Nursing Care Plan for Deviations in Growth Patterns

Deviations in intrauterine growth patterns not only increase the risk of morbidity and mortality in the early newborn period, but may also have long-term implications for altered growth and development and for altered CNS function and learning disabilities in childhood.

This general plan of care is designed to facilitate optimal nursing management of the infant with deviations in intrauterine growth and is to be used in conjunction with the CPs: The Neonate at Two Hours to Two Days of Age, and The Preterm Infant, as appropriate. Growth deviations are classified as SGA, intrauterine growth retardation/restriction (IUGR), and LGA.


SGA/IUGR: Any newborn whose birth weight falls at or below the 10th percentile on classification charts, considering local factors (e.g., ethnicity, altitude).

LGA/Macrosomic: Any newborn whose birth weight is at or above the 90th percentile on classification charts, considering local population at any week in gestation (with special attention to determining appropriate gestational age), or who at birth weighs more than 4000 g (8 lb 13 oz).

NURSING PRIORITIES
1. Maintain physiological homeostasis.
2. Prevent and/or treat complications.
3. Identify/minimize effects of birth trauma.
4. Provide family with appropriate information/strategies for meeting short- and long-term needs associated with
growth deviation.

Nursing diagnosis: Impaired gas exchange may be related to Alveolar capillary membrane changes (decreased surfactant levels, retained pulmonary fluid, meconium aspiration), altered oxygen supply (diaphragmatic paralysis/phrenic nerve paralysis, increased intracranial pressure) possibly evidenced by restlessness/irritability; inability to move secretions, tachypnea, cyanosis, hypoxia.

Desired Outcome
1. Display spontaneous, unassisted regular respiratory effort with rate of 30–50/min; and ABGs WNL.
2. Be free of apnea and complications of hypoxia/lung disease.

Nursing intervention with rationale:
1. Review history for abnormal prenatal growth patterns and/or reduced amounts of amniotic fluid, as detected by ultrasonography/fundal changes.
Rationale: Low-birth-weight infant or infant with IUGR suffers chronic intrauterine asphyxia, resulting in hypoxia/malnutrition. Fetal contribution to the amniotic pool is reduced in the stressed infant. Macrosomia can be related to maternal diabetes, prolonged pregnancy, heredity, and inappropriate nutrition. Macrosomia in IDM results from excess release of growth hormone (thyroid stimulation), increasing the number of cells and/or organ size throughout the body.

2. Note type of delivery and intrapartal events indicative of hypoxia.
Rationale: Infant with chronic hypoxia will be more susceptible to acidosis/respiratory depression/persistent fetal circulation (PFC) after delivery. Cesarean birth increases risk of excess mucus because thoracic compression by the birth canal does not occur as in a vaginal delivery.

3. Note time/onset of breathing and Apgar scores. Observe ensuing respiratory patterns.
Rationale: The infant with intrapartal asphyxia may present with a delayed onset of respirations and altered respiratory pattern. Apgar scores aid in evaluation of the degree of depression or asphyxia of the newborn at birth and are directly correlated with serum pH/degree of infant acidosis.

4. Assess respiratory rate, depth, effort. Observe and report signs and symptoms of respiratory distress, distinguishing from symptoms associated with polycythemia.
Rationale: Infant with altered growth is more susceptible to respiratory distress associated with chronic asphyxia in SGA infant, inadequate surfactant levels in IDM,

5. Auscultate breath sounds regularly.
Rationale: Presence of crackles/rhonchi reflect respiratory congestion and need for intervention.

6. Suction nasopharynx/endotracheal tube as needed, after first providing supplemental oxygen.
Rationale: Ensures patency of airway, removes excess mucus. Supplemental oxygen reduces hypoxic effect of procedure.

7. Auscultate apical pulse; note presence of cyanosis.
Rationale: Tachypnea, bradycardia, and cyanosis may occur in response to altered oxygen levels.

8. Prevent iatrogenic complications associated with cold stress, metabolic imbalance, and caloric insufficiency.
Rationale: Such complications increase metabolic demands and oxygen needs.

9. Ensure availability of resources in the event complications occur.
Equipment for oxygenation, suction, intubation, assisted ventilation, resuscitation, and chest tube placement must be readily available in the event of severe/prolonged respiratory distress.

10. Monitor transcutaneous oxygen/pulse oximeter readings.
Rationale: Identifies therapy needs/effectiveness.

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Nursing Care Plan for Hysterectomy/TAHBSO

Hysterectomy is the surgical removal of the uterus through an abdominal incision. It may be a total hysterectomy (removal of the uterus and cervix) or panhysterectomy (removal of the uterus, cervix, fallopian tubes and ovaries). It is done to treat endometriosis, tumors (benign and malignant of the cervix, endometrium, or muscle of the uterus), severe abnormal bleeding, and prolapse of the uterus.

Nursing diagnosis for hysterectomy: Body image disturbance related to biophysical factor of hormonal imbalance and loss of body part resulting in loss of childbearing ability and possible sexual dysfunction.

Expected Outcomes: Improved body image evidenced by verbalization of more positive feelings about loss of childbearing function and self-worth; adaptation to hormonal changes with treatment.

Nursing intervention with rationale:
I. Assess for:
1. Knowledge of effect of surgery on sexuality and physiology.
Rationale: Provides information about feeling of loss and meaning to patient.

2. Feelings about changes and effect on femininity, relationships, self-worth.
Rationale: Provides information about impact on personal life.

II. Administer:
1. Hormone (estrogen)
Rationale: Acts to provide estrogen replacement in bilateral oophorectomy

III. Perform or Provide
1. Encouragement to express feelings about changes in life and acceptance by others.
Rationale: Facilitates communication about impact surgery has on lifestyle.

2. Opportunity for makeup and hair grooming.
Rationale: Provides active interest in personal appearance, which enhances self-image.

3. Support and opportunity for interaction with partner and others.
Rationale: Improves and maintains relationships with partner.

4. Encouragement and praise qualities and behaviors that have positive effect on self-image.
Rationale: Supports and reinforces adaptation to loss.

IV. Teach Patient and Family:
1. Inform that may feel depressed and have crying spells following surgery.
Rationale: Response to hormonal changes of vacillation in estrogen and progesterone levels.

2. Inform that menstruation will cease.
Rationale: Effect of total hysterectomy

3. Inform that hot flashes and other menopausal changes may occur.
Rational: Symptoms of surgically induced menopause from bilateral oophorectomy

4. Administration of hormonal therapy.
Rationale: Provides needed and accurate hormone replacement.

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Nursing Care Plan for Low Back Pain

Chronic pain in the lumbar region usually caused by the straining of paravertebral muscles, herniation, and degeneration of the nucleus pulposus, osteoarthritis of the lumbosacral spine.

Nursing diagnosis for low back pain: Chronic pain relater to intermittent physical discomfort and disability caused by degenerative processes, strain, poor body mechanics.

Expected Outcomes: Reduced or relief of pain for extended lengths of time evidenced by absence of muscle spasm and verbalizations that able to manage pain effectively.

Nursing intervention with rationale:
I. Assess for:
1. Location, length and severity of pain, posture, body mechanics (sitting, standing, stooping, walking), what relieves or precipitates back pain.
Rationale: Provides data base for control of and prevention of pain.

II. Administer:
1. Analgesic (aspirin, acetaminophen, ibuprofen)
Rationale: Acts to control pain by interfering with CNS pain pathways.

2. Muscle relaxants (dantrolene)
Rationale: Acts to relax muscle spasm.

III. Perform or Provide:
1. Cold or heat application; massage to area every 4 hours.
Rationale: Provides comfort and relaxation of muscles to ease pain.

2. Bedrest with head elevated and knees flexed.
Rationale: Promotes comfort and relieves tension on back.

3. Pelvic traction continuously in proper body alignment.
Relieves pressure on nerves of lumbosacral area.

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Nursing Care Plan for Pulmonary Embolus

Pulmonary embolism is a condition in which the pulmonary vasculature is blocked by foreign matter such as blood clot, air, tumor tissue, bone, or by needle or catheter. Usually the result of peripheral venous thrombosis, it may lead to pulmonary infarction and pulmonary hypertension. This plan, which includes intervention specific to this condition, may be used in association with thrombophlebitis/thrombosis.

Nursing Diagnoses: Ineffective breathing pattern related to chest pain, decreased lung expansion caused by emboli with severity depending on size and number of vessels occluded. Impaired gas exchange related to altered blood flow caused by obstruction of circulation to the pulmonary vascular bed.

Expected Outcomes: Adequate ventilation evidenced by reduction in dyspnea, hypoxia, respiration within normal baseline limits for rate depth, and ease, ABGs within normal range.

Nursing Intervention
I. Assess for:
A. Respiratory status including history and physical examination especially thrombus/thrombophlebitis of both peripheral and deep veins.
Rationale: Provides data base and baselines.

B. Respiratory rate, depth, ease, dyspnea, tachypnea, tachycardia, cough, chest pain, hemoptysis; crackles, and accentuated pulmonic heart sound on auscultation.
Rationale: Changes indicate whether emboli are small, medium, or massive-sized.

II. Monitor, descibe, record:
A. Vital signs, chest sounds evey 2 to 4 hours, respiratory rate, quality.
Rationale: Indicates any changes in status leading to possible complications.

B. Chest X-ray.
Rationale: May indicate infarction, pulmonary effusion, consolidation.

C. Perfusion and ventilation scanning.
Rationale: Reflects pulmonary circulation and gas movement through lungs; size of clot.

D. Pulmonary angiography.
Rationale: Determines emboli in pulmonary vascular system; filling defect in pulmonary vessels.

E. Arterial blood gas.
Rationale: Decreasd PaO2 level indicates hypoxemia caused by inadequate oxygen supply.

III. Administer:
A. Oxygen via cannula or mask at rate based on ABGs.
Rationale: Provides oxygen to maintain oxygenation of tissues.

IV. Perform/Provide:
A. Bedrest in semi-Fowlers position.
Rationale: Reduces oxygen demand and facilitates chest expansion.

B. Deep breathing exercises, coughing, postural drainage if needed.
Rationale: Promotes adequate breathing pattern and air intake; prevents atelectasis.

C. Stay with patient, give reassurance and emotional support.
Rationale: Reduces anxiety and fear caused by pain and dyspnea.

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High Blood Pressure Makes Pneumonia Deadlier

Elevated blood sugar levels may help predict death in pneumonia patients, researchers say.

The new study included nearly 6,900 patients, average age 60, with community-acquired pneumonia who were admitted to hospitals and private practices in Austria, Germany and Switzerland between 2003 and 2009.

Community-acquired pneumonia, one of the leading infectious diseases in industrialized nations, is a major cause of illness and death, according to background information in the study published online May 29 in the journal BMJ.


Compared to patients with normal glucose levels at admission, those with elevated levels had a higher risk of death within 28 and 90 days. The higher a patient's glucose levels, the greater the risk of death, the investigators said in a journal news release.

The death rate within 90 days was 3 percent for patients without diabetes and normal glucose levels, 10 percent for those without diabetes but with elevated glucose levels, and 14 percent for patients with diabetes, regardless of their glucose levels on admission, the study revealed.

The findings show the necessity of glucose testing and close glucose monitoring after patients with community-acquired pneumonia are discharged from hospital, in order to diagnose diabetes and to prevent further complications, concluded Dr. Philipp Lepper, of the University Hospital of Saarland in Germany, and colleagues.

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Dose of Zinc Helps Sick Babies Recover

A simple, cheap dose of zinc helps the recovery of newborns suffering from bacterial infections such as pneumonia and meningitis, according to an Indian study reported on Thursday in The Lancet.

Doctors gave 10-milligram daily supplements of zinc to 332 babies who were being given antibiotic treatment at hospitals in New Delhi, and compared the outcome against 323 infants who were given a placebo as well as antibiotics.

The three-year probe, running from 2005 to 2008, focussed on babies aged between one week and four months.

Compared to the non-zinc group, children who were given the supplements were 40-percent less likely to experience treatment failure.

This was defined as needing a second course of antibiotics within a week or intensive care, or culminating in death, the study found.

In the zinc group, 34 treatment failures occurred, compared to 55 in the placebo group.
Use of zinc also reduced the number of deaths, but not by a margin considered statistically significant.

"Zinc is an accessible, low-cost intervention that could add to the effect of antibiotic treatment and lead to substantial reductions in infant mortality," said lead researcher Shinjini Bhatnagar from the All India Institute of Medical Sciences.

The benefit would be highest in developing countries where several million children die from infection each year and where second-line antibiotics and intensive care may be unavailable, he said.

Zinc can be easily administered, either as a syrup or as a soluble tablet, according to the investigation.

Previous research has found that zinc supplements help cure diarrhoea and pneumonia in small children younger than five years old.

Still unclear is why zinc works. One theory is that the mineral has a moderating influence on the immune system, preventing over-inflammation that disrupts drug therapy and leads to tissue injury.

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Nursing Research Bowel Elimination Among Elder Adults

Bowel elimination is the end process of digestion resulting from interactions of the central and autonomic nervous systems, and endocrine, gastrointestinal and musculoskeletal systems. Three major bowel elimination problems have been studied and consistently have been shown to affect the older population: constipation, incontinence, and colorectal cancer (American Cancer Society, 2003a; Hogstel, 2001; Memorial Sloan-Kettering Cancer Center, 2003; Vogelzang 1999).

Constipation, defined as the accumulation of feces in the lower intestines with difficulty evacuating this waste, is the most common complaint among older adults (Abrams, Beers, Berkow,&Fletcher, 1995). According to Annells and Koch (2002), laxatives have become the most commonly sought treatment for constipation. More than one third of older adults use weekly laxatives to reduce strain and enhance fecal elimination (Reiss & Evans, 2002). Research findings demonstrate that increasing fiber and fluid in the diet significantly decreases the need for laxative use and stool softeners (Howard, West, & OssipKlein, 2000; Robinson & Rosher, 2002).

Vogelzang (1999) cited seven reasons for constipation in the elderly. Multiple medications (polypharmacy) had been identified as a primary reason for constipation, especially in nursing home residents. Six or more medications have been shown to adversely effect motility of the digestive tract (Vogelzang). Older adults living at home may be at an even higher risk for overdose related to self medication with over-the-counter drugs (Vogelzang). In addition, limited income influences the quality of food purchased and the degree of fiber-rich foods incorporated into the older adult’s diet. Annual income is less than $6,000 in 40%of olderAmericans, leaving them limited funds for groceries. Most do not take advantage of funded food programs. Selection of the same foods is common, leading to a poorly balanced diet (Vogelzang). Non-healthy snacking throughout the day also counteracts appetite as well as bowel regularity. Lack of social interaction, physical inactivity, nausea caused by contaminated food due to unclean food preparation, and inadequate cooking skills also have been identified as contributing factors to risk for constipation (Vogelzang). Constipation can be controlled by a well-balanced diet high in fiber, adequate hydration (at least 6–8 eight ounce glasses of water/day), along with increased activity (Hinrichs, Huseboe, Tang, & Titler, 2001).

Fecal incontinence has been shown to contribute to decreased social activity (Giebel, Lefering, Troidl, & Blochl, 1998). Older adults are embarrassed that incontinence may occur in public, so they tend to limit outside activity with friends and family. There exists a strong correlation between urinary and fecal incontinence (Chassagne et al., 1999). In a survey conducted by Giebel and colleagues, 500 randomly selected older adults in Germany responded to a questionnaire about bowel habits. It was found that 4.8% were unable to control solid stool, whereas 19.6% experienced at least one type of incontinence. Women had more of a problem with pasty or liquid stools. They also experienced an urgent sensation to quickly reach the toilet. Men described soiling their underwear as most problematic. Controlling flatus was also described as a concern. Findings suggest that the lack of control associated with bowel habits plus the reduction in activities necessitate interventions aimed at education about intestinal health and dietary change. Another study done on fecal incontinence enrolling 1,186 older adults 60 years of age and older in a long-term care setting identified five risk factors associatedwith fecal incontinence: (1) history of urinary incontinence, (2) neurological disease, (3) poor mobility, (4) severe cognitive decline, and (5) age greater than 70 (Chassagne et al.). Fecal incontinence associated with impaction and diarrhea occurred in 234 (20%) of the sample. The study showed an association between permanent fecal incontinence and overall poor health in older adults.

In summary, older adults are at risk for developing bowel elimination complications, which may be associated with the physiological changes occurringwith advancing age and lack of screening. Screening for cancer needs to be done on all elderly, regardless of advanced age. Diets high in fiber, adequate hydration, increased activity, and education programs encourage prevention of complications.

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Nursing Care Plan Severe Hypertension | Activity Intolerance

Nursing Diagnosis: Activity intolerance may be related to generalized weakness and imbalance between oxygen supply and demand possibly evidenced by verbal report of fatigue or weakness; abnormal heart rate or BP response to activity; exertional discomfort or dyspnea; and electrocardiogram (ECG) changes reflecting ischemia; dysrhythmias.

Desired Outcomes:
Participate in necessary/desired activities.
Report a measurable increase in activity tolerance.
Demonstrate a decrease in physiologic signs of intolerance.

Nursing Intervention with Rationale:
1. Assess the client’s response to activity, noting pulse rate more than 20 beats/min faster than resting rate; marked increase in BP during/after activity (systolic pressure increase of 40 mm Hg or diastolic pressure increase of 20 mm Hg); dyspnea or chest pain; excessive fatigue and weakness; diaphoresis; dizziness or syncope.
Rationale: The stated parameters are helpful in assessing physiologic responses to the stress of activity and, if present, are indicators of overexertion.

2. Instruct client in energy-conserving techniques; e.g., using chair when showering, sitting to brush teeth or comb hair, carrying out activities at a slower pace.
Rationale: Energy-saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand.

3. Encourage progressive activity/self-care when tolerated. Provide assistance as needed.
Rationale: Gradual activity progression prevents a sudden increase in cardiac workload. Providing assistance only as needed encourages independence in performing activities.

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Nursing Care Plan Hypertension | Acute Headache Pain

Nursing diagnosis: Acute headache pain may be related to increased cerebral vascular pressure possibly evidenced by reports of throbbing pain located in suboccipital region, present on awakening, and disappearing spontaneously after being up and about; reluctance to move head, rubbing head, avoidance of bright lights and noise, wrinkled brow, clenched fists; and reports of stiffness of neck, dizziness, blurred vision, nausea, and vomiting.

Desired Outcomes
Report pain/discomfort is relieved/controlled.
Verbalize methods that provide relief.
Follow prescribed pharmacologic regimen.

Nursing Intervention with Rationale:
1. Determine specifics of pain; e.g., location, characteristics, intensity (0–10 scale), onset/duration. Note nonverbal cues.
Rationale: Facilitates diagnosis of problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy.

2. Encourage/maintain bedrest during acute phase.
Rationale: Minimizes stimulation/promotes relaxation.

3. Provide/recommend nonpharmacologic measures for relief of headache; e.g., cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques (guided imagery, distraction); and diversional activities.
Rationale: Measures that reduce cerebral vascular pressure and that slow/block sympathetic response are effective in relieving headache and associated complications.

4. Eliminate/minimize vasoconstricting activities that may aggravate headache; e.g., straining at stool, prolonged coughing, bending over.
Rationale: Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure.

5. Assist client with ambulation as needed.
Rationale: Dizziness and blurred vision frequently are associated with vascular headache. Client may also experience episodes of postural hypotension, causing weakness when ambulating.

6. Provide liquids, soft foods, frequent mouth care if nosebleeds occur or nasal packing has been done to stop bleeding.
Rationale: Promotes general comfort. Nasal packing may interfere with swallowing or require mouth breathing, leading to stagnation of oral secretions and drying of mucous membranes.

7. Administer medications as indicated: analgesics
Rationale: Reduce/control pain and decrease stimulation of the sympathetic nervous system.

8. Administer Antianxiety agents; e.g., lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium)
Rationale: May aid in the reduction of tension and discomfort that is intensified by stress.

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Nursing Care Plan Preterm Infant | Risk for Impaired Skin Integrity

Nursing diagnosis: Risk for impaired skin integrity may be related tothin skin, fragile capillaries near the skin surface, absence of subcutaneous fat over bony prominences, inability to change positions to relieve pressure points, use of restraints (protecting invasive lines/tubes), alterations in nutritional state.

Desired Outcomes: Maintain intact skin. Be free of dermal injury.

Nursing intervention with rationale:
1. Inspect skin, noting areas of redness or pressure.
Rationale: Identifies areas of potential dermal breakdown, which can result in sepsis.

2. Provide mouth care using saline or glycerin swabs. Apply petroleum jelly to lips.
Rationale: Helps prevent drying and cracking of lips associated with absence of oral intake or the drying effects of oxygen therapy.

3. Avoid application of harsh topical agents; carefully wash off povidone-iodine solutions after procedures.
Rationale: Helps prevent skin breakdown and loss of protective epidermal barrier.


4. Provide range-of-motion exercises, routine position changes, and fleece or flotation pad.
Rationale: Helps prevent possible necrosis related to edema of dermis or lack of subcutaneous fat over bony prominences.

5. Minimize use of tape to secure tubes, electrodes, urine bags, IV lines, and so forth.
Rationale: Removal of tape may accidentally remove epidermal layer, because cohesion is stronger between tape and stratum corneum than between dermis and epidermis.

6. Bathe infant using sterile water and mild soap. Wash only grossly soiled body parts. Minimize manipulation of infant’s skin.
Rationale: After 4 days, skin develops some bactericidal properties because of acid pH. Frequent bathing using alkaline soaps or moisturizers may raise skin pH, compromising normal flora and natural defense mechanisms that protect against invading pathogens.

7. Change electrodes only when necessary.
Rationale: Frequent changing may contribute to skin irritation/dermal injury.

8. Apply antibiotic ointment to nares, mouth, and lips if they are cracked or irritated.
Rationale: Promotes healing of lesions associated with administration of oxygen; reduces risk of infection.

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