Acute Pain Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Acute Pain related to inflammatory processes, fever and tissue damage.

Acute Pain NANDA Definition : Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Characteristics :

• Patient reports pain
• Guarding behavior, protecting body part
• Self-focused
• Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
• Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
• Facial mask of pain
• Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
• Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)

Goal :
Pain is reduced / no pain

Expected outcomes:

• Report: no pain / controlled
• Demonstrate use of relaxation skills.
• Another method to improve comfort

Nursing Interventions Acute Pain Nursing Care Plan for Peritonitis

Independent:

1. Investigate reports of pain, noting location, duration, intensity (scale 0-10) and characteristics (shallow, sharp, constant)
Rationale: The change in location / intensity not common but may indicate the occurrence of complications. Pain tends to be constant, more intense, and spread upward, pain can occur if local abscess.

2. Maintain semi-Fowler's position as indicated
Rationale: Facilitate drainage of fluids / injury, because of gravity and helps minimize the pain due to movement.

3. Provide comfort measures, sample the back massage, deep breathing, relaxation or visualization exercises.
Rationale: Increase relaxation and may enhance the patient's coping abilities by refocusing attention.

4. Provide oral care. Eliminate unpleasant environmental stimuli.
Rational: Lowering nausea / vomiting that can increase the pressure or pain intrabdomen.


Collaboration:

Give medications as indicated:

• Analgesic
• Antiemetics
• Antipyretic

Rational: Lowering the metabolic rate and irritable bowel because of toxin circulating / local, which helps relieve pain and improve healing.

Reduces nausea / vomiting, which can increase abdominal pain

Lowering of discomfort related to fever or chills.

Ineffective Breathing Pattern Nursing Care Plan for Congestive Heart Failure (CHF)

Ineffective Breathing Pattern

NANDA Definition: The exchange of air inspiration and / or expiration inadequate.

Characteristics:

• Decrease pressure inspiration / expiration
• Decrease in air changes per minute
• Using additional respiratory muscle
• Nasal flaring
• Dyspnea
• Orthopnea
• Changes in chest deviation
• Shortness of breath
• Assumption of 3-point position
• Breathing pursed-lip
• Phase lasts very long expiratory
• Increased anterior-posterior diameter
• Respiratory average / minimum
  
  • Infants: less than 25 or more than 60
  • Age 1-4: less than 20 or more than 30
  • Age 5-14: less than 14 or more than 25
  • Age over 14: less than 11 or more than 24
• Depth of respiration
  • Adult tidal volume of 500 ml at rest
  • Infant tidal volume of 6-8 ml / kg
• Timing ratio
  
• Decrease in vital capacity

Heart Failure





Congestive heart failure is a pathophysiological state of abnormalities in cardiac function so that the heart is not able to pump blood to meet the metabolic needs of tissues and or ability to exist if accompanied by an abnormal elevation of diastolic volumes.

Predisposing factor is a disease that causes decreased ventricular function and the circumstances that limit ventricular filling. Precipitating factors including an increased intake of salt, anti-disobedient treatment of heart failure, AMI (possibly hidden), an attack of hypertension, acute arrhythmia, infection or fever, pulmonary embolism, anemia, thyrotoxicosis, pregnancy and infective endocarditis.


Nursing Diagnosis Ineffective Breathing Pattern for Congestive Heart Failure (CHF)

Goal: The pattern of breathing effectively, after the act of diving in hospital nursing, respiration normal, no additional breath sounds and the use of auxiliary respiratory muscles. And normal blood gas analysis.

Expected Outcomes:

• Regular breathing pattern
• Respiration returned to normal 16-24 times / minute

Nursing Interventions  Ineffective Breathing Pattern for Congestive Heart Failure (CHF)
 
1. Monitor respiratory depth, frequency, and chest expansion.
Rationale: Knowing the level of excess oxygen demand

2. Note the respiratory efforts include the use of auxiliary breathing muscles.
Rationale: Indicates oxygen therapy

3. Auscultation of breath sounds and note if there are additional breath sounds.
Rational: To declare the existence of pulmonary congestion or accumulation of secretions. Indicate the need for further intervention.

4. Elevate the head (position semifowler) and help to achieve a comfortable position. Collaboration of Oxygen and BGA inspection.
Rational: Meningggikan head and semi-Fowler position to reduce the burden and meringakan effort to breathe.

Decreased Cardiac Output - Nursing Care Plan for Angina Pectoris

Decreased Cardiac Output

NANDA Definition :

Inadequate blood pumped by the heart to meet metabolic demands of the body

Related Factors:

Myocardial infarction or ischemia, valvular disease, cardiomyopathy, serious dysrhythmia, ventricular damage, altered preload or afterload, pericarditis, sepsis, congenital heart defects , vagal stimulation, stress, anaphylaxis, cardiac tamponade

Angina Pectoris



Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. Angina is a common presenting symptom (typically, chest pain) among patients with coronary artery disease. A comprehensive approach to diagnosis and to medical management of angina pectoris is an integral part of the daily responsibilities of health care professionals.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Cardiac Pump Effectiveness
Circulatory Status
Tissue Perfusion: Abdominal Organs
Tissue Perfusion: Peripheral
Vital Signs Status


NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Cardiac Care: Acute
Circulatory Care

Client Outcomes

Demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain
Remains free of side effects from the medications used to achieve adequate cardiac output
Explains actions and precautions to take for cardiac disease.

Nursing Intervention for Angina Pectoris

1. Monitor vital signs, eg heart rate, blood pressure.
   Rationale: Tachycardia can occur because of pain, anxiety, hypoxemia, and decreased cardiac output. Changes also occur in blood pressure (hypertension or hypotension) due to cardiovascular response.
2. Record the color and the presence / quality of the pulse.
   Rationale: decreased peripheral circulation when cardiac output falls, making skin color pale or gray (depending on the level of hypoxia) and decreased strength of peripheral pulses.
3. Maintain bed rest in a comfortable position during the acute episode.
   Rationale: Lowering the oxygen consumption / demand, lowering employment and risk of myocardial decompensation.
4. Provide supplemental oxygen as needed
   Rationale: Increase the supply of oxygen to the need to improve myocardial contractility, decrease ischemia, and lactic acid levels.