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NURSING CARE PLANS Hyperthermia Assessment Nursing Diagnosis s> Hyperthermia Scientific Explanation Diabetes Mellitus Type 2 is a chronic

c o> manifested: metabolic disease impairing insulin >increased body temp. of 38.3 production in the pancreas and/or insulin resistance, therefore leading to >weakness its hallmark sign, hyperglycemia. The >pale nail beds excess glucose in the blood exerts >skin warm to touch hyperosmolar effect, After 3 days of NI, the pt. will maintain thus increasing blood volume and viscosity leading to >flushed skin decreased perfusion as manifested in >diabetic right pale nailbeds. In the core temp within normal range. >encourage an increase in oral fluid intake. >for hygiene maintenance Long term: >monitor all sources of fluid loss such as urine. >to prevent dehydration. The pt. shall have maintained a core temp within normal range. >to determine further loss of fluids. Long term: After 3 hrs of NI, the pt.s temp will decrease from 37.8C to 36.8C >monitor and record VS. >to monitor pts condition and to establish baseline data. Short term: >establish rapport >to gain trust and cooperation. The pt.s temp shall have decreased from 37.8C to 36.8C Objectives Interventions Rationale Expected Outcome Short term:


long run, a decreased peripheral perfusion leads to a decreased sensation because of delayed transport >auscultate breath sounds. of nutrients and O2 to peripheral >emphasize importance of proper hand washing.

and prevent infection.

may manifest:

>to determine presence of abnormal breath sounds like rales.




nerves, which causes peripheral nerve degeneration. The pt then becomes susceptible to wound, and upon the development of wound, there will be poor wound healing resulting from a delayed biochemical mediation caused by the hyperviscosity of >administer replacement fluids and electrolytes. >render TSB.

>to promote heat loss by evaporation and conduction.

>loss of consciousness

>to support circulating volume and tissue perfusion.


>to reduce metabolic demands and oxygen consumption.

blood. Bacteria take this opportunity and proliferate easily in a hyperglycemic environment. Their presence initiates an inflammatory response, thus pyrogens are released which act upon the thermoregulatory center of the brain, leading to an increase in core temperature AEB body temp of 37.8 and skin warm to touch >administer medications as indicated. >encourage high calorie diet. >to mange the underlying cause. >regulate IVF as ordered. >to meet increasing metabolic needs. >maintain bed rest. >to maintain proper hydration.

Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood.


Nursing Diagnosis S> Ineffective O> The patient tissue may manifest: perfusion >Headache related to >Body decreased weakness hemoglobin >Chest Pain concentration in the blood.

Scientific Explanation Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Management is directed at removing vasoconstricting factors improving peripheral blood flow, and reducing metabolic demands on the body. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient. If the decreased perfusion is acute and protracted, it can have devastating effects on the

Objectives Short Term: After 3 hrs of nursing interventions patient will verbalize understanding of condition and therapeutic regimen.

Interventions >Establish rapport


Evaluation Short Term: The patient shall have verbalized understanding of condition and therapeutic regimen. Long Term: The patient shall have demonstrated increased perfusion as effectively available.

>to gain the trust and cooperation of the patient. >Assess >to have a patients general health condition status of the patient. > Monitor vital >to obtain signs baseline data > to prevent further complications of the disease condition > to boost immune system

> Emphasize Long Term: the recommended After 2 days o diet Nursing Intervention the patient will >Instruct demonstrate patient to increased increase intake perfusion as of vitamin C effectively like orange available. juice, calamansi juice

>Instruct > to promote patient to tissue repair increase intake of protein like meat and tofu

patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ damage or death.

>Circulation is potentially compromised with a cannula. It should be removed as soon as therapeutically safe. >Administer >This saturates oxygen as circulating needed. hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues. >This promotes >Position optimal lung properly. ventilation and perfusion. The patient will experience optimal lung expansion in upright position.

>Do passive range-ofmotion (ROM) exercises to unaffected extremity every 2 to 4 hours. >Prepare for removal of arterial catheter as needed.

>Exercise prevents venous stasis.

Impaired skin integrity related to presence of scars and dry wound on left legs secondary to BKA Assessment Nursing Diagnosis Scientific Explanation Objectives Nursing Interventions Rationale Expected Outcome

Impaired skin integrity to O> the patient related presence of may manifest: scars and dry >irritability wound on left legs >itchiness secondary to BKA >pain


Skin or integumentary system is the largest multifunctional organ of the body. It becomes altered when there are internal and external forces occur such as invasion of microorganisms that could trigger infection.

>To gain trust Short Term: from the patient. The patient shall have baseline verbalized >Monitor vital >For feelings of data. signs. increased self assess esteem and >Identify underlying >To ability to contributing condition. manage factors. situation. >Instruct patient to increase fluid intake up to 8- 10 > to prevent Long Term: The patient dehydration glasses of water shall have Long Term: displayed > Remind the client After 2 days of to avoid eating timely healing > to not alleviate nursing of skin lesions foods that are fatty the patients interventions, without and sweet. condition the patient will complications be able display >Instruct patient to timely healing increase intake of of skin lesions vitamin C like >to boost without orange juice, immune system complications. calamansi juice >Instruct patient to increase intake of protein like meat >Topromote and tofu tissue repair

Short Term: After 4-6 hours of nursing interventions, the patient will be able to verbalize feelings of increased self esteem and ability to manage situation.

>Establish rapport.

>Stretch linens

>to comfort


>Helpful in alleviating >Encourage patient and to verbalize anxiety feelings about the refocusing attention, which condition. can relieve pain, and to know pain development >Keep the area clean/dry, carefully dress wounds, support incision, prevent infection. >To prevent cross contamination and to assists bodys natural process of repair.

Activity Intolerance related to Fatigue and discomfort

Nursing Diagnosis S> Activity O> the patient Intolerance may manifest: related to >abnormal Fatigue and heart rate or discomfort blood pressure response to activity >cyanosis Assessment

Scientific Explanation Activity Intolerance a psychological or physiological energy to endure or complete required or desired daily activities. And due to previous pain and blood loss that cause oxygen that decreases muscle tone and result to body weakness.


Short Term: After 4-6 hours of nursing interventions, the patient will >Assess patients be able to condition verbalize and use energyconservation techniques. > Monitor vital signs Long Term: After 2 days of >Instruct patient to nursing increase fluid interventions, intake up to 8- 10 the patient will glasses of water be able to maintain Remind the activity level > client to avoid within capabilities, as eating foods that fatty and evidenced by are sweet. normal heart rate and blood pressure during >Instruct patient to activity, as well increase intake of C like as absence of vitamin orange juice, shortness of calamansi juice breath, weakness, and >Instruct patient to fatigue. increase intake of protein like meat and tofu

Nursing Interventions >Establish rapport

Rationale >to gain the trust and cooperation of the patient. >to have a general health status of the patient.

Expected Outcome Short Term: The patient shall be able to verbalize and use energyconservation techniques.

Long Term: >to obtain The patient shall be able to baseline data maintain activity within > to prevent level capabilities, as dehydration evidenced by normal heart rate and blood pressure during > to not alleviate activity, as well the patients as absence of condition shortness of breath, weakness, and fatigue. > to boost immune system

>To promote tissue repair

>Stretch linens

>to comfort


aids in >Assess patient's >This defining what level of mobility. patient is capable of, which is necessary before setting realistic goals. >Observe document response activity. and >Close monitoring serves as a guide for optimal to progression of activity.

>Depression over >Assess inability to emotional perform required response to activities can change in physical further aggravate status. the activity intolerance. >Rest between activities provides time for energy conservation and recovery.

>Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation. >Refrain

>Patients with limited activity from tolerance need to

performing nonessential procedures. > Teach energy conservation techniques like: Sitting to do tasks, Changing positions often, Storing frequently used items within easy reach

prioritize tasks. > To conserve energy also because Standing requires more work, Changing positions often This distributes work to different muscles to avoid fatigue. Changing positions often This distributes work to different muscles to avoid fatigue, Storing frequently used items within easy reach This avoids bending and reaching.

Disturbed Body Image related to below the knee amputation Assessment Nursing Diagnosis Scientific Explanation Objectives Interventions Rationale Evaluation

S> O> The patient may manifests: >body malaise >pallor on the extremities >decrease movement >discomfort > BKA left >Low self esteem >Irritability >depressive mood state.

Disturbed Body Image related to below the knee amputation

After 2 days o Nursing Intervention the patient will demonstrate techniques that to increase enables of resumption of intake vitamin C like activities. Throughout the life orange juice, span, body image calamansi juice changes as a matter of development, >Instruct patient growth, maturation, to increase changes related to intake of protein childbearing and like meat and pregnancy, changes tofu that occur as a result of aging, and changes >Acknowledge that occur or are normalcy of imposed as a result of emotional injury or illness. response to actual or

Body image is the attitude a person has about the actual or perceived structure or function of all or part of his or her body. This attitude is dynamic and is altered through interaction with other persons and situations and influenced by age and developmental level. As an important part of ones self-concept, body image disturbance can have profound impact on how individuals view their overall selves.

Short Term: After 3 hrs of nursing interventions patient will verbalize willingness to participate in therapeutic activities. Long Term:

>Establish rapport

>to gain the trust Short Term: and cooperation The patient shall of the patient. have verbalized willingness to in >to have a participate >Assess general health therapeutic patients status of the activities. condition patient. Long Term: >to obtain The patient shall > Monitor vital baseline data signs have demonstrated techniques that to prevent enables resumption > Emphasize > further the of activities. complications of recommended the disease diet condition > to boost immune system >Instruct patient

> to promote tissue repair

>Stages of grief over loss of a body part or function are normal, and

In cultures where ones appearance is important, variations from the norm can result in body image disturbance. The importance that an individual places on a body part or function may be more important in determining the degree of disturbance than the actual alteration in the structure or function. Therefore the loss of a limb may result in a greater body image disturbance for an athlete than for a computer programmer. The loss of a breast to a fashion model or a hysterectomy in a nulliparous woman may cause serious body image disturbances even though the overall health of the individual has been improved. Removal of skin lesions, altered elimination resulting

perceived typically involve a change in body period of denial, structure or the length of function. which varies from individual to individual. may >Help patient >Patients identify actual perceive changes that are not changes. present or real, or they may be placing unrealistic value on a body structure or function. >It is worthwhile to encourage the >Encourage patient to verbalization of separate feelings positive or about changes in negative body structure feelings about and/or function actual or from feelings perceived about self-worth. change. >Opportunities for positive feedback >Assist patient and success in in incorporating social situations actual changes may hasten into ADLs, adaptation. social life, interpersonal relationships, and

from bowel or bladder surgery, and head and neck resections are other examples that can lead to body image disturbance.

occupational activities.

>Professional caregivers >Demonstrate represent a positive caring microcosm of in routine society, and their activities. actions and behaviors are scrutinized as the patient plans to return to home, to work, and to other activities. >This compensates for actual changed >Teach patient body structure adaptive and function. behavior >Asking patients to remember other body image issues and how they were managed may help patient adjust to the current issue.

>Help patient identify ways of coping that have been useful in the past.