Paralytic Ileus - Risk for Hypovolemic Shock and Impaired Bowel Elimination

Paralytic Ileus is a paralysis of the intestine. It is a complicated medical condition that is characterized by partial or total non-mechanical obstruction of the large or small intestine. This blockage occurs when the intestinal muscles suffer a paralysis. Even a partial paralysis that makes the intestinal muscles inactive is enough to cause this disorder. Such a state of inactivity makes it difficult for food to pass through the intestine. It creates an intestinal blockage and gives rise to serious complications.

Paralytic ileus can affect any part of the intestine. Causes can include:

• Abdominal surgery
• Pelvic surgery
• Infection
• Certain medications, including antidepressants and pain medications that affect muscles and nerves
• Muscle and nerve disorders, such as Parkinson's disease

Nursing Diagnosis for Paralytic Ileus : Risk for Hypovolemic Shock
related to: the lack of body fluid volume.

Goal: hypovolemic shock does not occur.

Expected outcomes:

• Vital signs are within normal limits,
• volume of body fluid balance,
• fluid intake met.

Interventions:

1. Monitor general condition
Rationale: Establish baseline data to determine the patient's deviation from normal condition.

2. Observations of vital signs
Rationale: It is a reference to determine the patient's general condition.

3. Assess fluid intake and output
Rationale: To determine the body's fluid balance.

4. Collaboration in the provision of intravenous fluids
Rationale: To meet the water balance.


Nursing Diagnosis for Paralytic Ileus : Impaired Bowel Elimination
related to: constipation

Goal: Impaired elimination pattern does not occur

Expected outcomes: Patterns of normal bowel elimination

Interventions:

1. Assess and record the frequency, color and consistency of stool
Rationale: To determine the presence or absence of abnormalities that occur in fecal elimination.

2. Auscultation of bowel sounds
Rationale: To determine whether or not normal bowel movements.

3. Encourage clients to drink plenty
Rationale: To stimulate spending feces.

4. Collaboration in the provision of laxative therapy
Rationale: To provide ease of elimination needs.

Nanda - Hyperthermia - NIC NOC

Definition: the body temperature rises above the normal range

Limitation Characteristics:

• The increase in body temperature above the normal range
• Offensive or convulsions (seizures)
• Skin redness
• Addition of RR
• Tachycardia
• Hand feels warm to the touch

Related Factors:

• disease / trauma
• increased metabolism
• excessive activity
• the influence of medication / anesthesia
• inability / reduced ability to sweat
• exposure to hot environment
• dehydration
• improper attire

NOC: Thermoregulation

Expected outcomes:

• Body temperature within normal range
• Pulse and RR in the normal range
• No skin discoloration and no dizziness, feeling comfortable

NIC:

Fever Treatment

• Monitor the temperature as much as possible
• Monitor IWL
• Monitor skin color and temperature
• Monitor blood pressure, pulse and RR
• Monitor decreased level of consciousness
• Monitor WBC, Hb, and Hct
• Monitor intake and output
• Give anti-pyretic
• Provide treatment to address the cause of the fever
• Cover the patient
• Perform tapid sponge
• Give intravenous fluids
• Compress patients in the groin and axilla
• Increase air circulation
• Provide treatment to prevent shivering

Temperature regulation

• Monitor the temperature at least every 2 hours
• Plan for continuous temperature monitoring
• Monitor blood pressure, pulse, and RR
• Monitor skin color and temperature
• Monitor signs of hyperthermia and hypothermia
• Increase fluid intake and nutrition
• Cover the patient to prevent the loss of body warmth
• Teach the patient how to prevent fatigue due to heat
• Discuss the importance of temperature regulation and the possible negative effects of the cold
• Tell about the indications of fatigue and needed emergency treatment
• Teach indication of hypothermia and handling required
• Give anti pyretic if necessary

Vital sign monitoring

• Monitor blood pressure, pulse, temperature, and RR
• Note the fluctuations in blood pressure
• Monitor vital signs while the patient is lying down, sitting or standing
• Auscultation of blood pressure in both arms and compare
• Monitor blood pressure, pulse, RR, before, during, and after activity
• Monitor the quality of the pulse
• Monitor respiratory rate and rhythm
• Monitor lung sounds
• Monitor abnormal breathing patterns
• Monitor temperature, color, and moisture
• Monitor peripheral cyanosis
• Monitor the Cushing's triad (widening pulse pressure, bradycardia, increased systolic)
• Identify the causes of changes in vital sign

Nanda - Ineffective Individual Coping - NIC NOC

Defining characteristics:

• Sleep disorders
• Chemical abuse
• Decline in the use of social support
• Poor concentration
• Fatigue
• Complained about the inability of coping
• Destructive behavior toward self / others
• The inability to meet the expectations of the role

Related factors:

• Gender differences in coping strategies
• Confidence level is inadequate
• Uncertainty
• Ineffective social support
• Situational crisis / maturasional
• The degree of high-level treatment

NOC Labels: Coping

Expected outcomes:

• Shows the flexibility of the role
• Shows the flexibility of the role of family members
• Conflict issues
• Can set the value of family issues
• Manage the problem
• Involving family members in making decisions
• Express feelings and emotional freedom
• Shows a strategy to manage the problem
• Using stress reduction strategies
• Care for the needs of family members
• Determine priorities
• Determine the timetable for the routine, and family activities
• Schedule for respite care
• Have a plan on the condition of gravity
• Maintain financial stability
• Seeking help when needed
• Using social support

NOC assessment information:

1 = not done at all

2 = rarely done

3 = sometimes done

4 = often

5 = always done


NIC: Improved coping

• Respect the patient's understanding of the disease process and self-concept
• Appreciate and discuss the substitute response to the situation
• Respect the client's attitude toward the changing roles and relationships
• Support the use of spiritual resources upon request
• Use a calm approach and provide assurance
• Provide information about the actual diagnosis, and prognosis handlers
• Provide a realistic option at this aspect of care
• Support the use of appropriate defensive mechanism
• Encourage family involvement in an appropriate manner
• Help patients to identify positive strategies to overcome these limitations and to manage lifestyle and role changes
• Help clients to adapt and anticipate changes in client
• Help clients identify the possibilities that can occur.

Pathophysiology of Space Occupying Lesion (SOL)

A space occupying lesion is any abnormal tissue found on or in an organism, usually damaged by disease or trauma.

A space occupying lesion of the brain is usually due to malignancy but it can be caused by other pathology such as an abscess or a haematoma. Almost half of intracerebral tumours are primary but the rest have originated outside the CNS and are metastases.

The symptoms are also dependent on the area of the brain affected:

• Temporal lobe – dysphasia, contralateral homonymous hemianopia, amnesia
• Frontal lobe – Hemiparaesis, personality change, executive dysfunction
• Parietal lobe – Hemisensory loss, astereogenesis (can’t recognise objects by touch alone), reduced 2-point discrimination
• Occipital lobe – contralateral visual field defects, palinopsia (see things again once stimulus has left field of vision)
• Cerebellum – DASHING: Dysdiadochokinesis, Ataxia, Slurred speech, Hypotonia, Intention tremor, Nystagmus, Gait abnormalities
• Personality change – irritability, lack of concentration, socially inappropriate behaviour.

Pathophysiology of Space Occupying Lesion (SOL)

Brain tumors cause neurological disorders. Symptoms occur sequentially. This emphasizes the importance of history in the examination of the client. The symptoms should be addressed in a time perspective.

Neurologic symptoms in brain tumors typically considered to be caused by two factors focal disorder, caused by the tumor and intracranial pressure. Focal disruption occurs when an emphasis on brain tissue and infiltration / invasion of the brain parenchyma by direct tissue damage neurons. Of course the greatest dysfunction occurs in tumors that grew most rapidly.

Changes in blood supply due to the pressure caused by the growing tumor causing brain tissue necrosis. Impaired arterial blood supply is generally manifest as an acute loss of function and may be confused with primary cerebrovascular disorders. Seizures as a manifestation of neuro sensitivity changes associated with compression of the invasion and changes in blood supply to the brain tissue. Some tumors form cysts that also suppress the surrounding brain parenchyma so that aggravate focal neurological disorders.

Increased intra-cranial pressure can be caused by several factors: the increase of the mass in the skull, the formation of edema around the tumor and cerebrospinal circulation changes. Tumor growth causes increasing mass, because the tumor will take a relatively from the rigid skull. Malignant tumors cause edema in brain tissue. The mechanisms are not entirely understood, but due to the difference in osmotic allegedly causing bleeding. Venous obstruction and edema caused by damage to the blood brain barrier, all lead to an increase in intracranial volume. Observation of the circulation of cerebrospinal fluid from the ventricle into the sub-arachnoid laseral cause hidrocepalus.

Increased intracranial pressure would endanger the life, when it occurs rapidly due to a cause that has been discussed previously. Compensation mechanism takes many days / months to be effective and therefore not useful when intracranial pressure arise quickly. This compensation mechanism among other works lowering intra-cranial blood volume, cerebrospinal fluid volume, intracellular fluid content and reduce parenchymal cells. The increase in pressure resulting in untreated ulcer or serebulum herniation. Herniation occurs when the medial lobe gyrus temporals shifted to inferior through territorial notch by the masses in the cerebral hemispheres. Herniation pressing metencephalon cause loss of consciousness and hit the third nerve. In the cerebellar herniation, tonsillar before shifting down through the foramen magnum by a posterior mass. Compression of the medulla oblongata and stop breathing occur quickly. Intracranial fast is progressive bradycardia, systemic hypertension (widening pulse pressure and respiratory problems).

Atelectasis - Symptoms, Prevention and Treatment

Atelectasis is the collapse of part or (much less commonly) all of a lung.

The primary cause of atelectasis is obstruction of the bronchus serving the affected area. This condition may be caused by obstruction of the major airways and bronchioles, by pressure on the lung from fluid or air in the pleural space, or by pressure from a tumor outside of the lung.

Symptoms of Atelectasis : Breathing difficulty, Chest pain, Cough, Fever, low-grade, usually after surgery.

Atelectasis is diagnosed by clinical exam, close monitoring of a post-operative clinical course, and x-ray.

Prevention of Atelectasis

• Encourage movement and deep breathing in anyone who is bedridden for long periods.
• Keep small objects out of the reach of young children.
• Maintain deep breathing after anesthesia.

Treatment of Atelectasis

If atelectasis is due to obstruction of the airway, the first step in treatment is to remove the cause of the blockage. This may be done by coughing, suctioning, or bronchoscopy. If a tumor is the cause of atelectasis, surgery may be necessary to remove it. Antibiotics are commonly used to fight the infection that often accompanies atelectasis. In cases where recurrent or long-lasting infection is disabling or where significant bleeding occurs, the affected section of the lung may be surgically removed.

Anxiety - NCP for Pulmonary Edema

Pulmonary edema is an abnormal buildup of fluid in the air sacs of the lungs, which leads to shortness of breath.

Early symptoms of pulmonary edema include:

• shortness of breath upon exertion
• sudden respiratory distress after sleep
• difficulty breathing, except when sitting upright
• coughing

In cases of severe pulmonary edema, these symptoms will worsen to:

• labored and rapid breathing
• frothy, bloody fluid containing pus coughed from the lungs (sputum)
• a fast pulse and possibly serious disturbances in the heart's rhythm (atrial fibrillation, for example)
• cold, clammy, sweaty, and bluish skin
• a drop in blood pressure resulting in a thready pulse

The health care provider will perform a physical exam and use a stethoscope to listen to your lungs and heart. The following may be detected:

• Abnormal heart sounds
• Crackles in your lungs, called rales
• Increased heart rate (tachycardia)
• Pale or blue skin color (pallor or cyanosis)
• Rapid breathing (tachypnea)

Nursing Diagnosis : Anxiety related to Threat / Change in Health Status

Goal: Anxiety can be overcome

Expected outcomes:

• Reported fear / anxiety disappear or decrease to the level that can be handled, looks relaxed and resting / sleeping properly.

Nursing Intervention :

1) Record the degree of anxiety and fear. Inform the patient / person close to the patient, the normal feelings and push expressing feelings.
Rational:
Understanding that feelings (which are based plus oxygen imbalances that threaten) normal can help patients improve some sense of emotional control.

2) Explain the disease process and procedures in the level of the patient's ability to understand and handle information. Assess the current situation and the measures taken to address the problem.
Rational:
Eliminate anxiety as insecurity and reduce fear about personal safety. In the early phase of explanation needs to be repeated with frequent and short because the patient has decreased the scope of attention.

3) Provide comfort measures, ie, back massage, change of positions.
Rational:
Tool to reduce stress and indirect care to enhance relaxation and coping skills.

4) Help patients to identify behavioral help, eg a comfortable position, focus on breathing, relaxation techniques.
Rational:
Giving patients control measures to reduce anxiety and muscle tension.

5) Support the patient / significant other in accepting the reality of the situation, especially the plan for a long period of recuperation. Involve patients in planning and participation in care.
Rational:
Coping mechanisms and participation in treatment programs may improve learning patients to receive the expected result of the disease and improve some sense of control.

6) Watch out for out of control behavior or increased cardiopulmonary dysfunction, eg worsening dyspnea and tachycardia.
Rational:
Developing the capacity of anxiety requires further evaluation and possible intervention with anti-anxiety medication.

Hyperthyroidism - Assessment and Nursing Diagnosis

Hyperthyroidism is a condition in which the thyroid gland makes too much thyroid hormone. The condition is often referred to as an "overactive thyroid."

Causes of Hyperthyroidism

• Hyperthyroidism occurs when the thyroid releases too much of its hormones over a short (acute) or long (chronic) period of time. Many diseases and conditions can cause this problem, including:
• Getting too much iodine
• Graves disease (accounts for most cases of hyperthyroidism)
• Inflammation (thyroiditis) of the thyroid due to viral infections or other causes
• Noncancerous growths of the thyroid gland or pituitary gland
• Some tumors of the testes or ovaries
• Taking large amounts of thyroid hormone

Symptoms of Hyperthyroidism

• Palpitations
• Heat intolerance
• Nervousness
• Insomnia
• Breathlessness
• Increased bowel movements
• Light or absent menstrual periods
• Fatigue
• Fast heart rate
• Trembling hands
• Weight loss
• Muscle weakness
• Warm moist skin
• Hair loss
• Staring gaze

Assessment for Hyperthyroidism

1. Health Perceptions
Knowledge of the disease and the side effects of drugs.

2. Metabolic Nutrition
Changes in food intake, such as appetite and increases food intake, body weight decreased.

3. Elimination
Changes in fecal elimination, increased frequency of bowel movements or many times. Every meal tend to defecate, urine in large quantities.

4. Activity and Exercise
Experiencing chest pain / angina, tachycardia despite the break, dysrhythmias, and murmur, dyspnea experienced during the activity / rest muscle weakness, severe accidents, muscle atrophy.

5. Rest and Sleep
Insomnia.

6. Cognitive Sensory
Complained of impaired vision rapid eye fatigue, blurred vision, orbital pain, exophthalmos.

7. Coping Mechanisms
Emotional instability, experiencing severe stress both emotional and physical, psychological conditions.

8. Sexual Relations
Decreased libido, hipomenorea, amenorrhoea and impotence.

9. Self-Concept
Less confident because of physical changes such as the eye.


Nursing Diagnosis for Hyperthyroidism

1. Decreased Cardiac Output
2. Fatigue
3. Disturbed Thought Processes
4. Imbalanced Nutrition
5. Anxiety
6. Impaired Tissue Integrity
7. Knowledge Deficit