nsg care- bn.docx

7/21/2019 Nsg care- BN.docx

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Nursing Diagnosis for

Nephrolithiasis

1. Acute Painrelated to tissue trauma, increased ureteric contraction, edema formation.

2. Impaired Urinary Eliminationrelated to irritation of the kidney / ureter, mechanical

obstruction, inflammation, bladder stimulation by a stone.

3. Risk for DeficientFluid Volume related to neusea, vomiting.

4. Knowledge Deficitrelated to misinformation.

Expected Results

1. Comfort the ain resolved.

2. !maired elimination attern is resolved.

3. "o deficit fluid.

4. #he client $ill oen u re%uests for information.

Nursing Inter!ention for Nephrolithiasis

1. &bserve and record the location, duration, intensity of ain distribution.

2. '(lain the cause of ain.

3. )ake a control gate on the back.

4. #each rela(ation techni%ues.

*. +ive fluid intake 3 ml - 4 ml / day.

. Collaborative rovision of medicines.

. )onitor intake / outut.

0. &bserve urination.

. reare a laboratory urine.


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1. &bservation circumstances bladder.

11. Collaboration laboratory e(amination.

12. &bserve and record abnormalities such as vomiting.

13. )onitor vital signs.

14. +ive a diet based on the rogram.

1*. Collaboration giving intravenous fluids.

1. +ive an e(lanation of the disease rocess.

1. '(lain the imortance of fluid intake 3 - 4 ml / hr.

10. '(lain about diabetes management.

1. iscuss $ith the client / kelguarga about the rule of treatment tyes of food.

2. !nstruct the client to do activity regularly.

Nursing Diagnosis for Dia"etes #ellitus

1. !maired tissue erfusion related to $eakening / decreased blood flo$ to the area

gangrene due to obstruction of blood vessels.

2. !ntegrity of the tissue disorder related to gangrene in the e(tremities.

Nursing Inter!ention for Dia"etes #ellitus

1. !maired tissue erfusion related to $eakening / decreased blood flo$ to the area gangrene

due to obstruction of blood vessels.

+oal 5

eriheral Circulation remain normal.

6esult Criteria 5

alable eriheral ulse strong and regular


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#he color of the skin around the $ound $as not ale / cyanotic

#he skin around the $ound felt hot.

'dema did not occur and in7uries from getting $orse.

8ensory and motor imrovement.

"ursing !ntervention 5

#each the atient to mobili9e

6ational 5 the mobili9ation imroves blood circulation.

#each about the factors $hich can increase blood flo$ 5

'levate feet slightly lo$er than the heart :the osition of elevation at rest;, avoid crossing

legs, avoiding tight bandage, avoid the use of illo$s, hamstrings and so forth.

6ational 5 to increase blood flo$ through so that does not haen edema.

#each about the modification of risk factors such as 5

&;.6ational 5 giving vasodilators $ill increase the dilation of blood vessels so that tissue

erfusion can be imroved, $hile checking blood sugar regularly to kno$ the rogressand state of the atient, to imrove o(ygenation =>& areas ulcer / gangrene.

2. !ntegrity of the tissue disorder related to gangrene in the e(tremities.

+oal 5 #he achievement of the $ound healing rocess.

6esult Criteria 5

ecreased edema around the $ound.

#he resence of granulation tissue.

#he stench of in7ury is reduced.



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#each a distraction and rela(ation techni%ues.

6ational 5 distraction and rela(ation techni%ues can reduce ain felt by atients.


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o #he inability to roduce or consume food or li%uids ade%uately nausea, anore(ia.

o ifficulty che$ing, $eight loss, dryness of mucous membranes.

*. =ygiene

o #he difficulties to imlement self-care activities, deendence on others.

. "eurosensory

o #ingling in hands and feet, s$ollen 7oints

. ain / comfort

o #he acute hase of ain :robably not accomanied by soft tissue s$elling in the

7oints. chronic ain and stiffness :esecially in the morning;.

0. 8ecurity

o 8kin shiny, taut, nodules sub mitaneus

o 8kin lesions, foot ulcers

o #he difficulty in handling the task / household maintenance

o )ild fever settled

o ryness in the eyes and mucous membranes

. 8ocial !nteraction

o amage interaction $ith family or others, the changing role5 isolation.

1. Counseling / @earning

o Family history of rheumatic

o

#he use of health foods, vitamins, cure disease $ithout testing

o =istory ericarditis, valve lesion edge. ulmonary fibrosis, leuritis.

Nursing Diagnosis for %steoarthritis


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1. ain


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imagination, and breath control.'ngage in activities of entertainment that is suitable for

individual situations.

+ive the drug before activity / e(ercise that is lanned as directed.


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attack, $ith sasms of the bronchial musculature, edematous s$elling of the bronchial $all and

increased mucus secretion. !n the initial stage, the atient can be totally symtom-free for long

eriods of time in the intervals bet$een the attacks. ronchial asthma is usually intrinsic :no cause can be

demonstrated;, but is occasionally caused by a secific allergy :such as allergy to mold, dander,dust;.


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o isnea at rest or in resonse to activity or e(ercise.

o >reath $orsened $hen the atient lay suine in bed.

o Bsing the drug ventilator, for e(amle5 raising the shoulders, $iden the nose.

o #he e(istence of $hee9ing breath sounds.

o #he recurrent coughing.

4. Circulation

o #he increasing blood ressure.

o #here is an increasing fre%uency of heart.

o #he color of skin or mucous membranes normal / gray / cyanosis.

o 6edness or s$eating.

*. 'go integrity

o e sensitive to stimuli

o 6estlessness

. "utrition

o

o !nability to eat due to resiratory distress.

o Deight loss due to anore(ia.

. 8osal 6elations

o

o #he limited hysical mobility.

o ifficult to talk or stammering.


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o #he e(istence of deendence on others.

0. 8e(uality

o ecrease in libido.

Nursing Diagnosis for &ronchial Asthma

1. !neffective air$ay clearance related to the accumulation of mucus.

2. !neffective breathing attern related to decreased lung e(ansion.

3. !maired nutrition less than body re%uirements related to inade%uate intake.

Nursing Inter!ention for for &ronchial Asthma

1. !neffective air$ay clearance related to the accumulation of mucus.

+oal 5

#he Day of breath effectively.

6esult Criteria 5

8hortness reduced

Coughing reduced

Clients can issue a sutum

Dhee9ing is reduced / lost.

Vital signs $ithin normal limits.



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during the stress / the rocess of acute infection. 6esiratory fre%uency can be slo$ed

do$n and elongated than the e(iration of insiration.


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y 8usan Fralick->all, sy, )8", 6"

Print Article

'o !iew the $ourse %utline and take the exam online( click here)

*or a printer+friendly !ersion of the exam you can print out( complete and mail to

AD,AN$E(click here)

-earning .cope /012

3 contact hour

Expires April 34( 5236

7ou can earn 3 contact hour of continuing education credit in three ways 38 9rade and

certificate are a!aila"le immediately after taking the online test) 58 .end the answer sheet

:or a photocopy8 to AD,AN$E for Nurses( -earning .cope( 5422 ;ori


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Prussia( PA 3402=) 18 *ax the answer sheet to =32+5>?+305=) If faxing or mailing( allow 12

days to recei!e certificate or notice of failure) A certificate of credit will "e awarded to

participants who achie!e a passing grade of >2@ or "etter)

#erion #atters is an appro!ed pro!ider of continuing nursing education "y the

Pennsyl!ania .tate Nurses Association :No) 553+1+%+248( an accredited appro!er "y the

American Nurses $redentialing $enters $ommission on Accreditation)

#erion #atters is also appro!ed as a pro!ider "y the $alifornia &oard of Registered

Nursing :No) 315128 and "y the *lorida &oard of Nursing :No) 154?8)

'he goal of this continuing education offering is to pro!ide the latest information to nurses

a"out systemic lupus erythematosus :.-E8) After reading this article( you will "e a"le to

3) Recogni


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#he causes still elude hysicians, yet it is thought to be associated $ith heredity, viruses,

ultraviolet light e(osure and some drugs. 8@' is characteri9ed by eriods of e(acerbations of

illness, called flares, and eriods of remission. Bnderstanding ho$ to revent and treat flares

hels eole $ith 8@' maintain better health.

%ther *orms of -upus

iscoid luus is a form of luus dermatitis that can be isolated to the skin, $ithout internal

disease. #he dermatitis consists of a red, raised rash that aears on the face, scal or else$here.

#he raised areas may become thick and scaly and may cause scarring. #he rash may last for days

or years and may recur.


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*atigue

Fatigue is a fre%uent and ervasive roblem $ith multile adverse conse%uences for atients

$ith 8@'. < total of *3G-0G of 8@' atients identify fatigue as one of their rimary

symtoms, resulting in decreased %uality of life and increased risk of $ork disability and

healthcare costs.*8ome factors associated $ith the fatigue include decreased aerobic caacity

obesity slee-$ake disturbances and non-restorative slee deression subotimal vitamin

levels and ain, coe(isting fibromyalgia, thyroid disease and anemia.

'hrom"osis

6arely, luus atients can develo very serious, even life-threatening comlications of blood

clotting, :stroke, heart attack, ulmonary embolism;. )ost hysicians and researchers focus on

the role of antihosholiid antibodies :a@; as the most imortant risk factor for thrombosis in

luus. a@ refers to an autoimmune, hyer-coagulable state caused by antibodies forming against

cell membrane hosholiids that rovoke blood clots in both arteries and veins.a@ can be

comlicated by thrombocytoenia :lo$ latelet count; and valvular heart disease.

Potential .ymptoms B $omplications Cith .-E


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sychosis in 8@' can be found :u to *G; as a secondary effect from medication and/or

inflammation of brain tissue, increased intracranial ressure or cerebral thrombosis.

"eurosychiatric systemic luus erythematosus :"8@'; is based uon $hat is already kno$n

of the athogenesis of the disease5 autoantibodies, microvascular disease and the roduction of

inflammatory mediators :i.e., cytokines;. 'ven after scientific e(loration, it is very unlikely a

single biomarker $ill reliably redict all neurosychiatric events. 8troke, headaches and sei9ures

also can be art of the "8@' rofile. Careful treatment often rests $ith steroids and

immunosuressants, although these drug categories can cause sychosis as to(ic side effects.

Infections

!nfections are one of the most common causes of morbidity, hositali9ation and death in atients

$ith 8@'.1

>acterial infections make u the ma7ority of reorted infectious comlications in atients $ith8@'. #he most fre%uent tyes of infection are resiratory, urinary tract and soft tissue infections.

romt treatment of any identified or susected infection is recommended. >asic hygiene and

sanitation, including fre%uent hand $ashing, are the cornerstones of revention of many

infectious diseases. Careful use of immunosuressive theray may lessen infection risk, and

antimalarial medication may have rotective effects against ne$ infections.

Varicella-9oster virus :shingles or heres 9oster; is one of the most commonly reorted viral

infections in 8@'. =eres 9oster may result in $idesread disease in atients $ith 8@' or may

be comlicated by suerinfection and ostheretic neuralgia. !t tends to be a late comlication,

usually aearing five years after 8@' diagnosis and commonly during eriods of inactive ormild 8@' disease activity. 6isk factors for heres 9oster include renal disease, concurrent or

rior malignancy, and a9athiorine and cyclohoshamide :immunosuressant; use. #here are

currently no clear recommendations on the administration of the heres 9oster vaccine in atients

$ith 8@', but it should be offered to atients over age $ith secial attention to timing in

atients $ho may be treated $ith high-dose rednisone or other immunosuressants.

=uman aillomavirus :=V; is a common viral infection in atients $ith 8@'. Domen $ith

8@' have a threefold increase in the rate of abnormal cervical cytology smears comared $ith

the general oulation. rohyla(is $ith the vaccine is offered even though recommendations for

use are not forthcoming.

#he annual incidence of influen9a in the general oulation is under 2G ho$ever, the rate of

infection in 8@' atients is not $ell defined. #he vaccine is reventative for many flu strains, yet

less so $ith immunosuressive diseases. #he influen9a vaccine has been sho$n to cause an

increase in autoantibody formation in some atients ho$ever, this does not translate into clinical

flares of luus. +iven the risk of otentially more severe resentations of influen9a in atients


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$ith 8@', yearly vaccination is recommended.

Diagnostics 'ypical B Differential


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antihosholiid antibodies. #he resence of luus nehritis and 6aynaud henomenon strongly

redicts thrombosis. #hese findings hel to identify atients $ho may benefit from rohylactic

theray.

"eurodiagnostic evaluation suorts magnetic resonance imaging over comuted tomograhy

scanning, because subtle areas of ischemia may be seen $ith greater sensitivity. #he most

common findings $ith either study are varying si9es of ischemic 9ones of cortical or subcortical

infarcts, according to the si9e of vessel involved and the mechanism of stroke. < clinical

diagnostic roblem occurs $hen the )6! reveals multile, small signal intensities in the $hite

matter, making it difficult to distinguish bet$een multile sclerosis and 8@'.

'lectroencehalograhy may be helful to confirm the focal oint of an aarently diffuse

encehaloathy in atients $ith 8@'. ''+ is most useful for atients $ith sei9ures $hose cases

are difficult to manage.

Dhen embolic stroke occurs in atients $ith roven or susected 8@', echocardiograhy isobligatory to assess for valvular and other intracardiac lesions. Cardiac emboli also remain the

most likely cause of non-embolic stroke syndromes of 8@' atients. #ransesohageal

echocardiograhy may be helful in select cases.

)uscle $eakness in atients $ith 8@' may result from inflammatory myoathy, medication-

induced myoathy, neuromuscular 7unction dysfunction, neuroathies or from other

musculoskeletal disturbances. 'lectromyograhy may distinguish inflammatory vs. non-

inflammatory myoathy. eriheral nerve dysfunction in 8@' resents as single or multile

nerve disturbance, often $ith sensory and motor symtoms. #he tyical findings of each of these

conditions may be demonstrated on nerve conduction studies.

"erve biosy may be helful in determining an initial diagnosis of active vasculitis. )uscle

biosy may rovide the only reliable differentiation bet$een inflammatory and medication-

induced myoathy.

'reatment

#here is no cure for 8@', yet many medications can slo$ and amend some symtoms. #reatment

of 8@' should be rovided in cooeration $ith a consulting rheumatologist. #heraeutic

intervention deends on the severity of an acute attack. "8

are used for less-threatening symtoms.

Corticosteroids are used in lo$-dose oral, high-dose oral or high-dose !V regimens, according to

the severity of otential organ damage. revious steroid theray may rovoke an adrenocortical

deficiency state, thus comlicating the course of 8@' $ith otential roblems in blood ressure,

glucose, $ater and electrolyte regulation. 8teed medication aroach is erformed in luus

nehritis because of its fre%uency, severity and %uantifiable imrovement or deterioration, but


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the same treatment aroaches are generally alied to other organ systems, including the central

and eriheral nervous systems and muscular disease.11,12

!f there is mild disease or symtoms that affect %uality of life $ithout organ-threatening disease,

the follo$ing may be rescribed5

H acetaminohen or "8

H antimalarial drugs such as hydro(ychloro%uine :e.g., la%uenil;

H lo$-dose corticosteroids and/or toical corticosteroid creams or ointments

H sunscreens, sun block and toical steroid creams for skin rashes or hotohobia. 13

!f there is more severe disease, the follo$ing may be rescribed5

H corticosteroids, such as rednisone

H immunosuressive medicines, such as a9athiorine, belimumab, cyclohoshamide,

mycohenolate mofetil or methotre(ate11-13

H anti-> cell theray, such as ritu(imab

!f there has been arterial or venous thrombosis or if the atient has antihosholiid antibody

syndrome, an anticoagulant may be rescribed :e.g., asirin, $arfarin;.

#reatment and revention recommendations include5

H yearly influen9a shot

H neumococcal vaccination :every five years;

H regular a smears to screen for cervical dyslasia caused by =V :there are currently no

recommendations or data regarding the use of the =V vaccine in atients $ith 8@' outside the

recommendations for the general oulation;H #> skin test rior to starting immunosuressive agents and treatment $ith isonia9id :!"=; for

atients $ith latent #> infection

H heatitis > serology at baseline in all atients

H heatitis C serology at baseline in atients $ith risk factors

H =!V serology at baseline in atients $ith risk factors

H diet/sulement recommendations include the use of fish oils, fla( seed :to decrease

inflammation; and ='< :dehydroeiandrosterone; to reduce steroid needs.

%ngoing #anagement of .-E

hysical theray often is beneficial for atients $ith 8@'. #he role of the hysical theraist is to

assess each atient and to determine an effective lan of care to hel reduce ain, stiffness and

inflammation as $ell as to imrove 7oint range of motion and functional mobility.14

Jey oints to kee in mind $hen develoing a # rogram for a atient $ith 8@' include5

H '(ercises should be individuali9ed. For atients $ith redominant 7oint ain or arthritis,

techni%ues used in rheumatoid arthritis may be helful.


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H


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#anagea"le $ondition

8ystemic luus hails as a multifaceted disease $ith otentially life-threatening comlications, yet

it can be $ell-managed for a lifetime of controllable symtoms. #here are many diagnostic

indicators and treatments available to eole of all ages, in varying degrees of the disease.

8cientists are finding ne$ genetic information associated $ith this autoimmune disease and

trends for effective treatment emerge daily. hysicians indicate that luus atients can live a

otentially tyical life $ith modifications to lifestyle, diet and treatment otions.

References

1. orner #, +iesecke C, @isky . )echanisms of >cell autoimmunity in 8@'.Arthritis Res

Ther.21113:*;5243.

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