdrawal, cardiac arrest, death

Diagnosis

• Decreased cardiac output related to acute bleeding.
• Fluid volume deficit related to hemorrhage.
• Nutrition less than body requirements related to chronic alcoholism, necessity for NPO status.
• Risk for injury related to mental status changes.

Goals

• The client will maintain adequate fluid balance.
• The client will remain free from injury.
• The client will identify activities to minimize complication pre- and post-operatively.
• The client will have an acceptable blood pressure measurement reading.

Interventions

• Assess and monitor vital signs frequently.
• Assess cardiac status and monitor telemetry.
• Monitor labs especially CBC and electrolytes.
• Monitor for changes in mental status and signs and symptoms of acute alcohol withdrawal.
• Teach client what to expect before, during, and after procedures/ surgery to control bleeding.
• Monitor strict intake and output.
• Administer vasopressin as indicated by physician.
• Prepare client for surgery as indicated by physician.
• Maintain a patent IV line and administer fluids as indicated by physician.
• Insert an NG tube as indicated by physician to maintain esophageal rest.
• Administer blood transfusions as indicated by physician.

87-ERCP (Endoscopic Retrograde Cholangiopancreatography)

About

A procedure where a scope is entered into the esophagus down through the stomach and into the duodenum. Die is injected to help visualize the pancreatic duct and common bile duct. Used to help diagnose and visualize stones, biliary obstruction, disease, injury, strictures.

Assess

Assess for allergies to iodine, seafood, contrast medium; assess vital signs, remove dentures, and perform a pre-operative checklist. Make sure patient has been NPO prior to procedure.

Complications

• Peritonitis, abdominal perforation, pancreatitis, gastrointestinal bleed, aspiration

Diagnosis

• Knowledge deficit related to procedure.
• Risk for infection related to procedure.
• Risk for injury related to complications from procedure.

Goals

• The client will demonstrate knowledge of pre-, intra-, and post-operative activities.
• The client will remain free from injury, infection and complication.

Interventions

• Maintain the client NPO pre-procedure and post-procedure.
• Assess for gag reflex prior to initiating oral intake.
• Assess vital signs prior to procedure, during procedure and post-procedure.
• Teach client signs and symptoms to report to health care provider.
• Teach client activities prior to procedure and post-procedure to minimize risks of complication.
• Assess abdomen, pain levels frequently post-operatively.
• Notify physician immediately of post-procedure vomiting, fever, pain, abdomen distention.

86-Cirrhosis

About

Damage and ischemia of the liver. Common causes are long-term alcohol abuse and hepatitis.

Assess

Hx of alcoholism, liver disease, IV drug use, exposure to toxins; fatigue, weight change, itching, spider angiomas, jaundice, ascites, GI complaints, lever tenderness, hepatomegaly, anemia, portal hypertension

Complications

Ascites

Hemorrhage

Portal systemic hypertension

Liver transplant; death

Diagnosis

• Chronic pain related to enlarged liver
• Fatigue related to malnutrition
• Disturbed thought processes related to accumulation of ammonia as disease progresses
• Chronic sorrow related to chronic illness

Goals

• The client will identify components of disease treatment plan.
• The client will be free from injury.

Interventions

• Monitor fluid balance, vital signs, pulse oximetry, intakes/ outputs, daily weight, and electrolytes.
• Monitor for complications, including neurological changes.
• Monitor for signs/ symptoms of active bleeding ( hypotension, tachycardia, bruising, petechiae, purpura, etc.).
• Monitor clotting factors and ammonia levels.
• Monitor for esophageal varices.
• Administer medications, as ordered.
• Monitor for drug accumulation and toxicity since liver metabolism may be compromised.
• Assist with procedures ( balloon tamponade, shunts, etc.) as indicated.
• Teach client about disease management and treatment strategies.
• Teach client s/s of complications related to disease.
• Teach home care strategies to manage disease including diet, medicines, abstention from alcohol.
• Monitor for signs/ symptoms of complications.

85-Cholecystitis

About

Inflammation of the gallbladder frequently caused by stones in the gall bladder or surrounding biliary tubes. May require surgical removal of the gall bladder ( cholecystectomy).

Assess

Nausea, vomiting, abdomen pain, increased pain after eating fatty meals, heartburn, fever, jaundice, clay colored stools

Complications

• Cholecystectomy- surgery to remove the gallbladder
• Cholecystectomy, peritonitis, biliary obstruction

Diagnosis

• Acute pain related to biliary obstruction or surgical intervention
• Risk for ineffective breathing related to surgical incision causing pain with increased lung expansion
• Ineffective therapeutic regimen related to deficient knowledge of disease treatment, prevention of exacerbation, and potential for surgical intervention

Goals

• The client will identify strategies to manage symptoms and prevent exacerbation.
• The client will describe a decrease in pain or discomfort.

Interventions

• Monitor for pain and discomfort.
• Monitor VS, bowel sounds, abdomen assessment.
• Administer medications ( analgesics, anticholinergics, etc.) as ordered.
• Teach client to avoid fatty and spicy foods.
• Teach client about medications including rationale, side effects, dosing schedule.
• Assist with preparation for procedures as indicated by physician.
• Monitor for signs/ symptoms of complications.

84-Cholecystectomy

About

Surgery to remove the gall bladder.

Assess

Incision, bleeding, bruising, circulation; Vital signs, pulse oximetry, pain level.

Complications

Post cholecystectomy syndrome- monitor for abd pain with vomiting for months after surgery.

Infection; post-operative complications ( pneumonia, DVT, constipation, paralytic ileus, pain, PE)

Diagnosis

• Acute pain related to surgical procedure
• Risk for infection related to surgical procedure
• Deficient knowledge related to post surgical treatment regimen

Goals

• The client will understand pre-, intra-, and post-operative instructions.
• The client will remain free from post-operative complications.

Interventions

• Monitor vital signs every 15 minutes X 2, 30 minutes X2, one hour X2, than every 4 hours ( may have different guidelines for each clinical agency).
• Monitor for signs and symptoms of infection.
• Implement incentive spirometry pre-operatively.
• Encourage to do IS post-operatively at least ten times an hour.
• Teach abdominal splinting.
• Apply elastic compression stockings and/or sequential compression device as ordered.
• Maintain NPO prior to surgery and start with clear liquids after surgery.
• Encourage early ambulation to avoid complications.
• Teach client signs and symptoms requiring immediate follow-up by a health care provider.
• Monitor for signs/ symptoms of complications.

83-Ascites

About

Collection of fluid in the peritoneal space usually as a result of liver disease.

Assess

Fluid volume excess, weight gain, fluid filled abdomen, able to palpate waves on abdomen if pressing one side to the other, shortness of breath, pain

Complications

Portal systemic hypertension

Spontaneous bacterial peritonitis

Discomfort, dyspnea

Diagnosis

• Imbalanced nutrition: less than body requirements related to loss of appetite
• Impaired comfort related to large abdominal girth
• Ineffective breathing pattern related to excessive abdominal pressure

Goals

• The client will have a decrease in fluid accumulation in abdomen.
• The client will have a normal or near normal blood pressure.

Interventions

• Monitor fluid balance, vital signs, pulse oximetry, intakes/ outputs, daily weight, and electrolytes.
• Measure abdominal girth every morning using the same marks around the largest part of the abdomen. Monitor for increases in fluid.
• Implement a low-sodium diet.
• Administer diuretics as ordered.
• Assist with procedures ( paracentesis) as indicated.
• Monitor for signs/ symptoms of complications.

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82-Plantar Fasciitis

About

Inflammation in the muscle found in the arch of the foot.

Assess

Pain in the arch of the foot, usually unilateral; increased pain with weight-bearing.

Complications

Surgery

Diagnosis

• Acute pain related to tissue inflammation
• Impaired physical mobility related to pain when ambulating

Goals

• The client will state a decrease in pain.
• The client will be an active participant in exercise or therapy.

Interventions

• Apply ice or cool compresses to area.
• Encourage rest for a period of time to facilitate healing.
• Encourage active participation with physical therapy, stretching exercises.
• Encourage use of orthotics or arch support, as indicated.
• Administer medications ( NSAIDS, steroids, etc.), as ordered, to decrease inflammation.
• Monitor for signs/ symptoms of complications.

81-Paget's Disease

About

Bone modeling that results in large bony deposits that are very weak.

Assess

Pain; history of fracture; bone deformities, spinal deformities, joint discomfort; bowed legs or arms; flushed, warm skin.

Complications

Heart failure; fractures; kidney stones; gout;

Diagnosis

• Risk for injury related to excessive weakened bones
• Body image disturbance related to musculoskeletal disfigurement
• Knowledge deficit related to nutrition requirements, disease management, and prevention of 

Goals

• The client will state a decrease in pain.
• The client will maintain or improve current level of mobility.

Interventions

• Assist client with ADL's, as needed.
• Encourage active participation in ADL's as much as the client is able to tolerate.
• Encourage active participation in physical therapy and/ or occupational therapy.
• Administer medications as ordered; including bisphosphonates, calcitonin, Vitamin D and Calcium, and NSAIDS, etc.
• Teach client techniques to maintain mobility and prevent atrophy ( including range of motion exercises, low weight-bearing exercises).
• Teach client about medication therapy, including continuing therapy after discharge.
• Teach client dietary strategies to improve calcium and Vitamin D intake ( increased milk and dairy, leafy green vegetables, and fortified products)
• Monitor for signs/ symptoms of complications.

80-Osteoporosis

About

Decreased bone density resulting in increased incidence of fractures, sometimes correlates to decreased calcium and vitamin D and estrogen.

Assess

Shortened height, back pain, decreased intake of calcium and vitamin D; bone density tests; Serum calcium, Vitamian D; Nutritional status; Bone pain; Fall risk

Complications

Fractures- institute safety precautions; surgery

Diagnosis

• Risk for injury related to musculoskeletal changes
• Knowledge deficit related to diet and exercise recommendations
• Impaired physical mobility related to musculoskeletal changes and pain

Goals

• The client will identify factors that promote increased calcium intake.
• The client will identify methods to reduce complications associated with disease.

Interventions

• Identify client at increased risk for falls and institute safety precautions.
• Assess for modifiable risk factors ( i.e. sedentary lifestyle, decreased dietary intake of calcium and vitamin D).
• Administer medications, as ordered ( calcium with vitamin D, hormone replacements, bisphosphonates, calcitonin, etc.).
• Teach client dietary strategies to improve calcium intake ( increased milk and dairy, leafy green vegetables, and calcium fortified products)
• Encourage client to maintain an active lifestyle with exercises ( walking, swimming, range of motion exercises) to prevent fractures.
• Monitor for signs/ symptoms of complications.

79-Osteomylitis

About

Inflammation and bacterial infection in bone tissue.

Assess

Temperature, Vital signs; Recent injuries; pain, redness, swelling, and tenderness when palpating over injured bone; Blood cultures; s/s of sepsis; skin lesions, ulcers, infections; Elevated WBC's.

Complications

Sepsis- systemic infection

Skin ulceration, surgery, pain

Diagnosis

Acute pain related to inflammation and infection

Knowledge deficit related to treatment and medication regimen

Goals

• The client will demonstrate understanding of medication therapy and treatment.
• The client will have pain levels less than 4 on a zero to ten scale.

Interventions

• Assess site of infection, labs, vitals.
• Apply dressings and irrigate wounds using surgical asepsis, as ordered.
• Administer antibiotics, as ordered, via IV initially.
• Administer pain medications prn as ordered by a physician.
• Teach client about medication therapy, including continuing therapy after discharge, even if symptoms improve.
• Teach client how to care for wounds, as needed, for continuing care after discharge.
• Prepare client for special procedures ( hyperbaric oxygen therapy, surgery) as indicated by a physician.
• Monitor for signs/ symptoms of complications.

78-Osteomalacia

About

Demineralization of the bone, causing spongy bones; rickets caused by poor vitamin D intake and/or absorption.

Assess

Dietary intake of calcium and vitamin D; activity patterns; exposure to sunlight; history of GI diseases causing malabsorption of Vitamin D and Calcium; Muscle weakness and bone pain; spontaneous fractures

Complications

Injury; fractures

Diagnosis

• Risk for injury related to softening of bone
• Imbalanced nutrition less than body requirements related to inadequate vitamin D and calcium in diet

Goals

• The client will remain free from injury.
• The client will verbalize interventions to increase vitamin D intake.

Interventions

• Assess for modifiable risk factors ( i.e. sedentary lifestyle, decreased dietary intake of calcium and vitamin D).
• Administer medications, as ordered by a physician ( vitamin D).
• Identify clients at increased risk for falls and institute safety precautions.
• Encourage clients to get five minutes of sun exposure each day to increase vitamin D absorption.
• Teach clients dietary strategies to improve vitamin D intake ( increased milk, eggs, chicken, and fortified products).
• Monitor for signs/ symptoms of complications.

77-Muscular dystrophy

About

Degenerative disease effecting the muscles.

Assess

Muscle weakness and fatigue, atrophy; decreased mobility; pain, genetic history, lab values show elevated muscle enzymes.

Complications

Respiratory muscle weakness and failure; multi-organ system failure; immobility

Diagnosis

• Impaired physical mobility related to muscle weakness and dysfunction
• ineffective airway clearance related to muscle weakness and inability to cough
• Fatigue related to disease process

Goals

• The client will state measures to improve mobility.
• The client will identify adaptive techniques to accommodate for impaired mobility.

Interventions

• Administer medications as ordered; including steroids.
• Assist client with ADL's, as needed.
• Encourage active participation in ADL's as much as the client is able to tolerate.
• Encourage active participation in physical therapy and/ or occupational therapy.
• Teach client techniques to maintain mobility and prevent atrophy ( including range of motion exercises).
• Monitor for signs/ symptoms of complications.

76-Laminectomy

About

Surgery to access the disks by removing part of the laminae and facet joints.

Assess

Incision, bleeding, bruising, presence of clear drainage on surgical dressing, circulation; Vital signs, pulse oximetry, pain level.

Complications

Infection; post-operative complications ( CSF leak, failed therapy, pneumonia, DVT, constipation, paralytic ileus, pain, PE)

Diagnosis

• Acute pain related to surgical procedure
• Risk for infection related to surgical procedure
• Deficient knowledge related to post surgical treatment regimen

Goals

• The client will understand pre-, intra-, and post-operative instructions.
• The client will remain free from post-operative complications.

Interventions

• Teach client what to expect pre-, intra-, and post-operatively.
• Maintain NPO prior to surgery and start with clear liquids after surgery.
• Monitor vital signs every 15 minutes X 2, 30 minutes X2, one hour X2, than every 4 hours ( may have different guidelines for each clinical agency).
• Monitor incision for redness, edema, drainage, bruising. Monitor dressing for clear drainage which may indicate CSF leak.
• Administer pain medications prn as ordered.
• Encourage coughing and deep breathing and position changes to facilitate movement of respiratory secretions.
• Apply elastic compression stockings and/or sequential compression device as ordered.
• Monitor for signs/ symptoms of complications.

75-Joint Dislocation

About

A process whereby a distal and proximal joint are no longer in alignment.

Assess

Pain, joint deformity, shortened limb, decreased mobility; X-ray confirmation.

Complications

Avascular necrosis, neurovascular compromise, compartment syndrome

Diagnosis

• Acute pain related to skeletal deformity.
• Risk for injury related to complications.
• Immobility related to physical injury.

Goals

• The client will state a pain level less than 4 after medication intervention.
• The client will remain free from injury including neurovascular compromise.
• The client will be able to identify activity restrictions after reduction of joint deformity.
• The client will describe symptoms requiring immediate follow-up.

Interventions

• Immobilize the joint until able to be reduced by physician or specialist.
• Monitor neurovascular assessments every hour. Notify physician immediately if pulselessness, parasthesias, paralysis, pallor, or increased pain.
• Teach client how to monitor for decreasing circulation to extremity.
• Teach client activity restrictions and adaptive techniques to maintain mobility.
• Administer analgesics as indicated by physician.
• Prepare for surgery if indicated.

74-fracture

About

A partial or complete break in a bone.

Assess

Open wounds, bleeding, ecchymosis ( bruising), infection, decreased pulses distal to injury, pallor, numbness, tingling, increased temperature; Pain; increased risk of blood clots.

Complications

Infection- monitor for s/s of infection.

Acute compartmental syndrome- monitor for circulation to area distal to joint including pulses, pallor, warmth, pain, pressure, paralysis or parasthesias.

Impaired tissue integrity; pain; immobility

DVT; fat embolism syndrome- use prophylactic anticoagulants as ordered.

Diagnosis

• Acute pain related to trauma
• Impaired physical mobility related to trauma and limb immobilization
• Risk for impaired skin integrity related to presence of cast

Goals

• The client will identify adaptive techniques to accommodate for impaired mobility.
• The client will identify a pain level less than 4 on a zero to ten scale, zero being none and 10 being the worst imaginable.
• The client will identify signs and symptoms requiring immediate follow-up by health care provider.

Interventions

• Monitor client with limb injuries or surgeries for s/s of impaired circulation ( pain, pallor, decreased pulses, paralysis, and parasthesias).
• Monitor for complications, including hemorrhage and impaired tissue perfusion.
• Monitor for s/s of infection around injury ( temp, increased WBC's, pain, redness, edema, increased drainage, odor).
• Immobilize affected body part, as indicated.
• Prepare for surgery, casting, splinting as indicated.
• Administer pain medications prn as ordered.
• Teach client what to expect prior to, during, and after procedures.
• Teach patient how to use adaptive techniques to maintain mobility including crutches, walker as indicated.
• Monitor for signs/ symptoms of complications.

73-Dehydration- Hypovolemia

About

Decreased blood and body fluids.

Assess

Low urine output ( or excessive urine output if Diabetes Insipidus or SIADH), skin torpor, cbc, low blood pressure, tachycardia, dry mucous membranes, electrolyte disturbances.

Complications

Electrolyte disturbance; injury; dysrhythmias

Diagnosis

• Deficient fluid volume related to active fluid volume loss
• Knowledge deficit related to treatment and prevention of dehydration

Goals

• The client will be able to tolerate 8-10 glasses of fluid a day.
• The client will maintain normal electrolytes.

Interventions

• Monitor VS for hypotension or tachycardia, indicative of increasing hypovolemia.
• Monitor electrolytes for hypokalemia and other abnormalities.
• Assess mucous membranes and moisten as needed.
• Monitor strict intakes and outputs.
• Administer IV fluids, as ordered by a physician, and oral fluids to maintain hydration.
• Institute fall precautions to prevent injury from orthostatic hypotension, weakness, dizziness.
• Monitor for signs/ symptoms of complications.

72-Degenerative Joint Disease

aAbout

See osteoarthritis, as it is now most commonly referred as.

Assess

See Osteoarthritis.

Complications

Total joint replacement

Chronic pain; immobility

Diagnosis

See osteoarthritis

Goals

• The client will state measures to improve mobility.
• The client will identify adaptive techniques to accommodate for impaired mobility.
• The client will identify a pain level less than 4 on a zero to ten scale, zero being none and 10 being the worst imaginable.

Interventions

• Encourage joint mobility to prevent contractures and muscle atrophy.
• Administer NSAIDS, analgesics, etc. as ordered.
• Encourage client to do low weight-bearing exercises, i.e. swimming.
• Encourage weight loss ( for overweight individuals) to decease pressure on weight bearing joints.
• Teach client about dietary changes to help lose weight if obesity is a contributing factor.
• Teach client range of motion exercises to maintain joint mobility.
• Teach client to use assistive devices, as ordered.
• Teach client about medications, including NSAIDS and/ or analgesics, to help manage pain.
• Encourage client to use alternative methods to relieve pain, including relaxation techniques, positioning, use of heat, etc.
• Prepare for surgery, if indicated. See Total Joint Replacement.
• Monitor for signs/ symptoms of complications.

71-Compartmental Syndrome

About

Inflammation and vascular congestion due to compression of areas above or below the effected body area.

Assess

Pain, sensation, redness, bruising, swelling; Monitor for cap refill, temperature, vitals, parasthesias ( numbness, tingling); weakened pulses and pallor of tissue requires immediate intervention.

Complications

Immobility; infection; amputation; acute renal failure- early, emergent treatment to prevent complications.

Fasciotomy- may be needed to relieve buildup of pressure.

Diagnosis

• Ineffective tissue perfusion related to pressure, swelling and edema within compartment
• Acute pain related to edema, pressure of compromised body part
• Risk for injury related to changes in limb compromising blood flow and tissue perfusion

Goals

• The client will identify symptoms that require immediate intervention after injury or surgery.
• The client will have no long-term damage from complication.

Interventions

• Assess client frequently for progression of symptoms.
• Initiate interventions to decrease pressure, as indicated- removal of casts, loosening of dressings.
• If pressure is sustained, prepare client for surgery as indicated.
• Monitor all clients with limb injuries or surgeries for s/s of impaired circulation ( pain, pallor, decreased pulses, paralysis, and parasthesias).
• Monitor for s/s of infection to distal areas to injury ( temp, increased WBC's, pain, redness, edema, increased drainage, odor).
• Monitor for signs/ symptoms of complications.

70-Carpal Tunnel Syndrome

About

Compression of a nerve in the hand due to excessive, repetitive use and inflammation.

Assess

Phalen's test, assess for pain in the hands, radiation of pain; numbness or tingling; assess length and extent of use of hands for work or repetitive tasks.

Complications

Chronic pain

Surgery- may need surgery to repair damage and relieve painful symptoms.

Diagnosis

Chronic pain related to pressure on median nerve in hand

Goals

• The client will have pain levels less than 4 on a zero to ten scale.
• The client will demonstrate techniques to reduce strain on joint.

Interventions

• Assess client's pain level on a scale of 0 to 10, 0 being none and ten being the worst imaginable.
• Assess activities that place client at increased risk of repeated injury or impaired rehabilitation ( keyboarding, repetitive hand exercises as in golf, racquetball)
• Teach client exercises and immobilization techniques ( night splinting) to help rehabilitate hand and prevent further injury.
• Administer NSAIDS, analgesics, etc. as ordered.
• Teach client to take NSAIDS with food to prevent gastrointestinal upset.
• Assist physician with interventions, as needed, to improve pain levels ( i.e. corticosteroid injections, splinting)
• Monitor for signs/ symptoms of complications.

69-Bone Tumors

About

Metastatic or benign growths effecting the skeletal system. Vary in degree of symptoms based on the type of bone tumor it is. Metastatic bone tumors ( those arising after another cancer spreads) are more common than a primary malignant bone tumor.

Assess

May be asymptomatic; bone masses, pain, aches, malaise, disabilities, weight loss, spinal cord metastasis with accompanying neurological deficits

Complications

Malignancy, metastasis, fractures, injury

Diagnosis

• Acute pain related to bone overgrowth or fractures.
• Knowledge deficit related to disease process and management.
• Risk for injury related to weakened bone structure.
• Self care deficit related to changes in physical ability.

Goals

• The client will remain free from injury.
• The client will state a pain level less than 4 after medication intervention.
• The client will discuss concerns and fears related to treatment and disease process.
• The client will identify treatment, medical management, complications of disease and when to follow-up.
• The client will participate with ADL's as much as able.

Interventions

• Assess and monitor pain, vital signs, range-of-motion, skeletal abnormalities, symptoms, patient's understanding of disease process.
• Administer analgesics as prescribed.
• Prepare client for surgical intervention, procedures as indicated by physician.
• Explain all procedures to client and pre-medicate with analgesics as necessary.
• Provide support to patient and family during procedures, diagnosis, follow-up, exacerbations.
• Teach client about disease management and treatment strategies.
• Encourage client to discuss feelings associated with disease and treatment.
• Encourage client to participate with ADL's as much as possible.
• Collaborate with physical therapy and/or occupation therapy for strengthening, weight-bearing, adaptive techniques.
• Support extremities during transferring and/or repositioning.

68-Amputation

About

Removal of a body part, typically the lower extremities either above the knee ( AKA) or below the knee ( BKA) because of gangrenous or necrotic conditions.

Assess

Assess stump of extremity amputated; assess for capillary refill, sensation, color, warmth; assess for pain or "phantom pain" effecting the limb; Assess psychosocial coping; Assess mobility, compliance with rehabilitation.

Complications

Infection- monitor site for drainage, odor, redness, etc. Notify physician if increased temperature.

Tissue ischemia- monitor for circulation to flap.

Ineffective coping

Diagnosis

• Impaired physical mobility related to loss of limb
• Acute pain related to actual tissue damage from surgical procedure and phantom limb pain.
• Grieving related to loss of body part
• Disturbed body image related to loss of limb

Goals

• The client will be able to state care for the affected body limb after surgery.
• The client will have adequate tissue perfusion after surgery.

The client will state pain level acceptable after intervention.

Interventions

• Assess the limb for pinkness, warmth, and positive arterial pulses at area proximal to the amputated limb.
• Assess the clients pain frequently on a scale of 0 to 10, zero being no pain and 10 being the worst pain imaginable.
• Assess the client's coping abilities, encourage positive coping measures and opportunities to grieve.
• Monitor for signs and symptoms of an infection ( site, temp, etc).
• Administer pain medications, as prescribed by a physician, as needed for pain levels at or above four.
• Encourage active participation in a rehabilitative program both inpatient and in the community.
• Monitor for signs/ symptoms of complications.

67-Tuberculosis

About

Highly communicable bacterial infection in the lungs causing inflammation and growths within the lungs; can cause subsequent infections to other areas of the body.

Assess

Weight loss, night sweats, fever, chills, cough that does not go away, shortness of breath, living in crowded areas or past exposure to TB.

Complications

Drug resistant strains of TB- must maintain strict adherence to drug therapy.

Spread of infection to close contacts- administer prophylactic treatment to close contacts.

Diagnosis

• Impaired gas exchange related to disease process
• Readiness for enhanced therapeutic regimen management related to medication schedule and prevention of complications of disease and transmission to others

Goals

• The client will verbalize the components of the medication regimen, and state reasons why adherence is important.
• The client will be able to identify ways to prevent the spread of infection to others.

Interventions

• Wear an N95 fit-tested respirator mask when in contact with the client.
• Monitor lungs sounds, vitals, and intake/ output while the client is hospitalized.
• Maintain strict airborne precautions while the  client is hospitalized.
• Encourage adequate rest during the acute illness phase.
• Encourage testing of close contacts, including family members, so that treatment may begin for those clients.
• Encourage adequate nutrition to prevent the return of opportunistic infections or active TB infection.
• Provide opportunities for the client to express concerns and fears while hospitalized.
• Teach the client ways to decrease the transmission to others, including masking in crowds, covering mouth and nose when sneezing or coughing.
• Teach the client about the medication regimen and possible drug resistance developing if treatment plan is not followed.
• Teach the client ways to manage side effects of medications.
• Monitor for signs/ symptoms of complications.