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Acute Pain - Nursing Care Plan for Acute Coronary Syndrome

Acute coronary syndrome (ACS) refers to a group of conditions due to decreased blood flow in the coronary arteries such that part of the heart muscle is unable to function properly or dies. The most common symptom is chest pain, often radiating to the left arm or angle of the jaw, pressure-like in character, and associated with nausea and sweating. Acute coronary syndrome usually occurs as a result of one of three problems: ST elevation myocardial infarction (30%), non ST elevation myocardial infarction (25%), or unstable angina (38%).

Nursing Care Plan for Acute Coronary Syndrome

Nursing Diagnosis : Acute Pain related to tissue ischemia secondary to coronary artery occlusion.

Goal: pain experienced by the patient can be reduced.

Expected outcomes:
  • The client states chest pain is gone / controlled.
  • The client can demonstrate relaxation techniques.
  • The client may indicate reduced tension, relaxed and easy to move.
Nursing Interventions:

1. Provide a comfortable environment, calm, and give slow activity.
R /: Lowering external stimuli in which anxiety and heart strain and limited coping skills and decisions on the current situation.

2. Assist the client in relaxation techniques such deep breaths / slowly, distraction, visuallisasi, guidance imagination.
R /: Helps in reducing the pain response.

3. Provide supplemental oxygen by nasal cannula or mask as indicated.
R /: Increase the amount of oxygen available for the use of the myocardium and also reduces discomfort with respect to tissue ischemia.

4. Give the drug as indicated.
R /: To control pain and increase peace of patients to the healing process runs smoothly.

Activity Intolerance and Altered Tissue Perfusion r/t Leukemia

Nursing Care Plan for Leukemia

Nursing Diagnosis for Leukemia : Activity Intolerance related to general weakness, increased metabolic rate.

The client is able to tolerate the activity.

Expected outcomes:
  • Increased tolerance activity can be measured.
  • Participate in activities that can be measured.
  • Shows signs of physiological decline intolerant.
Nursing Intervention:
  • Evaluation reports weakness, note the inability to participate in activities.
  • Implementation of energy saving techniques.
  • Schedule eat about chemotherapy.

  • Give supplemental O2.

Nursing Diagnosis for Leukemia : Altered Tissue Perfusion related to cessation of blood flow, secondary; destruction of human existence.

Adequate perfusion.

Expected outcomes:
  • Balanced inputs and outputs.
  • Urine output of 30 mL / h.
  • Capillary refill less than 2 seconds.
  • Stable vital signs.
  • Strong peripheral pulses palpable.

Nursing Intervention:
  • Monitor vital signs.
  • Assess the skin to the cold, pale, humidity, capillary refill.
  • Note the change in the level of consciousness.
  • Maintain adequate fluid intake.
  • Evaluation of edema.
  • Supervise laboratory tests: blood gas analysis, AST / ALT, CPK, BUN.
  • Serum electrolytes, provide a replacement as indicated.
  • Give hypo osmolar fluid.

Pain (acute / chronic) related to Leukemia

Nursing Diagnosis for Leukemia: Pain (acute / chronic) related to physical agents such as enlargement of organs / lymph nodes, bone marrow which is packed with leukemia cells: anti-leukemic treatment chemical agents.

Pain resolved.

Expected outcomes:
  • Assess pain.
  • Monitor vital signs, notice of non-verbal instructions eg muscle tension, restlessness.
  • Give a quiet environment and less stressful stimuli.
  • Place in a comfortable position and chock joints, extremities with pillows.
  • Change position periodically and gentle range of motion exercises help.
  • Provide comfort measures.
  • Review the comfort of the patient's own intervention.
  • Evaluate and support the patient's coping mechanisms.
  • Suggest to do pain management techniques.
  • Help therapeutic activity, relaxation techniques.
Monitor the state of uric acid.
Give medications as indicated.
Antianxiety agent.Pain (acute / chronic) related to Leukemia.

Risk for Fluid Volume Deficit related to Leukemia

Nursing Care Plan for Leukemia

Nursing Diagnosis : Risk for Fluid Volume Deficit related to excessive loss: vomiting, bleeding, diarrhea. Decreased fluid intake: nausea, anorexia. Increased fluid requirements: fever, hypermetabolic.

Fluid volume are met.

Expected outcomes:
  • Adequate fluid volume.
  • Mucosa moist.
  • Stable vital signs.
  • Palpable pulse.
  • Urine output: 30 ml / h.
  • Capillary refill: less than 2 seconds.
  • Nursing Intervention:
  • Monitor input / output.
  • Weigh weight per day.
  • Monitor blood pressure and heart frequency.
  • Evaluation tugor skin, capillary and conditions of mucous membranes.
  • Give fluid intake of 3-4 liters / day.
  • Inspection for ptekie skin, ecchymosis area, noticed bleeding gums, rust-colored blood, faeces and urine occult bleeding from the puncture invasive further.
  • Implementation of measures to prevent tissue injury.
  • Limit oral care to wash the mouth when indicated.
  • Give refined diet.
  • Give IV fluids as indicated.
  • Supervise laboratory tests.
  • Give the red blood cells, platelets, clotting factors.
  • Maintain a central vascular access device.
  • Give medications as indicated.

Risk for Infection Nursing Care Plan for Leukemia

Nursing Diagnosis for Leukemia: Risk for infection related to the decline in the body's defense system, the secondary; white blood cell maturation disorders, increased number of immature lymphocytes, imonosupresi, bone marrow suppression.

The patient is free from infection.

Expected outcomes:
  • Normotermia.
  • Culture results (-).
  • Improved healing.
Nursing Intervention:
  • Place in a special room, limit visitors.
  • Wash hands for all personnel and visitors.
  • Monitor temperature, consider the relationship between the increase in temperature with chemotherapy treatment.
  • Prevent chills: increase fluid, give baths compress.
  • Suggest to frequently change position, breath and cough.
  • Auscultation of breath sounds, crackles, inspection secretion to change characteristics.
  • Inspection skin to tender, erythematous.
  • Inspection of oral mucous membranes.
  • Improve the patient's perineal hygiene.
  • Give uninterrupted rest period.
  • Suggest to increase high in protein and fluid input.
  • Avoid invasive procedures if possible.
  • Give medications as indicated.
  • Avoid antipyretic containing aspirin.

Ineffective Breathing Pattern and Altered Urinary Elimination r/t Glomerulonephritis

Nursing Care Plan for Glomerulonephritis

Nursing Diagnosis : Ineffective breathing pattern related to the inflammatory process.
characterized by : the patient complained of shortness of breath.

Expected outcomes :
Demonstrate effective breathing patterns, shortness of reduced or lost.

Intervention and Rationale :
1. Assess respiratory frequency and depth of chest expansion.
R / : Frequency of breath usually increased, dyspnea and an increase in breath work. Limited chest expansion indicates the presence of chest pain.

2. Elevate the head position and aids in changing the position.
R / : higher head position enables lung expansion and ease breathing. Changing the position of improving charging different lung segments which improves the gas diffusion.

3. Helping patients overcome fear in breathing.
R / : Fear breathe increase occurs hypoxemia.

4. Collaboration in the provision of supplemental oxygen.
R / : Maximizing breathing and lower the breath work.

Nursing Diagnosis : Altered Urinary Elimination related to capacity or bladder irritation secondary to infection.
characterized by oliguria / anuria.

Expected outcomes :
Shows the continuous flow of urine with adequate urine output for individual situation.

Interventions and Rational
1. Record the complaint urine (slight decline / cessation of urine flow suddenly)
R / : Decrease sudden flow of urine may indicate obstruction / dysfunction.

2. Observe and record the color of urine, hematuria note.
R / : Urine can be a bit pink.

3. Keep an eye on vital signs.
R / : fluid balance indicator shows the level of hydration and fluid replacement therapy effectiveness.

4. Collaboration in the administration of intravenous fluids.
R / : Helps maintain hydration / circulation adequate volume and the flow of urine.

Ineffective Tissue Perfusion related to Glomerulonephritis

Impaired Gas Exchange - Nursing Care Plan for Anaphylactic Shock

Nursing Diagnosis for Anaphylactic Shock : Impaired Gas Exchange

Anaphylactic shock is a hypersensitivity response mediated by immunoglobulin E (hypersensitivity type I) is characterized by cardiac output and arterial pressure decreased great. This is caused by the presence of an antigen-antibody reaction which arises as soon as a sensitive antigen into the circulation. Anaphylactic shock is a clinical manifestation of anaphylaxis which is a distributive shock, characterized by the presence of significant hypotension due to sudden vasodilation of the blood vessels and accompanied the collapse of blood circulation which can lead to death. Anaphylactic shock is a case of gravity, but too narrow to describe anaphylaxis as a whole, because of severe anaphylaxis can occur in the absence of hypotension, as the main symptoms of anaphylaxis with airway obstruction.

Clinical manifestations of anaphylaxis vary widely. In the clinic, there are 3 types of anaphylactic reaction, namely the rapid reaction which occurs several minutes to 1 hour after exposure to the allergen; moderate reaction occurs between 1 and 24 hours after exposure to the allergen; and slow reactions occurred more than 24 hours after exposure to the allergen.

Symptoms may begin with a new prodormal symptoms become severe, but sometimes directly heavy. Based on the degree of the complaint, anaphylaxis is also divided into mild, moderate, and severe. Mild often with symptoms of peripheral tingling, warm sensation, tightness in the mouth, and throat. Can also occur nasal congestion, periorbital swelling, pruritus, sneezing, and watery eyes. Onset of symptoms started within the first 2 hours after exposure. Degrees were able to cover all the mild symptoms plus bronchospasm and airway or laryngeal edema with dyspnea, cough and wheezing. Facial redness, warm, anxiety, and itching are also common. Onset of symptoms similar to a mild reaction. The degree of weight have a very sudden onset with signs and symptoms are the same as those mentioned above with the rapid progress towards bronkospame, laryngeal edema, severe dyspnea, and cyanosis. Can be accompanied by symptoms of dysphagia, abdominal cramps, vomiting, diarrhea, and convulsions. Cardiac arrest and coma are rare. Death can result from respiratory failure, ventricular arrhythmias or irreversible shock.

Symptoms can occur immediately after exposure to the antigen and can occur in one or more target organs, such as cardiovascular, respiratory, gastrointestinal, skin, eyes, central nervous system and urinary system, and other systems. Complaints are often found in the initial phase is fear, burning in the mouth, itching of the eyes and skin, heat and tingling in the limbs, shortness, hoarseness, nausea, dizziness, fatigue and abdominal pain.

In the respiratory system occur hyperventilation, decreased pulmonary blood flow, decreased oxygen saturation, increased pulmonary pressure, respiratory failure, and a decrease in tidal volume. Upper respiratory tract can be impaired if the tongue or oropharynx involved causing stridor. Hoarse voice could even no sound at all if edema continues to deteriorate. Complete airway obstruction is the most frequent cause of death in anaphylaxis. Wheezing breath sounds occur when the lower respiratory tract is interrupted due to bronchospasm or mucosal edema. In addition, a cough, nasal congestion, and sneezing.

Nursing Care Plan for Anaphylactic Shock

Nursing Diagnosis : Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.

Goal: expected gas exchange problems handled
with expected outcomes: no shortness of breath, adequate ventilation, no symptoms of respiratory distress.

Nursing Interventions:
  • Assess frequency, depth and ease breathing.
  • Maintain patency of the airway to give the position, exploitation, and the use of tools.
  • Assess the level of consciousness / mental changes.
  • Collaboration give oxygen therapy correctly, according to the condition of clients.
  • Collaboration give medicines.
Rational :
  • Increased respiratory effort may indicate the degree of hypoxemia and useful in the evaluation of the degree of respiratory distress.
  • Because airway obstruction may affect ventilation and impairs gas exchange.
  • Therefore, systemic hypoxemia can be demonstrated first by the restless and sensitive excitatory later by progressive mental decline.
  • The aim of oxygen therapy is to maintain PaO 2 above 60 mm Hg, oxygen is supplied with appropriate delivery methods tolerance client.
  • Used to prevent allergic reactions / inhibit histamine release, lose weight and spasm of the airway, respiratory inflammation and dyspnea.

NANDA Nursing