Nursing Care Plan for Cushing\'s Syndrome PDF

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Nursing Care Plan...

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CUES AND EVIDENCES Subjective cues: “Wala nako ganahi sa akong lawas. Magsakit akong buot magtan-aw sa salamin. Ug luya na kayo ko.” As verbalized by the patient. Objective cues: -Abnormal fat distribution along with edema -Moon face Cervicodorsal fat (buffalo hump) -Trunk obesity -Muscle wasting -Capillary fragility -Wasting of bone matrix: ecchymosis, osteoporosis, slender limbs, striae (purple). -Virilism in women -Hirsutism

NURSING DIAGNOSIS Disturbed body image related to altered physical appearance, impaired sexual functioning, and decreased activity level.

OBJECTIVE By the end of the nursing care, the patient will be able to: -verbalize feelings about the changes in appearance, sexual function and activity level. -demonstrate enhanced body image and selfesteem as evidenced by ability to look at, touch, talk about, and care for actual and perceived altered body parts and functions.

NURSING INTERVENTION

RATIONALE

EVALUATION

By the end of nursing care the patient was -Establish rapport with the patient -To incorporate trust in all able to: procedures to be done. -verbalize feelings about the changes in -Assess the client’s coping -To check how patient appearance, sexual mechanism. cope up with the function and activity situation. level. -Assess for any changes in personal appearance -To note and report to the -demonstrate caused by the cortisol attending physician. And do enhanced body image nursing intervention. excess. and self-esteem as evidenced by ability to -Assess patient’s feelings -To know if there’s withdrawal look at, touch, talk about their changed from social interaction. about, and care for appearance and coping actual and perceived mechanism. -To help patient develop realistic altered body parts and -Reassure the patient that expectations about the change in functions. the physical changes are physical appearance. -Goal met result of the elevated hormone levels and most will resolve when those -To enhance patient’s coping levels return to normal. strategies. -Encourage the patient to verbalize feelings about -To support the patient’s the body image changes adjustments to his or her -Promote an atmosphere of appearance. INDEPENDENT:

acceptance caring.

and

positive

-To facilitate patient in adjusting to the current situation.

-Promote coping methods to deal with the client’s change in appearance (e.g., adequate grooming, flattering clothes). -To help the patient in calming. DEPENDENT: -Administer medication indicated by the physician.

as

-To check and know the health status of the patient.

-Follow and do the laboratory exams and tests as indicated by -To provide social support and the physician. offer coping strategies that have proven successful. COLLABORATIVE: -Refer to local support groups.

CUES AND EVIDENCES Objective cues: -Abnormal fat distribution along with edema -Moon face Cervicodorsal fat (buffalo hump) -Trunk obesity -Muscle wasting -Capillary fragility -Wasting of bone matrix: ecchymosis, osteoporosis, slender limbs, striae (purple). -Virilism in women -Hirsutism

NURSING DIAGNOSIS Risk for injury related to weakness

OBJECTIVE By the end of the nursing care, the patient will be able to: -be free of fractures or soft tissues injuries. -implement measures to prevent injury

NURSING INTERVENTION INDEPENDENT:

RATIONALE

EVALUATION

By the end of nursing care the incorporate patient was able -Establish rapport with -To trust in all to: the patient procedures to be -be free of -Assess the skin done. frequently to check -To check because fractures or soft are the tissues injuries. for reddened areas, these skin breakdown, symptoms of the -implement tearing, or syndrome. measures to excoriation. prevent injury. -Assess the skin for -To give appropriate intervention. -Goal met signs of bruising. -Assess the patient for decreased height and kyphosis (forward rounding of the back).

-To monitor the occurrence of the symptoms.

-To check, since this is a sign of GI -Assess the feces bleeding.

for occult blood. -Ask the patient about problems with poor wound healing.

-To assess the deteriorating immune function. -To check with the loss bone density.

-Prepare the -To avoid skin patient for a bone breakdown. density evaluation. -To prevent falls -Instruct the and fractures. patient about keeping the skin clean and -To help in moisturized. -Discuss with controlling the site patient safety that is bleeding. measures for ambulation and daily activities. -To reduce the risks -Apply direct of cutting the skin. pressure over venipuncture sites, injection sites, or wounds for at least 1 minute or longer. -To help in keeping oneself clean. -Instruct the patient in activities to decrease risk for -To

prevent

bleeding: Use an electric razor. Use a soft toothbrush.

fractures injuries.

and

-To avoid pain and during -Assist the patient injury with ambulation activities. and hygiene when weak and fatigued. -Use assistive devices during ambulation to prevent falls and fractures. -Instruct the patient to correct body mechanics

-To alleviate existing symptoms.

-To help monitor the dietary intake of the patient.

DEPENDENT: -Administer medication as indicated.

-To help prevent muscle loss. -To strengthen the bones.

COLLABORATIVE: -Encourage the client to eat a highfiber diet with

adequate intake.

fluid

-Encourage the client to eat a highprotein diet. -Encourage the client to increase dietary intake of calcium, and vitamin D.

CUES AND EVIDENCES Objective cues: -Abnormal fat distribution along with edema -Moon face Cervicodorsal fat (buffalo hump) -Trunk obesity -Muscle wasting

NURSING DIAGNOSIS Risk for infection related to altered protein metabolism and inflammatory response.

OBJECTIVE By the end of the nursing care, the patient will be able to: -identify interventions to prevent risk for

NURSING INTERVENTION

RATIONALE

EVALUATION

By the end of nursing care the patient was -Establish rapport with the patient -To incorporate trust in all able to have a: procedures to be done. -Assess frequently for subtle signs -Corticosteroids mask -identify of infections. signs of inflammation and interventions to infection. prevent risk for infection. -Avoid unnecessary exposure to INDEPENDENT:

-Capillary fragility -Wasting of bone matrix: ecchymosis, osteoporosis, slender limbs, striae (purple). -Virilism in women -Hirsutism

infection.

-Cortisol suppresses the immune system. -display an Therefore clients may absence of develop infection more -Stress the importance of adequate frequently. infection as evidenced by rest. normal body -A patient who is under temperature long-term stress tends to and normal suffer from bacterial -Use strict medical and surgical white blood infection, cold, asepsis when providing care. cell count. and flu viruses. people with infections.

-Encourage turning, coughing, and deep breathing and incentive spirometry every 2–4 hours. -Stress proper handwashing techniques.

-Emphasized the importance of good nutrition.

DEPENDENT: -Administer medications as

-A patient is susceptible to infection from a variety of bacteria, viruses, fungi and other microorganisms that live naturally on the skin and in the hospital. -This will assist in the mobilization of secretions.

-Handwashing serves as the first-line defense against crosscontamination/nosocomial infections. -Adequate nutrition enhances immune system natural defense

-display an absence of infection as evidenced by normal body temperature and normal white blood cell count. -Goal met

mechanism.

indicated by the physician. COLLABORATIVE:

-To alleviate any symptoms or condition.

-Follow up laboratory results.

-To monitor the health status of the patient.

CUES AND EVIDENCES Subjective cues: “Akong panit dali ra masamaran. Unya dugay kayo maayo inig masamad. Hubag akong kamot ug nawong” as verbalized by the

NURSING DIAGNOSIS Impaired skin integrity related to edema, impaired healing and thin and fragile skin.

OBJECTIVE By the end of the nursing care, the patient will be able to: -display timely healing of skin lesions, wounds, or pressure sores

NURSING INTERVENTION

RATIONALE

By the end of nursing care the patient was able to:

INDEPENDENT: -To incorporate trust in all procedures to be done. -To assess and have a baseline on the treatment that should be done. -Obtain history of condition, -To check for dehydration including age at onset, original and monitor condition. -Establish patient

rapport

EVALUATION

with

the

-display timely healing of skin lesions, wounds, or pressure sores without complications. -maintain optimal nutrition

patient. Objective cues: -Abnormal fat distribution along with edema -Moon face Cervicodorsal fat (buffalo hump) -Trunk obesity -Muscle wasting -Capillary fragility -Wasting of bone matrix: ecchymosis, osteoporosis, slender limbs, striae (purple). -Virilism in women -Hirsutism

without complications. -maintain optimal nutrition and physical wellbeing -participate in prevention measures and treatment program. -verbalize feelings of increased selfesteem and ability to manage situation.

site or characteristics of lesions, duration of problem, and changes that have occurred overtime. -To check for infection and -Note skin color, texture, and know necessary turgor. Assess areas of least intervention. pigmentation for color changes -To monitor the condition -Inspect skin on daily basis, of the wounds and plan for describing wound or lesion appropriate care. characteristics and changes observed. -To assist body’s natural -Keep the area clean and dry, process of repair. carefully dress wounds, manage incontinence, and stimulate circulation to surrounding areas. -To protect the wound -Use appropriate barrier and/or surrounding tissues. dressings, wound coverings, drainage appliances, vacuumassisted closure device and skinprotective agents for open, draining wounds and stomas -To enhance understanding -Reposition patient on regular and cooperation. schedule, involving patient in reasons for and decisions about times and positions. DEPENDENT:

and physical well-being -participate in prevention measures and treatment program. -verbalize feelings of increased self-esteem and ability to manage situation.

-Goal met

-Administer medications, indicated by the physician.

as

-To help in the wound healing and to prevent infection.

COLLABORATIVE: -To assist with developing -Consult with wound specialist, plan of care for as indicated. problematic or potentially problematic wounds.

-To remove nonviable, -Assist with debridement or contaminated, or infected enzymatic therapy, as indicated. tissue....