Nanda Nursing Diagnosis

Many patients on ventilators are now being transferred from the intensive care unit (ICU) to medical-surgical units with problems including (1) neuromuscular deficits, such as quadriplegia with phrenic nerve injury or high C-spine injuries, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS); (2) COPD with respiratory muscle atrophy and malnutrition (inability to wean); and (3)

Kidney stones (calculi) are formed of mineral deposits, most commonly calcium oxalate and calcium phosphate; however, uric acid, struvite, and cystine are also calculus formers. Although renal calculi can form anywhere in the urinary tract, they are most commonly found in the renal pelvis and calyces. Renal calculi can remain asymptomatic until passed into a ureter and/or urine flow is obstructed

Incontinent urinary diversions: These ostomies require permanent stoma care and external collecting devices.Ileal conduit: Ureters are anastomosed to a segment of ileum, resected with the blood supply intact (usually 15–20 cm long). The proximal section is closed, and the distal end brought to skin opening to form a stoma (a passageway, not a storage reservoir).Colonic conduit: This is a similar

Bleeding duodenal ulcer is the most frequent cause of massive upper gastrointestinal (GI) hemorrhage, but bleeding may also occur because of gastric ulcers, gastritis, and esophageal varices. Severe vomiting can precipitate gastric bleeding as a result of a tear in the mucosa at the gastroesophageal junction (Mallory-Weiss syndrome). Stress ulcers are often associated with severe burns, major

With current advances in technology and knowledge of immune responses at the molecular level, organ and tissue transplantation is becoming more commonplace. The most frequently transplanted organs are the kidney, liver, and heart. The major problem to be overcome is the immunologic response of the patient to donor tissues. The ability of the immune system to distinguish self from nonself is

Nutritional status is a key factor in patient’s overall immune function and a patient’s ability to mount a stress response. Underfeeding a patient may lead to increased nosocomial infections, poor wound healing, respiratory muscle dysfunction, and respiratory failure. Overfeeding patients, in contrast, may increase physiological stress and lead to problems such as hyperglycemia, fluid overload,

Joint replacement is indicated for irreversibly damaged joints with loss of function and unremitting pain (e.g., degenerative and rheumatoid arthritis [RA]), selected fractures (e.g., hip/femoral neck), joint instability, and congenital hip disorders. The surgery can be performed on any joint except the spine. Hip and knee replacements are the most common procedures. The prosthesis may be

Thyroidectomy, although rare, may be performed for patients with thyroid cancer, hyperthyroidism, and drug reactions to antithyroid agents; pregnant women who cannot be managed with drugs; patients who do not want radiation therapy; and patients with large goiters who do not respond to antithyroid drugs.The two types of thyroidectomy include:Total thyroidectomy: The gland is removed completely.

Thrombophlebitis is a condition in which a clot forms in a vein, associated with inflammation/trauma of the vein wall or a partial obstruction of the vein. Clot formation is related to (1) stasis of blood flow, (2) abnormalities in the vessel walls, and (3) alterations in the clotting mechanism (Virchow’s triad). Young women and the elderly are at greatest risk.Thrombophlebitis can affect

The individual identified as HIV-seropositive is one who is asymptomatic and does not meet the Centers for Disease Control and Prevention (CDC) definition for AIDS. Studies reveal that persons with HIV-positive status may remain asymptomatic for 10 or more years. During the period of asymptomatic infection, the individual has HIV in the blood and is contagious to others. Patients may live longer

Surgery may be needed to diagnose or cure a specific disease process, correct a structural deformity, restore a functional process, or reduce the level of dysfunction/pain. Although surgery is generally elective or preplanned, potentially life-threatening conditions can arise, requiring emergency intervention. Absence or limitation of preoperative preparation and teaching increases the need for

Subtotal gastrectomy or gastric resection is indicated for gastric hemorrhage/intractable ulcers, dysfunctional lower esophageal sphincter, pyloric obstruction, perforation, cancer.CARE SETTINGInpatient surgical unit.RELATED CONCERNSCancerPancreatitisPeritonitisPsychosocial aspects of careSurgical interventionTotal nutritional support: parenteral/enteral feedingUpper gastrointestinal/esophageal

Many drugs and volatile substances are subject to misuse/abuse. This disorder is a continuum of phases incorporating a cluster of cognitive, behavioral, and physiological symptoms that include loss of control over use of the substance and a continued use of the substance despite adverse consequences. A number of factors have been implicated in the predisposition to abuse a substance: biological,

The leading causes of spinal cord injury (SCI) include motor vehicle crashes, falls, acts of violence, and sporting injuries. The mechanism of injury influences the type of SCI and the degree of neurological deficit. Spinal cord lesions are classified as a complete (total loss of sensation and voluntary motor function) or incomplete (mixed loss of sensation and voluntary motor function).Physical

Sickle cell disease (sickle hemoglobinopathies) is a group of genetic diseases, the most common forms being homozygous hemoglobin SS disease (sickle cell anemia), hemoglobin SC disease, and sickle [beta]-thalassemia.Sickle cell disease primarily affects black populations and people of Mediterranean, South/Central American, Arabian, and East Indian descent. It renders the individual vulnerable to

Sepsis is a syndrome characterized by clinical signs and symptoms of severe infection that may progress to septicemia and septic shock. Septicemia implies the presence of an infection of the blood caused by rapidly multiplying microorganisms or their toxins, which can result in profound physiological changes and systemic sepsis. The pathogens can be bacteria, fungi, viruses, or rickettsiae. The

Seizures (convulsions) are the result of uncontrolled electrical discharges from the nerve cells of the cerebral cortex and are characterized by sudden, brief attacks of altered consciousness, motor activity, and/or sensory phenomena.Seizures can be associated with a variety of cerebral or systemic disorders as a focal or generalized disturbance of cortical function. Sensory symptoms arise from

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease involving connective tissue and characterized by destruction and proliferation of the synovial membrane, resulting in joint destruction, ankylosis, and deformity.Although the cause is unknown, researchers speculate that a virus may initially trigger the body’s immune response, which then becomes chronically activated and turns

Respiratory alkalosis is a loss of carbon dioxide (PCO2 < 35 mm Hg) with a resultant decrease of carbonic acid (H2CO3) due to a marked increase in the rate of respirations. The two primary mechanisms that trigger hyperventilation are (1) hypoxemia and (2) direct stimulation of the central respiratory center of the brain (such as occur with high fever, head trauma/CNS lesions, early salicylate

RESPIRATORY ACID-BASE IMBALANCESThe body has the remarkable ability to maintain plasma pH within a narrow range of 7.35–7.45. It does so by means of chemical buffering mechanisms involving the lungs and kidneys. Although simple acid-base imbalances (e.g., respiratory acidosis) do occur, mixed acid-base imbalances are more common (e.g., the respiratory acidosis/metabolic acidosis that occurs with

Chronic renal failure (CRF) is the end result of a gradual, progressive loss of kidney function. Causes include chronic infections (glomerulonephritis, pyelonephritis), vascular diseases (hypertension, nephrosclerosis), obstructive processes (renal calculi), collagen diseases (systemic lupus), nephrotoxic agents (drugs, such as aminoglycosides), and endocrine diseases (diabetes,

Acute renal failure (ARF) has four well-defined stages: onset, oliguric or anuric, diuretic, and convalescent. Treatment depends on stage and severity of renal compromise. ARF can be divided into three major classifications, depending on site:Prerenal: Prerenal failure is caused by interference with renal perfusion (e.g., blood volume depletion, volume shifts [“third-space” sequestration of fluid

The peritoneum serves as the semipermeable membrane permitting transfer of nitrogenous wastes/toxins and fluid from the blood into a dialysate solution. Peritoneal dialysis is sometimes preferred because it uses a simpler technique and provides more gradual physiological changes than hemodialysis.The manual single-bag method is usually done as an inpatient procedure with short dwell times of only

Head and neck cancer refers to a malignancy that lies above the clavicle but excludes the brain, spinal cord, axial skeleton, and vertebrae. Although head and neck cancer accounts for 5% of all malignant disease, disability is great because of the potential loss of voice, disfigurement, and social consequences. The majority of the laryngeal neoplasms (95%) are squamous cell carcinomas that arise

Although many still believe it to be a problem of the past, pulmonary tuberculosis (TB) is on the rise. Most frequently seen as a pulmonary disease, TB can be extrapulmonary and affect organs and tissues other than the lungs. In the United States, incidence is higher among the homeless, drug-addicted, and impoverished populations, as well as among immigrants from or visitors to countries in which

The emotional response of the patient during illness is of extreme importance. The mind-body-spirit connection is well established; it is known, for example, that when a physiological response occurs, there is a corresponding psychological response. Also, there are physiological conditions that have a psychological component, for example, the emotional instability associated with steroid therapy

Many men older than age 75 have small, slow-growing prostate tumors that cause little harm. However, surgical resection of the portion of the prostate gland encroaching on the urethra may be required to improve urinary flow and relieve acute urinary retention regardless of the patient’s age. Note: Laser prostatectomy is being done in routine practice; however, published data relative to the

Pneumonia is an inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange. Primary pneumonia is caused by the patient’s inhaling or aspirating a pathogen. Secondary pneumonia ensues from lung damage caused by the spread of bacteria from an infection elsewhere in the body. Likely causes include various infectious agents, chemical irritants (

Inflammation of the peritoneal cavity, caused by either bacteria or chemicals, can be primary or secondary, and acute or chronic. Primary peritonitis is a rare condition in which the peritoneum is infected via the blood/lymphatic circulation. Secondary sources of inflammation are the GI tract, ovaries/uterus, urinary system, traumatic injuries, or surgical contaminants. Surgical intervention may

Encompasses problems related to childhood through adolescence.CARE SETTINGAny setting in which nursing contact with children occurs/care is provided.ASSESSMENT FACTORS (IN ADDITION TO ROUTINE ASSESSMENTS)Age and genderDevelopmental levelPatterns of communication with SOsPerception of body and its functions: in health and illnessBehavior when anxious, afraid, withdrawn, angrySIGNIFICANT

Pancreatitis is a painful inflammatory condition in which the pancreatic enzymes are prematurely activated resulting in autodigestion of the pancreas. The most common cause of pancreatitis are biliary tract disease and alcoholism, but can also result from such things as abnormal organ structure, blunt trauma, penetrating peptic ulcers, and drugs such as sulfonamides and glucocorticoids.

Weight reduction surgery has been reported to improve several comorbid conditions such as sleep apnea, glucose intolerance and frank diabetes, hypertension, and hyperlipidemia. A number of surgical treatments for morbid obesity have been tried and discarded because of ineffectiveness or complications. The procedure of choice is vertical-banded gastroplasty, although the Roux-en-Y gastric bypass

 Myocardial infarction (MI) is caused by marked reduction/loss of blood flow through one or more of the coronary arteries, resulting in cardiac muscle ischemia and necrosis.CARE SETTINGInpatient acute hospital, step-down, or medical unit.RELATED CONCERNSAnginaDysrhythmiasHeart failure: chronicPsychosocial aspects of careThrombophlebitis: deep vein thrombosisPatient Assessment DatabaseACTIVITY/

Multiple sclerosis (MS) is the most common of the demyelinating disorders and the predominant CNS disease among young adults. It is a chronic disorder in which irregular demyelination of the CNS (brain and spinal cord) results in emotional changes and varying degree of cognitive, motor, and sensory dysfunction at the central and peripheral level.It is a perivascular inflammatory response,

Metabolic alkalosis is characterized by a high pH (loss of hydrogen ions) and high plasma bicarbonate caused by excessive intake of sodium bicarbonate, loss of gastric/intestinal acid, renal excretion of hydrogen and chloride, prolonged hypercalcemia, hypokalemia, and hyperaldosteronism. Compensatory mechanisms include slow, shallow respirations to increase CO2 level and an increase of

The body has the remarkable ability to maintain plasma pH within the narrow range of 7.35–7.45. It does so by means of chemical buffering mechanisms by the kidneys and the lungs. Although single acid-base (e.g., metabolic acidosis) imbalances do occur, mixed acid-base imbalances are more common (e.g., metabolic acidosis/respiratory acidosis as occurs with cardiac arrest).METABOLIC ACIDOSIS (

The choice of treatment for breast cancer depends on tumor type, size, and location, as well as clinical characteristics (staging). Therapy may include surgical intervention with/without radiation, chemotherapy, and hormone therapy. The use of gene therapy and stem cell rescue (autologous bone marrow transplantation) is under investigation. Breast reconstruction is often done at the time of

Lung cancer is the leading cause of cancer death in the United States and usually develops within the wall or epithelium of the bronchial tree. The two major categories are small cell lung cancers (SCLC), such as oat cell; and non–small cell lung cancers (NSCLC), which include adenocarcinoma, squamous cell and large cell carcinomas.Prognosis is generally poor, varying with the type of cancer and

The term leukemia describes a malignant disorder of the blood and lymph-forming tissues of the body. The blood’s cellular components originate primarily in the marrow of bones such as the sternum, iliac crest, and cranium. All blood cells begin as immature cells (blasts or stem cells) that differentiate and mature into RBCs, platelets, and various types of WBCs. In leukemia, many immature or

Inflammatory bowel disease (IBD): Researchers believe that IBD may result from a complex interplay between genetic and environmental factors. Similarities involve (1) chronic inflammation of the alimentary tract and (2) periods of remission interspersed with episodes of acute inflammation.Ulcerative colitis (UC): A chronic condition of unknown cause usually starting in the rectum and distal

Hyperthyroidism is a metabolic imbalance that results from overproduction of the thyroid hormones triiodothyronine (T3) and thyroxine (T4). The most common form is Graves’ disease, but other forms of hyperthyroidism include toxic adenoma, TSH-secreting pituitary tumor, subacute or silent thyroiditis, and some forms of thyroid cancer.Thyroid storm is a rarely encountered manifestation of

A herniated disc (herniated nucleus pulposus) [HNP] is a major cause of severe, chronic, and recurrent back pain.Herniation, either complete or partial, of the nuclear material in the vertebral areas of L-4 to L-5, L-5 to S-1, or C-5 to C-6, C-6 to C-7 is most common and may be the result of trauma or degenerative changes associated with the aging process.CARE SETTINGMost disc problems are

Hepatitis is a widespread inflammation of the liver that results in degeneration and necrosis of liver cells. Inflammation of the liver can be due to bacterial invasion, injury by physical or toxic chemical agents (e.g., drugs, alcohol, industrial chemicals), viral infections (hepatitis A, B, C, D, E, G), or autoimmune response. Although most hepatitis is selflimiting, approximately 20% of acute

The lung may collapse partially or completely because of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) collecting in the pleural/potential space. The intrathoracic pressure changes induced by increased pleural space volumes reduce lung capacity, causing respiratory distress and gas exchange problems and producing tension on mediastinal structures that can impede