Nursing Care Plan for Pancreatitis

Nursing diagnosis: risk for deficient Fluid Volume/Bleeding Risk factors may include Excessive losses—vomiting, gastric suctioning Increase in size of vascular bed (vasodilation effects of kinins) Third-space fluid transudation, ascites formation Alteration of clotting process, hemorrhage Possibly evidenced by (Not applicable; presence of signs and symptoms establishes an actual diagnosis) Desired Outcomes/Evaluation Criteria—Client Will Hydration Maintain adequate hydration as evidenced by stable vital signs, good skin turgor, prompt capillary...

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Nursing Care Plan for Dementia

Nursing diagnosis: risk for Injury/Trauma Risk factors may include Inability to recognize or identify danger in environment, impaired judgment Disorientation, confusion, agitation, irritability, excitability Weakness, muscular incoordination, balancing difficulties, disturbed perception (e.g., missing chairs, steps) Seizure activity Possibly evidenced by: (Not applicable; presence of signs and symptoms establishes an actual diagnosis) Desired Outcomes/Evaluation Criteria—Family/Caregiver(s) Will Safe Home Environment Recognize potential risks...

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Nursing Care Plan for Hemodialysis

Nursing diagnosis: risk for deficient Fluid Volume Risk factors may include Ultrafiltration Fluid restrictions, actual blood loss—systemic heparinization or disconnection of the shunt Possibly evidenced by (Not applicable; presence of signs and symptoms establishes an actual diagnosis) Desired Outcomes/Evaluation Criteria—Client Will Hydration Maintain fluid balance as evidenced by stable vital signs, good skin turgor, moist mucous membranes, absence of bleeding, and appropriate weight. Nursing intervention with rationale: 1. Measure all sources...

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Nursing Care Plan for Urinary Diversion

Nursing diagnosis: risk for infection Risk factors may include Inadequate primary defenses—break in skin or incision, reflux of urine into urinary tract Possibly evidenced by (Not applicable; presence of signs and symptoms establishes an actual diagnosis) Desired Outcomes/Evaluation Criteria—Client Will Immune Status Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile. Knowledge: Infection Control Verbalize understanding of individual causative or risk factors. Demonstrate techniques or lifestyle changes to...

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Nursing Care Plan for Prostatectomy

Nursing diagnosis: acute Pain related to irritation of the bladder mucosa; reflex muscle spasm associated with surgical procedure or pressure from bladder balloon (traction) Possibly evidenced by Reports of painful bladder spasms Facial grimacing, guarding, restlessness Autonomic responses Desired Outcomes/Evaluation Criteria—Client Will Pain Level Report pain is relieved or controlled. Appear relaxed and sleep and rest appropriately. Pain Control Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation. Nursing...

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Nursing Care Plan for Rheumatoid Arthritis

Nursing diagnosis: acute/chronic Pain related to injuring agents—distention of tissues by accumulation of fluid/inflammatory process, destruction of joint Possibly evidenced by Reports of pain, discomfort; fatigue Self-narrowed focus Distraction behaviors; autonomic responses Guarding, protective behavior Desired Outcomes/Evaluation Criteria—Client Will Pain Level Report pain is relieved or controlled. Appear relaxed and able to sleep, rest, and participate in activities appropriately. Pain Control Follow prescribed pharmacological regimen. Incorporate...

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Nursing Care Plan for Cancer

Nursing diagnosis: acute/chronic Pain related to disease process—compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation, metastasis to bones; side effects of various cancer therapy agents Possibly evidenced by Reports of pain Self-focusing, narrowed focus Alteration in muscle tone; facial mask of pain Distraction/guarding behaviors Autonomic responses, restlessness (acute pain) Desired Outcomes/Evaluation Criteria—Client Will Pain Level Report maximal...

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Nursing Care Plan for Pediatric Considerations

Nursing diagnosis: acute/chronic Pain related to injuring agents—biological, chemical, physical, psychological Possibly evidenced by Verbal cues Changes in appetite and eating, sleep pattern Guarding, protective behavior; restlessness, moaning, crying, irritability Autonomic responses Desired Outcomes/Evaluation Criteria—Child Will Pain Level Report or indicate pain is relieved or controlled. Manifest decreased restlessness and irritability. Demonstrate age-appropriate blood pressure (BP), pulse, and respiratory rates. Pain Disruptive...

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Nursing Care Plan for Total Joint Replacement

Nursing diagnosis: knowledge deficit related to lack of exposure or recall, information misinterpretation Possibly evidenced by Questions, request for information, statement of misconception Inaccurate follow-through of instructions, development of preventable complications Desired Outcomes/Evaluation Criteria—Client Will Knowledge: Disease Process Verbalize understanding of surgical procedure and prognosis. Correctly perform necessary procedures and explain reasons for the actions. Nursing intervention with rationale: 1. Review disease process,...

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Nursing Care Plan for Burns

Nursing diagnosis: risk for Infection Risk factors may include Inadequate primary defenses—destruction of skin barrier, traumatized tissues Inadequate secondary defenses—decreased Hgb, suppressed inflammatory response Environmental exposure, invasive procedures Possibly evidenced by (Not applicable; presence of signs and symptoms establishes an actual diagnosis) Desired Outcomes/Evaluation Criteria—Client Will Burn Healing Achieve timely wound healing free of purulent exudate and be afebrile. Nursing intervention with rationale: 1. Implement...

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Nursing Care Plan for Urinary Tract Infection (UTI)

Urinary tract infections (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra. Approximately 20% to 25% of women have a UTI sometime during their lifetime, and acute UTIs account for approximately 7 million healthcare visits per year for young women. About 20% of women who develop a UTI experience recurrences. Women are more prone to UTIs than men because of natural anatomic variations. The female urethra is only about 1 to 2 inches in length, whereas the male urethra is 7 to 8 inches long....

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Nursing Care Plan for Pneumonia

Pneumonia is an infection of the lungs involving alveoli that are in contact with bronchioles or complete lobes. The disease is identified by the causative agents that may be bacterial, viral, fungal, or protozoan and may be termed lobar or bronchopneumonia. Nursing Diagnosis: Ineffective airway clearance related to decreased energy and fatigue resulting in decreased coughing and accumulation of secretions; tracheobronchial secretions related to inflammation resulting in increased mucus accumulation. Ineffective breathing pattern related to pain...

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Nursing Care Plan for Kidney Stones (Renal Calculi)

Kidney stones (calculi) are formed of mineral deposits, most commonly calcium oxalate and calcium phosphate; however, uric acid, struvite, and cystine are also calculus formers. Renal calculi vary in size, with 90% of them smaller than 5 mm in diameter; some, however, grow large enough to prevent the natural passage of urine through the ureter. Calculi may be solitary or multiple. Approximately 80% of these stones are composed of calcium salts. Other types are the struvite stones (which contain magnesium, ammonium, and phosphate), uric acid stones,...

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Nursing Care Plan for Gunshot Wound

Penetrating trauma from a gunshot wound (GSW) can cause devastating injuries. The most commonly injured organs and tissues are the intestines, liver, vascular structures, spleen, and intrathoracic structures. Evaluating injuries is difficult; it is important to determine the type of weapon, energy dissipated from the weapon, firing range of the weapon at the time of injury, and characteristics of the injured tissue. Gunshot wound can lead to the need for extensive débridement, resection, or amputation. Among the many complications are sepsis, exsanguination,...

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Nursing Care Plan for Hyperthermia

Nursing diagnosis: Hyperthermia related to increased metabolic rate, illness; dehydration; direct effect of circulating endotoxins on the hypothalamus, altering temperature regulation Possibly evidenced by Increase in body temperature higher than normal range Flushed skin, warm to touch Increased respiratory rate, tachycardia Desired Outcomes/Evaluation Criteria—Client Will Thermoregulation Demonstrate temperature within normal range and be free of chills. Experience no associated complications. Nursing intervention with rationale: 1. Monitor...

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