Nursing Interventions Acute Pain for Myocardial Infarction

Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).
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Acute Pain

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

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Comfort Level
• Medication Response
• Pain Control

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Analgesic Administration
• Conscious Sedation
• Pain Management
• Patient-Controlled Analgesia Assistance

Expected Outcomes

• Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.

Nursing Intervention for Myocardial Infarction

• Observation of the characteristics, location, time, and the course of chest pain.
• Instruct the client to stop activity and rest during an attack.
• Help the client to do relaxation techniques, eg deep breathing, distraction behavior, visualization, or imagination guidance.
• Maintain oxygenation with bicanul example (2-4 lt / min)
• Monitor vital signs (pulse and blood pressure) every two hours.
• Collaboration with the health team in providing analgesic.

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Pneumonia is an inflammation of the lung tissue affecting one or both sides of the chest that often occurs as a result of an infection. Infection can be caused by a lot of different micro-organisms – viruses (eg respiratory syncytial virus), bacteria, fungi (eg histoplasmosis) and parasites. In addition to infection, pneumonia can also be caused by corrosive chemicals breathed into the lungs or toxic smoke inhalation from a fire.

Rarely, pneumonia can result from you breathing in something that you are allergic to. This may be related to a hobby or to your employment. The medical term for pneumonia caused by an allergy is extrinsic allergic alveolitis. An example of this condition is farmer’s lung, caused by breathing in the dust from mouldy hay.

Pneumonia is still a common disease affecting around 1 per cent of the adult UK population each year. Many people die from it every year, most commonly women and especially people over the age of 70. The overall death rate due to pneumonia is currently 5 per cent, ie around 1 in 20 people contracting the condition die from it.

Half of all pneumonia cases are caused by bacteria. The bacteria, known as streptococcus pneumoniae is the main cause of the most typical pneumonia.

www.netdoctor.co.uk

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Pneumonia Nursing Diagnosis :

1. Ineffective airway clearance related to tracheal bronchial inflammation, increased sputum production is characterized by:

• Changes in frequency, depth of breathing
• Abnormal breath sounds
• Dyspnea, cyanosis
• Effective or ineffective cough with / without sputum production.

Effective airway with the following criteria:

• Cough effective
• Breath of normal
• The sound of breathing clean
• Cyanosis

Nursing Interventions:

Assess the frequency / depth of breathing and chest movement
Rational: tachypnea, breathing shallow and asymmetrical chest movements frequently occur
because of discomfort.

Auscultation of lung area, record the time there's an area of ​​decreased airflow and breath sounds
Rational: decrease in blood flow occurred in the area of ​​consolidation with fluid.

Let the effective coughing techniques
Rational: cough is a natural cleaning mechanism for maintaining airway patent.

Sucking as indicated
Rational: stimulate coughing or clearing the airway of mechanical noise on the factors
unable to perform effectively because of cough or a decreased level of consciousness.

Give fluids at least
Rational: liquid (especially warm) mobilizing and removing secretions

Collaboration with physicians for drug delivery as indicated: mukolitik, ex.
Rational: a tool to reduce bronchial spasms with mobilization of secretions, analgesic given to improve the cough by decreasing the discomfort but should be used carefully, because it can reduce cough effort / suppress breathing.

2. Impaired gas exchange related to the oxygen-carrying blood disorder, characterized by impaired oxygen delivery:

• Dyspnea, cyanosis
• Tachycardia
• Nervous / mental changes
• Hypoxia

Nursing Intervention:
Assess the frequency / depth and ease of breathing
Rational: the manifestation of respiratory distress depends on the indication of the degree of lung involvement and general health status.

Observation of the color of skin, mucous membranes and nails. Note the presence of peripheral cyanosis (nail) or central cyanosis.
Rational: nails showed cyanosis vasoconstriction body's response to fever / chills, but cyanosis on the ears, mucous membranes and skin around the mouth indicate systemic hypoxemia.

Assess mental status.
Rational: nervous irritability, confusion and somnolence may indicate cerebral hypoxia or decreased oxygen.

Elevate the head and thrust frequently change position, breathe deeply and cough effectively.
Rationale: This action increases the maximum inspiration, increased spending secretions to improve ventilation ineffective.

Ineffective Airway Clearance related to Bronchiectasis

Ineffective Airway Clearance related to Sinusitis - Nursing Diagnosis and Interventions

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Preoperative and Postoperative Intussusception Nursing Diagnosis and Interventions

Intussusception

Intussusception occurs when a segment of bowel telescopes (similar to closing of a telescope) into a segment just distal to it. It is the most common cause of intestinal (bowel) obstruction (blockage) between 3 months and 6 years of age. The ileocolic (small bowel into the colon) intussusception is the most common type although it may occur anywhere in the small bowel and colon.

Anatomy

• The demarcation between the duodenum (1st part of small bowel) and the jejunum (2nd part of small bowel) is the ligament of Treitz (see Surgery of the Duodenum) (Figure 1)
• The jejunum makes up about one third of the proximal small bowel
• The ileum is the distal two thirds of the small bowel
• The jejunum, ileum, and associated mesenteries (supporting and suspending structures) are attached to the back wall of the abdomen. They are completely covered with peritoneum (single layer of cells that line the surface of the abdomen and bowel)
• The ileum joins the cecum (first part of the colon) in the right lower quadrant at the ileocecal valve near the appendix
• The small bowel possesses an extensive lymphatic network that aids in the absorption of nutrients. It drains from the bowel wall into adjacent lymph vessels and lymph nodes and ultimately getting into larger lymphatics that finally empty into the left subclavian vein. The lymphatics of the small bowel play a major role in immune response (response to infection)

Pathology

• The telescoping process is known as intussusception (Figure 2)
• The leading proximal segment (intussusceptum) almost always telescopes into the distal segment (intussuscipens)
• There may be a leading edge in the form of a polyp, inverted appendiceal stump, Meckel's diverticulum (See Surgery of the Jejunum and Ileum) or tumor
• The leading edge gets caught up in the downstream peristalsis (wavelike action of the bowel wall that propels food) and is pulled into the distal bowel
• In most cases the cause is unknown but viruses are thought to induce hyperplasia (increased size) of Peyer's patches (lymphoid tissue) in the end of the ileum

Intussusception Preoperative Nursing Diagnosis and Interventions

Acute pain related to intestinal invagination

Goal: reduction in pain according to the perceived tolerance of children.

Results Criteria : The child shows no signs of pain or discomfort to a minimum.

Intervention:

• Observation of baby behavior as an indicator of pain, can be sensitive excitatory and highly sensitive to treatment or lethargic or unresponsive.
• Treatment of infants with very soft.
• Explain the causes of pain and reassure parents about the purpose of diagnostic tests and treatment.
• Reassure your child that analgesics are given to reduce pain that is felt.
• Explain about intussusception and intestinal hydrostatic reduction can reduce the intussusception.
• Explain the risk of recurrent pain.
• Collaboration: give analgesics to relieve pain.

Postoperative Intussusception Nursing Diagnosis and Interventions

Acute pain related to surgical incision
.
Goal: reduction in pain according to the tolerance in children.

Results Criteria : The child shows no signs of pain or discomfort to a minimum.

Intervention:

• Avoid palpation operating area when not needed.
• Insert rectal tube if indicated, to free air.
• Push for waste water to prevent distention of urinary vesicles.
• Give oral care to provide comfort.
• Lubrication of the nostrils to reduce irritation.
• Provide a comfortable position on the child if there are no contraindications.
• collaboration:
• Give an analgesic to treat pain.
• Give antiemetics to order for nausea and vomiting.

Nursing Diagnosis Appendicitis : Pain, Impaired skin integrity, Anxiety

DIAGNOSIS
The nurses in the short stay unit identify the following nursing diagnoses for Ms. Lynn after surgery.
• Impaired skin integrity, related to surgical incisions
• Pain, related to surgical intervention
• Anxiety, related to situational crisis

EXPECTED OUTCOMES
The expected outcomes for the plan of care are:
• Incisions will heal without infection or complications.
• Will verbalize adequate pain relief.
• Will verbalize decreased anxiety.
• Returns to preoperative activities.

PLANNING AND IMPLEMENTATION
The following nursing interventions are planned
and implemented for Ms. Lynn.
• Assess pain using a pain scale; provide analgesics as needed.
• Teach pain management following discharge.
• Teach abdominal splinting during coughing, turning, or ambulating as needed.
• Teach home care of incisions.
• Discuss activity limitations as ordered.
• Instruct to report fever or warmth, redness, or drainage from
the incisions.

EVALUATION
On discharge the following evening, Ms. Lynn is fully ambulatory.
Her appetite has returned, and she is tolerating food and fluids
well. Her temperature is normal.The nurse provides Ms. Lynn with
written and verbal information on postoperative care following an
appendectomy.

11 Diabetes Nanda Nursing Diagnosis

Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.[2] This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).

There are three main types of diabetes mellitus (DM).

Type 1 DM results from the body's failure to produce insulin, and presently requires the person to inject insulin or wear an insulin pump. This form was previously referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes".
Type 2 DM results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was previously referred to as non insulin-dependent diabetes mellitus (NIDDM) or "adult-onset diabetes".
The third main form, gestational diabetes occurs when pregnant women without a previous diagnosis of diabetes develop a high blood glucose level. It may precede development of type 2 DM.


Common nursing diagnosis found in Diabetes Mellitus

Imbalanced Nutrition: More than Body Requirements, Fear, Risk for Injury, Activity Intolerance, Deficient Knowledge, Risk for Impaired Skin Integrity, Ineffective Coping, Deficient knowledge (diagnosis and treatment), Disturbed sensory perception: Visual, tactile, Imbalanced nutrition: Less than body requirements, Impaired urinary elimination, Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral, Risk for infection, Sexual dysfunction


13 Diabetes Nanda Nursing Diagnosis by nursing priority

1. Imbalanced Nutrition: Less/More than Body Requirements
2. Ineffective tissue perfusion: Renal, cardiopulmonary, peripheral
3. Impaired urinary elimination
4. Disturbed sensory perception: Visual, tactile
5. Activity Intolerance
6. Ineffective Coping
7. Sexual dysfunction
8. Fear
9. Deficient Knowledge
10. Deficient knowledge (diagnosis and treatment)
11. Risk for Impaired Skin Integrity
12. Risk for Injury
13. Risk for Infection

4 Pneumonia Nursing Diagnosis

What are the nursing diagnosis for pneumonia

Impaired gas exchange related to effects of alveolar-capillary membrane changes.

Ineffective airway clearance related to effects of infection, excessive tracheobronchial secretions, fatigue and decreased energy, chest discomfort and muscle weakness.

Clients with pneumonia may have one or more of the following:

Acute pain related to the effects of inflammations of parietal pleura, coughing

Deficient fluid volume related to increased respiratory rate.

Deficient fluid volume related to fever, infection and increased metabolic rate.

Disturbed sleep pattern related to pain, dyspnea, unfamiliar environment (hospitalization).

Potential for pleural effusion.

According to Medical-Surgical Nursing: Critical Thinking for Collaborative Care 5th ed. Donna D. Ingnatavicius and M. Linda Workman

Nursing Diagnosis List

Nursing Diagnosis for Activity Intolerance
Nursing Diagnosis for Acute Confusion
Nursing Diagnosis for Acute Pain
Nursing Diagnosis for Acute respiratory distress syndrome (ARDS)
Nursing Diagnosis for Alteration in Bowel Elimination : Constipation
Nursing Diagnosis for Altered Sleep
Nursing Diagnosis for Alzheimer's Disease
Nursing Diagnosis for Anemia
Nursing Diagnosis for Angina Pectoris
Nursing Diagnosis for Anxiety
Nursing Diagnosis for Appendicitis
Nursing Diagnosis for ARDS - Acute Respiratory Distress Syndrome
Nursing Diagnosis for Asthma
Nursing Diagnosis for Atrial Septal Defect
Nursing Diagnosis for Bartolinitis
Nursing Diagnosis for Benign Prostatic Hyperplasia BPH
Nursing Diagnosis for Bowel incontinence
Nursing Diagnosis for Bronchopneumonia
Nursing Diagnosis for Cholera
Nursing Diagnosis for Chronic Pain
Nursing Diagnosis for Cirrhosis
Nursing Diagnosis for Colon Cancer
Nursing Diagnosis for Congestive Heart Failure (CHF)
Nursing Diagnosis for COPD
Nursing Diagnosis for Cushing's Syndrome
Nursing Diagnosis for Cystitis
Nursing Diagnosis for Decreased Cardiac Output
Nursing Diagnosis for Deficient Fluid Volume
Nursing Diagnosis for Deficient Knowledge
Nursing Diagnosis for Dementia
Nursing Diagnosis for Diabetes Mellitus
Nursing Diagnosis for Disturbed Body Image
Nursing Diagnosis for Disturbed Sleep Pattern
Nursing Diagnosis for Dysentery
Nursing Diagnosis for Dyspepsia
Nursing Diagnosis for Empyema
Nursing Diagnosis for Encephalitis
Nursing Diagnosis for Endocarditis
Nursing Diagnosis for Excess Fluid Volume
Nursing Diagnosis for Fatigue
Nursing Diagnosis for Glomerulonephritis
Nursing Diagnosis for Goitre
Nursing Diagnosis for Hemorrhagic Stroke
Nursing Diagnosis for Hepatitis
Nursing Diagnosis for Hepatocellular Carcinoma
Nursing Diagnosis for Hydatidiform Mole
Nursing Diagnosis for Hydrocephalus
Nursing Diagnosis for Hyperemesis Gravidarum
Nursing Diagnosis for Hypertension
Nursing Diagnosis for Hyperthermia
Nursing Diagnosis for Imbalanced Nutrition : Less Than Body Requirements
Nursing Diagnosis for Impaired Gas Exchange
Nursing Diagnosis for Impaired Physical Mobility
Nursing Diagnosis for Impaired Skin Integrity
Nursing Diagnosis for Impaired Verbal Communication
Nursing Diagnosis for Ineffective Airway Clearance
Nursing Diagnosis for Ineffective Breathing Pattern
Nursing Diagnosis for Ineffective Coping
Nursing Diagnosis for Ineffective Thermoregulation
Nursing Diagnosis for Ischemic Stroke
Nursing Diagnosis for Kidney Stones / Nephrolithiasis
Nursing Diagnosis for Kwashiorkor
Nursing Diagnosis for Lung Abscess
Nursing Diagnosis for Marasmus
Nursing Diagnosis for Meningitis
Nursing Diagnosis for Myocardial Infarction
Nursing Diagnosis for Myocarditis
Nursing Diagnosis for Myopia
Nursing Diagnosis for Nephrotic Syndrome
Nursing Diagnosis for Osteoarthritis
Nursing Diagnosis for Osteoporosis
Nursing Diagnosis for Peptic Ulcer
Nursing Diagnosis for Placenta Previa
Nursing Diagnosis for Pleural Effusion
Nursing Diagnosis for Pneumonia
Nursing Diagnosis for Poliomyelitis
Nursing Diagnosis for Pregnancy Induced Hypertension
Nursing Diagnosis for Pyelonephritis
Nursing Diagnosis for Risk for Deficient Fluid Volume
Nursing Diagnosis for Risk for Imbalanced Body Temperature
Nursing Diagnosis for Risk for Infection
Nursing Diagnosis for Risk for Injury
Nursing Diagnosis for Scabies
Nursing Diagnosis for Schizophrenia
Nursing Diagnosis for Self Care Deficit
Nursing Diagnosis for Self-Care Deficit
Nursing Diagnosis for Sepsis
Nursing Diagnosis for Sleep Pattern Disturbance
Nursing Diagnosis for Smallpox
Nursing Diagnosis for Spinal Cord Tumor
Nursing Diagnosis for Stroke
Nursing Diagnosis for Tuberculosis
Nursing Diagnosis for Tuberculous Spondylitis
Nursing Diagnosis for Typhoid Fever
Nursing Diagnosis for Urolithiasis
Nursing Diagnosis for UTI Urinary Tract Infections
Nursing Diagnosis for Violence

Impaired Physical Mobility Sample NCP

Impaired physical mobility related to (i.e. ordered bedrest fx, ortho. surgery, stroke, etc.) as evidenced by (i.e. poor skin turgor, unsteady gait, cast, traction, paralysis,etc.)


Planned Nursing Actions/Orders

1. Assess joint mobility, muscle strength, and ability to move at the start of shift and q4hr


2. Teach and monitor ROM exercises q4hr & prn


3. Teach & monitor leg & ankle exercises q4hr & prn


4. Assess for pain-location, quality, & severity q3hr & prn


5. Medicate for pain as ordered prn

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Nursing Diagnosis Ineffective Airway Clearance

Ineffective Airway Clearance

• ( )Actual
• ( )Potential

Related To :

• Atrificial airway
• Excessive or thick secretions
• Inability to cough effectively
• Infection
• Obstruction/restriction
• Pain
• Other

As evidenced by :
Major:

• Ineffective cough.
• Inability to remove airway secretions.

Minor:

• Abnormal breath sounds.
• Abnormal respiratory rate, rythm, depth.

Plan and Outcome

The patient will:

• Maintain patent airway A.E.B.:
  • Clear breath sounds or breath sounds consistent with own baseline.
  • Respirations easy and un-labored.
  • Normal resp. rate.
• Other:

Nursing Interventions

• Assess respiratory rate, depth, rythm, effort, and breath sounds q ___ hours.
• Position: HOB elevated ___ degrees.
• Promote optimum level of activity for best possible lung expansion :
  • Ambulate q ___ for ___ min.
  • Chair q ___ for ___ min.
  • Turn/reposition q ___.
• Suction q ___ hours (and prn) per:
  • Nasal
  • Oral
  • Tracheal
• Encourage fluids when indicated.
• Other:________________

Patient/Significant other signature



__________________________
RN signature