Nursing care plan hysterectomy

I. Indications—surgical removal of the uterus
a. Malignancies: 11% of hysterectomies
b. Nonmalignant conditions, such as endometriosis, fibroid
tumors; pelvic relaxation with uterine prolapse that leads
to disabling levels of pain, discomfort, uterine bleeding,
emotional stress
c. Life-threatening bleeding or hemorrhaging, such as
obstetric or traumatic complication; irreparable rupture of
the uterus
d. Treatment of intractable pelvic infection

II. Procedures
a. Abdominal hysterectomy
i. Subtotal or partial: removal of body of uterus; cervical
stump remains
ii. Total: removal of the uterus and cervix
iii. Total with bilateral salpingo-oophorectomy: removal of
uterus, cervix, fallopian tubes, and ovaries
iv. Total pelvic exenteration (TPE): Complex, aggressive
surgical procedure involving radical hysterectomy
with dissection of pelvic lymph nodes, bilateral
salpingo-oophorectomy, total cystectomy, and
abdominoperineal resection of the rectum; colostomy
and/or urinary conduit are created, and vaginal
reconstruction may or may not be performed. (Refer to
additional care plans regarding fecal or urinary
diversions, as appropriate.)
b. Vaginal hysterectomy or laparoscopically assisted vaginal
hysterectomy (LAVH)
i. Limited to certain conditions, such as uterine prolapse,
cystocele or rectocele, carcinoma in situ, and high-risk
obesity
ii. Requires removal of cervix
iii. Advantages: less pain, no visible (or much smaller)
scars, shorter hospital stay, and shorter recovery period
of about 3 to 4 weeks (vaginal) and 2 weeks (LAVH)
versus approximately 6 weeks (abdominal)
iv. Research suggests laparoscopic procedure is associated
with a higher rate of complications than abdominal
hysterectomy.
c. Laparoscopic supracervical hysterectomy (LSH)
i. Can be performed in presence of mild to moderate
adhesions or large uterus
ii. Three or four small abdominal incisions with
uterus removed in small pieces through a tube in the
umbilical incision
iii. Removal of cervix not required
iv. Usually done on outpatient basis, with a recovery
period of about 1 week

III. Statistics (Gor et al, 2006; National Uterine Fibroids
Foundation, 2004)
a. Morbidity: 600,000 are performed annually; 37% of all
women undergo hysterectomy by age 60 in the United States.
b. Mortality: Approximately 660 women die annually.
c. Cost: $5 billion annually in the United States

Care Setting
Procedure is performed in inpatient acute surgical unit or
short-stay unit or outpatient, depending on type performed.

Related Concerns
Cancer
Psychosocial aspects of care
Surgical intervention(for general considerations
and interventions)
Thrombophlebitis: deep vein thrombosis

Nursing Priorities
1. Support adaptation to change.
2. Prevent complications.
3. Provide information about procedure, prognosis, and treatment
needs.

Discharge Goals
1. Dealing realistically with situation.
2. Complications prevented or minimized.
3. Procedure, prognosis, and therapeutic regimen understood.
4. Plan in place to meet needs after discharge.

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Nursing care plan urolithiasis renal calculi

I. Pathophysiology
a. Presence of stones anywhere in the urinary tract
i. Most commonly found in the renal pelvis and calyces
1. Stones forming in the kidney—nephrolithiasis
2. Stones formed in the ureters—ureterolithiasis
ii. May be single or multiple calculi, ranging in size from a
grain of salt to the size of a pebble or staghorn calculus
b. Composition of calculi
i. Formed of mineral deposits—predominantly calcium
oxalate and calcium phosphate
ii. Uric acid, struvite, and cystine are also calculus formers
II. Etiology
a. Slow urine flow allows accumulation of crystals—damaging
the lining of the urinary tract and decreasing the number of
inhibitor substances that would prevent crystal accumulation
(Winkleman, 2006).
b. May remain asymptomatic until passed into a ureter or
urine flow is obstructed, at which time the potential for
renal damage is acute and the level of pain is at its highest
c. Causes: dehydration; heredity; excessive intake of vitamins
C and D, grapefruit juice, and purines (gout); congenital
renal abnormalities; and some medications, such as
acetazolamide (Diamox) or indinavir (Crixivan)
d. Risk factors: men aged 30 to 50, postmenopausal women;
gender, male-to-female ratio 3:1; heredity; recurrent urinary
tract infections; inflammatory bowel disease; hyperparathyroidism;
hypertension; insulin resistance; prolonged bedrest;
spinal cord injury; geographic location—southeastern United
States; use of antacids or aspirin
III. Statistics (Centers for Disease Control and Prevention
[CDC], 2006)
a. Morbidity: In 2000, there were 2 million doctor visits and
outpatient hospital visits by adults with primary diagnosis
of “calculus of kidney and ureters”; in 2004, there were
171,000 adult hospital admissions with primary diagnosis of
“calculus of kidney and ureters.”
b. Mortality: Rare and related to development of acute renal
failure or comorbidities.
c. Cost: In 2000, $2.07 billion expended for evaluation and
treatment of kidney stones.

Care Setting
Treatment is often handled at the community level or as an
outpatient; acute episodes occasionally require inpatient
treatment on a medical or surgical unit. On occasion, surgery
is necessary to remove the stone(s).

Related Concerns
Fluid and electrolyte imbalances,
Metabolic acidosis—primary base bicarbonate deficiency,
Metabolic alkalosis—primary base bicarbonate excess,
Psychosocial aspects of care,
Renal failure: acute,

Nursing Priorities
1. Alleviate pain.
2. Maintain adequate renal functioning.
3. Prevent complications.
4. Provide information about disease process, prognosis, and
treatment needs.

Discharge Goals
1. Pain relieved or controlled.
2. Fluid and electrolyte balance maintained.
3. Complications prevented or minimized.
4. Disease process, prognosis, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan prostatectomy

I. Indications
a. Benign prostatic hyperplasia (BPH)-related complications
i. Urinary retention
ii. Frequent urinary tract infections
iii. Bladder stones
iv. Recurrent gross hematuria
v. Kidney damage from long-standing blockage
vi. Failure to respond to medical or minimally invasive
treatments
b. Prostate cancer is the second leading cause of cancer death
in the United States.

II. Procedures
a. Minimally invasive prostatectomy
i. Transurethral therapy using microwave
ii. Transurethral needle ablation (TUNA) using low-level
frequency thermal energy
iii. Laser ablation
iv. Cryotherapy—freezing of cancerous cells
v. Electrovaporization
vi. Transurethral resection of the prostate (TURP)
1. Most common procedure for the long-term treatment
of BPH
2. Obstructive prostatic tissue of the medial lobe surrounding
the urethra is removed by means of a cystoscope
introduced through the urethra.
b. Open surgical approaches performed when the prostate is
overly enlarged (greater than 75 g), the bladder has been damaged,
or when there are complicating factors, such as cancer.
i. Robot assisted—nerve sparing, uses a laparoscope, and
several incisions are made in the abdomen
ii. Suprapubic prostatectomy
1. Obstructing prostatic tissue is removed through a low
midline incision made through the bladder.
2. Preferred approach if bladder stones are present
iii. Retropubic prostatectomy
1. Hypertrophied prostatic tissue mass located high in
the pelvic region is removed through a low
abdominal incision without opening the bladder.
iv. Perineal prostatectomy
1. Laparoscopy removal of larger tumors or in presence
of cancerous lymph nodes or nerve invasion
2. Large prostatic masses low in the pelvic area are
removed through an incision between the scrotum and
the rectum.

III. Statistics
a. Morbidity: In 2005, 155,000 prostatectomy procedures
were performed in short-stay hospitals in the United States
(Centers for Disease Control and Prevention [CDC], 2007);
in 2007, 50,000 procedures were robotic assisted.
b. Mortality: Prostatectomy is a relatively low-risk procedure
(Guilli et al, n.d.).
c. Cost: In 2004, hospital costs for treatment of prostate cancer
totaled $657 million; most commonly performed procedures
are prostatectomy and TURP (Milenkovic et al, 2007).

Care Setting
Client is treated in inpatient acute surgical unit.

Related Concerns
Benign prostatic hyperplasia (BPH),
Cancer,
Psychosocial aspects of care,
Surgical intervention,

Nursing Priorities
1. Maintain homeostasis and hemodynamic stability.
2. Promote comfort.
3. Prevent complications.
4. Provide information about surgical procedure, prognosis,
treatment, and rehabilitation needs.

Discharge Goals
1. Urinary flow restored or enhanced.
2. Pain relieved or controlled.
3. Complications prevented or minimized.
4. Procedure, prognosis, therapeutic regimen, and rehabilitation
needs understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan benign prostatic hyperplasia BPH

I. Pathophysiology
a. Overgrowth of normal, nonmalignant cells that cause
progressive enlargement of the prostate gland, resulting in
bladder outlet obstruction with urinary retention, leakage,
and frequency (Shiller, 2007)
b. Additional complications: bladder wall trabeculation, detrusor
muscle enlargement, narrowing of urethra, incontinence,
and acute or chronic renal failure (Springhouse, 2005)

II. Classification (American Urological Association [AUA],
2003)
a. International scoring system has been adopted worldwide.
b. Questions, and subsequent scoring, focus on degree of
incomplete emptying, frequency, intermittency, urgency,
weak stream, straining, nocturia, as well as impact on
quality of life.
i. Score of 0 to 7: mildly symptomatic
ii. Score of 8 to 19: moderately symptomatic
iii. Score of 20 to 35: severely symptomatic

III. Etiology
a. Cause is unknown, although testosterone and other
hormones may affect growth.
b. Microscopically characterized as a hyperplastic process
with the number of cells in the gland increasing with age
c. Most commonly seen in men older than age 50 years

IV. Statistics
a. Morbidity: An estimated 14 million men in the United States
have symptoms related to benign enlargement (Leveillee
et al, 2006); symptoms present in 50% of males by age 50
and 80% of males by age 80; accounts for 375,000 hospitalizations
annually (Gilchrist, 2004).
b. Mortality: Generally related to renal failure, infection, and
complications of surgery.
c. Cost: Direct and indirect costs to private sector related to
BPH treatment estimated to be $3.9 billion (Saigal &
Joyce, 2005).

Care Settings
Client is treated at the community level, with more acute
care provided during outpatient procedures.

Related Concerns
Prostatectomy,
Psychosocial aspects of care,
Renal failure: acute,

Nursing Priorities
1. Relieve acute urinary retention.
2. Promote comfort.
3. Prevent complications.
4. Help client deal with psychosocial concerns.
5. Provide information about disease process, prognosis, and
treatment needs.

Discharge Goals
1. Voiding pattern normalized.
2. Pain or discomfort relieved.
3. Complications prevented or minimized.
4. Dealing with situation realistically.
5. Disease process, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

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Nursing care plan urinary diversions urostomy post operative care

I. Procedure
a. Diversion of urine out of the body through an opening in the
abdominal wall bypassing the bladder, which requires a
pouch to be worn outside the body; or, a continent diversion
involving the creation of a pouch or bladder inside the body,
usually using part of the digestive tract
b. Types
i. Incontinent urinary diversions
1. Ileal conduit
2. Colonic conduit
3. Ureterostomy
ii. Continent urinary diversions
1. Catheterizable urinary reservoir: Kock reservoir or
Indiana (ileocecal) pouch
2. Orthotopic continent urinary diversion: neobladder

II. Etiology (Costa & Kreder, 2006)
a. Bladder cancer, primary or metastatic, requiring
cystectomy—fourth most common cancer in the
United States
b. Neurogenic bladder, such as may occur following spinal
cord injury
c. Severe radiation injury to the bladder
d. Intractable incontinence
e. Chronic pelvic pain syndromes
III. Statistics
a. Morbidity: In 2008, an estimated 68,810 new cases of
bladder cancer were reported in the United States; male-tofemale
ratio is 2.6:1; in 2005, median age at diagnosis was
age 73 (National Cancer Institute [NCI], 2008).
b. Mortality: Rate is reportedly 1% to 3% for radical cystectomy,
often associated with advanced age and comorbidities
(Lohr & Sherk, 2004).

Care Setting
Client is treated in acute surgical unit.

Related Concerns
Cancer,
Peritonitis,
Psychosocial aspects of care,
Surgical intervention,

Nursing Priorities
1. Prevent complications.
2. Assist client and significant other (SO) in physical and
psychosocial adjustment.
3. Support independence in self-care.
4. Provide information about procedure, prognosis, treatment
needs, potential complications, and resources.

Discharge Goals
1. Complications prevented or minimized.
2. Adjusting to perceived or actual changes.
3. Self-care needs met by self or with assistance, as necessary.
4. Procedure, prognosis, therapeutic regimen, and potential
complications understood and sources of support identified.
5. Plan in place to meet needs after discharge.

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Nursing care plan hemodialysis HD

I. Procedure
a. Removal of urea and other toxic products and correction of
fluid and electrolyte imbalances
b. Blood is shunted through an artificial kidney or membrane
(dialyzer) for removal of toxins and excess fluid and then
returned to the venous circulation.
c. Requires placement of vascular access
i. Arteriovenous (AV) fistula: usually requires at least 2 to
4 months to heal before it can be used, providing
sufficient time so that those involved are prepared and
can perform home hemodialysis, if appropriate
ii. AV graft: may be indicated in presence of small veins,
usually ready for use within 2 to 3 weeks
iii. Temporary access: provides immediate access with insertion
of a catheter into a vein in the neck, chest, or groin

II. Types
a. Intermittent HD procedure
i. Requires permanent AV access, such as primary AV
fistula or synthetic graft
ii. Usually performed three times per week for 3 to 5 hours
per procedure, or six to seven times per week for 1.5 to
2 hours
b. Continuous renal replacement therapy (CRRT) (Paton, 2007)
i. Blood is usually accessed via a central venous catheter.
ii. Treatment for acute renal failure (ARF) with fluid and
toxins removed at a continuous and slower rate than
intermittent HD
iii. May be indicated for clients with ARF and who are too
hemodynamically unstable to tolerate conventional
hemodialysis
iv. Commonly used types of CRRT
1. Slow continuous ultrafiltration (SCUF)
2. Continuous venovenous hemofiltration via ultrafiltration
and convection
3. Continuous venovenous hemofiltration
4. Continuous venovenous hemodialysis
5. Continuous venovenous hemodiafiltration

III. Statistics
a. Morbidity: In 2005, and estimated 312,000 Americans
received in-center hemodialysis and 2,000 received home
dialysis (National Kidney and Urologic Diseases
Information Clearinghouse [NKUDIC], 2008).
b. Cost: Estimates vary from $35,000 to $60,000 annually
per client; in 2002, Medicare payments for outpatient
hemodialysis were approximately $3.4 billion (U.S. Renal
Data System [USRDS], 2004).

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Nursing care plan peritoneal dialysis PD

I. Procedure
a. Requires a surgically placed abdominal catheter and uses
the peritoneum to filter toxins and excess fluid from the
body
b. Fluid removal is controlled by adjusting the dextrose
concentration in the dialysate (e.g., 1.5%, 2.5%, 4.25%) to
create an osmotic gradient for water with higher dextrose
concentrations and more frequent exchanges increasing the
rate of fluid removal.
c. May be preferred over hemodialysis because it uses a
simpler technique and provides more gradual physiological
changes
d. Long-term PD typically calls for four exchanges a day
(or night), each with a dwell time of 4 to 6 hours.
e. Manual single-bag method is usually done as an inpatient
procedure with short dwell times of only 30 to 40 minutes
and is repeated until desired effects achieved.

II. Types
a. Continuous ambulatory peritoneal dialysis (CAPD)
i. Most commonly used type of long-term PD, allowing
client to manually manage the procedure at home with
bag and gravity flow
ii. Some clients experience problems with the long overnight
dwell time because, as dextrose in the solution crosses
into body, it becomes glucose and starts to draw fluid
from the peritoneal cavity back into the body, thereby
reducing the efficiency of the exchange and requiring a
mini-cycler machine during the night.
b. Automated peritoneal dialysis (APD)
i. Continuous cycler-assisted peritoneal dialysis (CCPD)
1. Allows individual to walk around during extended
daytime cycle with solution in abdomen
2. May be method of choice for younger individuals
engaged in school or work activities
ii. Nocturnal intermittent peritoneal dialysis (NIPD)
1. Usually reserved for individuals with substantial
remaining renal function
2. May improve uremia-associated sleep apnea
(Perl & Chan, 2007)

III. Statistics
a. Morbidity: In 2005, more than 25,000 Americans received
PD (National Kidney and Urologic Diseases Information
Clearinghouse [NKUDIC], 2008).
b. Costs: In 2002, Medicare payments for outpatient PD were
approximately $200 million (U.S. Renal Data System
[USRDS], 2004).

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Nursing care plan renal dialysis general considerations

I. Procedure
a. Process that substitutes for kidney function by removing
excess fluid and accumulated endogenous or exogenous toxins
b. Type of fluid and solute removal depends on the client’s
underlying pathophysiology, current hemodynamic status,
vascular access, availability of equipment and resources,
and healthcare providers’ training

II. Indications
a. Treatment for acute renal failure (ARF) or chronic end-stage
renal disease (ESRD)
b. Emergency removal of toxins due to drug overdose, acute
life-threatening hyperkalemia, severe acidosis, and uremia

III. Types
a. Choice of dialysis is determined by three main factors.
i. Type of renal failure (acute or chronic)
ii. Client’s particular physical condition
iii. Access to dialysis resources
b. Two primary types of dialysis
i. Hemodialysis (HD)
1. Requires placement of a venous access and a machine
removing the blood from the body, running it through
a dialyzer, and then returning it to the body
2. Conventional HD may be done three times a week
over 3 to 4 hours, either at a facility or in the home;
or, daily dialysis may be done during the day or night
hours (nocturnal dialysis).
ii. Peritoneal dialysis (PD)
1. Requires a surgically placed abdominal catheter for
infusing dialysate fluid into the peritoneal cavity for a
predetermined dwell time and then draining it out
2. Procedure may be carried out at home through gravity
or automated pump.
IV. Statistics (National Kidney and Urologic Diseases
Information Clearinghouse [NKUDIC], 2005; U.S. Renal
Data System [USRDS], 2007)
a. Morbidity: In 2005, 341,319 individuals with ESRD
reportedly received dialysis in the United States, with
314,000 receiving HD (most of them in dialysis centers)
and approximately 26,000 receiving PD.
b. Mortality: The probability of survival of clients receiving
dialysis at 1 year is 78.3%; at 2 years, 63.6%; at 5 years,
32.1%; and at 10 years, 10.3% (NKUDIC, 2008).
c. Costs: In 2002, Medicare payments for outpatient HD and
PD were approximately $3.6 billion (USRDS, 2004).

Care Setting
Primary focus is at the community level at the dialysis center,
although inpatient acute stay may be required during initiation
of therapy.

Related Concerns
Anemias—iron deficiency, anemia of chronic disease, pernicious,
aplastic, hemolytic,
Heart failure: chronic,
Peritonitis,
Psychosocial aspects of care,
Sepsis/septicemia,
Total nutritional support: parenteral/enteral feeding,
Transplantation considerations—postoperative and lifelong,

Nursing Priorities
1. Promote homeostasis.
2. Maintain comfort.
3. Prevent complications.
4. Support client independence and self-care.
5. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Fluid and electrolyte balance maximized.
2. Complications prevented or minimized.
3. Discomfort alleviated.
4. Dealing realistically with current situation; independent
within limits of condition.
5. Disease process, prognosis, and therapeutic regimen
understood.
6. Plan in place to meet needs after discharge.

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Nursing care plan renal failure chronic

I. Pathophysiology
a. End result of the gradual, progressive destruction of
nephrons and decrease in glomerular filtration rate (GFR),
resulting in loss of kidney function that produces major
changes in all body systems
b. Chronic kidney disease (CKD), although ultimately irreversible,
may be slowed by improved standardized blood
tests and availability of new drugs to control blood pressure

II. CKD stages correspond to the degree of nephron loss
(Choka, 2005; Verrelli, 2006).
a. Decreased renal reserve
i. GFR may be normal; slightly higher than normal, stage I:
greater than or equal to 90 mL/min/1.73 m2; or somewhat
less than normal, stage II: 60 to 89 mL/min/1.73 m2.
ii. Kidney dysfunction is present; however, it may be undiagnosed
due to lack of symptoms—blood urea nitrogen/
creatinine (BUN/Cr) ratio is normal and nephron loss at
less than 75%.
b. Renal insufficiency
i. Nephron loss at 75% to 90%; GFR is moderately
(stage III: 30 to 59 mL/min/1.73 m2) to severely
(stage IV: 15 to 29 mL/min/1.73 m2) reduced.
ii. Slight elevation in BUN/Cr
iii. Polyuria and nocturia present—high output failure
c. End-stage renal disease (ESRD)
i. Nephron loss at greater than 90% with a GFR of only
10% to 15% (stage V: less than 15 mL/min/1.73 m2)
ii. Fluid and electrolyte abnormalities
iii. Azotemia and uremia present
iv. Dialysis required

III. Etiology (Holcomb, 2005; Verrelli, 2006)
a. Multiple causes
i. Acute tubular necrosis (ATN) from unresolved acute
renal failure (ARF)
ii. Chronic infections: glomerulonephritis, pyelonephritis,
beta-hemolytic streptococci infection
iii. Vascular diseases: hypertensive nephrosclerosis, renal
artery stenosis, renal vein thrombosis, vasculitis
iv. Obstructive processes: long-standing renal calculi,
benign prostatic hyperplasia (BPH)
v. Cystic disorders: polycystic or medullary kidney disease
vi. Collagen diseases: systemic lupus erythematosus
(SLE) and collagen vascular disease
vii. Tumors: malignant (multiple myeloma) or benign
viii. Nephrotoxic agents: drugs, such as aminoglycosides,
tetracyclines; contrast dyes; heavy metals
ix. Endocrine diseases: diabetes mellitus (DM), hyperparathyroidism
x. Long-standing systemic hypertension
b. Such comorbidities as diabetes and hypertension are
responsible for more than 70% of all cases of ESRD.
c. Highest incidence of ESRD occurs in individuals older than
age 65 years (Verrelli, 2006); over the last decade, there has
been a 98% increase in incidence in those aged 75 years
and older (Alper & Young, 2008).

IV. Statistics
a. Morbidity: In 2005, 485,000 individuals were treated for
ESRD in the United States; with 90,000 new cases reported
annually, 341,000 receiving dialysis, and more than
140,000 having a functioning kidney transplant (National
Kidney Foundation [NFK], 2008); renal transplantation
success rates exceed 90% (National Institutes of Health
[NIH], 2007).
b. Mortality: In 2005, 81,500 deaths were associated with
ESRD in the United States (Morbidity and Mortality
Weekly Report [MMWR], 2007) due to (1) cardiovascular
disease, (2) sepsis, and (3) cerebrovascular disease
(Alper, 2008).
c. Cost: The Medicare program spends approximately
$19 billion for care of patients with ESRD, representing
6% of Medicare expenditures (NIH, 2007)

Care Setting
Primary focus is at the community level, although inpatient
acute hospitalization may be required for life-threatening
complications.

Related Concerns
Anemias—iron deficiency, anemia of chronic disease,
pernicious, aplastic, hemolytic,
Fluid and electrolyte imbalances,
Heart failure: chronic,
Hypertension: severe,
Metabolic acidosis—primary base bicarbonate deficiency,
page
Psychosocial aspects of care,
Upper gastrointestinal/esophageal bleeding,
Additional associated nursing diagnoses are found in:
Renal dialysis—general considerations,
Renal failure: acute,
Seizure disorders,

Nursing Priorities
1. Maintain homeostasis.
2. Prevent complications.
3. Provide information about disease process, prognosis,
and treatment needs.
4. Support adjustment to lifestyle changes.

Discharge Goals
1. Fluid and electrolyte balance stabilized.
2. Complications prevented or minimized.
3. Disease process, prognosis, and therapeutic regimen
understood.
4. Dealing realistically with situation and initiating necessary
lifestyle changes.
5. Plan in place to meet needs after discharge.

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Nursing care plan renal failure acute

I. Pathophysiology
a. Sudden decrease in kidney function, which may or may not
be associated with a decrease in urine output and results in a
buildup of toxic wastes, such as urea and creatinine in the
blood
b. Three well-defined stages: oliguric or anuric, diuretic, and
convalescent (Choka, 2005)
i. Oliguric
1. Filtration capability is reduced because of debris and
damage to renal tubules.
2. Output is greatly reduced—may be less than
400 mL/day.
3. If anuria present, catastrophic injury has likely
occurred in both kidneys—as in obstructive uropathy
or, less commonly, in bilateral renal artery occlusion,
acute cortical necrosis, or rapidly progressive
glomerulonephritis (Agraharkar & Gupta, 2007).
ii. Diuretic
1. May skip oliguric phase and begin to make large
quantities (may be several liters) of urine
2. Client with oliguria will progress through diuretic
phase during recovery.
3. Urine is dilute because of kidney’s inability to
concentrate.
iii. Convalescent
1. Renal blood flow and filtration improves.
2. Process of recovery is gradual, often weeks to
months; in many cases, some degree of renal
insufficiency persists.

II. Classification—dependent on site
a. Prerenal failure (azotemia): decreased renal perfusion
manifested by reduced urine output because of decreased
glomerular filtration rate (GFR)
b. Renal or intrinsic failure: associated with parenchymal
changes with damage to the renal tubules (acute tubular
necrosis [ATN]) caused by ischemia or nephrotoxic
substances
c. Postrenal failure: results from an obstruction in the urinary
tract anywhere from the tubules to the urethral meatus

III. Etiology
a. Multiple causes: ischemia and toxicity (most common),
obstructions
i. Prerenal failure: blood volume depletion due to hemorrhage,
“third-space” sequestration of fluid as in edema or
ascites in advanced liver disease, or burns; dehydration
due to gastrointestinal (GI) losses or overuse of diuretics;
septic or anaphylactic shock; heart failure (HF) with renal
insufficiency, myocardial infarction (MI), trauma; renal
artery obstruction; and use of certain drugs, such as
nonsteroidal anti-inflammatory drugs (NSAIDs),
cyclooxygenase inhibitors, angiotensin-converting enzyme
(ACE) inhibitors
ii. Intrinsic failure: ischemia and hypoperfusion similar to
prerenal hypoperfusion (except that correction of the
causative factor may be followed by continued oliguria
for up to 30 days) associated with prolonged acute renal
failure (ARF), blood transfusion reaction, or renal artery
stenosis; and direct damage from nephrotoxic substances,
such as radiocontrast media, cyclosporine,
heavy metals (e.g., lead, mercury), cytotoxic drugs
(e.g., certain chemotherapy agents), certain antibiotics
(e.g., carbenicillins, aminoglycosides)
iii. Postrenal failure: most commonly occurs with stones in
the ureters, bladder, or urethra; from trauma or edema
associated with infection, prostatic hypertrophy, or
cancer; cervical cancer; strictures of renal artery
iv. If underlying cause is corrected, the nephrons may
recover; however, in some cases, damage is permanent
and renal failure becomes chronic.
b. Community- or hospital-acquired
i. Most community-acquired ARF is secondary to volume
depletion; as many as 90% of cases are estimated to
have a potentially reversible cause (Sinert & Peacock,
2006).
ii. Hospital-acquired ARF often occurs in the intensive
care unit (ICU) setting and is commonly the end result
of multiorgan failure.
c. Risk factors: advanced age, chronic infection, diabetes, hypertension,
immune disorders such as lupus or scleroderma

IV. Statistics (Agraharkar & Gupta, 2007; Sinert, 2006)
a. Morbidity: Upon hospital admission, approximately 1% of
clients have ARF, whereas during hospitalization, the
estimated incidence of ARF is 2% to 5%.
b. Mortality: The rate for hospital-acquired ARF is as high as
40% to 80% and is directly correlated to the severity of
comorbidities; with the advent of dialysis, the most common
causes of death associated with ARF include sepsis, cardiac
failure, and pulmonary failure; rates are generally lower for
nonoliguric ARF than for oliguric ARF because the former
is usually caused by drug-induced nephrotoxicity and
interstitial nephritis, which are associated with fewer systemic
complications; individuals with ARF who are older
than age 80 have mortality rates similar to younger adults.

Care Setting
Client will be treated in inpatient acute medical or surgical
unit.

Related Concerns
Metabolic acidosis—primary base bicarbonate deficiency,
Fluid and electrolyte imbalances,
Psychosocial aspects of care,
Renal dialysis—general considerations,
Renal failure: chronic,
Sepsis/septicemia,
Total nutritional support: parenteral/enteral feeding,
Upper gastrointestinal/esophageal bleeding,

Nursing Priorities
1. Reestablish or maintain fluid and electrolyte balance.
2. Prevent complications.
3. Provide emotional support for client and significant
other (SO).
4. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Homeostasis achieved.
2. Complications prevented or minimized.
3. Dealing realistically with current situation.
4. Disease process, prognosis, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.

I. Pathophysiology
a. Sudden decrease in kidney function, which may or may not
be associated with a decrease in urine output and results in a
buildup of toxic wastes, such as urea and creatinine in the
blood
b. Three well-defined stages: oliguric or anuric, diuretic, and
convalescent (Choka, 2005)
i. Oliguric
1. Filtration capability is reduced because of debris and
damage to renal tubules.
2. Output is greatly reduced—may be less than
400 mL/day.
3. If anuria present, catastrophic injury has likely
occurred in both kidneys—as in obstructive uropathy
or, less commonly, in bilateral renal artery occlusion,
acute cortical necrosis, or rapidly progressive
glomerulonephritis (Agraharkar & Gupta, 2007).
ii. Diuretic
1. May skip oliguric phase and begin to make large
quantities (may be several liters) of urine
2. Client with oliguria will progress through diuretic
phase during recovery.
3. Urine is dilute because of kidney’s inability to
concentrate.
iii. Convalescent
1. Renal blood flow and filtration improves.
2. Process of recovery is gradual, often weeks to
months; in many cases, some degree of renal
insufficiency persists.
II. Classification—dependent on site
a. Prerenal failure (azotemia): decreased renal perfusion
manifested by reduced urine output because of decreased
glomerular filtration rate (GFR)
b. Renal or intrinsic failure: associated with parenchymal
changes with damage to the renal tubules (acute tubular
necrosis [ATN]) caused by ischemia or nephrotoxic
substances
c. Postrenal failure: results from an obstruction in the urinary
tract anywhere from the tubules to the urethral meatus

III. Etiology
a. Multiple causes: ischemia and toxicity (most common),
obstructions
i. Prerenal failure: blood volume depletion due to hemorrhage,
“third-space” sequestration of fluid as in edema or
ascites in advanced liver disease, or burns; dehydration
due to gastrointestinal (GI) losses or overuse of diuretics;
septic or anaphylactic shock; heart failure (HF) with renal
insufficiency, myocardial infarction (MI), trauma; renal
artery obstruction; and use of certain drugs, such as
nonsteroidal anti-inflammatory drugs (NSAIDs),
cyclooxygenase inhibitors, angiotensin-converting enzyme
(ACE) inhibitors
ii. Intrinsic failure: ischemia and hypoperfusion similar to
prerenal hypoperfusion (except that correction of the
causative factor may be followed by continued oliguria
for up to 30 days) associated with prolonged acute renal
failure (ARF), blood transfusion reaction, or renal artery
stenosis; and direct damage from nephrotoxic substances,
such as radiocontrast media, cyclosporine,
heavy metals (e.g., lead, mercury), cytotoxic drugs
(e.g., certain chemotherapy agents), certain antibiotics
(e.g., carbenicillins, aminoglycosides)
iii. Postrenal failure: most commonly occurs with stones in
the ureters, bladder, or urethra; from trauma or edema
associated with infection, prostatic hypertrophy, or
cancer; cervical cancer; strictures of renal artery
iv. If underlying cause is corrected, the nephrons may
recover; however, in some cases, damage is permanent
and renal failure becomes chronic.
b. Community- or hospital-acquired
i. Most community-acquired ARF is secondary to volume
depletion; as many as 90% of cases are estimated to
have a potentially reversible cause (Sinert & Peacock,
2006).
ii. Hospital-acquired ARF often occurs in the intensive
care unit (ICU) setting and is commonly the end result
of multiorgan failure.
c. Risk factors: advanced age, chronic infection, diabetes, hypertension,
immune disorders such as lupus or scleroderma

IV. Statistics (Agraharkar & Gupta, 2007; Sinert, 2006)
a. Morbidity: Upon hospital admission, approximately 1% of
clients have ARF, whereas during hospitalization, the
estimated incidence of ARF is 2% to 5%.
b. Mortality: The rate for hospital-acquired ARF is as high as
40% to 80% and is directly correlated to the severity of
comorbidities; with the advent of dialysis, the most common
causes of death associated with ARF include sepsis, cardiac
failure, and pulmonary failure; rates are generally lower for
nonoliguric ARF than for oliguric ARF because the former
is usually caused by drug-induced nephrotoxicity and
interstitial nephritis, which are associated with fewer systemic
complications; individuals with ARF who are older
than age 80 have mortality rates similar to younger adults.

Care Setting
Client will be treated in inpatient acute medical or surgical
unit.

Related Concerns
Metabolic acidosis—primary base bicarbonate deficiency,
Fluid and electrolyte imbalances,
Psychosocial aspects of care,
Renal dialysis—general considerations,
Renal failure: chronic,
Sepsis/septicemia,
Total nutritional support: parenteral/enteral feeding,
Upper gastrointestinal/esophageal bleeding,

Nursing Priorities
1. Reestablish or maintain fluid and electrolyte balance.
2. Prevent complications.
3. Provide emotional support for client and significant
other (SO).
4. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Homeostasis achieved.
2. Complications prevented or minimized.
3. Dealing realistically with current situation.
4. Disease process, prognosis, and therapeutic regimen
understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan lymphomas

I. Pathophysiology
a. Malignant growth involving reticuloendothelial and
lymphoid system, resulting in accumulation of abnormal
lymphocytes in lymph tissue forming masses; may travel
to distant sites, including the lungs, liver, gastrointestinal
(GI) tract, meninges, skin, and bones
b. Major sites of lymphoid tissue are lymph nodes, spleen,
thymus gland, adenoids and tonsils, and digestive tract.
II. Classification
a. Defined by clinical, immunological, molecular, genetic, and
histological characteristics
b. Based on histological characteristics, lymphomas are divided
into two major categories: Hodgkin’s disease or Hodgkin
lymphoma (HL), with five subtypes, and non-Hodgkin
lymphoma (NHL) with 30 subtypes.
i. HL
1. Slow, insidious onset; superficial lymphadenopathy in
cervical, supraclavicular, or mediastinal lymph nodes,
which are firm, rubbery, and freely movable
2. Spreads in a generally predictable manner to contiguous
lymph nodes via lymphatic channels
ii. NHL
1. Most fall into two broad categories related to the
clinical features: nodular indolent lymphomas and
diffuse, aggressive lymphomas.
2. When normal follicular structure of the nodes remains
intact, the lymphoma is called follicular or nodular,
whereas if malignant cells destroy the follicles, the
lymphoma is considered diffuse.
3. May be separated into two categories—low-grade
lymphomas and aggressive lymphomas, which includes
intermediate-grade and high-grade lymphomas
a. With or without treatment, low-grade lymphomas
can transform into more aggressive lymphomas or
the tumor replaces blood or lymph tissue leading to
multiple systemic dysfunction and death.
b. Intermediate- and high-grade lymphomas tend to be
more responsive to treatment.
c. Further staging is done to determine treatment
options and prognosis.
iii. Stages I to IV reflect the microscopic appearance of
involved lymph nodes and the extent and severity of the
disorder.
iv. May be further classified by letters of the alphabet
(A, B, etc.) according to symptoms present at the time
of diagnosis

III. Etiology (Hu & Hale, 2005)
a. Exact causes are unknown.
b. Several factors have been linked to an increased risk.
i. Age: Risk of NHL generally increases with advancing
age; HL in the elderly population is associated with a
poorer prognosis than in younger clients.
ii. Infection: human immunodeficiency virus (HIV); human
T-lymphocytic virus type 1 (HTLV-1); Epstein-Barr virus
(EBV), one of the etiological factors in mononucleosis;
Helicobacter pylori; hepatitis B or C virus
iii. Medical conditions that compromise the immune system:
HIV; autoimmune diseases; conditions requiring
immunosuppressive therapy, such as following organ
transplant; inherited immunodeficiency diseases; or
treatment with phenytoin
iv. Exposure to toxic chemicals: occupational exposure to
pesticides, herbicides, or benzene and other solvents;
woodworking
IV. Statistics
a. Morbidity: In 2007, 71,380 people were diagnosed with
lymphoma in the United States (Leukemia & Lymphoma
Society, 2006); the 5-year survival rate is 77% to 83%
for HL and 42% to 53% for NHL (Dunleavy et al, 2007);
incidence of NHL is consistently higher than HL, with
NHL the fifth most common cancer in the United States
(Leukemia & Lymphoma Society: Facts 2007–2008).
b. Mortality: In 2001, there were an estimated 26,300 deaths
from NHL (Gajra et al, 2007); mortality rate increases with
age (Dunleavy et al, 2007).
c. Cost: In 2004, projected costs for care were $4.6 billion
(National Cancer Institute [NCI], 2007).

Care Setting
The client receives acute inpatient care on a medical unit for
initial evaluation and treatment and then at the community
level. This plan of care addresses potential complications
that may be encountered in acute care or hospice settings.

Related Concerns
Anemias—iron deficiency, anemia of chronic disease, pernicious,
aplastic, hemolytic,
Cancer,
Adult leukemias,
Psychosocial aspects of care,
Sepsis/septicemia,
Spinal cord injury (acute rehabilitative phase),
Transplantation considerations—postoperative and lifelong,
Upper gastrointestinal/esophageal bleeding,

Nursing Priorities
1. Provide physical and psychological support during extensive
diagnostic testing and treatment regimen.
2. Prevent complications.
3. Alleviate pain.
4. Provide information about disease process, prognosis, and
treatment needs.

Discharge Goals
1. Complications prevented or minimized.
2. Dealing with individual situation realistically.
3. Pain relieved or controlled.
4. Disease process, prognosis, possible complications, and
therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan adult leukemias

I. Pathophysiology: malignant disorder of the blood and bone
marrow characterized by the uncontrolled accumulation of
white blood cells (WBCs)
a. Blood cells originate primarily in the marrow of bones,
such as the sternum, iliac crest, and cranium, and begin as
immature cells (blasts or stem cells) that differentiate and
mature into red blood cells (RBCs), platelets, and various
types of WBCs.
b. Production of normal blood cells markedly decreased,
leading to anemia, thrombocytopenia, neutropenia
c. Rapid growth of immature or ineffective WBCs and delayed
cell death lead to their accumulation in bone marrow, blood,
spleen, and liver.

II. Categories
a. Dependent on the type of cell involved—myelogenous or
lymphocytic—as well as duration: acute (acute myelogenous
leukemia [AML], acute lymphocytic leukemia [ALL]);
or chronic (chronic myelogenous leukemia [CML], chronic
lymphocytic leukemia [CLL])
i. Acute
1. WBCs proliferate so rapidly that they lose the ability
to regulate cell division and do not differentiate into
mature cells.
2. Most common form in adults is AML, which affects
different types of WBCs, with the exception of
lymphocytes.
3. Progresses rapidly without treatment
ii. Chronic
1. Chronic forms have few or no blast cells.
2. Most common form is CLL, which is characterized by
abnormal increase in lymphocytes.
3. Develops gradually and progresses more slowly than
acute forms

III. Etiology
a. Exact cause is unknown.
b. Risk factors (Seiter, 2006)
i. Antecedent histological disorders: diseases of the bone
marrow, such as myelodysplastic syndrome (MDS)
ii. Environmental exposures: radiation, smoking, benzene
iii. Prior chemotherapy
iv. Genetics or congenital disorders: develop more often in
children
IV. Statistics
a. Morbidity: In 2007, an estimated 44,240 new cases of
leukemia (all types) were diagnosed in the United States;
diagnosed more often in males than females; chronic
leukemias account for 7% more cases than acute; most
cases occur in older adults, with more than half occurring
after age 67 (The Leukemia & Lymphoma Society’s SEER
Facts 2007–2008); with AML, the median age of onset is
65 years (Seiter, 2006).
b. Mortality: In 2005, an estimated 9,000 deaths from AML
in the United States were reported (Seiter, 2006); majority
of those with CLL live 5 to 10 years; however, presence
of complications may shorten survival to 2 to 3 years
(Perry & Rasool, 2005).
c. Cost: Projected cost for care was $2.6 billion in 2004
(National Cancer Institute [NCI], 2007).

Care Setting
Client receives acute inpatient care on medical or oncology
unit for initial evaluation and treatment, typically for 4 to
6 weeks, and then at the community level.

Related Concerns
Cancer,
Psychosocial aspects of care,
Transplantation considerations—postoperative and lifelong,

Nursing Priorities
1. Prevent infection during acute phases of disease and
treatment.
2. Maintain circulating blood volume.
3. Alleviate pain.
4. Promote optimal physical functioning.
5. Provide psychological support.
6. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Complications prevented or minimized.
2. Pain relieved or controlled.
3. Activities of daily living (ADLs) met by self or with
assistance.
4. Dealing with disease realistically.
5. Disease process, prognosis, and therapeutic regimen
understood.
6. Plan in place to meet needs after discharge.

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Nursing care plan sickle cell crisis

I. Pathophysiology
a. Formation of abnormal hemoglobin chains containing
hemoglobin S: When red blood cells (RBCs) are exposed to
low oxygen saturation states, hemoglobin S causes the beta
cells to contract and clump together inside the cell, thus
distorting its shape.
b. Hemolysis occurs as the sickled cells clump together and
obstruct blood flow, rendering the individual vulnerable to
repeated painful crises, which can progressively destroy
vital organs.
i. Vaso-occlusive and thrombocytic crisis
ii. Hypoplastic and aplastic crisis
iii. Hyperhemolytic crisis
iv. Splenic sequestration crisis
c. Plasma clotting factors likely participate in the microthrombi
in the prearterioles.
d. After recurrent episodes of sickling, membrane damage
occurs, and the cells are no longer capable of resuming their
normal shape upon reoxygenation.

II. Etiology
a. Sickle hemoglobinopathies compose a group of genetic
diseases, with the most common forms being homozygous
hemoglobin SS disease (HbSS) or sickle cell anemia, hemoglobin
SC disease, and sickle cell beta-thalassemia or Thal.
b. Primarily affects black populations of African descent as
well as people of South and Central American, Caribbean,
Mediterranean, Arabian, and East Indian descent
(Distenfeld & Woermann, 2007, Taher & Kazzi, 2007)
c. Vaso-occlusive crisis is often triggered by infection,
dehydration, fever, or local trauma.
III. Statistics
a. Morbidity: 1 in 500 African Americans has inherited sickle
cell hemoglobin from both parents and therefore has the
disease; more than 70,000 people in the United States have
sickle cell disease (National Heart, Lung and Blood
Institute [NHLBI], 2008), accounting for over 83,000
hospital admissions in 2004 (Steiner & Miller, 2006).
b. Mortality: In 2004, there were 699 adult deaths
(Steiner & Miller, 2006).
c. Cost: In 2004, approximately $488 million was spent for
hospital costs (Steiner & Miller, 2006).

Care Setting
Sickle cell disease is generally managed at the community
level, with many of the interventions included here being
appropriate for this focus; however, this plan of care
addresses sickle cell crisis, which usually requires hospitalization
during the acute phase to address oxygenation
and severe pain.

Related Concerns
Cerebrovascular accident (CVA)/stroke,
Cholecystitis with cholelithiasis,
Chronic obstructive pulmonary disease (COPD) and asthma,

Cirrhosis of the liver,
Heart failure: chronic,
Pneumonia,
Psychosocial aspects of care,
Seizure disorders,
Sepsis/septicemia,

Nursing Priorities
1. Promote adequate cellular oxygenation and perfusion.
2. Alleviate pain.
3. Prevent complications.
4. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Oxygenation and perfusion are adequate to meet cellular
needs.
2. Pain relieved or controlled.
3. Complications prevented or minimized.
4. Disease process, future expectations, potential complications,
and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan anemias iron deficiency anemia of chronic disease pernicious aplastic hemolytic

I. Pathophysiology: decreased number of circulating red
blood cells (RBCs), reduction in the amount of hemoglobin
(Hgb) in the RBCs, or a combination of both, resulting in
diminished oxygen-carrying capacity of the blood
a. Iron deficiency anemia (ID): inadequate iron stores, which
results in insufficient Hgb (key molecule in RBCs), causing
cells to appear abnormal, unusually small (microcytic), and
pale (hypochromic)
b. Anemia of chronic disease (ACD): accompanies chronic
inflammatory, infectious, or neoplastic disorders
c. Pernicious anemia (PA): lack of intrinsic factor in the stomach
results in inability to absorb vitamin B12 causing abnormal
RBC formation
d. Aplastic anemia: failure of bone marrow to produce cells,
including RBCs and white blood cells (WBCs) and platelets
e. Hemolytic anemia: premature destruction of RBCs

II. Etiology
a. Adult anemia is usually defined as a Hgb level lower than
11 g/dL, with severe anemia defined as Hgb lower than
8 g/dL.
b. Associated with many physiological complications, including
dyspnea, fatigue, dizziness, decreased cognition,
impaired sleep, sexual dysfunction, and significant
debilitation
c. ID
i. Lack of iron in the body due to a variety of causes
1. Blood loss due to disease, such as gastric or duodenal
ulcers, diverticula, hemorrhoids, ulcerative colitis;
injury or trauma; or certain medications, including
aspirin or nonsteroidal anti-inflammatory drugs
(NSAIDs)
2. Inadequate nutrition, such as not eating enough foods
that contain iron
3. Malabsorption syndromes, such as not utilizing iron
from food that is eaten
4. Lead exposure
ii. Most frequently occurring form of anemia
d. ACD
i. Primarily due to slowed production of RBCs as a result
of low reticulocyte production
ii. Develops slowly and is only evident after time
iii. Symptoms are usually associated with the disease
causing the anemia rather than the anemia itself.
iv. Second most prevalent form of anemia (Hebbar &
Gibson, 2006; Krantz, 1994)
e. PA—an autoimmune disorder
i. Characterized by the production of autoantibodies to
gastric parietal cells and their secretory product—intrinsic
factor—which is needed for vitamin B12 absorption
ii. Conditions that interfere with the body’s absorption
and use of B12 include Crohn’s and Whipple’s diseases,
gastrectomy or gastric bypass, and the use of
chemotherapeutic medications.
f. Aplastic anemia—bone marrow failure
i. May be associated with conditions that affect
erythropoietin production and secretion, such as certain
cancers and cancer treatments and renal, hepatic, or
endocrine disorders
ii. Other known causes include exposure to chemicals, such
as benzene, insecticides, solvents; certain drugs, such as
chemotherapy, gold, seizure medications, some antibiotics;
viruses, such as HIV, Epstein-Barr; immune conditions,
such as systemic lupus erythematosus, rheumatoid arthritis;
radiation; and certain inherited disorders, such as Fanconi’s
anemia.
g. Hemolytic anemia—marked by an accelerated destruction
of RBCs
i. Several types of hemolytic anemias, including sickle cell
anemia (see Sickle Cell Crisis)
ii. Causes include hereditary factors, such as sickle cell
trait or disease; blood transfusion reactions; acute viral
or infectious agents; certain drugs, such as quinidine,
penicillin, and methyldopa; and toxins, such as
chemicals and venoms.

III. Statistics
a. Morbidity: Approximately 3.5 million Americans have anemia
(National Heart, Lung and Blood Institute [NHLBI],
2007); in 1996, an estimated 2.1 million individuals
younger than age 45 had anemia (Montoya et al, 2002); in
1999, 174,600 nursing home residents had anemia in the
United States (CureResearch, 2003).
b. Morbidity: 4,627 people die from anemia annually in the
United States (CureResearch, 2003).
c. Cost: $6.4 billion is spent annually (CureResearch, 2003).

Nursing Priorities
1. Enhance tissue perfusion.
2. Provide nutritional and fluid needs.
3. Prevent complications.
4. Provide information about disease process, prognosis,
and treatment regimen.

Care Setting
Clients are treated at the community level except in the presence
of severe cardiovascular or immune compromise.
Although the medical treatments vary widely due to the
many variations in anemia presentation, nursing care for the
anemic client has a common theme: managing physical
symptoms and maximizing quality-of-life issues.

Related Concerns
Acquired immunodeficiency syndrome (AIDS),
Burns: thermal, chemical, and electrical—acute and convalescent
phases,
Cancer,
Cirrhosis of the liver,
Heart failure: chronic,
Psychosocial aspects of care,
Renal failure: acute,
Renal failure: chronic,
Rheumatoid arthritis (RA),
Pulmonary tuberculosis (TB),
Upper gastrointestinal/esophageal bleeding,

Discharge Goals
1. ADLs met by self or with assistance of others.
2. Complications prevented or minimized.
3. Disease process, prognosis, and therapeutic regimen
understood.
4. Plan in place to meet needs after discharge.

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Nursing care plan metabolic alkalosis primary base bicarbonate excess

I. Pathophysiology
a. Increase in base or bicarbonate (HCO3
–) concentration, generally
reflecting a relative loss or shift of hydrogen (H+)
and/or gain in HCO3
–.
b. Organ systems most often involved are the kidneys and the
gastrointestinal (GI) tract.
c. Consequences of the condition on organ systems dependent
on degree of alkalemia and underlying pathology.

II. Etiology
a. Chloride-responsive: Urine chloride is less than 20 mEq/L
and decreased extracellular fluid (ECF) volume.
i. GI acid losses: vomiting, nasogastric suction, diarrhea
associated with villous adenoma
ii. Diuretics: Thiazides and loop diuretics interfere with
reabsorption of sodium and chloride in the renal tubules,
causing loss of chloride.
iii. HCO3
– excess: correction of respiratory acidosis, chronic
ingestion of large doses of antacids
iv. Laxative abuse
b. Chloride-resistant: Urine chloride is greater than 20 mEq/L
and increased ECF volume.
i. Renal acid loss: primary or secondary hyperaldosteronism,
thiazides or loop diuretics, hypokalemia and
hypomagnesemia; genetic deficiency of 11-B-HSD2 or
inhibition by licorice, chewing tobacco
ii. Renal artery stenosis
c. Other causes
i. Carbohydrate feeding after starvation
ii. Hypercalcemia
iii. Multiple blood transfusions
d. Compensatory mechanisms
i. Rapid excretion of HCO3
– by the kidneys whenever
plasma level exceeds 24 mmol/L—requires normal
kidney function, with the ability to filter HCO3
– and to
excrete excess H+
ii. Hypoventilation: slow, shallow respirations to increase
retention of carbonic acid

III. Statistics
a. Morbidity: Primarily related to the underlying disease;
therefore, separate statistics are not collected; most
common acid-base imbalance in hospitalized adults
(Huang & Priestley, 2007).
b. Mortality: 45% for arterial pH over 7.55; 80% for arterial
pH over 7.65 (Yaseen & Thomas, 2007).

Care Setting
This condition does not occur in isolation but rather is a
complication of a broader problem that may require inpatient
care in a medical-surgical or subacute unit.

Related Concerns
Plans of care are specific to predisposing factors.
Fluid and electrolyte imbalances,
Renal dialysis—general considerations,
Respiratory acidosis (primary carbonic acid excess),
Respiratory alkalosis (primary carbonic acid deficit),

Nursing Priorities
1. Achieve homeostasis.
2. Prevent or minimize complications.
3. Provide information about condition, prognosis, and
treatment needs, as appropriate.

Discharge Goals
1. Physiological balance restored.
2. Free of complications.
3. Condition, prognosis, and treatment needs understood.
4. Plan in place to meet needs after discharge.

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Nursing care plan metabolic acidosis primary base bicarbonate deficiency

I. Pathophysiology
a. Reflects a relative excess of acid or hydrogen (H+) and a
deficit of base or bicarbonate (HCO3
–)
b. Gain of strong acid may be endogenous (for example,
ketoacids from lipid metabolism) or exogenous (for
example, NH4Cl infusion).
c. Bicarbonate loss may occur via the bowel or kidneys.

II. Etiology—characterized by normal or high anion gap
situations (Priestley, 2007; Thomas & Hamwai, 2007)
a. Normal anion gap (or nonanion gap) acidosis is associated
with loss of bicarbonate from the body, gain of chloride, or
decreased ammonia production.
i. Gastrointestinal (GI) losses: vomiting, diarrhea, smallbowel
and pancreatic or biliary fistulas, ileal loop bladder
ii. Early renal failure
iii. Obstructed ileostomy
iv. Infusion of ammonium chloride, hyperalimentation;
intravenous (IV) sodium chloride in presence of
preexisting kidney dysfunction; acidifying drugs
b. High anion gap acidosis reflects accumulation of organic
anions.
i. Diabetic ketoacidosis
ii. Severe malnutrition or starvation, high-fat,
low-carbohydrate diets; parenteral lipid administration
iii. Alcoholic lactic acidosis
iv. Renal tubular necrosis
v. Poisoning: salicylate intoxication (after initial stage),
paraldehyde intoxication; drug therapy including acetazolamide
(Diamox), isoniazid (INH); or NH4Cl
c. Compensatory mechanisms
i. Hyperventilation to reduce PaCO2
ii. Decreased renal secretion of H+, less production of
ammonia, and excretion of HCO3

iii. Treatment of underlying condition

III. Statistics: Morbidity and mortality are primarily related to
the underlying disease; therefore, separate statistics are not
collected.

Care Setting
This condition does not occur in isolation but rather is a
complication of a broader problem that may require inpatient
care in a medical-surgical or subacute unit.

Related Concerns
Plans of care are specific to predisposing factors.
Fluid and electrolyte imbalances,
Renal dialysis—general considerations,
Respiratory acidosis (primary carbonic acid excess),
Respiratory alkalosis (primary carbonic acid deficit),

Nursing Priorities
1. Achieve homeostasis.
2. Prevent or minimize complications.
3. Provide information about condition, prognosis, and
treatment needs, as appropriate.

Discharge Goals
1. Physiological balance restored.
2. Free of complications.
3. Condition, prognosis, and treatment needs understood.
4. Plan in place to meet needs after discharge.

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Nursing care plan total nutritional support parenteral enteral feeding

I. Pathophysiology: Malnutrition is a disorder of body composition
in which nutritional intake is less than required and
results in reduced organ function, abnormalities in blood
chemistry, reduced body mass, and worsened clinical outcomes.
a. Nutritional status is affected by multiple factors, including
eating behaviors, disease states, economics, and environment.
b. In the acutely or chronically ill client, the impact of malnutrition
includes muscle mass loss, progressive weakness,
potential for infection, poor healing, and a higher rate of
systemic complications.
c. When oral intake is inadequate or not possible, specifically
designed nutritional therapy can be administered via an
enteral or parenteral route to prevent or correct proteincalorie
malnutrition.

II. Clinical Indication for Feeding
a. Preexisting nutritional deprivation; unplanned or unexplained
loss of 10% in body weight
b. Anticipated or actual inadequate energy intake by mouth,
such as inability to consume food or drink orally for 7 days
or more, based on individual nutritional status
c. Critically ill individuals, because of their increased metabolic
demands and limited nutritional reserve, commonly
require nutritional support.
d. The Joint Commission for Accreditation of Healthcare
Organizations (JCAHO) recognizes the negative impact of
malnutrition in hospitals and long-term care institutions and
has, in turn, made nutritional assessment, support, and
ongoing reassessment an essential part of accreditation
requirements (JCAHO, 1997).

III. Etiology of Malnutrition
a. Can exist in persons who are underfed or overfed, occurring
in both extremely thin and obese individuals
b. May result from an inadequate or unbalanced diet,
digestive difficulties, absorption problems, or other medical
conditions
i. Acute conditions, such as surgery, severe burns, infections,
and trauma, that drastically increase short-term
nutritional requirements
ii. Chronic diseases associated with nutrient loss, nutrient
demand, and with malabsorption, such as celiac disease,
cystic fibrosis, pancreatic insufficiency, pernicious
anemia
iii. Conditions and treatments associated with malnutrition
through decreased intake, such as depressed appetite, difficulty
swallowing, and nausea associated with both cancer
and chemotherapy, as well as with HIV/AIDS and its drug
therapies
c. Certain age groups, such as elderly clients, require fewer
calories but continue to require adequate nutritional support
because they are often less able to absorb nutrients, due in
part to decreased stomach acid production, and are more
likely to have one or more chronic ailments that may affect
their nutritional status.

IV. Routes for Feeding
a. Enteral nutrition
i. Gastrointestinal (GI) intubation is preferred for clients
with functional GI tract, but who are unable to consume
an adequate nutritional intake or for whom oral intake is
contraindicated or impossible.
ii. Feeding may be done via flexible catheter (such as
nasogastric [NG], orogastric tube) or enterostomy (such
as gastrostomy, duodenostomy, or jejunostomy tube).
iii. Feeding may be short-term for supplementation of oral
intake or long-term to provide for all of client’s nutrition.
b. Parenteral nutrition
i. May be chosen because of altered metabolic states or
when mechanical or functional abnormalities of the GI
tract prevent enteral feeding
ii. Goals are to improve the client’s nutritional status;
establish and maintain a positive nitrogen balance;
improve or maintain muscle strength and mass; promote
weight gain; and encourage the healing process through
infusion of amino acids, fat, carbohydrates, trace
elements, vitamins, and electrolytes, as indicated.
iii. The average adult requires approximately 1,500 calories
per day in order to maintain energy stores.
iv. Nutritional support is provided via an intravenous (IV)
route, either centrally or peripherally.
1. Central: Formula is concentrated hyperosmolar and
must be infused via a central vein (subclavian or
jugular) into the superior vena cava or peripherally
inserted central catheter (PICC), inserted into the arm
and passed into a major blood vessel.
2. Peripheral: Formula is similar, but less concentrated than
central formula and is infused via a peripheral vein.

Care Setting
Client may be treated in any setting, including community
or home care.

Related Concerns
Acquired immunodeficiency syndrome (AIDS),
Anemias,
Burns: thermal, chemical, and electrical—acute and convalescent
phases,
Cancer,
Cirrhosis of the liver,
Chronic obstructive pulmonary disease (COPD) and asthma,
page 120
Diabetes mellitus/diabetic ketoacidosis,
Eating disorders: anorexia nervosa/bulimia nervosa,
Eating disorders: obesity,
Fluid and electrolyte imbalances,
Fractures,
Inflammatory bowel disease (IBD): ulcerative colitis,
Crohn’s disease,
Obesity: bariatric surgery—gastric partitioning/gastroplasty,
gastris bypass,
Pancreatitis,
Psychosocial aspects of care,
Renal failure: chronic,
Surgical intervention,

Nursing Priorities
1. Promote consistent intake of adequate calorie and protein
requirements.
2. Prevent complications.
3. Minimize energy losses and needs.
4. Provide information about condition, prognosis, and
treatment needs.

Discharge Goals
1. Nutritional intake adequate for individual needs.
2. Complications prevented or minimized.
3. Fatigue alleviated.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan pancreatitis

I. Pathophysiology
a. Inflammation of pancreas with premature activation of pancreatic
enzymes resulting in localized damage to the pancreas,
autodigestion, and fibrosis of the pancreas
b. Leads to wide range of metabolic consequences and lifethreatening
complications, such as hypovolemia, shock,
acute renal failure, diabetes, acute respiratory distress syndrome
(ARDS), and multiorgan failure
II. Types
a. Acute
i. Sudden inflammation occurs over a short period of time.
ii. Severity ranges from mild abdominal discomfort to a
life-threatening illness.
iii. Can result in bleeding into the gland, serious tissue
damage, infection, and cyst formation
iv. Release of enzymes and toxins into bloodstream can
damage other vital organs, including the heart, lungs, and
kidneys.
b. Chronic
i. Commonly follows acute episode when inflammation is
ongoing
ii. Development may be delayed, as in alcohol abuse.
III. Etiology
a. Acute
i. Biliary tract disease, such as obstruction by gallstones, is
most common cause—about 40% (Gardner et al, 2008).
ii. Alcohol abuse—approximately 35% (Gardner et al,
2008)
iii. Trauma: blunt or penetrating
iv. Procedures: endoscopic or surgical
v. Viral infections: mumps, mononucleosis, varicella
vi. Bacterial infections: Mycoplasma pneumoniae,
salmonellosis, tuberculosis
vii. Drugs: sulfonamides, glucocorticoids, thiazide diuretics,
nonsteroidal anti-inflammatory drugs (NSAIDs)
viii. Unknown cause—about 10% to 15% of cases
b. Chronic (Obideen & Yashke, 2008)
i. Intraductal obstruction: alcohol abuse, stones, or tumors
ii. Alcohol abuse—about 60% of cases
iii. Direct toxins and toxic metabolites
iv. Recurrent acute pancreatitis that heals with fibrosis
v. Ischemia from obstruction and fibrosis exacerbates or
perpetuates disease, rather than in initiating disease
vi. Autoimmune disorders: primary biliary cirrhosis, renal
tubular acidosis
IV. Statistics
a. Morbidity: An estimated 87,000 individuals are diagnosed
with chronic pancreatitis annually in the United States
(Obideen & Yashke, 2008); more than 220,000 were estimated
to be hospitalized for acute pancreatitis in 2007
(Gardner et al, 2008).
b. Mortality: Rate is less than 1% for mild acute pancreatitis,
but can approach 10% to 30% for severe acute pancreatitis
(Lie, 2007); biliary pancreatitis associated with higher
mortality rate than alcoholic pancreatitis; in presence of
necrosis without organ failure, mortality rate is near zero,
but with organ failure rate is approximately 30%
(Gardner et al, 2008).
c. Cost: More than $2 billion is spent annually in the
United States (Fagenholz, 2007).

Care Setting
The client is treated in an inpatient acute medical unit or
intensive care unit (ICU) for initial incident or exacerbations
with serious complications; otherwise, condition is managed
at the community level.

Related Concerns
Alcohol: acute withdrawal,
Substance dependence/abuse rehabilitation,
Diabetes mellitus/diabetic ketoacidosis,
Peritonitis,
Psychosocial aspects of care,
Renal failure: acute,
Sepsis/septicemia,
Total nutritional support: parenteral/enteral feeding,

Nursing Priorities
1. Control pain and promote comfort.
2. Prevent and treat fluid and electrolyte imbalance.
3. Reduce pancreatic stimulation while maintaining adequate
nutrition.
4. Prevent complications.
5. Provide information about disease process, prognosis,
and treatment needs.

Discharge Goals
1. Pain relieved or controlled.
2. Hemodynamically stable.
3. Complications prevented or minimized.
4. Disease process, prognosis, potential complications, and
therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan cirrhosis of the liver

I. Pathophysiology (Murphy, 2006)
a. Alteration in structure and degenerative changes resulting
from buildup of diffuse bands of fibrotic connective tissue
causing widespread destruction of hepatic cells, impairing
liver function, and impeding blood flow through the liver
b. Compensated cirrhosis: Liver function may continue for some
time, even with significant scarring, but metabolic abnormalities
can occur, such as coagulation defects and malnutrition.
c. Decompensated cirrhosis: progression of failure with
significant complications, such as portal hypertension with
bleeding varices, ascites, peritonitis, hepatorenal syndrome,
and encephalopathy
II. Etiology
a. Rate of progression of fibrosis to cirrhosis varies for
unknown reasons.
b. Multiple causation (Wolf, 2007)
i. Hepatitis C (26%), B, and D (15%)
ii. Alcoholic liver disease (21%)
iii. Cholestatic diseases: biliary atresia, primary biliary
cirrhosis, cystic fibrosis, primary sclerosing cholangitis
iv. Miscellaneous liver disorders, including autoimmune,
Wilson’s disease, alpha1-antitrypsin deficiency,
hemochromatosis
v. Injury from trauma, drugs, or other environmental toxins
III. Treatment
a. Goals are to slow the progression of the disease and
alleviate the symptoms.
b. Liver transplantation is currently the only life-saving procedure
for end-stage disease.
IV. Statistics
a. Morbidity: In 2005, 112,000 hospitalizations for chronic
liver disease or cirrhosis; approximately 17,000 individuals
awaiting liver transplant (Scientific Registry of Transplant
Recipients [SRTR], 2007).
b. Mortality: Approximately 35,000 deaths annually due
to chronic liver disease and cirrhosis (Wolf, 2007); in
2005, cirrhosis and other liver disorders were listed
as the 12th leading cause of death in the United States
(Hsiang-Ching, 2008).

Care Setting
Client may be hospitalized on a medical unit during initial
or recurrent acute episodes with potentially life-threatening
complications. Otherwise, this condition is managed at the
community, outpatient level.

Related Concerns
Alcohol: acute withdrawal,
Substance dependence/abuse rehabilitation,
Fluid and electrolyte imbalances,
Psychosocial aspects of care,
Renal dialysis—general considerations,
Renal failure: acute,
Total nutritional support: parenteral/enteral feeding,
Upper gastrointestinal/esophageal bleeding,

Nursing Priorities
1. Maintain adequate nutrition.
2. Prevent complications.
3. Enhance self-concept and acceptance of situation.
4. Provide information about disease process, prognosis,
potential complications, and treatment needs.

Discharge Goals
1. Nutritional intake adequate for individual needs.
2. Complications prevented or minimized.
3. Deals effectively with current reality.
4. Disease process, prognosis, potential complications, and
therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

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Nursing care plan hepatitis

I. Pathophysiology
a. Causes widespread damage to liver cells (hepatocytes) either
directly or indirectly from inflammation or autoimmune
response
b. May be acute or chronic
i. Acute: Swelling of hepatocytes reduces ability to detoxify
drugs; produce clotting factors, plasma proteins, bile, and
glycogen; and store fat-soluble vitamins.
ii. Chronic: inflammation and necrosis of liver of more than
6 months’ duration
II. Etiology
a. Infectious causes: viral, bacterial, fungal, or parasitic
i. Viruses are designated by letters A through G, with several
terms used interchangeably, for example, hepatitis B is
known as HBV or HepB; types A through D are endemic
in the United States and transmitted by blood and other
body fluids, sexual or close contact with infected person,
and fecal contamination of food and water.
ii. Other viruses: cytomegalovirus (CMV), Epstein-Barr virus
(EBV), Mycobacterium avium complex (MAC), herpes
simplex, varicella-zoster, toxoplasmosis, and histoplasmosis
b. Noninfectious causes: physical or toxic chemical agents,
autoimmune
i. Toxic agents: carbon tetrachloride, vinyl chloride; alcohol,
cocaine, acetaminophen, isoniazid, anabolic steroids,
methyldopa, erythromycin; poisonous mushrooms
ii. Autoimmune: no identifiable etiology; two types, with
type 1 most common form in North America
III. Statistics
a. Morbidity: HAV, HBV, and HCV cause more than 90%
of cases of acute viral hepatitis in the United States
(Buggs & Kim, 2006).
i. The Centers for Disease Control and Prevention (CDC)
reported 7,653 acute clinical cases of HAV in 2003, with
the estimate of actual clinical cases at 33,000 and
estimated number of new infections in the United States
at 61,000 (Gilroy & Mukherjee, 2006).
ii. About 1.25 million people are chronic HBV carriers,
and the disease causes about 5,000 deaths each year
(Mukherjee, 2005); 22,000 pregnant women in the
United States are infected with HBV and can transmit
the virus to their newborns.
iii. HCV is a leading cause of chronic hepatitis and cirrhosis
worldwide; studies have shown that almost 30% of
persons with human immunodeficiency virus (HIV)
infection also have hepatitis (Baker, 2007).
b. Mortality: Approximately 100 Americans die from HAV,
and another 5,000 die from cirrhosis and 1,000 from liver
cancer due to HBV infections (Buggs & Kim, 2006);
chronic liver disease associated with persistent hepatitis
virus infection accounts for an estimated 16,000 deaths
per year—70% from HCV, 20% from HBV, and 10% from
combined infection with HCV and HBV (Gilroy &
Mukherjee, 2006); fatality rate for hepatits E is 4%
(Schwartz et al, 2006).
c. Cost: Annual cost associated with HAV is estimated at
$200 million in the United States (Hepatitis Foundation
International [HFI], 2003).

Care Setting
Care can frequently be provided in the outpatient setting or
at the community level. In states of acute hepatic inflammation,
brief inpatient acute care on a medical unit may be
required to monitor and treat hepatic failure or hepatic
encephalopathy.

Related Concerns
Alcohol: acute withdrawal,
Cirrhosis of the liver,
Psychosocial aspects of care,
Renal dialysis—general considerations,
Substance dependence/abuse rehabilitation,
Total nutritional support: parenteral/enteral feeding,

Nursing Priorities
1. Reduce demands on liver while promoting physical wellbeing.
2. Prevent complications.
3. Enhance self-concept and acceptance of situation.
4. Provide information about disease process, prognosis, and
treatment needs.

Discharge Goals
1. Basic self-care needs are met.
2. Complications prevented or minimized.
3. Dealing with reality of current situation.
4. Disease process, prognosis, transmission, and therapeutic
regimen understood.
5. Plan in place to meet needs after discharge.

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