Author: Dr. Prince

Nursing Care Plans for Hypothyroidism – Best Nursing Care Plans(2022)

This article discusses Nursing Care Plans for Hypothyroidism plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Hypothyroidism, also called underactive thyroid disease, is a common disorder. Hypothyroidism causes the thyroid gland not to make enough thyroid hormone. The thyroid gland is located in the front lower part of your neck. Hormones released by the gland travel through the bloodstream and affect nearly every part of your body, from your heart and brain to muscles and skin.

Thyroid Hormone

The thyroid controls how the body’s cells use energy from food through the process known as metabolism. Among other things, your metabolism affects the body’s temperature, heartbeat, and how well the body burns calories. Lack of enough thyroid hormone makes the body processes slow down. That means that the body makes less energy, and metabolism becomes sluggish.

Symptoms of Hypothyroidism

Symptoms of hypothyroidism may be vague and can often mimic other conditions. They may include:

Changes in the menstrual cycle
Constipation
Depression
Dry hair and hair loss
Dry skin
Elevated cholesterol
Fatigue
Greater sensitivity to cold
Hoarse voice
Joint pain, stiffness, and swelling
Problems with memory
Muscle aches and stiffness
Muscle weakness
Puffy face
Slow heart rate
Swelling of the thyroid gland (goitre)
Unexplained weight gain or difficulty losing weight
Carpal tunnel syndrome

Hypothyroidism Symptoms in Infants

Cold hands and feet
Constipation
Extreme sleepiness
Hoarse cry
Little or no growth
Low muscle tone (floppy infant)
Persistent jaundice (yellowing of the skin and whites of the eyes)
Poor feeding habits
Puffy face
Stomach bloating
Swollen tongue
Umbilical hernia

Hypothyroidism Symptoms in Teenager and Children

Delays in puberty
Delays in growth and shorter stature
Slow mental development
Slower development of permanent teeth

Causes of Hypothyroidism

The most common cause of hypothyroidism is Hashimoto’s thyroiditis. “Thyroiditis” is an inflammation of the thyroid gland. Hashimoto’s thyroiditis is an autoimmune disorder. With Hashimoto’s, your body produces antibodies that attack and destroy the thyroid gland. A viral infection may also cause thyroiditis.

Other causes of hypothyroidism include:

Radiation therapy to the neck area. Treating certain cancers, such as lymphoma requires radiation to the neck. Radiation damages the cells in the thyroid. This makes it more difficult for the gland to produce hormones.

Radioactive iodine treatment. This treatment is commonly prescribed to people who have an overactive thyroid gland, a condition known as hyperthyroidism. However, radiation destroys the cells in the thyroid gland. This usually leads to hypothyroidism.

Use of certain medications. Certain medicines to treat heart problems, psychiatric conditions, and cancer can sometimes affect the production of thyroid hormones. These include amiodarone (Cordarone, Pacerone), interferon alpha, and interleukin-2.

Thyroid surgery. Surgery to remove the thyroid will lead to hypothyroidism. If only part of the thyroid is removed, the remaining gland may still produce enough hormone for the body’s needs.

Too little iodine in the diet. The thyroid needs iodine to produce thyroid hormone. Your body doesn’t make iodine, so you need to get it through your diet. Iodized table salt is rich in iodine. Other food sources of iodine include shellfish, saltwater fish, eggs, dairy products, and seaweed. Iodine deficiency is rare in the U.S.

Pregnancy. The reason isn’t clear, but sometimes, thyroid inflammation occurs after pregnancy. This is called postpartum thyroiditis. Women with this condition usually have a severe increase in thyroid hormone levels followed by a sharp drop in thyroid hormone production. Most women with postpartum thyroiditis will regain their normal thyroid function.

Problems with the thyroid at birth. Some babies may be born with a thyroid gland that did not develop correctly or does not work properly. This type of hypothyroidism is called congenital hypothyroidism—most hospitals in the U.S. screen babies at birth for this disease.

Pituitary gland damage or disorder. Rarely, a problem with the pituitary gland can interfere with thyroid hormone production. The pituitary gland makes a hormone called thyroid-stimulating hormone (TSH), which tells your thyroid how much hormone it should make and release.

Disorder of the hypothalamus. An extremely rare form of hypothyroidism can occur if the hypothalamus in the brain does not produce enough of a hormone called TRH. TRH affects the release of TSH from the pituitary gland.

Primary hypothyroidism is caused by a problem with the thyroid gland itself.

Secondary hypothyroidism occurs when another problem interferes with the thyroid’s ability to produce hormones. For example, the pituitary gland or hypothalamus produces hormones that trigger the release of thyroid hormone. A problem with one of these glands can make your thyroid underactive.

Hypothyroidism Risk Factors

Women, particularly older women, are more likely to develop hypothyroidism than men. You are also more likely to develop hypothyroidism if you have a close family member with an autoimmune disease. Other risk factors include:

Race (being white or Asian)
Age (growing older)
Prematurely graying hair
Autoimmune disorders such as type 1 diabetes, multiple sclerosis, rheumatoid arthritis, celiac disease, Addison’s disease, pernicious anemia, or vitiligo
Bipolar disorder
Down syndrome
Turner syndrome

Diagnosis of Hypothyroidism

If you have symptoms of hypothyroidism, your doctor will order blood tests to check hormone levels. These may include:

Thyroid-stimulating hormone (TSH)

T4 (thyroxine)

Lower-than-normal T4 levels usually mean you have hypothyroidism. However, some people may have increased TSH levels while having normal T4 levels. This is called subclinical (mild) hypothyroidism. It is believed to be an early stage of hypothyroidism.

If your test results or physical exam of the thyroid are abnormal, your doctor may order a thyroid ultrasound or thyroid scan to check for nodules or inflammation.

Hypothyroidism Treatment

Doctors prescribe a synthetic (human-made) thyroid hormone T4 to treat hypothyroidism. This pill is taken daily.

Regular blood tests are required to check the thyroid hormone levels to enable the doctor to make any needed adjustments to medication dose from time to time.

If the dosage is too high, it causes several side effects, including:

Appetite increases
Can’t sleep
Heart palpitations
Shakiness

People with severe hypothyroidism or heart disease may start out with a low dose of synthetic hormone and then gradually increase the amount so their hearts can adjust to it.

Complications of Hypothyroidism

Untreated, hypothyroidism may cause complications, such as:

Balance problems. Older women are at extra risk for balance problems if their thyroid hormone levels are too low.
Goiter. If the thyroid is always trying to produce more hormones, the gland can swell and change the appearance of the neck.
Heart problems. Hypothyroidism puts a person at greater risk for heart disease and can raise LDL or “bad” cholesterol levels.
Infertility. Too little thyroid hormone may disrupt the production of eggs (ovulation) and make it harder to conceive.
Joint pain. Low levels of thyroid hormone can cause aches and pains in the joints and muscles and tendonitis.
Mental health issues. Low thyroid hormones can cause memory or concentration lapses and decreased interest in activities a person used to enjoy.
Obesity. Although hypothyroidism may curb your appetite, a person can gain weight because the metabolism slows down too and doesn’t burn enough calories.
Peripheral neuropathy. Over time, low thyroid hormones can damage the peripheral nerves. A person may notice pain, tingling, or numbness in the limbs.
Thyroid problems in a pregnant woman can affect the developing baby. During the first three months of pregnancy, the baby receives all thyroid hormones from its mother. If the mother has hypothyroidism, the baby does not get enough thyroid hormone. This can lead to problems with mental development.
Extremely low levels of thyroid hormone can cause a life-threatening condition called myxedema. Myxedema is the most severe form of hypothyroidism. A person with myxedema can lose consciousness or go into a coma. The condition can also cause the body temperature to drop very low, which can cause death.

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**Nursing Care Plans for Hypothyroidism**

Nursing Diagnosis for Hypothyroidism

Deficient Knowledge
Fatigue
Imbalanced Nutrition: More than Body Requirements

Nursing Care Plans for Hypothyroidism Based on Diagnosis

Nursing Care Plan 1: Diagnosis – Deficient Knowledge

It may be related to:

Lack of exposure to hypothyroidism.
New disease process.
Unfamiliarity with information resources.

Possibly evidenced by

Limited questioning about hypothyroidism and taking thyroid hormone replacement.
Verbalization of lack of information about the disease and its management.

Desired Outcomes

The patient and family members will verbalize correct information about hypothyroidism and taking thyroid hormone replacement.

Nursing Interventions	Rationale
Assess the patient’s knowledge of hypothyroidism and thyroid hormone replacement therapy.	Patient teaching should begin with the current knowledge about the disease and its management.
Provide information about hypothyroidism.	Patients experiencing hypothyroidism may have impaired memory, confusion, hearing loss, and a decreased attention span. These neurologic changes can hinder learning new information. Teaching sessions should be planned at times when the patient is best able to concentrate. Recalling information is needed to facilitate learning. Using written information reinforces verbal presentation.
Educate the patient and family regarding thyroid hormones.	Levothyroxine sodium (Synthroid) is an artificial thyroid hormone that is used to treat hypothyroidism.
Instruct the patient to take the dose in the morning to avoid insomnia.	Thyroid hormone should be taken regularly to achieve a hormone balance.
Instruct the patient to take the medication on an empty stomach.	The patient is initially given a small dose that gradually increases until a euthyroid state is achieved. When the thyroid hormone level increases, the patient experiences insomnia and weight loss.
Teach the expected benefits and possible side effects.	The patient should report symptoms such as chest pain/palpitations; these happen due to increased metabolic and oxygen consumption.
Emphasized the importance of rest periods.	Avoid undue fatigue; the activity level will eventually increase as the euthyroid state is achieved.
Encourage the patient to follow appointments for blood workups (T3, T4, and TSH levels).	These levels help determine the effectiveness of pharmacotherapy
Describe the signs and symptoms of over-and-under dosage of the medications.	This will serve as a check for the patient to determine if the therapeutic levels are met.
Encourage the patient to have medical identification about hormone therapy and to inform all health care providers.	Medical identification provides other health care providers with information to guide decisions about care. Levothyroxine is highly protein-bound in circulation. This drug characteristic contributes to many drug interactions. The patient needs to notify all health care providers about taking this drug.

Nursing Care Plan 2: Diagnosis – Fatigue

It may be related to an impaired metabolic state.

Possibly evidenced by:

Lethargic or listless.
Compromise concentration.
Increased rest requirements.
Unable to complete the desired activities.
Verbalizes overwhelming lack of energy.

Desired Outcomes

The patient will identify the basis of fatigue and individual areas of control.

The patient will verbalize a reduction of fatigue and increase the ability to complete desired activities.

Nursing Interventions	Rationale
Assess the patient’s ability to perform activities of daily living (ADLs).	With minimal exertion, the patient may experience fatigue due to a slow metabolic rate. This symptom hinder the patient’s ability to perform daily activities (e.g., self-care, eating)
Note daily energy patterns.	This will help in determining the pattern/timing of activity.
Assess the patient’s energy level, muscle strength, and muscle tone.	A slow metabolism can result in decreased energy levels. The muscle may be weaker and joints stiffer due to mucin deposits in joints and interstitial spaces. This type of cellular edema may contribute to delayed muscle contraction and relaxation. The patient may report generalized weakness and muscle pain.
Plan care to allow individually adequate rest periods. Schedule activities for periods when the patient has the most energy.	This will ensure maximum participation.
Provide stimulation through conversation and nonstressful activities.	Promotes interest without putting too much stress on the patient.
Promote an environment conducive to relieving fatigue.	Patient with hypothyroidism often complains of being cold even in a warm environment.

Nursing Care Plan 3: Diagnosis – Unfamiliarity with information resources.

It may be related to greater intake than metabolic needs.

Possibly evidenced by:

Decreased appetite.
Sedentary activity level.
Weight gain.

Desired Outcomes

A patient will maintain a stable weight and take in necessary nutrients.

Nursing Interventions	Rationale
Assess the patient’s weight.	Due to excess fluid volume and low basal metabolic rate, patients with hypothyroidism experience weight gain and difficulty losing extra weight
Assess the patient’s appetite.	Patients with hypothyroidism have decreased appetite. This opposite relationship between weight gain and decreased appetite is a manifestation finding in hypothyroidism.
Provide a food diary to the patient.	Looking into the patient’s food intake over the 24 hours will provide baseline data for an individualized nutritional plan for the patient’s changing metabolic needs.
Educate the patient and family regarding body weight changes in hypothyroidism.	Teaching the patient and family will make them understand the opposite relationship between appetite and weight gain in hypothyroidism. During the start of the thyroid hormone replacement therapy, the patient can experience weight loss. However, there will be an increase in appetite. This change may require a calorie-controlled diet to prevent additional weight gain.
Collaborate with a dietician to determine the patient’s caloric needs.	The dietician can calculate the appropriate caloric requirements to maintain nutrient intake and achieve a stable weight.
Encourage the patient to eat six small meals throughout the day.	This will make sure that the patient has an adequate intake of nutrients in the patient with decreased energy levels.
Provide assistance and encouragement as needed during mealtime.	Due to a decrease in energy levels, the patient will need support to ensure the adequate intake of essential nutrients.
Encourage the intake of foods rich in fiber.	Hypothyroidism slows the action of the digestive tract causing constipation.
Encourage the patient to follow a low-cholesterol, low-calorie, low-saturated-fat diet.	When thyroid hormone levels are low, the body doesn’t break down and remove bad cholesterol as efficiently as usual; Also, since the patient has a slow metabolism, they require fewer calories to support the metabolic need.

Related FAQs

1. What are some nursing interventions for hyperthyroidism?

Nursing Management

Monitor vital signs, especially heart rate and blood pressure (both increase in hyperthyroidism)
Ask if the patient has chest pain (Due to increased heart work)
Listen to the heart for murmurs.
Obtain ECG (atrial arrhythmias may occur in hyperthyroidism)
Teach the patient to relax.

2. What can you teach a patient with hypothyroidism?

Start slow, with a 5 to 15 minute walk each day. Try to work up to 10,000 steps, or 3 20-minute walks each day. Remember, hypothyroidism is associated with increased cholesterol and an increased risk of heart disease. Correcting hypothyroidism generally improves cholesterol levels.

3. What is hypothyroidism nursing?

Hypothyroidism is a disorder in which the thyroid produces and releases insufficient thyroid hormone into the bloodstream, also known as underactive thyroid, which causes fatigue, weight gain, and an inability to tolerate cold temperatures.

4. What would be the priority intervention for the nurse to do for a patient in thyroid storm?

If thyroid storm is suspected, emergency treatment needs to be instituted immediately. Patients may need cardiac monitoring, intubation and mechanical ventilation with supplemental oxygen, and IV fluids. The patient requires antithyroid medications and may receive IV corticosteroids and beta-adrenergic medications.

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May 5, 2022

Nursing Care Plans for Impaired Urinary Elimination – Best Nursing Care Plans(2022)

This article discusses Nursing Care Plans for Impaired Urinary Elimination plus its causes, symptoms, preventions, treatments, and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

The body is a complicated system of organs and systems that work together to produce nourishment for the organism’s survival. The urinary tract is one such organ that plays a vital role in this process. It removes excess water, electrolytes, acids, and other substances from your bloodstream, preventing them from being reabsorbed. If you have a problem with any part of this procedure, you may have problems with urine elimination (IUE).

Impaired urinary elimination can be unpleasant and inconvenient, and it can significantly influence one’s quality of life. Nurses can help patients understand what’s causing their symptoms and how to avoid or manage them.

Impaired Urinary Elimination

Impaired urinary elimination is the inability to remove body wastes from the kidneys in urine. Impaired urinary elimination can be caused by a physical anomaly, a sensory impairment, or a side effect of an illness or disease. Bladder distention, painful urination, and a complete loss of bladder control are all possible symptoms. Treatment options range from noninvasive bladder training to surgical procedures, depending on the cause.

Causes of Impaired Urinary Elimination

There are many possible causes for impaired urine production and excretion. Many of these can be divided into obstructive causes and non-obstructive.

Obstructive Causes

This is usually due to enlargement of the distal urethra and bladder or narrowing of the urethral lumen. These obstructions are considered partial if there is some flow through the obstacle without severe discomfort. Obstruction can result from benign prostatic hyperplasia (BPH), urinary tract infections (UTIs), urethral strictures, or bladder stones, as well as a pelvic mass.

Non Obstructive Causes

Infection such as UTI or prostatitis
Vaginal yeast infections (Candida)
Autoimmune disorders like Lupus
Dementia
Diabetes mellitus type 1 or 2
Parkinson’s disease
Other factors such as fever, dehydration, or a lack of fluids can also contribute to an inability to urinate normally.

Signs and Symptoms of Impaired Urinary Elimination

Frequency or incontinence

Urgency to urinate

Pain during urination

Difficulty starting urination

Blood in the urine (hematuria)

Cloudy urine due to bacterial infection

Increased thirst

Unusual discharge from the reproductive organs (dysuria)

Factors Related to Impaired Urinary Elimination

The following are some of the factors that are closely related to impaired Urinary elimination:

Bladder outlet obstruction
Bladder atony
Diminished bladder cues
Decreased bladder capacity
Disruption in bladder innervation
Environmental barriers
Multiple causalities
Small bladder
Sensory-motor impairment
Incompetent bladder

Nursing Care Plans for Impaired Urinary Elimination

Goals and Outcomes

The following are the common goals and expected outcomes for impaired urinary elimination:

**Nursing Care Plans for Impaired Urinary Elimination**

Patient demonstrates behaviors and techniques to prevent retention/urinary infection.
Patient identifies the cause of incontinence.
Patient maintains balanced I&O with clear, odor-free urine, free of bladder distension/urinary leakage.
Patient provides a rationale for treatment.
Patient verbalizes understanding of the condition.

Nursing Care Plan 1: Urethritis

Nursing Diagnosis: Impaired Urinary Elimination related to urethritis as evidenced by dysuria and urinary frequency

Desired Outcome: The patient will be able to achieve a normal pattern of urinary elimination.

Interventions	Rationales
Assess the patient’s current pattern of elimination and compare it with their normal pattern before the manifestations/ symptoms of benign prostatic hyperplasia/ hypertrophy.	To establish baseline data on urinary elimination pattern
Administer the prescribed antibiotic for urethritis. The choice of antibiotic is based on the urine culture and sensitivity test result. The usual course of antibiotics for urethritis runs for 7 to 10 days.	To treat the underlying infection.
Palpate the bladder and observe for bladder distention.	To check for bladder distention and bladder retention.
Encourage the patient to void every 2 to 3 hours.	To facilitate flushing of bacteria from the bladder and avoid urine accumulation.
Teach the patient some lifestyle changes related to the prevention of urethritis. Including proper perineal hygiene, adequate oral hydration (at least 2 liters of fluids per day, if not contraindicated), and avoidance of undergarments that have non-breathing materials or are constricting/ tight-fitting	Wiping the perineal area from front to back rather than back to front can prevent the travel of normal flora of the anus to the urethra, where they become UTl-causing pathogens. Adequate oral hydration results in more urine production leading to flushing bacteria from the bladder once the urine is eliminated. Undergarments that are made of non-breathing or tight-fitting promote moisture formation. This encourages bacteria growth.
Encourage the patient to avoid or reduce the intake of urinary irritants such as colas, alcohol, tea, and coffee.	To aid in the recovery of the patient.

Nursing Care Plan 2: Benign Prostatic Hypertrophy/ Hyperplasia (BPH)

Nursing Diagnosis: Impaired Urinary Elimination secondary to mechanical obstruction due to an enlarged prostate, as evidenced by dysuria and urinary frequency

Desired Outcome:

The patient will be able to achieve a better pattern of urinary elimination as evidenced by post-void residuals of less than 50 ml without any dribbling.

Interventions	Rationales
Assess the patient’s current pattern of elimination and compare it with their normal pattern (i.e., before urethritis).	To establish baseline data on urinary elimination pattern
Administer the prescribed medication for BPH	To treat the underlying cause of impaired urinary elimination, which is the mechanical obstruction of urine flow due to the enlargement of the prostate.
Palpate the bladder and observe for bladder distention.	To check for bladder distention and bladder retention.
Encourage the patient to void every 2 to 3 hours.	To avoid urine accumulation and alleviate bladder distention
Insert an indwelling catheter as required	To help evacuate urine from the bladder. Catheterization might be uncomfortable for a BPH patient, but it effectively relieves pain and discomfort due to an overly distended bladder.
Educate the patient about sitz bath.	Sitz bath has been proven effective in relaxing urinary muscles and reducing edema if any. It also promotes comfort and pain relief due to the enlarged prostate.
Teach the patient some lifestyle changes related to impaired urinary elimination, including proper perineal hygiene, adequate oral hydration (at least 2 liters of fluids per day, if not contraindicated), and avoidance of undergarments that have non-breathing materials or are constricting/ tight-fitting	Wiping the perineal area from front to back rather than back to front can prevent the travel of normal flora of the anus to the urethra, where they become UTl-causing pathogens. Adequate oral hydration results in more urine production leading to flushing bacteria from the bladder once the urine is eliminated. Undergarments made of non-breathing materials or are tight-fitting may add to the patient’s discomfort.
Encourage the patient to avoid or reduce the intake of urinary irritants such as colas, alcohol, tea, and coffee.	To aid in the recovery of the patient.

Nursing Care Plan 3: Urolithiasis (Stones in the Urinary Tract)

Nursing Diagnosis: Impaired Urinary Elimination related to the formation of stones in the urinary tract as evidenced by pain when voiding, dysuria, distended bladder, and urinary frequency

Desired Outcome

The patient will be able to achieve a better pattern of urinary elimination as evidenced by painless urinary elimination, improving bladder muscle tone, and normal urinary frequency.

Interventions	Rationales
Assess the patient’s current pattern of elimination and compare it with their normal pattern (i.e., prior to urolithiasis).	To establish baseline data on urinary elimination pattern
Administer alpha-blockers as prescribed.	Currently, there is no medication to treat urolithiasis directly. However, alpha-blockers may be administered to relax the muscles of the ureter. This will enable the small renal stones (renal calculi) to pass and be eliminated from the body.
Palpate the bladder and observe for bladder distention. Use a portable bladder scanner as needed.	To check for bladder distention and bladder retention.
Encourage the patient to void every 2 to 3 hours.	To facilitate flushing the renal calculi from the bladder and avoid urine accumulation.
Insert an indwelling catheter as required.	To help evacuate urine, stone, and other debris from the bladder.
Strain every urine voided and document the renal stone and urine characteristics.	The characteristic renal stones and urine provide crucial information in the further treatments that of the renal are needed by the patient.
Teach the patient some lifestyle changes related to preventing more renal stones. These include: adequate oral hydration(at least 2 liters of fluids per day, if not contraindicated), drink fruit juices, particularly cranberry.	Adequate oral hydration results in more urine production leading to flushing of debris, small renal stones, and bacteria from the bladder once the urine is eliminated. Fruit juices help acidify urine. juice
Collect blood samples for renal function tests.	To monitor the status of kidney function.
Encourage the patient to avoid or reduce the intake of urinary irritants such as colas, alcohol, tea, and coffee.	To aid in the recovery of the patient.

Nursing Care Plan 4: Renal Failure

Impaired Urinary Elimination related glomerular malfunction to secondary to renal failure as evidenced by an increase in lab results (BUN, creatinine, uric acid, and eGFR levels), oliguria or anuria, and urinary retention

Desired Outcome

The patient will actively participate in the treatment plan and will be able to demonstrate behaviors that will help prevent complications.

Interventions	Rationales
Assess the patient’s current pattern of elimination and compare it with their normal pattern prior to having	To establish baseline data on urinary elimination pattern
Weigh the patient daily. Commence strict input and output monitoring. Note the characteristics of the urine.	To assess the fluid volume status of the patient. To check for signs of worsening renal function and perfusion.
Palpate the bladder and observe for bladder distention. Use a bladder scan as needed.	To check for bladder distention and bladder retention.
Teach the patient some lifestyle changes, including proper perineal hygiene, adequate oral hydration (at least 2 liters of fluids per day, if not contraindicated), and avoid undergarments that have non-breathing materials or are constricting/ tight-fitting.	To promote wellness and prevent UTI. Acute renal failure is a major risk factor for UTIs due to reduced immunity and related metabolic disorders. Wiping the perineal area from front to back rather than back to front can prevent the travel of normal flora of the anus to the urethra, where they become UTl-causing pathogens. Undergarments made of non breathing materials or tight-fitting promote moisture formation. This encourages bacterial growth.
Collect blood samples for renal function tests.	To monitor the status of kidney function.
Encourage the patient to avoid or reduce the intake of urinary irritants such as colas, alcohol, tea, and coffee.	To aid in the recovery of the patient.

Nursing Care Plan 5: Guillain-Barre Syndrome

Nursing Diagnosis: Impaired Urinary Elimination related to neuromuscular impairment secondary to Guillan Barre Syndrome as evidenced by distended bladder, paralysis, and urinary retention

Desired Outcome

The patient will be able to achieve a better pattern of urinary elimination as evidenced by painless urinary elimination, improving bladder muscle tone, and post-void residuals of less than 50 ml.

Interventions	Rationales
Assess the patient’s current pattern of elimination. Assess the effect of paralysis on the patient’s elimination	To establish baseline data on urinary elimination patterns.
Palpate the bladder and observe for bladder distention. Use a portable bladder scanner as needed.	To check for bladder distention and bladder retention.
Encourage the patient to void every 2 to 3 hours.	To facilitate emptying the bladder and avoid urine retention and bladder distention.
Insert an indwelling catheter as required.	To help evacuate urine and debris from the bladder.
Commence an input and output chart	To monitor the patient’s in important data on the pat
Teach the patient some lifestyle changes, including proper perineal hygiene, adequate oral hydration (at least 2 liters of fluids per day, if not contraindicated).	Adequate oral hydration results in more urine production leading to flushing of debris, small renal stones, and bacteria from the bladder once the urine is eliminated.
Collect blood samples for renal function tests.	To monitor the status of kidney function.
Encourage the patient to avoid or reduce the intake of urinary irritants such as colas, alcohol, tea, and coffee.	To aid in the recovery of the patient.

Summary

The inability to completely empty the bladder is known as urinary retention. It is either acute or chronic in nature. Prostate enlargement and elderly individuals are the most typical causes of this illness in men. Managing the underlying reasons, resolving infections such as UTIs and prostatitis, and using non-steroidal anti-inflammatory medicines are all options for treatment (NSAIDs).

Related FAQs

1. What are interventions for impaired urinary elimination?

Nursing Interventions

Encourage adequate fluid intake (2–4 L per day), avoiding caffeine and use of aspartame, and limiting intake during late evening and at bedtime. Recommend use of cranberry juice/vitamin C. Sufficient hydration promotes urinary output and aids in preventing infection.

2. What are the priority nursing diagnosis related to urinary elimination?

A literature search combined with clinical observation and review of anatomy and physiology helped to identify five specific nursing diagnoses. They are: urinary retention, stress incontinence, urge incontinence, reflex incontinence, and uncontrolled incontinence.

3. Is impaired elimination a nursing diagnosis?

Impaired Urinary Elimination is a NANDA diagnosis that refers to any disturbance to the urine elimination. It is commonly used to create a nursing care plan for patients with genito-urinary disorders, such as urinary tract infections or UTIs, and renal diseases, such as acute kidney injury and chronic renal failure.

4. What are some nursing interventions for elimination?

Common nursing interventions related to facilitating elimination include inserting and managing urinary catheters, obtaining urine specimens, caring for ostomies, providing patient education to promote healthy elimination, and preventing complications.

5. What is urinary elimination care?

Urinary elimination is a basic human function that can be compromised by illness, surgery, and other conditions. Urinary catheterization may be used to support urinary elimination in patients who are unable to void naturally. Urinary catheterization may be required: In cases of acute urinary retention.

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May 4, 2022

Nursing Care Plans for Impaired Skin Integrity – Best Nursing Care Plans(2022)

This article discusses Nursing Care Plans for Impaired Skin Integrity plus its causes, symptoms, preventions, treatments and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

The skin is the largest organ in the human body and is a protective barrier. It protects the body from heat, light, injury, and infection. Skin integrity relates to skin health. A skin integrity problem might indicate the skin is damaged, exposed to injury, or inefficient to repair and recover normally. The key marker of quality care is the maintenance of skin integrity and preventing pressure ulcers. With this, the nurse must identify at-risk individuals and the myriad factors that place patients at risk for skin damage.

Pressure, shear, and friction from immobility put an individual at risk for altered skin integrity. Patients who are overweight, paralyzed, with spinal cord injuries, those who are bedridden and confined to wheelchairs, and those with edema are also at the highest risk for altered skin integrity. Other factors that hasten skin breakdown include age, the normal loss of elasticity, inadequate nutrition, environmental moisture, and vascular insufficiency. Special beds, mattresses, and other useful devices provide pressure relief and pressure redistribution.

Nurses should have the skills and knowledge to deal with patients at risk for impaired skin integrity because overall skin assessment is not a one-time event confined to admission. It demands to be repeated regularly to ascertain whether any alterations in skin condition have transpired. Training in wound management can help in creating impaired skin integrity care plans.

Nursing Care Plans for Impaired Skin Integrity – Causes of Impaired Skin Integrity

Internal:

Poor nutritional state (obesity, emaciation, dehydration)
Edema
Impaired circulation
Neuropathy
Disease processes (diabetes, autoimmune disorders)

External:

Hyperthermia
Hypothermia
Radiation
Chemicals
Extremes in age
Physical immobilization/bedrest
Paralysis
Surgery
Cognitive impairment
Moisture/secretions
Shearing/friction/pressure

Nursing Care Plans for Impaired Skin Integrity – Signs and Symptoms Impaired Skin Integrity

Pain
Itching
Numbness to affected and surrounding skin

Nursing Assessment for Impaired Skin Integrity

The following nursing assessments are done for the nursing diagnosis risk for impaired skin integrity that you can use in your “assessment column” in developing your impaired skin integrity care plan.

**Nursing Care Plans for Impaired Skin Integrity**

Assessment	Rationale
Assess the overall condition of the skin.	Assessment of the skin condition provides baseline data for possible interventions for the nursing diagnosis Risk for Impaired Skin Integrity. Normal skin condition differs among individuals. Healthy skin should have good turgor (an indication of moisture), feel warm and dry to the touch, be free from impairment (cuts, wounds, abrasions, excoriation, outbreaks, and rashes), and have quick capillary refill (less than 6 seconds). Patients with advanced age are at high-risk risk for skin impairment because the skin is less elastic, has less moisture, and has thinning of the epidermis.
Check on bony prominences such as the sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of the head).	Specific areas where the skin is stretched tautly are at higher risk for the breakdown because the possibility of ischemia to the skin is high as a result of compression of skin capillaries between a hard surface (e.g., mattress, chair, or table) and the bone. For lightly pigmented skin, pressure areas appear to be red. These areas appear to be red, blue, or purple hue spots for darker skin tones.
Evaluate the patient’s awareness of the sensation of pressure.	Usually, individuals change position off pressure areas every few minutes; these occur automatically, even during sleep. Patients who are unaware of sensation tend to do nothing, thus resulting in prolonged pressure on skin capillaries and eventually in skin ischemia.
Use an objective tool for pressure ulcer risk assessment.	These are validated tools for risk assessment. Acute care: Assessment should be every 24 to 48 hours or sooner if the patient’s condition changes. Long-term care: Assess on admission, weekly for 4 weeks, and then quarterly and whenever resident’s condition changes.
Braden Scale	This is a widely used scale. It consists of six subscales: sensory, perception, moisture, activity and mobility, nutrition, and friction/shear.
Norton scale	This system remains popular due to its ease of use. It includes the assessment of physical condition, mental condition, activity, mobility, and incontinence.
Evaluate the patient’s strength to move (e.g., shift weight while sitting, turn over in bed, move from bed to chair).	The greatest risk factor in skin breakdown is immobility.
Assess patient’s nutritional status, including weight, weight loss, and serum albumin levels.	An albumin level less than 2.5 g/dL is a grave sign, indicating severe protein depletion and a high risk of skin breakdown.
Assess for fecal/urinary incontinence.	Stool may contain enzymes that cause skin breakdown. The urea in urine turns into ammonia within minutes and is caustic to the skin. Use of diapers and incontinence pads hastens skin breakdown.
Assess for history or presence of AIDS or other immunological problems.	Skin lesions or Kaposi’s sarcoma is an early manifestation of diseases related to HIV.
Assess for a history of radiation therapy.	Radiated skin becomes thin and friable, may have less blood supply, and is at higher risk for breakdown.
Assess for edema.	Skin tightened tautly over edematous tissue is at risk for impairment.
Assess the amount of shear (pressure exerted laterally) and friction (rubbing) on the patient’s skin.	A typical cause of shear is elevating the head of the patient’s bed: the body’s weight is displaced downward onto the patient’s sacrum. Typical causes of friction include the patient rubbing heels or elbows against bed linen and moving the patient up in bed without the use of a lift sheet.
Assess the surface that the patient consumes most of his or her time on (e.g., mattress for a bedridden patient, cushion for people in wheelchairs).	Patients who spend the majority of their time on one surface require a pressure reduction or pressure relief device to distribute pressure more evenly and reduce the risk for breakdown.
Assess for environmental moisture (e.g., wound drainage, high humidity).	Moisture may contribute to skin maceration.
Assess the skin for:
Dermatitis or exposure to chemical irritants	These conditions can cause inflammation, resulting in redness and itching, and may cause blisters.
Pruritus (itching) or mechanical trauma	Itching or mechanical traumas can result in disruptions to skin integrity and reduce its barrier function.
Long-term steroid use.	Long-term steroid use may leave skin papery thin, and prone to injury.
Reassess the skin regularly and whenever the patient’s condition or treatment plan results in an increased number of risk factors.	The incidence and onset of skin breakdown are directly related to the number of risk factors present.

Nursing Care Plans for Impaired Skin Integrity Based on Diagnosis

Nursing Care Plans for Impaired Skin Integrity: Care Plan 1 – Diagnosis: Kawasaki Disease

Impaired skin integrity related to edema formation secondary to Kawasaki disease. Evidenced by bilateral swelling of the legs and feet and a small cut on the left ankle.

Desired Outcome

A patient will have healed left ankle wound, and further skin damage will be prevented.

Interventions	Rationales
Assess the skin for its integrity, color, moisture, and texture.	Kawasaki disease affects the skin and can cause erythematous rashes and edema, particularly on the hands, arms, legs, and feet.
Assess the level of edema on the legs and cut on the ankle	Baseline data will help in the evaluation of progress after interventions are made.
Encourage the patient to elevate legs and avoid putting them in a dependent position for a long period of time.	Putting legs in a dependent position will worsen leg edema.
Encourage mobility	Physical activity helps promote circulation and fluid drainage.
Dress wounds as needed, avoiding tight, constricting, and sticky dressings.	As needed, the wound will need to be dressed and cleaned. Sticky dressings may be challenging to remove and cause further damage.
Encourage patient to avoid wearing constricting clothing	Tight clothing can further irritate skin damage and rashes.
Encourage proper hydration	Dehydration can cause further skin injury due to skin dryness.

Nursing Care Plans for Impaired Skin Integrity: Care Plan 2 – Diagnosis: Diabetes

Risk for impaired skin integrity due to decreased circulation from popliteal artery obstruction secondary to Type 2 diabetes

Desired Outcome

The patient’s foot will remain intact while waiting for vascular treatment.

Interventions	Rationales
Assess skin integrity, taking note of color, moisture, texture, and pulses regularly.	Baseline data is needed for prompt evaluation after interventions are made. It will also help in the regular assessment of the progress of nursing care.
Encourage the use of footwear at all times.	Diabetes can affect sensation in the extremities. Patients may not notice the injury.
Encourage daily moisturization of feet.	Moisturizing feet every day provides an opportunity to assess the integrity of the feet daily. Also, moisturizing the feet helps keep their intact skin integrity.
Check water temperature when washing feet.	Patients may not notice if the water is too hot due to reduced sensation.
Encourage patient to maintain short toenails	Long toenails can cause damage to the skin.
Discuss smoking cessation programs if the patient is a smoker	Vascular problems are worsened by smoking, also, the success of vascular treatments such as angioplasty can be affected if the patient will not stop smoking after having it.
Monitor and maintain a normal blood sugar level Hyperglycemia and hypoglycemia can both affect vascular health.
Review medications	Some medications used in type 2 diabetes can predispose patients to foot problems, though research is still inconclusive.
Prepare patient for vascular treatment.	Depending on the medical plan, the patient may have to undergo surgical treatment.

Nursing Care Plans for Impaired Skin Integrity: Care Plan 3 – Diagnosis: Pressure ulcers / Bedsores

Impaired skin integrity secondary to decreased mobility. Evidenced by the presence of a stage 2 pressure ulcer on the sacrum.

Desired Outcome

The patient’s bedsore will show optimal healing, and further bedsores will be prevented.

Interventions	Rationales
Assess and record the integrity of the skin	To provide baseline data to assess care.
Regularly assess the condition of bedsoreTo regularly assess the progress of healingPromote regular turning or position changeTo prevent prolonged pressure on one area of the bodyAssess the ability of the patient to mobilizeTo assess the extent of physical activities that the patient can do.
Provide appropriate mattress and cushion	Pressure release mattresses and cushions are helpful to prevent sores from occurring, and they help spread equal pressure to the body when sitting and lying down.
Clean and dress bedsore as needed	Sacral sores are prone to infection due to their location.
Clean or assist the patient in cleaning himself after opening bowels	due to the location of bedsore, it can easily be reached by stool when bowels are opened.
Refer to physiotherapy	Physiotherapists can help assess mobility and advise on positioning and mobility aids.
Change sheets regularly and avoid folds and creases.	Creases on sheets can cause pressure on the skin.
Provide pain relief as needed	Bedsores can be uncomfortable for patients. Providing pain relief will help encourage patients to mobilize and change positions.

Nursing Care Plans for Impaired Skin Integrity: Care Plan 4 – Diagnosis: Impetigo

Impaired Skin Integrity related to infection of the skin secondary to impetigo.

Evidenced by:

Red sores around the area of the nose and mouth
Discharge from the sores for a couple of days
Development of yellowish-brown crust,
Mild itching
Pain
Soreness

Desired Outcome

The patient will re-establish healthy skin integrity by following a treatment regimen for impetigo.

Intervention	Rationale
Assess the patient’s skin on his/her whole body.	To determine the severity of impetigo and any affected areas that require special attention or wound care.
Isolate the patient in his/her room, at home, ideally for 10 days.	Impetigo is an infectious/ communicable skin disease. The patient needs to be isolated ideally for 7 to 10 days after starting treatment.
The affected area should be soaked first in warm water to remove the scabs, wet compresses may also be used. This is followed by the application of the prescribed antibiotic cream or ointment directly to the affected areas.	Removal of scabs prior to applying the topical antibiotic promotes good absorption of the medication.
Administer antibiotics as prescribed. Ensure that the patient finishes the course of antibiotics prescribed by the physician.	Impetigo is generally treated through the use of antibiotic therapy. If the infection is mild and has not spread to other areas of the body, the sores can be treated through the use of over-the-counter antibiotic cream containing bacitracin as a home remedy. Application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection. The doctor may also prescribe oral antibiotic drugs in patients who have a lot of impetigo sores. Even if the symptoms have already improved and healing is evident, it is still essential to finish the course of antibiotic therapy to prevent recurrence of infection and antibiotic resistance.
Educate the patient and caregiver about proper wound hygiene by washing the sores with soap and water. Advise the patient and caregiver to prevent scratching the affected areas.	It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. The sores may cause mild itching, but it is advisable to prevent the child from scratching the affected areas to prevent the worsening of the infection.
Teaching the patient/ caregiver the proper application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection.	Proper application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection.

Nursing Care Plans for Impaired Skin Integrity: Care Plan 5 – Diagnosis: Necrotizing Fasciitis/ Skin Gangrene

Impaired Skin Integrity related to the infective process of necrotizing fasciitis.

Evidenced by:

Positive tissue biopsy result
Gangrenous skin tissue
Erythema
Pain on the affected site

Desired Outcome

The patient will be able to experience optimal wound healing and avoid the spread of infection to the rest of the skin to preserve its integrity.

Interventions	Rationales
Assess vital signs and monitor the signs of infection.	To establish baseline observations and check the progress of the infection as the patient receives medical treatment.
Prepare the patient for surgical debridement.	It involves the resection of the gangrenous tissue to prevent further spread of the condition to other vital organs. It involves extensive and complete removal of dead tissue even beyond the area of necrosis.
Place silver-containing dressings on the affected site/s after each debridement.	Dressings containing silver compounds are helpful in addressing the topical and direct antibiotic treatment of the affected tissues.
Administer the prescribed antibiotics.	To treat the underlying bacterial cause of necrotizing fasciitis.
Encourage proper hand hygiene and skincare.	To preserve integrity to the rest of the skin.

Related FAQs

1. What is the nursing diagnosis for impaired skin integrity?

Nursing Diagnosis: Impaired skin integrity (pressure ulcers) secondary to decreased mobility as evidenced by presence of stage 2 pressure ulcer on the sacrum. Desired Outcome: Patient’s bedsore will show optimal healing, and further bedsores will be prevented.

2. What nursing interventions are essential to maintain skin integrity?

The following are strategies to promote and maintain skin integrity: Moisturize dry skin to maximize lipid barriers; moisturize at minimum twice daily. Avoid hot water during bathing; this will increase dry, cracked skin. Protect skin with a moisture lotion or barrier as indicated.

3. What is a goal for impaired skin integrity?

GOAL: Promote circulation to tissues by reducing or eliminating pressure. Possible risk factors that decrease circulation or cause unrelieved pressure to tissues: ▪ Immobility (diagnosis that leads to immobility, such as CVA, MS, end stage Alzheimer’s, etc.) ▪ Decreased sensory perception

4. How do you promote good skin integrity?

KEEP THE SKIN CLEAN AND DRY: Clean the skin with a mild soap and warm water and rinse thoroughly. Gently pat dry.
Apply Lotions and ointments as prescribed- to prevent skin breakdown. This promotes skin integrity. …
Never massage over an area of skin that is reddened or there is skin breakdown.

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May 4, 2022

Nursing Care Plans for Hyponatremia – Best Nursing Care Plans (2022)

This article discusses Nursing Care Plans for Hyponatremia plus its causes, symptoms, preventions, treatments and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Hyponatremia is a condition in which your blood contains insufficient sodium. You require sodium in your bloodstream to keep track of how much water is in and around your body’s cells.

It can occur due to medical issues, medications you may be on, or excessive water consumption.

The amount of water in your body grows due to the low sodium, causing your cells to inflate. This can cause a slew of issues. Some are minor, but others can be dangerous and even fatal.

If your blood sodium level is between 135 and 145 milliequivalents per liter (mEq/L), it’s normal. It’s hyponatremia if it’s less than 135 mEq/L.

Symptoms of Hyponatremia

If your hyponatremia is minor, you may not have any symptoms. Symptoms usually arise when your sodium level rises or falls unexpectedly.

Hyponatremia symptoms include:

Vomiting and nausea

Fatigue

Confusion or a headache

Muscle cramps or spasms are common symptoms of menopause.

Irritability and agitation

Weakness

Severe Hyponatremia Symptoms

Nausea or vomiting

Confusion

Seizures

Coma or loss of awareness

Causes of Hyponatremia

Sodium is an essential nutrient in your body. It keeps your blood pressure in check, supports your nerves and muscles, and keeps your body’s fluid balance in check.

Sodium levels in the blood should be between 135 and 145 milliequivalents per liter (mEq/L). When the sodium level in your blood goes below 135 mEq/L, you have hyponatremia.

Hyponatremia can be caused by a variety of illnesses and lifestyle factors, including:

Medications in particular. Some medications, including diuretics, antidepressants, and pain relievers, can interfere with the normal hormonal and kidney processes that keep sodium levels in the healthy normal range.

Problems with the heart, kidneys, and liver. Fluid accumulation in the body can be caused by congestive heart failure and certain disorders of the kidneys or liver, which dilute the sodium in the body and lower the overall level.

Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH). High quantities of the anti-diuretic hormone (ADH) are produced in this disease, causing your body to retain water rather than excreting it regularly through your urine.

Dehydration is caused by chronic, severe vomiting or diarrhea and other factors. This causes your body to lose electrolytes like sodium while raising ADH levels.

Drinking an excessive amount of water. Excessive water consumption can induce low sodium levels by obstructing the kidneys’ capacity to eliminate water. Drinking too much water during endurance exercises like marathons and triathlons might dilute the sodium concentration of your blood because you lose sodium through sweat.

Hormonal shifts Adrenal gland insufficiency (Addison’s disease) impairs the ability of your adrenal glands to generate hormones that assist keep your body’s sodium, potassium, and water balance in check. Low thyroid hormone levels can also cause low blood sodium levels.

Ecstasy – recreational drug. This amphetamine raises the risk of hyponatremia, which can be severe and even fatal.

Adrenal gland disorders. Conditions related to the adrenal gland can cause either inadequate or too much production of hormones that help regulate sodium, potassium, and water levels.

Risk Factors of Hyponatremia

Factors that may increase the risk of hyponatremia include:

Age. Hyponatremia may be more common in older persons due to age-related changes, the use of certain drugs, and a higher risk of developing a chronic disease that disrupts the body’s sodium balance.

Certain medications. Thiazide diuretics, as well as several antidepressants and pain relievers, can make you more susceptible to hyponatremia. Ecstasy, a recreational drug, has also been connected to fatal hyponatremia cases.

Conditions that cause your body to excrete less water. Kidney disease, syndrome of inappropriate anti-diuretic hormone (SIADH), and heart failure, among other medical disorders, can raise your risk of hyponatremia.

Physical exertion at a high level. Hyponatremia is more likely in people who drink too much water when participating in marathons, ultramarathons, triathlons, and other long-distance, high-intensity events.

Diagnosis of Hyponatremia

History taking
Physical examination
Urinalysis – to check for urine concentration by means of measuring urine sodium and osmolality levels.
Blood test – Biochemistry to check for the level of sodium (normal serum sodium level is 135-145mEq/L). ADH test- to measure the level of circulating ADH in the body (normal ADH range is 0-5 picograms/mL)

Complications of Hyponatremia

If you suffer hyponatremia regularly (chronic hyponatremia), your sodium levels will drop slowly over several days, and you will be less likely to develop issues. However, if you have acute hyponatremia, your sodium levels drop rapidly. This can lead to:

Rapid enlargement of the brain
Coma
Death

Treatment of Hyponatremia

The severity of your hyponatremia and the cause of your hyponatremia will determine how you are treated. If you have an excess of water in your body, you may need to reduce the amount of liquids you drink. Your healthcare professional may adjust your diuretic (water pill) use to raise blood sodium levels. One or more of the following may also be required:

Intravenous (IV) fluid – To raise the amount of sodium in your blood, sodium solutions may be delivered through your vein. In most cases, this is done in a hospital.

Sodium retentive drugs: These drugs assist your kidneys in excreting significant amounts of urine. This causes the excess water to leave your body while keeping the sodium inside.

Dialysis: If your kidneys aren’t functioning correctly, you may need dialysis to get rid of the excess water in your body.

Prevention of Hyponatremia

Hyponatremia can be avoided by taking the following steps:

Treat any problems that are present. Treatment for hyponatremia-causing illnesses, such as adrenal gland insufficiency can help prevent low blood sodium levels.
Make an effort to educate oneself. Be mindful of the signs and symptoms of low blood sodium if you have a medical condition that puts you at risk for hyponatremia or if you take diuretic drugs. Always discuss the dangers of a new drug with your doctor.
When participating in high-intensity activities, take care. Athletes should only drink as much water as they lose during a race via sweating. Thirst is a valuable indicator of how much water or other fluids you require.
During strenuous activity, consider drinking sports beverages. When participating in endurance events such as marathons, triathlons, and other strenuous exercises, see your doctor about replacing water with sports beverages containing electrolytes.
Water should be consumed in moderation. Water is essential for good health, so make sure you drink plenty of it. But don’t go overboard. Thirst and urine color are typically the best indicators of how much water you require. You’re probably receiving enough water if you’re not thirsty and your pee is pale yellow.

Nursing Care Plans for Hyponatremia Based on Diagnosis

Nursing Care Plan 1: Imbalanced Nutrition

Evidenced by nausea, vomiting, weakness, loss of appetite,

and verbalization of decreased energy levels

Desired Outcome

The patient will be able to achieve weight within their normal BMI range, demonstrating healthy eating patterns and choices.

Intervention	Rationale
Explain to the patient the relation of altered sodium levels to nausea and vomiting and loss of appetite.	To help the patient understand why nausea and vomiting are associated with loss of appetite is one of the signs of hyponatremia.
Create a daily weight chart and a food and fluid chart. Discuss with the patient the short-term and long-term goals of weight loss.	To effectively monitor the patient’s daily nutritional intake and progress in weight loss goals.
Help the patient, select appropriate dietary choices to follow a high caloric diet.	To increase the caloric intake of the patient that can be used by the body to increase energy levels and be able to perform ADLs
Refer the patient to the dietitian.	To provide more specialized care for the patient in terms of nutrition and diet in relation to hyponatremia.

Nursing Care Plan 2: Electrolyte Imbalance related to hyponatremia

It is evidenced by nausea, vomiting, serum sodium level of 100 mEq/L, irritability, and fatigue.

Desired Outcome

The patient will be able to re-establish a normal electrolyte and fluid balance.

Intervention	Rationale
Obtain a urine sample and blood samples from the patient.	Urinalysis – to check for urine concentration by means of measuring urine sodium and osmolality levels. Blood test – Biochemistry to check for the level of sodium (normal serum sodium level is 135-145mEq/L); ADH test – to measure the level of circulating ADH in the body (normal ADH range is 0-5 picograms/mL)
Place the patient on fluid restriction as per the physician’s order.	Fluid restriction helps to prevent more buildup of fluid in the body.
Administer a slow intravenous sodium solution as prescribed.	A slow intravenous sodium solution is given to raise the sodium level in the bloodstream.
Start a strict input and output monitoring.	To accurately measure the patient’s input and output and ensure that fluid restriction is performed.
In case of SIADH-induced hyponatremia, administer vasopressin antagonists as prescribed.	To block the action of the vasopressin ADH.

Hyponatremia Nursing Intervention

There are several different forms of nursing interventions for hyponatremia patients, as listed below:
Maintain the patient’s fluid intake and output on an hourly basis.
Every day, weigh yourself to keep track of your fluid volume.
To detect dehydration and correctly record the state of hydration, monitor and evaluate skin turgor.
To detect pulmonary edema, closely monitor vital signs and take note of breathing rate and depth.
Check for indications of edema and hypertension in the hyponatremia patient.
As advised, keep an eye out for signs of circulatory excess.
Foods high in sodium, such as milk, meat, eggs, carrots, beets, and celery, should be consumed.
Ensure that the patient consumes 90 to 250 mEq of sodium every day.
Neuromuscular changes, such as dwindling consciousness, weariness, and muscular weakness, should be monitored and observed.
As needed, give supplemental oxygen to a drowsy or unconscious patient.
Patients with sodium imbalances are frequently perplexed and act erratically. As a result, take precautions.
Maintain a calm atmosphere.

Maintain a low, locked position for the bed.
To avoid falling, keep the side rails up.
Keep a nurse’s phone nearby and instruct the patient to call a nurse if they need help.
Keep a close eye on hyponatremia patients for any signs of convulsions and call a doctor.
As directed, use seizure precautions.
To measure the efficiency of IV fluids, keep track of serum sodium levels in the lab.
Administer the prescribed medication.
Use an infusion pump to carefully give the 3 percent or 5% sodium-containing solution as directed.
Check for symptoms of infiltration, such as redness or irritation, at the IV site.
Determine the etiology of hyponatremia, such as sodium loss or fluid overload.
As a result of the dry mouth and decreased saliva production, give mouth care regularly.
Instead of simple water, rinse the nasogastric tube with regular saline.
As directed, prepare the patient for dialysis.
Acute life-threatening conditions should be addressed immediately, and supportive treatment should be initiated.

Related FAQs

1. What is a nursing diagnosis for hyponatremia?

Risk for: Excess Fluid Volume (Hyponatremia) or Deficient Fluid Volume (Hypernatremia) Elimination disorders related to a decrease in urine volume. Disturbed Thought Processes. Risk for Injury related to seizures.

2. What nursing interventions for a patient with hyponatremia include?

Options include:

Intravenous fluids. Your doctor may recommend IV sodium solution to slowly raise the sodium levels in your blood. …
Medications. You may take medications to manage the signs and symptoms of hyponatremia, such as headaches, nausea and seizures.

3. What nursing interventions will you provide for a patient with fluid imbalance?

There are specific nursing interventions for fluid and electrolyte imbalances that can aid in alleviating the patient’s condition.

Monitor turgor.
Urine concentration.
Oral and parenteral fluids.
Oral rehydration solutions.
Central nervous system changes.
Diet.

4. What is the management of hyponatremia?

In general, hyponatremia is treated with fluid restriction (in the setting of euvolemia), isotonic saline (in hypovolemia), and diuresis (in hypervolemia). A combination of these therapies may be needed based on the presentation. Hypertonic saline is used to treat severe symptomatic hyponatremia.

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May 4, 2022

Nursing Care Plans for Hyperglycemia – Best Nursing Care Plans(2022)
This article discusses Nursing Care Plans for Hyperglycemia plus its causes, symptoms, preventions, treatments and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

Hyperglycemia or High blood sugar affects people who have diabetes. Several factors can contribute to hyperglycemia in people with diabetes, including food and physical activity choices, illness, nondiabetes medications, or skipping or not taking enough glucose-lowering medication.

It’s important to treat hyperglycemia because if left untreated, hyperglycemia can become severe and lead to severe complications requiring emergency care, such as a diabetic coma. In the long term, persistent hyperglycemia, even if not severe, can lead to complications affecting your eyes, kidneys, nerves, and heart.

Symptoms of Hyperglycemia

Hyperglycemia doesn’t cause symptoms until glucose values are significantly elevated — usually above 180 to 200 milligrams per deciliter (mg/dL), or 10 to 11.1 millimoles per liter (mmol/L). Symptoms of hyperglycemia develop slowly over several days or weeks. The more prolonged blood sugar levels stay high, the more serious the symptoms become. However, some people who’ve had type 2 diabetes for a long time may not show any symptoms despite elevated blood sugar levels.

Early signs and symptoms

Recognizing early signs and symptoms of hyperglycemia can help you treat the condition promptly. Watch for:
- Frequent urination
- Increased thirst
- Blurred vision
- Fatigue
- Headache
Later signs and symptoms

If hyperglycemia goes untreated, it can cause toxic acids (ketones) to build up in the blood and urine (ketoacidosis). Signs and symptoms include:
1. Fruity-smelling breath
2. Nausea and vomiting
3. Shortness of breath
4. Dry mouth
5. Weakness
6. Confusion
7. Coma
8. Abdominal pain
Causes of Hyperglycemia

During digestion, the body breaks down carbohydrates from foods — such as bread, rice, and pasta — into various sugar molecules. One of these sugar molecules is glucose, a main energy source for the body. Glucose is absorbed directly into the bloodstream after a person eats, but it can’t enter most tissues’ cells without the help of insulin — a hormone secreted by the pancreas.

When the glucose level in the blood rises, it signals the pancreas to release insulin. The insulin unlocks the cells so that glucose can enter and provide the fuel cells needed to function properly. Any extra glucose is stored in the liver and muscles in the form of glycogen.

This process lowers the amount of glucose in the bloodstream and prevents it from reaching dangerously high levels. As the blood sugar level returns to normal, so does the secretion of insulin from the pancreas.

Diabetes drastically lowers insulin’s effects on the body. This may be because the pancreas cannot produce insulin (type 1 diabetes), or it may be because the body is resistant to the effects of insulin or doesn’t produce enough insulin to maintain a normal glucose level (type 2 diabetes). As a result, glucose tends to build up in the bloodstream (hyperglycemia) and may reach dangerously high levels if not treated properly. Insulin or other drugs are used to lower blood sugar levels.

Risk Factors of Hyperglycemia

Many factors can contribute to hyperglycemia, including:
1. Not using enough insulin or oral diabetes medication
2. Not injecting insulin properly or using expired insulin
3. Not following your diabetes eating plan
4. Being inactive
5. Having an illness or infection
6. Using certain medications, such as steroids
7. Being injured or having surgery
8. Experiencing emotional stress, such as family conflict or workplace challenges
9. Illness or stress can trigger hyperglycemia because hormones produced to combat illness or stress can also cause your blood sugar to rise. Even people who don’t have diabetes may develop transient hyperglycemia during severe illness. But people with diabetes may need to take extra diabetes medication to keep blood glucose near normal during illness or stress.
Complications of Hyperglycemia

Long-term complications

Keeping the blood sugar in a healthy range can help prevent many diabetes-related complications. Long-term complications of untreated hyperglycemia can include:
1. Cardiovascular disease
2. Nerve damage (neuropathy)
3. Kidney damage (diabetic nephropathy) or kidney failure
4. Damage to the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness
5. Clouding of the normally clear lens of your eye (cataract)
6. Feet problems caused by damaged nerves or poor blood flow can lead to serious skin infections, ulcerations, and in some severe cases, amputation.
7. Bone and joint problems
8. Teeth and gum infections
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Nursing Care Plans for Hyperglycemia

Emergency complications

If blood sugar rises high enough or for a prolonged period, it can lead to two severe conditions.

Diabetic ketoacidosis. Diabetic ketoacidosis develops when a person doesn’t have enough insulin in their body. When this happens, sugar (glucose) can’t enter the cells for energy. Blood sugar level rises, and the body breaks down fat for energy.

This process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually “spillover” into the urine. Left untreated, diabetic ketoacidosis can lead to a diabetic coma and be life-threatening.

Hyperglycemic hyperosmolar state. This condition occurs when people produce insulin, but it doesn’t work properly. Blood glucose levels may become very high — greater than 1,000 mg/dL (55.6 mmol/L). Because insulin is present but not working properly, the body can’t use either glucose or fat for energy.

Glucose is then spilled into the urine, causing increased urination. Left untreated, the diabetic hyperglycemic hyperosmolar state can lead to life-threatening dehydration and coma. Prompt medical care is essential.

Prevention of Hyperglycemia

Follow your diabetes meal plan.

If you take insulin or oral diabetes medication, you must be consistent about the amount and timing of your meals and snacks. The food you eat must balance the insulin working in your body.

Monitor blood sugar.

Depending on your treatment plan, you may check and record your blood sugar level several times a week or several times a day. Careful monitoring is the only way to ensure that your blood sugar level remains within your target range. Note when your glucose readings are above or below your goal range.

Take medication as prescribed by the doctor.

Adjust your medication if you change your physical activity. The adjustment depends on the blood sugar test results and on the type and length of the activity.

Nursing Diagnosis for Hyperglycemia

1. Nursing diagnosis -Diabetes (NANDA I – 2012)

Definition: A carbohydrate, fat, and protein metabolism disorder is usually characterized by elevated blood glucose levels due to low insulin production or utilization. It can lead to severe complications if left untreated.

Diagnosis Rationales:

-Functional Oral Intake (NANDA I – 2012)

Applicable for patients who are unable to tolerate their usual diet due to vomiting or nausea

– Nutrition, Less Than Body Requirements (NANDA I – 2012)

Applicable for patients who are unable to eat because of symptoms such as nausea and vomiting or have difficulty chewing or swallowing

– Disturbed Body Image (NANDA I – 2012)

Applicable for a patient who is unable to perceive their body shape due to excess weight

-Chronic pain (NANDA I – 2012)

Applicable for patients with diabetes-related problems such as neuropathy, eye problems, foot ulcers that cause chronic pain

-Thermal Incompetence (NANDA I – 2012)

Applied for patients with diabetes mellitus or hyperthermia

– Acute Pain (NANDA I – 2012)

Applicable for patients experiencing acute illness related to complications from diabetes

-Constipation (NANDA I – 2012)

Applicable for patients with neuropathy and other body issues that cause constipation

–Impaired Skin Integrity, Risk for (NANDA I – 2012)

Applied to diabetic foot ulcer patient who is at risk of skin breakdown

-Altered Nutrition, Less Than Body Requirements (NANDA I – 2012)

Applicable for a patient with nausea and vomiting who are unable to tolerate oral intake

-Chronic Sorrow (NANDA I – 2012)

Applicable for patient grieving a loss of skin integrity or limb related to diabetes 1

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Nursing Care Plans for Hyperglycemia

2. Nursing diagnosis -Electrolyte imbalance

Diagnosis Rationales:

-Fluid Volume Deficit (NANDA I – 2012)

Applicable for a patient who presents with dehydration due to vomiting or diarrhea

-Deficient Knowledge (NANDA I – 2012)

Applied to a patient who makes errors in medication dosage or timing

– Alteration in Consciousness, Unilateral (NANDA I – 2012)

Applicable for a patient with unilateral stroke due to hypertension

– Altered Nutrition: Less Than Body Requirements (NANDA I – 2012)

Applicable for a patient with malnutrition due to metabolic disorders 1

3. Nursing diagnosis -Metabolic acidosis

Diagnosis Rationales:

–Fluid Volume Deficit (NANDA I – 2012)

Applicable for a patient with diabetes mellitus who are unable to maintain their fluid balance

-Deficient Knowledge (NANDA I – 2012)

Applicable for the patient who is unable to manage their treatment because of lack of education or support

– Sensory-Perceptual Alterations (NANDA I – 2012)

Applied for the patient with blurred vision due to severe hyperglycemia

Other Nursing Diagnosis:

-A medical history and physical examination

-A blood test to measure glucose levels such as:
- Hemoglobin A1c
- Fasting glucose test
-A test measuring the amount of sugar in a sample of urine

Nursing diagnosis of diabetes can be challenging if it is undiagnosed. Failure to diagnose and treat hyperglycemia can lead to severe complications such as:

-Vision loss

-Nerve damage

-Kidney damage

-Heart disease

–Stroke

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Nursing Care Plans for Hyperglycemia

Nursing Care Plans for Hyperglycemia

The nursing care plan should be prepared by a registered nurse and include the following;

Patient Education

-Educate diabetic patients on the following:

-How to monitor their blood glucose level

-When and how many times per day they should check their glucose levels (usually before meals, at bedtime, and any time they feel like they need to)

-What the average blood sugar range is for a healthy individual (70-110)

-Signs of hyperglycemic episodes

-How diabetes mellitus can be treated using a medication, insulin, or other means.

-Ways to decrease the risk of hyperglycemia (eating a healthy diet, exercising)

-Encourage the patient with diabetes to check their blood glucose level throughout the day and be aware of the symptoms of hyperglycemia.

-Teach the patient with type 2 diabetes how to monitor their hemoglobin A1C levels for evidence of lacking control over hyperglycemia.

-Encourage diabetic patients to participate in activities they enjoy, such as walking or swimming, even if they have an illness.

-Teach a patient how to recognize and treat diabetes mellitus or hyperglycemia episodes using the evidence-based steps from previous studies.

Nursing Interventions for Hyperglycemia

1. Prevent complications related to hyperglycemia:

Educate the patient on the importance of monitoring blood glucose levels throughout each day and report any changes to a health care provider.

Provide mental health interventions as appropriate:
1. Ensure a patient with diabetes follow a healthy diet and exercises regularly to prevent diabetes mellitus or hyperglycemia episodes.
2. Provide counseling when a diabetic patient is unable to maintain adequate blood glucose levels on their own.
2. Patient Education:

Teach the patient about how to manage their blood glucose level.

Insulin injection and monitoring of blood glucose levels should be taught to diabetic patients who are not self-managing their disease with diet or oral medications.

Teaching diabetes management requires sound knowledge of each component that contributes to the overall metabolism in the human body.

3. Insulin injection:

Insulin injection is the primary means of managing type 1 diabetes in today’s society. The timing and amount of insulin administered depend on several factors:
- Age
- Weight
- Physical activity level
- Blood glucose level and any other medications that may be used (Wittels 1996).
Teaching diabetic patients to administer their insulin injections is of utmost importance because this allows them to become self-reliant in the long run. This reduces the number of doctor appointments and reduces health care costs in the long run.

Incidentally, administering insulin injections requires proper knowledge and understanding of how it works. Insulin acts as a key that unlocks cells from burning glucose for fuel because of a lack of insulin in the body. Hence, glucose is stored as glycogen and fat.

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Nursing Care Plans for Hyperglycemia

The cells are now locked away from burning glucose for fuel and instead start to burn the now available energy source: fat and protein. Thus, when the body has enough insulin, all excess glucose that does not get used in the body receives transferred into fat and then stored. This is how insulin works in a nutshell.

The goal of diabetes management is to maintain blood glucose levels within the normal range (70-110mg/dl) as much as possible. However, this may not always be possible, and a therapeutic range must be set for each individual.

Related FAQs

1. What are nursing interventions for hyperglycemia?

Emergency treatment for severe hyperglycemia
- Fluid replacement. You’ll receive fluids — usually through a vein (intravenously) — until you’re rehydrated. …
- Electrolyte replacement. Electrolytes are minerals in your blood that are necessary for your tissues to function properly.
- Insulin therapy.
2. What nursing interventions would you consider for a patient with diabetes?

Nursing Interventions
- Educate about home glucose monitoring. …
- Review factors in glucose instability. …
- Encourage client to read labels. …
- Discuss how client’s antidiabetic medications work. …
- Check viability of insulin. …
- Review type of insulin used. …
- Check injection sites periodically.
3. What is a diabetic care plan?

A diabetes care plan, or diabetes medical management plan (DMMP), is a tool that helps people manage diabetes in day-to-day life. DMMPs are helpful, because diabetes is a challenging, long-term condition, and it often requires a person to change their diet, lifestyle, and daily routines.

4. What is the nursing care plan for hypoglycemia?

Provide food or other sources of glucose as directed for hypoglycemia. A rapidly absorbed form of glucose is indicated to manage hypoglycemia. These forms of glucose may include oral intake of hard candy or fruit juice. For the patient who cannot take something orally, intravenous injection of glucose may be indicated.

Read More:

https://customnursingassignments.com/nursing-care-plans-for-shingles/

https://customnursingassignments.com/nursing-care-plans-for-gestational-diabetes-mellitus/
May 4, 2022

Author: Dr. Prince

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