Nursing Care Plan for Cushing's Syndrome
Nursing Diagnosis : Excess Fluid Volume related to excessive secretion of cortisol due to sodium and fluid retention.
Goal: The client shows the volume of fluid balance.
Intervention:
1. Measure intake output.
2. Avoid excessive fluid intake when the patient's hypernatremia.
3. Measure vital signs (BP, pulse, RR) every 2 hours.
4. Measure weight.
5. Monitor ECG for abnormalities (electrolyte imbalance).
6. Collaboration lab results (electrolytes: Na, K, Cl).
Rationale :
1. Shows the status of the transfer fluid circulating volume and response to pain.
2. Provide some sense of control in the face of attempts restriction.
3. Increased blood pressure, increased pulse and respiratory rate decreases indicate excess fluid.
4. Changes in body weight showed impaired fluid balance.
5. Hypernatremia and hypokalemia showed indications of excess fluid.
6. Shows fluid retention and should be limited.
Nursing Diagnosis : Activity Intolerance related to muscle weakness and changes in protein metabolism.
Goal: The client showed activity returned to normal after the act of nursing
Nursing Intervention :
1. Assess client's ability to perform activities.
2. Increase bed rest / sit.
3. Note the response to activities such as tachycardia, dyspnea, fatigue.
4. Increase active involvement of the patient in accordance with his ability.
5. Provide assistance activities as needed.
6. Provide appropriate entertainment activities such as watching TV and listening to radio.
Rationale :
1. Knowing the client's level of development activity.
2. Periods of rest are energy saving techniques.
3. Response showed an increase in O2, fatigue and weakness.
4. Adding a level of confidence and self-esteem of patients both in abundance according to the level of activity is tolerated.
5. Meet the needs of client activity.
6. Increase relaxation and energy savings, refocus and improve coping.
Nursing Diagnosis : Risk for Infection related to a decrease in immune response, inflammatory response.
Goal: Infection does not occur after the intervention.
Nursing Intervention :
1. Assess for signs of infection.
2. Measure vital signs every 8 hours.
3. Wash hands before and after nursing action.
4. Restrict visitors as indicated.
5. Place the client in isolation as indicated.
6. Antibiotics as indicated.
Rationale :
1. Presence of signs of infection (tumor, rubor, dolor, calor, functionalist laesa) is an indicator of infection.
2. Temperature increased an indicator of infection.
3. Prevent cross infection.
4. Reducing Exposure to other infectious pathogens.
5. Isolation techniques may be needed to prevent the spread / protect other patients from infection process.
6. Antibiotic therapy to reduce the risk of nosocomial infection.
