Nursing Diagnosis related to Diabetes Mellitus (Type 1 and Type 2)

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body.

The two types of diabetes are referred to as type 1 and type 2. Former names for these conditions were insulin-dependent and non-insulin-dependent diabetes, or juvenile onset and adult onset diabetes.

Type 1 Diabetes Mellitus

  • Associated with HLA DR3 and DR4 and islet cell antibodies around the time of diagnosis. Patients always need insulin treatment and are prone to ketoacidosis.
  • The term ‘type 1a diabetes’ is applied to the development of type 1 diabetes resulting from an autoimmune T cell-mediated islet cell destruction.
  • Risks of developing type 1 diabetes are broadly similar in all ethnic groups; however, there is increasing evidence that certain infectious agents or certain components of diet in early childhood trigger the development of autoimmunity to the pancreatic beta cells in genetically susceptible individuals.
  • Concordance is >30% in identical twins; four genes are thought to be important. One (6q) determines islet sensitivity to damage – eg, from viruses or cross-reactivity from cow’s milk-induced antibodies.
  • Approximately 15% of those with diabetes – usually juvenile-onset, but may occur at any age. It may be associated with other autoimmune diseases. It is characterised by insulin deficiency.

Type 2 diabetes Mellitus

  • Type 2 diabetes is associated with excess body weight and physical inactivity.
  • Type 2 diabetics may eventually need insulin treatment.
  • Caused by impaired insulin secretion and insulin resistance and has a gradual onset.
  • All racial groups are affected but increased prevalence in people of South Asian, African, African-Caribbean, Polynesian, Middle-Eastern and American-Indian ancestry.
  • Approximately 85% of those with diabetes; they are usually older at presentation (usually >30 years of age) but it is increasingly diagnosed in children and adolescents.

Symptoms of diabetes can develop suddenly (over days or weeks) in previously healthy children or adolescents, or can develop gradually (over several years) in overweight adults over the age of 40. The classic symptoms include feeling tired and sick, frequent urination, excessive thirst, excessive hunger, and weight loss.

Ketoacidosis, a condition due to starvation or uncontrolled diabetes, is common in Type I diabetes. Ketones are acid compounds that form in the blood when the body breaks down fats and proteins. Symptoms include abdominal pain, vomiting, rapid breathing, extreme lethargy, and drowsiness. Patients with ketoacidosis will also have a sweet breath odor. Left untreated, this condition can lead to coma and death.

With Type II diabetes, the condition may not become evident until the patient presents for medical treatment for some other condition. A patient may have heart disease, chronic infections of the gums and urinary tract, blurred vision, numbness in the feet and legs, or slow-healing wounds. Women may experience genital itching.

 

Nursing Diagnosis related to Diabetes Mellitus

1. Risk for Infection

related to:
high glucose levels
reduction in leukocyte function.

2. Imbalanced Nutrition, Less Than Body Requirements

related to
poor nutrition intake.

3. Fluid Volume Deficit

related to:
osmotic diuresis (hyperglycemia).

4. Activity Intolerance

related to:
physical weakness.

5. Knowledge Deficit: about the disease process

related tyo: lack of information.

6. Risk for Impaired Skin Integrity

related to:
immobilization
neuropathy.

Hypertension – 5 Nursing Diagnosis and Interventions

Nursing Care Plan for HypertensionHypertension is the term used to describe high blood pressure.

Blood pressure is a measurement of the force against the walls of your arteries as the heart pumps blood through the body.

The top number is called the systolic blood pressure, and the bottom number is called the diastolic blood pressure.

  • Normal blood pressure is when blood pressure is lower than 120/80 mmHg most of the time.
  • High blood pressure (hypertension) is when blood pressure is 140/90 mmHg or above most of the time.
  • If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called pre-hypertension.
  • Many factors can affect blood pressure, including:
  • How much water and salt you have in your body
  • The condition of your kidneys, nervous system, or blood vessels
  • The levels of different body hormones

Most of the time, there are no symptoms. Symptoms that may occur include:

  • Confusion
  • Ear noise or buzzing
  • Fatigue
  • Headache
  • Irregular heartbeat
  • Nosebleed
  • Vision changes

 

Nursing Care Plan for Hypertension

Nursing Diagnosis I :

Decreased Cardiac Output

NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body

NOC:

  • Demonstrate stable cardiac rhythm and rate within patient’s normal range.
  • Maintain blood pressure within individually acceptable range.
  • Participate in activities that reduce blood pressure /cardiac workload.

Interventions :

1. Monitor blood pressure, measure in both arms/thighs three times, use correct cuff size and accurate technique.
Rationale : Comparison of pressures provides a more complete picture of vascular involvement/scope of problem. Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated.

2. Note dependent/general edema.
Rationale : May indicate heart failure, renal or vascular impairment.

3. Note presence, quality of central and peripheral pulses.
Rationale : Pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion.

4. Observe skin color, moisture, temperature, and capillary refill time.
Rationale : Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/decreased output.

 

Nursing Diagnosis II :

Acute Pain

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

NOC :

  • Verbalize methods that provide relief.
  • Report pain/discomfort is relieved/controlled.
  • Follow prescribed pharmacological regimen.

Interventions :

1. Assess pain scale. Determine specifics of pain, e.g., location, characteristics.
Rationale : Helpful in evaluating effectiveness of therapy.

2. Encourage bedrest during acute phase.
Rationale : Minimizes stimulation/promotes relaxation.

3. Assist patient with ambulation as needed.
Rationale : Patient may also experience episodes of postural hypotension, causing weakness when ambulating.

4. Minimize vasoconstricting activities that may aggravate headache.
Rationale : Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure.

 

Nursing Diagnosis III :

Activity Intolerance

NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

NOC :

  • Demonstrate a decrease in physiological signs of intolerance.
  • Participate in necessary/desired activities.
  • Report a measurable increase in activity tolerance.

Interventions :

1. Encourage progressive activity/self-care when tolerated. Provide assistance as needed.
Rationale : Gradual activity progression prevents a sudden increase in cardiac workload. Providing assistance only as needed encourages independence in performing activities.

2. Instruct patient in energy-conserving techniques, e.g., using chair when showering, sitting to brush teeth or comb hair, carrying out activities at a slower pace.
Rationale : Energy-saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand.

 

Nursing Diagnosis IV :

Imbalanced Nutrition : more than body requirements

NANDA Definition: Intake of nutrients that exceeds metabolic needs

NOC :

  • Initiate/maintain individually appropriate exercise program.
  • Nutritional Status: Nutrient Intake (NOC) Demonstrate change in eating patterns (e.g., food choices, quantity) to attain desirable body weight with optimal maintenance of health.
  • Identify correlation between hypertension and obesity.

Interventions :

1. Discuss necessity for decreased caloric intake and limited intake of fats, salt, and sugar as indicated.
Rationale : Excessive salt intake expands the intravascular fluid volume and may damage kidneys, which can further aggravate hypertension.

2. Determine patient’s desire to lose weight.
Rationale : Motivation for weight reduction is internal. The individual must want to lose weight.

3. Review usual daily caloric intake and dietary choices.
Rationale : Identifies current strengths/weaknesses in dietary program.

4. Instruct and assist in appropriate food selections, such as a diet rich in fruits, vegetables, and low-fat dairy foods.
Rationale : Avoiding foods high in saturated fat and cholesterol is important in preventing progressing atherogenesis.

 

Nursing Diagnosis V :

Deficient Knowledge

NANDA Definition: Absence or deficiency of cognitive information related to a specific topic

NOC :
Identify drug side effects and possible complications that necessitate medical attention.
Verbalize understanding of disease process and treatment regimen.
Maintain blood pressure within individually acceptable parameters.

Interventions :

1. Define and specify the desired blood pressure limits. Describe hypertension and its effect on the heart, blood vessels, kidneys, and brain.
Rationale : Provides a basis for understanding blood pressure elevation, and describes commonly used medical terms. Understanding that high blood pressure can occur without symptoms is the center allows patients to continue treatment, even when it feels good.

2. Assist patients in identifying the risk factors that can be modified, for example, obesity, a diet high in sodium, saturated fat, and cholesterol, sedentary lifestyle, smoking, alcohol consumption, stress lifestyle.
Rationale : Risk factors that have been shown to contribute to hypertension and cardiovascular and renal disease.

Risk for Infection – Nursing Care Plan for Anemia

Risk for Infection - Nursing Care Plan for AnemiaAnemia is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100 ml and in women as hemoglobin of less than 12.0 gram/100 ml.

Anemia is caused essentially through two basic pathways. Anemia is caused by either:

  • a decrease in production of red blood cells or hemoglobin, or
  • an increase in loss or destruction of red blood cells.

Other types of anemia include:

  • Anemia due to B12 deficiency
  • Anemia due to folate deficiency
  • Anemia due to iron deficiency
  • Anemia of chronic disease
  • Hemolytic anemia
  • Idiopathic aplastic anemia
  • Megaloblastic anemia
  • Pernicious anemia
  • Sickle cell anemia
  • Thalassemia

Symptoms of anemia may include the following : fatigue, decreased energy, weakness, shortness of breath, lightheadedness, palpitations (feeling of the heart racing or beating irregularly) and looking pale.

Symptoms of severe anemia may include : chest pain, angina, or heart attack, dizziness, fainting or passing out and rapid heart rate.

Anemia is typically diagnosed on a complete blood count. Apart from reporting the number of red blood cells and the hemoglobin level, the automatic counters also measure the size of the red blood cells by flow cytometry, which is an important tool in distinguishing between the causes of anemia. Examination of a stained blood smear using a microscope can also be helpful, and it is sometimes a necessity in regions of the world where automated analysis is less accessible.

Nursing Diagnosis for Anema : Risk for Infection related to decreased immunity, invasive procedures

Goal:

  • There are no risk factors for infection

Expected outcomes:

  • free of symptoms of infection,
  • normal leukocyte numbers (4-11000)
  • vital signs within normal limits.

Nursing Interventions:

Control of infection:

  • Clean up the environment after use for other patients.
  • Limit visitor when necessary and recommended for adequate rest.
  • Instruct patient’s family to wash their hands before and after contact with the client.
  • Use anti-microbe soap for hand washing.
  • Make hand washing before and after nursing actions.
  • Use clothes and gloves as a protective device.
  • Maintain aseptic environment during the installation of equipment.
  • Perform wound care, and dresing infusion, catheter every day if any.
  • Increase intake of nutrients, and adequate fluid.
  • Give antibiotics according to the program.

Protection of infection:

  • Monitor signs and symptoms of systemic and local infections.
  • Monitor granulocytes and WBC count.
  • Monitor susceptibility to infection.
  • Maintain aseptic technique for each action.
  • Inspection of the skin and mucous mebran redness, heat.
  • Monitor changes in energy levels.
  • Encourage clients to improve mobility and exercise.
  • Instruct the client to take antibiotics according to the program.
  • Teach family / client about the signs and symptoms of infection and report suspected infection.

Acute Pain – Nursing Care Plan for Hemorrhoids

Acute Pain - Nursing Care Plan for HemorrhoidsHemorrhoids are swollen veins in the anal canal. Hemorrhoids are very unpleasant and troublesome situation where by the veins during the anus or even the rectum are excessively distended and swollen.

The most common cause is straining during bowel movements.

Hemorrhoids may be caused by:

  • Straining during bowel movements
  • Constipation
  • Sitting for long periods of time
  • Anal infections
  • Certain diseases, such as liver cirrhosis

Hemorrhoids may be inside or outside the body.

  • Internal hemorrhoids occur just inside the anus, at the beginning of the rectum. E
  • External hemorrhoids occur at the anal opening and may hang outside the anus.

The most common symptoms of both internal and external hemorrhoids include:

  • Bleeding during bowel movements. You might see streaks of bright red blood on toilet paper after you strain to have a bowel movement.
  • Itching.
  • Rectal pain. It may be painful to clean the anal area.

Constipation and straining during bowel movements raise your risk for hemorrhoids. To prevent constipation and hemorrhoids, you should:

  • Drink plenty of fluids, at least eight glasses per day.
  • Eat a high-fiber diet of fruits, vegetables, and whole grains.
  • Consider fiber supplements.
  • Use stool softeners to prevent straining.

Nursing Diagnosis : Acute Pain related to physical injury agent (surgical incision)

Goal:

  • Increased patient comfort,
  • Pain control

Expected outcomes:

  • Patients reported decreased pain, pain scale 2-3.
  • Calm facial expression and can rest, sleep.
  • Vital signs are within normal limits.

Nursing Interventions

Pain management:

1. Assess pain comprehensively including location, characteristics, duration, frequency, quality factor and precipitation.
2. Observation of nonverbal reactions inconvenience.
3. Use therapeutic communication techniques to determine the client’s experience of pain before.
4. Provide a quiet environment.
5. Reduce pain precipitation factor.
6. Teach non-pharmacological techniques (relaxation, distraction, etc.) to overcome the pain.
7. Give analgesics to reduce pain.
8. Evaluation of pain reducers / pain control.
9. Collaboration with the doctor if there are complaints about the administration of analgesics were not successful.
10. Monitor patient acceptance of pain management.

Analgesic administration:

1. Check program providing analgesic; types, dosage, and frequency.
2. Check history of allergy.
3. Determine the analgesic of choice, route of administration and optimal dosage.
4. Monitor vital signs.
5. Give analgesics on time especially when pain appears.
6. Evaluation of analgesic efficacy, side effects signs and symptoms.

NCP COPD with 10 Nursing Diagnosis

Nursing Care Plan for COPDChronic obstructive pulmonary disease (COPD) is one of the most common lung diseases. It makes it difficult to breathe. There are two main forms of COPD:

  • Chronic bronchitis, which involves a long-term cough with mucus
  • Emphysema, which involves destruction of the lungs over time

Symptoms of COPD :

  • a cough that lasts a long time, or coughing up “stuff” (mucus)
  • feeling short of breath, especially when you are making an effort (climbing stairs, exercising)
  • many lung infections that last a long time (the flu, acute bronchitis, pneumonia, etc.)
  • wheezing (a whistling sound when you breathe)
  • feeling tired (fatigue)
  • losing weight without trying

There is no cure for COPD, but there are good treatments:

  • Quitting smoking, and staying away from smoke and air pollution
  • Taking COPD medications, which can include pills, inhalers (puffers), and supplemental oxygen
  • Joining a pulmonary rehabilitation program, a special class that teaches exercise and COPD management

Nursing Diagnosis for COPD

1. Ineffective breathing pattern

related to: shortness of breath,bronchoconstriction, mucus, airway irritants.

2. Ineffective Airway Clearance

related to: increased sputum production, bronchoconstriction, ineffective cough,
bronchopulmonary infection, fatigue / lack of energy.

3. Impaired Gas Exchange

related to: ventilation perfusion inequality.

4. Imbalanced Nutrition: less than body requirements

related to: anorexia.

5. Activity Intolerance

related to: imbalance between oxygen supply with demand.

6. Disturbed sleep pattern

related to: discomfort, sleeping position.

7. Anxiety

related to: threat to self-concept, threat of death, purposes that are not being met.

8. Ineffective Individual Coping

related to: anxiety, lack of socialization, depression, low activity levels and an inability to work.

9. Self-care Deficit : Bathing / Hygiene Self-care deficit

related to: fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency.

10. Knowledge Deficit

related to: lack of information, do not know the source of information.

Hypertension Nanda Nursing Diagnosis

Hypertension Nanda Nursing DiagnosisHypertension or high blood pressure is a measurement of the force against the walls of the arteries as the heart pumps blood through the body. It increases the risk of associated cardiovascular (heart) diseases such as stroke, myocardial infarction, failure of kidneys or heart, other vascular complications.

Blood pressure readings are usually given as two numbers — for example, 120 over 80 (written as 120/80 mmHg). One or both of these numbers can be too high.

Hypertension is often the result of our lifestyle choices over many years. It comes as little surprise that as we get older we are at greater risk of developing high blood pressure. It is that condition which increases the risk of having a stroke, developing heart disease or having a heart attack. Our poor lifestyle choices have become deeply ingrained habits, but a habit is only a learned behaviour that we can change or replace.

The top number is your systolic pressure.

  • It is considered high if it is over 140 most of the time.
  • It is considered normal if it is below 120 most of the time.

The bottom number is your diastolic pressure.

  • It is considered high if it is over 90 most of the time.
  • It is considered normal if it is below 80 most of the time.

Many factors can affect blood pressure, including:

  • How much water and salt you have in your body
  • The condition of your kidneys, nervous system, or blood vessels
  • The levels of different body hormones

Symptoms that may occur include:

  • Confusion
  • Ear noise or buzzing
  • Fatigue
  • Headache
  • Irregular heartbeat
  • Nosebleed
  • Vision changes

The measurements need to be repeated over time, so that the diagnosis can be confirmed.

If you monitor your blood pressure at home, you may be asked the following questions:

  • What was your most recent blood pressure reading?
  • What was the previous blood pressure reading?
  • What is the average systolic (top number) and diastolic (bottom number) reading?
  • Has your blood pressure increased recently?

Nursing Diagnosis for Hypertension

1. Decreased Cardiac Output

2. Ineffective Tissue Perfusion: Cardiopulmonary, Gastrointestinal and Peripheral

3. Activity Intolerance

4. Acute Pain

5. Imbalanced Nutrition: More Than Body Requirements

6. Ineffective Coping