Nursing Care Plan for HNP Herniated Nucleus Pulposus

Nursing Care Plan for HNP Herniated Nucleus Pulposus

Herniated Nucleus Pulposus
Intervertebral Discs are the cartilage plates that form a cushion between the vertebral bodies. Hard and fibrous material is combined in one capsule. Such as ball bearings in the middle of the disc called the nucleus pulposus. Herniated nucleus pulposus is a rupture of the nucleus pulposus.

Herniated nucleus pulposus into the vertebral bodies can be above or below it, can also directly into the vertebral canal.

Pain can occur in any part such as cervical spine, thoracic (rarely) or lumbar. Clinical manifestations depend on the location, speed of development (acute or chronic) and the effect on surrounding structures. Lower back pain is severe, chronic and recurring (relapse).

Diagnostic Examination
1. Spinal RO: Shows the degenerative changes in the spine
2. MRI: to localize even small disc protrusion, especially for lumbar spinal disease.
3. CT Scan and Myelogram if the clinical and pathological symptoms are not visible on MRI
4. Electromyography (EMG): to localize the specific spinal nerve roots are exposed.

Assessment Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Anamnesa
   The main complaint, history of present treatments, medical history past, family health history.

2. Physical examination
Assessment of the patient's problem consists of onset, location and spread of pain, paresthesias, limited mobility and limited function of the neck, shoulders and upper extremities.Assessment in the area include palpation of the cervical spine which aims to assess muscle tone and rigidity.

3. Examination Support

Diagnosis Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute Pain
2. Impaired physical mobility
3. Anxiety
4. Knowledge deficient

Intervention Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute pain related to nerve compression, muscle spasm
 a. Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10
 b. Maintain bed rest, semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position
 c. Use logroll (board) during a change of position
 d. Auxiliary mounting brace / corset
 e. Limit your activity during the acute phase according to the needs
 f. Teach relaxation techniques
 g. Collaboration: analgesics, traction, physiotherapy

2. Impaired physical mobility related to pain, muscle spasms, and damage neuromuskulus restrictive therapy
 a. Give / aids patients to perform passive range of motion exercises and active
 b. Assist patients in ambulation activity progressively
 c. Provide good skin care, massage point pressure after rehap change of position. Check the state of the skin under the brace with a specific time period.
 d. Note the emotional responses / behaviors in immobilizing
 e. Demonstrate the use of auxiliary equipment such as a cane.
 f. Collaboration: analgesic

3. Anxiety related to ineffective individual coping
 a. Assess the patient's anxiety level
 b. Provide accurate information
 c. Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities.
 d. Review of secondary problems that may impede the desire to heal and may hinder the healing process.
 e. Involve the family

4. Knowledge deficient related to the lack of information about the condition, prognosis
 a. Explain the process of disease and prognosis, and restrictions on activities
 b. Give information about your own body mechanics to stand, lift and use the shoes backer
 c. Discuss about treatment and side effects.
 d. Suggest to use the board / mat is strong, a small pillow under your neck a little flat, bed side with knees flexed, avoid the tummy.
 e. Avoid the use of heaters in a long time
 f. Give information about the signs that need attention such as puncture pain, loss of sensation /  ability to walk.

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Nursing Care Plan For Myocardial Infarction (MI)

Myocardial infarction (MI or AMI for acute myocardial infarction) is the rapid development of myocardial necrosis (die of heart cells) caused by a critical imbalance between oxygen supply and demand of the myocardium.

This is serious medical condition that sometimes called as a heart attack or a coronary thrombosis. The medical team should be take quickly action to give treatment and Nursing Care to prevent complication or die.

With myocardial infarction, reduce blood flow in one of the coronary arteries leads to myocardial ischemia, injury and necrosis. From the ECG result, with a Q-wave MI it's mean that the tissue damage extends through all myocardial layers. Non-Q-wave MI, ussually only the innermost layer is damage.

Possible causes of Myocardial infarction (MI) are : Coronary artery occlusion, Coronary spasm and Coronary stenosis. There are some risk factors to develop of Myocardial infarction such as :

• Aging


• Decrease serum HDL levels


• Diabetes Mellitus


• Drug use, specifically use of amphetamines or cocaine


• Elevated serum Triglyceride, LDL and Cholesterol levels


• Excessive intake of saturated fats, carbohydrates, or salt


• Family history of CAD


• Hypertension


• Obesity


• Post menopausal women


• Sedentary lifestyle


• Smoking


• Stress

Nursing Care Plan For Myocardial Infarction (MI):

Assessment findings on the patient with myocardial infarction are : Dyspnea, Diaphoresis, Arrhythmias, Tachicardia, Anxiety, Pallor, Hypotension, Nausea and vomiting, Elevated temperature. The specific complain from the patient is crushing substernal chest pain (may radiate to the jaw, back and arms) that unrelieved by rest or nitroglycerin (NGT) tablet.

Diagnostic evaluation patient with myocardial infarction:

• ECG show deep, wide @ wave ; elevated or depressed ST segment; and T wave inversion or cardiac arrythmias.


• Blood chemistry test result show increased creatine kinase (CK), lactate dehydrogenase (LD), lipid, and troponin T levels; increased WBC count; positive CK_MB fraction; and flipped LD1.

Nursing diagnoses for patient myocardial infarction (MI) are:

1. Chest discomfort (pain) due to an inbalance Oxygen (O2) demand supply


2. Potential Arrhythmias related to decrease cardiac output


3. Respiratory difficulties (dyspnoea) due to decrease CO


4. Anxiety & fear of death related to his condition


5. Activity intolerance related to limitations imposed


6. Potential for complications of thrombolytic therapy


7. Discharge medications, follow up & Health teachings

Planing and goals of nursing care plan;

• The patient won't develop preventable complication


• The patient will understand the necessary treatment and lifestyle changes.

Nursing Intervention for myocardial infarction (MI):

1. Monitor ECG result to detect ischemia, injury new or extended infarction, arrhythmia, and conduction defects


2. Monitor, record vital signs and hemodynamic variables to monitor response to the therapy and detects complication


3. Administer oxygen as prescribe to improve oxygen supply to the heart


4. Obtain an ECG reading during acute pain to detect myocardial ischemia, injury or infarction


5. Maintain the patient's prescribed diet to reduce fluid retention and cholesterol levels


6. Provided postoperative care if necessary to avoid postoperative complications and help the patient achieve a full recovery


7. Allay the patient's anxiety because the anxiety increase oxygen demands.

Nursing Evaluation for myocardial infarction (MI):

• The patient explains how and when to take medicine and state reportable adverse reaction


• The patient describes appropriate lifestyle changes to reduce the risk of future cardiac event


• The patient experiences no complication after heart attack (myocardial infarction)

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Nursing Care Plan For Discharge Patient

When the doctor decided that the patient already in the good condition, The nurses have to prepare what they must do or see what is the patient needs after discharge from hospital.

Nursing care pan for the discharge patient do not important for the patient only, but to the family also the nurses should explain what they can do related to patient's needs.

Plan and Outcome data :

• The patient or family's discharge planning will begin on day of admission including preparation for the education and or equipment.



• On the day of discharge, patient / family will receive verbal and written instructions concerning: Medications, Diet, Activity, Treatments, Follow up appointments, Signs and symptoms to observe for (when to contact the doctor), Care of incisions, wounds, etc.



• Other data may can help.

Nursing Care Plan For Discharge Patient

Nursing Interventions :

1. Assess needs of patient/family beginning on the day of admission and continue assessment during hospitalization.



2. Anticipated needs/services:
   
   • Respiratory equipment,
   
   
   • Hospital bed,
   
   
   • Wheel chair, Walker,
   
   
   • Home health nurse,
   
   
   • Home PT/OT/ST
   
   



3. Involve the patient/family in the discharge process.



4. Discuss with physician the discharge plan and obtain orders if needed.



5. Contact appropraite personnel with orders.



6. Provide written and verbal instructions at the patient/family's level of understanding.



7. Verbally explain instructions to patient/family prior to discharge and provide patient/family with a written copy.



8. Ascertain that patient has follow-up care arranged at discharge.


9. Provide verbal and written information on what signs and symptoms to observe and when to contact the physician.



10. Assess if any community resources should be utilized (i.e.: Home Health Nurse), and contact appropriate personnel.



11. Document all discharge teaching on Discharge Instruction Sheet and Nursing notes.



12. Other: ...

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Nursing Care Plan For Acute Renal Failure

Acute renal failure (ARF) or Acute Kidney Injury (AKI) is a rapid loss (breakdown or decrease) of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea and creatinine) and non-nitrogenous waste products that are normally excreted by the kidney.

Acute Renal Failure (ARF) is classified as :

1. Pre Renal; occurs as a result of renal hypoperfusion which usually responds well to rehydration, or result from condition that diminish blood flow to the kidney.



2. Intra Renal; result from damage to the kidneys, usually from acute tubular necrosis. In critically ill patients other insults such as infection, hypoxia, drugs etc, may convert a simple problem of poor perfusion into one of acute tubular necrosis where there is structural damage to the renal parenchyma. The patient may not die from renal failure although this may be present at the time of death. There is a high mortality in patients who develop ARF in the context of other severe illness.



3. Post Renal (obstructive); result from bilateral obstruction of urine flow. The most common cause of obstructive uropathy in men is prostate.

Acute renal failure has four phases : onset, oliguric-anuric, diuretic and convalescent. The convalescent period can last up to 12 months.

The possible causes of acute renal failure are Acute glomerulonephritis, Acute tubular necrosis, Anaphylaxis, Benign prostatic hyperplasia, Blood transfusion reaction, Burns, Cardiopulmonary bypass, Collagen disease, Congenital deformity, Dehydration, Diabetes Mellitus, Heart failure, Cardiogenic shock, Endocarditis, Malignant hypertension, Hemorrhage, Infection (pyelonephritis and septicemia), Neprotoxins (antibiotics, X-ray dyes, pesticides and anesthetic) and Thrombi or emboli.

Nursing care plan (NCP) or nursing intervention for the patients who diagnosed as acute renal failure during admitted on the hospital should be complete, comprehensive monitor and quick action in order to improve of patient's condition.

A. Assessment Findings on Acute Renal Failure

During assessment, the nurses may find some sign and symptom of acute renal failure. There are many complain from patient related to his/her condition such as ; Anorexia, Nausea, Vomiting, Costovertebral plain, Headache, diarrhea or constipation, Irritability, Restlessness, Lethargy, Drowsiness, Stupor, Coma, Pallor, Ecchymosis, Stomatitis, Thick tenaciouse sputum, Urine output less than 400 ml/day for 1 to 2 weeks and then followed by diuresis (3 to 5 L/day) for 2 to 3 weeks, Weight gain.

B. Diagnostic Evaluation for Acute Renal Failure

1. Arterial blood gas (ABG) analysis shows metabolic acidosis.


2. Blood chemistry shows increased potassium, phosphorus, magnesium, blood urea nitrogen (BUN) creatinine, and uric acid levels. Also decreased of calcium, carbon dioxide, and sodium levels.


3. Creatinine clearance is low


4. Excretory urography shows decreased renal perfusion and function.


5. Glomerular filtration rate (GFR) is 20 - 40 ml/minute (renal insufficiency), 10 - 20 ml/minute (renal failure), or less than 10 ml/minute (end-stage renal disease).


6. Hematology shows decreased hemoglobin (Hb) level, hematocrit (HCT), and erythrocytes. Also increase of prothrombin time (PT) and partial thromboplastin time (PTT).


7. Urine chemistry shows albuminuria, proteinuria, increase sodium levels {casts, red blood cells (RBCs), and white blood cells (WBCs)}, and urine specific gravity greater than 1.025 which continue fixed at less than 1.010.

C. Nursing Diagnose (Problems) in Acute Renal Failure

• Ineffective tissue perfusion (renal)


• Excess fluid volume


• Risk for infection


• Risk for deficient fluid volume.

D. Treatment of Acute Renal Failure

• Continuous arteriovenous hemofiltration


• Low protein, increased carbohydrate, moderate fat, and moderate calorie dietwith potassium, sodium and phosphorus intake regulated according to serum levels


• Peritoneal dialysis or hemodialysis


• Fluid intake restricted to the amount needed to replace fluid loss.


• Transfusion therapy with packed RBCs administered over 1 to 3 hours as tolerated.

E. There are Many of Drug Therapy Options

• Alkalinizing agent ; sodium bicarbonate


• Antacid ; aluminum hydroxide (AlternaGEL)


• Antibiotic ; cefazolin (Ancef)


• Anticonvulsant ; phenytoin (Dilantin)


• Antiemetic ; prochlorperazine (Compazine)


• Antipyretic ; acetaminophen (Tylenol)


• Beta-adrenergic blocker ; dopamine (Intropin) initially to improve renal perfusion


• Cation exchange resin ; sodium polystyrene sulfonate (Kayexalate)


• Diuretic ; furosemide (Lasix) , metolazone (Zaroxolyn)

F. Planing and Goal of Nursing Care Plane

1. The client will have normal fluid and electrolyte levels


2. The client will experience no preventable complication


3. The client will understand the means by which His/Her family members will implement health teaching after discharge.

G. Nursing Intervention for Acute Renal Failure

To the nursing intervention, the nurses should be have good knowledge to decide which phase of his/her patient related to the acute renal failure. Base on that information, bellow are some nursing intervention they can do to the patient with acute renal failure :

* Oliguric-anuric phase ; In this phase, the client's urine output falls bellow 400 ml/day. With resultant electrolyte imbalance, metabolic acidosis, and retention of nitrogenouse wastes from non functioning nephrons. This pahse may last up to 14 days. The Nurses should be follow these steps :

1. Maintain the client on complete bed rest, organize care to provide long rest periods. Activity increase the rate of metabolism, which increase production of nitrogenouse waste product.


2. Implement intervention to prevent infection and the complications of immobility. Because She/He is on bed rest, the client becomes susceptible to the hazards of immobility. Infection is a serious risk and the leading cause of death in client with acute renal failure.


3. Observe the client for metabolic acidosis to identify complication of renal failure.Observe the fluid and electrolyte balance hourly.


4. Insert an indwelling urinary catheter and measure output and specific gravity hourly. These action allow the nurse to monitor the kidneys, which have the major role in regulating fluid and electolyte balance. High potassium levels can occur.


5. Provide only enough fluid intake to replace urine output to avoid an edema caused by excessive fluid intake.


6. Monitor the client's diet to provide high carbohydrates, adequate fats, and low protein. If client receives high calories from fat and carbohydrate metabolism, the body doesn't break down protein for energy. Protein is thus available for growth and repair.


7. Reduce the client's potassium intake to help prevent elevated potassium levels. Protein catabolism causes potassium release from cells into the serum.


8. Observe for the arrhytmias and cardiac arrest to identify complications of high serum potassium.


9. Provide frequent oral hygiene to avoid tissue irritation and sometime ulcer formation caused by urea and other acid waste products excreted through the skin and mucous membranes.


10. Provide the client with hard candy and chewing gum to stimulate saliva flow and decrease thirst.


11. Maintain skin care with cool water to relive pruritus and remove uremic frost (white crystal formed on skin from excretion of urea).


12. Administer stool softeners to prevent colon irritation from high levels urea and organic acids.


13. Provide emotional reassurance to the client and family members to help decrease anxiety levels caused by the fact that the client has an acute illness with unknown prognosis.


14. Explain treatments and progress to the client to help reduce anxiety.


15. Provide hemodialysis or peritoneal dialysis as ordered.

* Early diuretic phase ; During early diuretic phase, which last about 10 days, the client excretes a large volume (over 3,0000 ml/day) of very dilute urine. The glomeruli are beginning to function effectively, but tubules aren't, and the client still experiences electrolyte imbalance, retention of nitrogenous waste product and metabolism acidosis. The nurse should be do intervention such as ;

1. Assess fluid and electrolyte balance to identify continued fluid and electrolyte imbalance when the renal tubules aren't functioning.


2. Assess the emotional status of the client and family members to provide support because the prognosis is still uncertain.


3. Continue interventions used during the oliguric phase.

* Late Diuretic phase ; In the late diuretic phase, the client is still excreting more fluid than normal. Urine specific gravity is increasing because the tubules are beginning to function effectively. Fluid, electrolyte and acid-base balances are returning to normal. In this condition, The nurse should do the following steps ;

1. Continuing implementations of the early diuretic phase. Allow the client to engage in nonstrenuous activity for brief periods and increase the activity level gradually. Don't let him/her become fatigued which may increase the rate of metabolism and overwork the kidneys.


2. Teach the client to prevent infection and to avoid the factors that caused renal failure to help prevent a recurrence.

H. Evaluation of Nursing Intervention

• The client regains fluid and electrolyte balance.


• The client understands the rationale behind activity restriction.

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Nursing Care Plan For Heart Failure

Heart Failure also called as Cardiac failure, Congestive Heart Failure (CHF). Heart failure (HF) is a medical condition in which a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's metabolic needs.

Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It should not be confused with cardiac arrest. So, the Nursing Care Plan for Heart Failure cases are little different with others heart problems.

Heart failure can occur on the left-sided or right-sided of the heart. Left-sided heart failure causes mostly pulmonary sign and symptom, such as shortness of breath, dyspnea on exertion and a moist cough. Right-sided heart failure causes systemic sign, such as edema and swelling, jugular vein distention and hepatomegaly.


The possible causes of heart failure are atherosclerosis, cardiac conduction defects, chronic obstructive pulmonary disease, fluid overload, hypertension, MI, pulmonary hypertension, valvular insufficiency, valvular stenosis.

Nursing Care Plan For Heart Failure :

A. Assessment Findings on Heart Failure Cases

1. Left-sided heart failure ; Dyspnea, Crackles, Orthopnea, Paroxysmal noctural dyspnea, Tachypnea, Tachycardia, Gallop rhythm (third or S3 and fourth or S4 heart sound), Fatigue, Anxiety, Arrhythmias and Cough.


2. Righ-sided heart failure ; Dependent edema, Weight gain, Fatique, Jugular vein distention, Tachycardia, Gallop rhythm (S3 or S4), Nausea, Anorexia, Hepatomegaly and Ascites.

B. Diagnostic Evaluation

1. Left-sided heart failure ;
   
   • ABG levels indicate hypoxemia and hypercapnia.
   
   
   • Blood chemistry test results reveal decreased potassium and sodium levels and increased BUN and creatinine levels.
   
   
   • Chest X-ray shows increased pulmonary congestion and left ventricular hypertrophy.
   
   
   • ECG may show left ventricular hypertrophy or acute ST-T wave changes.
   
   
   • Echocardiography shows increased size of cardiac chambers and decreased wall motion. Hymodinamic monitoring reveals increased PAP and PAWP and decreased cardiac output.
   
   


2. Righ-sided heart failure ;
   
   • ABG levels indicate hypoxemia.
   
   
   • Blood chemistry test results show decreased sodium and potassium levels and inc creatinine levels.
   
   
   • Chest X-ray reveals pulmonary congestion, cardiomegaly, and pleural effusions.
   
   
   • ECG may show left and right ventricular hypertrophy or acute ST_T wave changes.
   
   
   • Echo cardiogram shows increased size of chambers and decreased in wall motion.
   
   
   • Hemodynamic monitoring show increased right atrial pressure, CVP, and right ventricular pressure and also decrease cardiac output.
   
   

C. Nursing Diagnoses

• Excess fluid volume


• Activity intolerance


• Ineffective health maintenance

Due to possible cases above, the best treatment are :

• Low-sodium diet and limited intake of fluid


• Intra-aortic balloon pump (IABP)


• Oxygen therapy (possible intubation and mechanical ventilator)


• Left ventricular assist device (for left-seded heart failure)


• Paracentesis (for right-sided heart failure)


• Thoracentesis (for right-sided heart failure)

There are many of drugs therapy option, such as :

• Analgesic (morphine sulfat IV)


• Angiotensin-converting enzyme (ACE) inhibitor; {captropil (capoten), enalapril (vasotec), lisinopril (prinivil)}


• Beta-adrenergic blocker ; {carvedilol (coreg), metoprolol (lopressor)}


• Cardiac glycoside; digoxin (lanoxin)


• Diuretic; {bumetanide (bumex), furosemide (lasix), metolazone (zaroxolyn), spironolactone (aldactone)}


• Inotropic agent; {amrinone lactate (inocor), dobutamine hydrochloride (dobutrex), dopamine hydrochloride (intropin)}


• Nitrate; {isosorbite dinitrete (isordil), nitroglycerin (nitro-bid)}


• Vasodilator; nitroprusside sodium (nitropress)

D. Planing and Goals of Nursing Care

1. The clients will understand how to cope with necessary lifestyle changes.


2. The client won't develop preventable complication


3. The client will will understand how to continue therapy at home.

E. Nursing Intervention For Heart Failure

1. Assess cardiovascular status, vital sign and hemodynamic variable to detect signs of reduced cardiac output.


2. Assess respiratory status to detect increasing fluid in the lungs and respiratory failure.


3. Keep the client in semi-fowler's position to increase chest expansion and improve ventilation.


4. Administer medication as prescribed, to enhance cardiac performance and reduce excess fluids.


5. Administer oxygen to enhance arterial oxygenation.


6. Measure and record intake and output, Intake greater than output may indicated fluid retention.


7. Monitor laboratory test result to detect electrolyte imbalances, renal failure, and impaired cardiac circulation.


8. Provide suctioning, if necessary assist with turning and encourage coughing and deep breathing to prevent pulmonary complication.


9. Restrict oral fluid to avoid worsening the client's condition.


10. Weigh the client daily to detect fluid retention. A weight gain of 2lb (0,9 kg) in 1 day or 5 lb (2,3 kg) in 1 week indicates fluid gain.


11. Measure and record the client's abdominal girth. An increased in abdominal girht suggests worsening fluid retention and right-sided heart failure.


12. Make sure the client maintains a low-sodium diet to reduce fluid accumulation.


13. Encourage the client to express feelings, such as a fear of dying to reduce anxiety.

F. Evaluation of Nursing Care on Heart Failure Disease.

1. The client accurately describes recommended dietary restriction and medication regimens.


2. The client hasn't experienced complication


3. The client verbalizes important sign and symptom to report.

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Nursing Care Plan For Hypertension

Hypertension or High blood pressure (HBP) is a medical condition in which the blood pressure is chronically elevated in the arteries or blood vessels. Hypertension is also categorized according to etiology: as primary/essential (approximately 95% of all cases), when it has no identifiable cause; or secondary, which occurs as a result of an identifiable, sometimes correctable, pathologic condition.

1. Hypertension (Blood pressure) of 160/100 mmHg or above

This is definitely high, In this level the patient should be treat with medication to lower it. Otherwise, Persistent hypertension can make serious problem such as strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure.

2. Hypertension (Blood pressure) of 140/90 mmHg to 160/100 mmHg

This level called as 'mild' high blood pressure. For many people the risk from mild high blood pressure is small, and drug treatment is not indicated. Anyway, in this range they will get advised medication to lower it. Hypertension increases with age and is one of the major risk factors in the development of cardiovascular disease.

3. Hypertension (Blood pressure) between 130/80 and 140/90 mmHg

For most people this level is fine, But in some group of people this level is too high for them. Treatment to lower the blood pressure if it is 130/80 mmHg or higher may be considered if some one :

• Have developed a complication of diabetes, especially kidney problems.


• Have had a serious cardiovascular event such as a heart attack, transient ischaemic attack (TIA) or stroke.


• Have certain chronic (ongoing) kidney diseases.

General causes of Hypertension ; Coartaction of the aorta, Cushing's disease, Neurologic disorder, No Known cause (essential hypertension, Oral contraceptive use, Pheochromocytoma, Pregnancy, Primary hyperaldosteronism, Renovascular disease, Thyroid (Pituitary or Parathyroid disease), also use of drug (cocaine, epoetin alfa, cyclosporin).


Risk factors to get hypertension are ; Aging, Atherosclerosis, Diet (sodium and caffein), Family history, Obesity, Race (insidence is higher in blacks), Sex (incidence is higher in males older than age 40), Smoking and Strees.

Nursing Care Plan For Hypertension :

The Nurses must collect some data during assessment ; Asymptomatic, Elevated blood pressure, Dizziness, Headache, Left ventricular hypertrophy, Heart failure, Cerebral ischemia, Renal Failure, Papilledema, Vsual disturbance (including blindness).

See the diagnostic evaluation ;

• ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias; e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs), may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.


• Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilatation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour; e.g., bulging of left cardiac border, may suggest ventricular aneurysm.


• Sonograms (echocardiogram, Doppler and transesophageal echocardiogram): May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.


• Heart scans: Technetium-99m (99mTc) pyrophosphate scaning (also known as hot spot myocardial imaging and infarct avid imaging): Used to detect recent myocardial infaction and its extent.


• Multigated acquisition (MUGA): Measures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.


• Exercise or pharmacologic stress myocardial perfusion (e.g., dipyridamole [Persantine] or thallium scan): Evaluates blood flow, determines presence of myocardial ischemia and wall motion abnormalities.


• Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.


• Cardiac magnetic resonance imaging (MRI): Helps detect congenital heart disease, valvular heart disease, and vascular disorders such as thoracic aneurysm. It also helps detect cardiac tumors and structural anomalies.


• Cardiac catheterization: Abnormal pressures are indicative of and help differentiate right-sided versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected


• into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some clients to determine the underlying disorder, such as myocarditis or amylodosis.


• BNP (Beta-type natruiretic peptide): Affects cardiac function and vascular tone and renal function. Low levels indicate worsening heart failure.


• Liver enzymes: Elevated in liver congestion/failure.


• Digoxin and other cardiac drug levels: Monitored to determine therapeutic range and correlate expected response with client response.


• Bleeding and clotting times: Determine therapeutic range for anticoagulant therapy and/or identify those at risk for excessive clot formation.


• Electrolytes: May be altered because of fluid shifts/decreased renal function and medications (e.g., diuretics, ACE inhibitors).


• Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased PCO2 (late).


• BUN/creatinine: Elevated BUN suggests decreased renal perfusion as may occur with HF and/or as a side effect of prescribed medications (e.g., diuretics and ACE inhibitors). Elevation of both BUN and creatinine is indicative of renal failure.


• Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.


• Complete blood count (CBC): May reveal anemia (major contributor/exacerbating factor in HF), polycythemia, or dilutional changes indicating water retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.


• ESR: May be elevated, indicating acute inflammatory reaction (especially if viral infection is cause of HF).


• Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF. Hypothroydism can also cause or exacerbate HF.


• Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.

Nursing Priorities For Care Plan :

1. Improve myocardial contractility/systemic perfusion.


2. Reduce fluid volume overload.


3. Prevent complications.


4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

Nursing Action or Nursing Intervention :

1. Assess Cardiovascular status including vital signs to detect cardiac compromise.


2. Take an average of two or more blood pressure readings to establish hypertension.


3. Check the client's blood pressure in lying, sitting, and standing position to determine if orthostatic hypotension is present. Also check for pallor, diaphoresis, and vertigo.


4. Assess neurologic static and observe the client for changes that may indicated an alteration in cerebral perfussion (CVA or hemorrhage).


5. Monitor and record intake and output and daily weight to detect fluid volume overload.


6. Administer medications as prescribed to lower blood pressure.


7. Make sure the client maintains a low-sodium, low-cholesterol diet to help minimize hypertention.


8. Encourage the client to express feelings about daily stress to reduce anxity.


9. Maintain a quiet environment to reduce stress.

Planing and Goals of Nursing Care :

1. The client will exhibit a reduction in blood pressure


2. The client will express understanding and acceptance of necessary lifestyle changes.


3. Complications prevented/resolved.


4. Optimum level of activity/functioning attained.


5. Disease process/prognosis and therapeutic regimen understood.


6. Plan in place to meet needs after discharge.

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Nursing Care Plane For Anxiety

To decide what kind of nursing intervention or nursing management for the anxiety's patient, the Nurses should make an assessment in two point ; Actual or Potential before they make their nursing care plan (NCP) note. Then the nurses collect some information, why the patient become anxiety.

May be related to :

• Anesthesia intervention


• Anticipated or actual pain


• Him or Her condition (Disease)


• Invasive/noninvasive procedure during treatment


• Loss of significant other


• Threat to self-concept


• Other may appear on Him/Her self

To help and support the assessment's data, look and check on :

• Physiological; Elevated Blood Pressure , Pulls and Respiration. Insomnia, Restlessnes, Dry mouth, Dilated pupils, Frequent urination, Diarrhea.


• Emotional; Patient complains of apprehension, nervousness, tension


• Cognitive; Inability to concentrate. Orientation to past. Blocking of thoughts, hyper-attentiveness

Plan and Outcome data :
The patient will :

• Demonstrate a decrease in anxiety A.E.B.:
  
  • A reduction in presenting physiological, emotional, and/or cognitive manifestations of anxiety.
  
  
  • Verbalization of relief of anxiety.
  
  


• Discuss/demonstrate effective coping mechanisms for dealing with anxiety.


• Other:...

Nursing Interventions :

1. Assist patient to reduce present level of anxiety by:
   
   • Provide reassurance and comfort.
   
   
   • Stay with person.
   
   
   • Don't make demands or request any decisions.
   
   
   • Speak slowly and calmly.
   
   


2. Attend to physical symptoms. Describe symptoms: Give clear, concise explanations regarding impending procedures.


3. Focus on present situation.


4. Identify and reinforce coping strategies patient has used in the past.


5. Discuss advantages and disadvantages of existing coping methods.


6. Discuss alternate strategies for handling anxiety. (Eg.: exercise, relaxation techniques and exercises, stress management classes, directed conversation (by nurse), assertiveness training)


7. Set limits on manipulation or irrational demands.


8. Help establish short term goals that can be attained.


9. Reinforce positive responses.


10. Initiate health teaching and referrals as indicated:

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Nursing Care Plan For Depressive Disorder

Depressive disorder is define as mood disorder which characterized by symptoms that persist over minimum 2-week period. The Nursing Care Plan for depressive disorder will address the problem according the criteria of disorder, like;  anhedonia, insomnia or hypersomnia, depressed mood, fatique or energy lost, significant change in weight, feeling of worthlessness or guilty, diminished concentration or indecisiveness, increase or decreased psychomotor activity, recurrent death or suicidal thought.

The common symptoms of depressive disorder are apathy, sadness, hopelessness, helplessness, worthlessness, guilty, sleep disturbance, anger, etc. Sometimes followed by other symptoms like; thoughst of death, fatique, decreased libido, psychomotor agitation, dependency, passiveness, spontanious crying without apparent cause.

Before giving nursing care plan for patient with depressive disorder, there are things should asses, including;

1. History of onset of symptoms.
2. The presence of non-mood psychiatric disorder.
3. Interpersonal and coping abilities.
4. Level of stressor.
5. Presence and or level of suicidal ideation.
6. Presence of comorbid subtance, alcohol and medication.
7. Patient resources and social support systems.
8. Physical examination to rule out possibility of the presence of medical ilness.

Key Nursing Interventions for Depressed Patients;

1. Accept patients where they are and focus on their strengths.
2. Reinforce decision making by patients.
3. Never reinforce hallucinations or delusions.
4. Respond to anger theraupeutically.
5. Spend time with withdrawn patients.
6. Make decision for patients that they are not ready to make for them self.
7. Involve patients in activities in which they can experience success.

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Nursing Care Plan For Acute Head Injury

Acute head injury result from a trauma to the head leading to brain injury or bleeding within the brain, It's can make edema and hypoxia. Head injury cases is the leading cause of death in the first four decades of life. A head injury also called Traumatic Brain Injury (TBI) is classified by brain injury type; fracture, hemorrhage (epidural, subdural, intracerebral or subarachnoid) and trauma.

The management or nursing care plan (NCP) for patient with an acute head injury are divided on the several levels including prevention, pre-hospital care, immediate hospital care, acute hospital care, and rehabilitation.

In order to give accurate nursing care plan to the patients, The nurses should understand the principles behind medical treatments. It focuses on the evidence based practice that nurses use in assessing, intervening and managing a severe head injury.
A. Assessment Findings on Acute Head Injury

Possible causes of acute head injury are assault, automobile accident, blunt trauma, fall and penetrating trauma. The medical team should be perform serious and critical care to handle this cases, So that they can finding correct assessment may happened to the patients such as:

• Disorientation to time, place or person
• Unequal pupil size, loss of pupillary reaction
• Decreased LOC
• Paresthesia
• Otorrhea, rhinorea, frequent swallowing.

To quickly asses a patient's level of consciousness and to uncover baseline change, use the Glasgow Coma Scale. If the patient has already applied with an endotracheal tube and can't response verbally, use the abbreviation "T" score.


B. Diagnostic Evaluation for Acute Head Injury

The doctors are who responsible to the patient in the emergency department, they will order some examination trough CT scan or MRI (possible for hemorrhage, cerebral edema, or shift of midline structure), EEG (may reveal seizure activity), ICP monitoring (possible increased of ICP) and skull X-ray (may be fracture).

C. Nursing Diagnose in Acute Head Injury

• Ineffective tissue perfusion (cerebral)
• Risk for Injury
• Decreased intracranial adaptive capacity.

D. Treatment of Acute Head Injury

• Cervical collar (until neck injury is ruled out)
• Craniotomy; surgical incision into te cranium (may be necessary to evacuate a hematoma or evacuate contents to make room for swelling to prevent herniation)
• Oxygen (O2) Therapy; intubation and mechanical ventilation (to provide controlled hyperventilation to decrease elevate ICP)
• Restricted oral intake for 24 to 48 hours
• Ventriculostomy; insertion of a drain into the ventricles (to drain CSF in the presence of hydrocephalus, which may occur as a result of head injury; can also be used to monitor ICP).

E. Drug Therapy Options for Head Injury Cases

• Analgesic; codein phosphate
• Anesthetic; Lidocin (Xylocaine)
• Anticonvulsant; Phenytoin (Dilantin)
• Barbiturate; pentobarbital (Nembutal), if unable to control ICP with diuresis
• Diuretic; mannitol (Osmitrol), furosemide (Lasic) to combat cerebral edema
• Dopamine (Intropin) to maintain cerebral perfusion pressure above 50 mmHg (if blood pressure is low and ICP is elevated)
• Glucocorticoid; dexamethasone (Decadron) to reduce cerebral edema
• Histamin-2 (H2) receptor antagonist such as cimetidine (tagamet), ranitidine (Zantag), famotidine (Pepcid), nizatidine (Axid)
• Mucosal barriel fortifier; sucralfate (Carafate)
• Posterior pituitary : vasopressin (Pitressin) if client develops diabetes insipidus.

F. Planing and Goal on Nursing Care Plan

• The patient will have improved cerebral perfusion
• The patient will have decreased ICP
• The patient will have remain free from injury.

G. Implementation of Nursing Care Plan Procedure

1. Assest neurologic and respiratory status to monitor for sign of increased ICP and respiratory distress
2. Monitor and record vital sign and intake and output, hemodynamic variables, ICP, cerebral perfusion pressure, specific gravity, laboratory studies, and pulse oximetry to detect early sign of compromise.
3. Observe for sign of increasing ICP to avoid treatment delay and prevent neurologic compromise
4. Assess for CSF leak as evidenced by otorhea or rinorrhea. CSF leak could leave the patient at risk for infection
5. Assess for pain. Pain may cause anxiety and increase ICP
6. Check cough and gag reflex to prevent aspiration
7. Check for sign of diabetes insipidus (low urine specific gravity, high urine output) to maintain hydration
8. Administer I.V fluids to maintain hydration
9. Administer Oxygen to maintain position and patency of endotracheal tube if present, to maintain airway and hyperventilate the patient and to lower ICP
10. Provide suctioning; if patient is able, assist with turning, coughing, and deep breating to prevent pooling of secretions
11. Maintain postion, patency and low suction of NGT to prevent vomiting
12. Maintain seizure precautions to maintain patient safety
13. Administer medication as prescription to decrease ICP and pain
14. Allow a rest period between nursing activities to avoid increase in ICP
15. Encourage the patient to express feeling about changes in body image ot allay anxiety
16. Provide appropriate sensory input and stimuli with frequent reorientation to foster awarness of the environtment
17. Provide means of communication, such as a communcation board to prevent anxiety
18. Provide eye, skin, and mouth care to prevent tissue damage
19. Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown.

H. Evaluation of Goals in the Nursing Care Plan

• The patient has improved LOC
• The patient hasdoest not exhibit signs of increased ICP
• The patient hasremains free from injury

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