Critical Elements of Nursing (aka Foundations of Nursing)

Nursing Diagnoses & Pathophysiology
Nursing Diagnosis

  1. Nausea related to headache pain as evidenced by vomiting.
  2. Pain related to headache as evidenced by pt stated she had pain of a 10 on a 1-10 pain scale for 24 hours.
  3. Activity intolerance related to headache pain as evidenced by patient states headache pain worsens when she tries to do activities.
  4. Anxiety related to lack of knowledge about medical procedures as evidenced by patient asking if she “will have to lie flat and have a headache” after the procedure.
  5. Risk for fluid volume deficit related to vomiting.

Pathophysiology

Headache is a symptom of something occurring in the head. It can be caused by several conditions such as sinus inflammation, vascular dilation, allergic reaction, stroke, etc. There are 4 types of stroke: 2 caused by blockages, and two by bleeding. Cerebral thrombosis is a blood clot that forms in the brain in the brain blocking the oxygen supply to a portion of the brain. Cerebral embolism is a clot that moves to the brain (or brain’s blood supply) from another part of the body and blocks it. Also this may be a fat or air embolism as well as a blood clot. Cerebral and subarachnoid hemorrhages are caused by ruptured blood vessels. Hemorrhage (or bleeding) from an artery in the brain can be caused by a head injury or a burst aneurysm. Aneurysms are blood-filled pouches that balloon out from weak spots in the artery wall. They are often caused or made worse by high blood pressure. Signs of a stroke are a sudden onset of weakness or numbness especially on one side of the body, sudden confusion and difficulty speaking, sudden trouble with vision, sudden loss of balance or coordination, sudden severe headache with no known cause. All signs are due to lack of oxygenation to the part of the brain that controls the body function that is affected.

Pathophysiology

End stage renal disease can be linked to several other disease factors including diabetes mellitus and hypertension. The glomerulus of the kidney no long can filter effectively to remove toxic substances from the blood stream. Also the kidney can no longer produce Erythropoietin, which is the hormone that stimulates the red bone marrow to form red blood cells. This can cause anemia. The kidneys do not get rid of the phosphate so the levels rise - this may cause itch. Vitamin D is not activated so calcium levels fall - this may cause tiredness. Manifestations of this disease include fatigue, nausea, and edema. Hemodialysis can be used to externally filter toxins out of the blood. A strict diet can help to reduce the rate at which the toxic byproducts of metabolism are produced.

Pathophysiology

Septic shock occurs most often among hospitalized patients, especially men over age 40 and women ages 25 to 45. Bacteria produce septicemia in persons whose resistance is already compromised by an exiting condition. Infection also results from transplantation of bacteria from other areas of the body through surgery or foreign bodies placed into the human body. Sepsis is evidenced by fever and pain caused by the inflammation process. As the leukocytes attack the invading organism they release histamine that makes them “leaky”. So all the blood pools in that area making it warm, flushed and presses on the nerves causing pain. The white blood cells also release interluken, which causes the temperature center in the brain to raise the core body temperature. My patient presented in the ER with a fever of 101.5 oF and bleeding around the site of her AV shunt that was surgically placed two days before her ER visit.