Nursing Care Plan for Diverticulitis

Diverticulitis occur when fecal material becomes lodged in these pouches causing inflammation and bacterial invasion.

Nursing Diagnosis: Pain related to physical injuring agents (bacterial invasion) causing edema, irritability, spasm of colon.

Expected Outcomes: Relief or control of pain evidenced by verbalization that pain reduced or absent.

Nursing intervention with rationale:
I. Assess for:
A. Intermittent abdominal pain in left lower quadrant, cramping.
Rationale: Indicates diverticulosis.

B. Severity, type of pain, referred back pain, abdominal guarding, flexed knees, mass in left lower quadrant.
Rationale: Data for possible diverticulitis.

II. Administer:
A. Analgesic (acetaminophen, aspirin, codeine)
Rationale: Acts to reduce pain by interrupting CNS pain pathways.

B. Anticholinergic (propatheline).
Rationale: Acts to control muscle spasm.

III. Perform/Provide
A. Bedrest, reduced stimuli
Rationale: Reduces pain perception.

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Nursing Care Plan Gestational Diabetes Mellitus | Risk for Fetal Injury

Nursing Care Plan for Gestational Diabetes Mellitus

Nursing Diagnosis: Risk for fetal injury related to elevated maternal serum glucose levels, changes in circulation.

Desired Outcomes: Display normally reactive NST and negative OCT and/or CST. Be full-term, with size appropriate for gestational age.

Nursing intervention and rationale:
1. Determine White’s classification for diabetes; explain classification and significance to client/couple.
Rationale: Fetus is at less risk if White’s classification is A, B, or C. The client with classification D, E, or F who develops kidney or acidotic problems or PIH is at high risk. As a means of determining prognosis for perinatal outcome, White’s classification has been used in conjunction with (1) evaluation of diabetic control or lack of control and (2) presence or absence of Pederson’s prognostically bad signs of pregnancy (PBSP), which include acidosis, mild/severe toxemia, and pyelonephritis. The National Diabetes Data Group Classification, which includes diabetes mellitus (type I, insulin-dependent; type II, non–insulin-dependent), impaired glucose tolerance, and gestational diabetes mellitus, has not yet had prognostic significance in predicting perinatal outcomes.

2. Note client’s diabetic control before conception.
Rationale: Strict control (normal HbA1c levels) before conception helps reduce the risk of fetal mortality and congenital anomalies.

3. Assess fetal movement and FHR each visit as indicated. Encourage client to periodically count/record fetal movements beginning about 18 weeks’ gestation, then daily from 34 weeks’ gestation on.
Rationale: Fetal movement and FHR may be negatively affected when placental insufficiency and maternal ketosis occur.

4. Monitor fundal height each visit.
Rationale: Useful in identifying abnormal growth pattern (macrosomia or IUGR, small or large for gestational age [SGA/LGA]).

5. Monitor urine for ketones. Note fruity breath.
Rationale: Irreparable CNS damage or fetal death can occur as result of maternal ketonemia, especially in the third trimester.

6. Provide information and reinforce procedure for home blood glucose monitoring and diabetic management.
Rationale: Decreased fetal/newborn mortality and morbidity complications and congenital anomalies are associated with optimal FBS levels between 70 and 96 mg/dL, and 2-hr postprandial glucose level of less than 120 mg/dL. Frequent monitoring is necessary to maintain this tight range and to reduce incidence of fetal hypoglycemia or hyperglycemia.

7. Monitor for signs of pregnancy-induced hypertension (PIH) (edema, proteinuria, increased blood pressure).
Rationale: About 12%–13% of diabetic individuals develop hypertensive disorders owing to cardiovascular changes associated with diabetes. These disorders negatively affect placental perfusion and fetal status.

8. Provide information about possible effect of diabetes on fetal growth and development.
Rationale: Helps client to make informed decisions about managing regimen and may increase cooperation.

9. Review procedure and rationale for amniocentesis using L/S ratio and presence of PG.
Rationale: When maternal/placental functioning is impaired before term, fetal lung maturity is criterion used to determine whether survival is possible. Hyperinsulinemia inhibits and interferes with surfactant production; therefore, in the diabetic client, testing for presence of PG is more accurate than using L/S ratio.

10. Assist with preparation for delivery of fetus vaginally or surgically if test results indicate placental aging and insufficiency.
Rationale: Helps ensure positive outcome for neonate. Incidence of stillbirths increases significantly with gestation more than 36 wk. Macrosomia often causes dystocia with cephalopelvic disproportion (CPD).

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Nursing Care Plan Gestational Diabetes Mellitus | Risk for Maternal Injury

This nursing care plan for gestational diabetes mellitus is designed for the nursing diagnosis of risk for maternal injury may be related to changes in diabetic control, abnormal blood profile/anemia, tissue hypoxia, altered immune response.

Desired Outcomes: Remain normotensive. Maintain normoglycemia, free of signs/symptoms of ketoacidosis. Be free of complications (e.g., infection, placental separation).

Nursing intervention with rationale:
1. Note White’s classification for diabetes. Assess degree of diabetic control (Pederson’s criteria).
Rationale: Client classified as D, E, or F is at higher risk for complications, as is client with PBSP.

2. Assess client for vaginal bleeding and abdominal tenderness.
Rationale: Vascular changes associated with diabetes place client at risk for abruptio placentae.


3. Monitor for signs and symptoms of preterm labor.
Rationale: Overdistension of uterus caused by macrosomia or hydramnios may predispose client to early labor.

4. Assist client in learning home monitoring of blood glucose, to be done a minimum of 4 times/day.
Rationale: Allows greater accuracy than urine testing because renal threshold for glucose is lowered during pregnancy. Facilitates tighter control of serum glucose levels.

5. Request that client check urine for ketones daily.
Rationale: Ketonuria indicates presence of starvation state, which may negatively affect the developing fetus.

6. Identify for episodes of hyperglycemia.
Rationale: Diet/insulin regulation is necessary for normoglycemia, especially in second and third trimesters, when insulin requirements often double (may quadruple in third trimester).

7. Assess for and/or monitor presence of edema.
Rationale: Because of vascular changes, the diabetic client is prone to excess fluid retention and PIH. The severity of the vascular changes before pregnancy influences the extent and time of onset of PIH.

8. Determine fundal height; check for edema of extremities and dyspnea.
Rationale: Hydramnios occurs in 6%–25% of pregnant diabetic clients; may possibly be associated with increased fetal contribution to amniotic fluid, because hyperglycemia increases fetal urine output.

9. Instruct in insulin administration, as required. Ensure that client is adept at self-administration, either subcutaneously (SC) or with pump, depending on client’s needs or care setting.
Rationale: Insulin requirements are decreased in first trimester, then double and may even quadruple as the pregnancy progresses. Highly motivated and capable clients may do well with a continuous subcutaneous insulin infusion pump to more naturally meet insulin needs.

10. Start IV therapy with 5% dextrose; administer glucagon SC if client is hospitalized with insulin shock and is unconscious. Follow with protein-containing fluids/foods, e.g., 8 oz skim milk when client is able to swallow.
Rationale: Glucagon is a naturally occurring substance that acts on liver glycogen and converts it to glucose, which corrects hypoglycemic state. (Note: Hypertonic glucose [D50] administered IV may have negative effects on fetal brain tissue because of its hypertonic action.) Protein helps sustain normoglycemia over a longer period of time.

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Nursing Care Plan for Circumcision

Circumcision is a surgical procedure in which the prepuce (foreskin) of the penis is separated from the glans, and a portion is excised. This elective procedure is performed in the United States based on parental choice for reasons related to hygiene, religion, tradition, social norms, and culture. It is usually performed at 12–24 hr of age or when the infant is considered physically stable. Frequency of this procedure has declined in recent years to approximately 62%.


NURSING PRIORITIES
1. Provide parents with sufficient information to make an informed choice.
2. Promote comfort and healing.
3. Identify and minimize postoperative complications.
4. Instruct parent(s) in proper care of circumcised infant.

DISCHARGE CRITERIA
1. Void appropriately past procedure.
2. Free of complications.
3. Parent(s) understand care needs and signs/symptoms requiring further evaluation.

Nursing diagnosis: Acute pain related to trauma to/edema of tender tissues possibly evidenced by crying, irritability, changes in sleep pattern, refusal to eat

Desired Outcome:
1. Appear relaxed, appropriately consolable.
2. Resume normal sleeping and eating patterns.

Nursing intervention with rationale
1. Provide pacifier (dipped in sugar, if desired), stroke lightly, and talk gently to infant during procedure. Observe infant response.
Rationale: Provides distraction and sense of reassurance to soothe the infant

2. Remove infant from restraints immediately following procedure. Calm infant by holding, cuddling, dressing, and talking to him. Encourage parents to feed and cuddle infant.
Rationale: A sense of uneasiness occurs because of positioning and restraint. Acute pain occurs at the time of surgical procedure, because the foreskin contains numerous nerve endings. Change of position, freedom of movement, and tactile activities refocus infant’s attention and comfort infant. Feeding may promote relaxation. Note: Infant’s turning head away, increased restlessness, hiccuping suggest overstimulation, which may further distress the infant.

3. Apply petroleum jelly and gauze dressing loosely around glans, as appropriate. Leave in place for at least 24 hr.
Rationale: Protects against adherence to diaper and direct contact with urine.

4. Position infant on side or back, not on abdomen. Loose diaper or use no diaper at all for 24–72 hr following procedure. Note continued placement of plastic rim following circumcision with plastic bell.
Rationale: Prevents friction or pressure on the penis. Plastic rim remains in place for 5–7 days. Plastic bell falls off by itself when glans is healed. Note: Removal of the bell by the healthcare provider may be

5. Avoid use of soaps on penis; clean with clear water.
Rationale: Soap may cause irritation, increasing discomfort, and may cause plastic bell to fall off prematurely.

6. Protect the surgical site from alcohol when caring for umbilicus.
Rationale: Alcohol may cause stinging, adding to infant’s discomfort.

7. Note infant’s behavior following procedure.
Rationale: Acute pain following the procedure may last approximately 30 min, whereas discomfort related to trauma, edema, and irritation from clothing may last for up to 7 days until healing is completed.

8. Assist with dorsal penile nerve block with 1% lidocaine without epinephrine or chloroprocaine (Nesacine).
Rationale: Although it is not used routinely, anesthesia abolishes the pain and distress manifested in the

9. Apply topical agents, e.g., EMLAcream (lidocaine and prilocaine) to penis.
Rationale: Topical agent applied 1-2 hr before procedure may be as effective as nerve block without associated risks.

10. Administer acetaminophen drops as indicated.
Rationale: Helps ease acute pain, enhances effects of calming behaviors.

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Nursing Diagnosis Generalized Anxiety Disorder | Sleep Pattern Disturbance

This care plan is designed for patients with generalized anxiety disorder with a nursing diagnosis of sleep pattern disturbance may be related to psychological stress; and repetitive thoughts possibly evidenced by reports of difficulty in falling asleep/awakening earlier or later than desired; not feeling rested, and dark circles under eyes; frequent yawning.

Desired Outcomes: (1) Verbalize understanding of relationship of anxiety and sleep disturbance; (2) Identify appropriate interventions to promote sleep; and (3) Report improvement in sleep pattern, increased sense of wellbeing, and feeling well-rested.

Nursing intervention with rationale:
1. Determine type of sleep pattern disturbance present, including usual bedtime, rituals/routines, number of hours of sleep, time of arising, environmental needs, and how much of a problem it is to client.
Rationale: Identification of individual situation and degree of interference with functioning determines need for/appropriate interventions.

2. Provide quiet environment, comfort measures (e.g., back rub, wash hands/face, bath), and sleep aids, such as warm milk. Restrict use of caffeine and alcohol before bedtime.
Rationale: Promotes relaxation and cues for falling asleep. Stimulating effects of caffeine/alcohol interfere with ability to fall asleep.

3. Discuss use of relaxation techniques/thoughts, visualization.
Rationale: Promotes reduction of anxious feelings, resulting in improved sleep/rest.

4. Suggest ways to handle waking/not sleeping (e.g., do not lie in bed and think, but get up and remain inactive, or do something boring).
Rationale: Having a plan can reduce anxiety about not sleeping.

5. Involve client in exercise program, avoiding exercise within 2 hours of going to bed.
Rationale: Increases fatigue, promotes sleep but avoids excessive stimulation from activity before bedtime.

6. Avoid use of sedatives, when possible.
Rationale: Sedative drugs interfere with REM sleep and affect quality of rest. A rebound effect may lead to intense dreaming, nightmares, and more disturbed sleep.

7. Administer medications as indicated, e.g., zolpidem (Ambien).
Rationale: Although drug is recommended for short-term use only, it may be beneficial until other therapeutic interventions are successful.

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Nursing Care Plan for Seizure | Risk for Ineffective Airway Clearance |

This care plan is designed for patients suffering from seizure disorder with a nursing diagnosis of risk for ineffective airway clearance related to neuromuscular impairment; tracheobronchial obstruction; and perceptual/cognitive impairment.

Desired Outcome: Maintain effective respiratory pattern with airway patent/aspiration prevented.

Nursing intervention with rationale:
1. Encourage patient to empty mouth of dentures/foreign objects if aura occurs and to avoid chewing gum/sucking lozenges if seizures occur without warning.
Rationale: Reduces risk of aspiration/foreign bodies lodging in pharynx.

2. Place in lying position, flat surface; turn head to side during seizure activity.
Rationale: Promotes drainage of secretions; prevents tongue from obstructing airway.

3. Loosen clothing from neck/chest and abdominal areas.
Rationale: Facilitates breathing/chest expansion.

4. Insert plastic airway or soft roll as indicated and only if jaw is relaxed.
Rationale: If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning/respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue.

5. Suction as needed.
Rationale: Reduces risk of aspiration/asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 min.

6. Administer supplemental oxygen/bag ventilation as needed postictally.
Rationale: May reduce cerebral hypoxia resulting from decreased circulation/oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in/out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem exists (e.g., foreign body/aspiration).

7. Prepare for/assist with intubation, if indicated.
Rationale: Presence of prolonged apnea postictally may require ventilatory support.

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