test: أغسطس 2018

الأربعاء، 29 أغسطس 2018

336-Vasectomy

About

Surgical interruption of the vas deferens to promote male sterilization.

Assess

Bleeding, incision, vital signs, lung sounds, bowel sounds, knowledge related to procedure and post-operative care

Complications

Post-operative complications including atelectasis, pneumonia, DVT, PE, infection, hemorrhage, paralytic ileus, bowel obstruction.

Diagnosis

Knowledge deficit related to possible surgical intervention
Acute pain related to surgical procedure
Ineffective health maintenance related to care after surgery
Sexual dysfunction related to perceived body changes
Risk for infection
Sexual dysfunction related to perceived body changes

Goals

The client will understand pre-, intra-, and post-operative instructions.
The client will be free from infection.
The client will be able to normally eliminate urine and have positive bowel sounds.
The client will demonstrate effective coughing and deep breathing and incentive spirometry post-operatively.
The client will ambulate at least three times daily after post-op day 1.
The client will identify signs and symptoms that require follow-up or indicate infection.
The client will have a pain of less than 4 on a VAS 0-10 pain scale.
The client will verbalize concerns and fears related to change in body image and sexual functioning.

Interventions

Teach client what to expect prior to, during, and after procedures.
Teach client coughing and deep breathing exercises to minimize risk of pneumonia.
Post-operatively, monitor VS every 15 minutes X 2, every 30 Minutes X 2, every 1 hour X 2, than every 4 hours ( may have different guidelines for each clinical agency).
Monitor voiding amount, color and clarity.
Elevate scrotum and apply ice intermittently to perineal area for several hours post-operatively
Initiate early ambulation to minimize risks of complications.
Administer medicines ( analgesics, stool softeners, etc.) as ordered.
Teach client signs and symptoms of infection that should be reported to physician.
Monitor for signs/ symptoms of complications.

Infection of the vagina and tissues surrounding either by fungus or bacteria; usually a result in alteration of the pH of the vagina which produces an environment conducive to bacterial or fungal growth.

Assess

Vaginal itching, burning, discharge, burning, irritation, difficult or painful urination, erythema to vulvovaginal area.

Complications

Re-infection, transmission to partner

Diagnosis

Knowledge deficit related to disease process and management
Pain related to inflammation and infection.
Risk for infection

Goals

The client will be free from infection.
The client will identify health behaviors to decrease the risk of infection.
The client will verbalize a decrease in pain less than 4 on a 0-10 pain scale.

Interventions

Assess vaginal area for redness, discharge, excoriation, swelling.
Monitor vitals, wbc's, and site of infection for signs of worsening.
Administer antibiotics, antifungals and analgesics as prescribed.
Administer sitz baths for discomfort and teach patient how to administer.
Teach client proper hygiene, hand-washing, infection prevention strategies.
Encourage increase in fluids and rest during the healing process.
Teach client signs and symptoms of re-infection, need for abstinence while infected, and treatment of infected partners to prevent re-infection.

335-Varicocele

About

Dilation of the veins around and behind the testis.

Assess

Mostly asymptomatic, infertility

Complications

Testicular atrophy; infertility

Diagnosis

Anticipatory grieving related to inability to conceive a child
Knowledge deficit related to possible surgical intervention

Goals

The client will verbalize understanding of surgical procedure to remove varicocele.
The client will regain fertility.

Interventions

Encourage client to discuss feelings regarding infertility.
Administer medications, as ordered.
Teach client what to expect pre-, intra-, and post-operatively.
Teach client to abstain from sexual intercourse for one week post-operatively.
Teach s/s of infection or decreased circulation to scrotal/ testicular area that must be reported to health care provider.
Arrange follow-up appointment.
Monitor for signs/ symptoms of complications.

334-Vaginitis

About

Inflammation of the lower female genital tract, with or without bacterial infection.

Assess

Symptoms, itching, discharge color and odor, difficulty with urination, palpate the abdomen for pain, recent history of infection, sexual activity, erythema, assist with pelvic examination

Complications

STD's; re-infection: pelvic inflammatory disease

Diagnosis

Acute pain related to inflamed tissues
Ineffective health maintenance related to knowledge deficit regarding self-care
Ineffective sexuality patterns related to pain with intercourse and abstinence for treatment

Goals

The client will be free from infection.
The client will be able to identify ways to decrease risk of recurrent infections.

Interventions

Assess symptoms, vaginal area, sexual history.
Assist physician with pelvic exam, as necessary.
Administer medications ( antibiotics, STD treatments, etc.) as ordered.
Teach client about medications, rationale for use, and potential side-effects.
Teach client to avoid intercourse while symptoms continue.
Teach client that partner may also need to be treated to prevent reoccurrence.
Encourage safe sex strategies.
Teach potential symptoms indicating worsening and need for follow-up.
Teach proper perineal hygiene ( wipe front to back, use water, no douching or feminine hygiene sprays, monitor for symptoms).
Monitor for signs/ symptoms of complications.

333-Testicular Cancer

About

Malignancy of one or both testicles usually diagnosed in men from adolescent to 35 years of age.

Assess

Palpable mass in testicle( s), swelling of testicle( s), undescended testicle( s)

Complications

Metastasis, infertility, blood clots, treatment related complications ( radiation- burns, organ damage, tissue inflammation; chemo- neutropenia, alopecia, infection, altered immune function, renal failure, nausea, weight loss, fatigue, malaise; surgery- DVT, PE, pneumonia, atelectasis, constipation, bowel obstruction, infection, pain), severe pain, death

Diagnosis

Knowledge deficit related to disease process and management
Pain related to disease process.
Ineffective coping related to concerns and fears regarding diagnosis and treatment.
Anticipatory grieving related to diagnosis and treatment.
Risk for infection related to immune system dysfunction and compromise.
Risk for injury.

Goals

The client will identify treatment options for disease.
The client will verbalize concerns and fears related to diagnosis and treatment options.
The client will identify signs and symptoms that require immediate follow-up.
The client will identify signs and symptoms of infection.
The client will identify methods to decrease the risk of infection.
The client will remain free form complications of treatment and disease.

Interventions

Prepare client for surgery, as indicated. ( Orchiectomy)
Assess vitals, CBC with differential, pain level and location, presence of other masses, knowledge about disease and treatment options.
Prepare client for additional diagnostics to rule out other malignancies or metastasis.
Discuss with client option for sperm banking in case of post-disease infertility.
Encourage coughing and deep breathing exercises and incentive spirometry to prevent respiratory infections.
Administer chemotherapy and prepare for radiation therapy as indicated by physician.
Provide opportunities for client to verbalize concerns, feelings, and fears related to diagnosis and treatment.
Teach client signs and symptoms of infection or complications to report immediately to health care provider.
Teach client methods to prevent infection including hand-washing, avoiding large crowds, monitoring temperature.
Teach client factors that can increase the likelihood of additional malignancies ( smoking, excessive sun, alcohol, carcinogens).
Teach client potential complications related to therapy ( additional malignancy, infertility, infections, immune dysfunction, fatigue).
Monitor for complication of treatment ( chemo, radiation therapy).

332-TURP

About

Trans Urethral Radical Prostatectomy; Surgery to remove the prostate gland through the urethra.

Assess

Urinary drainage, irrigation, color of urine, presence of clots; assess incision if present, pain, vitals

Complications

Post-operative complications- infection, pneumonia, pain, paralytic ileus, constipation, blood clots

Hemorrhage, clots, urinary retention

Diagnosis

Knowledge deficit related to post-operative care
Acute pain related to surgical procedure
Risk for urinary retention related to obstruction of urethra or clots in catheter
Risk for infection related to invasive procedure and portal of entry from catheter

Goals

The client will have slightly pink to clear urine output without clots.
The client will state positive pain relief.
The client will state understanding of pre-, intra-, and post-operative instructions.

Interventions

Teach client what to expect prior to, during, and after procedure.
Assess understanding of surgical procedure.
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 urine output, color, clarity.
Monitor for s/s of infection, urinary retention, excessive bleeding.
Administer medicines ( analgesics, etc.) as ordered.
Maintain a patent urinary catheter with continuous bladder irrigation as ordered.
Perform intermittent manual irrigation of urinary catheter as indicated.
Teach client methods to reduce post-operative complications ( incentive spirometry, early ambulation, etc).
If going home with catheter, teach proper catheter care and application of a leg-bag.
If catheter is ordered to be removed, monitor for urinary output and residuals as indicated.
Monitor for signs/ symptoms of complications.

331-TRAM (transverse rectus abdominis myocutaneous) Flap

About

Reconstructive procedure for mastectomy clients involving transplant of abdominal muscles, blood vessels, and tissue to the breast area.

Assess

Bleeding, incision, vital signs, lung sounds, bowel sounds, knowledge related to procedure and post-operative care

Complications

Post-operative complications including atelectasis, pneumonia, DVT, PE, infection, hemorrhage, paralytic ileus, bowel obstruction.

Tissue necrosis and loss of Flap

Diagnosis

Knowledge deficit related to possible surgical intervention
Acute pain related to surgical procedure
Constipation related to anesthesia, pain medications
Ineffective health maintenance related to care after surgery
Sexual dysfunction related to perceived body changes
Risk for impaired tissue perfusion
Risk for infection
Sexual dysfunction related to perceived body changes

Goals

The client will understand pre-, intra-, and post-operative instructions.
The client will be free from infection.
The client will be able to normally eliminate urine and have positive bowel sounds.
The client will demonstrate effective coughing and deep breathing and incentive spirometry post-operatively.
The client will have positive sensation, capillary refill to transplanted tissue site.
The client will ambulate at least three times daily after post-op day 1.
The client will identify signs and symptoms that require follow-up or indicate infection.
The client will have a pain of less than 4 on a VAS 0-10 pain scale.
The client will verbalize concerns and fears related to change in body image and sexual functioning.

Interventions

Teach client what to expect prior to, during, and after procedures.
Teach client coughing and deep breathing exercises to minimize risk of pneumonia.
Post-operatively, monitor VS every 15 minutes X 2, every 30 Minutes X 2, every 1 hour X 2, than every 4 hours ( may have different guidelines for each clinical agency).
Monitor voiding amount, color and clarity.
Monitor sensation and capillary refill to transplanted tissue every two hours.
Notify physician if unable to void greater than 6 hours after removing indwelling catheter.
Provide proper catheter care; monitor for s/s of infection.
Initiate early ambulation to minimize risks of complications.
Administer medicines ( analgesics, stool softeners, hormone replacement, etc.) as ordered.
Perform assessments every 4-8 hours to monitor for complications ( circulation, oxygenation, auscultation, etc).
Monitor for signs/ symptoms of complications.
Encourage client to discuss feelings associated with changes in body image.
Encourage client to splint abdomen and walk with a slightly stooped posture to prevent strain on incision.

330-Syphilis

About

Infectious disease caused by Trepenoma pallidum and is contracted congenitally or by sexual contact.

Assess

Cancer ( lesion, usually painless), progresses to rash and lesions all over body ( secondary stage), Tertiary stage involves multiple organs and complications. May also have flu-like symptoms after being infected.

Complications

Transmission of infection, progression of infection, multisystem organ failure, arthritis, dementia, meningitis, stroke

Diagnosis

Acute pain related to inflammation of cervix
Anxiety related to diagnosis
Knowledge deficit related to disease, transmission, and management
Risk for infection and spread of infection

Goals

The client will verbalize concerns related to diagnosis and treatment.
The client will have a decrease in pain less than 4 on a 0-10 scale.
The client will identify methods to prevent the spread of infection.
The client will identify safe sex methods ( abstinence, condoms, spermicidal, etc.)
The client will be free from complications.
The client will be able to identify treatment strategies and signs and symptoms requiring additional treatment.

Interventions

Assess perineal tissue integumentary for rashes, ability to urinate, vital signs, pain levels, knowledge of disease process, treatment and transmission
Monitor rash, neuro status, intake and output, pain levels.
Administer antibiotic agents and analgesics as ordered by a physician.
Keep lesions clean and dry.
Use contact precautions with direct patient contact and strict handwashing before and after patient contact.
Teach client signs and symptoms of disease exacerbation, worsening.
Teach client methods to prevent the spread of infection to others.
Teach client self-care including medication regimen, proper hygiene to prevent secondary infections, safe sexual practices.
Encourage client to verbalize fears and concerns related to diagnosis and treatment.

329-Spermatocele

About

Cyst filled with fluid around epididymis.

Assess

Epididymis discomfort

Complications

Pain, discomfort

Diagnosis

Acute pain related to enlarged spermatocele

Goals

The client will have a decrease in discomfort.

Interventions

Administer analgesics as ordered.
Teach client about the disorder and potential treatment options as indicated.
Teach client about medications to help alleviate symptoms, side effects, and contraindications.
If surgical intervention, teach client about pre-, intra-, and post-operative activities.
Monitor for signs/ symptoms of complications.

328-Salpingo-oophorectomy

About

Surgical removal of ovary( s) and fallopian tubes.

Assess

Bleeding, incision, vital signs, lung sounds, bowel sounds, knowledge related to procedure and post-operative care

Complications

Post-operative complications including atelectasis, pneumonia, DVT, PE, infection, hemorrhage, paralytic ileus, bowel obstruction.

Onset of surgical menopause

Diagnosis

Sexual dysfunction related to perceived body changes
Knowledge deficit related to possible surgical intervention
Acute pain related to surgical procedure
Constipation related to anesthesia, pain medications
Ineffective health maintenance related to care after surgery
Risk for infection
Sexual dysfunction related to perceived body changes

Goals

The client will understand pre-, intra-, and post-operative instructions.
The client will be free from infection.
The client will be able to normally eliminate urine and have positive bowel sounds.
The client will demonstrate effective coughing and deep breathing and incentive spirometry post-operatively.
The client will ambulate at least three times daily after post-op day 1.
The client will identify signs and symptoms that require follow-up or indicate infection.
The client will have a pain of less than 4 on a VAS 0-10 pain scale.
The client will verbalize concerns and fears related to change in body image and sexual functioning.

Interventions

Teach client what to expect prior to, during, and after procedures.
Teach client coughing and deep breathing exercises to minimize risk of pneumonia.
Post-operatively, monitor VS every 15 minutes X 2, every 30 Minutes X 2, every 1 hour X 2, than every 4 hours ( may have different guidelines for each clinical agency).
Monitor voiding amount, color and clarity.
Monitor vaginal bleeding, notify physician if bleeding increases.
Notify physician if unable to void greater than 6 hours after removing indwelling catheter.
Provide proper catheter care; monitor for s/s of infection.
Initiate early ambulation to minimize risks of complications.
Administer medicines ( analgesics, stool softeners, hormone replacement, etc.) as ordered.
Perform assessments every 4-8 hours to monitor for complications ( circulation, oxygenation, auscultation, etc).
Monitor for signs/ symptoms of complications.
Encourage client to discuss feelings associated with changes in body image and sexual function.

327-Prostatitis

About

Inflammation of the prostate gland.

Assess

Difficulty with urination, urgency, rectal pain, perineal pain, decreased libido, ejaculatory pain; may have fever, chills

Complications

Epididymitis; prostate abscess; cystitis

Diagnosis

Acute pain related to inflammation

Urinary retention related to outlet obstruction and swelling

Goals

The client will be free form infection.

Interventions

Monitor pain levels and utilize prn medications if elevated.
Encourage increased fluid intake.
Administer antibiotics, stool softeners, NSAIDS, etc. as ordered.
Teach about antibiotic therapy including duration, side effects, rationale for use.
Teach client activities that may help promote draining of the prostate ( masturbating, sexual intercourse).
Teach client to avoid medications ( antihistamines, anticholinergics, decongestants) that may cause urinary retention.
Teach client to abstain from alcohol, caffeine, and other foods/drinks that may irritate symptoms.
Monitor for signs/ symptoms of complications.

326-Prostate Cancer

About

Malignancy of the prostate causing enlargement and possible urinary obstruction. More common with advancing age of men.

Assess

Difficulty with urination, frequency of urination, hematuria, painful ejaculation, urinary retention

Complications

Diagnosis

Knowledge deficit related to disease process and management
Pain related to disease process.
Ineffective coping related to concerns and fears regarding diagnosis and treatment.
Anticipatory grieving related to diagnosis and treatment.
Risk for infection related to immune system dysfunction and compromise.
Risk for injury.

Goals

The client will identify treatment options for disease.
The client will verbalize concerns and fears related to diagnosis and treatment options.
The client will identify signs and symptoms that require immediate follow-up.
The client will identify signs and symptoms of infection.
The client will identify methods to decrease the risk of infection.
The client will remain free form complications of treatment and disease.

Interventions

Assess vitals, PSA ( prostate specific antigen), CBC with differential, pain level and location, presence of other masses, knowledge about disease and treatment options.
Prepare client for surgery, as indicated. ( TURP, prostatectomy, etc)
Prepare client for additional diagnostics to rule out other malignancies.
Encourage coughing and deep breathing exercises and incentive spirometry to prevent respiratory infections.
Administer chemotherapy and prepare for radiation therapy as indicated by physician.
Provide opportunities for client to verbalize concerns, feelings, and fears related to diagnosis and treatment.
Teach client signs and symptoms of infection or complications to report immediately to health care provider.
Teach client methods to prevent infection including hand-washing, avoiding large crowds, monitoring temperature.
Teach client factors that can increase the likelihood of additional malignancies ( smoking, excessive sun, alcohol, carcinogens).
Teach client potential complications related to therapy ( additional malignancy, infertility, infections, immune dysfunction, fatigue).
Monitor for complication of treatment ( chemo, radiation therapy).

325-Pelvic Inflammatory Disease

About

Inflammatory condition of the pelvis and possibly associated structures of the fallopian tubes, ovaries, uterus.

Assess

Vaginal discharge, abdomen or pelvic pain, increased pain with straining, fever, fatigue, nausea, vomiting, general malaise and increased pain with pelvic examination

Complications

Peritonitis, abscess, scar tissue over fallopian tubes, ectopic pregnancy, sepsis, thrombophlebitis

Diagnosis

Knowledge deficit related to disease process and management
Pain related to inflammation and infection.
Risk for infection

Goals

The client will be free from infection.
The client will identify health behaviors to decrease the risk of infection.
The client will verbalize a decrease in pain less than 4 on a 0-10 pain scale.

Interventions

Assess vitals, vaginal discharge, pain level, bowel sounds.
Monitor vitals, wbc's, and site of infection for signs of worsening.
Administer antibiotics and analgesics as prescribed.
Apply heat compresses to abdomen as prescribed to relieve discomfort.
Teach client proper hygiene, hand-washing, infection prevention strategies.
Encourage increase in fluids and rest during the healing process.
Teach client signs and symptoms of re-infection, need for abstinence while infected, and treatment of infected partners to prevent re-infection.
Teach client that yearly exam are necessary to prevent complications.

324-Ovarian Cancer

About

Malignancy of the ovaries causing large pelvic masses; often diagnosed in late disease due to difficulty screening for disease. High mortality rate due to late diagnosis and metastasis to peritoneal organs.

Assess

Enlarged abdomen, bloating, constipation, urinary difficulties, pelvic pressure, abdominal pain, back pain, pelvic pain. Symptoms are vague and usually non-specific making early diagnosis of disease difficult.

Complications

Diagnosis

Knowledge deficit related to disease process and management
Pain related to disease process.
Ineffective coping related to concerns and fears regarding diagnosis and treatment.
Anticipatory grieving related to diagnosis and treatment.
Risk for infection related to immune system dysfunction and compromise.
Risk for injury.

Goals

The client will identify treatment options for disease.
The client will verbalize concerns and fears related to diagnosis and treatment options.
The client will identify signs and symptoms that require immediate follow-up.
The client will identify signs and symptoms of infection.
The client will identify methods to decrease the risk of infection.
The client will remain free form complications of treatment and disease.

Interventions

Assess vitals, CBC with differential, pain level and location, presence of other masses, knowledge about disease and treatment options.
Prepare client for surgery, as indicated. ( Hysterectomy with bilateral salpingo-oopharectomy; omenectomy, tumor resection, peritoneal washings)
Prepare client for additional diagnostics to rule out other malignancies.
Encourage coughing and deep breathing exercises and incentive spirometry to prevent respiratory infections.
Administer chemotherapy and prepare for radiation therapy as indicated by physician.
Provide opportunities for client to verbalize concerns, feelings, and fears related to diagnosis and treatment.
Teach client signs and symptoms of infection or complications to report immediately to health care provider.
Teach client methods to prevent infection including hand-washing, avoiding large crowds, monitoring temperature.
Teach client factors that can increase the likelihood of additional malignancies ( smoking, excessive sun, alcohol, carcinogens).
Teach client potential complications related to therapy ( additional malignancy, infertility, infections, immune dysfunction, fatigue).
Teach patient that continued follow-up is necessary to diagnose return of cancer or malignancy. ( CA-125, mammography, CT-scans, Pelvic exams)
Monitor for complication of treatment ( chemo, radiation therapy).

323-Oophorectomy

About

Surgical removal of ovary( s).

Assess

Bleeding, incision, vital signs, lung sounds, bowel sounds, knowledge related to procedure and post-operative care

Complications

Post-operative complications including atelectasis, pneumonia, DVT, PE, infection, hemorrhage, paralytic ileus, bowel obstruction.

Onset of surgical menopause

Diagnosis

Sexual dysfunction related to perceived body changes
Knowledge deficit related to possible surgical intervention
Acute pain related to surgical procedure
Constipation related to anesthesia, pain medications
Ineffective health maintenance related to care after surgery
Sexual dysfunction related to perceived body changes

Goals

The client will understand pre-, intra-, and post-operative instructions.
The client will be free from infection.
The client will be able to normally eliminate urine and have positive bowel sounds.
The client will demonstrate effective coughing and deep breathing and incentive spirometry post-operatively.
The client will ambulate at least three times daily after post-op day 1.
The client will identify signs and symptoms that require follow-up or indicate infection.
The client will have a pain of less than 4 on a VAS 0-10 pain scale.
The client will verbalize concerns and fears related to change in body image and sexual functioning.

Interventions

Teach client what to expect prior to, during, and after procedures.
Teach client coughing and deep breathing exercises to minimize risk of pneumonia.
Post-operatively, monitor VS every 15 minutes X 2, every 30 Minutes X 2, every 1 hour X 2, than every 4 hours ( may have different guidelines for each clinical agency).
Monitor voiding amount, color and clarity.
Monitor vaginal bleeding, notify physician if bleeding increases.
Notify physician if unable to void greater than 6 hours after removing indwelling catheter.
Provide proper catheter care; monitor for s/s of infection.
Initiate early ambulation to minimize risks of complications.
Administer medicines ( analgesics, stool softeners, hormone replacement, etc.) as ordered.
Perform assessments every 4-8 hours to monitor for complications ( circulation, oxygenation, auscultation, etc).
Monitor for signs/ symptoms of complications.
Encourage client to discuss feelings associated with changes in body image and sexual function.

322-Myomectomy

About

Surgical removal of uterine fibroid tissue and masses through open incision or laparoscope.

Assess

Bleeding, incision, vital signs, lung sounds, bowel sounds, knowledge related to procedure and post-operative care

Complications

Post-operative complications including atelectasis, pneumonia, DVT, PE, infection, hemorrhage, paralytic ileus, bowel obstruction.

Diagnosis

Knowledge deficit related to possible surgical intervention
Acute pain related to surgical procedure
Constipation related to anesthesia, pain medications
Ineffective health maintenance related to care after surgery
Risk for infection

Goals

The client will understand pre-, intra-, and post-operative instructions.
The client will be free from infection.
The client will be able to normally eliminate urine and have positive bowel sounds.
The client will demonstrate effective coughing and deep breathing and incentive spirometry post-operatively.
The client will ambulate at least three times daily after post-op day 1.
The client will identify signs and symptoms that require follow-up or indicate infection.
The client will have a pain of less than 4 on a VAS 0-10 pain scale.

Interventions

Teach client what to expect prior to, during, and after procedures.
Teach client coughing and deep breathing exercises to minimize risk of pneumonia.
Post-operatively, monitor VS every 15 minutes X 2, every 30 Minutes X 2, every 1 hour X 2, than every 4 hours ( may have different guidelines for each clinical agency).
Monitor voiding amount, color and clarity.
Notify physician if unable to void greater than 6 hours after removing indwelling catheter.
Provide proper catheter care; monitor for s/s of infection.
Initiate early ambulation to minimize risks of complications.
Administer medicines ( analgesics, stool softeners, etc.) as ordered.
Perform assessments every 4-8 hours to monitor for complications ( circulation, oxygenation, auscultation, etc).
Monitor for signs/ symptoms of complications.
Encourage client to discuss feelings associated with changes in body image.

321-Menstrual Disorders

About

Pain with menses, increased bleeding with menses.

Assess

Age of menarche, obstetric history, contraceptives, pain, pattern of menstruation, associated factors with pain, timing of pain

Complications

Dysfunctional uterine bleeding, treatment specific complications, sexual dysfunction

Diagnosis

Acute pain related to cramping
Impaired comfort related to excessive bloating or fluid retention
Fear related to loss of large amounts of blood
Deficient fluid volume related to large volumes of blood loss

Goals

The client will state a decrease in pain.
The client will identify pharmacological and nonpharmacological methods to reduce symptoms.

Interventions

Assess onset, length, palliative measures, and type of symptoms.
Incorporate dietary measures to manage symptoms.
Encourage exercise, adequate rest, relaxation techniques.
Administer medications ( NSAIDS, ovulation suppression meds, birth control pills, etc.) as ordered.
Teach the client side effects and rationale for use of medication( s).
Encourage alternative methods to relieve pain including heat, massage, distraction.
Monitor for signs/ symptoms of complications.

320-Menopause

About

Normal aging process of women's health characterized by the inability to reproduce, end of menses, and a decrease in estrogen.

Assess

Changes in menstruation frequency and timing, hot flashes, night sweats, mood changes, memory loss, vaginal dryness

Complications

Treatment specific complications; sexual dysfunction; stress urinary incontinence

Diagnosis

Ineffective sexual patterns related to inadequate lubrication
Ineffective thermoregulation related to changes in hormone levels
Impaired comfort related to "hot flashes"

Goals

The client will state understanding of normal aging process and symptom management,

Interventions

Assess last menstrual period and symptoms.
Administer estrogen therapies, alternative agents, or other medications as ordered.
Teach client about medications and potential contraindications and side effects.
Teach client to use lubricants during intercourse and to prevent vaginal tearing/ dryness.
Encourage exercise, healthy eating, and increased intake of calcium and vitamin D.
Teach client how to do kegel exercises to prevent stress urinary incontinence.
Encourage client to verbalize feelings about body changes and changes in sexual functioning.
Monitor for signs/ symptoms of complications.

319-Mastitis

About

Inflammation or infection of breast tissue, most common in lactating women.

Assess

Inflammation of breast tissue, pain, nipple discharge of blood, pus, or sanguineous fluid, fever, elevated WBC's

Complications

Sepsis, abscess

Diagnosis

Knowledge deficit related to disease process and management
Pain related to inflammation and infection.
Risk for infection

Goals

The client will be free from infection.
The client will identify health behaviors to decrease the risk of infection.
The client will verbalize a decrease in pain less than 4 on a 0-10 pain scale.

Interventions

Assess breasts, nipples for discharge, vital signs, pain level, knowledge of infection prevention strategies.
Monitor vitals, wbc's, and site of infection for signs of worsening.
Administer antibiotics and analgesics as prescribed.
Apply cool compresses to breast tissue to relieve discomfort.
Teach client proper hygiene, hand-washing, infection prevention strategies.
Encourage increase in fluids and rest during the healing process.

318-Mastectomy

About

Surgery to remove all breast tissue and possibly some lymph nodes in immediate area.

Assess

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

Complications

Ineffective coping; body image disturbance

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

Teach client what to expect pre-, intra-, and post-operatively.
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.
Apply elastic compression stockings and/or sequential compression device as ordered.
Encourage coughing and deep breathing and early ambulation to facilitate movement of respiratory secretions.
Administer pain medications prn as ordered.
Teach client to maintain special Bra for 23 hours every day until follow-up appointment.
Encourage client to discuss feeling associated with loss of body part.
Provide support group information for client with additional resources for reconstruction options.
Monitor for signs/ symptoms of complications.

317-Lymphedema

About

Swelling and edema of the affected side of the body where mastectomy and lymph node removal or biopsy has occurred due to impaired lymphatic flow through altered lymph node channels.

Tissue swelling resulting from increased lymphatic fluid accumulation and lymphatic vessel occlusion.

Assess

Swelling of tissues, especially increased in the dependant position. Usually effects the arms after axillary lymph node removal. Can also effect the genitalia.

Complications

infection, immobility of affected extremity, tissue necrosis

Diagnosis

Risk for infection.
Risk for injury.
impaired tissue perfusion related to edematous condition.
Acute pain related to tissue swelling and inflammation.
Body image disturbance related to altered appearance of body part.

Goals

The client will have a reduction in edema to affected body area.
the client will remain free form infection.
The client will have positive distal pulses with good capillary refill to the extremity affected.
The client will state a pain level less than 4 after medication intervention.
The client will identify strategies to reduce edema and promote lymphatic fluid drainage back into the body.

Interventions

Assess body area affected for signs of infection, necrosis, impaired circulation, swelling, impaired movement.
teach client how to monitor extremity for signs of impaired circulation, infection, and tissue compromise.
Apply pressure reducing sleeves, as prescribed, to extremities.
Encourage elevation of extremities or body parts to promote drainage of fluid back to body via gravity.
Administer diuretics, as ordered.
Consult with trained therapists to perform manual lymphatic drainage.
Avoid tourniquets, blood pressure cuffs on affected extremity after lymph node removal.
Encourage client to talk about feelings related to appearance of extremities.

316-Hysterectomy

About

Removal of uterus; may also remove ovaries ( oopharectomy), fallopian tubes, and cervix.

Assess

Bleeding, incision, vital signs, lung sounds

Complications

Bleeding, urinary retention, surgical menopause if ovaries removed

Post-operative complications- infection, pneumonia, pain, paralytic ileus, constipation, blood clots

Diagnosis

Sexual dysfunction related to perceived body changes
Knowledge deficit related to possible surgical intervention
Acute pain related to surgical procedure
Constipation related to anesthesia, pain medications
Ineffective health maintenance related to care after surgery

Goals

The client will understand pre-, intra-, and post-operative instructions.
The client will be free from infection.
The client will be able to normally eliminate urine.

Interventions

Teach client what to expect prior to, during, and after procedures.
Teach client coughing and deep breathing exercises to minimize risk of pneumonia.
Post-operatively, monitor VS every 15 minutes X 2, every 30 Minutes X 2, every 1 hour X 2, than every 4 hours ( may have different guidelines for each clinical agency).
Monitor voiding amount, color and clarity.
Monitor vaginal bleeding, notify physician if bleeding increases.
Notify physician if unable to void greater than 6 hours after removing indwelling catheter.
Provide proper catheter care; monitor for s/s of infection.
Initiate early ambulation to minimize risks of complications.
Administer medicines ( analgesics, stool softeners, hormone replacement, etc.) as ordered.
Perform assessments every 4-8 hours to monitor for complications ( circulation, oxygenation, auscultation, etc).
Monitor for signs/ symptoms of complications.

315-Hydrocele

About

Fluid collection around the testis.

Assess

Swelling of the tissue around the testes; usually asymptomatic

Complications

Pain, discomfort

Diagnosis

Acute pain related to enlarged hydrocele

Goals

The client will have a decrease in discomfort.

Interventions

Administer analgesics as ordered.
Teach client about the disorder and potential treatment options as indicated.
Teach client about medications to help alleviate symptoms, side effects, and contraindications.
If surgical intervention, teach client about pre-, intra-, and post-operative activities.
Teach client how to empty drain post surgically and to monitor for infection.
Monitor for signs/ symptoms of complications.

314-Herpesvirus Type 2

About

Sexually transmitted disease that has periods of remission and exacerbation characterized by lesions and blisters of the genitalia. It is la lifelong viral infection. Transmitted by skin contact to herpetic lesions, by wet contaminated surfaces, self transmission from mouth cold sores.

Assess

Itching, pain, blisters in genitourinary area; fever, malaise, fatigue, headache, muscle aches, and painful urination

Complications

Transmission of infection, neonatal transmission, spread of infection, meningitis

Diagnosis

Acute pain related to blisters and lesions
Anxiety related to diagnosis
Knowledge deficit related to disease, transmission, and management
Risk for infection and spread of infection

Goals

The client will verbalize concerns related to diagnosis and treatment.
The client will have a decrease in pain less than 4 on a 0-10 scale.
The client will identify methods to prevent the spread of infection.
The client will identify safe sex methods ( abstinence, condoms, spermicidal, etc.)
The client will be free from complications.
The client will be able to identify treatment strategies and signs and symptoms requiring additional treatment.

Interventions

Assess perineal tissue, ability to urinate, vital signs, pain levels, knowledge of disease process, treatment and transmission
Monitor lesions, intake and output, pain levels.
Administer antiviral agents and analgesics as ordered by a physician.
Keep lesions clean and dry.
Administer sitz bath to relieve discomfort.
Use contact precautions with direct patient contact and strict handwashing before and after patient contact.
Teach client signs and symptoms of disease exacerbation, worsening.
Teach client methods to prevent the spread of infection to others.
Teach client self-care including medication regimen, proper hygiene to prevent secondary infections, safe sexual practices.
Encourage client to verbalize fears and concerns related to diagnosis and treatment.

312-Erectile Dysfunction

About

An inability to have intercourse due to inadequate or nonexistent erection.

Assess

Sexual history, medical history, hormone testing, ultrasonography

Complications

Treatment specific complications; sexual dysfunction

Diagnosis

Sexual dysfunction related to altered body function

Goals

The client will be able to have sexual intercourse or achieve sexual arousal.

Interventions

Assess contributing factors; physical, psychosocial, idiopathic
Encourage client to discuss feelings regarding decrease in sexual function.
Administer medications, as ordered, to aid in achieving an erection or maintaining an erection.
Teach client how to administer medications, rationale, side effects.
Provide support for client during process of determining cause and treating disorder.
Discuss other treatment modalities, as indicated.
Monitor for signs/ symptoms of complications.

313-Gonorrhoeae

About

Sexually transmitted disease that can cause inflammation to the cervix and extending organs. Often coexists with Chlamydia.

Assess

May be asymptomatic, can have urinary difficulty and pain, discharge from vagina or penis, swollen testicles

Complications

Transmission of infection, infertility, cervical inflammation, pelvic inflammatory disease

Diagnosis

Acute pain related to inflammation of cervix
Anxiety related to diagnosis
Knowledge deficit related to disease, transmission, and management
Risk for infection and spread of infection

Goals

The client will verbalize concerns related to diagnosis and treatment.
The client will identify methods to prevent the spread of infection.
The client will identify safe sex methods ( abstinence, condoms, spermicidal, etc.)
The client will be free from complications.
The client will be able to identify treatment strategies and signs and symptoms requiring additional treatment.

Interventions

Assess perineal tissue, ability to urinate, vital signs, pain levels, knowledge of disease process, treatment and transmission
Monitor intake and output & pain levels.
Administer antibiotic agents ( usually combo therapy for treatment of both Chlamydia and gonorrhea) as ordered by a physician.
Keep lesions clean and dry.
Administer sitz bath to relieve discomfort.
Use contact precautions with direct patient contact and strict handwashing before and after patient contact.
Teach client signs and symptoms of disease exacerbation, worsening.
Teach client methods to prevent the spread of infection to others.
Teach client self-care including medication regimen, proper hygiene to prevent secondary infections, safe sexual practices.
Encourage client to verbalize fears and concerns related to diagnosis and treatment.

311-Epididymitis

About

Inflammation of the epididymitis, can be bacterial or non-bacterial origin.

Assess

Scrotal edema, pain, pressure. History of STD's. Fever, chills.

Complications

Orchiectomy; epididymectomy

Diagnosis

Risk for infection related to inflammation
Acute pain related to inflammatory process

Goals

The client will be free from infection and have no further complications.

Interventions

Monitor for signs and symptoms of infection.
Teach client about medication therapy, disease process, s/s of complications.
Administer antibiotics, NSAIDS, etc. as ordered.
Encourage abstention from sexual intercourse, rest with scrotal elevation, use of scrotal support, ice packs, and sitz baths to promote comfort and decrease strain on spermatic cord.
If related to STD's, encourage client's partner to also be treated, utilize safe sexual practices.
Monitor for signs/ symptoms of complications.