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Nursing Interventions for Tetralogy of Fallot

Nursing Diagnosis : Decreased Cardiac Output r / t ineffective circulation, secondary to the presence of cardiac malformations

Goal: Children can maintain adequate cardiac output

NOC:

  • Vital signs are normal with age.
  • There is no dyspnea, rapid breathing and deep, cyanosis, anxiety / lethargy, tachycardia, murmurs.
  • Clients composmetis.
  • Akral warm.
  • Peripheral pulse strong and equal on both extremities.
  • Capillary refill time less than 3 seconds.
  • Urine output of 1-2 ml / kg / hour.

Intervention:
  1. Monitor vital signs, peripheral pulses, capillary refill by comparing measurements at both extremities while standing, sitting and lying down if possible.
  2. Assess and record the apical pulse for 1 full minute.
  3. Observation of cyanotic attacks.
  4. Give a knee-chest position in children.
  5. Observe for signs of decreased sensory: lethargy, confusion, and disorientation.
  6. Monitor intake and output adequately.
  7. Provide adequate rest time for children and accompany children during activity.
  8. Serve foods that are easily digestible and reduce the consumption of caffeine.
  9. Collaboration in the examination serial ECGs, chest radiographs, administration of anti dysrhythmias.
  10. Collaboration of oxygen.
  11. Collaboration IV fluid administration.
Source : http://nandacareplan.blogspot.com/2013/12/decreased-cardiac-output-tetralogy-of.html

Nursing Interventions for Chronic Pain

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring, without an anticipated or predictable end and a duration >6 months (NANDA); a state in which an individual experiences pain that persists for a month beyond the usual course of an acute illness or a reasonable duration for an injury to heal, is associated with a chronic pathologic process, or recurs at intervals for months or years (Bonica, 1990)

Defining Characteristics:

Subjective
Pain is always subjective and cannot be proved or disproved. The client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). Clients with cognitive abilities who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify their current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).

Objective
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in its assessment, especially in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite or the inability to ambulate, perform activities of daily living (ADLs), work, or sleep. Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, and increase or decrease in respiratory rate and depth may be present but are usually not present with chronic pain that is relatively stable. Clients with chronic, cancer, or nonmalignant pain may experience threats to self-image; a perceived lack of options for coping; and worsening helplessness, anxiety, and depression. Chronic pain may affect almost every aspect of the client's daily life, including concentration, work, and relationships.


Related Factors:
Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; nerve injury (neuropathic pain)
NOTE: The cause of chronic nonmalignant pain may not be known because pain is a new science and an area of diverse types of problems.

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Pain Level
Pain Control
Comfort Level
Pain: Disruptive Effects

Client Outcomes

Uses pain rating scale to identify current level of pain intensity, determines a comfort/function goal, and maintains a pain diary (if client has cognitive abilities)
Describes the total plan for drug and nondrug pain relief, including how to safely and effectively take medicines and integrate nondrug therapies
Demonstrates ability to pace self, taking rest breaks before they are needed
Functions on an acceptable ability level with minimal interference from pain and medication side effects (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Pain Management, Analgesic Administration

Read More :
Nursing Interventions and Rationales for Chronic Pain

Nursing Interventions for Acute Pain

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months (NANDA)

Defining Characteristics:

Subjective

Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).

Objective

Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.

Related Factors:

Actual or potential tissue damage (mechanical [e.g., incision or tumor growth],
thermal [e.g., burn],
or chemical [e.g., toxic substance])



NOC

Suggested NOC Labels

Pain Level, Pain Control, Comfort Level
Pain: Disruptive Effects

Client Outcomes

Uses a pain rating scale to identify current level of pain intensity and determines a comfort/function goal (if client has cognitive abilities)
Describes how unrelieved pain will be managed
Reports that the pain management regimen relieves pain to a satisfactory level with acceptable or manageable side effects
Performs activities of recovery with a reported acceptable level of pain (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)
States an ability to obtain sufficient amounts of rest and sleep
Describes a nonpharmacological method that can be used to control pain


NIC

Suggested NIC Labels

Conscious Sedation
Patient-Controlled Analgesia (PCA) Assistance

Read More :

Nursing Interventions and Rationales for Acute Pain

2 Nursing Interventions for Encephalitis

Nursing Care Plan for Encephalitis 

Encephalitis is irritation and swelling (inflammation) of the brain, most often due to infections.

Some patients may have symptoms of a cold or stomach infection before encephalitis symptoms begin.

When a case of encephalitis is not very severe, the symptoms may be similar to those of other illnesses, including:
  • Fever that is not very high
  • Mild headache
  • Low energy and a poor appetite

Other symptoms include:
  • Clumsiness, unsteady gait
  • Confusion, disorientation
  • Drowsiness
  • Irritability or poor temper control
  • Light sensitivity
  • Stiff neck and back (occasionally)
  • Vomiting

Symptoms in newborns and younger infants may not be as easy to recognize:
  • Body stiffness
  • Irritability and crying more often (these symptoms may get worse when the baby is picked up)
  • Poor feeding
  • Soft spot on the top of the head may bulge out more
  • Vomiting

Emergency symptoms:
  • Loss of consciousness, poor responsiveness, stupor, coma
  • Muscle weakness or paralysis
  • Seizures
  • Severe headache
  • Sudden change in mental functions:
    • "Flat" mood, lack of mood, or mood that is inappropriate for the situation
    • Impaired judgment
    • Inflexibility, extreme self-centeredness, inability to make a decision, or withdrawal from social interaction
    • Less interest in daily activities
    • Memory loss (amnesia), impaired short-term or long-term memory

Nursing Interventios for Encephalitis

High risk of infection associated with lower body resistance to infection

Goal :
no infection

Expected results :
Healing on time with no evidence of spread of infection endogenous

Nursing Intervention :
Defense aseptic technique and proper hand washing techniques either nurses or visitors. Monitor and limit visitors.
R /. reduce the risk of patients exposed to secondary infection. control the spread of the source of infection.
Measure the temperature on a regular basis and clinical signs of infection.
R /. Detecting early signs of infection
Give antibiotics as indicated
R /. Drugs are selected depending on the type of infection and sensitivity of the individual.

High risk of injury associated with seizure activity

Goal :
There was no trauma

Results expected :
Not having a seizure
No trauma

Nursing Intervention :
Give safety to patients by giving bearings, fixed the bed barriers and give a booster attached to the mouth, the airway remains free.
R /. Protect patients in case of seizure, booster mouth somewhat tongue is not bitten.
Note: enter the booster mouth when the mouth just relaxation.
Maintain bed rest in the acute phase.
R /. Lowering the risk of falling / injury during the vertigo.
Collaboration
Give the drug as an indication as delantin, valum, etc..
R /. An indication for treatment and prevention of seizures.
Observation of vital signs
R /. Early detection of seizures for possible further action.