Nurse Care Plan

Bulimia nervosa (BN) is an eating disorder that is characterized by repeated episodes of binge eating. During binges, the individual rapidly consumes large amounts of high-caloric food (upward of 2000 to 5000 calories), usually in secrecy. The binge is followed by self-deprecating thoughts, guilt, and anxiety over fear of weight gain. Purging is used to relieve these fears. The strict definition used by the Diagnostic and Statistical Manual of Mental Disorders indicates that persons need to have two binge-eating episodes per week for at least 3 months. Most bulimic patients purge by inducing vomiting or using laxatives, but some use excessive exercise and diuretics. The individual is caught in a binge-purge cycle that can recur multiple times each day, several times a week, or at an interval of up to 2 weeks to months. Bulimic patients experience frequent weight fluctuations of 10 pounds or more but are usually able to maintain a near-normal weight.

As persons with anorexia nervosa (AN) mature, they may turn to bulimic behavior as a way of controlling food intake. In contrast to people with AN, bulimic individuals are aware that their behavior is abnormal but conceal their illness because of embarrassment. Persons with bulimia typically have difficulty with direct expression of feelings, are prone to impulsive behavior, and
may have problems with alcohol and other substance abuse. Because they can maintain a near normal weight and, if females, have regular menstrual periods, the problem may go undetected. Bulimic behaviors have been known to persist for decades. Depending on the severity and duration of the condition, there are significant health consequences. Chronic induced vomiting of stomach contents produces volume depletion and a hypochloremic alkalosis. Dizziness, syncope, thirst, orthostatic changes in vital signs, and dehydration occur with volume depletion. Renal compensation for the metabolic alkalosis and volume depletion leads to further electrolyte imbalances, which may predispose the AN patient to cardiac dysrhythmias, muscle cramps, and weakness. Discoloration of the teeth and dental caries are common because of chronic self-induced vomiting. Laxative abuse is a potentially dangerous form of purging, leading to volume depletion, increased colonic motility, abdominal cramping, and loss of electrolytes in a watery diarrhea. Irritation of intestinal mucosa or hemorrhoids from rapid and frequent stools may cause rectal bleeding. When laxative abuse stops, transient fluid retention, edema, and constipation are common.

The cause of BN is unknown, but bulimia is generally attributed to a combination of psychological, genetic, and physiological causes. The onset occurs in late adolescence when the individual has left or is preparing to leave home. Experts suggest that the stress and depression that accompany this transition lead to binging and purging as a way of coping with these changes. Obesity usually precedes the onset of bulimia , and strict dieting usually triggers the binge-purge cycling. Changes in neurotransmitter metabolism, and in particular serotonin, and response to antidepressants suggest a biochemical component to the condition. Cultural pressures toward thinness may also contribute to the onset of bulimia .

Nursing care plan assessment and examination
Bulimic patients often report a family history of affective disorders, especially depression. The patient may describe patterns of weight fluctuation and frequent dieting, along with a preoccupation with food; this cluster of characteristics may be the first sign of bulimia . Complaints such as hematemesis, heartburn, constipation, rectal bleeding, and fluid retention may be the initial reasons the patient seeks healthcare from a primary healthcare provider. Patients may also have evidence of esophageal tears or ruptures, such as pain during swallowing and substernal burning. If patients seek treatment for bulimia , they usually have exhausted a variety of ways to control their binging and purging behavior. A detailed history of dieting, laxative and diuretic use, and the frequency and pattern of binging and purging episodes is essential. You may need to make a direct inquiry about binging and purging patterns for those patients who are seeking help but are ashamed to volunteer the information. Assess which foods and situations are most likely to trigger a binge.

Often, no symptoms are noted on the physical examination. Obtain the patient’s weight and compare it with the normal weight range for age and height. In patients with chronic vomiting, you may notice parotid swelling, which gives the patient a characteristic “chipmunk” facial appearance. Assess the patient for signs of dehydration such as poor skin turgor, dry mucous membranes, and dry skin. Note dental discoloration and caries from excessive vomiting, scars on the back of the hand from chronic self-induced vomiting, and conjunctival hemorrhages. Poor abdominal muscle tone may be evidence of rapid weight fluctuations. Tearing or fissures of the rectum may be present on rectal examination because of frequent enemas. A neurological assessment is important to rule out possible signs of a brain tumor or seizure disorder. Chronic hypokalemia from laxative or diuretic abuse may lead to an irregular pulse or even cardiac arrest and sudden death.

Assess the patient’s current career goals, peer and intimate relationships, psychosexual development, self-esteem, and perception of body image. Pay particular attention to any signs of depression and suicidal ideation and behavior. Assess the patient’s ability to express feelings and anger; determine the patient’s methods for coping with anxiety, as well as impulse control. Assess the family’s communication patterns, especially how the family deals with conflict and solves problems. Assess the degree to which the family supports the patient’s growth toward independence and separation.

Nursing care plan primary nursing diagnosis: Altered nutrition: Less than body requirements related to recurrent vomiting after eating; excessive laxative and diuretic use; and preoccupation with weight, food, or diets.

Nursing care plan intervention and treatment
Patients with bulimia generally do not need hospitalization unless they experience severe electrolyte imbalance, dehydration, or rectal bleeding. The bulimia is usually managed with individual behavioral and group therapy, family education and therapy, medication, and nutritional counseling. Work with the interdisciplinary team to coordinate efforts and refer the patient to the physician to evaluate the need for antidepressants and anti-anxiety medication. Work with the patient to evaluate the effectiveness of antidepressant or antianxiety medications, as well as to explore ways to identify situations that precede depression and anxiety. Work with the dietitian to ensure that the patient is educated about appropriate nutrition and dietary intake. Encourage the patient to participate in individual, family, and group sessions to help the patient develop ways to express feelings, handle anger, enhance self-esteem, explore career choices, and develop sexual identity and assertiveness skills.

Teach the patient to choose correct portion sizes. Encourage the patient to eat slowly and avoid performing other activities such as reading or watching television while eating. Most patients are encouraged not to use diet foods or drinks until a stable body weight is established. Encourage the patient to eat a low-sodium diet to prevent fluid retention. Fluid retention is common until the body readjusts its fluid balance; the patient may need support if she or he experiences edema of the fingers, ankles, and face. As he or she begins to eat and drink normally, support the patient if he or she becomes upset about weight gain and reassure the patient that the weight gain and swelling are temporary. Also encourage the patient to establish a normal exercise routine but to avoid extremes.

The goals of nursing interventions are to enhance self-esteem, facilitate growth in independence, manage separation from the family, develop sexual identity, and make career choices. Explore ways for the patient to identify and express feelings, manage anger and stress, develop assertive communication skills, and control impulses or delay gratification. Help the patient learn ways to cope with feelings of anxiety and depression, as opposed to binging and purging.

Explore ways to reduce the patient’s vomiting, laxative, and diuretic abuse. Some patients respond well to contracting or behavioral management to reduce these behaviors. Educate the family about appropriate nutrition. Explore ways the family can manage conflict, and support the patient’s move toward independence.

Nursing care plan discharge and home health care guidelines
Teach the patient ways to avoid binge-purge episodes through a balanced diet. Discuss effective ways of coping with needs and feelings. Explore ways to identify and handle stress and anxiety. Teach the patient strategies to increase self-esteem. Explore ways to maintain increased independence
and the patient’s own choices.

Cleft lip and cleft palate are facial malformations of the upper lip or palate that are the fourth most common congenital abnormality in the United States. They may appear separately or, more commonly, together. The malformation is a result of a failure of the maxillary and median nasal processes to fuse during the second month of embryonic development. Cleft lip may vary from a small notch to a complete cleft that extends into the base of the nose. When cleft palate occurs alone, it is midline, but when it occurs with cleft lip, it may extend into either side of the soft palate. Related complications of cleft lip/cleft palate include dental malformations, frequent otitis media leading to hearing impairment, speech difficulties, and social isolation due to poor self-image and speech impairments.

A genetic cause for cleft lip/cleft palate is likely; however, environmental exposure to teratogens during critical embryonic development cannot be ruled out. Cleft lip with or without cleft palate is etiologically and genetically distinct from isolated cleft palate. Isolated cleft palate has a greater incidence of associated anomalies. There is a twofold increase in the occurrence of clefts with maternal smoking in early pregnancy.

Nursing care plan physical assessment and examination
A family history of cleft lip or cleft palate may or may not exist. Identical twins are more likely to share the disorder than are fraternal twins. Inquire about teratogen exposure during the first trimester of pregnancy.

The cleft lip may vary from a small notch to a widespread open cleft and may be unilateral or bilateral. The cleft palate also varies in the extent of the malformation: it can involve only the uvula, extend into the soft and hard palate, or be unilateral, bilateral, or midline.

Parents’ and families’ adjustments to an infant with cleft lip or cleft palate may be difficult. The deformity is usually readily observable at birth and often totally unexpected. Support for the family is essential and includes explanations of the surgical procedures and long-term prognosis.

Nursing care plan primary nursing diagnosis: Altered nutrition: Less than body requirements related to inadequate intake.

Nursing care plan intervention and physical treatment
CL and CP are treated with a combination of surgery, speech therapy, and orthodontic work. Surgical repair of a CL is performed within the first month after birth. The repair improves the child’s ability to suck. The optimal time to surgically correct a CP is controversial. Times range from 28 days of life to 18 months. Most surgeons prefer to perform the surgery at an early age, before faulty speech habits develop. The more extensive the surgery required, the later the surgery may occur. Surgical repair of CL (cheiloplasty) is usually uncomplicated with no long-term intervention, other than possible scar revision. Surgical repair of CP (palatoplasty) is more extensive and may require more than one surgery. If the infant has horseshoe defect, surgery may be impossible. A contoured speech bulb attached to the back of a denture appliance to occlude the nasopharynx may help the child speak.

Because of the long-term, multidisciplinary nature of services needed for the child, assist the parents in accessing appropriate support within the health care system. Support the parents before and during the surgical procedure by identifying the positive features of the newborn. Call the infant by name. Current surgical practices provide excellent repairs with minimal scarring. Encourage parents to discuss their feelings about the child’s appearance. Sharing pictures of children with successful CL repairs may help the parents cope with their fears and anxieties.

Depending on the severity of the cleft, children with CL/CP will have problems sucking. Work with the parents and experiment with devices that will improve nutrition, such as different kinds of nipples. The infant may feed better if the parents use a nipple with a flange that occludes the cleft or a large, soft nipple with large holes. Try holding the infant at different positions during feeding (e.g., at a 60- to 80-degree angle). Breastfeeding can be successfully carried out as long as the mother can maintain a seal during nursing. In some nursing pairs, the breast tissue may help form the seal. Otherwise, the mother can use the hand not holding the infant or she can use a molded nipple.

Parents should be allowed to verbalize fears and anxiety about the deformity. The first time parents see their baby, they may experience shock, disappointment, or guilt. If you help them see the baby’s assets, you encourage bonding and acceptance. Allow ample time for the parents to hold the infant to promote bonding. Explain the surgical procedure and postoperative care to parents.

The postoperative management of an infant with a CL focuses on protection of the operative site. Arm restraints prevent the child from rubbing the site and from self-injury. Hang baby toys within reach of the baby’s restrained hands. Many infants are more comfortable in an infant seat rather than lying in a crib. In order to avoid facial contact with the sheets, do not place infants on their stomachs for sleep. Pacifiers are contraindicated, and feeding methods should be designed to reduce any tension on the suture line. Use a cotton-tipped applicator and a cleansing solution to clean the suture line. An antibiotic ointment may be prescribed. Pain should be controlled with analgesic medication and nonpharmacologic strategies such as holding and rocking.

The postoperative management of an infant with a CP centers on prevention of injury to the operative site. Do not place sharp or potentially injurious objects in the child’s mouth (spoons, forks, straws, etc.). Feeding may be done from the side, but self-feeding is prohibited. After feeding, make sure to cleanse the child’s mouth with water or a cleansing solution.

Nursing care plan discharge and home health care guidelines
Teach the parents feeding techniques, how to observe for aspiration, and to bubble the infant frequently. After surgery, teach the parents to avoid putting objects into the infant’s mouth.

Teach the parents to care for the incision and to assess the incision for infection. Explain the importance of keeping the infant’s hands away from the face. Tell the parents that it is important to hold the infant and remove the restraints from time to time.

Teach the parents the signs of pain in an infant, and explore with them nonpharmacologic methods to relieve pain. Review with the parents the analgesic medication dosage, time, and route.

Instruct parents that the child may have more recurrent middle ear infections than other children. The child may also need orthodontic or speech therapy at some time because of the deformity of the mouth and palate.

Cerebrovascular accident (CVA), or “stroke,” is the interruption of normal blood flow in one or more of the blood vessels that supply the brain. The tissues become ischemic, leading to hypoxia or anoxia with destruction or necrosis of the neurons, glia, and vasculature. Cerebrovascular accident is the third leading cause of death in the United States and affects more than 600,000 Americans annually with 160,000 deaths per year. The incidence of first-time strokes is approximately 400,000 per year, but as the population ages, the incidence will increase to 1 million per year by 2050.

A Cerebrovascular accident is an acute neurological injury that occurs because of changes in the blood vessels of the brain. The changes can be intrinsic to the vessel (atherosclerosis, inflammation, arterial dissection, dilation of the vessel, weakening of the vessel, obstruction of the vessel) or extrinsic, such as when an embolism travels from the heart. Although reduced blood flow interferes with brain function, the brain can remain viable with decreased blood flow for long periods of time. However, total cessation of blood flow produces irreversible brain infarction within 3 minutes. Once the blood flow stops, toxins released by damaged neurons, cerebral edema, and alterations in local blood flow contribute to neuron dysfunction and death. Complications of cerebrovascular accident include unstable blood pressure, sensory and motor impairment, infection (encephalitis), pneumonia, contractures, and pulmonary emboli.
Thrombosis, embolism, and hemorrhage are the primary causes of CVA. In cerebral thrombosis, the most common cause of cerebrovascular accident, a blood clot obstructs a cerebral vessel. The most common vessels involved are the carotid arteries of the neck and the arteries in the vertebrobasilar system at the base of the brain near the circle of Willis. Cerebral thrombosis also contributes to transient ischemic attacks (TIAs), which are temporary episodes (10 to 30 minutes) of poor cerebral perfusion caused by partial occlusion of the arterial lumen. A thrombotic cerebrovascular accident that causes a slow evolution of symptoms over several hours is called a stroke in evolution. When the condition stabilizes, it is called a completed stroke.

In an embolic cerebrovascular accident, a clot is carried into the cerebral circulation, usually by the carotid arteries. Blockage of an intracerebral artery results in a localized cerebral infarction. Hemorrhagic cerebrovascular accident results from hypertension, rupture of an aneurysm, arteriovenous malformations, or bleeding disorder. Risk factors thought to cause blood vessel changes that cause vessel walls to be more susceptible to rupture and hemorrhage include elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, cigarette smoking, and a sedentary lifestyle.

Nursing care plan assessment and examination
Determine if the patient is on any medications or abuses intravenous drugs. Elicit a history of neurological deficits. Determine if the patient has experienced an inability to recognize familiar objects or persons through sensory stimuli (agnosia) or any memory loss (amnesia). Elicit a history of speech difficulties such as an inability to understand language or express language (aphasia), poorly articulated speech (dysarthria), or any other form of speech impairment (dysphasia). Determine if the patient has lost the ability to comprehend written words (alexia), read written words (dyslexia), or write (agraphia). Establish a history of visual difficulties such as double vision (diplopia), defective vision, or blindness in the right or left halves of the visual fields of both eyes (homonymous hemianopia), lack of depth perception, color blindness, blindness, blurring on the affected side, or drooping eyelids (ptosis).

Elicit a history of motor difficulties such as the inability to move the muscles (akinesia), inability to perform purposeful acts or manipulate objects (apraxia), poor coordination, impairment of voluntary movement (dyskinesia), muscular weakness or partial paralysis affecting one side of the body (hemiparesis), or paralysis of one side of the body (hemiplegia). Ask if the patient has experienced numbness and ascertain the specific location. Determine if the patient has experienced headaches. Establish a history of personality changes such as flat affect or distractibility.

If the patient appears unconscious, quickly determine his or her airway status and level of consciousness. If the patient is conscious, he or she may be experiencing a TIA or a stroke in evolution. Determine the level of orientation; ability to respond to questions of intellectual functioning; and speech, hearing, and vision ability. Lightly touch the patient’s skin on various parts of the body and ask the patient to identify the location. Apply firm pressure to various parts of the body and observe the patient’s responses. Be sure to test skin sensations sensed in both hemispheres of the body and compare the responses. Begin your assessment by determining the patient’s understanding of your commands and the appropriateness of her or his verbal and nonverbal responses. In left-hemisphere cerebrovascular accident, there is likely to be loss of language ability, although memory may be intact. In right-hemisphere cerebrovascular accident, patients are often confused and disoriented, but the ability to speak remains. Determine the presence of hemiplegia or hemiparesis and the patient’s muscle strength, gait, and balance. Assess the patient’s cranial nerves (V, VII, IX, X, and XII) to determine the patient’s tongue movement and ability to chew and swallow, as well as the presence of a gag reflex. Assess the patient for the presence of hemianopia by observing whether he or she sees objects on either side of the midvisual field. If the patient is disoriented or has lost the ability to understand language (receptive aphasia), assessing hemianopia is difficult. Try handing the patient a fork on the affected side, and ask the patient to tell you what it is you are holding or ask the patient to pick up the fork.

During the early stages of their condition, many patients with cerebrovascular accident experience great despair and frustration trying to communicate their needs. The inability to communicate causes profound depression. Although patients may laugh or cry or display outbursts of anger and frustration at unusual times, it is impossible to know with any certainty if these responses are inappropriate for the patient.

Nursing care plan primary nursing diagnosis: Sensory-perceptual alterations: Visual, auditory, kinesthetic, and tactile, as related to tissue injury.

Nursing care plan intervention and treatment
The treatment needs to be initiated rapidly, within 6 hours of the onset of symptoms. Medical management for patients with cerebrovascular accident typically includes support of vital functions and ongoing surveillance to identify early neurological changes as the patient’s condition evolves. Although the hallmark of stroke is the abrupt onset of neurological symptoms and deficits due to the interruption of the vascular supply to a specific brain region, therapeutic intervention may save tissue that is at risk for infarction. Recombinant tissue-plasminogen activator (rt-PA) can improve outcome for some patients with acute nonhemorrhagic ischemic stroke if it is given within 3 hours of the onset of symptoms.

When a cerebrovascular accident has occurred, the treatment consists of maintaining life, reducing intracranial pressure (ICP), limiting the extension of the cerebrovascular accident, and preventing complications. For patients who cannot maintain airway, breathing, and circulation independently, assist with endotracheal intubation, ventilation, and oxygenation as prescribed. In hemorrhagic cerebrovascular accident, surgery may be required to evacuate a hematoma or to stop bleeding. A ventricular shunt may be placed to drain cerebrospinal fluid. Physical therapy is begun as soon as the patient’s condition stabilizes. Flaccid muscles soon become spastic and subject to contractures. Use passive range-of-motion exercises on the affected side. Strengthening the unaffected side assists the patient in compensating for the losses of the opposite hemisphere. The physical therapist teaches the patient to transfer with the use of assistive devices, and the physical or occupational therapist teaches the patient how to perform self-care activity.

Position the patient to maintain a patent airway by elevating the head of the bed 30 degrees to promote pulmonary drainage and limit upper airway obstruction. Suction the patient’s mouth and, if needed, the nasopharynx and trachea. Before suctioning, oxygenate the patient well; to minimize ICP increases, limit suctioning to 20 to 30 seconds at a time.

The patient with a cerebrovascular accident is at extremely high risk for complications caused by immobility. If appropriate, use compression boots to promote venous return and help prevent phlebitis. To reduce the risk of pulmonary infection, promote skin integrity, and prevent contractures, turn and reposition the patient every 2 hours. Keep the patient’s joints in a functional position, and keep the affected hand elevated slightly on a pillow. Use a trochanter roll to prevent external rotation of the hip. Keep the patient safe by putting the bed in a low position and keeping the side rails up.

Prevent aspiration pneumonia by first determining the patient’s ability to handle solids and liquids. Keep a suction machine nearby while feeding the patient. Some patients have difficulty with liquids, so thicken fluids with soft foods like cooked cereal, applesauce, soup, or mashed potatoes.

Make sure the patient has a bowel movement each morning after breakfast to stimulate normal peristalsis and prevent constipation. A catheter may be in place immediately after the cerebrovascular accident, but the goal is to have the patient gain control through a bladder training program. If the patient has expressive aphasia (inability to transform sounds into speech), give the patient ample time to respond to questions and be supportive if the patient becomes frustrated during speech. Be sure to accept any method of self-expression the patient uses, such as pointing, gesturing, or writing. Some patients find it easier to point to a picture that describes a word rather than trying to say the word.

Nursing care plan discharge and home health care guidelines
Teach the family to check for skin breakdown and the development of contractures and to take appropriate preventative measures. Be sure the family performs frequent range-of-motion activities, as taught in the rehabilitation unit. Advise the family whom to call in an emergency. Be sure that the patient and family understand the importance of maintaining the mobility and selfcare routine developed in the rehabilitation unit. Be sure that the social worker or rehabilitation personnel have provided the family with a list of resources for in-home care. Determine whether a home care agency will be providing in-home supervision and ongoing physical therapy support. Advise the family how to seek ongoing support for home maintenance.

Atelectasis means “incomplete expansion,” and is defined as the collapse of lung tissue because of airway obstruction, an abnormal breathing pattern, or compression of the lung tissue. Obstructive atelectasis is the most common type. When the airway becomes completely obstructed, the gas distal to the obstruction becomes absorbed into the pulmonary circulation and the lung collapses. When gas is removed from portions of the lungs, unoxygenated blood passes unchanged through capillaries, and hypoxemia results.

The obstruction, which occurs at the level of the larger or smaller bronchus, can be caused by a foreign body, tumor, or mucous plugging. Nonobstructive atelactasis is caused by loss of contact between the parietal and the visceral pleurae, as well as compression, loss of surfactant, and replacement of parenchymal tissue by scarring or infiltrative disease. Abnormal breathing patterns, such as hypoventilation and a slow respiratory rate, can also lead to Atelectasis. In such cases, the lung does not fully expand, which causes the lower airways to collapse.

Causes of Atelectasis
Atelectasis occurs most frequently after surgery and is a major concern for acute care nurses.
Patients with abdominal and/or thoracic surgery are the most susceptible, especially in the older age group. The duration of the surgery is also a risk factor. Patients in surgery for more than 4 hours have a 50% incidence of severe atelectasis, compared with a 19% incidence for those in surgery for 2 hours. Other causes of atelectasis are mucous plugs in patients who smoke heavily and inflammation from inflammatory lung disease. Atelectasis also occurs in patients with central nervous system depression following a drug overdose or a critical cerebral event such as a cerebrovascular accident.

Nursing care plan assessment and examination
Assess the patient for such preoperative risk factors as obesity, pre-existing respiratory problems, and smoking. Because surgical patients are at risk, be alert for component of the postoperative history that may contribute to atelectasis: a decrease in total lung volume because of pain and splinting, changes in breathing patterns from incisional discomfort or medications, advanced age, and a need for an increased fraction of inspired oxygen (FiO2). Other factors include use of narcotic analgesics that depress the respiratory drive, immobility, a decrease in consciousness, muscular weakness, hypotension, sepsis, and use of a nasogastric tube.
The patient may appear asymptomatic if small areas of the lung are involved, or they may appear acutely ill with extreme shortness of breath and clinical signs of oxygen deficit such as confusion, agitation, rapid heart rate, and even combative behavior when large areas are affected. Suprasternal, substernal, and intercostal retractions may be present, depending on the severity of atelectasis. Percussion reveals a dullness over the affected lung area. When the patient’s breath sounds are auscultated, you may hear decreased breath sounds or even find breath sounds to be absent. In addition, many patients have fine, late inspiratory crackles and coarse crackles or wheezes with airway obstruction.

The patient with atelectasis may be very anxious if breathing becomes too difficult. If the atelectasis is a result of foreign body aspiration by a child, the parents may be upset and guilty. Determine the patient’s and parents’ abilities to cope with the stressful situation.

Nursing care plan primary nursing diagnosis Ineffective airway clearance related to obstruction and lung collapse.

Nursing care plan intervention and treatment plan
Patients in pain, especially following abdominal and thoracic surgery, tend to breathe shallowly to decrease their discomfort. Pain medications allow them to breathe more deeply and expand their lungs. Use caution in overmedicating patients, however, because that will reduce respiratory excursion. In the immediate postoperative period, narcotic analgesia is often prescribed because it is readily reversible by naloxone (Narcan).

Incentive spirometry, chest percussion, and postural drainage may be prescribed by the physician to increase gas exchange and to decrease the risk of atelectasis. Oxygen may be delivered with humidification to improve clearance of mucus. If atelectasispersists, the physician may prescribe a mask with continuous positive airway pressure (CPAP). With the use of a CPAP mask, positive airway pressure is maintained throughout the respiratory cycle. In addition, CPAP prevents and reverses airway closure, thus expanding the lung volumes and reestablishing the functional residual capacity (FRC). If atelectasis persists and hypoxemia becomes life-threatening, endotracheal intubation and mechanical ventilation with positive-pressure ventilation and positive end-expiratory pressure (PEEP) may be necessary, but these aggressive therapies are usually not needed.

Instruct the preoperative patient on coughing and deep-breathing exercises prior to surgery, before incisional pain makes learning difficult. Teach the patient breathing exercises, such as pursed-lip breathing and abdominal breathing to expand the lungs. As soon as the patient is awake and alert after surgery, with a patent airway and adequate breathing, encourage him or her to cough and breathe deeply to help expand the lung. If the patient has abdominal or thoracic incisions, use a pillow to splint the incision to reduce discomfort during breathing exercises. Encourage the patient to use the incentive spirometer at the bedside every 2 hours when she or he is awake.

Encourage the patient to ambulate as soon as possible to reduce complications of immobility, which cause retention of secretions and decreased lung volumes. Seating the patient upright allows the patient to breathe more deeply because the lungs can expand better. Turn patients on bedrest at least every 2 hours.

Encourage patients who can expectorate secretions to cough; place a paper bag on the side rails of the bed for sanitary tissue disposal. If the patient is not on fluid restriction, explain that he or she should drink at least 2 to 3 L of fluid a day to liquefy secretions. If the patient is unresponsive, suction the patient endotracheally to remove sputum and to stimulate coughing.

If a child has developed atelectasis because of foreign-body obstruction, teach the parents to maintain a safe environment. The most commonly aspirated objects are safety pins and hard foods such as corn, raisins, and peanuts. Parents should not allow children to run or walk while eating because activity predisposes the child to aspiration. Teach the patient and family to evaluate all toys for removable parts; explain that coins are commonly aspirated and should not be given to children. Explain to parents that they should not allow a young child to play with baby powder during diaper changes because if the top is altered and powder spills onto the child’s face, the child can inhale it.

Nursing care plan discharge and home health care guidelines
To prevent atelectasis, instruct the patient prior to surgery about coughing, deep breathing, and early ambulation. Encourage the patient to request and take pain medications to assist with deep-breathing exercises. Explain that an adequate fluid intake is important to help loosen secretions and aid in their removal.

Instruct patients regarding the use of any medications they are to take at home. Discuss the indications for use and any adverse effects. If patients are placed on antibiotics, instruct them to finish all of the antibiotics even if they feel better before the prescription is completed.

Infection with Chlamydia trachomatis is the most common sexually transmitted infection (STI) in the United States today, with approximately 5 million cases reported annually. While chlamydial infections are reportable in all 50 states, underreporting of this STI is substantial owing to the number of individuals who may have the infection and not know it. Because 70% of women and 50% of men with chlamydial infections are asymptomatic, they transmit the disease but are unaware that they harbor the bacteria. Untreated infections in women can result in cervicitis, endometritis, acute salpingitis, bartholinitis, irregular menses, ectopic pregnancy, pelvic inflammatory disease, and infertility. Untreated infections in men can result in nongonococcal urethritis (NGU), epididymitis, or prostatitis. Infections in either gender can result in proctitis, lymphogranuloma venereum (LGV), and, potentially, infertility and sterility.

During pregnancy, C. trachomatis may be transmitted from mother to fetus, which may cause premature rupture of the membranes, premature labor, and increased fetal morbidity and mortality. Pregnant women who deliver vaginally or by cesarean section can transmit the bacteria to their infants. These newborns can develop otitis media, conjunctivitis, blindness, meningitis, gastroenteritis, respiratory infections, and pneumonia. Because mothers are often asymptomatic, medical personnel are unaware that the maternal-infant transmission has occurred until infants become very ill.
C. trachomatis is an obligate, gram-negative, intracellular bacterium with several different immunotypes. It resembles a virus in that it requires a tissue culture for isolation, but like a bacteria, it has RNA and DNA and is susceptible to antibiotics. It is transmitted through sexual intercourse and from mother to fetus during birth. The chlamydial infections exists in two forms: The elementary bodies are the infectious particles that enter uninfected cells; and the reticulate bodies are an active form of the organism that reproduce and form more elementary bodies that are released from the bursting infected cell and can then infect other cells. Replication begins only 12 hours after invasion. The pathogen invades and reproduces inside of the cells that line the cervix, endometrium, fallopian tubes, and urethra. Symptoms can occur after a 1- to 3-week incubation period; however, overt symptoms often occur late in the disease.

Nursing care plan assessment and physical examination
Although sexual activity is potentially a sensitive topic, it is critical to obtain a detailed sexual and gynecologic history. Inquire about the number of partners, use of barrier protection and birth control measures, participation in oral or anal intercourse, and previous STIs. Most patients who present with C. trachomatis have a history of multiple sex partners and engaging in sexual intercourse without the use of barrier protection. Often, patients are also positive for gonorrhea. Inquire if the patient has any thin or purulent discharge, burning or frequent urination, mucus-covered stools, lower abdominal pain, dyspareunia (painful sexual intercourse), headache, nausea, vomiting, chills, or bleeding after intercourse. Often, patients are asymptomatic, and some may complain only of an increase in vaginal discharge. Male patients may report dysuria, urinary frequency, and pruritus. Ask the patient if she or he is experiencing any diarrhea, tenesmus, or pruritus, any of which indicates that the infection involves the rectum.

For females, inspect the vagina, cervix, and labia and note any mucopurulent discharge. Bartholin glands may be involved. Gently touch the cervix; note any bleeding (friable cervix). Inspect males for purulent discharge at the urinary meatus. Scrotal swelling occurs if the organism has caused epididymitis. Inspect the anus for discharge and excoriation. If LGV is present, ulcerative lesions on the cervix, vagina, labia, anal/rectal area, or penis may occur. Enlarged lymph nodes also can be palpated in the groin. If these nodes rupture, they secrete a thick yellow granular substance.

Assess the patient’s knowledge of STIs and the implications. Assess the patient’s ability to cope with having an STI. The diagnosis of an STI can be very upsetting to a male or female who believes he or she was involved in a monogamous relationship. Patients may feel embarrassed and guilty about their condition. Inquire about the patient’s ability to obtain condoms. Identify all partners with whom the patient has been sexually active so that they can be examined and treated. Assess the patient’s support system; this is especially important if the patient is pregnant.

Nursing care plan primary nursing diagnosis: Infection related to bacterial invasion.

Nursing care plan intervention and treatment
chlamydial infections can easily be cured with oral antibiotics, and patients are rarely hospitalized. Patients need to know to continue to take medication as ordered, even if the symptoms subside. Follow-up with both partners is recommended to assure that neither partner is still infected. Patients should abstain from sexual intercourse until they are infection free.

Because patients are often asymptomatic, nurses need to identify those patients at risk for chlamydial infections and recommend screening. Prevention is an important nursing intervention. Teach patients that monogamous relationships with uninfected partners, use of mechanical barriers, and simultaneously treating the partner to prevent reinfection are ways to prevent transmission of C. trachomatis. Emphasize that it is possible for them to carry and transmit the bacteria, even if they are asymptomatic. Since a chlamydial infections is easily cured by antibiotics, teach the patient about taking the medications properly. Instruct patients to take all medication until the course of treatment is finished, even if the symptoms subside. Explain that the patient should abstain from intercourse until all medication is gone to prevent reinfection. For discomfort, teach the patient about warm sitz baths and taking prescribed analgesics as ordered.

Nursing care plan discharge and home health care guidelines
Be sure the patient understands the correct dosage, route, and time of the medication, as well as the importance of taking all prescribed medication, even if the symptoms resolve. Emphasize any dietary restrictions.

Teach the patient about the importance of barrier contraception, especially latex condoms. Often, patients on oral contraceptives do not realize that, although they probably will not get pregnant, they are not protecting themselves from STIs. Emphasize the importance of follow-up visits to assure that the infection has resolved. Encourage the patient to enforce follow-up of all sexual partners and to refrain from intercourse during antibiotic therapy to prevent reinfection. While experts recommend that all women less than 25 years of age be screened annually for chlamydia, this recommendation for routine screening does not include men.

Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third most common female pelvic cancer. It is estimated that 3710 women will die fromcervical cancer in 2005. The death rate from cervical cancer has steadily declined over the past 50 years owing to the increased use of the Papanicolaou exam, which detects cervical changes before cancer develops. Cervical cancer is of three types: dysplasia, carcinoma in situ (CIS), and invasive carcinoma. In dysplasia, the lower third of the epithelium contains abnormal cells with the earliest form of premalignant changes. These changes are considered preinvasive, and the atypical cells have some degree of surface maturation. CIS is carcinoma confined to the epithelium. The full thickness of the epithelium contains abnormally proliferating cells. Both dysplasia and CIS are considered preinvasive cancers and, with early detection, have a 5-year survival rate of 73% to 92%. Invasive carcinoma occurs when cancer cells penetrate the basement membrane. Metastasis occurs through local invasion and by way of the lymphatic ducts. As many as 10 years can elapse between the preinvasive and the invasive stages. A further 5 years can be added if one considers the precancerous changes that occur in atypical cells and dysplasia as the first step of malignancy.

Worldwide studies suggest that sexually transmitted human papillomaviruses (HPVs), type 16 or 18, are the primary cause of cervical cancer. Major risk factors associated with cancer of the cervix include early sexual activity, multiple sexual partners, or early first pregnancy; postnatal lacerations; grand multiparity; sexual partners with a history of penile or prostatic cancer or those uncircumcised; exposure to diethylstilbestrol (DES) in utero; smoking, use of oral contraceptives for more than 10 years, and a history of cervicitis or sexually transmitted diseases.
Nursing care plan physical examination and assessment
Because early cervical cancer is usually asymptomatic, establish a thorough history with particular attention to the presence of the risk factors and the woman’s menstrual history. Establish a history of later symptoms of cervical cancer, including abnormal bleeding or spotting (between periods or after menopause); metrorrhagia (bleeding between normal menstrual periods) or menorrhagia (increased amount and duration of menstrual bleeding); dysparuenia and postcoital bleeding; leukorrhea in increasing amounts and changing over time from watery to dark and foul; and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss; abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs; or other symptoms associated with neoplasms, such as fatigue.

Conduct a pelvic examination. Observe the patient’s external genitalia for signs of inflammation, bleeding, discharge, or local skin or epithelial changes. Observe the internal genitalia. The normal cervix is pink and nontender, has no lesions, and has a closed os. Cervical tissue with cervical cancer appears as a large reddish growth or deep ulcerating crater before any symptoms are experienced; lesions are firm and friable. The Pap smear is done before the bimanual examination. Palpate for motion tenderness of the cervix (Chandelier’s sign); a positive Chandelier’s sign (pain on movement) usually indicates an infection. Also examine the size, consistency (hardness may reflect invasion by neoplasm), shape, mobility (cervix should be freely movable), tenderness, and presence of masses of the uterus and adnexa. Conduct a rectal exam; palpate for abnormalities of contour, motility, and the placement of adjacent structures. Nodular thickenings of the uterosacral and cardinal ligaments may be felt.

Uneasiness, embarrassment about a pelvic examination, or fear of the unknown may be issues for the patient. Determine the patient’s level of knowledge about a pelvic exam and what she expects. Determine her recommended Pap test screening schedule, as well as how she obtains the results and their meaning. If the patient requires follow-up to a positive Pap smear, assess her anxiety and coping mechanisms. Stressors may be fear of the unknown, of sexual dysfunction, of cancer, or of death, or she may have self-concept disturbances.

Nursing care plan primary nursing diagnosis: Pain (acute) related to postprocedure swelling and nerve damage.

Nursing care plan intervention and treatment
Teaching about and providing access to regular Pap screening tests for high-risk and other women are the most important preventive interventions. The importance of regular Pap smears cannot be understated because cervical CIS is 100% curable. Embarrassment, modesty, and cultural values may make seeking a gynecological examination most difficult for some women. Provide clear explanations and respect the patient’s modesty.

When a patient requires surgery, prepare her mentally and physically for the surgery and the postoperative period. Be certain to teach the patient about vaginal discharges that may follow a surgical procedure. Teach the patient that she will probably have to refrain from douching, using tampons, and coitus until healing occurs. Discuss any changes that may affect the patient’s sexual function or elimination mechanisms. Explain to the patient that she will feel fatigued and that she should gradually increase activity, but should not do heavy lifting or strenuous or rough activity or sit for long periods. Encourage the patient to explore her feelings and concerns about the experience and its implications for her life and lifestyle. Provide the patient who has undergone a hysterectomy with information about what to expect.

If internal radiation is the treatment, the primary focus of the nursing interventions is to prepare the patient for the treatment, to promote her comfort, and to lessen her sense of isolation during the treatment. Explain to the patient and significant others the reason for the time-restricted visits while the insert is in place. Nursing care is of shorter duration and of essential nature only during this time; therefore, ensure that before the insertion of the implant, the patient has a bath and clean bed linen. Decrease the patient’s feelings of isolation by providing diversionary activities and frequent interaction from a safe distance. If the patient has external radiation, teach her about how the treatment is given, how the skin is prepared, and how blood tests to monitor white blood cell count are done. Explain that her immunity to common colds and other illnesses is lessened, and teach the patient the proper use of antiemetics and antidiarrhetics.

Treatment depends on the stage of the cancer, the woman’s age, and concern for future childbearing. Preinvasive lesions (CIS) can be treated by conization, cryosurgery, laser surgery, or simple hysterectomy (if the patient’s reproductive capacity is not an issue). All conservative treatments require frequent follow-up by Pap tests and colposcopy because a greater level of risk is always present for the woman who has had CIS. A cone-shaped piece of tissue is removed from the cervix after epithelial involvement is clearly outlined as described with the cone biopsy. The cone includes all the abnormal and some normal tissue. Following this procedure, the woman can still have children. The major complication is postoperative bleeding.

Nursing care plan discharge and home health care guidelines
Make sure the patient knows all the postprocedure complications. Provide a phone number to call if any complications occur. Ensure that the patient understands the need for ongoing Pap smears if appropriate. Vaginal cytological studies are recommended at 4-month intervals for 2 years, every 6 months for 3 years, and then annually.

Cirrhosis is a chronic liver disease that is characterized by destruction of the functional liver cells, which leads to cellular death. Cirrhosis along with other chronic liver diseases result in up to 35,000 deaths each year in the United States and is the ninth leading cause of death. In cirrhosis , the damaged liver cells regenerate as fibrotic areas instead of functional cells, causing alterations in liver structure, function, blood circulation, and lymph damage. The major cellular changes include irreversible chronic injury of the functional liver tissue and the formation of regenerative nodules. These changes result in liver cell necrosis, collapse of liver support networks, distortion of the vascular bed, and nodular regeneration of the remaining liver cells. The classification of cirrhosis is controversial at present. However, most types may be classified by a mixture of causes and cellular changes, defined as follows: alcoholic; cryptogenic and postviral or postnecrotic; biliary; cardiac; metabolic, inherited, and drug-related; and miscellaneous. The first three types are the most commonly seen, accounting for 55% to 90% of cases of cirrhosis. Although each of these types has a different etiology, the clinical findings, including portal vein hypertension and eventual liver failure, are much the same
Liver cirrhosis is most commonly associated with hepatitis C (26% of the cases) alcohol abuse (21%), hepatitis C plus alcohol abuse (15%), cryptogenic causes (etiology not determined; 18%), hepatitis B (15%), and other miscellaneous causes (5%) such as malnutrition, protein deficiency, biliary disease, and chemical toxins. Alcoholic liver disease is also known as Laennec’s, portal, nutritional, and fatty cirrhosis.

Nursing care plan liver cirrhosis physical assessment and examination
Determine if the patient has experienced personality changes such as agitation, forgetfulness, and disorientation. Inquire about fatigue, drowsiness, mild tremors, or flulike symptoms. Ask about any past or present symptoms that may indicate cirrhosis, such as changes in bowel habits or menstrual irregularities. Elicit a history of easy bruising, nosebleeds, or bleeding gums. Determine the patient’s drinking patterns and how long they have existed. Determine if the patient has had early-morning nausea and vomiting, anorexia, indigestion, weight loss, weakness, lethargy, epigastric discomfort, or altered bowel habits. Ask about any recent sexual dysfunction.

Inspect for signs of muscle atrophy. Note whether the patient’s abdomen is protruding. Assess the patient’s skin, sclera, and mucous membranes, observing for poor skin turgor, signs of jaundice, bruising, spider angiomas, and palmar erythema (reddened palms). Observe the patient’s trunk, and note the presence of gynecomastia (enlarged breasts). Observe the abdomen for distension, an everted umbilicus, and caput medusae (a plexus of dilated veins about the umbilicus); measure the abdominal girth. When assessing the patient’s upper extremities, test for asterixis (liver flap or flapping tremor). Have the patient stretch out her or his arm and hyperextend the wrist with the fingers separated, relaxed, and extended. The patient in stages II (impending) and III (stuperous) of hepatic encephalopathy may have a rapid, irregular flexion and extension (flapping) of the wrist. Note any tenderness or discomfort in the patient’s abdomen. Palpate for hepatomegaly by gently rolling the fingers under the right costal margin. The liver is normally soft and usually can be felt under the costal margin. Percuss the patient’s abdomen. Note a shifting dullness in the abdomen if ascites is present. Auscultate the abdomen and assess for hypoactive, hyperactive, or normal bowel sounds.

Cirrhosis is a chronic disease that dictates lifestyle changes for the patient and significant others. Determine the patient’s response to the diagnosis and his or her ability to cope with change. Identify the patient’s past ability to cope with stressors, and determine if these mechanisms were successful.

Nursing care plan liver cirrhosis with a primary nursing diagnosis of Fluid volume excess related to retention.

Nursing care plan liver cirrhosis intervention and treatment plan
Patients are placed on a well-balanced, high-calorie (2500 to 3000 calories per day), moderate- to high-protein (75 g of high-quality protein per day), low-fat, low-sodium diet (200 to 1000 mg per day), with additional vitamins and folic acid. Accurate fluid intake and output are important to prevent fluid volume overload; for most patients, intake should be limited to 500 to 1000 mL per day. Frequently, vitamin K injections are ordered to improve blood clotting factors. If coagulopathies worsen, treatment may require whole blood or fresh-frozen plasma to maintain the hematocrit and hemoglobin. If alcohol is the primary etiologic factor in liver cirrhosis, strongly encourage the patient to cease drinking.

Surgical intervention includes a LaVeen continuous peritoneal jugular shunt (peritoneovenous shunt), which may be inserted for intractable ascites. This procedure allows the continuous shunting of ascitic fluid from the abdominal cavity through a one-way valve into a silicone tube that empties into the superior vena cava. Paracentesis may be performed if conditions warrant. Indicators include a large volume of ascitic fluid that compromises the patient’s respirations, causes abdominal discomfort, or poses a threat of rupturing an umbilical hernia.

Commonly seen in cirrhosis patients are esophageal varices due to portal vein hypertension. Varices can rupture as a result of anything that increases the abdominal venous pressure, such as coughing, sneezing, vomiting, or the Valsalva’s maneuver. To remedy bleeding of esophageal varices, a Sengstaken-Blakemore tube can be placed. In cases of irreversible chronic liver disease, liver transplantation is an option; however, there are selection criteria. Candidates for liver transplantation fall into three categories: those with irreversible chronic liver disease; those with malignancies of the liver and biliary tree; and those with fulminant hepatic failure. Liver transplantation is considered an important therapeutic option for patients with end-stage liver disease, with 1-year and 5-year survival rates of 70% and 60%, respectively.

Nursing considerations in the cirrhotic patient are to avoid infection and circulatory problems. Turn the patient and encourage coughing and deep breathing every 2 hours to prevent pneumonia.

Because bleeding can occur, monitor the patient closely for signs of hypovolemia. Test any stool and emesis for blood. Follow closely any break in the patient’s skin integrity for increased bleeding, and apply pressure to injection sites. Warn the patient against straining at stool, blowing her or his nose, or sneezing too vigorously. Suggest the patient use a soft toothbrush and an electric razor. Because of fatigue, muscle atrophy, and wasting, the patient needs to rest. Plan activities to include regular rest periods. To prevent breakdown of the skin, place the patient on an egg-crate or air mattress. Avoid using soap to bathe the patient; use moisturizing agents or lubricating lotion. Use pressure-reducing mattresses or specialty beds to prevent skin breakdown. Apply lotion and massage areas of the skin that are potential breakdown sites.

Encourage the patient to verbalize questions, anxieties, and fears. In conversation, note any behavioral or personality changes, including increasing stupor, lethargy, or hallucinations. Arouse the patient periodically to determine his or her level of consciousness. Emotional and psychological support for the patient and family are important to eliminate anxiety and poor self-esteem. Involve the family members in the patient’s care as a means of improving the patient’s morale.

Nursing care plan discharge and home health care guidelines
Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use exacerbates the disease. Stress that alcoholic liver disease in its early stages is reversible when the patient abstains from alcohol. Encourage family involvement in alcohol abuse treatment. Assist the patient in obtaining counseling or support for her or his alcoholism. Encourage the patient to seek frequent medical follow-up. Visits from a community health nurse to monitor the patient’s progress and to help with any questions or problems at home are also helpful. Refer the patient to an alcohol support group or liver transplant support group.