Disturbed Body Image — Nursing Diagnosis

October 3, 2011, 11:02 am

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Nursing Diagnosis:

Disturbed Body Image

Definition of Disturbed Body Image

Confusion in mental picture of one’s physical self
Body image is the attitude a person has about the actual or perceived structure or function of all or part of his or her body. This attitude is dynamic and is altered through interaction with other persons and situations and influenced by age and developmental level. As an important part of one’s self-concept, body image disturbance can have profound impact on how individuals view their overall selves.
Throughout the life span, body image changes as a matter of development, growth, maturation, changes related to childbearing and pregnancy, changes that occur as a result of aging, and changes that occur or are imposed as a result of injury or illness.
In cultures where one’s appearance is important, variations from the norm can result in body image disturbance. The importance that an individual places on a body part or function may be more important in determining the degree of disturbance than the actual alteration in the structure or function. Therefore the loss of a limb may result in a greater body image disturbance for an athlete than for a computer programmer. The loss of a breast to a fashion model or a hysterectomy in a nulliparous woman may cause serious body image disturbances even though the overall health of the individual has been improved. Removal of skin lesions, altered elimination resulting from bowel or bladder surgery, and head and neck resections are other examples that can lead to body image disturbance.
• The nurse’s assessment of the perceived alteration and importance placed by the patient on the altered structure or function will be very important in planning care to address body image disturbance.

Defining Characteristics of Disturbed Body Image

Verbalization about altered structure or function of a body part
Verbal preoccupation with changed body part or function
Naming changed body part or function
Refusal to discuss or acknowledge change
Focusing behavior on changed body part and/or function
Actual change in structure or function
Refusal to look at, touch, or care for altered body part
Change in social behavior (e.g., withdrawal, isolation, flamboyance)
Compensatory use of concealing clothing or other devices

Related Factors of Disturbed Body Image

Situational changes (e.g., pregnancy, temporary presence of a visible drain or tube, dressing, attached equipment)
Permanent alterations in structure and/or function (e.g., mutilating surgery, removal of body part [internal or external])
Malodorous lesions
Change in voice quality
Expected Outcomes Patient
Demonstrates enhanced body image and self-esteem as evidenced by ability to look at, touch, talk about, and care for actual or perceived altered body part or function.

Ongoing Assessment Disturbed Body Image

Assess perception of change in structure or function of body part (also proposed change). The extent of the response is more related to the value or importance the patient places on the part or function than the actual value or importance. Even when an alteration improves the overall health of the individual (e.g., an ileostomy for an individual with precancerous colon polyps), the alteration results in a body image disturbance.
Assess perceived impact of change on activities of daily living (ADLs), social behavior, personal relationships, and occupational activities.
Assess impact of body image disturbance in relation to patient’s developmental stage. Adolescents and young adults may be particularly affected by changes in the structure or function of their bodies at a time when developmental changes are normally rapid, and at a time when developing social and intimate relationships is particularly important.
Note patient’s behavior regarding actual or perceived changed body part or function. There is a broad range of behaviors associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it.
Note frequency of self-critical remarks.

Therapeutic Interventions Disturbed Body Image

Acknowledge normalcy of emotional response to actual or perceived change in body structure or function. Stages of grief over loss of a body part or function are normal, and typically involves a period of denial, the length of which varies from individual to individual.
Help patient identify actual changes. Patients may perceive changes that are not present or real, or they may be placing unrealistic value on a body structure or function.
Encourage verbalization of positive or negative feelings about actual or perceived change. It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth.
Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation.
Demonstrate positive caring in routine activities. Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the patient plans to return to home, to work, and to other activities.

Disturbed Body Image Education/Continuity of Care

Teach patient about the normalcy of body image disturbance and the grief process.
Teach patient adaptive behavior (e.g., use of adaptive equipment, wigs, cosmetics, clothing that conceals altered body part or enhances remaining part or function, use of deodorants). This compensates for actual changed body structure and function.
Help patient identify ways of coping that have been useful in the past. Asking patients to remember other body image issues (e.g., getting glasses, wearing orthodontics, being pregnant, having a leg cast) and how they were managed may help patient adjust to the current issue.
Refer patient and caregivers to support groups composed of individuals with similar alterations.

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Disturbed Body Image — Burn Injury Nursing Care Plan (NCP)

March 31, 2012, 5:30 am

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Nursing Diagnosis: Body Image disturbed/Role Performance, ineffective

May be related to

Situational crisis: traumatic event, dependent patient role; disfigurement, pain

Possibly evidenced by

Negative feelings about body/self, fear of rejection/reaction by others
Focus on past appearance, abilities; preoccupation with change/loss
Change in physical capacity to resume role; change in social involvement

Desired Outcomes

Incorporate changes into self-concept without negating self-esteem.
Verbalize acceptance of self in situation.
Talk with family/SO about situation, changes that have occurred.
Develop realistic goals/plans for the future.

Disturbed Body Image — Burn Injury Nursing Care Plan (NCP)

Nursing Interventions	Rationale
Assess meaning of loss/change to patient/SO, including future expectations and impact of cultural/religious beliefs.	Traumatic episode results in sudden, unanticipated changes, creating feelings of grief over actual/perceived losses. This necessitates support to work through to optimal resolution.
Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial.	Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push patient before ready to deal with situation. Denial may be prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems.
Set limits on maladaptive behavior (e.g., manipulative/ aggressive). Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery.	Patient and SO tend to deal with this crisis in the same way in which they have dealt with problems in the past. Staff may find it difficult and frustrating to handle behavior that is disrupting/not helpful to recuperation but should realize that the behavior is usually directed toward the situation and not the caregiver.
Be realistic and positive during treatments, in health teaching, and in setting goals within limitations.	Enhances trust and rapport between patient and nurse.
Encourage patient/SO to view wounds and assist with care as appropriate.	Promotes acceptance of reality of injury and of change in body and image of self as different.
Provide hope within parameters of individual situation; do not give false reassurance.	Promotes positive attitude and provides opportunity to set goals and plan for future based on reality.
Assist patient to identify extent of actual change in appearance/body function.	Helps begin process of looking to the future and how life will be different.
Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals.	Words of encouragement can support development of positive coping behaviors.
Show slides or pictures of burn care/other patient outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what patient has seen.	Allows patient/SO to be realistic in expectations. Also assists in demonstration of importance of/necessity for certain devices and procedures.
Encourage family interaction with each other and with rehabilitation team.	Maintains/opens lines of communication and provides ongoing support for patient and family.
Provide support group for SO. Give information about how SO can be helpful to patient.	Promotes ventilation of feelings and allows for more helpful responses to patient.
Role-play social situations of concern to patient.	Prepares patient/SO for reactions of others and anticipates ways to deal with them.
Refer to physical/occupational therapy, vocational counselor, and psychiatric counseling, e.g., clinical specialist psychiatric nurse, social services, psychologist, as needed.	Helpful in identifying ways/devices to regain and maintain independence. Patient may need further assistance to resolve persistent emotional problems (e.g., posttrauma response).

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Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:37 am

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NURSING DIAGNOSIS: Self-Esteem/Body Image disturbed

May be related to

Biophysical changes/altered physical appearance
Uncertainty of prognosis, changes in role function
Personal vulnerability
Self-destructive behavior (alcohol-induced disease)

Possibly evidenced by

Verbalization of change/restriction in lifestyle
Fear of rejection or reaction by others
Negative feelings about body/abilities
Feelings of helplessness, hopelessness, or powerlessness

Desired Outcomes

Verbalize understanding of changes and acceptance of self in the present situation.
Identify feelings and methods for coping with negative perception of self.

8 Liver Cirrhosis Nursing Care Plan (NCP)

Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Discuss situation/encourage verbalization of fears and concerns. Explain relationship between nature of disease and symptoms.	Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol (70%) or other drug use.
Support and encourage patient; provide care with a positive, friendly attitude.	Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person.
Encourage family/SO to verbalize feelings, visit freely/participate in care.	Family members may feel guilty about patient’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to patient. Participation in care helps them feel useful and promotes trust between staff, patient, and SO.
Assist patient/SO to cope with change in appearance; suggest clothing that does not emphasize altered appearance, e.g., use of red, blue, or black clothing.	Patient may present unattractive appearance as a result of jaundice, ascites, ecchymotic areas. Providing support can enhance self-esteem and promote patient sense of control.
Refer to support services, e.g., counselors, psychiatric resources, social service, clergy, and/or alcohol treatment program.	Increased vulnerability/concerns associated with this illness may require services of additional professional resources.

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Disturbed Body Image — Anorexia & Bulimia Nervosa Nursing Care Plan (NCP)

May 5, 2012, 3:25 am

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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.

7 Eating Disorders (Anorexia & Bulimia Nervosa) Nursing Care Plan (NCP)

Disturbed Body Image — Anorexia & Bulimia Nervosa Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Have patient draw picture of self.	Provides opportunity to discuss patient’s perception of self/body image and realities of individual situation.
Involve in personal development program, preferably in a group setting. Provide information about proper application of makeup and grooming.	Learning about methods to enhance personal appearance may be helpful to long-range sense of self-esteem/image. Feedback from others can promote feelings of self-worth.
Suggest disposing of “thin” clothes as weight gain occurs. Recommend consultation with an image consultant.	Provides incentive to at least maintain and not lose weight. Removes visual reminder of thinner self. Positive image enhances sense of self-esteem.
Assist patient to confront changes associated with puberty/sexual fears. Provide sex education as necessary.	Major physical/psychological changes in adolescence can contribute to development of eating disorders. Feelings of powerlessness and loss of control of feelings (in particular sexual sensations) lead to an unconscious desire to desexualize self. Patient often believes that these fears can be overcome by taking control of bodily appearance/development/function.
Establish a therapeutic nurse/patient relationship.	Within a helping relationship, patient can begin to trust and try out new thinking and behaviors.
Promote self-concept without moral judgment	Patient sees self as weak-willed, even though part of person may feel sense of power and control (e.g., dieting/weight loss).
States rules clearly regarding weighing schedule, remaining in sight during medication and eating times, and consequences of not following the rules. Without undue comment, be consistent in carrying out rules.	Consistency is important in establishing trust. As part of the behavior modification program, patient knows risks involved in not following established rules (e.g., decrease in privileges). Failure to follow rules is viewed as patient’s choice and accepted by staff in matter-of-fact manner so as not to provide reinforcement for the undesirable behavior.
Respond (confront) with reality when patient makes unrealistic statements such as “I’m gaining weight, so there’s nothing really wrong with me.”	Patient may be denying the psychological aspects of own situation and is often expressing a sense of inadequacy and depression.
Be aware of own reaction to patient’s behavior. Avoid arguing.	Feelings of disgust, hostility, and infuriation are not uncommon when caring for these patients. Prognosis often remains poor even with a gain in weight because other problems may remain. Many patients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive-compulsive symptoms, drug abuse, and psychosexual dysfunction. Nurse needs to deal with own response/feeling so they do not interfere with care of patient.
Assist patient to assume control in areas other than dieting/weight loss, e.g., management of own daily activities, work/leisure choices.	Feelings of personal ineffectiveness, low self-esteem, and perfectionism are often part of the problem. Patient feels helpless to change and requires assistance to problem-solve methods of control in life situations.
Help patient formulate goals for self (not related to eating) and create a manageable plan to reach those goals, one at a time, progressing from simple to more complex.	Patient needs to recognize ability to control other areas in life and may need to learn problem-solving skills to achieve this control. Setting realistic goals fosters success.
Note patient’s withdrawal from and/or discomfort in social settings.	May indicate feelings of isolation and fear of rejection/judgment by others. Avoidance of social situations and contact with others can compound feelings of worthlessness.
Encourage patient to take charge of own life in a more healthful way by making own decisions and accepting self as she or he is at this moment (including inadequacies and strengths).	Patient often does not know what she or he may want for self. Parents (mother) often make decisions for patient. Patient may also believe she or he has to be the best in everything and holds self responsible for being perfect.
Let patient know that is acceptable to be different from family, particularly mother.	Developing a sense of identity separate from family and maintaining sense of control in other ways besides dieting and weight loss is a desirable goal of therapy/program.
Use cognitive-behavioral or interpersonal psychotherapy approach, rather than interpretive therapy.	Although both therapies have similar results, cognitive-behavioral seems to work more quickly. Interaction between persons is more helpful for patient to discover feelings/impulses/needs from within own self. Patient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior.
Encourage patient to express anger and acknowledge when it is verbalized.	Important to know that anger is part of self and as such is acceptable. Expressing anger may need to be taught to patient because anger is generally considered unacceptable in the family, and therefore patient does not express it.
Assist patient to learn strategies other than eating for dealing with feelings. Have patient keep a diary of feelings, particularly when thinking about food.	Feelings are the underlying issue, and patient often uses food instead of dealing with feelings appropriately. Patient needs to learn to recognize feelings and how to express them clearly.
Assess feelings of helplessness/hopelessness.	Lack of control is a common/underlying problem for this patient and may be accompanied by more serious emotional disorders. Note: Fifty-four percent of patients with anorexia have a history of major affective disorder, and 33% have a history of minor affective disorder.
Be alert to suicidal ideation/behavior.	Intense anxiety/panic about weight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if patient is impulsive.
Involve in group therapy.	Provides an opportunity to talk about feelings and try out new behaviors.
Refer to occupational/recreational therapy.	Can develop interest and skills to fill time that has been occupied by obsession with eating. Involvement in recreational activities encourages social interactions with others and promotes fun and relaxation.

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Disturbed Body Image — Ileostomy & Colostomy Nursing Care Plan (NCP)

June 16, 2012, 5:36 am

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IC-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

Body Image (NOC)

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.

10 Ileostomy & Colostomy Nursing Care Plan (NCP)

Disturbed Body Image — Ileostomy & Colostomy Nursing Care Plan (NCP)

Nursing Interventions	Rationale
Ascertain whether support and counseling were initiated when the possibility and/or necessity of ostomy was first discussed.	Provides information about patient’s/SO’s level of knowledge and anxiety about individual situation.
Encourage patient/SO to verbalize feelings regarding the ostomy. Acknowledge normality of feelings of anger, depression, and grief over loss. Discuss daily “ups and downs” that can occur.	Helps patient realize that feelings are not unusual and that feeling guilty about them is not necessary/helpful. Patient needs to recognize feelings before they can be dealt with effectively.
Review reason for surgery and future expectations.	Patient may find it easier to accept/deal with an ostomy done to correct chronic/long-term disease than for traumatic injury, even if ostomy is only temporary. Also, patient who will be undergoing a second procedure (to convert ostomy to a continent or anal reservoir) may possibly encounter less severe self-image problems because body function eventually will be “more normal.”
Note behaviors of withdrawal, increased dependency, manipulation, or noninvolvement in care.	Suggestive of problems in adjustment that may require further evaluation and more extensive therapy.
Provide opportunities for patient/SO to view and touch stoma, using the moment to point out positive signs of healing, normal appearance, and so forth. Remind patient that it will take time to adjust, both physically and emotionally.	Although integration of stoma into body image can take months or even years, looking at the stoma and hearing comments (made in a normal, matter-of-fact manner) can help patient with this acceptance. Touching stoma reassures patient/SO that it is not fragile and that slight movements of stoma actually reflect normal peristalsis.
Provide opportunity for patient to deal with ostomy through participation in self-care.	Independence in self-care helps improve self-confidence and acceptance of situation.
Plan/schedule care activities with patient.	Promotes sense of control and gives message that patient can handle situation, enhancing self-concept.
Maintain positive approach during care activities, avoiding expressions of disdain or revulsion. Do not take angry expressions of patient/SO personally.	Assists patient/SO to accept body changes and feel all right about self. Anger is most often directed at the situation and lack of control individual has over what has happened (powerlessness), not with the individual caregiver.
Ascertain patient’s desire to visit with a person with an ostomy. Make arrangements for visit, if desired.	A person who is living with an ostomy can be a good support system/role model. Helps reinforce teaching (shared experiences) and facilitates acceptance of change as patient realizes “life does go on” and can be relatively normal.

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10 Ileostomy & Colostomy Nursing Care Plans

June 16, 2012, 1:00 pm

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Ileostomy and Colostomy Nursing Care Plans (NCP)

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 Care Plans

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

Nursing Priorities

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

Discharge Goals

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

1. 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. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

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

Nursing Interventions	Rationale
Inspect stoma and peristomal skin area with each pouch change. Note irritation, bruises (dark, bluish color), rashes	Monitors healing process and effectiveness of appliances and identifies areas of concern, need for further evaluation and intervention. Early identification of stomal necrosis or ischemia or fungal infection (from changes in normal bowel flora) provides for timely interventions to prevent serious complications. Stoma should be red and moist. Ulcerated areas on stoma may be from a pouch opening that is too small or a faceplate that cuts into stoma. In patients with an ileostomy, the effluent is rich in enzymes, increasing the likelihood of skin irritation. In patient with a colostomy, skin care is not as great a concern because the enzymes are no longer present in the effluent.
Clean with warm water and pat dry. Use soap only if area is covered with sticky stool. If paste has collected on the skin, let it dry, then peel it off.	Maintaining a clean and dry area helps prevent skin breakdown.
Measure stoma periodically: at least weekly for first 6 wk, then once a month for 6 mo. Measure both width and length of stoma.	As postoperative edema resolves (during first 6 wk), the stoma shrinks and size of appliance must be altered to ensure proper fit so that effluent is collected as it flows from the ostomy and contact with the skin is prevented.
Verify that opening on adhesive backing of pouch is at least 1⁄16 to 1⁄8 in (2–3 mm) larger than the base of the stoma, with adequate adhesiveness left to apply pouch.	Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area prevents the skin barrier wafer from being too tight. Note: Too tight a fit may cause stomal edema or stenosis.
Use a transparent, odor-proof drainable pouch.	A transparent appliance during first 4–6 wk allows easy observation of stoma without necessity of removing pouch/irritating skin.
Apply appropriate skin barrier: hydrocolloid wafer, karaya gun, extended-wear skin barrier, or similar products.	Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of pouch when necessary. Note: Sigmoid colostomy may not require use of a skin barrier once stool becomes formed and elimination is regulated through irrigation.
Empty, irrigate, and cleanse ostomy pouch on a routine basis, using appropriate equipment.	Frequent pouch changes are irritating to the skin and should be avoided. Emptying and rinsing the pouch with the proper solution not only removes bacteria and odor-causing stool and flatus but also deodorizes the pouch.
Support surrounding skin when gently removing appliance. Apply adhesive removers as indicated, then wash thoroughly.	Prevents tissue irritation or destruction associated with “pulling” pouch off.
Investigate reports of burning, itching, or blistering around stoma.	Indicative of effluent leakage with peristomal irritation, or possibly Candida infection, requiring intervention.
Evaluate adhesive product and appliance fit on ongoing basis.	Provides opportunity for problem solving. Determines need for further intervention.
Consult with certified wound, ostomy, continence nurse.	Helpful in choosing products appropriate for patient’s particular rehabilitation needs, including type of ostomy, physical/mental status, abilities to handle self-care, and financial resources.
Apply corticosteroid aerosol spray and prescribed antifungal powder as indicated.	Assists in healing if peristomal irritation persists and/or fungal infection develops. Note: These products can have potent side effects and should be used sparingly.

2. 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.

Nursing Interventions	Rationale
Ascertain whether support and counseling were initiated when the possibility and/or necessity of ostomy was first discussed.	Provides information about patient’s/SO’s level of knowledge and anxiety about individual situation.
Encourage patient/SO to verbalize feelings regarding the ostomy. Acknowledge normality of feelings of anger, depression, and grief over loss. Discuss daily “ups and downs” that can occur.	Helps patient realize that feelings are not unusual and that feeling guilty about them is not necessary or helpful. Patient needs to recognize feelings before they can be dealt with effectively.
Review reason for surgery and future expectations.	Patient may find it easier to accept or deal with an ostomy done to correct chronic or long-term disease than for traumatic injury, even if ostomy is only temporary. Also, patient who will be undergoing a second procedure (to convert ostomy to a continent or anal reservoir) may possibly encounter less severe self-image problems because body function eventually will be “more normal.”
Note behaviors of withdrawal, increased dependency, manipulation, or non involvement in care.	Suggestive of problems in adjustment that may require further evaluation and more extensive therapy.
Provide opportunities for patient/SO to view and touch stoma, using the moment to point out positive signs of healing, normal appearance, and so forth. Remind patient that it will take time to adjust, both physically and emotionally.	Although integration of stoma into body image can take months or even years, looking at the stoma and hearing comments (made in a normal, matter-of-fact manner) can help patient with this acceptance. Touching stoma reassures patient/SO that it is not fragile and that slight movements of stoma actually reflect normal peristalsis.
Provide opportunity for patient to deal with ostomy through participation in self-care.	Independence in self-care helps improve self-confidence and acceptance of situation.
Plan/schedule care activities with patient.	Promotes sense of control and gives message that patient can handle situation, enhancing self-concept.
Maintain positive approach during care activities, avoiding expressions of disdain or revulsion. Do not take angry expressions of patient and SO personally.	Assists patient and SO to accept body changes and feel all right about self. Anger is most often directed at the situation and lack of control individual has over what has happened (powerlessness), not with the individual caregiver.
Ascertain patient’s desire to visit with a person with an ostomy. Make arrangements for visit, if desired.	A person who is living with an ostomy can be a good support system/role model. Helps reinforce teaching (shared experiences) and facilitates acceptance of change as patient realizes “life does go on” and can be relatively normal.

3. Acute Pain

Nursing Diagnosis

Acute Pain

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.

Nursing Interventions	Rationale
Assess pain, noting location, characteristics, intensity (0–10 scale).	Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. Note: Pain in anal area associated with abdominal-perineal resection may persist for months.
Encourage patient to verbalize concerns. Active-listen these concerns, and provide support by acceptance, remaining with patient, and giving appropriate information.	Reduction of anxiety/fear can promote relaxation or comfort.
Provide comfort measures, e.g., mouth care, back rub, repositioning (use proper support measures as needed). Assure patient that position change will not injure stoma.	Prevents drying of oral mucosa and associated discomfort. Reduces muscle tension, promotes relaxation, and may enhance coping abilities.
Encourage use of relaxation techniques, e.g., guided imagery, visualization. Provide diversional activities.	Helps patient rest more effectively and refocuses attention, thereby reducing pain and discomfort.
Assist with ROM exercises and encourage early ambulation. Avoid prolonged sitting position.	Reduces muscle/joint stiffness. Ambulation returns organs to normal position and promotes return of usual level of functioning. Note: Presence of edema, packing, and drains (if perineal resection has been done) increases discomfort and creates a sense of needing to defecate. Ambulation and frequent position changes reduce perineal pressure.
Investigate and report abdominal muscle rigidity, involuntary guarding, and rebound tenderness.	Suggestive of peritoneal inflammation, which requires prompt medical intervention.
Administer medication as indicated, e.g., narcotics, analgesics, patient-controlled analgesia (PCA).	Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial, especially following anal-perineal repair.
Provide sitz baths.	Relieves local discomfort, reduces edema, and promotes healing of perineal wound.
Apply/monitor effects of transcutaneous electrical nerve stimulator (TENS) unit.	Cutaneous stimulation may be used to block transmission of pain stimulus.

4. 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.

Nursing Interventions	Rationale
Observe wounds, note characteristics of drainage.	Postoperative hemorrhage is most likely to occur during first 48 hr, whereas infection may develop at any time. Depending on type of wound closure (e.g., first or second intention), complete healing may take 6-8 mo.
Change dressings as needed using aseptic technique	Large amounts of serous drainage require that dressings be changed frequently to reduce skin irritation and potential for infection.
Encourage side-lying position with head elevated. Avoid prolonged sitting.	Promotes drainage from perineal wound/drains, reducing risk of pooling. Prolonged sitting increases perineal pressure, reducing circulation to wound, and may delay healing.
Irrigate wound as indicated, using normal saline (NS), diluted hydrogen peroxide, or antibiotic solution.	May be required to treat preoperative inflammation and/or infection or intraoperative contamination.
Provide sitz baths.	Promotes cleanliness and facilitates healing, especially after packing is removed (usually day 3–5).

5. 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. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

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.

Nursing Interventions	Rationale
Monitor intake and output (I&O) carefully, measure liquid stool. Weigh regularly.	Provides direct indicators of fluid balance. Greatest fluid losses occur with ileostomy, but they generally do not exceed 500–800 mL/day.
Monitor vital signs, noting postural hypotension, tachycardia. Evaluate skin turgor, capillary refill, and mucous membranes.	Reflects hydration status and/or possible need for increased fluid replacement.
Limit intake of ice chips during period of gastric intubation.	Ice chips can stimulate gastric secretions and wash out electrolytes.
Monitor laboratory results, e.g., Hct and electrolytes	Detects homeostasis or imbalance, and aids in determining replacement needs
Administer IV fluid and electrolytes as indicated.	May be necessary to maintain adequate tissue perfusion/organ function.

6. 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.

Nursing Interventions	Rationale
Obtain a thorough nutritional assessment.	Identifies deficiencies/needs to aid in choice of interventions.
Auscultate bowel sounds.	Return of intestinal function indicates readiness to resume oral intake.
Resume solid foods slowly.	Reduces incidence of abdominal cramps, nausea.
Identify odor-causing foods (e.g., cabbage, fish, beans) and temporarily restrict from diet. Gradually reintroduce one food at a time.	Sensitivity to certain foods is not uncommon following intestinal surgery. Patient can experiment with food several times before determining whether it is creating a problem.
Recommend patient increase use of yogurt, buttermilk, and acidophilus preparations.	May help prevent gas and decrease odor formation.
Suggest patient with ileostomy limit prunes, dates, stewed apricots, strawberries, grapes, bananas, cabbage family, beans, and avoid foods high in cellulose, e.g., peanuts.	These products increase ileal effluent. Digestion of cellulose requires colon bacteria that are no longer present.
Discuss mechanics of swallowed air as a factor in the formation of flatus and some ways patient can exercise control.	Drinking through a straw, snoring, anxiety, smoking, ill-fitting dentures, and gulping down food increase the production of flatus. Too much flatus not only necessitates frequent emptying, but also can cause leakage from too much pressure within the pouch.

7. 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. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

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.

Nursing Interventions	Rationale
Determine patient’s/SO’s sexual relationship before the disease and/or surgery and whether they anticipate problems related to presence of ostomy.	Identifies future expectations and desires. Mutilation and loss of privacy and/or control of a bodily function can affect patient’s view of personal sexuality. When coupled with the fear of rejection by SO, the desired level of intimacy can be greatly impaired. Sexual needs are very basic, and patient will be rehabilitated more successfully when a satisfying sexual relationship is continued and/or developed as desired.
Review with patient and/or SO sexual functioning in relation to own situation.	Understanding if nerve damage has altered normal sexual functioning helps patient/SO to understand the need for exploring alternative methods of satisfaction.
Reinforce information given by the physician. Encourage questions. Provide additional information as needed.	Reiteration of data previously given assists patient/SO to hear and process the knowledge again, moving toward acceptance of individual limitations or restrictions and prognosis (that it may take up to 2 yr to regain potency after a radical procedure or that a penile prosthesis may be necessary).
Discuss likelihood of resumption of sexual activity in approximately 6 wk after discharge, beginning slowly and progressing (cuddling, caressing until both partners are comfortable with body image and/or function changes). Include alternative methods of stimulation as appropriate.	Knowing what to expect in progress of recovery helps patient avoid performance anxiety and/or reduce risk of “failure.” If the couple is willing to try new ideas, this can assist with adjustment and may help to achieve sexual fulfillment.
Encourage dialogue between partners. Suggest wearing pouch cover, T-shirt, shortie nightgown, or underwear sexual activity.	Disguising ostomy appliance may aid in reducing feelings of self-consciousness, embarrassment during specifically designed for sexual contact.
Stress awareness of factors that might be distracting (unpleasant odors and pouch leakage). Encourage use of sense of humor.	Promotes resolution of solvable problems. Laughter can help individuals deal more effectively with difficult situation, promote positive sexual experience.
Problem-solve alternative positions for coitus.	Minimizing awkwardness of appliance and physical discomfort can enhance satisfaction.
Discuss or role play possible interactions or approaches when dealing with new sexual partners.	Rehearsal is helpful in dealing with actual situations when they arise, preventing self-consciousness about “different” body image.
Provide birth control information as appropriate and stress that impotence does not necessarily mean patient is sterile.	Confusion may exist that can lead to an unwanted pregnancy.
Arrange meeting with an ostomy visitor if appropriate.	Sharing of how these problems have been resolved by others can be helpful and reduce sense of isolation.
Refer to sex counseling or therapy if appropriate.	If problems persist longer than several months after surgery, a trained therapist may be required to facilitate communication between patient and SO.

8. 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.

Nursing Interventions	Rationale
Explain necessity to monitor intestinal function in early postoperative period.	Patient is more apt to be tolerant of disturbances by staff if he or she understands the reasons for or importance of care.
Provide necessary pouching system. Empty pouch before retiring and on a pre-agreed schedule.	Excessive flatus can occur despite interventions. Emptying on a regular schedule minimizes threat of leakage.
Let patient know that stoma will not be injured when sleeping.	Helps the patient to rest better if he is secure about stoma and ostomy function.
Restrict intake of caffeine containing foods or fluid.	Caffeine may delay patient’s falling asleep and interfere with REM (rapid eye movement) sleep, resulting in patient not feeling well rested.
Support continuation of usual bedtime rituals.	Promotes relaxation and readiness for sleep.
Determine cause of excessive flatus or effluent. Confer with dietitian regarding restriction of foods if diet-related.	Identification of cause enables institution of corrective measures that may promote sleep/rest.
Administer analgesics, sedatives at bedtime as indicated	Pain can interfere with patient’s ability to fall or remain asleep. Timely medication can enhance rest and sleep during initial postoperative period. Note: Pain pathways in the brain lie near the sleep center and may contribute to wakefulness.

9. Constipation/Diarrhea

Nursing Diagnosis

Risk for Constipation or Diarrhea

Risk factors may include

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

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

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

Nursing Interventions	Rationale
Ascertain patient’s previous bowel habits and lifestyle.	Assists in formulation of a timely or effective irrigating schedule for patient with a colostomy, if appropriate.
Investigate delayed onset or absence of effluent. Auscultate bowel sounds.	Postoperative paralytic and/or adynamic ileus usually resolves within 48–72 hr, and ileostomy should begin draining within 12–24 hr. Delay may indicate persistent ileus or stomal obstruction, which may occur postoperatively because of edema, improperly fitting pouch (too tight), prolapse, or stenosis of the stoma.
Inform patient with an ileostomy that initially the effluent is liquid. If constipation occurs, it should be reported to enterostomal nurse or physician.	Although the small intestine eventually begins to take on water-absorbing functions to permit a more semi solid, pasty discharge, constipation may indicate an obstruction. Absence of stool requires emergency medical attention.
Review dietary pattern and amount, type of fluid intake.	Adequate intake of fiber and roughage provides bulk, and fluid is an important factor in determining the consistency of the stool.
Review physiology of the colon and discuss irrigation management of sigmoid ostomy, if appropriate.	This knowledge helps patient understand individual care needs.
Demonstrate use of irrigation equipment per institution policy or under guidance of physician or certified wound, ostomy, continence nurse.	Irrigations may be done on a daily basis if appropriate, although there are differing views on this practice. Many believe cleaning the bowel on a regular basis is helpful. Others believe that this interferes with normal functioning.
Instruct patient in the use of closed-end pouch or a patch, dressing or Band-Aid when irrigation is successful and the sigmoid colostomy effluent becomes more manageable, with stool expelled every 24 hr.	Enables patient to feel more comfortable socially and is less expensive than regular ostomy pouches.
Involve patient in care of the ostomy on an increasing basis.	Rehabilitation can be facilitated by encouraging patient independence and control.
Instruct in use of TENS unit if indicated.	Electrical stimulation has been used in some patients to stimulate peristalsis and relieve postoperative ileus.

10. Knowledge Deficit

Nursing Diagnosis

Knowledge, deficient 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.

Nursing Interventions	Rationale
Evaluate patient’s emotional, cognitive, and physical capabilities.	These factors affect patient’s ability to master care-tasks and willingness to assume responsibility for ostomy care.
Include written, picture (photo, video, Internet) learning resources.	Provides references for obtaining support, equipment, and additional information after discharge to support patient efforts for independence in self-care.
Review anatomy, physiology, and implications of surgical intervention. Discuss future expectations, including anticipated changes in character of effluent.	Provides knowledge base from which patient can make informed choices, and offers an opportunity to clarify misconceptions regarding individual situation.
Instruct patient/SO in stomal care. Allot time for return demonstrations and provide positive feedback for efforts.	Promotes positive management and reduces risk of improper ostomy care and development of complications.
Recommend increased fluid intake during warm weather months.	Loss of normal colon function of conserving water and electrolytes can lead to dehydration and constipation.
Discuss possible need to decrease salt intake.	Salt can increase ileal output, potentiating risk of dehydration and increasing frequency of ostomy care needs and/or patient’s inconvenience.
Identify symptoms of electrolyte depletion: anorexia, abdominal muscle cramps, feelings of faintness or “cold” in arms, legs, general fatigue, weakness, bloating, decreased sensations in arms or legs.	Loss of colon function altering fluid and electrolyte absorption may result in sodium or potassium deficits requiring dietary correction with foods and fluids high in sodium (bouillon, Gatorade) or potassium (orange juice, prunes, tomatoes, bananas, Gatorade).
Discuss need for periodic evaluation and administration of supplemental vitamins and minerals as appropriate.	Depending on portion and amount of bowel resected, lack of absorption may cause deficiencies.
Stress importance of chewing food well, adequate intake of fluids with or following meals, only moderate use of high-fiber foods, avoidance of cellulose.	Reduces risk of bowel obstruction, especially in patient with ileostomy.
Review foods that may be a source of flatus. For example: carbonated drinks, beans, beer, cabbages, onions, fish and highly seasoned food.	These foods may be restricted or eliminated, based on individual reaction, for better ostomy control, or it may be necessary to empty the pouch more frequently if they are ingested.
Identify foods associated with diarrhea, such as green beans, broccoli, highly seasoned foods.	Promotes more even effluent and better control of evacuations.
Recommend foods used to manage constipation (bran, celery, raw fruits), and discuss importance of increased fluid intake.	Proper management can prevent or minimize problems of constipation.
Discuss resumption of presurgery level of activity. Suggest emptying the ostomy appliance before leaving home and carrying a fanny pack with fresh supplies. Recommend resources for obtaining attractive appliances and decorative cummerbunds as appropriate.	With a little planning, patient should be able to manage same degree of activity as previously enjoyed and in some cases increase activity level. A cummerbund can provide both physical and psychological support when patient is involved in activities such as tennis and swimming.
Talk about the possibility of sleep disturbance, anorexia, loss of interest in usual activities.	“Homecoming depression” may occur, lasting for months after surgery, requiring patience and support and ongoing evaluation as patient adjusts to living with a stoma.
Explain necessity of notifying healthcare providers and pharmacists of type of ostomy and avoidance of sustained-release medications.	Presence of ostomy may alter rate and extent of absorption of oral medications and increase risk of drug-related complications, e.g., diarrhea or constipation or peristomal excoriation. Liquid, chewable, or injectable forms of medication are preferred for patients with ileostomy to maximize absorption of drug.
Counsel patient concerning medication use and problems associated with altered bowel function. Refer to pharmacist for teaching and/or advice as appropriate.	Patient with an ostomy has two key problems: altered disintegration and absorption of oral drugs and unusual or pronounced adverse effects. Some of the medications that these patients may respond to differently include laxatives, salicylates, H₂receptor antagonists, antibiotics, and diuretics.
Discuss effect of medications on effluent, i.e., changes in color, odor, consistency of stool, and need to observe for drug residue indicating incomplete absorption	Understanding decreases anxiety regarding intestinal function and enhances independence in self-care.
Stress necessity of close monitoring of chronic health conditions requiring routine oral medications.	Monitoring of clinical symptoms and serum blood levels is indicated because of altered drug absorption requiring periodic dosage adjustments.

Other Nursing Care Plans

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

11 Burn Injury Nursing Care Plans

July 14, 2013, 2:00 am

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A burn injury is damage to your body’s tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.

A major burn is a catastrophic injury, requiring painful treatment and long period of rehabilitation. It’s commonly fatal or permanently disfiguring and incapacitating (both emotionally and physically).

Nursing Care Plans

Here are 11 burn injury nursing care plans (NCP).

1. Impaired Physical Mobility

May be related to

Neuromuscular impairment, pain/discomfort, decreased strength and endurance
Restrictive therapies, limb immobilization; contractures

Possibly evidenced by

Reluctance to move/inability to purposefully move
Limited ROM, decreased muscle strength control and/or mass

Desired Outcomes

Maintain position of function as evidenced by absence of contractures.
Maintain or increase strength and function of affected and/or compensatory body part.
Verbalize and demonstrate willingness to participate in activities.
Demonstrate techniques/behaviors that enable resumption of activities.

Nursing Interventions	Rationale
Maintain proper body alignment with supports or splints, especially for burns over joints.	Promotes functional positioning of extremities and prevents contractures, which are more likely over joints.
Note circulation, motion, and sensation of digits frequently.	Edema may compromise circulation to extremities, potentiating tissue necrosis and development of contractures.
Initiate the rehabilitative phase on admission.	It is easier to enlist participation when patient is aware of the possibilities that exist for recovery.
Perform ROM exercises consistently, initially passive, then active.	Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
Medicate for pain before activity or exercise.	Reduces muscle and tissue stiffness and tension, enabling patient to be more active and facilitating participation.
Schedule treatments and care activities to provide periods of uninterrupted rest.	Increases patient’s strength and tolerance for activity.
Encourage family/SO support and assistance with ROM exercises.	Enables family/SO to be active in patient care and provides more consistent therapy.
Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.	Combining activities produces improved results by enhancing effects of each.
Encourage patient participation in all activities as individually able.	Promotes independence, enhances self-esteem, and facilitates recovery process.
Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.	Combining activities produces improved results by enhancing effects of each.
Encourage patient participation in all activities as individually able.	Promotes independence, enhances self-esteem, and facilitates recovery process.

2. Knowledge Deficit

May be related to

Lack of exposure/recall
Information misinterpretation; unfamiliarity with 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.
Verbalize understanding of therapeutic needs.
Correctly perform necessary procedures and explain reasons for actions.
Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Interventions	Rationale
Review condition, prognosis, and future expectations.	Provides knowledge base from which patient can make informed choices.
Discuss patient’s expectations of returning home, to work, and to normal activities.	Patient frequently has a difficult and prolonged adjustment after discharge. Problems often occur (sleep disturbances, nightmares, reliving the accident, difficulty with resumption of social interactions, intimacy and sexual activity, emotional lability) that interfere with successful adjustment to resuming normal life.
Review and have patient/SO demonstrate proper burn, skin-graft, and wound care techniques. Identify appropriate sources for outpatient care and supplies.	Promotes competent self-care after discharge, enhancing independence.
Discuss skin care. Teach proper use of moisturizers, sunscreens, and anti-itching medications.	Itching, blistering, and sensitivity of healing wounds or graft sites can be expected for an extended time, and injury can occur because of the fragility of the new tissue.
Explain scarring process and necessity for and proper use of pressure garments when used.	Promotes optimal regrowth of skin, minimizing development of hypertrophic scarring and contractures and facilitating healing process. Note: Consistent use of the pressure garment over a long period can reduce the need for reconstructive surgery to release contractures and remove scars.
Encourage continuation of prescribed exercise program and scheduled rest periods.	Maintains mobility, reduces complications, and prevents fatigue, facilitating recovery process.
Identify specific limitations of activity as individually appropriate.	Imposed restrictions depend on severity and location of injury and stage of healing.
Emphasize importance of sustained intake of high-protein and high-calorie meals and snacks.	Optimal nutrition enhances tissue regeneration and general feeling of well-being. Note: Patient often needs to increase caloric intake to meet calorie and protein needs for healing.
Review medications, including purpose, dosage, route, and expected and/or reportable side effects.	Reiteration allows opportunity for patient to ask questions and be sure understanding is accurate.
Advise patient and/or SO of potential for exhaustion, boredom, emotional lability, adjustment problems. Provide information about possibility of discussion with appropriate professional counselors.	Provides perspective to some of the problems patient and/or SO may encounter, and aids awareness that assistance is available when necessary.
Identify signs and symptoms requiring medical evaluation: inflammation, increase or changes in wound drainage, fever/chills; changes in pain characteristics or loss of mobility and/or function.	Early detection of developing complications (infection, delayed healing) may prevent progression to more serious or life-threatening situations.
Stress importance of follow-up care and rehabilitation.	Long-term support with continual reevaluation and changes in therapy is required to achieve optimal recovery.
Provide phone number for contact person.	Provides easy access to treatment team to reinforce teaching, clarify misconceptions, and reduce potential for complications.
Ensure patient’s immunizations are current, especially tetanus.	To prevent further injury.
Identify community resources: skin or wound care professionals, crisis centers, recovery groups, mental health, Red Cross, visiting nurse, Amblicab, homemaker service.	Facilitates transition to home, provides assistance with meeting individual needs, and supports independence.

3. Disturbed Body Image

May be related to

Situational crisis: traumatic event, dependent patient role; disfigurement, pain

Possibly evidenced by

Negative feelings about body/self, fear of rejection/reaction by others
Focus on past appearance, abilities; preoccupation with change/loss
Change in physical capacity to resume role; change in social involvement

Desired Outcomes

Incorporate changes into self-concept without negating self-esteem.
Verbalize acceptance of self in situation.
Talk with family/SO about situation, changes that have occurred.
Develop realistic goals/plans for the future.

Nursing Interventions	Rationale
Assess meaning of loss or change to patient and SO, including future expectations and impact of cultural or religious beliefs.	Traumatic episode results in sudden, unanticipated changes, creating feelings of grief over actual or perceived losses. This necessitates support to work through to optimal resolution.
Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial.	Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push patient before ready to deal with situation. Denial may be prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems.
Set limits on maladaptive behavior. Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery.	Patient and SO tend to deal with this crisis in the same way in which they have dealt with problems in the past. Staff may find it difficult and frustrating to handle behavior that is disrupting and not helpful to recuperation but should realize that the behavior is usually directed toward the situation and not the caregiver.
Be realistic and positive during treatments, in health teaching, and in setting goals within limitations.	Enhances trust and rapport between patient and nurse.
Encourage patient and SO to view wounds and assist with care as appropriate.	Promotes acceptance of reality of injury and of change in body and image of self as different.
Provide hope within parameters of individual situation; do not give false reassurance.	Promotes positive attitude and provides opportunity to set goals and plan for future based on reality.
Assist patient to identify extent of actual change in appearance and body function.	Helps begin process of looking to the future and how life will be different.
Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals.	Words of encouragement can support development of positive coping behaviors.
Show pictures or videos of burn care and/or other patient outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what patient has seen.	Allows patient and SO to be realistic in expectations. Also assists in demonstration of importance of and/or necessity for certain devices and procedures.
Encourage family interaction with each other and with rehabilitation team.	To opens lines of communication and provides ongoing support for patient and family.
Provide support group for SO. Give information about how SO can be helpful to patient.	Promotes ventilation of feelings and allows for more helpful responses to patient.
Role-play social situations of concern to patient.	Prepares patient and SO for reactions of others and anticipates ways to deal with them.
Refer to physical and occupational therapy, vocational counselor, psychiatric counseling, clinical specialist psychiatric nurse, social services, and psychologist, as needed.	Helpful in identifying ways/devices to regain and maintain independence. Patient may need further assistance to resolve persistent emotional problems.
Provide referral to reconstructive surgeon for the patient disfigured by burns.	Reconstructive surgery can help patient gain self-esteem and confidence.
Provide through teaching and complete aftercare instructions for the patient. Stress importance of keeping the dressing dry and clean, elevating	Reinforcing teaching can help patient achieve self-care.

4. Fear/Anxiety

May be related to

Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement

Possibly evidenced by

Expressed concern regarding changes in life, fear of unspecific consequences
Apprehension; increased tension
Feelings of helplessness, uncertainty, decreased self-assurance
Sympathetic stimulation, extraneous movements, restlessness, insomnia

Desired Outcomes

Verbalize awareness of feelings and healthy ways to deal with them.
Report anxiety/fear reduced to manageable level.
Demonstrate problem-solving skills, effective use of resources.

Nursing Interventions	Rationale
Give frequent explanations and information about care procedures. Repeat information as needed.	Knowing what to expect usually reduces fear and anxiety, clarifies misconceptions, and promotes cooperation. Because of the shock of the initial trauma, many people do not recall information provided during that time.
Demonstrate willingness to listen and talk to patient when free of painful procedures.	Helps patient and SO know that support is available and that healthcare provider is interested in the person, not just care of the burn.
Involve patient and SO in decision making process whenever possible. Provide time for questioning and repetition of proposed treatments.	Promotes sense of control and cooperation, decreasing feelings of helplessness or hopelessness.
Assess mental status, including mood and affect, comprehension of events, and content of thoughts.	Initially, patient may use denial and repression to reduce and filter information that might be overwhelming. Some patients display calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism.
Investigate changes in mentation and presence of hypervigilance, hallucinations, sleep disturbances, nightmares, agitation, apathy, disorientation, and labile affect, all of which may vary from moment to moment.	Indicators of extreme anxiety and delirium state in which patient is literally fighting for life. Although cause can be psychologically based, pathological life-threatening causes must be ruled out.
Provide constant and consistent orientation.	Helps patient stay in touch with surroundings and reality.
Encourage patient to talk about the burn circumstances when ready.	Patient may need to tell the story of what happened over and over to make some sense out of a terrifying situation. Adjustment to the impact of the trauma, grief over losses and disfigurement can easily lead to clinical depression, psychosis, and posttraumatic stress disorder (PTSD).
Explain to patient what happened. Provide opportunity for questions and give honest answers.	Compassionate statements reflecting the reality of the situation can help patient and SO acknowledge that reality and begin to deal with what has happened.
Identify previous methods of coping and handling of stressful situations.	Past successful behavior can be used to assist in dealing with the present situation.
Create a restful environment, use guided imagery and relaxation exercises.	Patients experience severe anxiety associated with burn trauma and treatment. These interventions are soothing and helpful for positive outcomes.
Assist the family to express their feelings of grief and guilt.	The family may initially be most concerned about patient’s dying and/or feel guilty, believing that in some way they could have prevented the incident.
Be empathic and nonjudgmental in dealing with patient and family.	Family relationships are disrupted; financial, lifestyle or role changes make this a difficult time for those involved with patient, and they may react in many different ways.
Encourage family/SO to visit and discuss family happenings. Remind patient of past and future events.	Maintains contact with a familiar reality, creating a sense of attachment and continuity of life.
Involve entire burn team in care from admission to discharge, including social worker and psychiatric resources.	Provides a wider support system and promotes continuity of care and coordination of activities.

5. Impaired Skin Integrity

May be related to

Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting

Possibly evidenced by

Absence of viable tissue

Desired Outcomes

Wound Healing: Secondary Intention (NOC)
Demonstrate tissue regeneration.
Achieve timely healing of burned areas.

Nursing Interventions	Rationale
Assess and document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin.	Provides baseline information about need for skin grafting and possible clues about circulation in area to support graft.
Provide appropriate burn care and infection control measures.	Prepares tissues for grafting and reduces risk of infection/graft failure.
Maintain wound covering as indicated
Biosynthetic dressing (Biobrane);	Nylon fabric and/or silicon membrane containing collagenous porcine peptides that adheres to wound surface until removed or sloughed off by spontaneous skin reepithelialization. Useful for eschar-free partial-thickness burns awaiting autografts because it can remain in place 2–3 wk or longer and is permeable to topical antimicrobial agents.
Synthetic dressings: DuoDerm;	Hydroactive dressing that adheres to the skin to cover small partial-thickness burns and that interacts with wound exudate to form a soft gel that facilitates debridement.
Opsite, Acuderm.	Thin, transparent, elastic, waterproof, occlusive dressing (permeable to moisture and air) that is used to cover clean partial-thickness wounds and clean donor sites. Reduces swelling/limits risk of graft separation.
Elevate grafted area if possible. Maintain desired position and immobility of area when indicated.	Movement of tissue under graft can dislodge it, interfering with optimal healing.
Maintain dressings over newly grafted area and/or donor site as indicated: mesh, petroleum, nonadhesive.	Areas may be covered by translucent, nonreactive surface material (between graft and outer dressing) to eliminate shearing of new epithelium and protect healing tissue. The donor site is usually covered for 4–24 hr, then bulky dressings are removed and fine mesh gauze is left in place.
Keep skin free from pressure	Promotes circulation and prevents ischemia or necrosis and graft failure.
Evaluate color of grafted and donor site(s); note presence or absence of healing.	Evaluates effectiveness of circulation and identifies developing complications.
Wash sites with mild soap, rinse, and lubricate with cream several times daily after dressings are removed and healing is accomplished.	Newly grafted skin and healed donor sites require special care to maintain flexibility.
Aspirate blebs under sheet grafts with sterile needle or roll with sterile swab.	Fluid-filled blebs prevent graft adherence to underlying tissue, increasing risk of graft failure.
Prepare for/assist with surgical grafting or biological dressings:
Homograft (allograft);	Skin grafts obtained from living persons or cadavers are used as a temporary covering for extensive burns until person’s own skin is ready for grafting (test graft), to cover excised wounds immediately after escharotomy, or to protect granulation tissue.
Heterograft (xenograft, porcine);	Skin grafts may be carried out with animal skin for the same purposes as homografts or to cover meshed autografts.
Cultured epithelial autograft (CEA);	Skin graft obtained from uninjured part of patient’s own skin and prepared in a laboratory; may be full-thickness or partial-thickness. Note: This process takes 20–30 days from harvest to application. The new CEA sheets are 1–6 cell layers thick and thus are very fragile.
Artificial skin (Integra).	Wound covering approved by the Food and Drug Administration (FDA) for full-thickness and deep partial-thickness burns. It provides a permanent, immediate covering that reproduces the skin’s normal functions and stimulates the regeneration of dermal tissue.

6. Imbalanced Nutrition

May be related to

Hypermetabolic state (can be as much as 50%–60% higher than normal proportional to the severity of injury)
Protein catabolism
Anorexia, restricted oral intake

Possibly evidenced by

Decrease in total body weight, loss of muscle mass/subcutaneous fat, and development of negative nitrogen balance

Desired Outcomes

Demonstrate nutritional intake adequate to meet metabolic needs as evidenced by stable weight/muscle-mass measurements, positive nitrogen balance, and tissue regeneration.

Nursing Interventions	Rationale
Auscultate bowel sounds. Note hypoactive or absent bowel sounds.	Ileus is often associated with postburn period but usually subsides within 36–48 hr, at which time oral feedings can be initiated.
Maintain strict calorie count. Weigh daily. Reassess percentage of open body surface area and wounds weekly.	Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As burn wound heals, percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.
Monitor muscle mass and subcutaneous fat as indicated.	Indirect calorimetry, if available, may be useful in more accurately estimating body reserves or losses and effectiveness of therapy.
Provide small, frequent meals and snacks.	Helps prevent gastric distension or discomfort and may enhance intake.
Encourage patient to view diet as a treatment and to make food or beverage choices high in calories and protein.	Calories and proteins are needed to maintain weight, meet metabolic needs, and promote wound healing.
Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate.	Provides patient or SO sense of control; enhances participation in care and may improve intake.
Encourage patient to sit up for meals and visit with others.	Sitting helps prevent aspiration and aids in proper digestion of food. Socialization promotes relaxation and may enhance intake.
Provide oral hygiene before meals.	Clean mouth and clean palate enhances taste and helps promote a good appetite.
Insert nasogastric tube, as indicated.	To decompress the stomach and avoid aspiration of stomach contents.
Perform fingerstick glucose, urine testing as indicated.	Monitors for development of hyperglycemia related to hormonal changes or demands or use of hyperalimentation to meet caloric needs.
Refer to dietitian or nutrition support team.	Useful in establishing individual nutritional needs (based on weight and body surface area of injury) and identifying appropriate routes.
Provide diet high in calories or protein with trace elements and vitamin supplements.	Calories (3000–5000 per day), proteins, and vitamins are needed to meet increased metabolic needs, maintain weight, and encourage tissue regeneration. Note: Oral route is preferable once GI function returns.
Insert and maintain small feeding tube for enteral feedings and supplements if needed.	Provides continuous supplemental feedings when patient is unable to consume total daily calorie requirements orally. Note: Continuous tube feeding during the night increases calorie intake without decreasing appetite and oral intake during the day.
Administer parenteral nutrition solutions containing vitamins and minerals, as indicated.	Total parenteral nutrition (TPN) maintains nutritional intake and meets metabolic needs in presence of severe complications or sustained esophageal or gastric injuries that do not permit enteral feedings.
Monitor laboratory studies: serum albumin, prealbumin, Cr, transferrin, urine urea nitrogen.	Indicators of nutritional needs and adequacy of diet/therapy.
Administer insulin as indicated.	Elevated serum glucose levels may develop because of stress response to injury, high caloric intake, pancreatic fatigue.

7. Ineffective Tissue Perfusion

Risk factors may include

Reduction/interruption of arterial/venous blood flow, e.g., circumferential burns of extremities with resultant edema
Hypovolemia

Desired Outcomes

Maintain palpable peripheral pulses

Nursing Interventions	Rationale
Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities with circumferential burns. Compare with findings of unaffected limb.	Edema formation can readily compress blood vessels, thereby impeding circulation and increasing venous stasis or edema. Comparisons with unaffected limbs aid in differentiating localized versus systemic problems (hypovolemia or decreased cardiac output).
Elevate affected extremities, as appropriate. Remove jewelry or arm bands Avoid taping around a burned area.	Promotes systemic circulation and venous return that may reduce edema or other deleterious effects of constriction of edematous tissues. Prolonged elevation can impair arterial perfusion if blood pressure (BP) falls or tissue pressures rise excessively.
Obtain BP in unburned extremity when possible. Remove BP cuff after each reading, as indicated.	If BP readings must be obtained on an injured extremity, leaving the cuff in place may increase edema formation and reduce perfusion, and convert partial thickness burn to a more serious injury.
Investigate reports of deep or throbbing ache, numbness.	Indicators of decreased perfusion and/or increased pressure within enclosed space, such as may occur with a circumferential burn of an extremity (compartment syndrome).
Encourage active ROM exercises of unaffected body parts.	Promotes local and systemic circulation.
Investigate irregular pulses	Cardiac dysrhythmias can occur as a result of electrolyte shifts, electrical injury, or release of myocardial depressant factor, compromising cardiac output.
Maintain fluid replacement per protocol.	Maximizes circulating volume and tissue perfusion.
Monitor electrolytes, especially sodium, potassium, and calcium. Administer replacement therapy as indicated.	Losses or shifts of these electrolytes affect cellular membrane potential and excitability, thereby altering myocardial conductivity, potentiating risk of dysrhythmias, and reducing cardiac output and tissue perfusion.
Avoid use of IM/SC injections.	Altered tissue perfusion and edema formation impair drug absorption. Injections into potential donor sites may render them unusable because of hematoma formation.
Measure intracompartmental pressures as indicated.	Ischemic myositis may develop because of decreased perfusion.
Assist and prepare for escharotomy or fasciotomy, as indicated.	Enhances circulation by relieving constriction caused by rigid, nonviable tissue (eschar) or edema formation.

8. Acute Pain

May be related to

Destruction of skin/tissues; edema formation
Manipulation of injured tissues, e.g., wound debridement

Possibly evidenced by

Reports of pain
Narrowed focus, facial mask of pain
Alteration in muscle tone; autonomic responses
Distraction/guarding behaviors; anxiety/fear, restlessness

Desired Outcomes

Report pain reduced/controlled.
Display relaxed facial expressions/body posture.
Participate in activities and sleep/rest appropriately.

Nursing Interventions	Rationale
Cover wounds as soon as possible unless open-air exposure burn care method required.	Temperature changes and air movement can cause great pain to exposed nerve endings.
Elevate burned extremities periodically.	Elevation may be required initially to reduce edema formation; thereafter, changes in position and elevation reduce discomfort and risk of joint contractures.
Provide bed cradle as indicated.	Elevation of linens off wounds may help reduce pain.
Wrap digits or extremities in position of function (avoiding flexed position of affected joints) using splints and foot boards as necessary.	Position of function reduces deformities or contractures and promotes comfort. Although flexed position of injured joints may feel more comfortable, it can lead to flexion contractures.
Change position frequently and assist with active and passive ROM as indicated.	Movement and exercise reduce joint stiffness and muscle fatigue, but type of exercise depends on location and extent of injury.
Maintain comfortable environmental temperature, provide heat lamps, heat retaining body coverings.	Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling.
Assess reports of pain, noting location and character and intensity (0–10 scale).	Pain is nearly always present to some degree because of varying severity of tissue involvement and destruction but is usually most severe during dressing changes and debridement. Changes in location, character, intensity of pain may indicate developing complications (limb ischemia) or herald improvement and/or return of nerve function and sensation.
Provide medication and/or place in hydrotherapy (as appropriate) before performing dressing changes and debridement.	Reduces severe physical and emotional distress associated with dressing changes and debridement.
Encourage expression of feelings about pain.	Verbalization allows outlet for emotions and may enhance coping mechanisms.
Involve patient in determining schedule for activities, treatments, drug administration.	Enhances patient’s sense of control and strengthens coping mechanisms.
Explain procedures and provide frequent information as appropriate, especially during wound debridement.	Empathic support can help alleviate pain and/or promote relaxation. Knowing what to expect provides opportunity for patient to prepare self and enhances sense of control.
Provide basic comfort measures: massage of uninjured areas, frequent position changes.	Promotes relaxation; reduces muscle tension and general fatigue.
Encourage use of stress management techniques: progressive relaxation, deep breathing, guided imagery, and visualization.	Refocuses attention, promotes relaxation, and enhances sense of control, which may reduce pharmacological dependency.
Provide diversional activities appropriate for age and condition.	Helps lessen concentration on pain experience and refocus attention.
Promote uninterrupted sleep periods.	Sleep deprivation can increase perception of pain/reduce coping abilities.
Administer analgesics (narcotic and nonnarcotic) as indicated: morphine; fentanyl (Sublimaze, Ultiva); hydrocodone (Vicodin, Hycodan); oxycodone(OxyContin, Percocet).	The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect. Concerns of patient addiction or doubts regarding degree of pain experienced are not valid during emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated.

9. Risk for Infection

Risk factors may include

Inadequate primary defenses: destruction of skin barrier, traumatized tissues
Inadequate secondary defenses: decreased Hb, suppressed inflammatory response
Environmental exposure, invasive procedures

Desired Outcomes

Achieve timely wound healing free of purulent exudate and be afebrile.

Nursing Interventions	Rationale
Implement appropriate isolation techniques as indicated	Dependent on type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from simple wound and/or skin to complete or reverse to reduce risk of cross contamination and exposure to multiple bacterial flora.
Emphasize and model good handwashing technique for all individuals coming in contact with patient.	Prevents cross contamination; reduces risk of acquired infection.
Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered bed linens or gowns.	Prevents exposure to infectious organisms.
Monitor and/or limit visitors, if necessary. If isolation is used, explain procedure to visitors. Supervise visitor adherence to protocol as indicated.	Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against patient’s need for family support and socialization.
Shave or clip all hair from around burned areas to include a 1-in border (excluding eyebrows). Shave facial hair (men) and shampoo head daily.	Opportunistic infections (yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic antibiotic therapy.
Examine unburned areas (such as groin, neck creases, mucous membranes) and vaginal discharge routinely.	Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage.
Provide special care for eyes: use eye covers and tear formulas as appropriate.	Prevents adherence to surface it may be touching and encourages proper healing. Note: Ear cartilage has limited circulation and is prone to pressure necrosis.
Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp).	Identifies presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: A strong sweet, musty smell at a graft site is indicative of Pseudomonas.
Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage.	Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.
Monitor vital signs for fever, increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.	Water softens and aids in removal of dressings and eschar (slough layer of dead skin or tissue). Sources vary as to whether bath or shower is best. Bath has advantage of water providing support for exercising extremities but may promote cross-contamination of wounds. Showering enhances wound inspection and prevents contamination from floating debris.
Remove dressings and cleanse burned areas in a hydrotherapy or whirlpool tub or in a shower stall with handheld shower head. Maintain temperature of water at 100°F (37.8°C). Wash areas with a mild cleansing agent or surgical soap.	Early excision is known to reduce scarring and risk of infection, thereby facilitating healing.
Debride necrotic or loose tissue (including ruptured blisters) with scissors and forceps. Do not disturb intact blisters if they are smaller than 1–2 cm, do not interfere with joint function, and do not appear infected.	Promotes healing. Prevents autocontamination. Small, intact blisters help protect skin and increase rate of re-epithelialization unless the burn injury is the result of chemicals (in which case fluid contained in blisters may continue to cause tissue destruction).
Photograph wound initially and at periodic intervals.	Provides baseline and documentation of healing process.
Administer topical agents as indicated:	The following agents help control bacterial growth and prevent drying of wound, which can cause further tissue destruction.
Silver sulfadiazine (Silvadene);	Broad-spectrum antimicrobial that is relatively painless but has intermediate, somewhat delayed eschar penetration. May cause rash or depression of WBCs.
Mafenide acetate (Sulfamylon);	Antibiotic of choice with confirmed invasive burn-wound infection. Useful against Gram-negative or Gram-positive organisms. Causes burning or pain on application and for 30 min thereafter. Can cause rash, metabolic acidosis, and decreased Paco2.
Silver nitrate;	Effective against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, but has poor eschar penetration, is painful, and may cause electrolyte imbalance. Dressings must be constantly saturated. Product stains skin/surfaces black.
Bacitracin;	Effective against Gram-positive organisms and is generally used for superficial and facial burns.
Povidone-iodine (Betadine);	Broad-spectrum antimicrobial, but is painful on application, may cause metabolic acidosis or increased iodine absorption, and damage fragile tissues.
Hydrogels: Transorb, Burnfree.	Useful for partial- and full-thickness burns; filling dead spaces, rehydrating dry wound beds, and promoting autolytic debridement. May be used when infection is present.Systemic antibiotics are given to control general infections identified by culture and sensitivity. Subeschar clysis has been found effective against pathogens in granulated tissues at the line of demarcation between viable or nonviable tissue, reducing risk of sepsis.
Administer other medications as appropriate: Subeschar clysis or systemic antibiotics; Tetanus toxoid or clostridial antitoxin, as appropriate.	Tissue destruction and altered defense mechanisms increase risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
Place IV and/or invasive lines in non burned area.	Decreased risk of infection at insertion site with possibility of progression to septicemia.
Obtain routine cultures and sensitivities of wounds and/or drainage.	Allows early recognition and specific treatment of wound infection.

10. Risk for Deficient Fluid Volume

Risk factors may include

Loss of fluid through abnormal routes, e.g., burn wounds
Increased need: hypermetabolic state, insufficient intake
Hemorrhagic losses

Desired Outcomes

Demonstrate improved fluid balance as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes.

Nursing Interventions	Rationale
Monitor vital signs, central venous pressure (CVP). Note capillary refill and strength of peripheral pulses.	Serves as a guide to fluid replacement needs and assesses cardiovascular response. Note: Invasive monitoring is indicated for patients with major burns, smoke inhalation, or preexisting cardiac disease, although there is an associated increased risk of infection, necessitating careful monitoring and care of insertion site.
Monitor urinary output and specific gravity. Observe urine color and Hematest as indicated.	Generally, fluid replacement should be titrated to ensure average urinary output of 30–50 mL/hr (in the adult). Urine can appear red to black (with massive muscle destruction) because of presence of blood and release of myoglobin. If gross myoglobinuria is present, minimum urinary output should be 75–100 mL/hr to reduce risk of tubular damage and renal failure.
Estimate wound drainage and insensible losses.	Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 24–72 hr after burn injury.
Maintain cumulative record of amount and types of fluid intake.	Massive or rapid replacement with different types of fluids and fluctuations in rate of administration require close tabulation to prevent constituent imbalances or fluid overload.
Weigh daily.	Fluid replacement formulas partly depend on admission weight and subsequent changes. A 15%–20% weight gain can be anticipated in the first 72 hr during fluid replacement, with return to pre-burn weight approximately 10 days after burn.
Measure circumference of burned extremities as indicated.	May be helpful in estimating extent of edema and fluid shifts affecting circulating volume and urinary output.
Investigate changes in mentation.	Deterioration in the level of consciousness may indicate inadequate circulating volume and reduced cerebral perfusion.
Observe for gastric distension, hematemesis, tarry stools. Hematest nasogastric (NG) drainage and stools periodically.	Stress (Curling’s) ulcer occurs in up to half of all severely burned patients and can occur as early as the first week. Patients with burns more than 20% TBSA are at risk for mucosal bleeding in the gastrointestinal (GI) tract during the acute phase because of decreased splanchnic blood flow and reflex paralytic ileus.
Insert and maintain indwelling urinary catheter.	Allows for close observation of renal function and prevents urinary retention. Retention of urine with its by-products of tissue-cell destruction can lead to renal dysfunction and infection.
Insert and maintain large-bore IV catheter(s).	Accommodates rapid infusion of fluids.
Administer calculated IV replacement of fluids, electrolytes, plasma, albumin.	Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Replacement formulas vary but are based on extent of injury, amount of urinary output, and weight. Note: Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion.
Monitor laboratory studies: Hb/Hct, electrolytes, random urine sodium.	Identifies blood loss or RBC destruction and fluid and electrolyte replacement needs. Urine sodium less than 10 mEq/L suggests inadequate fluid resuscitation. Note: During first 24 hr after burn, hemoconcentration is common because of fluid shifts into the interstitial space.
Administer medications as indicated:
Diuretics: mannitol (Osmitrol);	May be indicated to enhance urinary output and clear tubules of debris and prevent necrosis if acute renal failure (ARF) is present.
Potassium;	Although hyperkalemia often occurs during first 24–48 hr (tissue destruction), subsequent replacement may be necessary because of large urinary losses.
Antacids: calcium carbonate (Titralac), magaldrate (Riopan);	Antacids may reduce gastric acidity;
histamine inhibitors: cimetidine (Tagamet) and ranitidine (Zantac).	histamine inhibitors decrease production of hydrochloric acid to reduce risk of gastric irritation and bleeding.
Add electrolytes to water used for wound debridement, as indicated.	Washing solution that approximates tissue fluids may minimize osmotic fluid shifts.

11. Risk for Ineffective Airway Clearance

Risk factors may include

Tracheobronchial obstruction: mucosal edema and loss of ciliary action (smoke inhalation); circumferential full-thickness burns of the neck, thorax, and chest, with compression of the airway or limited chest excursion
Trauma: direct upper-airway injury by flame, steam, hot air, and chemicals/gases
Fluid shifts, pulmonary edema, decreased lung compliance

Desired Outcomes

Demonstrate clear breath sounds, respiratory rate within normal range, be free of dyspnea/cyanosis.

Nursing Interventions	Rationale
Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum.	Exposure to materials burn can cause inhalation injury.
Draw blood samples for complete blood count, type and crossmatch and electrolyte glucose, blood urea nitrogen, creatinine, and ABG levels.	To have baseline data and may indicate choice of next steps of treatment.
Obtain history of injury. Note presence of preexisting respiratory conditions, history of smoking.	Causative burning agent, duration of exposure, and occurrence in closed or open space predict probability of inhalation injury. Type of material burned (wood, plastic, wool, and so forth) suggests type of toxic gas exposure. Preexisting conditions increase the risk of respiratory complications.
Assess gag and swallow reflexes; note drooling, inability to swallow, hoarseness, wheezy cough.	Suggestive of inhalation injury.
Monitor respiratory rate, rhythm, depth: note presence of pallor or cyanosis and carbonaceous or pink-tinged sputum.	Tachypnea, use of accessory muscles, presence of cyanosis, and changes in sputum suggest developing respiratory distress or pulmonary edema and need for medical intervention.
Auscultate lungs, noting stridor, wheezing or crackles, diminished breath sounds, brassy cough.	Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after burn.
Note presence of pallor or cherry-red color of unburned skin.	Suggests presence of hypoxemia or carbon monoxide.
Investigate changes in behavior or mentation: restlessness, agitation, altered LOC.	Although often related to pain, changes in consciousness may reflect developing or worsening hypoxia.
Monitor 24-hr fluid balance, noting variations/changes.	Fluid shifts or excess fluid replacement increases risk of pulmonary edema. Note: Inhalation injury increases fluid demands as much as 35% or more because of obligatory edema.
Elevate head of bed. Avoid use of pillow under head, as indicated.	Promotes optimal lung expansion or respiratory function. When head or neck burns are present, a pillow can inhibit respiration, cause necrosis of burned ear cartilage, and promote neck contractures.
Encourage coughing or deep breathing exercises and frequent position changes.	Promotes lung expansion, mobilization and drainage of secretions.
Suction (if necessary) with extreme care, maintaining sterile technique.	Helps maintain clear airway, but should be done cautiously because of mucosal edema and inflammation. Sterile technique reduces risk of infection.
Promote voice rest, but assess ability to speak and/or swallow oral secretions periodically.	Increasing hoarseness or decreased ability to swallow suggests increasing tracheal edema and may indicate need for prompt intubation.
Administer humidified oxygen via appropriate mode (face mask).	O₂ corrects hypoxemia and acidosis. Humidity decreases drying of respiratory tract and reduces viscosity of sputum.
Monitor and graph serial ABGs or pulse oximetry.	Baseline is essential for further assessment of respiratory status and as a guide to treatment. Pao2 less than 50, Paco2 greater than 50, and decreasing pH reflect smoke inhalation and developing pneumonia or ARDS.
Review serial chest x-rays.	Changes reflecting atelectasis and/or pulmonary edema may not occur for 2–3 days after burn
Provide and assist with chest physiotherapy and incentive spirometry.	Chest physiotherapy drains dependent areas of the lung, and incentive spirometry may be done to improve lung expansion, thereby promoting respiratory function and reducing atelectasis.
Prepare and assist with intubation or tracheostomy, as indicated	Intubation or mechanical support is required when airway edema or circumferential burn injury interferes with respiratory function or oxygenation.

Other Possible Nursing Care Plans

Post-trauma syndrome—may be related to life-threatening event, possibly evidenced by reexperiencing the event, repetitive dreams/nightmares, emotional numbness, and sleep disturbance.
Ineffective protection—may be related to extremes of age, inadequate nutrition, anemia, impaired immune system, possibly evidenced by impaired healing, deficient immunity, fatigue, anorexia.
Deficient diversional activity—may be related to long-term hospitalization, frequent or lengthy treatments, and physical limitations, possibly evidenced by expressions of boredom, restlessness, withdrawal and requests for something to do.
Risk for delayed development—risk factors may include effects of physical disability, separation from SO, and environmental deficiencies.

7 Eating Disorders: Anorexia & Bulimia Nervosa Nursing Care Plans

July 14, 2013, 5:50 am

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Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity. People with anorexia nervosa attempt to maintain a weight that’s far below normal for their age and height. To prevent weight gain or to continue losing weight, people with anorexia nervosa may starve themselves or exercise excessively.

Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating followed by self-induced vomiting, trying to get rid of the extra calories in an unhealthy way. 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 Care Plans

Nursing Priorities

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

Discharge Goals

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

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.

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

1. 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.

Nursing Interventions	Rationale
For Bulimia Nervosa:
Supervise the patient during mealtimes and for a specified period after meals (usually one hour).	Prevents vomiting during or after eating.
Identify the patient’s elimination patterns.	To prevent self-induces vomiting.
Assess her suicide potential.	Among patients with bulimia nervosa, warning signs include having more co-morbid psychiatric symptoms and reporting a history of sexual abuse.
Outline the risks of laxative, emetic, and diuretic abuse for the patient	Bulimic patients may include abuse of laxatives, emetics, and diuretics.
For Anorexia Nervosa:
Supervise the patient during mealtimes and for a specified period after meals (usually one hour).	To ensure compliance with the dietary treatment program. For hospitalized patient with anorexia, food is considered a medication.
Liquids are more acceptable than solid.	Fluids eliminate the need to choose between foods – something the patient with anorexia may find difficult.
Expect weight gain of about 1 lb (0.5 kg) per week.	To see the effectiveness of treatment regimen.
If edema or bloating occurs after the patient has returned to normal eating behavior, reassure her that this phenomenon is temporary.	She may fear that she’s becoming fat and stop complying with the plan of treatment.
For Bulimia and Anorexia:
Establish a minimum weight goal and daily nutritional requirements.	Malnutrition is a mood-altering condition, leading to depression and agitation and affecting cognitive function and decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work.
Use a consistent approach. Sit with patient while eating; present and remove food without persuasion and comment. Promote pleasant environment and record intake.	Patient detects urgency and may react to pressure. Any comment that might be seen as coercion provides focus on food. When staff responds in a consistent manner, patient can begin to trust staff responses. The single area in which patient has exercised power and control is food or eating, and he or she may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with patient and avoid manipulative games.
Provide smaller meals and supplemental snacks, as appropriate.	Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: Patient may feel bloated for 3–6 wk while body adjusts to food intake.
Make selective menu available, and allow patient to control choices as much as possible.	Patient who gains confidence in self and feels in control of environment is more likely to eat preferred foods.
Be alert to choices of low-calorie foods and beverages; hoarding food; disposing of food in various places, such as pockets or wastebaskets.	Patient will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
Maintain a regular weighing schedule, such as Monday and Friday before breakfast in same attire, and graph results.	Provides accurate ongoing record of weight loss or gain. Also diminishes obsessing about changes in weight.
Weigh with back to scale (depending on program protocols).	Although some programs prefer patient to see the results of the weighing, this can force the issue of trust in patient who usually does not trust others.
Avoid room checks and other control devices whenever possible.	External control reinforces feelings of powerlessness and therefore is usually not helpful.
Provide one-to-one supervision and have patient with bulimia remain in the day room area with no bathroom privileges for a specified period (2 hr) following eating, if contracting is unsuccessful.	Prevents vomiting during and after eating. Patient may desire food and use a binge-purge syndrome to maintain weight. Note: Patient may purge for the first time in response to establishment of a weight gain program.
Monitor exercise program and set limits on physical activities. Chart activity and level of work (pacing and so on).	Moderate exercise helps in maintaining muscle tone, weight and combating depression; however, patient may exercise excessively to burn calories.
Maintain matter-of-fact, nonjudgmental attitude if giving tube feedings, hyperalimentation, and so on.	Perception of punishment is counterproductive to patient’s self-confidence and faith in own ability to control destiny.
Be alert to possibility of patient disconnecting tube and emptying hyperalimentation if used. Check measurements, and tape tubing snugly.	Sabotage behavior is common in attempt to prevent weight gain.
Provide nutritional therapy within a hospital treatment program as indicated when condition is life-threatening.	Cure of the underlying problem cannot happen without improved nutritional status. Hospitalization provides a controlled environment in which food intake, vomiting and elimination, medications, and activities can be monitored. It also separates patient from SO (who may be contributing factor) and provides exposure to others with the same problem, creating an atmosphere for sharing.
Involve patient in setting up or carrying out program of behavior modification. Provide reward for weight gain as individually determined; ignore loss.	Provides structured eating situation while allowing patient some control in choices. Behavior modification may be effective in mild cases or for short-term weight gain.
Provide diet and snacks with substitutions of preferred foods when available.	Having a variety of foods available enables patient to have a choice of potentially enjoyable foods.
Administer liquid diet, tube feedings, hyperalimentation if needed.	When caloric intake is insufficient to sustain metabolic needs, nutritional support can be used to prevent malnutrition and death while therapy is continuing. High-calorie liquid feedings may be given as medication, at preset times separate from meals, as an alternative means of increasing caloric intake.
Blenderize and tube-feed anything left on the tray after a given period of time if indicated.	May be used as part of behavior modification program to provide total intake of needed calories.
Administer supplemental nutrition as appropriate.	Total parenteral nutrition (TPN) may be required for life-threatening situations; however, enteral feedings are preferred because they preserve gastrointestinal (GI) function and reduce atrophy of the gut.
Avoid giving laxatives.	Use is counterproductive because they may be used by patient to rid body of food and calories.
Administer medication as indicated: Cyproheptadine (Periactin);Tricyclic antidepressants: amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin); selective serotonin reuptake inhibitors (SSRIs): fluoxetine (Prozac); Antianxiety agents: alprazolam (Xanax); Antipsychotic drugs: chlorpromazine (Thorazine); Monoamine oxidase inhibitors (MAOIs): tranylcypromine sulfate (Parnate).	A serotonin and histamine antagonist that may be used in high doses to stimulate the appetite, decrease preoccupation with food, and combat depression. Does not appear to have serious side effects, although decreased mental alertness may occur. Lifts depression and stimulates appetite. SSRIs reduce binge-purge cycles and may also be helpful in treating anorexia. Note: Use must be closely monitored because of potential side effects, although side effects from SSRIs are less significant than those associated with tricyclics. Reduces tension, anxiety, nervousness and may help patient to participate in treatment.Promotes weight gain and cooperation with psychotherapeutic program; however, used only when absolutely necessary because of the possibility of extrapyramidal side effects. May be used to treat depression when other drug therapy is ineffective; decreases urge to binge in bulimia.
Assist with electroconvulsive therapy (ECT) if indicated. Discuss reasons for use and help patient understand this is not punishment.	In rare and difficult cases in which malnutrition is severe and life-threatening, a short-term ECT series may enable patient to begin eating and become accessible to psychotherapy.

2. 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.

Nursing Interventions	Rationale
Monitor and record vital signs, capillary refill, status of mucous membranes, skin turgor.	Indicators of adequacy of circulating volume. Orthostatic hypotension may occur with risk of falls and injury following sudden changes in position.
Note amount and types of fluid intake. Measure urine output accurately.	Patient may abstain from all intake, with resulting dehydration; or substitute fluids for caloric intake, disturbing electrolyte balance.
Discuss strategies to stop vomiting and laxative and diuretic use.	Helping patient deal with the feelings that lead to vomiting and laxative or diuretic use will prevent continued fluid loss. Note: Patient with bulimia has learned that vomiting provides a release of anxiety.
Identify actions necessary to regain or maintain optimal fluid balance (specific fluid intake schedule).	Involving patient in plan to correct fluid imbalances improves chances for success.
Review electrolyte and renal function test results.	Fluid, electrolyte shifts, decreased renal function can adversely affect patient’s recovery or prognosis and may require additional intervention.
Administer and monitor IV, TPN; electrolyte supplements, as indicated.	Used as an emergency measure to correct fluid and electrolyte imbalance and prevent cardiac dysrhythmias.

3. 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.

Nursing Interventions	Rationale
Be mindful of patient’s distorted thinking ability.	Allows caregiver to have more realistic expectations of patient and provide appropriate information and support.
Listen to or avoid challenging irrational, illogical thinking. Present reality concisely and briefly.	It is difficult to responds logically when thinking ability is physiologically impaired. Patient needs to hear reality, but challenging patient leads to distrust and frustration. Note: Even though patient may gain weight, she or he may continue to struggle with attitudes or behaviors typical of eating disorders, major depression, or alcohol dependence for a number of years.
Adhere strictly to nutritional regimen.	Improved nutrition is essential to improved brain functioning.
Review electrolyte and renal function tests.	Imbalances negatively affect cerebral functioning and may require correction before therapeutic interventions can begin.

4. 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.

Nursing Interventions	Rationale
Allow the patient to draw picture of self.	Provides opportunity to discuss patient’s perception of self and body image and realities of individual situation.
Encourage personal development program, preferably in a group setting. Provide information about proper application of makeup and grooming.	Learning about methods to enhance personal appearance may be helpful to long-range sense of self-esteem and image. Feedback from others can promote feelings of self-worth.
Suggest disposing of “thin” clothes as weight gain occurs. Recommend consultation with an image consultant.	Provides incentive to at least maintain and not lose weight. Removes visual reminder of thinner self. Positive image enhances sense of self-esteem.
Assist patient to confront changes associated with puberty and sexual fears. Provide sex education as necessary.	Major physical and psychological changes in adolescence can contribute to development of eating disorders. Feelings of powerlessness and loss of control of feelings (in particular sexual sensations) lead to an unconscious desire to desexualize self. Patient often believes that these fears can be overcome by taking control of bodily appearance, development, and function.
Establish a therapeutic nurse-patient relationship.	Within a helping relationship, patient can begin to trust and try out new thinking and behaviors.
Promote self-concept without moral judgment	Patient sees self as weak-willed, even though part of person may feel sense of power and control (dieting, weight loss).
States rules clearly regarding weighing schedule, remaining in sight during medication and eating times, and consequences of not following the rules. Without undue comment, be consistent in carrying out rules.	Consistency is important in establishing trust. As part of the behavior modification program, patient knows risks involved in not following established rules (decrease in privileges). Failure to follow rules is viewed as patient’s choice and accepted by staff in matter-of-fact manner so as not to provide reinforcement for the undesirable behavior.
Respond (confront) with reality when patient makes unrealistic statements such as “I’m gaining weight, so there’s nothing really wrong with me.”	Patient may be denying the psychological aspects of own situation and is often expressing a sense of inadequacy and depression.
Be aware of own reaction to patient’s behavior. Avoid arguing.	Feelings of disgust, hostility, and infuriation are not uncommon when caring for these patients. Prognosis often remains poor even with a gain in weight because other problems may remain. Many patients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive-compulsive symptoms, drug abuse, and psychosexual dysfunction. Nurse needs to deal with own response and feeling so they do not interfere with care of patient.
Assist patient to assume control in areas other than dieting and weight loss such as management of own daily activities, work, and leisure choices.	Feelings of personal ineffectiveness, low self-esteem, and perfectionism are often part of the problem. Patient feels helpless to change and requires assistance to problem-solve methods of control in life situations.
Help patient formulate goals for self (not related to eating) and create a manageable plan to reach those goals, one at a time, progressing from simple to more complex.	Patient needs to recognize ability to control other areas in life and may need to learn problem-solving skills to achieve this control. Setting realistic goals fosters success.
Note patient’s withdrawal and discomfort in social settings.	May indicate feelings of isolation and fear of rejection and judgment by others. Avoidance of social situations and contact with others can compound feelings of worthlessness.
Encourage patient to take charge of own life in a more healthful way by making own decisions and accepting self as she or he is at this moment (including inadequacies and strengths).	Patient often does not know what she or he may want for self. Parents (mother) often make decisions for patient. Patient may also believe she or he has to be the best in everything and holds self responsible for being perfect.
Let patient know that is acceptable to be different from family, particularly mother.	Developing a sense of identity separate from family and maintaining sense of control in other ways besides dieting and weight loss is a desirable goal of therapy and program.
Use cognitive-behavioral or interpersonal psychotherapy approach, rather than interpretive therapy.	Although both therapies have similar results, cognitive-behavioral seems to work more quickly. Interaction between persons is more helpful for patient to discover feelings, impulses, and needs from within own self. Patient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior.
Encourage patient to express anger and acknowledge when it is verbalized.	Important to know that anger is part of self and as such is acceptable. Expressing anger may need to be taught to patient because anger is generally considered unacceptable in the family, and therefore patient does not express it.
Assist patient to learn strategies other than eating for dealing with feelings. Have patient keep a diary of feelings, particularly when thinking about food.	Feelings are the underlying issue, and patient often uses food instead of dealing with feelings appropriately. Patient needs to learn to recognize feelings and how to express them clearly.
Assess feelings of helplessness and hopelessness.	Lack of control is a common and underlying problem for this patient and may be accompanied by more serious emotional disorders. Note: Fifty-four percent of patients with anorexia have a history of major affective disorder, and 33% have a history of minor affective disorder.
Be alert to suicidal ideation and behavior.	Intense anxiety and panic about weight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if patient is impulsive.
Involve in group therapy.	Provides an opportunity to talk about feelings and try out new behaviors.
Refer to occupational or recreational therapy.	Can develop interest and skills to fill time that has been occupied by obsession with eating. Involvement in recreational activities encourages social interactions with others and promotes fun and relaxation.

5. 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.

Nursing Interventions	Rationale
Identify patterns of interaction. Encourage each family member to speak for self. Do not allow two members to discuss a third without that member’s participation.	Helpful information for planning interventions. The enmeshed, over involved family members often speak for each other and need to learn to be responsible for their own words and actions.
Discourage members from asking for approval from each other. Be alert to verbal or nonverbal checking with others for approval. Acknowledge competent actions of patient.	Each individual needs to develop own internal sense of self-esteem. Individual often is living up to others’ (family’s) expectations rather than making own choices. Acknowledgment provides recognition of self in positive ways.
Listen with regard when patient speaks.	Sets an example and provides a sense of competence and self-worth, in that patient has been heard and attended to.
Encourage individuals not to answer to everything.	Reinforces individualization and return to privacy.
Communicate message of separation, that it is acceptable for family members to be different from each other.	Individuation needs reinforcement. Such a message confronts rigidity and opens options for different behaviors.
Encourage and allow expression of feelings (crying, anger) by individuals.	Often these families have not allowed free expression of feelings and need help and permission to learn and accept this.
Prevent intrusion in dyads by other members of the family.	Inappropriate interventions in family subsystems prevent individuals from working out problems successfully.
Reinforce importance of parents as a couple who have rights of their own.	The focus on the child with anorexia is very intense and often is the only area around which the couple interact. The couple needs to explore their own relationship and restore the balance within it to prevent its disintegration.
Prevent patient from intervening in conflicts between parents. Assist parents in identifying and solving their marital differences.	Triangulation occurs in which a parent-child coalition exists. Sometimes the child is openly pressed to ally self with one parent against the other. The symptom (anorexia) is the regulator in the family system, and the parents deny their own conflicts.
Be aware and confront sabotage behavior on the part of family members.	Feelings of blame, shame, and helplessness may lead to unconscious behavior designed to maintain the status quo.
Refer to community resources such as family therapy groups, parents’ groups as indicated, and parent effectiveness classes.	May help reduce overprotectiveness, support or facilitate the process of dealing with unresolved conflicts and change.

6. 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.

Nursing Interventions	Rationale
Observe for reddened, blanched, excoriated areas.	Indicators of increased risk of breakdown, requiring more intensive treatment.
Encourage bathing every other day instead of daily.	Frequent baths contribute to dryness of the skin.
Use skin cream twice a day and after bathing.	Lubricates skin and decreases itching.
Massage skin gently, especially over bony prominences.	Improves circulation to the skin, enhances skin tone.
Discuss importance of frequent position changes, need for remaining active.	Enhances circulation and perfusion to skin by preventing prolonged pressure on tissues.
Emphasize importance of adequate nutrition and fluid intake.	Improved nutrition and hydration will improve skin condition.

7. 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.

Nursing Interventions	Rationale
Determine level of knowledge and readiness to learn.	Learning is easier when it begins where the learner is.
Note blocks to learning (physical, intellectual,emotional).	Malnutrition, family problems, drug abuse, affective disorders, and obsessive-compulsive symptoms can be blocks to learning requiring resolution before effective learning can occur.
Provide written information for patient and SO(s).	Helpful as reminder of and reinforcement for learning.
Discuss consequences of behavior.	Sudden death can occur because of electrolyte imbalances; suppression of the immune system and liver damage may result from protein deficiency; or gastric rupture may follow binge-eating and vomiting.
Review dietary needs, answering questions as indicated. Encourage inclusion of high-fiber foods and adequate fluid intake.	Patient and family may need assistance with planning for new way of eating. Constipation may occur when laxative use is curtailed.
Encourage the use of relaxation and other stress-management techniques (visualization, guided imagery, biofeedback).	New ways of coping with feelings of anxiety and fear help patient manage these feelings in more effective ways, assisting in giving up maladaptive behaviors of not eating and binging-purging.
Assist with establishing a sensible exercise program. Caution regarding overexercise.	Exercise can assist with developing a positive body image and combats depression (release of endorphins in the brain enhances sense of well-being). However, patient may use excessive exercise as a way to control weight.
Discuss need for information about sex and sexuality.	Because avoidance of own sexuality is an issue for this patient, realistic information can be helpful in beginning to deal with self as a sexual being.

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.

8 Liver Cirrhosis Nursing Care Plans

July 14, 2013, 10:10 pm

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8 Liver Cirrhosis Nursing Care Plans (NCP)

Liver cirrhosis, also known as hepatic cirrhosis, is a chronic hepatic disease characterized by diffuse destruction and fibrotic regeneration of hepatic cells. As necrotic tissues yields to fibrosis, the diseases alters the liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causing hepatic insufficiency. Causes include malnutrition, inflammation (bacterial or viral), and poisons (e.g., alcohol, carbon tetrachloride, acetaminophen). Cirrhosis is the fourth leading cause of death in the United States among people ages 35 to 55 and represents a serious threat to long-term health.

These are the clinical types of cirrhosis:

Laennec’s cirrhosis is the most common type and occurs 30% to 50% of cirrhotic patients. Up to 90% of whom have a history of alcoholism. Liver damage results from malnutrition, especially of dietary protein, and chronic alcohol ingestion. Fibrous tissue forms in portal areas and around central veins.
Biliary cirrhosis occurs in 15% to 20% of patients, and results from injury or prolonged obstruction.
Postnecrotic cirrhosis stems from various types of hepatitis.
Pigment cirrhosis results from disorders such as hemochromatosis.
Idiopathic cirrhosis, has no known cause.
Noncirrhotic fibrosis may results from schistosomiasis or congenital hepatic fibrosis or may be idiopathic.

Nursing Care Plans

Here are 8 liver cirrhosis nursing care plans (NCP).

1. Imbalanced Nutrition

Nursing Diagnosis

Nutrition: imbalanced, less than body requirements

May be related to

Inadequate diet; inability to process/digest nutrients
Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
Abnormal bowel function

Possibly evidenced by

Weight loss
Changes in bowel sounds and function
Poor muscle tone/wasting
Imbalances in nutritional studies

Desired Outcomes

Demonstrate progressive weight gain toward goal with patient-appropriate normalization of laboratory values.
Experience no further signs of malnutrition.

Nursing Interventions	Rationale
Measure dietary intake by calorie count.	Provides important information about intake, needs and deficiencies.
Weigh as indicated. Compare changes in fluid status, recent weight history, skinfold measurements.	It may be difficult to use weight as a direct indicator of nutritional status in view of edema and/or ascites. Skinfold measurements are useful in assessing changes in muscle mass and subcutaneous fat reserves.
Encourage patient to eat; explain reasons for the types of diet. Feed patient if tiring easily, or have SO assist patient. Include patient in meal planning to consider his/her preferences in food choices.	Improved nutrition and diet is vital to recovery. Patient may eat better if family is involved and preferred foods are included as much as possible.
Encourage patient to eat all meals including supplementary feedings.	Patient may pick at food or eat only a few bites because of loss of interest in food or because of nausea, generalized weakness, malaise.
Give small, frequent meals.	Poor tolerance to larger meals may be due to increased intra-abdominal pressure and ascites (if present).
Provide salt substitutes, if allowed; avoid those containing ammonium.	Salt substitutes enhance the flavor of food and aid in increasing appetite; ammonia potentiates risk of encephalopathy.
Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold foods.	Aids in reducing gastric irritation and/or diarrhea and abdominal discomfort that may impair oral intake.
Suggest soft foods, avoiding roughage if indicated.	Hemorrhage from esophageal varices may occur in advanced cirrhosis.
Encourage frequent mouth care, especially before meals.	Patient is prone to sore and/or bleeding gums and bad taste in mouth, which contributes to anorexia.
Promote undisturbed rest periods, especially before meals.	Conserving energy reduces metabolic demands on the liver and promotes cellular regeneration.
Recommend cessation of smoking. Provide teaching on the possible negative effects of smoking.	Reduces excessive gastric stimulation and risk of irritation and may lead to bleeding.
Monitor laboratory studies: serum glucose, prealbumin and albumin, total protein, ammonia.	Glucose may be decreased because of impaired gluconeogenesis, depleted glycogen stores, or inadequate intake. Protein may be low because of impaired metabolism, decreased hepatic synthesis, or loss into peritoneal cavity (ascites). Elevation of ammonia level may require restriction of protein intake to prevent serious complications.
Maintain NPO status when indicated.	Initially, GI rest may be required in acutely ill patients to reduce demands on the liver and production of ammonia and urea in the GI tract.
Refer to dietitian to provide diet high in calories and simple carbohydrates, low in fat, and moderate to high in protein; limit sodium and fluid as necessary. Provide liquid supplements as indicated.	High-calorie foods are desired inasmuch as patient intake is usually limited. Carbohydrates supply readily available energy. Fats are poorly absorbed because of liver dysfunction and may contribute to abdominal discomfort. Proteins are needed to improve serum protein levels to reduce edema and to promote liver cell regeneration. Note: Protein and foods high in ammonia (gelatin) are restricted if ammonia level is elevated or if patient has clinical signs of hepatic encephalopathy. In addition, these individuals may tolerate vegetable protein better than meat protein.
Provide tube feedings, TPN, lipids if indicated.	May be required to supplement diet or to provide nutrients when patient is too nauseated or anorexic to eat or when esophageal varices interfere with oral intake.

2. Excess Fluid Volume

Nursing Diagnosis

Fluid Volume excess

May be related to

Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic hormone [SIADH], decreased plasma proteins, malnutrition)
Excess sodium/fluid intake

Possibly evidenced by

Edema, anasarca, weight gain
Intake greater than output, oliguria, changes in urine specific gravity
Dyspnea, adventitious breath sounds, pleural effusion
BP changes, altered CVP
JVD, positive hepatojugular reflex
Altered electrolyte levels
Change in mental status

Desired Outcomes

Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within patient’s normal range, and absence of edema.

Nursing Interventions	Rationale
Measure I&O, weigh daily, and note gain of more than 0.5 kg/day.	To assess circulating volume status, developing or resolution of fluid shifts, and response to therapeutic regimen. Positive balance/weight gain often reflects continuing fluid retention. Note: Decreased circulating volume (fluid shifts) may directly affect renal function and urine output, resulting in hepatorenal syndrome.
Monitor BP (and CVP if available). Note JVD and abdominal vein distension.	BP elevations are usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. Distension of external jugular and abdominal veins is associated with vascular congestion.
Assess respiratory status, noting increased respiratory rate, dyspnea.	Indicative of pulmonary congestion.
Auscultate lungs, noting diminished breath sounds and developing adventitious sounds.	Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications.
Monitor for cardiac dysrhythmias. Auscultate heart sounds, noting development of S₃/S₄ gallop rhythm.	May be caused by HF, decreased coronary arterial perfusion, and electrolyte imbalance.
Assess degree of peripheral edema.	Fluids shift into tissues as a result of sodium and water retention, decreased albumin, and increased antidiuretic hormone (ADH).
Measure abdominal girth.	Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins/fluid into peritoneal space. Note: Excessive fluid accumulation can reduce circulating volume, creating a deficit (signs of dehydration).
Encourage bedrest when ascites is present.	May promote recumbency induced diuresis.
Provide frequent mouth care; occasional ice chips (if NPO).	Decreases sensation of thirst.
Monitor serum albumin and electrolytes (particularly potassium and sodium).	Decreased serum albumin affects plasma colloid osmotic pressure, resulting in edema formation. Reduced renal blood flow accompanied by elevated ADH and aldosterone levels and the use of diuretics (to reduce total body water) may cause various electrolyte shifts/imbalances.
Monitor serial chest x-rays.	Vascular congestion, pulmonary edema, and pleural effusions frequently occur.
Restrict sodium and fluids as indicated.	Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to correct dilutional hyponatremia.
Administer salt-free albumin/plasma expanders as indicated.	Albumin may be used to increase the colloid osmotic pressure in the vascular compartment (pulling fluid into vascular space), thereby increasing effective circulating volume and decreasing formation of ascites.
Administer medications as indicated:
Diuretics: spironolactone (Aldactone), furosemide (Lasix)	Used with caution to control edema and ascites, block effect of aldosterone, and increase water excretion while sparing potassium when conservative therapy with bedrest and sodium restriction does not alleviate problem.
Potassium	Serum and cellular potassium are usually depleted because of liver disease and urinary losses.
Positive inotropic drugs and arterial vasodilators.	Given to increase cardiac output/improve renal blood flow and function, thereby reducing excess fluid.

3. Impaired Skin Integrity

Nursing Diagnosis

Skin Integrity, risk for impaired

Risk factors may include

Altered circulation/metabolic state
Accumulation of bile salts in skin
Poor skin turgor, skeletal prominence, presence of edema, ascites

Desired Outcomes

Maintain skin integrity.
Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.

Nursing Interventions	Rationale
Inspect pressure points and skin surfaces closely and routinely. Gently massage bony prominences or areas of continued stress. Use of emollient lotions and limiting use of soap for bathing may help.	Edematous tissues are more prone to breakdown and to the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis.
Encourage and assist patient with reposition on a regular schedule. Assist with active and passive ROM exercises as appropriate.	Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve and/or maintain joint mobility.
Recommend elevating lower extremities.	Enhances venous return and reduces edema formation in extremities.
Keep linens dry and free of wrinkles.	Moisture aggravates pruritus and increases risk of skin breakdown.
Suggest clipping fingernails short; provide mittens/gloves if indicated.	Prevents patient from inadvertently injuring the skin, especially while sleeping.
Provide perineal care following urination and bowel movement.	Prevents skin excoriation breakdown from bile salts.
Use alternating pressure mattress, egg-crate mattress, waterbed, sheepskins, as indicated.	Reduces dermal pressure, increases circulation, and diminishes risk of tissue ischemia.
Use calamine lotion and provide baking soda baths. Administer medications (as indicated) such as cholestyramine (Questran), hydroxyzine (Atarax), diphenhydramine (Benadryl).	May be soothing and can provide relief of itching associated with jaundice, bile salts in skin.

4. Ineffective Breathing Pattern

Nursing Diagnosis

Breathing Pattern, risk for ineffective

Risk factors may include

Intra-abdominal fluid collection (ascites)
Decreased lung expansion, accumulated secretions
Decreased energy, fatigue

Desired Outcomes

Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.

Nursing Interventions	Rationale
Monitor respiratory rate, depth, and effort.	Rapid shallow respiration or presence of dyspnea may appear because of hypoxia and/or fluid accumulation in the abdomen.
Auscultate breath sounds, noting crackles, wheezes, rhonchi.	May indicate developing complications. Presence of adventitious breath sounds may reflect accumulation of fluids or secretions. Absent or diminished sounds suggests atelectasis.
Investigate changes in level of consciousness.	Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma.
Keep head of bed elevated. Position on sides.	Facilitates breathing by reducing pressure on the diaphragm, and minimizes risk of aspiration of secretions.
Encourage frequent repositioning and deep-breathing exercises and coughing exercises.	Aids in lung expansion and mobilizing secretions.
Monitor temperature. Note presence of chills, increased coughing, changes in color and character of sputum.	Indicative of onset of infection, especially pneumonia.
Monitor serial ABGs, pulse oximetry, vital capacity measurements, chest x-rays.	Reveals changes in respiratory status, developing pulmonary complications.
Provide supplemental O₂ as indicated.	To treat or prevent hypoxia and if respirations and oxygenation is inadequate, mechanical ventilation may be required.
Demonstrate and assist with respiratory adjuncts: incentive spirometer.	Reduces incidence of atelectasis, enhances mobilization of secretions.
Prepare for/assist with acute care procedures:
Paracentesis	Occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures.
Peritoneovenous shunt.	Surgical implant of a catheter to return accumulated fluid in the abdominal cavity to systemic circulation via the vena cava; provides long-term relief of ascites and improvement in respiratory function.

5. Risk for Injury

Nursing Diagnosis

Risk for injury [hemorrhage]

Risk factors may include

Abnormal blood profile; altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; and release of thromboplastin)
Portal hypertension, development of esophageal varices

Desired Outcomes

Maintain homeostasis with absence of bleeding
Demonstrate behaviors to reduce risk of bleeding.

Nursing Interventions	Rationale
Closely assess for signs and symptoms of GI bleeding: check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus.	The esophagus and rectum are the most usual sources of bleeding because of their mucosal fragility and alterations in hemostasis associated with cirrhosis.
Observe for presence of petechiae, ecchymosis, bleeding from one or more sites.	Subacute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.
Monitor pulse, BP (and CVP if available).	An increased pulse with decreased BP and CVP can indicate loss of circulating blood volume, requiring further evaluation.
Note changes in mentation and LOC.	Changes may indicate decreased cerebral perfusion secondary to hypovolemia, hypoxemia.
Avoid rectal temperature; be gentle with GI tube insertions.	Rectal and esophageal vessels are most vulnerable to rupture.
Encourage use of soft toothbrush, electric razor, avoiding straining for stool, vigorous nose blowing, and so forth.	In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.
Use small needles for injections. Apply pressure to small bleeding and venipuncture sites for longer than usual.	Minimizes damage to tissues, reducing risk of bleeding and hematoma.
Advice to avoid aspiring-containing products.	Prolongs coagulation, potentiating risk of hemorrhage.
Monitor Hb/Hct and clotting factors.	Indicators of anemia, active bleeding, or impending complications.
Administer medications as indicated
Supplemental vitamins: vitamin K, D, and C.	Promotes prothrombin synthesis and coagulation if liver is functional. Vitamin C deficiencies increase susceptibility of GI system to irritation and/or bleeding.
Stool softeners	Prevents straining for stool with resultant increase in intra-abdominal pressure and risk of vascular rupture and hemorrhage.
Provide gastric lavage with room temperature and cool saline solution or water as indicated.	In presence of acute bleeding, evacuation of blood from GI tract reduces ammonia production and risk of hepatic encephalopathy.
Assist with insertion and maintenance of GI tube.	Temporarily controls bleeding of esophageal varices when control by other means (e.g., lavage) and hemodynamic stability cannot be achieved.
Prepare for surgical procedures: direct ligation (banding) or varices, esophagogastric resection, splenorenal-portacaval anastomosis.	May be needed to control active hemorrhage or to decrease portal and collateral blood vessel pressure to minimize risk of recurrence of bleeding.

6. Risk for Acute Confusion

Nursing Diagnosis

Risk for acute confusion

Risk factors may include

Alcohol abuse
Inability of liver to detoxify certain enzymes/drugs

Desired Outcomes

Maintain usual level of mentation/reality orientation.
Initiate behaviors/lifestyle changes to prevent or minimize recurrence of problem.

Nursing Interventions	Rationale
Observe for signs and symptoms of behavioral change and mentation: lethargy, confusion, drowsiness, slurring of speech, and irritability. Around patient at intervals as indicated.	Ongoing assessment of behavior and mental status is important because of fluctuating nature of impending hepatic coma.
Review current medication regimen. Note adverse drug reactions and effects of medication to the patient.	Adverse drug reactions or interactions (e.g., cimetidine plus antacids) may potentiate and/or exacerbate confusion.
Evaluate sleep and rest schedule.	Difficulty falling or staying asleep leads to sleep deprivation, resulting in diminished cognition and lethargy.
Note development and/or presence of asterixis, fetor hepaticus, seizure activity.	Suggests elevating serum ammonia levels; increased risk of progression to encephalopathy.
Consult with SO about patient’s usual behavior and mentation.	Provides baseline for comparison of current status.
Have patient write name periodically and keep this record for comparison. Report deterioration of ability. Have patient do simple arithmetic computations.	Easy test of neurological status and muscle coordination.
Reorient to time, place, person as needed.	Assists in maintaining reality orientation, reducing confusion and anxiety.
Maintain a pleasant, quiet environment and approach in a slow, calm manner. Encourage uninterrupted rest periods.	Reduces excessive stimulation and sensory overload, promotes relaxation, and may enhance coping.
Provide continuity of care. If possible, assign same nurse over a period of time.	Familiarity provides reassurance, aids in reducing anxiety, and provides a more accurate documentation of subtle changes.
Reduce provocative stimuli, confrontation. Refrain from forcing activities. Assess potential for violent behavior.	Avoids triggering agitated, violent responses; promotes patient safety.
Discuss current situation, future expectation.	Patient/SO may be reassured that intellectual (as well as emotional) function may improve as liver involvement resolves.
Maintain bedrest, assist with self-care activities.	Reduces metabolic demands on liver, prevents fatigue, and promotes healing, lowering risk of ammonia buildup.
Identify and provide safety needs. Supervise during smoking, put bed in low position, raise side rails and pad if necessary.	Reduces risk of injury when confusion, seizures, or violent behavior occurs.
Investigate temperature elevations. Monitor for signs of infection.	Infection may precipitate hepatic encephalopathy caused by tissue catabolism and release of nitrogen.
Recommend avoidance of narcotics or sedatives, anti anxiety agents, and limiting or restricting use of medications metabolized by the liver.	Certain drugs are toxic to the liver, whereas other drugs may not be metabolized because of cirrhosis, causing cumulative effects that affect mentation, mask signs of developing encephalopathy, or precipitate coma.
Eliminate or restrict protein in diet. Provide glucose supplements, adequate hydration.	Ammonia (product of the breakdown of protein in the GI tract) is responsible for mental changes in hepatic encephalopathy. Dietary changes may result in constipation, which also increases bacterial action and formation of ammonia. Glucose provides a source of energy, reducing need for protein catabolism. Note: Vegetable protein may be better tolerated than meat protein.
Assist with procedures as indicated: dialysis, plasmapheresis, or extracorporeal liver perfusion.	May be used to reduce serum ammonia levels if encephalopathy develops and other measures are not successful.

7. Disturbed Body Image/Self-Esteem

Nursing Diagnosis

Disturbed Body Image/Self-Esteem

May be related to

Biophysical changes/altered physical appearance
Uncertainty of prognosis, changes in role function
Personal vulnerability
Self-destructive behavior (alcohol-induced disease)

Possibly evidenced by

Verbalization of change/restriction in lifestyle
Fear of rejection or reaction by others
Negative feelings about body/abilities
Feelings of helplessness, hopelessness, or powerlessness

Desired Outcomes

Verbalize understanding of changes and acceptance of self in the present situation.
Identify feelings and methods for coping with negative perception of self.

Nursing Interventions	Rationale
Discuss situation and encourage verbalization of fears and concerns. Explain relationship between nature of disease and symptoms.	Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol or other drug use.
Support and encourage patient; provide care with a positive, friendly attitude.	Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person.
Encourage family/SO to verbalize feelings, visit freely and participate in care.	Family members may feel guilty about patient’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to patient. Participation in care helps them feel useful and promotes trust between staff, patient, and SO.
Assist patient/SO to cope with change in appearance; suggest clothing that does not emphasize altered appearance (color of clothes, etc).	Patient may present unattractive appearance as a result of jaundice, ascites, ecchymotic areas. Providing support can enhance self-esteem and promote patient sense of control.
Refer to support services. Counselors, psychiatric resources, social service, clery and alcohol treatment program may help.	Increased vulnerability and concerns associated with this illness may require services of additional professional resources.

8. Knowledge Deficit

Nursing Diagnosis

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 disease process/prognosis, potential complications.
Correlate symptoms with causative factors.
Identify/initiate necessary lifestyle changes and participate in care.

Nursing Interventions	Rationale
Review disease process and prognosis and future expectations.	Provides knowledge base from which patient can make informed choices.
Refer to dietitian or nutritionist.	Patients with cirrhosis needs close observation and sound nutritional counseling.
Stress importance of avoiding alcohol. Give information about community services available to aid in alcohol rehabilitation if indicated.	Alcohol is the leading cause in the development of cirrhosis.
Inform patient of altered effects of medications with cirrhosis and the importance of using only drugs prescribed or cleared by a healthcare provider who is familiar with patient’s history.	Some drugs are hepatotoxic (especially narcotics, sedatives, and hypnotics). In addition, the damaged liver has a decreased ability to metabolize all drugs, potentiating cumulative effect and/or aggravation of bleeding tendencies.
Review procedure for maintaining function of peritoneovenous shunt when present.	Insertion of a Denver shunt requires patient to periodically pump the chamber to maintain patency of the device. Patients with a LeVeen shunt may wear an abdominal binder and/or engage in a Valsalva maneuver to maintain shunt function.
Assist patient identifying support person(s).	Because of length of recovery, potential for relapses, and slow convalescence, support systems are extremely important in maintaining behavior modifications.
Emphasize the importance of good nutrition. Recommend avoidance of high-protein/salty foods, onions, and strong cheeses. Provide written dietary instructions.	Proper dietary maintenance and avoidance of foods high in sodium and protein aid in remission of symptoms and help prevent ammonia buildup and further liver damage. Written instructions are helpful for patient to refer to at home.
Stress necessity of follow-up care and adherence to therapeutic regimen.	Chronic nature of disease has potential for life-threatening complications. Provides opportunity for evaluation of effectiveness of regimen, including patency of shunt if used.
Discuss sodium and salt substitute restrictions and necessity of reading labels on food and OTC drugs.	Minimizes ascites and edema formation. Overuse of substitutes may result in other electrolyte imbalances. Food, OTC and/or personal care products (antacids, some mouthwashes) may contain sodium or alcohol.
Encourage scheduling activities with adequate rest periods.	Adequate rest decreases metabolic demands on the body and increases energy available for tissue regeneration.
Promote diversional activities that are enjoyable to patient.	Prevents boredom and minimizes anxiety and depression.
Recommend avoidance of persons with infections, especially URI.	Decreased resistance, altered nutritional status, and immune response (leukopenia may occur with splenomegaly) potentiate risk of infection.
Identify environmental dangers: exposure to hepatitis.	Can precipitate recurrence.
Instruct patient/SO of signs and symptoms that warrant notification of health care provider: increased abdominal girth; rapid weight loss/gain; increased peripheral edema; increased dyspnea, fever; blood in stool or urine; excess bleeding of any kind; jaundice.	Prompt reporting of symptoms reduces risk of further hepatic damage and provides opportunity to treat complications before they become life-threatening.
Instruct SO to notify health care providers of any confusion, untidiness, night wandering, tremors, or personality change.	Changes (reflecting deterioration) may be more apparent to SO, although insidious changes may be noted by others with less frequent contact with patient.

Other Nursing Diagnoses

Fatigue—decreased metabolic energy production, states of discomfort, altered body chemistry (e.g., changes in liver function, effect on target organs, alcohol withdrawal).
Imbalanced Nutrition: less than body requirements—inadequate diet; inability to process/digest nutrients; anorexia, nausea/vomiting, indigestion, early satiety (ascites); abnormal bowel function.
Risk for ineffective management—perceived benefit, social support deficit, economic difficulties.
Family Processes, dysfunctional: alcoholism—abuse of alcohol, resistance to treatment, inadequate coping/lack of problem-solving skills, addictive personality/codependency.
Risk for caregiver role strain—addiction or codependency, family dysfunction before caregiving situation, presence of situational stressors, such as economic vulnerability, hospitalization, changes in employment.

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6 Cushing’s Disease Nursing Care Plan

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Definition of Disturbed Body Image

Defining Characteristics of Disturbed Body Image

Related Factors of Disturbed Body Image

Ongoing Assessment Disturbed Body Image

Therapeutic Interventions Disturbed Body Image

Disturbed Body Image Education/Continuity of Care

Disturbed Body Image — Burn Injury Nursing Care Plan (NCP)

8 Liver Cirrhosis Nursing Care Plan (NCP)

Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

7 Eating Disorders (Anorexia & Bulimia Nervosa) Nursing Care Plan (NCP)

Disturbed Body Image — Anorexia & Bulimia Nervosa Nursing Care Plan (NCP): Nursing Interventions & Rationale

10 Ileostomy & Colostomy Nursing Care Plan (NCP)

Disturbed Body Image — Ileostomy & Colostomy Nursing Care Plan (NCP)

Nursing Care Plans

1. Risk for Impaired Skin Integrity

2. Disturbed Body Image

3. Acute Pain

4. Impaired Skin Integrity

5. Deficient Fluid Volume

6. Imbalanced Nutrition

7. Sexual Dysfunction

8. Disturbed Sleep Pattern

9. Constipation/Diarrhea

10. Knowledge Deficit

Other Nursing Care Plans

See Also

Nursing Care Plans

1. Impaired Physical Mobility

2. Knowledge Deficit

3. Disturbed Body Image

4. Fear/Anxiety

5. Impaired Skin Integrity

6. Imbalanced Nutrition

7. Ineffective Tissue Perfusion

8. Acute Pain

9. Risk for Infection

10. Risk for Deficient Fluid Volume

11. Risk for Ineffective Airway Clearance

Other Possible Nursing Care Plans

See Also

Nursing Care Plans

1. Imbalanced Nutrition

2. Deficient Fluid Volume

3. Disturbed Thought Process

4. Disturbed Body Image

5. Impaired Parenting

6. Impaired Skin Integrity

7. Knowledge Deficit

Other Possible Nursing Diagnoses

See Also

Nursing Care Plans

1. Imbalanced Nutrition

2. Excess Fluid Volume

3. Impaired Skin Integrity

4. Ineffective Breathing Pattern

5. Risk for Injury

6. Risk for Acute Confusion

7. Disturbed Body Image/Self-Esteem

8. Knowledge Deficit

Other Nursing Diagnoses

See Also