Author: Dr. Prince

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

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

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

customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us.(Nursing Care Plans for Gestational Diabetes Mellitus)

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

Shingles or herpes zoster is a viral infection that causes a painful rash. Although shingles can occur anywhere on the body, they often appear as a single stripe of blisters that wrap around either the left or the right side of the torso.

Shingles is caused by the varicella-zoster virus, which also causes chickenpox. After having chickenpox, the virus lies inactive in nerve tissue near the spinal cord and brain. Years later, the virus may reactivate as shingles.

Shingles isn’t a life-threatening condition, but it can be very painful. Vaccines can help reduce the risk of shingles. Early treatment can help shorten a shingles infection and lessen the chance of complications. Postherpetic neuralgia is the most common complication, which causes shingles pain for a long time after the blisters have cleared.

Nursing Care Plans for Shingles – Symptoms of Shingles

The signs and symptoms of shingles usually affect only a small section of one side of the body. These signs and symptoms may include:

Pain, burning, numbness, or tingling
Sensitivity to touch
A red rash that begins a few days after the pain
Fluid-filled blisters that break open and crust over
Itching

Some people also experience:

Fever
Headache
Sensitivity to light
Fatigue

Pain is usually the first symptom of shingles. For some, it can be intense. Depending on the location of the pain, it can sometimes be mistaken for a symptom of problems affecting the heart, lungs, or kidneys. Some people experience shingles pain without ever developing the rash.

Most commonly, the shingles rash develops as a stripe of blisters that wraps around either the left or right side of the torso. Sometimes the shingles rash occurs around one eye or on one side of the neck or face.

Nursing Care Plans for Shingles – Causes of Shingles

Shingles is caused by the varicella-zoster virus, which causes chickenpox. Anyone who’s had chickenpox may develop shingles. After recovering from chickenpox, the virus enters the nervous system and lies dormant for years.

Eventually, it may reactivate and travel along nerve pathways to the skin — producing shingles. But, not everyone who’s had chickenpox will develop shingles.

The reason for shingles is unclear. But it may be due to lowered immunity to infections as one grows older. Shingles is more common in older adults and in people who have weakened immune systems.

Varicella-zoster is part of a group of viruses called herpes viruses, which include the viruses that cause cold sores and genital herpes. Because of this, shingles is also known as herpes zoster. But the virus that causes chickenpox and shingles is not the same virus responsible for cold sores or genital herpes, a sexually transmitted infection.

Nursing Care Plans for Shingles – Risk Factors of Shingles

Anyone who has ever had chickenpox can develop shingles. Most adults in the United States had chickenpox when they were children, before the advent of the routine childhood vaccination that now protects against chickenpox.

Factors that may increase your risk of developing shingles include:

Being older than 50. Shingles is most common in people older than 50. The risk increases with age.
Having certain diseases. Diseases that weaken the immune system, such as HIV/AIDS and cancer, can increase the risk of shingles.
Undergoing cancer treatments. Radiation or chemotherapy can lower the resistance to diseases and may trigger shingles.
Taking certain medications. Drugs designed to prevent rejection of transplanted organs can increase shingles’ risk, as can prolonged use of steroids, such as prednisone.

Nursing Care Plans for Shingles – Diagnosis of Shingles

Physical examination and history taking – the characteristic rash is usually enough to suspect herpes zoster infection. Support from history taking and physical assessment often confirms the diagnosis. History of previous chickenpox infection is noted; pain and other signs and symptoms associated with herpes zoster infection are observed.

Other skin diseases will need to be ruled out if the rash and history are not conclusive to diagnose.

Nursing Care Plans for Shingles – Treatment of Shingles

Antivirals

Antiviral medications are prescribed to be taken within 72 hours of diagnosis. They slow down the progress of the rash and prevent complications.

Analgesia

The characteristic rash associated with herpes zoster infection is very painful. Over-the-counter painkillers are commonly given to relieve the discomfort caused by the pain.

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Shingles)

Antibiotics

If the rash leads to other skin breakdowns, which then gets infected, antibiotics are prescribed. However, if the bacterial infection is not detected, then it is not needed.

Tricyclic antidepressants

Sometimes the physician prescribes these to help ease the pain after the rash clears away. They can also help with depression.

Skincare

It is essential to keep the affected area clean, dry, and exposed to air as much as possible.

Nursing Care Plans for Shingles – Complications of Shingles

Complications from shingles can include:

Postherpetic neuralgia

For some people, shingles pain continues long after the blisters have cleared. This condition is known as postherpetic neuralgia, and it occurs when damaged nerve fibers send confused and exaggerated messages of pain from the skin to the brain.

Vision loss

Shingles in or around an eye (ophthalmic shingles) can cause painful eye infections that may result in vision loss.

Neurological problems

Depending on which nerves are affected, shingles can cause an inflammation of the brain (encephalitis), facial paralysis, or hearing or balance problems.

Skin infections

If shingles blisters aren’t properly treated, bacterial skin infections may develop.

Nursing Care Plans for Shingles – Prevention of Shingles

A shingles vaccine may help prevent shingles.

People who are eligible to get it should get the Shingrix vaccine in the U.S.

In the United States, Shingrix was approved by the Food and Drug Administration (FDA) in 2017. Studies suggest that Shingrix offers protection against shingles for more than five years. Shingrix is a nonliving vaccine made of a virus component. It is given in two doses, with 2-6 months between doses.

Shingrix is approved and recommended for people age 50 and older, including those who’ve previously received the Zostavax vaccine or had shingles.

The Zostavax vaccine is no longer sold in the U.S., but other countries may still use it.

Both shingles vaccine’s most common side effects are redness, pain, tenderness, swelling and itching at the injection site, and headaches.

The shingles vaccine doesn’t guarantee that one won’t get shingles. But this vaccine will likely reduce the course and severity of the disease and reduce the risk of postherpetic neuralgia.

The shingles vaccine is used only as a prevention strategy. It’s not intended to treat people who currently have the disease.

Nursing Care Plans for Shingles / Herpes Zoster Based on Diagnosis

Nursing Care Plans for Shingles – Nursing Care Plan 1: Diagnosis -Acute/Chronic Pain

May be related to nerve pain (most commonly cervical, lumbar, sacral, thoracic, or ophthalmic division of trigeminal nerve)

Possibly evidenced by:

Alteration in muscle tone
Facial mask of pain
Reports of burning, dull, or sharp pain
Reports of pain localized to the affected nerve

Desired Outcomes

A patient will be comfortable, as evidenced by the ability to rest.
A patient will report satisfactory pain control at levels less than 3 to 4 on a scale of 0 to 10.

Nursing Interventions	Rationale
Assess the patient’s description of pain or discomfort: severity, location, quality, duration, precipitating or relieving factors.	The patient may describe the pain as a tingling sensation, a burning pain, or extreme hyperesthesia in one area of the skin. These sensations usually precede the development of skin lesions by several days. Postherpetic neuralgia is a chronic pain syndrome that may continue after the skin lesions have healed. The patient may have constant pain or intermittent episodes of pain.
Assess for nonverbal signs of pain or discomfort.	Each individual has his or her own pain threshold and ways to express pain or discomfort. Some individuals may deny the experience of pain when it is present. Attention to associated signs may help the nurse evaluate the pain.
Educate the patient about the following measures:
Wear loose, nonrestrictive clothing made of cotton.	Constrictive, nonbreathing garments may rub lesions and aggravate skin irritation. Cotton clothing allows evaporation of moisture.
Apply cool, moist dressings to pruritic lesions several times a day with or without Burrow’s solution. Discontinue once the lesions have dried.	This provides relief and reduces the risk for secondary infection.
Avoid temperature extremes in both the air and bathwater.	Tepid water causes the least itching and burning.
Avoid rubbing or scratching the skin or lesion.	Scratching stimulates the skin, which in turn increases itchiness. It can also increase the possibility of secondary infection.
Use topical steroids (anti-inflammatory effect), anti-histamines (anti-itching effect, particularly useful at bedtime), and analgesics.	A variety of medications may be required to provide relief.
Administer medications as indicated.	Oral opioid analgesics (codeine, hydrocodone) are typically prescribed during the acute phase. Analgesics, antidepressants, and antiepileptic may be used in the management of postherpetic neuralgia. Topical preparations of postherpetic neuralgia include capsaicin cream (Zostrix) and lidocaine-prilocaine cream (EMLA).

Nursing Care Plans for Shingles – Nursing Care Plan 2: Diagnosis -Impaired Skin Integrity related to infection of the skin secondary to herpes zoster infection

Evidenced by:

A temperature of 39 degrees Celsius
Chills
Headache
Stabbing or shooting pain
Tingling of the skin
Photophobia
Body malaise

Desired Outcome

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

Intervention	Rationale
Assess the patient’s skin on his/her whole body.	To determine the severity of herpes zoster infection and any affected areas that require special attention or wound care.
Isolate the patient in his/her room ideally during the first 48 hours since the appearance of blisters.	Herpes zoster infection is an infectious/ communicable skin disease to people who have not had chickenpox before. It is also harmful to pregnant women as it can affect the unborn baby.
The affected area should be washed first in warm water, and wet compresses may also be used. This is followed by the application of the prescribed antipruritic cream or ointment directly to the affected areas.	Cleansing the skin and applying the topical antipruritic cream promotes relief of itchiness due to shingles.
Administer antiviral medication as prescribed. Ensure that the patient finishes the course of antibiotics prescribed by the physician.	Herpes zoster infection is generally treated through the use of antiviral therapy. If the rash leads to another skin breakdown which then gets infected, antibiotics are prescribed. Application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection. Even if the symptoms have already improved and healing is evident, it is still important to finish the course of antiviral therapy for at least 7 days.
Educate the patient and caregiver about proper skincare through washing the rash 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 unilateral rash 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 rash and further infection.	Proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection.

Nursing Care Plans for Shingles – Nursing Care Plan 3: Diagnosis – Risk for Disturbed Body Image

May be related to:

Preoccupation with changed body part
Visible skin lesions

Desired Outcomes

A patient will verbalize feelings about lesions and continues daily activities.
A patient will demonstrate positive body image, as evidenced by the ability to look at, talk about, and care for lesions.

Nursing Interventions	Rationale
Assess the patient’s perception of his or her changed appearance.	Because the course of an outbreak may span several weeks, patients typically need to work or carry out their usual routine; they may require assistance coping with changes in appearance.
Note verbal references to skin lesions.	Scarring may occur with repeated outbreaks or if lesions are infected. This may cause a preoccupation with appearance.
Discuss reasons for infectious isolation and procedures when indicated.	Taking time to sit down and talk/listen to the patient in the room decreases the feeling of isolation and loneliness.
Assist the patient in articulating responses to questions from others regarding lesions and infectious risk.	Patients may need some guidance in determining what to say to people who comment on the appearance of their skin. The rehearsal of set responses to anticipated questions may provide some reassurance.
Suggest the use of concealing clothing when lesions can be easily covered.	This approach may help the patient who is having problems adjusting to body-image changes.

Nursing Care Plans for Shingles – Nursing Care Plan 4: Diagnosis – Risk for Infection related to a contagious skin infection

Desired Outcome

A patient will prevent the spread of infection to the rest of the body, as well as cross-contamination to other people by following a treatment regimen for herpes zoster infection.

Intervention	Rationale
Assess the patient’s skin on his/her whole body.	To determine the severity of herpes zoster infection and any affected areas that require special attention or skincare.
Isolate the patient in his/her room ideally during the first 48 hours since the appearance of blisters.	Herpes zoster infection is an infectious/ communicable skin disease to people who have not had chickenpox before. It is also harmful to pregnant women as it can affect the unborn baby.
Administer antiviral medication as prescribed. Ensure that the patient finishes the course of antibiotics prescribed by the physician.	Herpes zoster infection is generally treated through the use of antiviral therapy. If the rash leads to other skin breakdowns, which then gets infected, antibiotics are prescribed. Application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection.
Educate the patient and caregiver about proper wound hygiene through washing the rash with soap and water.	It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. The rash may cause mild itching, but it is advisable to prevent the child from scratching the affected areas to prevent the worsening and spread of the infection.
Trim the patient’s fingernails and ensure frequent hand hygiene. Advise the patient and caregiver to prevent scratching the affected areas.	Long fingernails tend to harbor more bacteria. Scratching the infected skin areas will allow the bacteria to transfer into the fingernails and onto the fingerpads. When the patient touches other people or objects with infected hands, the infection will likely spread.
Teaching the patient/ caregiver the proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection.	Proper application of non-stick bandages over the affected areas can also help prevent the spread of rash and further infection.

Nursing Care Plans for Shingles – Nursing Care Plan 5: Diagnosis – Deficient Knowledge

May be related to:

Complexity of treatment
Emotional state affecting learning
Herpes zoster outbreak
New conditions and procedures

Possibly evidenced by:

Inadequate follow-up of instructions
Questioning members of the health care team
Verbalizing inaccurate information

Desired Outcomes

The patient or caregiver will verbalize needed information regarding the disease, signs and symptoms, treatment, and possible complications of herpes zoster.

Nursing Interventions	Rationale
Determine the patient’s and caregiver’s understanding of the disease condition, treatment, and complications.	The patient and caregiver need to understand that an occult disease may have weakened the patient and allowed the expression of the herpes zoster.
Because of potential infectivity, determine whether the patient’s caregiver or family has had chickenpox or varicella vaccine or is immunocompromised.	Even though the varicella vaccine does not confer immunity to shingles, it is less common in varicella-vaccinated adults than in those who have had chickenpox.
Provide necessary information to the patient and caregiver, including written information:	A patient may confuse terminology and confuse herpes zoster with genital herpes. Because the patient may be reluctant to ask, clarify this point for the patient. Patients must have a comprehensive understanding of their disease to participate in their own care actively.
Explanation of the need for isolation.	Patients should isolate their clothing and linen, including towels.
Description of herpes zoster, including how the disease is spread.	Fluids from lesions contain viruses, which are spread by direct contact.
Need to notify health care professionals of the signs of central nervous system (CNS) inflammation (changes in the level of consciousness).	The early assessment facilitates prompt treatment of complications.
Encourage herpes zoster vaccination (Zostavax).	This vaccination is recommended for individuals 60 years or older. It is not recommended for pregnant women or those with primary or acquired immunodeficiencies or any allergy to its components. A 50% decrease in future outbreaks and greater than 60% reduction in postherpetic neuralgia have been reported.

Related FAQs

1. What is the nursing management of shingles?

The management of shingles includes the use of analgesics and antivirals. Antivirals reduce the duration of viral shedding, reduce the severity and duration of acute pain, and reduce the risk of post-herpetic neuralgia.

2. How do you care for someone with shingles?

It is usually treated with an antiviral medication plus a steroid. Treatment of shingles usually includes a combination of antiviral and pain-relieving medications. The areas affected by the rash should be kept clean and dry.

3. What are the 4 main parts of a nursing care plan?

Components. A nursing care plan (NCP) usually includes nursing diagnoses, client problems, expected outcomes, and nursing interventions and rationales. These components are elaborated below: Client health assessment, medical results, and diagnostic reports

4. What interventions are required for patients with chickenpox or shingles?

Work restriction and isolation precautions

All patients with varicella or disseminated zoster should be placed on airborne and contact precautions until all lesions are crusted. For immunocompetent patients with dermatomal herpes zoster, standard precautions and complete covering of the skin lesions are recommended.

https://customnursingassignments.com/nursing-care-plans-for-gestational-diabetes-mellitus/

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

May 4, 2022

Nursing Care Plans for Gestational Diabetes Mellitus – Best Nursing Care Plans(2022)

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

Permalink: https://customnursingassignments.com/nursing-care-plans-for-gestational-diabetes-mellitus

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

Gestational diabetes mellitus (GDM) is a condition in which a hormone made by the placenta prevents the body from using insulin effectively. Glucose builds up in the blood instead of being absorbed by the cells.

Unlike type 1 diabetes, gestational diabetes is not caused by a lack of insulin but by other hormones produced during pregnancy that can make insulin less effective, a condition referred to as insulin resistance. Gestational diabetic symptoms disappear following delivery.

Approximately 3 to 8 percent of all pregnant women in the United States are diagnosed with gestational diabetes.

Causes Gestational Diabetes Mellitus

Although the cause of GDM is not known, there are some theories as to why the condition occurs.

The placenta supplies a growing fetus with nutrients and water and produces various hormones to maintain the pregnancy. Some of these hormones (estrogen, cortisol, and human placental lactogen) can block insulin. This is called the contra-insulin effect, which usually begins about 20 to 24 weeks into the pregnancy.

As the placenta grows, more of these hormones are produced, and the risk of insulin resistance becomes more significant. Normally, the pancreas is able to make additional insulin to overcome insulin resistance, but when the production of insulin is not enough to overcome the effect of the placental hormones, gestational diabetes results.

Risks Factors of Gestational Diabetes Mellitus

Although any woman can develop GDM during pregnancy, some of the factors that may increase the risk include the following:

Overweight or obesity
Family history of diabetes
Having given birth previously to an infant weighing greater than 9 pounds
Age (women who are older than 25 are at a greater risk for developing gestational diabetes than younger women)
Race (women who are African-American, American Indian, Asian American, Hispanic or Latino, or Pacific Islander have a higher risk)
Prediabetes, also known as impaired glucose tolerance
Although increased glucose in the urine is often included in the list of risk factors, it is not believed to be a reliable indicator for GDM.

Diagnosis of Gestational Diabetes Mellitus

The American Diabetes Association recommends screening for undiagnosed type 2 diabetes at the first prenatal visit in women with diabetes risk factors. In pregnant women not known to have diabetes, GDM testing should be performed at 24 to 28 weeks of gestation.

In addition, women with diagnosed GDM should be screened for persistent diabetes 6 to 12 weeks postpartum. It is also recommended that women with a history of GDM undergo lifelong screening for the development of diabetes or prediabetes at least every three years.

Treatment for Gestational Diabetes Mellitus

Specific treatment for gestational diabetes will be determined by your doctor based on:

Age, overall health, and medical history
The extent of the disease
Tolerance for specific medications, procedures, or therapies
Expectations for the course of the disease

Treatment for gestational diabetes focuses on keeping blood glucose levels in the normal range. Treatment may include:

Special diet
Exercise
Daily blood glucose monitoring
Insulin injections

Possible complications for the baby

Unlike type 1 diabetes, gestational diabetes generally occurs too late to cause birth defects. Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy. The insulin resistance from the contra-insulin hormones produced by the placenta does not usually occur until approximately the 24th week. Women with gestational diabetes mellitus generally have normal blood sugar levels during the critical first trimester.

The complications of GDM are usually manageable and preventable. The key to prevention is careful control of blood sugar levels just as soon as the diagnosis of diabetes is made.

Infants of mothers with gestational diabetes are vulnerable to several chemical imbalances, such as low serum calcium and low serum magnesium levels, but, in general, there are two major problems of gestational diabetes: macrosomia and hypoglycemia:

Macrosomia

Macrosomia refers to a baby who is considerably larger than normal. All of the nutrients the fetus receives come directly from the mother’s blood. If the maternal blood has too much glucose, the pancreas of the fetus senses the high glucose levels and produces more insulin in an attempt to use this glucose. The fetus converts the extra glucose to fat. Even when the mother has gestational diabetes, the fetus is able to produce all the insulin it needs. The combination of high blood glucose levels from the mother and high insulin levels in the fetus results in large fat deposits, which causes the fetus to grow excessively large.

Hypoglycemia

Hypoglycemia refers to low blood sugar in the baby immediately after delivery. This problem occurs if the mother’s blood sugar levels have been consistently high, causing the fetus to have a high insulin level in its circulation. After delivery, the baby continues to have a high insulin level, but it no longer has the high level of sugar from its mother, resulting in the newborn’s blood sugar level becoming very low. The baby’s blood sugar level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously.

Blood glucose is monitored very closely during labor. Insulin may be given to keep the mother’s blood sugar normal to prevent the baby’s blood sugar from dropping excessively after delivery.

Nursing Care Plans for Gestational Diabetes Mellitus Based on Diagnosis

Nursing Care Plan 1: Diagnosis – Risk for Maternal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

Risk factors

Altered immune response.
Anemia.
Changes in diabetic control.
Tissue hypoxia.

Desired Outcomes

A patient will be free of signs and symptoms of diabetic ketoacidosis (fruity-scented breath, excessive thirst, frequent urination, weakness, confusion).
A patient will remain normotensive.
A patient will maintain normoglycemia.

Nursing Interventions	Rationale
Assess client for vaginal bleeding and abdominal tenderness.	Vascular changes associated with diabetes place the client at risk for abruption placenta.
Determine the nature of any vaginal discharge.	If glycosuria is present, a client is more likely to develop monilial vulvovaginitis, which is caused by Candida albicans and may lead to oral thrush in newborns.
Assess for any signs and symptoms of UTI.	Early detection of UTI may prevent the occurrence of pyelonephritis, which can contribute to premature labor.
Assess and monitor for signs of edema.	Because of vascular changes, the diabetic client is prone to excess fluid retention and PIH. The severity of the vascular changes prior to pregnancy influences the extent and time of onset of PIH.
Determine fundal height; check for edema of extremities and dyspnea.	Hydramnios occurs in 6%-25% of pregnant diabetic clients. May be associated with an increased fetal contribution to amniotic fluid because hyperglycemia increases fetal urine output.
Identify episodes of hyperglycemia.	Diet and/or insulin regulation is necessary for normoglycemia, especially in second and third trimesters, when insulin requirements usually doubled.
Identify episodes of hypoglycemia.	Hypoglycemic episodes occur most frequently in the first trimester, owing to continuous fetal drain on serum glucose and amino acids and to low levels of HPL. In the presence of hypoglycemia, vomiting may lead to ketosis.
Monitor for signs and symptoms of pre-term labor. Hydramnios may predispose the client to early labor.	Overdistention of the uterus is caused by macrosomia.
Note White’s classification for diabetes. Assess the degree of diabetic control (Pederson’s Criteria).	Client classified as D, E, or F is at high risk for complications, as is a client with PBSP.
Assist client in learning home monitoring of blood glucose, to be done a minimum of 4 times/day.	Allows greater accuracy than urine testing because the renal threshold for glucose is lowered during pregnancy. Facilitates tighter control of serum glucose levels.
Request that client check urine for ketones daily.	Ketonuria indicates a presence of a starvation state, which may negatively affect the developing fetus.
Monitor client closely if tocolytic drugs are used to arrest labor.	Tocolytic drugs may increase serum blood glucose and insulin levels.
Monitor serum glucose level each visit.	Detects impending ketoacidosis; helps determine times of day during which client is prone to hypoglycemia.
Monitor Hematocrit and hemoglobin levels on the initial visit, then during the second trimester and at term.	Anemia may be present in a client with vascular involvement.
Obtain HbA1c every 2-4 weeks, as indicated.	Allows accurate assessment of glucose control for the past 60 days.
Monitor for total protein excretion, creatinine clearance, BUN, and uric acid levels.	Progressive vascular changes may impair renal function in severe or long-standing diabetes clients.
Obtain urinalysis and urine culture; administer antibiotics as indicated.	Helps prevent or treat pyelonephritis. Note: Some antibiotics might be contraindicated because of the danger of teratogenic effects.
Obtain culture of vaginal discharge, if present.	Candida vulvovaginitis can cause oral thrush in the newborn.
Prepare client for ultrasonography at 8, 12, 18, 26, and 36-38 weeks of gestation as indicated.	Determines fetal size using the biparietal diameter, femur length, and estimated fetal weight. The client is at risk for CPD and dystocia due to macrosomia.
Scheduled for ophthalmologic examination during the first trimester for all clients, and in second and third trimesters if clients are at class D, E, F.	Owing to several vascular involvements, background retinopathy may progress during pregnancy. Laser coagulation therapy may improve the client’s condition and reduce optic fibrosis.
Start IV therapy with 5% dextrose; administer glucagon SC if a client is hospitalized with insulin shock and is unconscious. Follow with protein-containing foods/fluids, e.g., 15 grams of beans.	Glucagon is a naturally occurring substance that acts on liver glycogen and converts it to glucose, which corrects the hypoglycemic state. (Note: Hypertonic Glucose D50 administered IV may have negative effects on fetal brain tissue because of its hypertonic action). Protein helps sustain normoglycemia over a longer period.

Nursing Care Plan 2: Diagnosis – Risk for Fetal Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.

Risk factors

Changes in circulation.
Elevated maternal serum blood glucose levels.

Desired Outcomes

A fetus will normally display reactive normal stress test and negative OCT and CST.

Nursing Interventions	Rationale
Determine White’s classification for diabetes; explain classification and significance to client/couple.	A fetus is at less risk if White’s classification is A, B, or C. The client with classification DD, E, or F who develops kidney or acidotic problems or PIH is at high risk. As a means of determining prognosis for a perinatal outcome, White’s classification has been used in conjunction with (1) evaluation of diabetic control or lack of control and (2) presence or absence of Pedersen’s prognostically bad signs of pregnancy (PBSP), which includes acidosis, mild/severe toxemia, and pyelonephritis. The National Diabetes Data Group Classification, which includes diabetes mellitus (type I, insulin-dependent; type II, noninsulin-dependent), impaired glucose tolerance, and gestational diabetes mellitus, has not yet had prognostic significance in predicting perinatal outcomes.
Determine client’s diabetic control before conception.	Strict control (normal HbA1c levels) before conception helps reduce the risk of fetal mortality and congenital abnormalities.
Monitor for signs of PIH (edema, hypertension, proteinuria).	About 12-13% of diabetic individuals develop hypertensive disorders owing to cardiovascular changes associated with diabetes. These disorders negatively affect placental perfusion and fetal status.
Monitor fundal height each visit.	Useful in identifying abnormal growth patterns (macrosomia or IUGR, small or large gestational age [SGA/LGA]).
Assess fetal movement and fetal heart rate each visit as indicated. Encourage the client to periodically record fetal movements at about 18 weeks gestation, then daily from 34 weeks gestation.	Fetal movement and fetal heart rate may be negatively affected when placental insufficiency and maternal ketosis occur.
Monitor urine for ketones. Note for fruity breath.	Irreparable CNS damage or fetal death can occur as a result of maternal ketonemia, especially in the third trimester.
Provide information about the possible effects of diabetes on fetal growth and development.	It helps the client to make informed decisions about managing regimens and may increase cooperation.
Provide information and reinforce procedures for home blood glucose monitoring and diabetic management.	Decreased fetal or newborn mortality and morbidity complications and congenital anomalies are associated with optimal FBS levels between 70 to 96 mg/dL and 2-hr postprandial glucose level of less than 120 mg/dL. Frequent monitoring is important to maintain this tight range and to reduce the incidence of fetal hypoglycemia or hyperglycemia.
Discuss rationale/procedure for carrying out periodic Oxytocin Challenge Test (OCT) or Contraction Stress Test (CST) beginning at 30-32 weeks’ gestation, depending on the diagnosis of NIDDM or GDM.	CST assesses placental perfusion of oxygen and nutrients to the fetus. Positive results indicate placental insufficiency, in which case the fetus may need to be delivered surgically.
Review rationale and procedure for periodic NSTs (e.g., weekly NST after 30 weeks gestation, twice-weekly NST after 36 weeks gestation).	Fetal activity and movement are good predictors of fetal wellness. Activity level decreases before alterations in FHR occur.
Review rationale and procedure for amniocentesis using lecithin-sphingomyelin ratio (L/S) ratio and the presence of phosphatidylglycerol (PG).	When there is impaired maternal/placental functioning before term, fetal lung maturity is a criterion used to determine whether survival is possible. Hyperinsulinemia inhibits and interferes with surfactant production; therefore, in the diabetic client, testing for the presence of PG is more accurate than using the L/S ratio.
Assess glycosylated albumin level at 24-28 weeks’ gestation, especially for a client in a high-risk category (history of macrosomic infants, previous GDM, or positive family history of GDM). Follow with oral glucose tolerance test (OGTT) if test results are positive.	Serum test for glycosylated albumin reflects glycemia over several days and may gain acceptance as a screening tool in determining GDM because it does not involve potentially harmful glucose loading as does with OGTT.
Assess HbA1c every 2-4 weeks, as indicated.	Incidence of congenitally malformed infants is increased in women with high HbA1c levels (greater than 8.5%) early in pregnancy or before conception. Note: HbA1c is not sensitive enough as a screening tool for GDM.
Obtain sequential serum or 24-hr urinary specimen for estriol levels after 30 weeks gestation.	Although estriol levels are not used as often now, falling levels may indicate decreased placental functioning, leading to a possibility of intrauterine growth restriction (IUGR) and stillbirth.
Verify Alpha-fetoprotein (AFP) levels are obtained at 14-16 weeks’ gestation.	Although AFP screen is recommended for all clients, it is especially important in this population because neural tube defects are greater in diabetic clients than in nondiabetic clients, particularly if poor control existed before pregnancy.
Review periodic creatinine clearance levels.	There is a slight parallel between renal vascular damage and impaired uterine blood flow.
Perform Nonstress test (NST) and Oxytocin Challenge Test (OCT)/Contraction Stress Test (CST), as appropriate.	Assesses fetal well-being and adequacy of placental perfusion.
As indicated, prepare for ultrasonography at 8, 12, 18, 28, and 36-38 weeks’ gestation.	Ultrasonography is useful in confirming gestation date and helps to evaluate intrauterine growth restriction (IUGR).
Assist as necessary with biophysical profile (BPP) assessment.	Provides a score to assess fetal well-being/risk, The criteria include NST results, fetal breathing movements, amniotic fluid volume, fetal tone, and fetal body movements. For each criterion met, a score of 2 is given. A total score of 8-10 is reassuring, a score of 4-7 indicates a need for further evaluation and retesting, and a score of 0-3 is ominous.
Assist with preparation for delivery of fetus vaginally or surgically if test results indicate placental aging and insufficiency.	Helps ensure a positive outcome for the neonate. The incidence of stillbirths increases significantly with gestation of more than 36 weeks. Macrosomia often causes dystocia with cephalopelvic disproportion (CPD).

Nursing Care Plan 3: Diagnosis – Risk for Altered Nutrition: Less than Body Requirements

Risk for Altered Nutrition: Less Than Body Requirements: At risk for an insufficient intake of nutrients to meet metabolic needs.

Risk factors

Inability to utilize nutrients appropriately.

Desired Outcomes

A patient will verbalize understanding of the individual treatment regimen and the need for frequent self-monitoring.
A patient will maintain fasting serum blood glucose levels between 60-100 mg/dl and 1-hour postprandial of no higher than 140 mg/dl.
A patient will gain at least 24-30 lbs prenatally or as appropriate for pre-pregnancy weight.
A patient will be free of signs and symptoms of diabetic ketoacidosis (fruity-scented breath, excessive thirst, frequent urination, weakness, confusion).

Nursing Interventions	Rationale
Assess and record dietary patterns and caloric intake using a 24-hour recall.	To help in evaluating the client’s understanding and/or compliance to a strict dietary regimen.
Assess understanding of the effect of stress on diabetes. Teach the patient about stress management and relaxation measures.	It is proven that stress can increase serum blood glucose levels, creating variations in insulin requirements.
Weigh the client every prenatal visit. Encourage the client to monitor weight at home between visits periodically.	Weight gain serves as an indicator for determining caloric adjustments.
Observe for the presence of nausea and vomiting, especially during the first trimester.	Nausea and vomiting may be brought about by a deficiency in carbohydrates, which may result in the metabolism of fats and the development of ketosis.
Teach the importance of regularity of meals and snacks (e.g., three meals or 4 snacks) when taking insulin.	Eating very frequent small meals improves insulin function.
Teach and demonstrate client to monitor sugar using a finger-stick method.	Insulin needs for the day can be adjusted based on periodic serum glucose readings. Note: Values obtained by reflectance meters maybe 10-15% lower/higher than plasma levels.
Provide information regarding any required changes in diabetic management; e.g., use of human insulin only, changing from oral diabetic drugs to insulin, self-monitoring of serum blood glucose levels at least twice a day (e.g., before breakfast and before dinner), and reducing/changing time for ingesting carbohydrates.	Metabolism and maternal/fetal needs fluctuate during the gestation period, requiring close monitoring and adaptation. Research suggests antibodies against insulin may cross the placenta, causing inappropriate fetal weight gain. The use of human insulin decreased the development of these antibodies. Reducing carbohydrates to less than 40% of the calories ingested reduces the degree of a postprandial peak of hyperglycemia. Because pregnancy provides severe morning glucose intolerance, the first meal of the day should be small, with minimal carbohydrates.
Provide information regarding the signs, symptoms, and hyperglycemia or hypoglycemia differences.	Hypoglycemia may be more sudden or severe during the first trimester, owing to an increased usage of glucose and glycogen by a client and developing fetus, as well as low levels of the insulin antagonist human placental lactogen (HPL). Ketoacidosis occurs more frequently during the second and third trimesters because of the resistance to insulin and elevated HPL levels. Sustained or intermittent pulse of hyperglycemia re mutagenic and teratogenic for the fetus in the first trimester; may also cause fetal hyperinsulinemia, macrosomia, inhibition of lung maturity, cardiac dysrhythmia, neonatal hypoglycemia, and risk of permanent neurologic damage. Maternal effects of hyperglycemia can include hydramnios, vaginal and urinary tract infections, hypertension, and spontaneous termination of pregnancy.
Recommend monitoring urine ketones on awakening and when a planned meal or snack is delayed.	Insufficient caloric intake is reflected by ketonuria, indicating a need for an increased intake of carbohydrates or additional snacks in the dietary plan (e.g., recurrent presence of ketonuria on awakening may be eliminated by 3 am a glass of milk). The presence of ketones during the second trimester may reflect “accelerated starvation” as the diminished effectiveness of insulin results in a catabolic state during fasting periods (e.g., skipping meals), causing maternal metabolism of fat. Adjustment of insulin type, dosage, and/or frequency must be required.
Instruct client to treat symptomatic hypoglycemia, if it occurs, with an 8-oz glass of milk and to repeat in 15 minutes if serum glucose levels remain below 70 mg/dl.	Using plenty of simple carbohydrates to treat hypoglycemia causes serum glucose values to elevate. A combination of complex carbohydrates and protein maintains normoglycemia longer and helps maintain the stability of serum glucose throughout the day.
Discuss the type of insulin, dosage and schedule (e.g., usually 4 times/day: 7:30am-NPH; 10am-regular; 4pm-NPH; 6pm-regular).	Division of insulin dosage considers basal maternal needs and mealtime insulin-to-food ratio and allows more freedom in meal-scheduling. Total daily dosage is based on gestational, current maternal body weight, and serum glucose levels. A mix of NPH and regular human insulin helps mimic the normal insulin release pattern of the pancreas, minimizing the “peak/valley” effect of serum glucose level. Note: Although some providers may choose to manage clients with GDM with oral hypoglycemic agents, insulin is still the drug of choice.
Adjust diet or insulin regimen to meet individual needs.	Prenatal metabolic needs change throughout the trimesters, and adjustment is determined by weight gain and laboratory test results. Insulin needs in the first trimester are 0.7 units/kg of body weight. Between 18-24 weeks of gestation, it increases to 0.8 unit/kg; at 34 weeks gestation, 0.9 unit/kg, and 1.0 unit/kg by 36 weeks gestation.
Monitor serum blood glucose levels (fasting blood sugar, preprandial 1 and two hr postprandial) on the first visit, then as indicated by the client’s condition.	Incidence of fetal and newborn abnormalities is decreased when fasting blood sugar levels range between 60 and 100 mg/dl, preprandial levels between 60 and 105 mg/dl, 1-hr postprandial remains below 140 mg/dl, and 2-hr postprandial is less than 120 mg/dl.
Ascertain results of HbA1c every 2-4weeks.	Provide an accurate picture of average serum glucose control during the preceding 60 days. Serum glucose control takes six weeks to normalize.
Coordinate multispecialty care conferences as appropriate.	Provides an opportunity to review the management of both pregnancy and diabetic conditions and to plan for special needs during intrapartum and postpartum periods.
Refer to a registered dietician to individualize diet and counsel regarding dietary questions.	Diet specific to the individual is necessary to maintain normoglycemia and to obtain desired weight gain. In-depth teaching promotes understanding of own needs and clarifies misconceptions, especially for a client with gestational diabetes. Note: New recommendations set dietary needs at 255 kcal/kg depending on the client’s current pregnant weight.
Prepare for hospitalization if diabetes is not controlled.	Infant morbidity is linked to maternal hyperglycemia-induced fetal hyperinsulinemia.

Related FAQs

1. What are the nursing diagnosis for gestational diabetes?

Nursing Diagnosis: Risk for Imbalanced Nutrition: Less than Body Requirements related to lack of ability to make use of nutrients appropriately secondary to gestational diabetes. Desired Outcomes: The patient will express an understanding of the treatment management process and the necessity of regular self-assessment.

2. What is the nursing management of gestational diabetes mellitus?

Management of GDM includes weight management, MNT, SMBG levels, exercise, and if necessary, medication if glucose targets are not met. It is imperative that women gain the appropriate amount of weight during pregnancy to prevent excessive pregnancy weight gain and postpartum weight retention.

3. What should a diabetes care plan include?

Treatment goals. Treatment goals are at the center of a diabetes type 2 care plan, because they dictate what the care plan must include. …
Blood glucose monitoring. …
Treatment for high or low blood sugar. …
Details of insulin therapy. …
Diet and exercise.

4. How do you monitor a patient with gestational diabetes?

Initial glucose challenge test.

You’ll drink a syrupy glucose solution. One hour later, you’ll have a blood test to measure your blood sugar level. A blood sugar level of 190 milligrams per deciliter (mg/dL), or 10.6 millimoles per liter (mmol/L), indicates gestational diabetes.

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

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

May 3, 2022

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

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

Permalink: https://customnursingassignments.com/nursing-care-plans-for-fever

customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us.(Nursing Care Plans for Fever)

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

A fever is a temporary increase in body temperature, often due to an illness. Having a fever is a sign that something out of the ordinary is going on in the body.

A fever may be uncomfortable for an adult but usually isn’t a cause for concern unless it reaches 103 F (39.4 C) or higher. A slightly elevated temperature may indicate a severe infection for infants and toddlers.

Fevers generally go away within a few days. Several over-the-counter medications lower a fever, but sometimes it’s better left untreated. Fever seems to play a vital role in helping the body fight off a number of infections.

Symptoms of Fever

A person has a fever when the temperature rises above its normal range. What’s normal for one person may be a little higher or lower than the average normal temperature of 98.6 F (37 C).

Depending on what’s causing the fever, additional fever signs and symptoms may include:

Sweating
Chills and shivering
Headache
Muscle aches
Loss of appetite
Irritability
Dehydration
General weakness

Children between the ages of 6 months and 5 years might experience febrile seizures. About a third of the children who have one febrile seizure will have another one, most commonly within the next 12 months.

Taking a temperature

To take a temperature, you can choose from several types of thermometers, including oral, rectal, ear (tympanic), and forehead (temporal artery) thermometers.

Oral and rectal thermometers generally provide the most accurate measurement of core body temperature. Ear or forehead thermometers, although convenient, provide less precise temperature measurements.

In infants, doctors generally recommend taking a temperature with a rectal thermometer.

When reporting a temperature to your or your child’s doctor, give the reading and explain how the temperature was taken.

Causes of Fever

Fever occurs when an area in the brain called the hypothalamus shifts the set point of the normal body temperature upward. When this happens, a person may feel chilled and add layers of clothing or wrap up in a blanket or may shiver to generate more body heat, eventually resulting in an elevated body temperature.

Normal body temperature varies throughout the day — it’s lower in the morning and higher in the late afternoon and evening. Although most people consider 98.6 F (37 C) normal, the body temperature can vary by a degree or more — from about 97 F (36.1 C) to 99 F (37.2 C) — and still be considered normal.

Fever or elevated body temperature might be caused by:

A virus
A bacterial infection
Heat exhaustion
Certain inflammatory conditions such as rheumatoid arthritis — inflammation of the lining of your joints (synovium)
A malignant tumor
Some medications, such as antibiotics and drugs, treat high blood pressure or seizures.
Some immunizations, such as diphtheria, tetanus, and acellular pertussis (DTaP), or pneumococcal vaccine

Complications of Fever

Children between the ages of 6 months and 5 years may experience fever-induced convulsions (febrile seizures), which usually involve loss of consciousness and shaking of limbs on both sides of the body. Although alarming for parents, most febrile seizures cause no lasting effects.

If a seizure occurs:

Lay the child on his or her side or stomach on the floor or ground
Remove any sharp objects that are near the child
Loosen tight clothing
Hold the child to prevent injury
Don’t place anything in the child’s mouth or try to stop the seizure

Prevention of Fever

Fever can be prevented by reducing exposure to infectious diseases. Here are some tips that can help:

Wash hands often and teach the children to do the same, especially before eating, after using the toilet, after spending time in a crowd or around someone who’s sick, after petting animals, and during travel on public transportation.

Show the children how to wash their hands thoroughly, covering each hand’s front and back with soap and rinsing completely under running water.

Carry hand sanitizer with you for times when you don’t have access to soap and water.

Try to avoid touching the nose, mouth, or eyes, as these are the main ways that viruses and bacteria can enter the body and cause infection.

Cover your mouth when you cough and your nose when you sneeze and teach your children to do likewise. Whenever possible, turn away from others when coughing or sneezing to avoid passing germs along to them.

Avoid sharing cups, water bottles, and utensils with children.

Treatments of Fever/Hyperthermia

Fever is usually associated with physical discomfort, and most people feel better when a fever is treated. But depending on your age, physical condition, and the underlying cause of your fever, you may or may not require medical treatment for the fever alone. Many experts believe that fever is a natural bodily defense against infection. There are also many non-infectious causes of fever.

Treatments vary depending on the cause of the fever. For example, antibiotics would be used for a bacterial infection such as strep throat.

The most common treatments for fever include over-the-counter drugs such as acetaminophen and nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen. Children and teens should not take aspirin because it’s linked to a condition called Reye’s syndrome.

Ways to lower a fever at home include:

Drinking a lot of clear liquids such as water, broth, and juices or a rehydration drink
Taking a lukewarm bath
Resting
Keeping yourself cool with lightweight clothing and bed coverings

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Fever)

Nursing Assessment and Rationales for Fever/Hyperthermia

Assessment is necessary to identify potential problems that may have led to hyperthermia and name any episode during nursing care.

1. Assess for signs of hyperthermia.

Assess for hyperthermia signs and symptoms, including flushed face, weakness, rash, respiratory distress, tachycardia, malaise, headache, and irritability. Monitor for reports of sweating, hot and dry skin, or being too warm.

2. Assess for signs of dehydration as a result of hyperthermia.

Look for signs of dehydration, including thirst, furrowed tongue, dry lips, dry oral membranes, poor skin turgor, decreased urine output, increased concentration of urine, and weak, fast pulse.

3. Monitor the patient’s heart rate and blood pressure.

HR and BP increase as hyperthermia progresses.

4. Identify the triggering factors for hyperthermia and review the client’s history, diagnosis, or procedures.

Understanding the changes in temperature or the cause of hyperthermia will help guide the treatment and nursing interventions.

5. Determine age and weight.

Extremes of age or weight increase the risk of the inability to control body temperature. The elderly are prone to hyperthermia because of the physiologic changes related to aging, the presence of chronic diseases, and the use of polypharmacy.

6. Accurately measure and document the client’s temperature every hour or as frequently as indicated or when there is a change in the client’s condition.

Using a consistent temperature measurement method, site, and device will help make accurate treatment decisions and assess trends in temperature. Use two modes of temperature monitoring if necessary. All non-invasive methods to measure body temperature have accuracy and precision variances unique to each type and method compared to core temperature methods. Note that the difference in temperatures between core temperature measurement and other non-invasive methods is considered to be 0.

7. Monitor fluid intake and urine output. If the patient is unconscious, central venous or pulmonary artery pressure should be measured to monitor fluid status.

Fluid resuscitation may be required to correct dehydration. The significantly dehydrated patient can no longer sweat, which is necessary for evaporative cooling.

Nursing Care Plans for Fever Based on Diagnosis

Nursing Care Plan 1: Diagnosis – Hyperthermia/Fever related to upper respiratory tract infection (URTI)

Evidenced by a temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

Desired Outcome

Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Interventions	Rationales
Assess the patient’s vital signs at least every 4 hours.	To assist in creating an accurate diagnosis and monitor the effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g., Paracetamol) administered.
Remove excessive clothing, blankets, and linens. Adjust the room temperature.	To regulate the environment’s temperature and make it more comfortable for the patient.
Administer the prescribed antibiotic and antipyretic medications.	Use the antibiotic to treat a bacterial infection, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.	To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.	Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.

Nursing Care Plan 2: Diagnosis – Hyperthermia/ Fever related to surgical wound infection

Evidenced by a temperature of 38.0 degrees Celsius, pus draining from the wound, shivering chills, and profuse sweating.

Desired Outcome

Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and no signs of surgical wound infection.

In addition to the nursing interventions mentioned previously, here are some possible actions related to this particular nursing diagnosis:

Interventions	Rationales
Perform a proper surgical wound cleaning and dressing change on a daily basis.	To perform appropriate wound care and aid in the healing process against the infection that has triggered the fever.
Inform the surgical doctor regarding the signs of surgical wound infection and inquire about the need to use antipyretic and antibiotic drugs.	Use the antibiotic to treat a bacterial infection, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Start intravenous therapy as prescribed. Encourage oral fluid intake if recommended postoperatively.	Hyperthermia can lead to dehydration.

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Fever)

Nursing Care Plan 3: Diagnosis – Alteration in comfort related to Fever/Hyperthermia.

Desired Outcome

Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

Interventions	Rationales
Remove excessive clothing, blankets, and linens. Adjust the room temperature.	To regulate the temperature of the environment and make it more comfortable for the patient.
Administer the prescribed antibiotic/ antiviral or antiparasitic and antipyretic medications.	Use the antibiotic/antiviral/antiparasitic drug to treat the infection, which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.
Offer a tepid sponge bath.	To facilitate the body in cooling down and to provide comfort.
Elevate the head of the bed.	Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.
Offer a cooling blanket to the patient.	To facilitate the body in cooling down and to provide comfort.

Nursing Care Plan 4: Diagnosis –Fluid Volume Deficit related to dehydration due to fever

Evidenced by a temperature of 39.0 degrees Celsius, skin turgidity, dark yellow urine output, profuse sweating, and blood pressure of 89/58.

Desired Outcome

Within 48 hours of nursing interventions, the patient will have a stabilized temperature within the normal range and will verbalize feeling more comfortable.

In addition to the nursing interventions mentioned previously, here are some possible actions related to this particular nursing diagnosis:

Interventions	Rationales
Commence a fluid balance chart, monitoring the input and output of the patient.	To monitor patient’s fluid volume accurately and effectiveness of actions to reverse dehydration.
Start intravenous therapy as prescribed. Encourage oral fluid intake.	To replenish the fluids lost from profuse sweating and to promote better blood circulation around the body.
Educate the patient (or guardian) on how to fill out a fluid balance chart at the bedside.	To help the patient or the guardian take ownership of the patient’s care, encourage them to drink more fluids as needed, or report any changes to the nursing team.
Monitor patient’s serum electrolytes and recommend electrolyte replacement therapy (oral or IV) to the physician as needed.	Sodium is one of the important electrolytes that are lost when a person is sweating. Hyponatremia or low serum sodium level may cause brain swelling.

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Fever)

Nursing Care Plan 5: Diagnosis –Fever/Hyperthermia related to possible catheter-associated UTI

Evidenced by a temperature of 38.7 degrees Celsius, cloudy urine, pain in the lower back, positive urine dipstick, and profuse sweating.

In addition to the nursing interventions mentioned previously, here are some possible actions related to this particular nursing diagnosis:

Interventions	Rationales
Collect a urine sample and send it to the lab for urinalysis and culture.	To confirm the medical diagnosis of urinary tract infection and determine the underlying bacteria that caused it.
Change the urinary catheter.	To remove the contaminated catheter and replace it with a new one that is fit for purpose.
Perform regular catheter care properly.	Regular catheter care is required to ensure that there is no recurrence of infection. This involves proper documentation to show that it is done frequently.

Related FAQs

1. What is the nursing care plan of fever?

Fever Nursing Care Plan

Remove excessive clothing, blankets and linens. Adjust the room temperature. To regulate the temperature of the environment and make it more comfortable for the patient. Administer the prescribed antibiotic/ antiviral or antiparasitic and anti-pyretic medications.

2. What are the interventions for fever?

In the case of a high fever, or a low fever that’s causing discomfort, your doctor may recommend an over-the-counter medication, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others). Use these medications according to the label instructions or as recommended by your doctor.

3. What is a plan of care in nursing?

What Is a Nursing Care Plan? A nursing care plan documents the process of identifying a patient’s needs and facilitating holistic care, typically according to a five-step framework. A care plan ensures collaboration among nurses, patients, and other healthcare providers.

4. What are the 4 key steps to care planning?

Here are four key steps to care planning:

Patient assessment. Patient identified goals (e.g. walking 5km per day, continue living at home)
Planning with the patient. How can the patient achieve their goals?
Implement.
Monitor and review.

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

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

May 3, 2022

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

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

Permalink: https://customnursingassignments.com/nursing-care-plans-for-edema

customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us.(Nursing Care Plans for Edema)

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

Edema is swelling that occurs when too much fluid is trapped in the body’s tissues, particularly the skin. There are different causes and types of edema. For example, pulmonary edema affects the lungs, while pedal edema causes swelling in the feet. Edema usually starts slowly, but the onset can be sudden. It is a common condition, but it can also signify a serious condition.

Edema

Edema, or water retention, causes swelling in the affected part of the body.

Edema refers to swelling and puffiness in different areas of the body. It most often occurs in the skin, especially in the hands, arms, ankles, legs, and feet. However, it can also affect the muscles, bowel, lungs, eyes, and brain.

Edema mainly occurs in older adults and pregnant people, but anyone can experience it.

Symptoms of Edema

Symptoms depend on the underlying cause, but swelling, tightness, and pain are common.

A person with edema may also notice:

Swollen, stretched, and shiny skin
Skin that retains a dimple after a few seconds of pressure
Puffiness of the ankles, face, or eyes
Aching body parts and stiff joints
Weight gain or weight loss
Decreased urine production
Fuller hand and neck veins
Visual anomalies

Symptoms can also depend on the type of edema a person has and which part of the body it affects.

Treatment of Edema

Treatment will also depend on the cause of edema.

Diuretics medication. They help get rid of excess fluid by increasing the rate of urine production by the kidneys. Different types work in different ways.

A doctor will recommend a specific treatment plan for macular edema, pulmonary edema, and other types of edema.

A person with edema could also try wearing compression garments and doing specific exercises to help.

Prevention of Edema

Wearing compression stockings can help reduce the swelling and discomfort associated with edema.

Some self-care techniques can help reduce or prevent edema. These include:

Reducing salt intake
Losing weight, if appropriate
Getting regular exercise
Raising the legs when possible to improve circulation
Wearing support stockings, which are available to purchase online
Not sitting or standing still for too long
Getting up and walking about regularly when travelling
Avoiding extremes of temperature, such as hot baths, showers, and saunas
Dressing warmly in cold weather
A masseuse or physical therapist may help remove the fluid by stroking firmly in the direction of the heart.

Oxygen may be useful for treating some types of edema. For example, an individual with cardiogenic pulmonary edema may need additional oxygen if they have difficulty taking in enough. Oxygen delivered through the nose may improve poor vision associated with diabetic macular edema, according to older research from 2004.

Types of Edema

There are many types of edema. Each one can indicate a range of further health conditions. Types include:

Peripheral Edema

This affects the feet, ankles, legs, hands, and arms. Symptoms include swelling, puffiness, and difficulty moving certain parts of the body.

Pulmonary Edema

This occurs when excess fluid collects in the lungs, making breathing difficult. This can result from congestive heart failure or acute lung injury. It is a serious condition, and it can be a medical emergency, leading to respiratory failure and death.

Cerebral Edema

This occurs in the brain. It can happen for a range of reasons, many of which are potentially life-threatening. Symptoms include:

Headache
Neck pain or stiffness
Whole or partial vision loss
Changes in consciousness or mental state
Nausea
Vomiting
Dizziness

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Edema)

Macular Edema

This is a serious complication of diabetic retinopathy. Swelling occurs in the macula, which is the part of the eye that enables detailed, central vision. The person may notice changes to their central vision and how they see colours.

Pitting Edema

With this type, which can occur in peripheral edema, pressure applied to the skin leaves an indent or pit in the skin.

Periorbital Edema

This refers to inflammation and puffiness around the eye or eyes. The puffiness is due to fluid buildup and is usually temporary.

Note: Edema can occur in other locations as well, but those mentioned above are the most common. Edema can indicate one of many serious health conditions. A person needs to check with a doctor if they are concerned about any kind of swelling.

Causes of Edema

Edema can result from circulatory problems, infection, tissue death, malnutrition, total body fluid overload, and electrolyte problems.

There are many other possible causes of edema, including:

Heart failure

If one or both of the heart’s lower chambers cannot pump blood properly, blood can accumulate in the limbs, causing edema.

Kidney disease or kidney damage

The body of a person with a kidney disorder may not be able to eliminate enough fluid and sodium from the blood. This puts pressure on the blood vessels, which causes some of the liquid to leak out. Swelling can occur around the legs and eyes.

Damage to the glomeruli, which are the capillaries in the kidneys that filter waste and excess fluids from the blood, can result in nephrotic syndrome. One symptom of this is a low level of protein albumin in the blood. This can lead to edema.

Liver disease

Cirrhosis affects liver function. It can lead to changes in the secretion of hormones and fluid-regulating chemicals and reduced protein production. This causes fluid to leak out of the blood vessels into the surrounding tissue.

Cirrhosis also increases pressure within the portal vein, which is the large vein that carries blood from the intestines, spleen, and pancreas to the liver. Edema can occur in the legs and abdominal cavity.

Certain medications

Certain medications can also increase the risk of edema.

These include:

Vasodilators, which are drugs that open blood vessels
Calcium channel blockers
Nonsteroidal anti-inflammatory drugs
Estrogens
Some chemotherapy drugs
Some diabetes drugs, such as thiazolidinediones

Pregnancy

During pregnancy, the body releases hormones that encourage fluid retention and the body to retain more sodium and water than usual. The face, hands, lower limbs, and feet may swell.

When a person is resting in a reclined position during pregnancy, the enlarged uterus can press on a vein known as the inferior vena cava. This can obstruct the femoral veins, leading to edema.

During pregnancy, the blood clots more easily. This can increase the risk of deep vein thrombosis (DVT), which is another potential cause of edema.

Eclampsia, which results from pregnancy-induced hypertension, or high blood pressure, can also cause edema.

Dietary factors

A number of dietary factors can also affect the risk of edema, such as:

Consuming too much salt (in people who are susceptible to developing edema)
Malnutrition, wherein edema can result from low protein levels in the blood.
A low intake of vitamin b 1, b 6, and b5

Diabetes

Some complications of diabetes include:

Cardiovascular disease
Acute renal failure
Acute liver failure
Protein-losing enteropathy is an intestinal condition that causes protein loss.
These complications, and certain medications for diabetes, can result in edema.
Diabetic macular edema is the swelling of the retina in diabetes.

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Edema)

Conditions affecting the brain

Some causes of swelling in the brain include:

Head injuries: A blow to the head may result in an accumulation of fluids in the brain.
Stroke: A major stroke can result in brain swelling.
Brain tumours: A brain tumour will accumulate water around itself, especially as it builds new blood vessels.

Allergies

Some foods and insect bites may cause edema of the face or skin in people who have allergies or sensitivities to them. Severe swelling can be a symptom of anaphylaxis.

Swelling in the throat can close a person’s airway, so they cannot breathe. This is a medical emergency.

Problems with the extremities

Some extremity-related causes of edema include:

A blood clot: Any blockage, such as a clot in a vein, can prevent the blood from flowing. As pressure increases in the vein, fluids start to leak into the surrounding tissue, causing edema.

Varicose veins: These usually occur because valves become damaged. Pressure increases in the veins, and they start to bulge. The pressure also increases the risk of fluids leaking into the surrounding tissue.

A cyst, growth, or tumour: Any lump can cause edema if it presses against a lymph duct or vein. As pressure builds up, fluids can leak into the surrounding tissue.

Lymphedema: The lymphatic system helps remove excess fluid from tissues. Any damage to this system — from a surgical procedure, an infection, or a tumour, for example — can result in edema.

Miscellaneous conditions

Some other possible causes of edema include:

Prolonged immobility: People who are immobile can develop edema in their skin for a long time. This can be due both to fluid pooling in gravity-dependent areas and the release of antidiuretic hormone from the pituitary.

High altitude: This, combined with physical exertion, can increase the risk of edema. Acute mountain sickness can lead to high-altitude pulmonary edema or high-altitude cerebral edema.

Burns and sunburn: The skin reacts to burns by retaining fluid. This causes localized swelling.

Infection or inflammation: Any infected or inflamed tissue can become swollen. This is usually most noticeable in the skin.

Menstruation and pre-menstruation: Hormone levels fluctuate during the menstrual cycle. During the days before menstruation, levels of progesterone are lower, and this may cause fluid retention.

Birth control pills: Any medication that contains estrogen can cause fluid retention. It is not uncommon for people to gain weight when they first start using birth control pills.

Menopause: Around menopause, hormone fluctuations can cause fluid retention. Hormone replacement therapy can also trigger edema.

Thyroid disease: Hormonal imbalances associated with thyroid problems can lead to edema.

Complications of Edema

Untreated edema can lead to:

Painful swelling, with pain that gets worse
Stiffness and difficulty walking
Stretched, itchy skin
Infection in the area of swelling
Scarring between the layers of tissue
Poor blood circulation
Loss of elasticity in the arteries, veins, and joints
Ulcerations on the skin

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Edema)

Nursing Assessment for Fluid Volume Excess/Edema

Assessment is required to distinguish possible problems that may have led to fluid volume excess and identify any incident that may occur during nursing care.

Assessment	Rationales
Review the patient’s history to determine the probable cause of the fluid imbalance.	Such information can assist in directing management. History may include increased fluids or sodium intake.
Monitor weight regularly using the same scale and preferably wearing the same amount of clothing at the same time of day.	Sudden weight gain may mean fluid retention. Different scales and clothing may show false weight inconsistencies.
Monitor input and output closely.	Dehydration may result from fluid shifting even if overall fluid intake is adequate.
Assess weight in relation to nutritional status.	In some patients with heart failure, the weight may be a poor indicator of fluid volume status. Poor nutrition and decreased appetite over time result in a decrease in weight, which may be accompanied by fluid retention even though the net weight remains unchanged.
Record intake if a patient is on fluid restriction.	Patients should be reminded to include items that are liquid at room temperatures, such as gelatin, sherbet, soup, and frozen juice pops.
Monitor and note BP and HR.	Sinus tachycardia and increased BP are evident in the early stages.
Review chest x-ray reports.	The x-ray studies show cloudy white lung fields as interstitial edema accumulates.
Assess urine output in response to diuretic therapy.	Recording two voids versus six voids after a diuretic medication may provide more useful information. Medications may be given intravenously because FVE in the abdomen may interfere with the absorption of oral diuretic medications.
Note for the presence of edema by palpating over the tibia, ankles, feet, and sacrum.	Edema occurs when fluid accumulates in the extravascular spaces. Dependent areas more readily exhibit signs of edema formation. Edema is graded from trace (indicating barely perceptible) to 4 (severe edema). Pitting edema is manifested by a depression that remains after one’s finger is pressed over an edematous area and then removed. Measurement of an extremity with a measuring tape is another method of the following edema.
Assess for crackles in the lungs, changes in respiratory pattern, shortness of breath, and orthopnea.	These signs are caused by an accumulation of fluid in the lungs.
Assess for bounding peripheral pulses and S3.	These assessment findings are signs of fluid overload.
Check for distended neck veins and ascites. Monitor abdominal girth to follow any ascites accurately.	Distended neck veins are caused by elevated CVP. Ascites occurs when fluid accumulates in extravascular spaces.
Review serum electrolytes, urine osmolality, and urine specific gravity.	All are indicators of fluid status and guide therapy.
Consider the need for an external or indwelling urinary catheter.	Treatment focuses on diuresis of excess fluid. Urinary catheters provide a more accurate measurement of the response to diuretics.
Check for excessive response to diuretics.	Significantly increased response to diuretics may lead to fluid deficit.

Nursing Care Plans for Edema

Nursing Interventions for Fluid Volume Excess

The following are the therapeutic nursing interventions for Fluid Volume Excess:

Interventions	Rationales
Instruct patient, caregiver, and family members regarding fluid restrictions, as appropriate.	Information and knowledge about the condition are vital to patients who will be co-managing fluids.
Limit sodium intake as prescribed.	Restriction of sodium aids in decreasing fluid retention
Monitor fluid intake.	This enhances compliance with the regimen.
Take diuretics as prescribed.	Diuretics aid in the excretion of excess body fluids.
Elevate edematous extremities, and handle with care.	Elevation increases venous return to the heart and, in turn, decreases edema. Edematous skin is more susceptible to injury.
Consider interventions related to specific etiological factors (e.g., inotropic medications for heart failure, paracentesis for liver disease).	Knowledge of etiological factors gives direction for subsequent interventions.
For acute cases of Fluid Volume Excess:
Cooperate with the pharmacist to maximally concentrate IV fluids and medications.	Concentration decreases unnecessary fluids.
Anticipate admission to an acute care setting for hemofiltration or ultrafiltration.	These therapies are very efficient techniques to draw off extra fluid.
Administer IV fluids through an infusion pump, if possible.	Pumps guarantee precise delivery of IV fluids.
Apply a heparin lock device.	This device maintains IV access and patency but decreases fluid delivered to the patient in a 24-hour period.
Place the patient in a semi-Fowler’s or high-Fowler’s position.	Raising the head of the bed provides comfort in breathing.
Aid with repositioning every 2 hours if the patient is not mobile.	Repositioning prevents fluid accumulation independent areas.
Educate patient and family members regarding fluid volume excess and its causes.	Information is key to managing problems.
Explain the rationale and intended effect of the treatment program.	Follow-up care will be the patient’s or caregiver’s responsibility. Information is necessary to make correct choices in the future.
Explain the need to use anti embolic stockings or bandages, as ordered.	These aids help promote venous return and minimize fluid accumulation in the extremities.
Educate patient and family members on the importance of proper nutrition, hydration, and diet modification.	Knowledge heightens compliance with the treatment plan.

Nursing Care Plans for Edema

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Nursing Care Plans for Edema)

Summary

Edema occurs when fluid builds up in the body. This causes swelling, which can sometimes be painful.

There are several potential causes of edema, including pregnancy, heart failure, liver disease, and certain medications. The treatment a person receives will depend on the cause.

Related FAQs

1. What are the nursing interventions for edema?

Treatment of Edema

Proper repositioning, such as elevating the legs with mild edema, may resolve it. Medications. Urine-increasing medications (diuretics) may be prescribed to treat more severe edema. Prolonged treatment typically focuses on removing or decreasing swelling.

2. What are the top 5 nursing interventions that need to be considered with a patient with a heart failure?

Nursing Priorities

Improve myocardial contractility/systemic perfusion.
Reduce fluid volume overload.
Prevent complications.
Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

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.

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

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

May 3, 2022

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

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

Permalink: https://customnursingassignments.com/nursing-care-plans-for-diverticulitis

customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us.(Nursing Care Plans for Diverticulitis)

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

Diverticulitis is the infection or inflammation of pouches that can form in your intestines. Diverticula are the name for these pouches. Diverticulitis is the infection or inflammation of pouches that can form in your intestines. These pouches are called diverticula.

The pouches generally aren’t harmful. They can show up anywhere in your intestines. If you have them, it’s called diverticulosis. If they become infected or inflamed, you have diverticulitis.

Sometimes, diverticulitis is minor. But it can also be severe, with a massive infection or perforation of the bowel.

The pouches are ordinarily harmless. They might appear in your intestines at any time. Diverticulosis is the medical term for having them. Diverticulitis occurs when they get infected or inflamed.

Diverticulitis might be modest at times. However, it can be severe, resulting in a considerable infection or intestinal perforation.

Diverticulitis

Diverticulitis is an inflammatory bowel disease that most commonly affects the colon. A bacterial infection of one or more of the pouches produced due to diverticulosis causes inflammation. The inflammation may appear quickly or develop gradually for 24 to 48 hours. This illness can affect any region of your colon, although the sigmoid colon is the most commonly affected (the last 5 feet).

Diverticula are one or more pockets or bulges that form in the wall of your colon. They are tiny, bulging pouches in the digestive tract walls, often seen in the colon or the lower part of the intestine.

Diverticula are like expanded areas or bubbles that form when you fill the inner tube of a bike tire with too much air. The increase in pressure from too much air being pumped into the inner tube causes the bubble to form where the rubber is the weakest. Similarly, increased pressure inside the colon causes pockets or bulges (diverticula) to form in weakened areas of your colon’s walls.

Diverticula can range from pea-size to much more extensive. Although they can form anywhere in the inner lining of your colon, they are most commonly found in your lower left side, in the S-shaped segment of your colon called the sigmoid colon.

What’s the difference between diverticulosis and diverticulitis?

The presence of these microscopic bulges or pockets (diverticula) in your colon is known as diverticulosis. They rarely cause symptoms or necessitate treatment. Diverticulosis, on the other hand, can result in diverticulitis.

Diverticulitis is an infection and inflammation of one or more diverticula. You might have discomfort, nausea, a fever, and other symptoms. This is a much more severe and even life-threatening illness.

Pathophysiology

This clinical manifestation can occur in any portion of the intestine, although it is most common in the Sigmoid colon, the lower part of the colon.

These herniations happen when blood vessels break through the muscle layer of the intestinal wall. When pressure builds up in the intestinal lumen, only the mucosal layers, not the muscular wall, generate an outpouching.

Diverticulitis develops when feces obstructs the diverticula, causing ischemia and inflammation. In addition, gut microorganisms may trigger an inflammatory response.

Risk Factors

Age. The risk for developing diverticulitis increase with age, with higher incidence noted among older people.
Gender. It is commonly seen in males under the age of 50.
Genetics. There are disorders like Marfan syndrome, Ehlers-Danlos syndrome and Williams-Beuren syndrome that can trigger the formation of diverticula.
Obesity. Excessive weight gain increases visceral fat, which is related to diverticulitis.
Smoking. Nicotine can decrease muscle tone and activity of the sigmoid colon.
Sedentary lifestyle. Lack of exercise and physical activity decreases intestinal motility, which increases the risk of acquiring the disease.
Diet. The consumption of high fat, low fibre diet is also associated with the development of diverticula.
Medications. There are certain drugs such as steroids, NSAIDs, and opioids due to their risk of diverticular bleeding.

Signs and Symptoms of Diverticulitis

Although most of the cases are painless, the following signs and symptoms of diverticulitis may develop, these include:

Abdominal pain. It is usually localized in the left lower quadrant of the abdomen, while those of Asian descent experience pain on the right side. Pain is described as steady and may last for several days. It may also worsen with straining, lifting or coughing
Nausea and vomiting
Bloating
Abdominal distention and tenderness
Abdominal cramps
Constipation
Elevated temperature
A palpable, tender rectal mass may be present

Complications of Diverticulitis

If you don’t treat it, diverticulitis can lead to serious complications that require surgery:

Abscesses, collections of pus from the infection, may form around the infected diverticula. If these go through the intestinal wall, you could get peritonitis. This infection can be fatal. You’ll need treatment right away.

Perforation or tear in the intestinal wall can lead to abscesses and infection because of waste leaking into the abdominal cavity.

Scarring can lead to a stricture or blockage of the intestine.

Fistulas can develop if an infected diverticulum reaches a nearby organ and connects. This most often happens between the large intestine and the bladder. It can lead to a kidney infection. Fistulas can also form between the large intestine and the skin or the vagina.

Stricture, which happens when the colon narrows in the affected area.

**Nursing Care Plans for Diverticulitis**

Diagnosis for Diverticulitis

If you have symptoms of diverticulitis, it’s important to be seen by your healthcare provider to get the correct diagnosis.

First, your healthcare provider will ask you about your medical history, including your current symptoms, the types of foods you normally eat, how often you have bowel movements and other questions about your bowel movements and review any medications you are currently taking. Your healthcare provider will check your abdomen for pain and tenderness.

Other tests that may be performed or ordered to help diagnose your condition include:

Blood test: Your blood is checked for signs of infection, such as a high white blood cell count.

Stool sample: Your stool sample is checked for the presence of abnormal bacteria or parasites as possible causes of your infection, abdominal pain, blood in stool, diarrhea or your other symptoms.

Digital rectal exam: In this physical exam, your healthcare provider gently inserts a gloved, lubricated finger into your rectum to feel for any problems in your anus or rectum.

CT scan: A CT scan can show infected or inflamed diverticula and reveal the severity of diverticulitis.

Barium enema (also called lower gastrointestinal tract radiography): A liquid containing barium is injected into your anus in this test. The liquid coats the inside of your colon, which helps make any problems in your colon more visible on X-rays.

Sigmoidoscopy: In this exam, a thin, flexible tube with a light on the end is inserted into your rectum and moved into your sigmoid colon. The tube is connected to a video camera. The camera allows a visual inspection of your sigmoid colon (where most diverticula form) and rectum.

Colonoscopy: In this exam, the full length of your colon can be examined. A thin, flexible, lighted tube with a camera, called a colonoscope, is inserted through your rectum and into your colon. During a colonoscopy, your colon is checked for abnormal growths, sores, ulcers, bleeding or other problems that could cause changes in bowel habits or abdominal pain. Tissue samples can be taken, and polyps can be removed.

Angiography: If you have rapid, heavy rectal bleeding, this procedure helps find where the bleeding is coming from. During this test, the arteries that supply the colon are injected with a harmless dye that allows the source of the bleeding to be seen.

Laboratory studies:

WBC

Hematocrit and Hemoglobin

Occult stool sample

C-reactive protein (CRP)

Urinalysis

Treatment of Diverticulitis

The treatment of diverticulitis will depend upon the severity of signs and symptoms.

1. At-home treatment. In uncomplicated diverticulitis, where there is the presence of mild symptoms, home treatment may be advised. The patient will be advised to maintain a liquid diet until the bowel heals and progress with a soft diet once the symptoms improve.

2. Antibiotics. In some cases, oral antibiotics may be prescribed to treat any infection. However, hospitalization is required for complicated diverticulitis with severe symptoms. The treatment would include intravenous antibiotics and tube insertion to drain the abdominal abscess.

3. Surgery. Surgical treatment may be required for people with complications such as obstruction, perforation, and abscess in the intestinal wall, as well as for those who are immunocompromised or people with recurrent episodes of diverticulitis. There are two types of surgical intervention to treat diverticulitis

4. Primary bowel resection. This can be performed as an open surgery or via a laparoscopic approach. It involves the removal of the affected intestinal segments and anastomosis of the healthy segments, which allows bowel movements to return to normal.

5. Bowel resection with colostomy. The surgeon creates an opening or a stoma to enable the passage of stool. This is recommended for severe inflammation and can be reversed once the inflammation has subsided.

6. Colonoscopy. The doctor may advise colonoscopy after six weeks of recovery. This diagnostic procedure is done once there is full recovery from a diverticulitis attack.

When is surgery for diverticulitis considered?

Surgery for diverticulitis is considered if you have:

Abscesses: An abscess is a contained or “walled-off” infection in the abdomen. If the fluid in an abscess (a collection of bacteria and white blood cells) is not successfully drained with a needle or catheter, surgery is needed. In surgery, the abscess is cleaned up, and the affected part of the colon is removed.
Perforation/peritonitis: A tear (perforation) in your colon allows pus or stool to leak into your abdominal cavity, resulting in peritonitis. This is a life-threatening infection that requires emergency surgery to clean the cavity and remove the damaged part of the colon.
Blockages or strictures: Previous infections in your colon can cause scars to form, which can result in a partial or complete blockage or strictures (narrowing of sections of the colon). A complete blockage requires surgery (partial blockage does not).
Fistulas: A fistula is an abnormal passageway or tunnel that forms and connects with another organ. An abscess that erodes into the surrounding tissue creates these passageways. A fistula in the colon can connect to the skin, bladder, vagina, uterus or another part of the colon. Most fistulas don’t close on their own, so surgery is needed.
Continued rectal bleeding (also called diverticular bleeding): Diverticular bleeding occurs when a small blood vessel near the diverticula bursts. Mild bleeding usually stops on its own, but about 20% of cases require treatment. Surgery may be needed if other attempts to stop the bleeding fail, such as clipping, drug infusion or cauterizing the bleeding artery. If bleeding is heavy and rapid, emergency surgery is needed.
Severe diverticulitis that has not responded to other treatment methods.
Multiple attacks despite following a high-fibre diet. You and your surgeon may decide surgery to remove the diseased part of the colon is the best method to prevent future attacks.

Nursing Care Plans for Diverticulitis

Nursing Care Plan 1: Acute Pain

It is related to the presence and inflammation of the diverticula as evidenced by a pain score of 10 out of 10, verbalization of right upper quadrant abdominal pain and cramping, guarding sign on the abdomen, abdominal rigidity, and restlessness.

Desired Outcome

The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and an absence of restlessness.

Interventions	Rationale
Administer prescribed pain medications.	To alleviate the symptoms of acute abdominal pain. Pain medication may include narcotics, anticholinergics, or smooth muscle relaxants.
Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.	To monitor the effectiveness of medical treatment for the relief of abdominal pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.
Elevate the head of the bed and position the patient in semi Fowler’s.	To increase the oxygen level by allowing optimal lung expansion.
Place the patient in complete bed rest during severe episodes of pain.	To reduce gastrointestinal stimulations, thereby decreasing GI activity.
Perform non-pharmacological pain relief methods: relaxation techniques such as deep breathing exercises, guided imagery, and provision of distractions such as TV or radio.	To provide optimal comfort to the patient.
Prepare the patient for surgery as ordered.	Severe acute pain due to obstruction from severe diverticulitis may require immediate surgical intervention.

Nursing Care Plan 2: Risk for Imbalanced Nutrition

Desired Outcome

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

Interventions	Rationale
Ask the patient’s preferences regarding food and drinks. Discuss with the patient the short term and long-term nutritional goals	To help the patient gain a sense of control in their nutritional intake and meal planning.
Create a daily weight chart and a food and fluid chart. Calculate caloric intake.	To effectively monitor the patient’s daily nutritional intake and progress in nutritional goals.
Help the patient to select appropriate dietary choices to follow a low-fat high fibre diet.	A low-fat high fibre diet is ideal for patients with diverticulitis.
Refer the patient to the dietitian.	To provide more specialized care for the patient in terms of nutrition and diet in relation to post-surgical status.

Nursing Care Plan 3: Risk for Infection post bowel resection

Desired Outcome

The patient will be able to avoid the development of an infection after surgery.

Interventions	Rationale
Assess vital signs and observe for any signs of infection.	Infection may be evidenced by fever and can be accompanied by respiratory distress.
Obtain daily blood samples as ordered.	To monitor neutrophil and white blood cell counts.
Teach the patient and caregiver how to perform proper hand hygiene.	To maintain patient safety and reduce the risk of infection.
Orient the patient and caregiver on how to perform proper wound care.	To ensure that the principles of asepsis are carefully followed when changing wound dressing.

Nursing Care Plan 4: Constipation related to the inflammatory process of diverticulitis

It is evidenced by type 1-2 stools on Bristol stool chart, inability to open bowels in the last three days, irritability.

Desired Outcome

The patient will be able to re-establish normal bowel elimination.

Interventions	Rationale
Commence a stool chart. Use a standardized stool assessment tool such as the Bristol stool chart.	To monitor the patient’s bowel pattern.
Administer laxatives as prescribed.	To help evacuate stools, the following laxatives can be used as prescribed: •Stimulant laxatives ‘Stool softeners, especially for the elderly patients •Bulk laxatives
Encourage to increase oral fluid intake as tolerated, ideally at least 2L per day. Check if the patient is in any fluid restriction before doing so.	To help soften the stool and make it easier to pass.
Encourage physical mobility and exercise as tolerated.	To increase bowel peristaltic movement.
Encourage fibre intake of at least 25 grams per day for women and 38 grams per day for men, as recommended by the dietitian.	To help the food move through the intestines. Examples of good dietary fibre

Related FAQs

1. What are some nursing diagnosis for diverticulitis?

Although most of the cases are painless, the following signs and symptoms of diverticulitis may develop, these include:

Abdominal pain. …
Nausea and vomiting.
Bloating.
Abdominal distention and tenderness.
Abdominal cramps.
Constipation.
Elevated temperature.
Palpable, tender rectal mass may be present.

2. What are some nursing interventions for diverticulitis?

(2) Treatment of mild cases of diverticulitis includes antibiotics, antispasmodics, stool softeners, and liquid diet. (3) Severe cases of diverticulitis, or cases that involve perforation, obstruction, fistula, or peritonitis may require surgical intervention.

3. What is the treatment plan for diverticulitis?

Diverticulitis is treated using diet modifications, antibiotics, and possibly surgery. Mild diverticulitis infection may be treated with bed rest, stool softeners, a liquid diet, antibiotics to fight the infection, and possibly antispasmodic drugs.

4. How do you assess for diverticulitis?

Doctors often diagnose diverticulitis using a computed tomography (CT) scan of your abdomen and pelvis. It is best to perform the scan with intravenous (IV) contrast when possible. Many centers will also ask that you drink a form of oral contrast. Both contrast materials make the intestinal tract easier to see.

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

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

May 3, 2022

Author: Dr. Prince

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

Introduction

Nursing Care Plans for Shingles – Symptoms of Shingles

Nursing Care Plans for Shingles – Causes of Shingles

Nursing Care Plans for Shingles – Risk Factors of Shingles

Nursing Care Plans for Shingles – Diagnosis of Shingles

Nursing Care Plans for Shingles – Treatment of Shingles

Nursing Care Plans for Shingles – Complications of Shingles

Nursing Care Plans for Shingles / Herpes Zoster Based on Diagnosis

Nursing Care Plans for Shingles – Nursing Care Plan 1: Diagnosis -Acute/Chronic Pain

Nursing Care Plans for Shingles – Nursing Care Plan 2: Diagnosis -Impaired Skin Integrity related to infection of the skin secondary to herpes zoster infection

Nursing Care Plans for Shingles – Nursing Care Plan 3: Diagnosis – Risk for Disturbed Body Image

Nursing Care Plans for Shingles – Nursing Care Plan 4: Diagnosis – Risk for Infection related to a contagious skin infection

Nursing Care Plans for Shingles – Nursing Care Plan 5: Diagnosis – Deficient Knowledge

Related FAQs

Read More:

Nursing Care Plans for Gestational Diabetes Mellitus – Best Nursing Care Plans(2022)

Introduction

Causes Gestational Diabetes Mellitus

Risks Factors of Gestational Diabetes Mellitus

Diagnosis of Gestational Diabetes Mellitus

Treatment for Gestational Diabetes Mellitus

Possible complications for the baby

Nursing Care Plans for Gestational Diabetes Mellitus Based on Diagnosis

Nursing Care Plan 1: Diagnosis – Risk for Maternal Injury

Nursing Care Plan 2: Diagnosis – Risk for Fetal Injury

Nursing Care Plan 3: Diagnosis – Risk for Altered Nutrition: Less than Body Requirements

Related FAQs

Read More:

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

Introduction

Symptoms of Fever

Causes of Fever

Complications of Fever

Prevention of Fever

Treatments of Fever/Hyperthermia

Nursing Assessment and Rationales for Fever/Hyperthermia

Nursing Care Plans for Fever Based on Diagnosis

Nursing Care Plan 1: Diagnosis – Hyperthermia/Fever related to upper respiratory tract infection (URTI)

Nursing Care Plan 2: Diagnosis – Hyperthermia/ Fever related to surgical wound infection

Nursing Care Plan 3: Diagnosis – Alteration in comfort related to Fever/Hyperthermia.

Nursing Care Plan 4: Diagnosis –Fluid Volume Deficit related to dehydration due to fever

Nursing Care Plan 5: Diagnosis –Fever/Hyperthermia related to possible catheter-associated UTI

Related FAQs

Read More:

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

Introduction

Edema

Symptoms of Edema

Treatment of Edema

Prevention of Edema

Types of Edema

Causes of Edema

Complications of Edema

Nursing Assessment for Fluid Volume Excess/Edema

Nursing Interventions for Fluid Volume Excess

Summary

Related FAQs

Read More:

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

Introduction

Diverticulitis

What’s the difference between diverticulosis and diverticulitis?

Pathophysiology

Risk Factors

Signs and Symptoms of Diverticulitis

Complications of Diverticulitis

Diagnosis for Diverticulitis

Treatment of Diverticulitis

When is surgery for diverticulitis considered?

Nursing Care Plans for Diverticulitis

Nursing Care Plan 1: Acute Pain

Nursing Care Plan 2: Risk for Imbalanced Nutrition

Nursing Care Plan 3: Risk for Infection post bowel resection

Nursing Care Plan 4: Constipation related to the inflammatory process of diverticulitis

Related FAQs

Read More: