Urolithiasis may form anywhere in the urinary tract but usually develop in the renal pelvis or the calyces of the kidneys. This is a nursing care plan for a patient with urolithiasis (renal calculi) experiencing impaired urinary elimination.

Nursing Diagnosis:

• Urinary Elimination, impaired

May be related to

• Stimulation of the bladder by calculi, renal or ureteral irritation
• Mechanical obstruction, inflammation

Possibly evidenced by

• Urgency and frequency; oliguria (retention)
• Hematuria

Goals: 

• Void in normal amounts and usual pattern.
• Experience no signs of obstruction.

Urolithiasis Nursing Interventions for Impaired Urinary Elimination with Rationale

Nursing Diagnosis: Impaired Physical Mobility

May be related to

• Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization)
• Psychological immobility

Possibly evidenced by

• Inability to move purposefully within the physical environment, imposed restrictions
• Reluctance to attempt movement; limited ROM
• Decreased muscle strength/control

Desired Outcomes

• Regain/maintain mobility at the highest possible level.
• Maintain position of function.
• Increase strength/function of affected and compensatory body parts.
• Demonstrate techniques that enable resumption of activities.

This is an examination about the concepts of Psychiatric Nursing! This 50-item psychiatric nursing exam will help you review and challenge your nursing knowledge about Psychiatric Nursing. If you are taking the board examination or nurse licensure examination or even the NCLEX, then this practice exam is just right for you!

This is part 5 of 10 examinations.

Guidelines:

• Read each question carefully and choose the best answer.
• You are given 1 minute and 20 seconds for each question.
• Answers & Rationale are given below. Be sure to read them!

1. The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?

A. The client spends more time by himself.
B. The client doesn’t engage in delusional thinking.
C. The client doesn’t harm himself or others.
D. The client demonstrates the ability to meet his own self-care needs.

2. The nurse formulates a nursing diagnosis of Impaired verbal communication for a client with schizotypal personality disorder. Based on this nursing diagnosis, which nursing intervention is most appropriate?

A. Helping the client to participate in social interactions
B. Establishing a one-on-one relationship with the client
C. Establishing alternative forms of communication
D. Allowing the client to decide when he wants to participate in verbal communication with the nurse

3. Since admission 4 days ago, a client has refused to take a shower, stating, “There are poison crystals hidden in the showerhead. They’ll kill me if I take a shower.” Which nursing action is most appropriate?

A. Dismantling the showerhead and showing the client that there is nothing in it
B. Explaining that other clients are complaining about the client’s body odor
C. Asking a security officer to assist in giving the client a shower
D. Accepting these fears and allowing the client to take a sponge bath

4. Drug therapy with thioridazine (Mellaril) shouldn’t exceed a daily dose of 800 mg to prevent which adverse reaction?

A. Hypertension
B. Respiratory arrest
C. Tourette syndrome
D. Retinal pigmentation

5. A client with paranoid personality disorder is admitted to a psychiatric facility. Which remark by the nurse would best establish rapport and encourage the client to confide in the nurse?

A. “I get upset once in a while, too.”
B. “I know just how you feel. I’d feel the same way in your situation.”
C. “I worry, too, when I think people are talking about me.”
D. “At times, it’s normal not to trust anyone.”

6. How soon after chlorpromazine (Thorazine) administration should the nurse expect to see a client’s delusional thoughts and hallucinations eliminated?

A. Several minutes
B. Several hours
C. Several days
D. Several weeks

7. A client is about to be discharged with a prescription for the antipsychotic agent haloperidol (Haldol), 10 mg by mouth twice per day. During a discharge teaching session, the nurse should provide which instruction to the client?

A. Take the medication 1 hour before a meal.
B. Decrease the dosage if signs of illness decrease.
C. Apply a sunscreen before being exposed to the sun.
D. Increase the dosage up to 50 mg twice per day if signs of illness don’t decrease.

8. A client with paranoid schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be most appropriate?

A. “Your behavior won’t be tolerated. Go to your room immediately.”
B. “You’re just doing this to get back at me for making you come to therapy.”
C. “Your cursing is interrupting the activity. Take time out in your room for 10 minutes.”
D. “I’m disappointed in you. You can’t control yourself even for a few minutes.”

9. Which of the following is one of the advantages of the newer antipsychotic medication risperidone (Risperdal)?

A. The absence of anticholinergic effects
B. A lower incidence of extrapyramidal effects
C. Photosensitivity and sedation
D. No incidence of neuroleptic malignant syndrome

10. The etiology of schizophrenia is best described by:

A. genetics due to a faulty dopamine receptor.
B. environmental factors and poor parenting.
C. structural and neurobiological factors.
D. a combination of biological, psychological, and environmental factors.

11. A client with schizophrenia who receives fluphenazine (Prolixin) develops pseudoparkinsonism and akinesia. What drug would the nurse administer to minimize extrapyramidal symptoms?

A. benztropine (Cogentin)
B. dantrolene (Dantrium)
C. clonazepam (Klonopin)
D. diazepam (Valium)

12. A client with a diagnosis of paranoid schizophrenia comments tothe nurse, “How do I know what is really in those pills?” Which of the following is the best response?

A. Say, “You know it’s your medicine.”
B. Allow him to open the individual wrappers of the medication.
C. Say, “Don’t worry about what is in the pills. It’s what is ordered.”
D. Ignore the comment because it’s probably a joke.

13. A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be most therapeutic?

A. “That must be frightening to you. Can you tell me how you feel about it?”
B. “There are no people living on Mars.”
C. “What do you mean when you say they’re going to invade the earth?”
D. “I know you believe the earth is going to be invaded, but I don’t believe that.”

14. A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:

A. sit in a quiet, dark room and concentrate on the voices.
B. listen to a personal stereo through headphones and sing along with the music.
C. call a friend and discuss the voices and his feelings about them.
D. engage in strenuous exercise.

15. A client with schizophrenia is receiving antipsychotic medication. Which nursing diagnosis may be appropriate for this client?

A. Ineffective protection related to blood dyscrasias
B. Urinary frequency related to adverse effects of antipsychotic medication
C. Risk for injury related to a severely decreased level of consciousness
D. Risk for injury related to electrolyte disturbances

16. A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client’s speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?

A. Dystonia
B. Akathisia
C. Pseudoparkinsonism
D. Tardive dyskinesia

17. The nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in the client’s plan of care?

A. Meeting all of the client’s physical needs
B. Giving the client an opportunity to express concerns
C. Administering lithium carbonate (Lithonate) as prescribed
D. Providing a quiet environment where the client can be alone

18. A client with a history of medication noncompliance is receiving outpatient treatment for chronic undifferentiated schizophrenia. The physician is most likely to prescribe which medication for this client?

A. chlorpromazine (Thorazine)
B. imipramine (Tofranil)
C. lithium carbonate (Lithane)
D. fluphenazine decanoate (Prolixin Decanoate)

19. Propranolol (Inderal) is used in the mental health setting to manage which of the following conditions?

A. Antipsychotic-induced akathisia and anxiety
B. The manic phase of bipolar illness as a mood stabilizer
C. Delusions for clients suffering from schizophrenia
D. Obsessive-compulsive disorder (OCD) to reduce ritualistic behavior

20. Every day for the past 2 weeks, a client with schizophrenia stands up during group therapy and screams, “Get out of here right now! The elevator bombs are going to explode in 3 minutes!” The next time this happens, how should the nurse respond?

A. “Why do you think there is a bomb in the elevator?”
B. “That is the same thing you said in yesterday’s session.”
C. “I know you think there are bombs in the elevator, but there aren’t.”
D. “If you have something to say, you must do it according to our group rules.”

21. A 26-year-old client is admitted to the psychiatric unit with acute onset of schizophrenia. His physician prescribes the phenothiazine chlorpromazine (Thorazine), 100 mg by mouth four times per day. Before administering the drug, the nurse reviews the client’s medication history. Concomitant use of which drug is likely to increase the risk of extrapyramidal effects?

A. guanethidine (Ismelin)
B. droperidol (Inapsine)
C. lithium carbonate (Lithonate)
D. alcohol

22. A client, age 36, with paranoid schizophrenia believes the room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn’t been employed in the last 14 years. Based on Erikson’s theories, the nurse should recognize that this client is in which stage of psychosocial development?

A. Autonomy versus shame and doubt
B. Generativity versus stagnation
C. Integrity versus despair
D. Trust versus mistrust

23. During a group therapy session in the psychiatric unit, a client constantly interrupts with impulsive behavior and exaggerated stories that cast her as a hero or princess. She also manipulates the group with attention-seeking behaviors, such as sexual comments and angry outbursts. The nurse realizes that these behaviors are typical of:

A. paranoid personality disorder.
B. avoidant personality disorder.
C. histrionic personality disorder.
D. borderline personality disorder.

24. The nurse is teaching a psychiatric client about her prescribed drugs, chlorpromazine and benztropine. Why is benztropine administered?

A. To reduce psychotic symptoms
B. To reduce extrapyramidal symptoms
C. To control nausea and vomiting
D. To relieve anxiety

25. A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis. Her physician prescribes the phenothiazine thioridazine (Mellaril) 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:

A. deeper sleep than CNS depressants.
B. greater sedation than CNS depressants.
C. a calming effect from which the client is easily aroused.
D. more prolonged sedative effects, making the client more difficult to arouse.

26. A woman is admitted to the psychiatric emergency department. Her significant other reports that she has difficulty sleeping, has poor judgment, and is incoherent at times. The client’s speech is rapid and loose. She reports being a special messenger from the Messiah. She has a history of depressed mood for which she has been taking an antidepressant. The nurse suspects which diagnosis?

A. Schizophrenia
B. Paranoid personality
C. Bipolar illness
D. Obsessive-compulsive disorder (OCD)

27. A client with paranoid schizophrenia is admitted to the psychiatric unit of a hospital. Nursing assessment should include careful observation of the client’s:

A. thinking, perceiving, and decision-making skills.
B. verbal and nonverbal communication processes.
C. affect and behavior.
D. psychomotor activity.

28. Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)?

A. Monthly blood tests will be necessary.
B. Report a sore throat or fever to the physician immediately.
C. Blood pressure must be monitored for hypertension.
D. Stop the medication when symptoms subside.

29. Important teaching for clients receiving antipsychotic medication such as haloperidol (Haldol) includes which of the following instructions?

A. Use sunscreen because of photosensitivity.
B. Take the antipsychotic medication with food.
C. Have routine blood tests to determine levels of the medication.
D. Abstain from eating aged cheese.

30. Positive symptoms of schizophrenia include which of the following?

A. Hallucinations, delusions, and disorganized thinking
B. Somatic delusions, echolalia, and a flat affect
C. Waxy flexibility, alogia, and apathy
D. Flat affect, avolition, and anhedonia

31. A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate (Prolixin Decanoate) by I.M. injection. Three days later, the client has muscle contractions that contort the neck. This client is exhibiting which extrapyramidal reaction?

A. Dystonia
B. Akinesia
C. Akathisia
D. Tardive dyskinesia

32. Hormonal effects of the antipsychotic medications include which of the following?

A. Retrograde ejaculation and gynecomastia
B. Dysmenorrhea and increased vaginal bleeding
C. Polydipsia and dysmenorrhea
D. Akinesia and dysphasia

33. A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior?

A. Word salad
B. Tangential
C. Perseveration
D. Avolition

34. An agitated and incoherent client, age 29, comes to the emergency department with complaints of visual and auditory hallucinations. The history reveals that the client was hospitalized for paranoid schizophrenia from ages 20 to 21. The physician prescribes haloperidol (Haldol), 5 mg I.M. The nurse understands that this drug is used in this client to treat:

A. dyskinesia.
B. dementia.
C. psychosis.
D. tardive dyskinesia.

35. Yesterday, a client with schizophrenia began treatment with haloperidol (Haldol). Today, the nurse notices that the client is holding his head to one side and complaining of neck and jaw spasms. What should the nurse do?

A. Assume that the client is posturing.
B. Tell the client to lie down and relax.
C. Evaluate the client for adverse reactions to haloperidol.
D. Put the client on the list for the physician to see tomorrow.

36. A client receiving fluphenazine decanoate (Prolixin Decanoate) therapy develops pseudoparkinsonism. The physician is likely to prescribe which drug to control this extrapyramidal effect?

A. phenytoin (Dilantin)
B. amantadine (Symmetrel)
C. benztropine (Cogentin)
D. diphenhydramine (Benadryl)

37. Important teaching for a client receiving risperidone (Risperdal) would include advising the client to:

A. double the dose if missed to maintain a therapeutic level.
B. be sure to take the drug with a meal because it’s very irritating to the stomach.
C. discontinue the drug if the client reports weight gain.
D. notify the physician if the client notices an increase in bruising.

38. A client is admitted to the psychiatric hospital with a diagnosis of catatonic schizophrenia. During the physical examination, the client’s arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. This client is exhibiting:

A. suggestibility.
B. negativity.
C. waxy flexibility.
D. retardation.

39. A client with borderline personality disorder becomes angry when he is told that today’s psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be most helpful in dealing with the client’s anger?

A. “If it had been your emergency, I would have made the other client wait.”
B. “I know it’s frustrating to wait. I’m sorry this happened.”
C. “You had to wait. Can we talk about how this is making you feel right now?”
D. “I really care about you and I’ll never let this happen again.”

40. A client begins clozapine (Clozaril) therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

A. Hepatitis
B. Infection
C. Granulocytopenia
D. Systemic dermatitis

41. Which nonantipsychotic medication is used to treat some clients with schizoaffective disorder?

A. phenelzine (Nardil)
B. chlordiazepoxide (Librium)
C. lithium carbonate (Lithane)
D. imipramine (Tofranil)

42. A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the following disorders?

A. Personality disorder
B. Mood disorder
C. Thought disorder
D. Amnestic disorder

43. When teaching the family of a client with schizophrenia, the nurse should provide which information?

A. Relapse can be prevented if the client takes the medication.
B. Support is available to help family members meet their own needs.
C. Improvement should occur if the client has a stimulating environment.
D. Stressful family situations can precipitate a relapse in the client.

44. A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other
conditions. Schizophrenia is characterized by:

A. loss of identity and self-esteem.
B. multiple personalities and decreased self-esteem.
C. disturbances in affect, perception, and thought content and form.
D. persistent memory impairment and confusion.

45. The nurse is providing care to a client with a catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:

A. ask the client which activity he would prefer to do first.
B. negotiate a time when the client will perform activities.
C. tell the client specifically and concisely what needs to be done.
D. prepare the client ahead of time for the activity.

46. The nurse is caring for a client who experiences false sensory perceptions with no basis in reality. These perceptions are known as:

A. delusions.
B. hallucinations.
C. loose associations.
D. neologisms.

47. The nurse is aware that antipsychotic medications may cause which of the following adverse effects?

A. Increased production of insulin
B. Lower seizure threshold
C. Increased coagulation time
D. Increased risk of heart failure

48. A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects a belief that one is:

A. highly important or famous.
B. being persecuted.
C. connected to events unrelated to oneself.
D. responsible for the evil in the world.

49. A man with a 5-year history of multiple psychiatric admissions is brought to the emergency department by the police. He was found wandering the streets disheveled, shoeless, and confused. Based on his previous medical records and current behavior, he is diagnosed with chronic undifferentiated schizophrenia. The nurse should assign highest priority to which nursing diagnosis?

A. Anxiety
B. Impaired verbal communication
C. Disturbed thought processes
D. Self-care deficient: Dressing/grooming

50. A client’s medication order reads, “Thioridazine (Mellaril) 200 mg P.O. q.i.d. and 100 mg P.O. p.r.n.” The nurse should:

A. administer the medication as prescribed.
B. question the physician about the order.
C. administer the order for 200 mg P.O. q.i.d. but not for 100 mg P.O. p.r.n.
D. administer the medication as prescribed but observe the client closely for adverse effects.

NURSING DIAGNOSIS: Urinary Elimination, impaired/Urinary Retention [acute]

May be related to

• Mechanical trauma, surgical manipulation, presence of local tissue edema, hematoma
• Sensory/motor impairment: nerve paralysis

Possibly evidenced by

• Sensation of bladder fullness, urgency
• Small, frequent voiding or absence of urinary output
• Overflow incontinence
• Bladder distension

Desired Outcomes

Urinary Elimination (NOC)

• Empty bladder regularly and completely.

Impaired Urinary Elimination — Hysterectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to

• Lack of exposure/recall
• Information misinterpretation
• Unfamiliarity with information resources

Possibly evidenced by

• Questions/request for information; statement of misconception
• Inaccurate follow-through of instructions, development of preventable complications

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

Knowledge: Disease Process (NOC)

• Verbalize understanding of condition and potential complications.
• Identify relationship of signs/symptoms related to surgical procedure and actions to deal with them.

Knowledge: Treatment Regimen (NOC)

• Verbalize understanding of therapeutic needs.

Knowledge Deficit — Hysterectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale

Definition

Hysterectomy is the surgical removal of the uterus, most commonly performed for malignancies and certain non malignant conditions (e.g., endometriosis/tumors), to control life-threatening bleeding/hemorrhage, and in the event of intractable pelvic infection or irreparable rupture of the uterus. A less radical procedure (myomectomy) is sometimes performed for removing fibroids while sparing the uterus.

Types

Subtotal (partial): Body of the uterus is removed; cervical stump remains.

Total: Removal of the uterus and cervix.

Total with bilateral salpingo-oophorectomy (TAHBSO): Removal of uterus, cervix, fallopian tubes, and ovaries is the treatment of choice for invasive cancer (11% of hysterectomies), fibroid tumors that are rapidly growing or produce severe abnormal bleeding (about one-third of all hysterectomies), and endometriosis invading other pelvic organs.

Vaginal hysterectomy or laparoscopically assisted vaginal hysterectomy (LAVH) may be done in certain conditions, such as uterine prolapse, cystocele/rectocele, carcinoma in situ, and high-risk obesity. These procedures offer the advantages of less pain, no visible (or much smaller) scars, and a shorter hospital stay and about half the recovery time, but are contraindicated if the diagnosis is obscure.

A very complex and aggressive surgical procedure may be required to treat invasive cervical cancer. Total pelvis exenteration (TPE) involves radical hysterectomy with dissection of pelvic lymph nodes and bilateral salpingo-oophorectomy, total cystectomy, and abdominoperineal resection of the rectum. A colostomy and/or a urinary conduit are created, and vaginal reconstruction may or may not be performed. These patients require intensive care during the initial postoperative period. (Refer to additional plans of care regarding fecal or urinary diversion as appropriate.)

Diagnostic Studies

• Pelvic examination: May reveal uterine/other pelvic organ irregularities, such as masses, tender nodules, visual changes of cervix, requiring further diagnostic evaluation.
• Pap smear: Cellular dysplasia reflects possibility of/presence of cancer.
• Ultrasound or computed tomography (CT) scan: Aids in identifying size/location of pelvic mass.
• Laparoscopy: Done to visualize tumors, bleeding, known or suspected endometriosis. Biopsy may be performed or laser treatment for endometriosis. Rarely, exploratory laparotomy may be done for staging cancer or to assess effects of chemotherapy.
• Dilation and curettage (D&C) with biopsy (endometrial/cervical): Permits histopathological study of cells to determine presence/ location of cancer.
• Schiller’s test (staining of cervix with iodine): Useful in identifying abnormal cells.
• Complete blood count (CBC): Decreased hemoglobin (Hb) may reflect chronic anemia, whereas decreased hematocrit (Hct) suggests active blood loss. Elevated white blood cell (WBC) count may indicate inflammation/infectious process.
• Sexually transmitted disease (STD) screen: Human papillomavirus (HPV) is present in 80% of patients with cervical cancer

Nursing Care Plans

Listed Below are 6 Hysterectomy Nursing Care Plan (NCP)

Low Self-Esteem

May be related to

• Concerns about inability to have children, changes in femininity, effect on sexual relationship
• Religious conflicts

Possibly evidenced by

• Expressions of specific concerns/vague comments about result of surgery; fear of rejection or reaction of significant other (SO)
• Withdrawal, depression

Desired Outcomes

• Verbalize concerns and indicate healthy ways of dealing with them.
• Verbalize acceptance of self in situation and adaptation to change in body/self-image.

Impaired Urinary Elimination

May be related to

• Mechanical trauma, surgical manipulation, presence of local tissue edema, hematoma
• Sensory/motor impairment: nerve paralysis

Possibly evidenced by

• Sensation of bladder fullness, urgency
• Small, frequent voiding or absence of urinary output
• Overflow incontinence
• Bladder distension

Desired Outcomes

• Empty bladder regularly and completely.

Constipation/Diarrhea

Risk factors may include

• Physical factors: abdominal surgery, with manipulation of bowel, weakening of abdominal musculature
• Pain/discomfort in abdomen or perineal area
• Changes in dietary intake

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Display active bowel sounds/peristaltic activity.
• Maintain usual pattern of elimination.

Ineffective Tissue Perfusion

Risk factors may include

• Hypovolemia
• Reduction/interruption of blood flow: pelvic congestion, postoperative tissue inflammation, venous stasis
• Intraoperative trauma or pressure on pelvic/calf vessels: lithotomy position during vaginal hysterectomy

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Demonstrate adequate perfusion, as evidenced by stable vital signs, palpable pulses, good capillary refill, usual mentation, individually adequate ­urinary output.
• Be free of edema, signs of thrombus formation.

Sexual Dysfunction

Risk factors may include

• Altered body structure/function, e.g., shortening of vaginal canal; changes in hormone levels, decreased libido
• Possible change in sexual response pattern, e.g., absence of rhythmic uterine contractions during orgasm; vaginal discomfort/pain (dyspareunia)

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Verbalize understanding of changes in sexual anatomy/function.
• Discuss concerns about body image, sex role, desirability as a sexual partner with SO.
• Identify satisfying/acceptable sexual practices and some alternative ways of dealing with sexual expression.

Knowledge Deficit

May be related to

• Lack of exposure/recall
• Information misinterpretation
• Unfamiliarity with information resources

Possibly evidenced by

• Questions/request for information; statement of misconception
• Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

• Verbalize understanding of condition and potential complications.
• Identify relationship of signs/symptoms related to surgical procedure and actions to deal with them.
• Verbalize understanding of therapeutic needs.

Additional Diagnoses

nursing care plan for endometrial cancer, vaginal bleeding ncp, impaired urinary elimation goals for home long and short yerm, nursing care plane of laparotomy, nursing care plan for low hemoglobin and hematocrit, nursing care plan for laparotomy, nursing care plan for exploratory laparotomy

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Definition

Cancer is a general term used to describe a disturbance of cellular growth and refers to a group of diseases and not a single disease entity. There are currently more than 150 different known types of cancer. Because cancer is a cellular disease, it can arise from any body tissue, with manifestations that result from failure to control the proliferation and maturation of cells.

Diagnostic Studies

Test selection depends on history, clinical manifestations, and index of suspicion for a particular cancer.

• Endoscopy: Used for direct visualization of body organs/cavities to detect abnormalities.
• Scans (e.g., magnetic resonance imaging [MRI], CT, gallium) and ultrasound: May be done for diagnostic purposes, identification of metastasis, and evaluation of response to treatment.
• Biopsy (fine-needle aspiration [FNA], needle core, incisional/excisional): Done to differentiate diagnosis and delineate treatment and may be taken from bone marrow, skin, organ, and so forth. Example: Bone marrow is done in myeloproliferative diseases for diagnosis; in solid tumors for staging.
• Tumor markers (substances produced and secreted by tumor cells and found in serum, e.g., carcinogenic embryonic antigen [CEA], prostate-specific antigen [PSA], alpha-fetoprotein, human chorionic gonadotropin [HCG], prostatic acid phosphatase, calcitonin, pancreatic oncofetal antigen, CA 15-3, CA 19-9, CA 125, and so on): Helpful in diagnosing cancer but more useful as prognostic indicator and/or therapeutic monitor. For example, estrogen and progesterone receptors are assays done on breast tissue to provide information about whether or not hormonal manipulation would be therapeutic in metastatic disease control. Note: Any hormone may be elevated because many cancers secrete inappropriate hormones (ectopic hormone secretion).
• Screening chemistry tests, e.g., electrolytes (sodium, potassium, calcium), renal tests (BUN/Cr), liver tests (bilirubin, AST, alkaline phosphatase, LDH), bone tests (calcium):Depend on individual condition, risk factors.
• CBC with differential and platelets: May reveal anemia, changes in RBCs and WBCs; reduced or increased platelets.
• Chest x-ray: Screens for primary or metastatic disease of lungs.

Nursing Priorities

1. Support adaptation and independence.
2. Promote comfort.
3. Maintain optimal physiological functioning.
4. Prevent complications.
5. Provide information about disease process/condition, prognosis, and treatment needs.

Discharge Goals

1. Patient is dealing with current situation realistically.
2. Pain alleviated/controlled.
3. Homeostasis achieved.
4. Complications prevented/minimized.
5. Disease process/condition, prognosis, and therapeutic choices and regimen understood.
6. Plan in place to meet needs after discharge.

Nursing Care Plans

Anticipatory Grieving

May be related to:

• Anticipated loss of physiological well-being (e.g., loss of body part; change in body function); change in lifestyle
• Perceived potential death of patient

Possibly evidenced by:

• Changes in eating habits, alterations in sleep patterns, activity levels, libido, and communication patterns
• Denial of potential loss, choked feelings, anger

Desired Outcomes:

• Identify and express feelings appropriately.
• Continue normal life activities, looking toward/planning for the future, one day at a time.
• Verbalize understanding of the dying process and feelings of being supported in grief work.

Situational Low Self-Esteem

May be related to

• Biophysical: disfiguring surgery, chemotherapy or radiotherapy side effects, e.g., loss of hair, nausea/vomiting, weight loss, anorexia, impotence, sterility, overwhelming fatigue, uncontrolled pain
• Psychosocial: threat of death; feelings of lack of control and doubt regarding acceptance by others; fear and anxiety

Possibly evidenced by

• Verbalization of change in lifestyle; fear of rejection/reaction of others; negative feelings about body; feelings of helplessness, hopelessness, powerlessness
• Preoccupation with change or loss
• Not taking responsibility for self-care, lack of follow-through
• Change in self-perception/other’s perception of role

Desired Outcomes

• Verbalize understanding of body changes, acceptance of self in situation.
• Begin to develop coping mechanisms to deal effectively with problems.
• Demonstrate adaptation to changes/events that have occurred as evidenced by setting of realistic goals and active participation in work/play/personal relationships as appropriate.

Acute Pain

May be related to

• Disease process (compression/destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation)
• Side effects of various cancer therapy agents

Possibly evidenced by

• Reports of pain
• Self-focusing/narrowed focus
• Alteration in muscle tone; facial mask of pain
• Distraction/guarding behaviors
• Autonomic responses, restlessness (acute pain)

Desired Outcomes

• Report maximal pain relief/control with minimal interference with ADLs.
• Follow prescribed pharmacological regimen.
• Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Altered Nutrition: Less Than Body Requirements

May be related to

• Hypermetabolic state associated with cancer
• Consequences of chemotherapy, radiation, surgery, e.g., anorexia, gastric irritation, taste distortions, nausea
• Emotional distress, fatigue, poorly controlled pain

Possibly evidenced by

• Reported inadequate food intake, altered taste sensation, loss of interest in food, perceived/actual inability to ingest food
• Body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle mass
• Sore, inflamed buccal cavity
• Diarrhea and/or constipation, abdominal cramping

Desired Outcomes

• Demonstrate stable weight/progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
• Verbalize understanding of individual interferences to adequate intake.
• Participate in specific interventions to stimulate appetite/increase dietary intake.

Risk for Fluid Volume Deficit

Risk factors may include

• Excessive losses through normal routes (e.g., vomiting, diarrhea) and/or abnormal routes (e.g., indwelling tubes, wounds)
• Hypermetabolic state
• Impaired intake of fluids

Desired Outcomes

• Display adequate fluid balance as evidenced by stable vital signs, moist mucous membranes, good skin turgor, prompt capillary refill, and individually adequate urinary output.

Fatigue

May be related to

• Decreased metabolic energy production, increased energy requirements (hypermetabolic state and effects of treatment)
• Overwhelming psychological/emotional demands
• Altered body chemistry: side effects of pain and other medications, chemotherapy

Possibly evidenced by

• Unremitting/overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to concentrate, lethargy/listlessness
• Disinterest in surroundings

Desired Outcomes

• Report improved sense of energy.
• Perform ADLs and participate in desired activities at level of ability.

Risk for Infection

Risk factors may include

• Inadequate secondary defenses and immunosuppression, e.g., bone marrow suppression (dose-limiting side effect of both chemotherapy and radiation).
• Malnutrition, chronic disease process
• Invasive procedures

Desired Outcomes

• Remain afebrile and achieve timely healing as appropriate.
• Identify and participate in interventions to prevent/reduce risk of infection.

Risk for Altered Oral Mucous Membranes

Risk factors may include

• Side effect of some chemotherapeutic agents (e.g., antimetabolites) and radiation
• Dehydration, malnutrition, NPO restrictions for more than 24 hr

Desired Outcomes

• Display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
• Verbalize understanding of causative factors.
• Demonstrate techniques to maintain/restore integrity of oral mucosa.

Risk for Impaired Skin Integrity

Risk factors may include

• Effects of radiation and chemotherapy
• Immunologic deficit
• Altered nutritional state, anemia

Desired Outcomes

• Identify interventions appropriate for specific condition.
• Participate in techniques to prevent complications/promote healing as appropriate.

Risk for Constipation/Diarrhea

Risk factors may include

• Irritation of the GI mucosa from either chemotherapy or radiation therapy; malabsorption of fat
• Hormone-secreting tumor, carcinoma of colon
• Poor fluid intake, low-bulk diet, lack of exercise, use of opiates/narcotics

Desired Outcomes

• Maintain usual bowel consistency/pattern.
• Verbalize understanding of factors and appropriate interventions/solutions related to individual situation.

Risk for Altered Sexuality Patterns

Risk factors may include

• Knowledge/skill deficit about alternative responses to health-related transitions, altered body function/
• structure, illness, and medical treatment
• Overwhelming fatigue
• Fear and anxiety
• Lack of privacy/SO

Desired Outcomes

• Verbalize understanding of effects of cancer and therapeutic regimen on sexuality and measures to correct/
• deal with problems.
• Maintain sexual activity at a desired level as possible.

Risk for Altered Family Process

Risk factors may include

• Situational/transitional crises: long-term illness, change in roles/economic status
• Developmental: anticipated loss of a family member

Desired Outcomes

• Express feelings freely.
• Demonstrate individual involvement in problem-solving process directed at appropriate solutions for the situation.
• Encourage and allow member who is ill to handle situation in own way.

Fear/Anxiety

May be related to:

• Situational crisis (cancer)
• Threat to/change in health/socioeconomic status, role functioning, interaction patterns
• Threat of death
• Separation from family (hospitalization, treatments), interpersonal transmission/contagion of feelings

Possibly evidenced by:

• Increased tension, shakiness, apprehension, restlessness, insomnia
• Expressed concerns regarding changes in life events
• Feelings of helplessness, hopelessness, inadequacy
• Sympathetic stimulation, somatic complaints

Desired Outcomes: 

• Display appropriate range of feelings and lessened fear.
• Appear relaxed and report anxiety is reduced to a manageable level.
• Demonstrate use of effective coping mechanisms and active participation in treatment regimen.

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Definition

Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces. This leads to an increased concentration of glucose in the blood (hyperglycaemia).

Types

• Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) is characterized by a lack of insulin production.
• Type 2 diabetes (formerly called non-insulin-dependent or adult-onset diabetes) is caused by the body’s ineffective use of insulin. It often results from excess body weight and physical inactivity.
• Gestational diabetes is hyperglycaemia that is first recognized during pregnancy.

Statistics

Diabetes affects 18% of people over the age of 65, and approximately 625,000 new cases of diabetes are diagnosed annually in the general population. Conditions or situations known to exacerbate glucose/insulin imbalance include (1) previously undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in excess of available insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5) stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a life-threatening emergency caused by a relative or absolute deficiency of insulin.

Nursing Priorities

1. Restore fluid/electrolyte and acid-base balance.
2. Correct/reverse metabolic abnormalities.
3. Identify/assist with management of underlying cause/disease process.
4. Prevent complications.
5. Provide information about disease process/prognosis, self-care, and treatment needs.

Discharge Goals

1. Homeostasis achieved.
2. Causative/precipitating factors corrected/controlled.
3. Complications prevented/minimized.
4. Disease process/prognosis, self-care needs, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

Diagnostic Studies

• Serum glucose: Increased 200–1000 mg/dL or more.
• Serum acetone (ketones): Strongly positive.
• Fatty acids: Lipids, triglycerides, and cholesterol level elevated.
• Serum osmolality: Elevated but usually less than 330 mOsm/L.
• Glucagon: Elevated level is associated with conditions that produce (1) actual hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack of insulin. Therefore, glucagon may be elevated with severe DKA despite hyperglycemia.
• Glycosylated hemoglobin (HbA_1C): Evaluates glucose control during past 8–12 wk with the previous 2 wk most heavily weighted. Useful in differentiating inadequate control versus incident-related DKA (e.g., current upper respiratory infection [URI]). A result greater than 8% represents an average blood glucose of 200 mg/dL and signals a need for changes in treatment.
• Serum insulin: May be decreased/absent (type 1) or normal to high (type 2), indicating insulin insufficiency/improper utilization (endogenous/exogenous). Insulin resistance may develop secondary to formation of antibodies.
• Electrolytes:
• Sodium: May be normal, elevated, or decreased.
• Potassium: Normal or falsely elevated (cellular shifts), then markedly decreased.
• Phosphorus: Frequently decreased.
• Arterial blood gases (ABGs): Usually reflects low pH and decreased HCO₃ (metabolic acidosis) with compensatory respiratory alkalosis.
• CBC: Hct may be elevated (dehydration); leukocytosis suggest hemoconcentration, response to stress or infection.
• BUN: May be normal or elevated (dehydration/decreased renal perfusion).
• Serum amylase: May be elevated, indicating acute pancreatitis as cause of DKA.
• Thyroid function tests: Increased thyroid activity can increase blood glucose and insulin needs.
• Urine: Positive for glucose and ketones; specific gravity and osmolality may be elevated.
• Cultures and sensitivities: Possible UTI, respiratory or wound infections.

Nursing Care Plans

This post contains 6 diabetes mellitus Nursing Care Plan (NCP)

Risk for Infection

Nursing Diagnosis:  Risk for Infection

Risk factors may include:

• High glucose levels, decreased leukocyte function, alterations in circulation
• Preexisting respiratory infection, or UTI

Desired Outcomes:

• Identify interventions to prevent/reduce risk of infection.
• Demonstrate techniques, lifestyle changes to prevent development of infection.

Risk for Disturbed Sensory Perception

Nursing Diagnosis: Sensory Perception, risk for disturbed (specify)

Risk factors may include

• Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance

Desired Outcomes

• Maintain usual level of mentation.
• Recognize and compensate for existing sensory impairments.

Powerlessness

Nursing Diagnosis: Powerlessness

May be related to

• Long-term/progressive illness that is not curable
• Dependence on others

Possibly evidenced by

• Reluctance to express true feelings; expressions of having no control/influence over situation
• Apathy, withdrawal, anger
• Does not monitor progress, nonparticipation in care/decision making
• Depression over physical deterioration/complications despite patient cooperation with regimen

Desired Outcomes: 

• Acknowledge feelings of helplessness.
• Identify healthy ways to deal with feelings.
• Assist in planning own care and independently take responsibility for self-care activities.

Imbalanced Nutrition Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements

May be related to:

• Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism)
• Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness
• Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process

Possibly evidenced by:

• Increased urinary output, dilute urine
• Reported inadequate food intake, lack of interest in food
• Recent weight loss; weakness, fatigue, poor muscle tone
• Diarrhea
• Increased ketones (end product of fat metabolism)

Desired Outcomes: 

• Ingest appropriate amounts of calories/nutrients.
• Display usual energy level.
• Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.

Deficient Fluid Volume

Nursing Diagnosis: Deficient Fluid Volume

May be related to

• Osmotic diuresis (from hyperglycemia)
• Excessive gastric losses: diarrhea, vomiting
• Restricted intake: nausea, confusion

Possibly evidenced by:

• Increased urinary output, dilute urine
• Weakness; thirst; sudden weight loss
• Dry skin/mucous membranes, poor skin turgor
• Hypotension, tachycardia, delayed capillary refill

Desired Outcomes:

• Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal range.

Fatigue

Nursing Diagnosis:  Risk for Infection

Risk factors may include:

• High glucose levels, decreased leukocyte function, alterations in circulation
• Preexisting respiratory infection, or UTI

Desired Outcomes:

• Identify interventions to prevent/reduce risk of infection.
• Demonstrate techniques, lifestyle changes to prevent development of infection.

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Definitions

An ileostomy is an opening constructed in the terminal ileum to treat regional and ulcerative colitis and to divert intestinal contents in colon cancer, polyps, and trauma. It is usually done when the entire colon, rectum, and anus must be removed, in which case the ileostomy is permanent. A temporary ileostomy is done to provide complete bowel rest in conditions such as chronic colitis and in some trauma cases.

A colostomy is a diversion of the effluent of the colon and may be temporary or permanent. Ascending, transverse, and sigmoid colostomies may be performed. Transverse colostomy is usually temporary. A sigmoid colostomy is the most common permanent stoma, usually performed for cancer treatment.

Nursing Priorities

1. Assist patient/SO in psychosocial adjustment.
2. Prevent complications.
3. Support independence in self-care.
4. Provide information about procedure/prognosis, treatment needs, potential complications, and community resources.

Discharge Goals

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

Nursing Care Plans

Here are 10 nursing care plans for fecal diversions: colostomy and ileostomy nursing care plans.

Risk for Impaired Skin Integrity

NURSING DIAGNOSIS: Skin Integrity, risk for impaired

Risk factors may include

• Absence of sphincter at stoma
• Character/flow of effluent and flatus from stoma
• Reaction to product/chemicals; improper fitting/care of appliance/skin

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Maintain skin integrity around stoma.
• Identify individual risk factors.
• Demonstrate behaviors/techniques to promote healing/prevent skin breakdown.

Disturbed Body Image

NURSING DIAGNOSIS: Body Image, disturbed

May be related to

• Biophysical: presence of stoma; loss of control of bowel elimination
• Psychosocial: altered body structure
• Disease process and associated treatment regimen, e.g., cancer, colitis

Possibly evidenced by

• Verbalization of change in body image, fear of rejection/reaction of others, and negative feelings about body
• Actual change in structure and/or function (ostomy)
• Not touching/looking at stoma, refusal to participate in care

Desired Outcomes

• Verbalize acceptance of self in situation, incorporating change into self-concept without negating self-esteem.
• Demonstrate beginning acceptance by viewing/touching stoma and participating in self-care.
• Verbalize feelings about stoma/illness; begin to deal constructively with situation.

Acute Pain

NURSING DIAGNOSIS: Pain, acute

May be related to

• Physical factors: e.g., disruption of skin/tissues (incisions/drains)
• Biological: activity of disease process (cancer, trauma)
• Psychological factors: e.g., fear, anxiety

Possibly evidenced by

• Reports of pain, self-focusing
• Guarding/distraction behaviors, restlessness
• Autonomic responses, e.g., changes in vital signs

Desired Outcomes

• Verbalize that pain is relieved/controlled.
• Display relief of pain, able to sleep/rest appropriately
• Demonstrate use of relaxation skills and general comfort measures as indicated for individual situation.

Impaired Skin Integrity

NURSING DIAGNOSIS: Skin/Tissue Integrity, impaired

May be related to

• Invasion of body structure (e.g., perineal resection)
• Stasis of secretions/drainage
• Altered circulation, edema; malnutrition

Possibly evidenced by

• Disruption of skin/tissue: presence of incision and sutures, drains

Desired Outcomes

• Achieve timely wound healing free of signs of infection.

Deficient Fluid Volume

NURSING DIAGNOSIS: Fluid Volume, risk for deficient

Risk factors may include

• Excessive losses through normal routes, e.g., preoperative emesis and diarrhea; high-volume ileostomy output
• Losses through abnormal routes, e.g., NG/intestinal tube, perineal wound drainage tubes
• Medically restricted intake
• Altered absorption of fluid, e.g., loss of colon function
• Hypermetabolic states, e.g., inflammation, healing process

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Maintain adequate hydration as evidenced by moist mucous membranes, good skin turgor and capillary refill, stable vital signs, and individually appropriate urinary output.

Imbalanced Nutrition

NURSING DIAGNOSIS: Nutrition: imbalanced, risk for less than body requirements

Risk factors may include

• Prolonged anorexia/altered intake preoperatively
• Hypermetabolic state (preoperative inflammatory disease; healing process)
• Presence of diarrhea/altered absorption
• Restriction of bulk and residue-containing foods

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Maintain weight/demonstrate progressive weight gain toward goal with normalization of laboratory values and be free of signs of malnutrition.
• Plan diet to meet nutritional needs/limit GI disturbances.

Sexual Dysfunction

NURSING DIAGNOSIS: Sexual Dysfunction, risk for

Risk factors may include

• Altered body structure/function; radical resection/treatment procedures
• Vulnerability/psychological concern about response of SO
• Disruption of sexual response pattern, e.g., erectile difficulty

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:

• Verbalize understanding of relationship of physical condition to sexual problems.
• Identify satisfying/acceptable sexual practices and explore alternative methods.
• Resume sexual relationship as appropriate.

Disturbed Sleep Pattern

NURSING DIAGNOSIS: Sleep Pattern, disturbed

May be related to

• External factors: necessity of ostomy care, excessive flatus/ostomy effluent
• Internal factors: psychological stress, fear of leakage of pouch/injury to stoma

Possibly evidenced by

• Verbalizations of interrupted sleep, not feeling well rested
• Changes in behavior, e.g., irritability, listlessness/lethargy

Desired Outcomes

• Sleep/rest between disturbances.
• Report increased sense of well-being and feeling rested.

Constipation/Diarrhea

NURSING DIAGNOSIS: Constipation/Diarrhea, risk for

Risk factors may include

• Placement of ostomy in descending or sigmoid colon
• Inadequate diet/fluid intake

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Establish an elimination pattern suitable to physical needs and lifestyle with effluent of appropriate amount and consistency.

Knowledge Deficit

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to

• Lack of exposure/recall information misinterpretation
• Unfamiliarity with information resources

Possibly evidenced by

• Questions; statement of misconception/misinformation
• Inaccurate follow-through of instruction/performance of ostomy care
• Inappropriate or exaggerated behaviors (e.g., hostile, agitated, apathetic, withdrawal)

Desired Outcomes

• Verbalize understanding of condition/disease process, prognosis, and potential complications.

• Verbalize understanding of therapeutic needs.
• Correctly perform necessary procedures, explain reasons for the action.
• Initiate necessary lifestyle changes.

Other Nursing Care Plans

1. Skin Integrity, risk for impaired—absence of sphincter at stoma, character/flow of effluent and flatus from stoma.
2. Coping, ineffective—situational crises, vulnerability.
3. Social Interaction, impaired—self-concept disturbance, concern for loss of control of bodily functions.

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Definitions

Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity.

Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating followed by self-induced vomiting. It may include abuse of laxatives and diuretics.

Although these disorders primarily affect women, approximately 5%–10% of those afflicted are men, and both disorders can be present in the same individual.

Nursing Priorities

1. Establish adequate/appropriate nutritional intake.
2. Correct fluid and electrolyte imbalance.
3. Assist patient to develop realistic body image/improve self-esteem.
4. Provide support/involve significant other (SO), if available, in treatment program.
5. Coordinate total treatment program with other disciplines.
6. Provide information about disease, prognosis, and treatment to patient/SO.

Discharge Goals

1. Adequate nutrition and fluid intake maintained.
2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
4. Self-esteem increased.
5. Disease process, prognosis, and treatment regimen understood.
6. Plan in place to meet needs after discharge.

Assessment

ACTIVITY/REST

• May report: Disturbed sleep patterns, e.g., early morning insomnia; fatigue
• Feeling “hyper” and/or anxious
• Increased activity/avid exerciser, participation in high-energy sports
• Employment in positions/professions that stress/require weight control (e.g., athletics such as gymnasts, swimmers, jockeys; modeling; flight attendants)
• May exhibit: Periods of hyperactivity, constant vigorous exercising

CIRCULATION

• May report: Feeling cold even when room is warm
• May exhibit: Low blood pressure (BP)
• Tachycardia, bradycardia, dysrhythmias

EGO INTEGRITY

• May report: Powerlessness/helplessness lack of control over eating (e.g., cannot stop eating/control what or how much is eaten [bulimia]); feeling disgusted with self, depressed or very guilty because of overeating
• Distorted (unrealistic) body image, reports self as fat regardless of weight (denial), and sees thin body as fat; persistent overconcern with body shape and weight (fears gaining weight)
• High self-expectations
• Stress factors, e.g., family move/divorce, onset of puberty
• Suppression of anger
• May exhibit: Emotional states of depression, withdrawal, anger, anxiety, pessimistic outlook

ELIMINATION

• May report: Diarrhea/constipation
• Vague abdominal pain and distress, bloating
• Laxative/diuretic abuse

FOOD/FLUID

• May report: Constant hunger or denial of hunger; normal or exaggerated appetite that rarely vanishes until late in the disorder (anorexia)
• Intense fear of gaining weight (females); may have prior history of being overweight (particularly males)
• Preoccupation with food, e.g., calorie counting, gourmet cooking
• An unrealistic pleasure in weight loss, while denying self pleasure in other areas
• Refusal to maintain body weight over minimal norm for age/height (anorexia)
• Recurrent episodes of binge eating; a feeling of lack of control over behavior during eating binges; a minimum average of two binge-eating episodes a week for at least 3 mo
• Regularly engages in self-induced vomiting (binge-purge syndrome bulimia) either independently or as a complication of anorexia; or strict dieting or fasting
• May exhibit: Weight loss/maintenance of body weight 15% or more below that expected (anorexia), or weight may be normal or slightly above or below normal (bulimia)
• No medical illness evident to account for weight loss
• Cachectic appearance; skin may be dry, yellowish/pale, with poor tugor (anorexia)
• Preoccupation with food (e.g., calorie counting, hiding food, cutting food into small pieces, rearranging food on plate)
• Irrational thinking about eating, food, and weight
• Peripheral edema
• Swollen salivary glands; sore, inflamed buccal cavity; continuous sore throat (bulimia)
• Vomiting, bloody vomitus (may indicate esophageal tearing [Mallory-Weiss syndrome])
• Excessive gum chewing

HYGIENE

• May exhibit: Increased hair growth on body (lanugo), hair loss (axillary/pubic), hair is dull/not shiny
• Brittle nails
• Signs of erosion of tooth enamel, gums in poor condition, ulcerations of mucosa

NEUROSENSORY

• May exhibit: Appropriate affect (except in regard to body and eating), or depressive affect
• Mental changes: Apathy, confusion, memory impairment (brought on by malnutrition/
• starvation)
• Hysterical or obsessive personality style; no other psychiatric illness or evidence of a psychiatric thought disorder present (although a significant number may show evidence of an affective disorder)

PAIN/DISCOMFORT

• May report: Headaches, sore throat/mouth, generalized vague complaints

SAFETY

• May exhibit: Body temperature below normal
• Recurrent infectious processes (indicative of depressed immune system)
• Eczema/other skin problems, abrasions/calluses may be noted on back of hands from sticking finger down throat to induce vomiting

SEXUALITY

• May report: Absence of at least three consecutive menstrual cycles (decreased levels of estrogen in response to malnutrition)
• Promiscuity or denial/loss of sexual interest
• History of sexual abuse
• Homosexual/bisexual orientation (higher percentage in male patients than in general population)
• May exhibit: Breast atrophy, amenorrhea

SOCIAL INTERACTION

• May report: Middle-class or upper-class family background
• History of being a quiet, cooperative child
• Problems of control issues in relationships, difficult communications with others/authority figures, poor communication within family of origin
• Engagement in power struggles
• An emotional crisis of some sort, such as the onset of puberty or a family move
• Altered relationships or problems with relationships (not married/divorced), withdrawal from friends/social contacts
• Abusive family relationships
• Sense of helplessness
• History of legal difficulties (e.g., shoplifting)
• May exhibit: Passive father/dominant mother, family members closely fused, togetherness prized, personal boundaries not respected

TEACHING/LEARNING

• May report: Family history of higher than normal incidence of depression, other family members with eating disorders (genetic predisposition)
• Onset of the illness usually between the ages of 10 and 22
• Health beliefs/practice (e.g., certain foods have “too many” calories, use of “health” foods)
• High academic achievement
• Substance abuse
• Discharge plan DRG projected mean length of inpatient stay: 6.4 days
• considerations: Assistance with maintenance of treatment plan

Diagnostic Studies

• Complete blood count (CBC) with differential: Determines presence of anemia, leukopenia, lymphocytosis. Platelets show significantly less than normal activity by the enzyme monoamine oxidase (thought to be a marker for depression).
• Electrolytes: Imbalances may include decreased potassium, sodium, chloride, and magnesium.
• Endocrine studies:
• Thyroid function: Thyroxine (T₄) levels usually normal; however, circulating triiodothyronine (T₃) levels may be low.
• Pituitary function: Thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) is abnormal in anorexia nervosa. Propranolol-glucagon stimulation test studies the response of human growth hormone (GH), which is depressed in anorexia. Gonadotropic hypofunction is noted.
• Cortisol metabolism: May be elevated.
• Dexamethasone suppression test (DST): Evaluates hypothalamic-pituitary function. Dexamethasone resistance indicates cortisol suppression, suggesting malnutrition and/or depression.
• Luteinizing hormone (LH) secretions test: Pattern often resembles those of prepubertal girls.
• Estrogen: Decreased.
• MHP 6 levels: Decreased, suggestive of malnutrition/depression.
• Serum glucose and basal metabolic rate (BMR): May be low.
• Other chemistries: AST elevated. Hypercarotenemia, hypoproteinemia, hypercholesterolemia.
• Urinalysis and renal function: Blood urea nitrogen (BUN) may be elevated; ketones present reflecting starvation; decreased urinary 17-ketosteroids; increased specific gravity/dehydration.
• Electrocardiogram (ECG): Abnormal tracing with low voltage, T-wave inversion, dysrhythmias.

Nursing Care Plans

Below are 7 Nursing Care Plan (NCP) for eating disorders anorexia nervosa & bulimia nervosa.

Imbalanced Nutrition

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements

May be related to

• Inadequate food intake; self-induced vomiting
• Chronic/excessive laxative use

Possibly evidenced by

• Body weight 15% (or more) below expected, or may be within normal range (bulimia)
• Pale conjunctiva and mucous membranes; poor skin turgor/muscle tone; edema
• Excessive loss of hair; increased growth of hair on body (lanugo)
• Amenorrhea
• Hypothermia
• Bradycardia; cardiac irregularities; hypotension

Desired Outcomes

• Verbalize understanding of nutritional needs.
• Establish a dietary pattern with caloric intake adequate to regain/maintain appropriate weight.
• Demonstrate weight gain toward individually expected range.

Deficient Fluid Volume

NURSING DIAGNOSIS: Fluid Volume actual or risk for deficient

May be related to

• Inadequate intake of food and liquids
• Consistent self-induced vomiting
• Chronic/excessive laxative/diuretic use

Possibly evidenced by (actual)

• Dry skin and mucous membranes, decreased skin turgor
• Increased pulse rate, body temperature, decreased BP
• Output greater than input (diuretic use); concentrated urine/decreased urine output (dehydration)
• Weakness
• Change in mental state
• Hemoconcentration, altered electrolyte balance

Desired Outcomes

• Maintain/demonstrate improved fluid balance, as evidenced by adequate urine output, stable vital signs, moist mucous membranes, good skin turgor.
• Verbalize understanding of causative factors and behaviors necessary to correct fluid deficit.

Disturbed Thought Process

NURSING DIAGNOSIS: Thought Processes, disturbed

May be related to

• Severe malnutrition/electrolyte imbalance
• Psychological conflicts, e.g., sense of low self-worth, perceived lack of control

Possibly evidenced by

• Impaired ability to make decisions, problem-solve
• Non–reality-based verbalizations
• Ideas of reference
• Altered sleep patterns, e.g., may go to bed late (stay up to binge/purge) and get up early
• Altered attention span/distractibility
• Perceptual disturbances with failure to recognize hunger; fatigue, anxiety, and depression

Desired Outcomes

• Verbalize understanding of causative factors and awareness of impairment.
• Demonstrate behaviors to change/prevent malnutrition.
• Display improved ability to make decisions, problem-solve.

Disturbed Body Image

NURSING DIAGNOSIS: Body image, disturbed/Self-Esteem, chronic low

May be related to

• Morbid fear of obesity; perceived loss of control in some aspect of life
• Personal vulnerability; unmet dependency needs
• Dysfunctional family system
• Continual negative evaluation of self

Possibly evidenced by

• Distorted body image (views self as fat even in the presence of normal body weight or severe emaciation)
• Expresses little concern, uses denial as a defense mechanism, and feels powerless to prevent/make changes
• Expressions of shame/guilt
• Overly conforming, dependent on others’ opinions

Desired Outcomes

• Establish a more realistic body image.
• Acknowledge self as an individual.
• Accept responsibility for own actions.

Impaired Parenting

NURSING DIAGNOSIS: Parenting, impaired

May be related to

• Issues of control in family
• Situational/maturational crises
• History of inadequate coping methods

Possibly evidenced by

• Dissonance among family members
• Family developmental tasks not being met
• Focus on “Identified Patient” (IP)
• Family needs not being met
• Family member(s) acting as enablers for IP
• Ill-defined family rules, function, and roles

Desired Outcomes

• Demonstrate individual involvement in problem-solving process directed at encouraging patient toward independence.
• Express feelings freely and appropriately.
• Demonstrate more autonomous coping behaviors with individual family boundaries more clearly defined.
• Recognize and resolve conflict appropriately with the individuals involved.

Impaired Skin Integrity

NURSING DIAGNOSIS: Skin Integrity, risk for impaired

Risk factors may include

• Altered nutritional/metabolic state; edema
• Dehydration/cachectic changes (skeletal prominence)

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes and actual diagnosis.]

Desired Outcomes

• Verbalize understanding of causative factors and absence of itching.
• Identify and demonstrate behaviors to maintain soft, supple, intact skin.

Knowledge Deficit

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care and discharge needs

May be related to

• Lack of exposure to/unfamiliarity with information about condition
• Learned maladaptive coping skills

Possibly evidenced by

• Verbalization of misconception of relationship of current situation and behaviors
• Preoccupation with extreme fear of obesity and distortion of own body image
• Refusal to eat; binging and purging; abuse of laxatives and diuretics; excessive exercising
• Verbalization of need for new information
• Expressions of desire to learn more adaptive ways of coping with stressors

Desired Outcomes

• Verbalize awareness of and plan for lifestyle changes to maintain normal weight.
• Identify relationship of signs/symptoms (weight loss, tooth decay) to behaviors of not eating/binging-purging.
• Assume responsibility for own learning.
• Seek out sources/resources to assist with making identified changes.

Other Possible Nursing Diagnoses

• Nutrition: imbalanced, risk for less than body requirements—inadequate food intake, self-induced vomiting, history of chronic laxative use.
• Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, perceived seriousness/benefits, mistrust of regimen and/or healthcare personnel, excessive demands made on individual, family conflict.

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Definition

A fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a discontinuity or break in a bone.

Types of Fracture

Five major types are as follows:

1. Incomplete: Fracture involves only a portion of the cross-section of the bone. One side breaks; the other usually just bends (greenstick).
2. Complete: Fracture line involves entire cross-section of the bone, and bone fragments are usually displaced.
3. Closed: The fracture does not extend through the skin.
4. Open: Bone fragments extend through the muscle and skin, which is potentially infected.
5. Pathological: Fracture occurs in diseased bone (such as cancer, osteoporosis), with no or only minimal trauma.

Nursing Priorities

1. Prevent further bone/tissue injury.
2. Alleviate pain.
3. Prevent complications.
4. Provide information about condition/prognosis and treatment needs.

Discharge Goals

1. Fracture stabilized.
2. Pain controlled.
3. Complications prevented/minimized.
4. Condition, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

Diagnostic Studies for Fracture

1. X-ray examinations: Determines location and extent of fractures/trauma, may reveal preexisting and yet undiagnosed fracture(s).
2. Bone scans, tomograms, computed tomography (CT)/magnetic resonance imaging (MRI) scans: Visualizes fractures, bleeding, and soft-tissue damage; differentiates between stress/trauma fractures and bone neoplasms.
3. Arteriograms: May be done when occult vascular damage is suspected.
4. Complete blood count (CBC): Hematocrit (Hct) may be increased (hemoconcentration) or decreased (signifying hemorrhage at the fracture site or at distant organs in multiple trauma). Increased white blood cell (WBC) count is a normal stress response after trauma.
5. Urine creatinine (Cr) clearance: Muscle trauma increases load of Cr for renal clearance.
6. Coagulation profile: Alterations may occur because of blood loss, multiple transfusions, or liver injury.

Nursing Care Plans

Here are 8 nursing care plans for fracture.

Risk for Trauma

Nursing Diagnosis: Risk for Trauma

Risk factors may include

• Loss of skeletal integrity (fractures)/movement of bone fragments

Desired Outcomes

• Maintain stabilization and alignment of fracture(s).
• Display callus formation/beginning union at fracture site as appropriate.
• Demonstrate body mechanics that promote stability at fracture site.

Acute Pain

Nursing Diagnosis: Acute Pain

May be related to

• Muscle spasms
• Movement of bone fragments, edema, and injury to the soft tissue
• Traction/immobility device
• Stress, anxiety

Possibly evidenced by

• Reports of pain
• Distraction; self-focusing/narrowed focus; facial mask of pain
• Guarding, protective behavior; alteration in muscle tone; autonomic responses

Desired Outcomes

• Verbalize relief of pain.
• Display relaxed manner; able to participate in activities, sleep/rest appropriately.
• Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Risk for Peripheral Neurovascular Dysfunction

Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction

Risk factors may include

• Reduction/interruption of blood flow
• Direct vascular injury, tissue trauma, excessive edema, thrombus formation
• Hypovolemia

Desired Outcomes

• Maintain tissue perfusion as evidenced by palpable pulses, skin warm/dry, normal sensation, usual sensorium, stable vital signs, and adequate urinary output for individual situation.

Risk for Impaired Gas Exchange

Nursing Diagnosis: Gas Exchange, risk for impaired

Risk factors may include

• Altered blood flow; blood/fat emboli
• Alveolar/capillary membrane changes: interstitial, pulmonary edema, congestion

Desired Outcomes

• Maintain adequate respiratory function, as evidenced by absence of dyspnea/cyanosis; respiratory rate and arterial blood gases (ABGs) within patient’s normal range.

Impaired Physical Mobility

Nursing Diagnosis: Impaired Physical Mobility

May be related to

• Neuromuscular skeletal impairment; pain/discomfort; restrictive therapies (limb immobilization)
• Psychological immobility

Possibly evidenced by

• Inability to move purposefully within the physical environment, imposed restrictions
• Reluctance to attempt movement; limited ROM
• Decreased muscle strength/control

Desired Outcomes

• Regain/maintain mobility at the highest possible level.
• Maintain position of function.
• Increase strength/function of affected and compensatory body parts.
• Demonstrate techniques that enable resumption of activities.

Impaired Skin Integrity

Nursing Diagnosis: Skin/Tissue Integrity, impaired: actual/risk for

May be related to

• Puncture injury; compound fracture; surgical repair; insertion of traction pins, wires, screws
• Altered sensation, circulation; accumulation of excretions/secretions
• Physical immobilization

Possibly evidenced by (actual)

• Reports of itching, pain, numbness, pressure in affected/surrounding area
• Disruption of skin surface; invasion of body structures; destruction of skin layers/tissues

Desired Outcomes

• Verbalize relief of discomfort.
• Demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing as indicated.
• Achieve timely wound/lesion healing if present.

Risk for Infection

Nursing Diagnosis: Risk for Infection

Risk factors may include

• Inadequate primary defenses: broken skin, traumatized tissues; environmental exposure
• Invasive procedures, skeletal traction

Desired Outcomes:

• Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.

Knowledge Deficit

Nursing Diagnosis: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to

• Lack of exposure/recall
• Information misinterpretation/unfamiliarity with information resources

Possibly evidenced by

• Questions/request for information, statement of misconception
• Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

• Verbalize understanding of condition, prognosis, and potential complications.
• Correctly perform necessary procedures and explain reasons for actions.

Other Nursing Diagnoses

1. Trauma, risk for—loss of skeletal integrity, weakness, balancing difficulties, reduced muscle coordination, lack of safety precautions, history of previous trauma.
2. Mobility, impaired physical—neuromuscular skeletal impairment; pain/discomfort, restrictive therapies (limb immobilization); psychological immobility.
3. Self-Care deficit—musculoskeletal impairment, decreased strength/endurance, pain.
4. Infection, risk for—inadequate primary defenses: broken skin, traumatized tissues; environmental exposure; invasive procedures, skeletal traction.

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