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Nursing Action for Client’s with Alzheimer’s disease (AD)

Alzheimer’s disease (AD) is a progressive, irreversible, degenerative neurologic disease that begins insidiously and is characterized by gradual losses of cognitive function and disturbances in behavior and affect. It is important to note that AD is not a normal part of aging.

Nursing Action for Client’s with Alzheimer’s disease (AD)

  • Encourage patient to participate in simple activities or hobbies.
  • Provide emotional support to the patient and his family.
  • check the the patient’s vital signs every qh
  • Use easy-to-understand sentences to convey messages.
  • Keep mealtimes simple and calm; avoid confrontations.
  • Monitor the patient’s fluid and food intake to detect imbalances.
  • Prevent burns by serving typically hot food and beverages warm.
  • Daily Monitor patient hygiene care such as mouth care face care and etc
  • Provide emotional support to reinforce a positive self-image.
  • Encourage patient to participate diffrent kind of Sociel activities.
  • Promote rest period without any noise.
  • Prevent falls and other accidents by removing obvious hazards and providing adequate lighting; install handrails in the home.

 

Nursing care Plan for Client with Angina pectoris

Angina pectoris is a chronic syndrome in which the client had suffered the typical chest pain like pressure, or feel heavy in the chest that often radiating to the left arm that arise at the time of the activity and immediately lost when the activity stops. (Prof. Dr. H.M. Sjaifoellah Noer, 1996)

Nursing care Plan for Client with Angina pectoris

  • Assess for vital signs and symptoms of pain such as facial grimacing, rubbing of neck or jaw, reluctance tomove, increased blood pressure, and tachycardia. Note onset, duration,location, and pattern of pain.
  • Use a pain rating scale toassess the patient’s perception of the pain’sseverity.
  • Administer sublingual nitroglycerin as ordered.
  • Instruct the patient to notifya nurse immediately whenexperiencing pain. Have the patient stop current activity,and place him on bed rest ina semi- to high Fowler’s position.
  • Administer oxygen asordered.
  • Obtain a 12-lead ECG immediately during acute chest pain
  • Give as per Order IV morphine in small doses to relieve pain and decrease preload.

Nursing intervention for Acute respiratory distress syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) is a severe form of acute lung injury characterized by sudden and progressive pulmonary edema, increasing  bilateral infiltrates,  hypoxemia unresponsive to oxygen supplementation, and the absence of an elevated left atrial pressure.

Nursing intervention for Acute respiratory distress syndrome (ARDS)
Closely monitor the patient; frequently assess effectiveness of treatment (eg, oxygen administration, nebulizer therapy, chest physiotherapy, endotracheal intubation or tracheostomy,mechanical ventilation, suctioning, bronchoscopy).
•Consider other needs of the patient (eg, positioning, anxiety, rest).
• Identify any problems with ventilation that may cause an anxiety reaction: tube blockage, other acute respiratory problems (eg, pneumothorax, pain), a sudden decrease in the oxygen level, the level of dyspnea; or ventilator malfunction.
• Sedation may be required to decrease the patient’s oxygen consumption, allow the ventilator to provide full support of ventilation, and decrease the patient’s anxiety.
• If sedatives do not work, paralytic agents (used for the shortest time possible) may be administered (with adequate sedation and pain management); reassure the patient that paralysis is a result of the medication and is temporary; describe the purpose and effects of the paralytic agents to the patient’s family.
•Closely monitor patients on paralytic agents: ensure that the patient is not disconnected from ventilator and that all ventilator and patient alarms are on at  all times, provide eye care, minimize complications related to neuromuscular blockade, anticipate the patient’s needs regarding pain and comfort.

Refrence
S. C., Bare, B.
G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth’s
textbook of medical-surgical nursing (12th ed.). Philadelphia:
Lippincott Williams & Wilkins.

Nurse Understand about Electrolytes

Electrolytes help regulate water distribution, govern acid-base balance, and transmit nerve impulses. They also contribute to energy generation and blood clotting.

Potassium (K)
Main intracellular fluid (ICF) cation
Regulates cell excitability
Permeates cell membranes, thereby  affecting the cell’s electrical status
Helps to control ICF osmolality and, conequently, ICF osmotic pressure

Magnesium (Mg)
A leading ICF cation
Contributes to many enzymatic and metabolic processes, particularly protein
synthesis
Modifies nerve impulse transmission
and skeletal muscle response (Unbalanced Mg concentrations dramatically affect neuromuscular processes.)

Phosphorus (P)
Main ICF anion
Promotes energy storage and carbohydrate, protein, and fat metabolism
Acts as a hydrogen buffer

Sodium (Na)
Main extracellular fluid (ECF) cation
Helps govern normal ECF osmolality (A shift in Na concentrations triggers a fluid
volume change to restore normal solute and water ratios.)
Helps maintain acid-base balance
Activates nerve and muscle cells
Influences water distribution (with chloride)

Chloride (Cl)
Main ECF anion
Helps maintain normal ECF osmolality
Affects body pH
Plays a vital role in maintaining acid base balance; combines with hydrogenions to produce hydrochloric acid.

Calcium (Ca)
A major cation in teeth and bones;
found in fairly equal concentrations in ICF and ECF
Also found in cell membranes, where it helps cells adhere to one another and
maintain their shape
Acts as an enzyme activator within cells  (Muscles must have Ca to contract.)
Aids coagulation
Affects cell membrane permeability and firing level

Bicarbonate (HCO3–)
Present in ECF
Primary funcion is regulating acid-base balance

Nursing Care Plan for Clients with Fluids/Electrolytes imbalance

Nursing Care Plan for Clients with Fluids/Electrolytes imbalance:

Maintain patient IV.
• Monitor intake and output.
• Assess skin and mucous membranes for signs of hypovolemia.
• Measure specific gravity if indicated.
• Assess for signs of hypervolemia (eg, pulmonary crackles, neck vein
distention).
• Measure serum electrolytes if indicated

Refrence
. American Society of PeriAnesthesia Nurses: Standards of PeriAnesthe-
sia Nursing Practice. Thorofare, NJ: American Society of PeriAnesthe-
sia Nurses, 2006
. McCarthy EJ: Ventilation perfusion relationships. AANA J 55(5), 1987
. Nagelhout J, Zaglaniczny K: Nurse Anesthesia, 4th ed. Philadelphia, PA:
WB Saunders, 2010
. MacRae MG: Closed claims studies in anesthesia: a literature review and
implications for practice. AANA J 75(4):267–275, 2007

 

 

Nursing Interventions for Clients with Oxygenation/Ventilation

• Monitor respiratory rate and breathing pattern every 15 min and PRN.
• Assess weaning parameters before extubation.
• Monitor end-tidal CO2 and pulse oximetry of mechanically ventilated
patients.
• Encourage patient to cough and deep-breathe.
• Elevate head of bed if not contraindicated.
• Use jaw thrust, head tilt, or oral, oropharyngeal, or nasopharyngeal airway to
maintain airway.
• Stimulate patient every few minutes (eg, call name, touch).
• Administer antiemetic as indicated.
• Position patient on side; suction and maintain airway if patient is vomiting.

Reference:

. American Society of PeriAnesthesia Nurses: Standards of PeriAnesthe-
sia Nursing Practice. Thorofare, NJ: American Society of PeriAnesthe-
sia Nurses, 2006
. McCarthy EJ: Ventilation perfusion relationships. AANA J 55(5), 1987
. Nagelhout J, Zaglaniczny K: Nurse Anesthesia, 4th ed. Philadelphia, PA:
WB Saunders, 2010
. MacRae MG: Closed claims studies in anesthesia: a literature review and
implications for practice. AANA J 75(4):267–275, 2007

Nursing Care Plan for Hyperthermia(Fever) related to Dengue

  • Assess every four hours the patient’s oral temperature
  • Ask the patient to remove blankets or heavy clothes
  • Use cool compress to the forehead , behind neck, and between the axilla and inguinal skin folds for the patient
  • Administer ordered antipyretics to the patient for a temperature greater than 38 C
  • Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated)
  • Explain to the patient and family sign of bleeding, and immediately report if bleeding occurs
  • Encourage and offer oral fluid intake every two hours to the patient
  • Give and oral hygiene aids.
  • Encourage low caloric diet intake
  • Nurse will instruct the patient to limit activates
  • Fan can be used
  • Sponge bathe will be applied if temperature still high

Nursing Action/Management for Client with (hyperglycemia) Diabetes Mellitus

  • Take and record vital signs
  • Monitor the temperature
  • Assess skin turgor and mucous membranes for signs of dehydration
  • Encourage the patient to increase fluid intake
  • Administer IVF as ordered by the Doctor
  • Administer anti-pyretic as prescribed by the Doctor.
  • Discuss eating habits and encourage diabetic diet as prescribed by the Doctor
  • Document actual weight, do not estimate.Note total daily intake including patterns and time of eating.
  • Auscultation bowel sounds, record the existence of abdominal pain / abdominal bloating, nausea, vomit that has not had time to digest food, maintain a state of fasting according to the indication.
  • Consult  dietician/physician for further assessment and recommendation regarding food preferences and nutritional support
  • Discuss with patient the need for activity
  • Promote energy conservation techniques by discussing ways of conserving energy while bathing, transferring and so on.
  • Provide adequate ventilation
  • Provide comfort and safety
  • Instruct patient to perform deep breathing exercises
  • Instruct client to increase Vitamins A, C and D and protein in her diet.
  • Instruct also patient to increase iron in diet
  • Administer oxygen as ordered.
  • Measure and record urine output hourly; report urine output less than 30ml for 2 consecutive hours.
  • Assess neurological status.
  • Monitor for hypoglycemia.
  • Assess serum ketones / acetone levels.

Standardized Hypoglycemia(Low Blood Sugar) Nursing Care Plan

  • Check blood sugar level on the onset of symptoms and recheck again after treatment within 15 to 30 minutes (until the blood sugar level is within or more 100mg/dl).
  • Administer fast- acting sugar containing food/ drink i.e. orange juice or candy.
  • After ingestion of simple sugars, the client may pursue a small snack or if it is meal time, he may consume his meal right away.
  • Encourage client to verbalize the signs and symptoms he felt during the onset and tell him to familiarize himself of these symptoms.
  • Assess for familial history of diabetes, medications taking, exercise and diet program and other essential data from the client.
  • Emphasize to take or wear any identification card notifying that he has a medical condition and it should have significant numbers like his physician or family members and medications, if there is any.
  • Educate client to monitor blood glucose regularly and should take with him any sugar containing food every time he would go out for work or any activity.

Standardized Nursing care plan for Diarrhea

  • Monitor intake/output,daily weight,calorie count as appropriate
  • If diarrhea is severe,recommend liquid diet
  • Assess pt usual weight,dietary preferences,and usual pattern of bowel elimination
  • Encourage high-calorie,high-protein,low residue diet in small,frequent meals(yogurt,poultry,custard,cooked vegetables)
  • If diarrhea is severe,recommend liquid diet.
  • Encourage foods high in potassium as appropriate(bananas,baked potatoes)
  • Monitor serum potassium,and other electrolytes.
  • Encourage intake plenty of fluid.
  • Assess bowel sounds and abdomen for rigidity.
  • Assess frequency,consistency,and volume of stoolling and document
  • Administer anti diarrheal medication as orderd.
  • Encourage pt to alternate rest and activity periods