NCPs are part and parcel of nursing.
I highly recommend these books which I used extensively when I was still studying.
I presume that the books I listed are readily available in your school library.
If not, GO ASK THEM TO BUY!
This is a random list or books that I remembered to be using.
-Nurse’s Pocket Guide by Doenges, et al (I have this one, very handy. However, most interventions lack rationale)
-Nursing Care Plans by Doenges, et la
-Maternal/Newborn Care Plans by Doenges, et la
-Nursing Diagnosis Manual by Doenges, et la
-Psychiatric Care Plans by Townsend & Doenges
-Nursing Care Plans by Gulanick & Myers (Very clear, extensive)
-Delmar's Pediatric Nursing Care Plans by Karla Luxner
Online NCP Constructor by Elsevier. Very useful. Promise. HERE.
If you are very resourceful, you can also use your medical-surgical books.
Showing posts with label NCP. Show all posts
Showing posts with label NCP. Show all posts
Saturday, February 9, 2008
NCP: Diarrhea, Amoebic Dysentery
Amoebic Dysentery
Need
ELIMINATION PATTERN
Nursing Diagnosis
Diarrhea related to infectious process.
Rationale:
Diarrhea may result from a variety of factors, including intestinal absorption disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. Problems associated with diarrhea, which may be acute or chronic, include fluid and electrolyte imbalance and altered skin integrity. Diarrhea may result from infectious processes or increased intestinal motility such as with irritable bowel disease. Treatment is based on addressing the cause of the diarrhea, replacing fluids and electrolytes, providing nutrition, and maintaining skin integrity.
Source:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=16
Objective of Care
Within my 8 hours of care my patient will be manifest the the following:
a. formed stool;
b. maintain good skin turgor and moist mucous membranes.
Nursing Interventions
1. Assess hydration status.
® Diarrhea can lead to profound dehydration and electrolyte imbalance.
2. Assess for temperature elevation, irritability, vomiting.
® Provides information about signs and symptoms associated with diarrhea.
3. Assess condition of perianal skin.
® Diarrheal stools may be highly corrosive, as a result of increased enzyme content.
4. Assess for fluid loss (dry skin and mucous memebranes, poor turgor).
® Indicates possible dehydration.
5. Encourage fluids.
® Fluids compensate for malabsorption and loss of nutrients.
6. Encourage to eat fiber-rich foods.
® To form consistency of stool.
7. Change diaper frequently as needed and wash area with warm water.
® Protects skin from excretions and secretions that are irritating that can cause skin breakdown.
8. Monitor intake and output.
® To assess for possible dehydration.
9. Avoidance of stimulants (e.g., caffeine, carbonated beverages).
® Stimulants may increase GI motility and worsen diarrhea.
10. Give antidiarrheal drugs as ordered.
® Most antidiarrheal drugs suppress GI motility, thus allowing for more fluid absorption.
11. Discuss proper food handling including proper handwashing
® Prevents transmission or spread of microorganisms to others and contamination of food.
Luxner, Karla, RNC, ND (2005). Delmar's Pediatric Nursing Care Plans 3rd ed.
Thomson Delmar Learning, Clifton Park, New York, USA. p. 136-137
Need
ELIMINATION PATTERN
Nursing Diagnosis
Diarrhea related to infectious process.
Rationale:
Diarrhea may result from a variety of factors, including intestinal absorption disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. Problems associated with diarrhea, which may be acute or chronic, include fluid and electrolyte imbalance and altered skin integrity. Diarrhea may result from infectious processes or increased intestinal motility such as with irritable bowel disease. Treatment is based on addressing the cause of the diarrhea, replacing fluids and electrolytes, providing nutrition, and maintaining skin integrity.
Source:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=16
Objective of Care
Within my 8 hours of care my patient will be manifest the the following:
a. formed stool;
b. maintain good skin turgor and moist mucous membranes.
Nursing Interventions
1. Assess hydration status.
® Diarrhea can lead to profound dehydration and electrolyte imbalance.
2. Assess for temperature elevation, irritability, vomiting.
® Provides information about signs and symptoms associated with diarrhea.
3. Assess condition of perianal skin.
® Diarrheal stools may be highly corrosive, as a result of increased enzyme content.
4. Assess for fluid loss (dry skin and mucous memebranes, poor turgor).
® Indicates possible dehydration.
5. Encourage fluids.
® Fluids compensate for malabsorption and loss of nutrients.
6. Encourage to eat fiber-rich foods.
® To form consistency of stool.
7. Change diaper frequently as needed and wash area with warm water.
® Protects skin from excretions and secretions that are irritating that can cause skin breakdown.
8. Monitor intake and output.
® To assess for possible dehydration.
9. Avoidance of stimulants (e.g., caffeine, carbonated beverages).
® Stimulants may increase GI motility and worsen diarrhea.
10. Give antidiarrheal drugs as ordered.
® Most antidiarrheal drugs suppress GI motility, thus allowing for more fluid absorption.
11. Discuss proper food handling including proper handwashing
® Prevents transmission or spread of microorganisms to others and contamination of food.
Luxner, Karla, RNC, ND (2005). Delmar's Pediatric Nursing Care Plans 3rd ed.
Thomson Delmar Learning, Clifton Park, New York, USA. p. 136-137
NCP: Ineffective Cerebral Tissue Perfusion, Cerebro-vascular Accident (CVA)
Cerebro-vascular Accident (CVA)
Need
ACTIVITY-EXERCISE PATTERN
Nursing Diagnosis
Ineffective cerebral tissue perfusion related to cerebral bleeding secondary to CVA bleed (120cc)
Rationale:
- Cerebrovascular disease refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of the entire cerebrovascular system. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the vessel lumen with transient or permanent effects. Hemorrhagic CVA is caused by other conditions such as a ruptured aneurysm, hypertension or other bleeding disorders.
Source:
Doenges, Marilynn, RN, et al. Nursing Care Plans 6th ed. F. A. Davis Company, Philadelphia, PA, USA. 2002
Objective of Care
Within my 8 hours span of care my patient will be able to have effective cerebral tissue perfusion as evidenced by:
a. improved level of consciousness;
b. stable vital signs.
Nursing Interventions
1. Assess vital signs. Get baseline parameters
® This help deterioration of the patients condition. It gives the opportunity to track changes.
2. Assess oxygenation.
® Oxygenation affects cerebral functioning.
3. Monitor neurological status frequently and compare with baseline.
4. Assess drainage of post operative site.
® Congestion can aggravate increase pressure.
® Assesses trends in the level of consciousness and potential for increased ICP.
5. Evaluate papillary reaction.
® Pupil reactions are regulated by the oculomotor cranial nerve and are useful in determining whether the brainstem is intact.
6. Assess skin color and temperature.
® Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.
7.Position head slightly elevated and in neutral position.
® Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
8. Provide quite, restful environment.
® Continual stimulation can increase ICP. Prevent rebleeding in the case of hemorrhage.
9. Provide passive ROM.
® Promotes collateral circulation.
10. Administer supplemental oxygen.
® Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/ edema formation.
11. Administer medications as indicated.
® Provides pharmacological for the condition.
Doenges, Marilynn, RN., et al (2004). Nurse’s Pocket Guide 9th ed. F.A. Davis Company, Philadelphia, PA, USA
Need
ACTIVITY-EXERCISE PATTERN
Nursing Diagnosis
Ineffective cerebral tissue perfusion related to cerebral bleeding secondary to CVA bleed (120cc)
Rationale:
- Cerebrovascular disease refers to any functional or structural abnormality of the brain caused by a pathological condition of the cerebral vessels or of the entire cerebrovascular system. This pathology either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation by a partial or complete occlusion of the vessel lumen with transient or permanent effects. Hemorrhagic CVA is caused by other conditions such as a ruptured aneurysm, hypertension or other bleeding disorders.
Source:
Doenges, Marilynn, RN, et al. Nursing Care Plans 6th ed. F. A. Davis Company, Philadelphia, PA, USA. 2002
Objective of Care
Within my 8 hours span of care my patient will be able to have effective cerebral tissue perfusion as evidenced by:
a. improved level of consciousness;
b. stable vital signs.
Nursing Interventions
1. Assess vital signs. Get baseline parameters
® This help deterioration of the patients condition. It gives the opportunity to track changes.
2. Assess oxygenation.
® Oxygenation affects cerebral functioning.
3. Monitor neurological status frequently and compare with baseline.
4. Assess drainage of post operative site.
® Congestion can aggravate increase pressure.
® Assesses trends in the level of consciousness and potential for increased ICP.
5. Evaluate papillary reaction.
® Pupil reactions are regulated by the oculomotor cranial nerve and are useful in determining whether the brainstem is intact.
6. Assess skin color and temperature.
® Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.
7.Position head slightly elevated and in neutral position.
® Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
8. Provide quite, restful environment.
® Continual stimulation can increase ICP. Prevent rebleeding in the case of hemorrhage.
9. Provide passive ROM.
® Promotes collateral circulation.
10. Administer supplemental oxygen.
® Reduces hypoxemia, which can cause cerebral vasodilation and increase pressure/ edema formation.
11. Administer medications as indicated.
® Provides pharmacological for the condition.
Doenges, Marilynn, RN., et al (2004). Nurse’s Pocket Guide 9th ed. F.A. Davis Company, Philadelphia, PA, USA
Saturday, February 2, 2008
NCP: Risk for Aspiration, Cerebro-vascular Accident (CVA)
Cerebro-vascular Accident (CVA)
Need
NUTRITIONAL-METABOLIC PATTERN
Nursing Diagnosis
Risk for aspiration related to poor coughing reflex secondary to COPD, CVA
Rationale:
Chronic conditions, including altered consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, use of tube feedings for nutrition, endotracheal intubation, or mechanical ventilation may be encountered in the home, rehabilitative, or hospital settings. Elderly and cognitively impaired patients are at high risk. Aspiration is a common cause of death in comatose patients.
Sources:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=04
Objective of Care
Within my 8 hours span of care my patient will be free from aspiration as evidenced by:
a. patent airway;
b. unlabored breathing.
Nursing Interventions
1. Monitor level of consciousness.
® A decreased level of consciousness is a prime risk factor for aspiration.
2. Assess cough and gag reflexes.
® A depressed cough or gag reflex increases the risk of aspiration.
3. Auscultate bowel sounds to evaluate bowel motility.
® Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. Elderly patients have a decrease in esophageal motility, which delays esophageal emptying. When combined with the weaker gag reflex of elderly patients, aspiration is a higher risk.
4. Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds for development of crackles and/or rhonchi.
® Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness.
5. In patients with endotracheal or tracheostomy tubes, monitor the effectiveness of the cuff.
® An ineffective cuff can increase the risk of aspiration.
6. Keep suction setup available and use as needed.
® This is necessary to maintain a patent airway.
7. Notify the physician or other health care provider immediately of noted decrease in cough and/or gag reflexes or difficulty in swallowing.
® Early intervention protects the patient’s airway and prevents aspiration.
8. Position patients who have a decreased level of consciousness on their sides.
® This protects the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions.
9. Check placement of NGT before feeding.
® A displaced tube may erroneously deliver tube feeding into the airway.
10. Check residuals before feeding. Hold feedings if residuals are high and notify the physician.
® High amounts of residual (>50% of previous hour’s intake) indicate delayed gastric emptying and can cause distention of the stomach leading to reflux emesis.
11. Maintain upright position for 30 to 45 minutes after feeding.
® The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. If the head of the bed cannot be elevated because of the patient’s condition, use a right side-lying position after feedings to facilitate passage of stomach contents into the duodenum.
12. Assist with postural drainage.
® Mobilizes thickened secretions.
Need
NUTRITIONAL-METABOLIC PATTERN
Nursing Diagnosis
Risk for aspiration related to poor coughing reflex secondary to COPD, CVA
Rationale:
Chronic conditions, including altered consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, use of tube feedings for nutrition, endotracheal intubation, or mechanical ventilation may be encountered in the home, rehabilitative, or hospital settings. Elderly and cognitively impaired patients are at high risk. Aspiration is a common cause of death in comatose patients.
Sources:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=04
Objective of Care
Within my 8 hours span of care my patient will be free from aspiration as evidenced by:
a. patent airway;
b. unlabored breathing.
Nursing Interventions
1. Monitor level of consciousness.
® A decreased level of consciousness is a prime risk factor for aspiration.
2. Assess cough and gag reflexes.
® A depressed cough or gag reflex increases the risk of aspiration.
3. Auscultate bowel sounds to evaluate bowel motility.
® Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. Elderly patients have a decrease in esophageal motility, which delays esophageal emptying. When combined with the weaker gag reflex of elderly patients, aspiration is a higher risk.
4. Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds for development of crackles and/or rhonchi.
® Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness.
5. In patients with endotracheal or tracheostomy tubes, monitor the effectiveness of the cuff.
® An ineffective cuff can increase the risk of aspiration.
6. Keep suction setup available and use as needed.
® This is necessary to maintain a patent airway.
7. Notify the physician or other health care provider immediately of noted decrease in cough and/or gag reflexes or difficulty in swallowing.
® Early intervention protects the patient’s airway and prevents aspiration.
8. Position patients who have a decreased level of consciousness on their sides.
® This protects the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions.
9. Check placement of NGT before feeding.
® A displaced tube may erroneously deliver tube feeding into the airway.
10. Check residuals before feeding. Hold feedings if residuals are high and notify the physician.
® High amounts of residual (>50% of previous hour’s intake) indicate delayed gastric emptying and can cause distention of the stomach leading to reflux emesis.
11. Maintain upright position for 30 to 45 minutes after feeding.
® The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. If the head of the bed cannot be elevated because of the patient’s condition, use a right side-lying position after feedings to facilitate passage of stomach contents into the duodenum.
12. Assist with postural drainage.
® Mobilizes thickened secretions.
NCP: Impaired Oral Mucous Membrane, Tonsillitis
Tonsillitis, ATP
Need
NUTRITIONAL-METABOLIC PATTERN
Nursing Diagnosis
Impaired oral mucous membrane related to infectious process as evidenced by inflamed tonsils.
Rationale:
Tonsillitis is a common occurrence during childhood. It occurs when the tonsils become inflamed as the body’s immune system attempts to fight off invading viruses or bacteria. Symptoms of tonsillitis include red, swollen tonsils that can be painful and make swallowing difficult. The tonsils may have whitish spots or white covering on them.
Sources:
http://pediatric.healthcentersonline.com/pediatriccoldflu/tonsillitis.cfm
Objective of Care
Within my 8 hours span of care my patient will be able to achieve the following:
a. demonstrate interventions that promote healthy oral mucosa;
b. show a decrease in symptoms such as temperature in normal range.
Nursing Interventions
1. Note presence of illness, disease or trauma.
® These conditions are most likely to cause inflammation of the tonsils.
2. Determine nutrition and fluid intake.
® Without proper nutrition and hydration the oral mucosa is more vulnerable to damage.
3. Evaluate client’s ability to provide self care.
® Self care places and important part in maintaining integrity of the oral cavity.
4. Review oral hygiene practice.
® Sometimes brushing is not enough or not properly done, professional care should be necessary.
5. Routinely inspect oral cavity for sores, lesions, and or bleeding.
® These are signs that the mucosa is impaired or damage.
6. Encourage fluids.
® To prevent dehydration.
7. Use soft-bristle toothbrush.
® Limit mucosal or gum irritation.
8. Instruct parents in oral hygiene techniques and proper dental care for infants or children.
® Encourages early initiation of good oral health practices and timely intervention for treatable problems.
9. Provide nutritional information.
® To correct deficiencies, reduce irritation/ gum disease, prevent dental caries.
10. Promote general health habits.
® Altered immune response can affect the oral mucosa.
Doenges, Marilynn, RN., et al (2004). Nurse’s Pocket Guide 9th ed.
F.A. Davis Company, Philadelphia, PA, USA
Need
NUTRITIONAL-METABOLIC PATTERN
Nursing Diagnosis
Impaired oral mucous membrane related to infectious process as evidenced by inflamed tonsils.
Rationale:
Tonsillitis is a common occurrence during childhood. It occurs when the tonsils become inflamed as the body’s immune system attempts to fight off invading viruses or bacteria. Symptoms of tonsillitis include red, swollen tonsils that can be painful and make swallowing difficult. The tonsils may have whitish spots or white covering on them.
Sources:
http://pediatric.healthcentersonline.com/pediatriccoldflu/tonsillitis.cfm
Objective of Care
Within my 8 hours span of care my patient will be able to achieve the following:
a. demonstrate interventions that promote healthy oral mucosa;
b. show a decrease in symptoms such as temperature in normal range.
Nursing Interventions
1. Note presence of illness, disease or trauma.
® These conditions are most likely to cause inflammation of the tonsils.
2. Determine nutrition and fluid intake.
® Without proper nutrition and hydration the oral mucosa is more vulnerable to damage.
3. Evaluate client’s ability to provide self care.
® Self care places and important part in maintaining integrity of the oral cavity.
4. Review oral hygiene practice.
® Sometimes brushing is not enough or not properly done, professional care should be necessary.
5. Routinely inspect oral cavity for sores, lesions, and or bleeding.
® These are signs that the mucosa is impaired or damage.
6. Encourage fluids.
® To prevent dehydration.
7. Use soft-bristle toothbrush.
® Limit mucosal or gum irritation.
8. Instruct parents in oral hygiene techniques and proper dental care for infants or children.
® Encourages early initiation of good oral health practices and timely intervention for treatable problems.
9. Provide nutritional information.
® To correct deficiencies, reduce irritation/ gum disease, prevent dental caries.
10. Promote general health habits.
® Altered immune response can affect the oral mucosa.
Doenges, Marilynn, RN., et al (2004). Nurse’s Pocket Guide 9th ed.
F.A. Davis Company, Philadelphia, PA, USA
Nursing Care Plan aka NCP
Appropriate Nursing Diagnosis for Certain Conditions
Cerebrovascular Accident
- Knowledge Deficit
- Impaired Skin Integrity (Pressure Ulcer)
- Risk for Impaired Skin Integrity
- Risk for Aspiration
- Impaired Thermo-regulation
Dengue Hemorrhagic Fever
- Hyperthermia
- Pain
- Knowledge Deficit
- Decreased Cardiac Output
Acute Tonsilo-pharyngitis (Tonsilitis)
- Hyperthermia
- Pain
- Knowledge Deficit
Pneumonia
- Hyperthermia
- Pain
- Knowledge Deficit
Acne
- Disturbed Body Image
- Knowledge Deficit
Surgery (Post-operative)
- Disturbed Body Image
- Knowledge Deficit
- Pain
I'll be updating the list.
Cerebrovascular Accident
- Knowledge Deficit
- Impaired Skin Integrity (Pressure Ulcer)
- Risk for Impaired Skin Integrity
- Risk for Aspiration
- Impaired Thermo-regulation
Dengue Hemorrhagic Fever
- Hyperthermia
- Pain
- Knowledge Deficit
- Decreased Cardiac Output
Acute Tonsilo-pharyngitis (Tonsilitis)
- Hyperthermia
- Pain
- Knowledge Deficit
Pneumonia
- Hyperthermia
- Pain
- Knowledge Deficit
Acne
- Disturbed Body Image
- Knowledge Deficit
Surgery (Post-operative)
- Disturbed Body Image
- Knowledge Deficit
- Pain
I'll be updating the list.
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