Tag Archives: nursing priorities

Nursing care plan total joint replacement

I. Purpose a. Definitive treatment for advanced, irreversibly damaged joints with loss of function and unremitting pain b. Commom conditions: degenerative and rheumatoid arthritis (RA); selected fractures, such as with hip and femoral neck; joint instability; congenital hip disorders; avascular … Continue reading

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Nursing care plan amputation

I. Pathophysiology—Partial or complete detachment of body part with residual extremity covered with well-vascularized muscle and skin, although reattachment surgery may be possible for fingers, hands, and arms a. Primarily two types of amputations i. Open or provisional: requires subsequent … Continue reading

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Nursing care plan fractures

I. Pathophysiology a. Discontinuity or break in a bone b. May be associated with serious injury to nerves, blood vessels, muscles, and/or organs c. More than 150 fracture classifications with five major types: incomplete, complete, closed, open, and pathologic II. … Continue reading

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Nursing care plan mastectomy

I. Purpose a. Removal of breast tissue due to presence of malignant or cancerous tumor changes b. Surgical procedures: dependent on tumor type, size, and location as well as clinical characteristics or staging i. Breast-conserving therapy ii. Lumpectomy iii. Partial … Continue reading

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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 … Continue reading

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Nursing care plan glaucoma

I. Pathophysiology a. Irreversible process in which the retinal ganglion cells—nerve cells in front of the optic nerve—die b. Death of retinal cells and degeneration or atrophy of the optic nerve fibers initially causes loss of peripheral vision, eventually leading … Continue reading

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Nursing care plan respiratory alkalosis

(PRIMARY CARBONIC ACID DEFICIT) I. Pathophysiology—acute or chronic increase in respiratory rate and volume, primarily triggered by hypoxemia or direct stimulation of the central respiratory center of the brain a. Acute: PaCO2 is below lower limit of normal, serum pH … Continue reading

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Nursing care plan respiratory acidosis

RESPIRATORY ACID-BASE IMBALANCES I. Pathophysiology—the body has the remarkable ability to maintain plasma pH within a narrow range of 7.35 to 7.45. a. Accomplished by chemical buffering mechanisms involving the lungs and kidneys i. Lungs compensate for acid-base imbalances resulting … Continue reading

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Nursing care plan pulmonary tuberculosis TB

I. Pathophysiology a. Bacterial infection by Mycobacterium tuberculosis bacilli (TB) i. Primarily affects the lungs (70% per Centers for Disease Control and Prevention [CDC], 2004) although it can invade other body systems ii. Airborne droplets are inhaled, with the droplet … Continue reading

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Nursing care plan ventilatory assistance

(MECHANICAL) I. Pathophysiology—impairment of respiratory function affecting O2 uptake and CO2 elimination, requiring mechanical assist to support or replace spontaneous breathing a. Inability to maintain adequate oxygenation (hypoxemia) b. Inability to maintain adequate ventilation due to apnea or alveolar hypoventilation … Continue reading

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Nursing care plan radical neck surgery

LARYNGECTOMY (POSTOPERATIVE CARE) I. Pathophysiology a. Malignancy lies above the clavicle, for instance lip, mouth, nasal cavity, paranasal sinuses, pharynx, larynx, but excludes the brain, spinal cord, axial skeleton, and vertebrae. b. Cancers limited to the vocal cords (intrinsic) tend … Continue reading

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Nursing care plan pneumothorax hemothorax

I. Pathophysiology a. Partial or complete collapse of lung due to accumulation of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) in the pleural space b. Intrathoracic pressure changes induced by increased pleural space volumes and reduced lung capacity, … Continue reading

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Nursing care plan lung cancer

Postoperative care I. Pathophysiology a. Usually develops within the wall or epithelium of the bronchial tree b. Prolonged exposure to cancer-promoting agents causes damage to ciliated cells and mucus-producing cells, leading to genetic mutations and development of dysplastic cells. II. … Continue reading

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Nursing care plan pneumonia

I. Pathophysiology a. Inflammation of the lung parenchyma associated with alveolar edema and congestion that impairs gas exchange b. Common pathogens i. Viruses 1. Common causative organisms include respiratory syncytial virus (RSV) and influenza 2. Accounts for approximately half of … Continue reading

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Nursing care plan chronic obstructive pulmonary disease

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND ASTHMA I. Pathophysiology a. Chronic obstructive pulmonary disease (COPD): chronic obstructive bronchitis and emphysema i. Chronic airflow limitations (CAL): caused by a mixture of small airway disease (obstructive bonchiolitis) and parenchymal destruction (emphysema) ii. … Continue reading

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Nursing care plan thrombophlebitis

DEEP VEIN THROMBOSIS (INCLUDING PULMONARY EMBOLI CONSIDERATIONS) I. Pathophysiology: Related to three factors known as the Virchow triad—stasis of blood flow, vessel wall injury, and alterations in the clotting mechanism. a. Mechanical (e.g., trauma, surgery) or physiological (e.g., hypertension, phlebitis) … Continue reading

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Nursing care plan cardiac surgery

POSTOPERATIVE CARE— CORONARY ARTERY BYPASS GRAFT (CABG), MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB), CARDIOMYOPLASTY, VALVE REPLACEMENT I. Purpose: to maximize cardiac output by improving blood flow and myocardial muscle function II. Types a. Reparative: closure of atrial or ventricular … Continue reading

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Nursing care plan dysrhytmias

I. Pathophysiology a. Abnormal formation or conduction of the electrical impulses within the heart i. Bradyarrhythmias: decreased intrinsic pacemaker function or block in conduction, often at atrioventricular (AV) junction or His-Purkinje system ii. Tachyarrhythmias: caused by reentry, often due to … Continue reading

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Nursing care plan Myocardial Infarction MI

MYOCARDIAL INFARCTION I. Pathophysiology a. Marked reduction or loss of blood flow through one or more of the coronary arteries, resulting in cardiac muscle ischemia, and over a finite period, resulting in necrosis b. Occurs most often due to coronary … Continue reading

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Nursing care plan angina CAD ACS

ANGINA (CORONARY ARTERY DISEASE, ACUTE CORONARY SYNDROME) I. Pathophysiology a. The disorder is characterized by a narrowing of coronary arteries due to atherosclerosis, spasm or, rarely, embolism. b. Atherosclerotic changes in coronary arteries results in damage to the inner layers … Continue reading

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