Nursing Diagnosis: Altered Tissue Perfusion related to hypothermia secondary to frostbite, as evidenced by insensitivity, blisters, severe pain in the affected area, hard or waxy-looking skin, and low body temperature. This will facilitate gastric emptying and reduce the risk of aspiration after feeding. There are 4 types of nursing diagnoses: risk-focused, problem-focused, health promotion-focused, or syndrome-focused. - Lack of suitable environments. The patient will successfully expectorate sputum. Discuss with the patient the short term and long-term goals of weight gain. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). Encourage the patient to use a tissue to cover the mouth and nose when coughing or sneezing. Health care providers should obtain a detailed travel history for patients being evaluated with fever and acute respiratory illness. St. Louis, MO: Elsevier. Suctioning is necessary when patients cannot cough out secretions properly due to weakness, thick mucus plugs, or extensive or tenacious mucus production. While everyone coughs occasionally to clean their throat, several diseases might induce more regular coughing. Ask the patient to repeat or demonstrate the self-administration details to you. The nursing diagnosis can be mental, spiritual, psychosocial, and/or physical. Desired Outcome: The patient will have suitable ventilation as demonstrated by a respiration rate within age-related parameters, the elimination of retractions, accessory muscle use and grunting, normal breath sounds, and oxygen saturation of greater than 94%. Also includes Vasodilation from either pharmaceutical, pharmacologic, or toxic substances. Aspiration of food in adults and unfamiliar objects in children. There are two types of bronchitis: Acute bronchitis is ussually caused by a viral infection and may begin after a cold. To allow the patient to relax while at rest and to facilitate effective stress management. Refractory asthma is a severe type of asthma that is non-reversible and does not respond to usual medical treatments for asthma. Teach the patient, significant others, and the family how to properly treat the wound, including handwashing, wound cleaning, changing the dressing, and applying topical treatments. Explain what COPD is, its types (emphysema, chronic bronchitis, or refractory asthma). Encourage the patient to cough to expectorate thick sputum. An increased pulse or breathing rate, as well as a loud, high-pitched crowing breath sound (stridor), indicate impaired breathing pattern. A full list of NANDA-I-approved nursing diagnoses can be found here. Outcomes and Planning - In this third step of the nursing process, the nurse develops a care plan drawing on information from the nursing diagnosis. It is a tool to help gather information and determine what type of doctor to see in order to have a more productive visit with the goal of getting the correct diagnosis sooner. Ascertain the patients responsiveness to activities. Increased heat loss Includes accidental hypothermia. Nursing care plans: Diagnoses, interventions, & outcomes. Problem-focused and risk diagnoses are the most difficult nursing diagnoses to write because they have multiple parts. Cold war history . The patient may be more relaxed with the elevated head of the bed, sleeping in a recliner, or leaning forward towards an overbed desk with pillow support. Assess the willingness of the patients caregiver to follow the recommended nutritional guidelines. Administer the prescribed COPD medications (e.g. A whirlpool bath is utilized to encourage blood flow to the affected area, remove dead tissue, allow for normal blood flow, and help to avoid infection. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. As directed by the doctor, administer respiratory medicines and oxygen. Intentional An induced state in order to preserve optimum neurologic functions. Bronchodilators: To dilate or relax the muscles on the airways. Smoking cessation: Quitting smoking is one of the crucial steps to combat COPD. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Nursing Diagnosis: Impaired Breathing Pattern related to laryngo tracheobronchial obstruction secondary to croup as evidenced by a barking cough, stridor on inspiration, hoarseness, and significant respiratory retraction. It is a state wherein the bodys core temperature falls below the normal limits of 36C. Patients can also experience chest tightness and excessive sputum production. To treat worsening or severe hypothermia. A score of 0 indicates that the fetus is not experiencing any respiratory distress, while a score between 7-10 indicates severe respiratory distress. Reduce the patients tension and over-stimulus. Minimizes the potential entry points for opportunistic pathogens. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. These diagnoses drive possible interventions for the patient, family, and community. They are also prone to worsening of the above signs and symptoms for several days. The goal of care involves life saving strategies and they are: Further In-patient care. Bowel movement and urine production return to normal as the patients intake of food and liquids is gradually increased. Teach deep breathing exercises and relaxation techniques. She found a passion in the ER and has stayed in this department for 30 years. This intervention makes the treatment selection easier. Smoking cessation may stop or slow down the progression of COPD. Chronic obstructive pulmonary disease or COPD. Nursing diagnoses handbook: An evidence-based guide to planning care. Surgical intervention: Lung volume reduction surgery, lung transplant, bullectomy (removal of bullae or large air spaces) are the most common surgical procedures performed to treat COPD. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Alternate periods of physical activity with 60-90 minutes of undisturbed rest. She received her RN license in 1997. drug class, use, benefits, side effects, and risks) to treat COPD. Alpha-1-antitrypsin deficiency: A small number of COPD patients has this genetic disorder where in there is a deficiency of the AAt, a protein that the, Higher risk of recurrent respiratory infections: COPD patients are highly vulnerable to bacteria and viruses that may cause infection. In cases of. Refer the patient to physiotherapy / occupational therapy team as required. Medical asepsis stops the spread of microorganisms and lowers the possibility of nosocomial infections. This intervention will help in speeding up the patients recovery. 3 Frostbite injuries would warrant surgical debridement to avoid gangrene development. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. It usually lasts for a week and usually causes a blocked nose followed by a running nose, sneezing, a sore throat and a cough. Some occupations also involved being exposed to chemical vapors and fumes. Tobacco smoking: Most COPD cases in developed countries are caused by smoking. Assess the patient for a potential infection source such as burning urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines. Impaired thermoregulation Associated with failure of the thermoregulation function of the hypothalamus. They range from the common cold to more severe illnesses like COVID-19, malaria, or AIDS. Monitoring of cardiac rhythm for identification of life-threatening arrythmias. Oftentimes, nurses will monitor the problems while the medical providers prescribe medications or obtain diagnostic tests. It focuses on the overall care of the patient while the medical diagnosis involves the medical aspect of the patients condition. Implementation - This is the part of the nursing . A smoking cessation team can provide further help and advice on how to stop smoking and can also monitor the patients progress when he/she is back in the community. Elevate the head of the bed if the patient has shallow respirations. Angiotensin-converting enzyme (ACE) inhibitors, Dizziness Nursing Diagnosis and Nursing Care Plan, Renal Calculi Nursing Diagnosis and Nursing Care Plan. During the acute period of his or her condition, bedrest is maintained to reduce metabolic requirements and conserve energy for recuperation. Nursing care plans: Diagnoses, interventions, & outcomes. 7. Second hand smoking, marijuana smoking, and pipe smoking can also cause COPD. This is accomplished by placing the damaged area in a whirlpool heated to 37 to 40 degrees Celsius for 30 to 45 minutes, or until the tips of the injured section flush. Collaborative problems are ones that can be resolved or worked on through both nursing and medical interventions. There are 4 types of nursing diagnoses according to NANDA-I. Frostbite wounds make the patient more prone to infection. To confirm the presence of an infection and its causative agent. Chronic obstructive pulmonary disease (COPD) is a long-term lung disease that involves the obstruction of airflow due to an inflammation of the lungs. Chemical irritants and allergens can exacerbate mucus production and bronchospasm. Saunders comprehensive review for the NCLEX-RN examination. A nursing assessment for people with hypothyroidism includes: 5. 6. Please follow your facilities guidelines and policies and procedures. The problem statement explains the patients current health problem and the nursing interventions needed to care for the patient. This is because the issue is serious and can put your life at stake. Learn how your comment data is processed. Explain the importance of coughing up phlegm. According to NANDA, some of the most common nursing diagnoses include pain, risk of infection, constipation, and body temperature imbalance. Consistency is essential to a successful treatment outcome. This will promote thermoregulation and avoid impaired circulation. St. Louis, MO: Elsevier. However, it is an essential tool that promotes patient safety by utilizing evidence-based nursing research. We and our partners use cookies to Store and/or access information on a device. As an Amazon Associate I earn from qualifying purchases. Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation between 88 to 92%, and verbalize ease of breathing. Evaluate the patients skin color, warmth, and capillary refill. As a result, the alveolar walls are unable to absorb oxygen normally, which then affects the oxygen level of the blood. Assess the usefulness of inspiratory muscle exercise. She received her RN license in 1997. Help the patient to select appropriate dietary choices to follow a high caloric diet. This technique attempts to promote relaxation and recovery as quickly as possible. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.. RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. Placed the To facilitate Nursing. To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity. The patients respiration rate will remain within the normal or target limits. According to NANDA-I, the simplest ways to write these nursing diagnoses are as follows: Problem-Focused Diagnosis related to ______________________ (Related Factors) as evidenced by _________________________ (Defining Characteristics). They are just as beneficial to nurses as they are to patients. A syndrome diagnosis refers to a cluster of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions. There are 4 types of nursing diagnoses according to NANDA-I. Pulmonary tuberculosis can induce a little patch of bronchopneumonia to diffuse severe inflammation, necrosis, pulmonary edema, and lung fibrosis. Patients who have diseases that are airborne could also require airborne and droplet precautions. This intervention generates resistance against outflowing air to avoid airway compression or constriction, assisting in air distribution through the lungs and relieving or reducing shortness of breath. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. Assess the patients mouth for white plaques. The rate of increase in body temperature should not exceed a few degrees per hour. Although these are big risk factors, not all smokers suffer from COPD. Someone caught in a winter storm; homeless man without proper shelter). Measurement of core temperature through the esophageal, rectal or bladder for more accurate readings. Taking over-the-counter medication, and drinking plenty of fluids can relieve the symptoms. Exposing the frostbitten area to direct or dry heat can cause further damage. While the highest score for APGAR is between 7-10 and indicates good fetal well-being, the Silverman and Andersen Index scoring is the opposite. The patient will remain free from infection, as evidenced by normal vital signs and absence of signs and symptoms of infection. Explain to the patient the hazards of smoking in further detail, especially secondhand smoke. Assess the patients vital signs every hour or more frequently if needed. Damaged or widened airways (Bronchiectasis), Inflammation of the tiny airways of the lung (, Reflux of the laryngopharynx (stomach acid flows up into the throat), Eosinophilic bronchitis without asthma (airway inflammation not caused by asthma), Clusters of inflammatory cells in different parts of the body, most commonly the lungs (Sarcoidosis), Severe scarring of the lungs due to an unidentified reason (Pneumofibrosis idiopathic).

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