Thursday, September 24, 2009

Nursing Key outcomes, interventions, and Patient teaching Nursing Care Plans for Abruptio Placentae (placenta abruption)

. Thursday, September 24, 2009

Nursing Key outcomes, interventions, and Patient teaching Nursing Care Plans for Abruptio Placentae (placenta abruption)

Key outcomes Nursing Care Plans for Abruptio Placentae (placenta abruption) the patient will:

  •  Express feelings of comfort.
  •  Express feelings of reduced anxiety.
  •  Communicate feelings about the situation.
  • Discuss fears and concerns.
  • Use available support systems, such as family and friends, to aid in coping.
  • Remain hemodynamically stable.
  • Patient's fluid volume will remain within normal parameters.
Nursing interventions Nursing Care Plans for Abruptio Placentae (placenta abruption)
  • Monitor Vital sign; blood pressure, pulse rate, respirations, central venous pressure, intake and output, and amount of vaginal bleeding.
  • Monitor fetal heart rate electronically.
  • If vaginal delivery is elected, provide emotional support during labor.
  • Because of the neonate's prematurity, the mother may not receive an analgesic during labor and may experience intense pain. Reassure the patient of her progress through labor, and keep her informed of the fetus's condition.
  • Encourage the patient and her family to verbalize their feelings. Help them to develop effective coping strategies. Refer them for counseling, if necessary.

Patient teaching Nursing Care Plans for Abruptio Placentae (placenta abruption)
  • Teach the patient to identify and report signs of placental abruption, such as bleeding and cramping.
  • Explain procedures and treatments to allay patient's anxiety.
  • Teach the patient to notify the doctor and come to the hospital immediately if she experiences any bleeding or contractions.
  • Prepare the patient and her family for the possibility of an emergency cesarean delivery, the delivery of a premature neonate, and the changes to expect in the postpartum period. Offer emotional support and an honest assessment of the situation.
  • Tactfully discuss the possibility of neonatal death. Inform the patient that the neonate's survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive disorders.
  • Inform the patient that frequent monitoring and prompt management greatly reduce the risk of death.
  • Inform the patient that she is at much higher risk of developing abruptio placentae in subsequent pregnancies.


Thursday, September 17, 2009

Nursing Care Plans for Bulimia Nervosa

. Thursday, September 17, 2009

Bulimia nervosa the binge and purge syndrome is an eating disorder, the essential features of bulimia nervosa include eating binges followed by feelings of guilt, humiliation, and self deprecation guilt, and anxiety over fear of weight gain. Characterized by extreme overeating, followed by self induced vomiting and abuse of laxatives, diuretics, strict dieting or fasting to overcome the effects of the binges. Unless the patient devotes an excessive amount of time to binging and purging, bulimia nervosa seldom is incapacitating.
Bulimia nervosa usually begins in adolescence or early adulthood and can occur simultaneously with anorexia nervosa. The disorder occurs predominantly in females and begins in adolescence or early adult life. Between 1% and 3% of adolescent and young females meet the diagnostic criteria for bulimia nervosa; 5% to 15% have some symptoms of the disorder.

Causes for Bulimia Nervosa
The exact cause of bulimia is unknown, but bulimia is generally attributed to a combination of psychological, genetic, and physiological causes. Such factors include family disturbance or conflict, sexual abuse, maladaptive learned behavior, struggle for control or self-identity, cultural overemphasis on physical appearance, and parental obesity. Bulimia nervosa is strongly associated with depression. Predisposing Factors to Anorexia Nervosa and Bulimia Nervosa

Complications for Bulimia Nervosa

  • Dental caries result from repetitive vomiting in bulimia nervosa.
  • Erosion of tooth enamel.
  • Parotitis
  • Gum infections.
  • Arrhythmias and even sudden death result from electrolyte imbalances.
  • Ipecac syrup intoxication can cause cardiac failure in patients who rely on this drug to induce vomiting.
  • Esophageal tears and gastric ruptures rare complications.
  • Mucosal damage can occur if patient with bulimia nervosa use laxatives and enemas.
  • Potential psychiatric complication of bulimia nervosa is suicide.
  • Bulimia nervosa patients are more prone to psychoactive substance use disorders.

Nursing Assessment Nursing Care Plans for Bulimia Nervosa
Patient history of bulimia nervosa is characterized by episodic binge eating several times per day. Commonly reports a binge eating episode during which she continues eating until abdominal pain. The Bulimia Nervosa patient usually preferred food that sweet, soft, and high in calories and carbohydrate. Unlike the anorexic nervosa patient bulimic patient usually can keep her eating disorder hidden, because patient's weight frequently fluctuates, but usually stays within the normal range through the use of diuretics, laxatives, vomiting, and exercise. The patient may complain of abdominal and epigastric, Amenorrhea, Painless swelling of the salivary glands, hoarseness, throat irritation or lacerations, and dental erosion. A Bulimia Nervosa patient commonly is perceived by others as a perfect person’s, However, the patient's psychosocial history may reveal an exaggerated sense of guilt, symptoms of depression, childhood trauma (especially sexual abuse), parental obesity, or a history of unsatisfactory sexual relationships.
Symptomatology for Bulimia Nervosa

  • Patients with Bulimia Nervosa usually solitary and secret and patients with Bulimia Nervosa able to consume thousands of calories in one binge episode.
  • Loss of control to stop eating After the binge has begun
  • After binge eats, the individual engages in inappropriate compensatory measures to avoid gaining weight, like self-induced vomiting, excessive use of laxatives, diuretics, or enemas, and extreme exercising.
  • Eating binges may be viewed as pleasurable but are followed by intense self criticism and depressed mood.
  • Patient with Bulimia Nervosa usually within normal weight range, some a few pounds underweight, and some a few pounds overweight.
  • Obsession with body image and appearance is a predominant feature of this disorder.
  • Binges usually alternate with periods of normal eating and fasting.
  • Excessive vomiting may lead to problems with dehydration and electrolyte imbalance.
  • Gastric acid in the vomitus may contribute to the erosion of tooth enamel.

Treatment for Bulimia Nervosa
Treatment of bulimia nervosa may continue for several years. Interrelated physical and psychological symptoms must be treated simultaneously.

Nursing diagnosis Nursing Care Plans for Bulimia Nervosa

  • Anxiety
  • Chronic low self-esteem
  • Constipation
  • Deficient fluid volume
  • Disturbed body image
  • Disturbed sleep pattern
  • Imbalanced nutrition: Less than body requirements
  • Ineffective coping
  • Social isolation

Nursing Key outcomes, interventions, Patient teaching Nursing Care Plans for Bulimia Nervosa


Sunday, September 13, 2009

Nursing Care Plans for Abruptio Placentae (placenta abruption)

. Sunday, September 13, 2009

Abruptio placentae also called placental abruption occur when the placenta prematurely separates from the uterine wall, usually after the 20th week of gestation, producing hemorrhage. This disorder may be classified according to the degree of placental separation and the severity of maternal and fetal symptoms. It is characterized by a triad of symptoms: vaginal bleeding, uterine hypertonus, and fetal distress. It can occur during the prenatal or intrapartum period
Abruptio placentae is most common in multigravidas usually in women older than age 35 and is a common cause of bleeding during the second half of pregnancy. On heavy maternal bleeding generally necessitates termination of the pregnancy. The fetal prognosis depends on the gestational age and amount of blood lost. The maternal prognosis is good if hemorrhage can be controlled.

Grading System for Abruptio Placentae (placenta abruption)
Grade 0 Less than 10% of the total placental surface has detached; the patient has no symptoms; however, a small retroplacental clot is noted at birth.
Grade I approximately 10%–20% of the total placental surface has detached; vaginal bleeding and mild uterine tenderness are noted; however, the mother and fetus are in no distress.
Grade II Approximately 20%–50% of the total placental surface has detached; the patient has uterine tenderness and tetany; bleeding can be concealed or is obvious; signs of fetal distress are noted; the mother is not in hypovolemic shock.
Grade III More than 50% of the placental surface has detached; uterine tetany is severe; bleeding can be concealed or is obvious; the mother is in shock and often experiencing coagulopathy; fetal death occurs.

Central abruption, the separation occurs in the middle, and bleeding is trapped
Between the detached placenta and the uterus, concealing the hemorrhage.

Marginal abruption, separation begins at the periphery and bleeding accumulates between
The membranes and the uterus and eventually passes through the cervix, becoming an external hemorrhage.

Causes for Abruptio Placentae (placenta abruption)
The cause of abruptio placentae is unknown; however, any condition that causes vascular changes at the placental level may contribute to premature separation of the placenta. Predisposing factors include:
  • Traumatic injury.
  • Placental site bleeding from a needle puncture during amniocentesis,
  • Chronic or pregnancy induced hypertension.
  • Multiparity
  • Short umbilical cord
  • Dietary deficiency
  • Smoking
  • Advanced maternal age
  • Pressure on the vena cava from an enlarged uterus.
The spontaneous rupture of blood vessels at the placental bed may result from a lack of resiliency or to abnormal changes in the uterine vasculature. The condition may be complicated by hypertension or by an enlarged uterus that can't contract sufficiently to seal off the torn vessels. Consequently, bleeding continues unchecked, possibly shearing off the placenta partially or completely.

Complications for Abruptio Placentae (placenta abruption)
  • Hemorrhage and shock.
  • Renal failure,
  • Disseminated intravascular coagulation.
  • Maternal and fetal death.
Nursing Assessment Nursing Care Plans for Abruptio Placentae (placenta abruption)
Abruptio placentae produces a wide range of clinical effects, depending on the extent of placental separation and the amount of blood lost from maternal circulation.
Obtain patient history obstetric history. Determine the date of the last menstrual period to calculate the estimated day of delivery and gestational age of the infant. Inquire about alcohol abuse, tobacco, and drug usage, and any trauma or abuse situations during pregnancy
  • Mild abruptio placentae with marginal separation usually report mild to moderate vaginal bleeding, vague lower abdominal discomfort, and mild to moderate abdominal tenderness.
  • Moderate abruptio placentae are about 50% placental separation usually report continuous abdominal pain and moderate, dark red vaginal bleeding. Onset of symptoms may be gradual or abrupt. Vital signs may indicate impending shock. Palpation reveals a tender uterus that remains firm between contractions.
  • Severe abruptio placentae about 70% placental separations patient usually report abrupt onset of agonizing, unremitting uterine pain (described as tearing or knifelike) and moderate vaginal bleeding. Vital signs indicate rapidly progressive shock. Palpation reveals a tender uterus with boardlike rigidity. Uterine size may increase in severe concealed abruptions.
Psychosocial Assessment to understanding patient’s situation and also the significant other’s degree of anxiety, coping ability, and willingness to support the patient

Diagnostic tests for Abruptio Placentae (placenta abruption)
  • Pelvic examination under double setup
  • Ultrasonography
  • Decreased hemoglobin level
  • Decreased platelet count.
  • Periodic assays for fibrin split products aid in monitoring the progression of abruptio placentae and in detecting DIC.
Treatment for Abruptio Placentae (placenta abruption)
Medical Treatment management goals of abruptio placentae are to assess, control, and restore the amount of blood lost and to deliver a viable infant and prevent coagulation disorders.

Nursing diagnoses Nursing Care Plans for Abruptio Placentae (placenta abruption)
Primary nursing diagnosis nursing care plans for abruptio placentae (placenta abruption) fluid volume deficit related to blood loss
Common nursing diagnosis fond in Nursing Care Plans for Abruptio Placentae (placenta abruption):
  • Acute pain
  • Anxiety
  • Deficient fluid volume
  • Dysfunctional grieving
  • Fear
  • Ineffective coping
  • Ineffective tissue perfusion: Cardiopulmonary


Saturday, September 12, 2009

Nursing outcomes, interventions, Patient teaching, Nursing Care Plans for Preeclampsia Pregnancy Induced Hypertension

. Saturday, September 12, 2009

Nursing outcomes, interventions, Patient teaching, Nursing Care Plans for Preeclampsia Pregnancy Induced Hypertension

Nursing Key outcomes Nursing Care Plans for Preeclampsia, The patient will:

  • Be able to perform activities of daily living without excessive fatigue.
  • Identify strategies to reduce anxiety.
  • Maintain optimal functioning within the confines of the visual impairment.
  • Maintain orientation to environment.
  • Verbalize fears and concerns
  • Demonstrate adaptive coping behaviors.
  • Exhibit signs of adequate cerebral and peripheral perfusion.
  • Avoid complications.
  • Fluid volume will remain within normal parameters.
  • The patient's urine output will remain within normal limits.

Nursing interventions Nursing Care Plans for Preeclampsia

  • Monitor the patient vital sign regularly for changes in blood pressure, pulse rate, respiratory rate, fetal heart rate, vision, level of consciousness, and deep tendon reflexes and for headache unrelieved by medication.
  • Immediately report changes.
  • Assess these signs before administering medications.
  • Monitor the extent and location of edema.
  • Elevate affected extremities to promote venous return.
  • Assess fluid balance by measuring intake and output and by checking daily weight.
  • Provide a quiet, darkened room until the patient's condition stabilizes.
  • Enforce strict bed rest.
  • Provide emotional support for the patient and family.
  • Explain to patients and family if the patient's condition necessitates premature delivery.

Patient teaching Nursing Care Plans for Preeclampsia

  • Teach the patient and her family how to identify and report signs and symptoms of preeclampsia and eclampsia.
  • Instruct the patient to maintain bed rest as ordered.
  • Advice her to lie in a left lateral position to increase venous return, Elevate affected extremities, cardiac output, and renal blood flow.
  • Stress the importance of adequate nutrition in the prenatal period.
  • Advise the patient to avoid foods high in sodium.
  • Explain the importance of scheduling and keeping prenatal visits.


Friday, September 11, 2009

Nursing Care Plans for Preeclampsia Pregnancy Induced Hypertension

. Friday, September 11, 2009

Pregnancy Induced Hypertension PIH is a potentially life-threatening disorder that usually develops after the 20th week of pregnancy. It typically occurs in nulliparous women and may be nonconvulsive or convulsive.
The cause of Preeclampsia is unknown it is often called the “disease of theories” because many causes have been proposed, yet none has been well established. occure approximately 7% of all pregnant women. Almost preeclampsia case occurs before the fetus is term. primary goals in nursing care plan for preeclampsia is prevent seizures, intracranial hemorrhage, and serious organ damage in the mother and to deliver a healthy term infant. Preeclampsia, the nonconvulsive form of the disorder, is marked by the onset of hypertension after 20 weeks of gestation. It develops in about 7% of pregnancies and may be mild or severe. The incidence is significantly higher in low socioeconomic groups. Eclampsia, the convulsive form, occurs between 24 weeks' gestation and the end of the first postpartum week. The incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease.
About 5% of women with preeclampsia develop eclampsia; of these, about 15% die of eclampsia or its complications. Fetal mortality is high because of the increased incidence of premature delivery Pregnancy Induced Hypertension PIH and its complications are the most common cause of maternal death in developed countries.

Causes for Preeclampsia
The cause of PIH is unknown. Geographic, ethnic, racial, nutritional, immunologic, and familial factors may contribute to preexisting vascular disease, which, in turn, may contribute to its occurrence. Age is also a factor. Adolescents and primiparas older than age 35 are at higher risk for preeclampsia. Other theories include a long list of potential toxic sources, such as autolysis of placental infarcts, autointoxication, uremia, maternal sensitization to total proteins, and pyelonephritis.

Complications for Preeclampsia
  • Intrauterine growth retardation (or restriction),
  • Placental infarcts, and
  • abruptio placentae.
  • Other possible complications include stillbirth of the neonate, seizures, coma, premature labor, renal failure, and hepatic damage in the mother.
Nursing Assessment Nursing Care Plans for Preeclampsia
  • A patient with mild preeclampsia typically reports a sudden weight gain,
  • The patient's history reveals hypertension
  • Inspection reveals generalized edema, especially of the face. Palpation may reveal pitting edema of the legs and feet.
  • Deep tendon reflexes may indicate hyperreflexia.
  • Oliguria
  • Blurred vision caused by retinal arteriolar spasms,
  • Epigastric pain or heartburn, irritability, and emotional tension.
  • Patient may complain of a severe frontal headache.
In a patient with severe preeclampsia:
Blood pressure readings increase to 160/110 mm Hg or higher on two occasions, 6 hours apart, during bed rest. Also,
Ophthalmoscopic examination may reveal vascular spasm, papilledema, retinal edema or detachment, and arteriovenous nicking or hemorrhage.

Diagnostic Highlights Nursing Care Plan For Preeclampsia
Hemolysis, elevated liver enzyme levels, and a low platelet count (HELLP syndrome) characterize severe eclampsia. A unique form of coagulopathy is also associated with this disorder.
  • Urine for protein and creatinine
  • Uric acid
  • Blood urea nitrogen (BUN)
  • Liver enzymes: AST, ALT, LDH,Bilirubin
  • Platelets
  • Coagulation studies
  • RBC (red blood cell)
  • Hgb (hemoglobin)
  • Hct (hematocrit)
Preeclampsia Treatment
Therapy for patients with preeclampsia is intended to halt the progress of the disorder specifically, the early effects of eclampsia, such as seizures, residual hypertension, and renal shutdown and to ensure fetal survival. Some physicians advocate the prompt inducement of labor, especially if the patient is near term; others follow a more conservative approach. Therapy may include:
  • complete bed rest in the preferred left lateral lying position to enhance venous return
  • an antihypertensive, such as methyldopa or hydralazine
  • magnesium sulfate to promote diuresis, reduce blood pressure, and prevent seizures if the patient's blood pressure fails to respond to bed rest and the antihypertensive and persistently rises above 160/100 mm Hg, or if central nervous system irritability increases.
  • If fetal life is endangered cesarean section or oxytocin inducement may be required to terminate the pregnancy.

Nursing diagnoses Nursing Care Plans for Preeclampsia
  • Activity intolerance
  • Anxiety
  • Disturbed sensory perception (visual)
  • Disturbed thought processes
  • Excess fluid volume
  • Fear
  • Impaired urinary elimination
  • Ineffective coping
  • Ineffective tissue perfusion: Cerebral, peripheral
  • Risk for injury

Key outcomes, Nursing interventions , Patient teaching , Nursing Care Plans for Preeclampsia Pregnancy Induced Hypertension


Saturday, September 5, 2009

Nursing Care Plans for Endometriosis

. Saturday, September 5, 2009

Nursing Care Plans for Endometriosis. Endometriosis is a hormonal and immune system disease characterized by a benign growth of endometrial tissue that occurs atypically outside of the uterine cavity. When endometrial tissue appears outside the lining of the uterine cavity, endometriosis results. Such ectopic tissue is generally confined to the pelvic area, most commonly around the ovaries, uterovesical peritoneum, uterosacral ligaments, and the cul-de-sac, but it can appear anywhere in the body.
This ectopic endometrial tissue responds to normal stimulation in the same way that the endometrium does. During menstruation, the ectopic tissue bleeds, which causes inflammation of the surrounding tissues. This inflammation causes fibrosis, leading to adhesions, which produce pain and infertility.  Active endometriosis usually occurs between ages 30 and 40. Severe symptoms of endometriosis may have an abrupt onset or may develop over many years. This disorder usually becomes progressively more severe during the menstrual years but tends to subside after menopause.

Causes for Endometriosis
The direct cause is unknown, but the most predominant theory is the retrograde menstruation theory, research focuses on the following possible causes:
  • Transportation (retrograde menstruation). During menstruation, the fallopian tubes expel endometrial fragments that implant outside the uterus.
  • Formation in situ. Inflammamsstion or a hormonal change triggers coelomic metaplasia.
  • Induction. The endometrium chemically induces undifferentiated mesenchyma to form endometrial epithelium. (This is the most likely cause.)
  • Immune system defects. Endometriosis may result from a specific defect in cell mediated immunity.
Complications for Endometriosis
Primary complication
  • Infertility.
Other complications
  • Spontaneous abortion,
  • Anemia due to excessive bleeding.
  • Emotional problems resulting from infertility.
Nursing Assessment Nursing Care Plans for Endometriosis
  • Patient History Elicit a complete history of the woman’s menstrual, obstetric, sexual, and contraceptive practices
  • The patient may complain of cyclic pelvic pain, infertility and, the classic symptom, acquired dysmenorrhea.
  • The patient typically reports pain in the lower abdomen, vagina, posterior pelvis, and back. This pain usually begins from 5 to 7 days before menses, reaches a peak, and lasts for 2 to 3 days.
  • Patient may complain of deep-thrust dyspareunia (ovaries and cul-de-sac);
  • suprapubic pain, dysuria, and hematuria
  • painful defecation, rectal bleeding with menses, and pain in the coccyx or sacrum
  • nausea and vomiting that worsen before menses and abdominal cramps
  • Palpation may disclose multiple tender nodules on uterosacral ligaments or in the rectovaginal septum.
  • Palpation may also uncover ovarian enlargement in the presence of endometrial cysts on the ovaries or thickened, nodular adnexa.
Diagnostic tests for Endometriosis
Scoring and staging system created by the American Society for Reproductive Medicine quantifies endometrial implants according to size, character, and location.
  • Stage I is minimal disease (0 to 5 points);
  • Stage II signifies mild disease (6 to 15 points);
  • Stage III, moderate disease (16 to 40 points); and
  • Stage IV, severe disease (more than 40 points).
Treatment for Endometriosis
The stage of the disease and the patient's age and desire to have children are considered in determining the course of treatment.
  • Conservative therapy for young women who want to bear children with androgens, which produce a temporary remission in Stages I and II.
  • Progestins and hormonal contraceptives also relieve symptoms.
  • Gonadotropin releasing analogues, such as leuprolide, suppress estrogen production.
  • Laparoscopy, used for diagnostic purposes, can also be used therapeutically to lyse adhesions, remove small implants, and cauterize implants. The goal is to remove as much of the ectopic endometrial tissue as possible
  • Laparoscopy also permits laser vaporization of implants. This surgery is usually followed with hormonal therapy to suppress the return of endometrial implants.
  • Surgery may be needed to rule out cancer.
  • Conservative surgery is possible, but the treatment of choice for women who don't want to bear children or for those who have extensive disease (Stages III and IV) is a total abdominal hysterectomy with bilateral salpingo-oophorectomy.
  • Minor gynecologic procedures are contraindicated immediately before and during menstruation.
Nursing diagnosis nursing care plans for endometriosis
Primary nursing diagnosis nursing care plans for endometriosis
Pain, chronic, related to cramping, internal bleeding, swelling, and inflammation during the menstrual cycle
Common nursing diagnosis found on nursing care plans for endometriosis:

  • Anxiety
  • Chronic pain
  • Deficient knowledge (diagnosis and treatment)
  • Disturbed body image
  • Fear
  • Ineffective coping
  • Risk for infection
  • Sexual dysfunction

Key outcomes Nursing Care Plans for Endometriosis

  • Comfort level, Pain control, Depression control, Pain: Disruptive effects, Pain: Psychological response
  • Patient will identify strategies to reduce anxiety.
  • Patient will express feelings of comfort.
  • Patient and her family will express understanding of the disorder and its treatment.
  • Patient will express feelings about self.
  • Patient will discuss fears and concerns.
  • Patient will develop adequate coping behaviors.
  • Patient will remain free from signs and symptoms of infection.
  • Patient will verbalize feelings regarding sexual impairment.

Patient teaching Nursing Care Plans for Endometriosis

  • Ensure that the patient understands the dosage, route, action, and side effects before going home.
  • Explain all procedures and treatment options. Clarify misconceptions about the disorder, associated complications, and fertility.
  • Advise adolescents to use sanitary napkins instead of tampons. This can help prevent retrograde flow in girls with a narrow vagina or small vaginal meatus.
  • Because infertility is a possible complication, counsel the patient who wants children not to postpone childbearing.
  • Advise the patient to have an annual pelvic examination and a Pap test.

Encourage the patient to be alert to her emotions, behavior, physical symptoms, diet, and rest and exercise. Encourage the patient to maintain open communication with her significant other and her family to discuss concerns she may have about the disease process.


Thursday, September 3, 2009

Nursing interventions, Key outcomes nursing care plans for Autistic disorder

. Thursday, September 3, 2009

Nursing Key Outcomes Nursing Care Plans For Autistic Disorder

  • The patient and his family will express reduced levels of anxiety.
  • Anxiety is maintained at a level at which client feels no need for self mutilation
  • Client initiates interactions between self and others, and use eye contact, facial responsiveness, and other nonverbal behavior
  • The patient's family will openly share feelings about the present situation.
  • As much as possible, the patient will demonstrate age-appropriate skills and behaviors.
  • The patient will perform self care activities independently.
  • The patient will develop peer relationships.
  • The patient’s family will identify and contact available resources as needed.
  • The patient and his family will practice safety measures and take safety precautions in the home.
  • The patient won't engage in self-destructive behaviors.
  • The patient will interact with family or friends.
Nursing interventions nursing care plans for Autistic disorder
  • Reduce self destructive behaviors.
  • Physically stop the child from harming himself.
  • Give verbal or physical reinforcement.
  • Foster appropriate use of language.
  • Provide positive reinforcement when the child indicates his needs correctly.
  • Encourage development of self esteem.
  • Encourage self care.
  • Encourage acceptance of minor environmental changes.
  • Provide emotional support to the parents.
  • Refer them to the Autism Society.

Nursing interventions nursing care plans for Autistic disorder based on nursing diagnosis

Nursing Diagnosis Risk for self mutilation
  • Intervene to protect child when self mutilate behaviors, Safety tools like helmet may be used to protect against head banging, hand mitts to prevent hair pulling, and appropriate padding to protect extremities from injury during hysterical movements.
  • Try to determine if self mutilate behaviors occur in response to increasing anxiety, and if so, to what the anxiety may be attributed.
  • To establish trust, Work on one to one basis with child.

Nursing Diagnosis Impaired social interaction
  • Build trust relationship with the child.
  • Provide child with familiar objects such as favorite toys, or favorite blanket.
  • Convey a manner of warmth, acceptance, and availability as client attempts to fulfill basic needs.
  • Do not force interactions.
  • Give positive reinforcement for eye contact. Gradually introduce use eye contact, facial responsiveness, and other nonverbal behavior
  • Support client with nurse presence as he or she endeavors to relate to others in the environment.

Nursing Diagnosis Impaired verbal communication
  • Maintain consistency in assignment of caregivers. Consistency facilitates trust and enhances the caregiver’s ability to understand the child’s attempts to communicate.
  • Anticipate and fulfill client’s needs until satisfactory communication patterns are established. Anticipating needs helps to minimize frustration while the child is learning communication skills.
  • Use the techniques of consensual validation and seeking clarification to decode communication patterns.
  • Use face to face approach.

Nursing Diagnosis Disturbed personal identity
  • Function in a one to one relationship with the child to establishment of trust.
  • Assist child to recognize separateness during self-care activities, such as dressing and feeding.
  • Point out, and assist child in naming, own body parts.
  • Gradually increase amount of physical contact, using touch to point out differences between client and nurse. 
  • Cautious in using touch until trust is established, client may be interpreted as threatening.
  • Use mirrors and drawings or pictures of the child to reinforce the child’s learning of body parts and boundaries.

Nursing Diagnosis Anxiety
Nursing Diagnosis Compromised family coping
Nursing Diagnosis Delayed growth and development
Nursing Diagnosis Dressing or grooming self-care deficit
Nursing Diagnosis Interrupted family processes
Nursing Diagnosis Risk for injury
Nursing Diagnosis Risk for self-directed violence
Nursing Diagnosis Social isolation

Patient teaching and home health guidance for Autistic disorder
  • Give knowledge to the parents about Autistic disorder to Help parent understand that the cause of this condition is unknown.
  • Teach the parents how to physically care for the child's needs.
  • Teach the parents how to identify signs of excessive stress and coping skills to use under these circumstances.
  • Emphasize that they'll be ineffective caregivers if they don't take the time to meet their own needs in addition to those of their child.

ngaglik81 is proudly powered by | Template by | Ngaglik81.blogspot Privacy Policy