nursing diagnosis for amebiasis

Nursing Diagnosis: Disturbed sleep patterns r/t interruptions due to coughing Cause Analysis: Time- limited interuptions of sleep amount and quality due to external factors Reference: Doenges, Moorhouse, & Murr; Nurse’s Pocket Guide: diagnoses, prioritized interventions, rationales, 12th ed. Cues Needs Objectives/ Planning Interventions Rationales Evaluation Subjective: “di man jud ko makatulog ug tarong” as verbalized by the patient Objective:  Restlessness  Frequent changing of position when lying Rest and comfort After 8 hours of nursing intervention, the patient will be able to: a. Sleep and rest well for at least 3 hours without any intervention b. Verbalize contentment of sleep c. Demonstrate increased sense of well being a. Assess clients usual sleep patterns and compare with current sleep disturbance b. Listen to reports of sleep quality and response for lack of good sleep c. Provide quiet environment and do comfort measures such as: • Straightening bed sheet, changing damp linens or gowns • Turn on soft music, calm TV program, or quiet environment, as client prefers d. Restriction of visitors during sleeping time e. Encourage appropriate indoor light settings during day and night, avoidance of daytime napping as appropriate for age and situation, being active during day and more passive in the evening f. Minimize sleep-disrupting factors such as reduce talking and other disturbing noises such as phones, alarms a. To ascertain intensity and duration of procedures b. Help’s clarify client’s perception of sleep quality and quantity and response to inadequate sleep c. To promote physical comfort and enhance relaxation d. Provide privacy for the patient while asleep e. Helps in promotion of normal sleep-wake patterns f. To promote readiness for sleep and improve sleep duration and quality Goal met as evidenced by client verbalize good sleep for 3 hours. Nursing Diagnosis: ineffective breathing pattern r/t unproductive cough possibly evidenced by pneumonia Cause Analysis: inspiration and/or expiration that does not provide adequate ventilation Reference: Doenges, Moorhouse, & Murr; Nurse’s Pocket Guide: diagnoses, prioritized interventions, rationales, 12th ed. Cues Needs Objectives/Planning Intervention Rationale Evaluation Objective: - Alterations in depth of breathing - pallor Activity –exercise Pattern Short-term goal: After 8 hours of nursing intervention the patient will be able to: • Demonstrate sense of well being such as breathing with regular rate and rhythm Long term goal; After 3 days of care, the patient will be able to: a. Demonstrate coping behaviors b. Initiate lifestyle changes c. Establish a normal, respiratory pattern as evidenced by the absence of cyanosis and other signs and symptoms of hypoxia d. Verbalize awareness of causative factors a. Auscultate chest b. Note rate and depth of respirations, type of breathing pattern c. Evaluate cough; presence of secretions d. Maintain calm attitude while dealing with client e. Stress importance of good posture and effective use of accessory muscles f. Encourage patient to provide a plan for smoking cessation g. Review environmental factors that may require avoidance of triggers or modification of lifestyle or environment h. Note emotional responses a. to evaluate presence/character of breath sounds b. provides data for further assessment c. indicates possible obstruction d. to limit level of anxiety e. to maximamize respiratory effort f. to promote continuity of wellness g. to limit impact on client’s breathing h. anxiety maybe causing or exacerbating acute or chronic hyperventilation Short-term:  goal met as evidence by breathing with regular rate and rhythm without using accessory muscles long-term goal: Goal met as evidenced by response to interventions, teaching, actions performed and treatment regimen. Nursing Diagnosis: risk for activity intolerance may be r/t patient verbalized “ luya pajud ako paminaw” Cause Analysis: insufficient physiological or psychological energy endure or complete required or desired daily activities. Reference: Doenges, Moorhouse, & Murr; Nurse’s Pocket Guide: diagnoses, prioritized interventions, rationales, 12th ed. Cues Needs Objectives/Planning Interventions Rationale evaluation Subjective: “luya pajud ako paminaw” as verbalized by the patient Objective: • pallor • cyanosis • fever of 39ºC • sunken eyes Activity-rest pattern Short- term goal: At the end of 8 hours of care, the patient will be able to : • report measurable increase in activity tolerance • identify ways to lessen external factors that could weakens the body Long term goal: After 3 days of nursing intervention, the patient will be able to: a. demonstrate a decrease in physiological signs of intolerance b. participate willingly in desired or necessary activities c. identify negative factors affecting activity tolerance and eliminate or reduce their effects if possible d. discuss ways to improve well- being a. Assess cardiopulmonary response to physical activity, including vital signs before, during and after activity. Note accelerating fatigue. b. Note client’s report of weakness, fatigue, pain, difficulty accomplishing tasks and/or insomnia. c. Monitor vital and cognitive signs, watching for changes in blood pressure, heart and respiratory rate; note skin pallor and/or cyanosis and presence of confusion d. Assist with activities and provide/monitor client’s use of assistive devices e. Adjust activities and reduce intensity level or discontinue activities that might cause undesired physiologic changes f. Give client information that provides evidence of daily/weekly progress g. Explain importance of rest in treatment plan and necessity for balancing activities with rest h. Assist with self- care activities as necessary. Provide for progressive increase in activities during recovery phase. i. Provide information regarding potential interfering factors with activity, such as smoking when one has respiratory problems or lack of motivation/interest in exercise j. Determine current activity level and physical condition with level classification system a. To have baseline data. b. Symptoms maybe a result of/or contribute to intolerance of activity c. To assist client to deal with contributing factors and manage activities within individual limits. d. To protect client from injury e. To prevent overexertion f. To sustain motivation g. Bedrest is maintained during acute phase to decrease metabolic demand, thus conserving energy for healing. h. Minimizes exhaustion and helps balance oxygen supply and demand. i. N j. Provides baseline for comparison and opportunity to track changes Short-term goal:  Goal met as evidenced by patient verbalize ways to increase activity tolerance such as taking medications regularly  Goal met as evidenced by client identify ways to lessen external factors such as quitting smoking, and avoidance of stressful activities. Long-term goal: Goal unmet. As evidenced by the patient’s appearance has still signs of pallor and cyanosis.   Nursing Diagnosis: impaired gas exchange r/t oxygen carrying blood disorders secondary to hypoxia Cause Analysis: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolocapillary membrane Reference: Doenges, Moorhouse, & Murr; Nurse’s Pocket Guide: diagnoses, prioritized interventions, rationales, 12th ed. Pages386-390 Cues Needs Objectives/planning Interventions Rationale evaluation Objective:  Pallor  Poor skin turgor  Pale nailbeds  hypoxia Activity- exercise pattern Short-term goal: After 3 hours nursing intervention, the patient will be able to:  Verbalize understanding of causative factors and appropriate interventions Long-term goal: After 3 days of care, the patient will be able to:  Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal limits and absence of symptoms of respiratory distress  Participate in treatment regimen within level of ability or situation  Experience no dyspnea or cyanosis  Verbalize good sleep  Emphasize normal breathing pattern ( using of accessory muscles won’t be noted) a. Maintain client airway. Place client in position of comfort with head of bed elevated 30 to 45 degrees b. Monitor respiratory rate and depth. Note use of accessory muscles or work of breathing. c. Auscultate breath sounds. Note crackles, wheezes, and areas of decreased or absent ventilation. d. Note presence of circumoral cyanosis. e. Note cough and purulent sputum production. f. Reposition frequently. Encourage coughing and deep-breathing exercises. Suction, as indicated. g. Emphasize the importance of nutrition h. Reinforce need for adequate rest, while encouraging activity and exercise i. Provide quiet environment to allow the patient to relax a. Elevating the head of bed enhances lung expansion and reduces respiratory effort. b. Rapid, shallow respirations occur because of hypoxemia, stress, and circulating endotoxins. Hypoventilation and dyspnea reflect ineffective compensatory mechanisms and are indications that ventilatory support is needed. c. Respiratory distress and the presence of adventitious sounds are indicators of pulmonary congestion, interstitial edema, and atelectasis. d. Circumoral cyanosis indicates inadequate central oxygenation and hypoxemia. e. Pneumonia is a common nosocomial infection that can occur by aspiration of oropharyngeal organisms or spread from other sites. f. Good pulmonary toilet is necessary for reducing ventilation/ perfusion imbalance and for mobilizing and facilitating removal of secretions to maximize gas exchange. g. To improve stamina and reducing the work of breathing h. To decrease dyspnea and improve quality of life i. External stimuli may prevent relaxation or inhibit sleep. Short term Goal met as evidenced by patient verbalize causative factors such as smoking Long-term Goal met as evidenced by :  Cyanosis not noted  verbalize good sleep for more than 2 hours  emphasized normal breathing pattern (using of accessory muscles not noted Nursing diagnosis: ineffective airway clearance r/t inability to clear secretions as evidenced by unproductive cough Cause analysis:inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway Reference: Doenges, Moorhouse, Murr:,Nurse’s pocket guide: diagnoses, prioritized interventions, and rationales, 12th ed. Pages 80-84 Cues Needs Objectives/planning Interventions Rationale Evaluation Subjective: “sige ko ug ubo pero wala jud plema mo gawas” as verbalized by the patient Objective:  Unproductive cough  Alterations in depth of breathing  Activity- rest pattern Short-term goal: At the end of 8 hours nursing intervention, the patient will be able to: a. Identify risk factors that may interfere with secretions b. Verbalize understanding of causes and therapeutic management c. Identify potential complications and how to initiate appropriate preventive or corrective measures/actions Long term goal: After 3 days of nursing intervention the patient will be able to: a. Demonstrate behaviors to improve or maintain clear airway b. Demonstrate absence/reduction of congestion as evidenced by:  breath sounds clear,  normal respirations evidenced by absence of adventitious breath sounds d. Participate in treatment programs according to conditions e. Monitor and record vital signs f. Assess patient’s condition g. Elevate head of the bed and encourage frequent position changes h. Keep back dry and loosen clothing i. Auscultate breath sounds and assess breathing movement j. Place the patient in the semi-fowler position, help/teach effective coughing and breathing exercises k. Increase fluid intake to at least 2000ml/day within cardiac tolerance l. Provide information about the necessity of raising and expectorating secretions versus swallowing them m. Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance n. Encourage deep-breathing and coughing exercises; splint chest/incision a. To obtain baseline data b. To know the patient’s general condition c. To promote maximal inspiration, enhance expectorations of secretions in order to improve ventilation d. To promote comfort and adequate ventilation e. To ascertain status and note progress f. Increased lung expansion, maximum ventilation opening areas of atelectasis and increased secretions movement to be easily removed g. Hydration can help liquefy vicious secretions and improve secretion clearance h. To report changes in color and amount in the event that medical intervention maybe needed to prevent or treat infection. i. Prevents/reduces fatigue j. To maximize effort Short term-goal: Goal met as evidence by  The client was able to identify potential complications such as smoking  Understands treatment regimen such as nebulization Long-term goal: Goal unmet as evidenced by:  Wheezes at left lower lung is still present when auscultated  Client’s x-ray still reveals hazy infiltrates