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FDAR that may used

in
Neurological Ward

Prepared by:

MIGUELITO M. GULTIANO
CSA – Student Nurse
Nursing Diagnosis for Neurological/Sensory Disorders

Glaucoma
 Disturbed visual sensory perception
 Anxiety (specify level)

Seizure disorders
 Risk for trauma or suffocation
 Risk for ineffective airway clearance or breathing pattern
 Low self-esteem
 Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Craniocerebral trauma (Acute Rehabilitative Phase)


 Ineffective cerebral tissue perfusion
 Risk for ineffective breathing pattern
 Disturbed sensory perception (specify)
 Disturbed thought process
 Impaired physical mobility
 Risk for infection
 Risk for imbalanced nutrition, less than body requirements
 Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Cerebrovascular Accident (CVA) or Stroke


 Ineffective cerebral tissue perfusion
 Impaired physical mobility
 Impaired verbal or written communication
 Disturbed sensory perception (specify)
 Self-care deficit
 Ineffective coping
 Risk for impaired swallowing
 Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Herniated Nucleus Pulposus (Ruptured Intervertebral Disc)


 Acute or chronic pain
 Impaired physical mobility
 Anxiety (specify level)
 Ineffective coping
 Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Disc Surgery
 Ineffective tissue perfusion
 Risk for trauma (spinal)
 Risk for ineffective airway clearance
 Risk for ineffective breathing pattern
 Acute pain
 Impaired physical mobility
 Constipation
 Risk for urinary retention
 Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Spinal Cord Injury (Acute Rehabilitative Phase)


 Risk for ineffective breathing pattern
 Risk for injury ( additional spinal injury)
 Impaired physical mobility
 Disturbed sensory perception
 Acute pain
 Anticipatory grieving
 Low self-esteem
 Constipation or bowel incontinence
 Impaired urinary elimination
 Risk for autonomic dysreflexia
 Risk for skin integrity
 Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Multiple Sclerosis
 Fatigue
 Self-care deficit (specify)
 Chronic low self-esteem (specify situation)
 Hopelessness or powerlessness ( specify degree)
 Risk for ineffective coping
 Disabled family coping
 Compromised coping
 Impaired urinary elimination
 Risk for caregiver role strain
 Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Nursing Diagnosis for Ischemic Stroke:


 Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
 Acute pain (painful shoulder) related to hemiplegia and disuse
 Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae
 Disturbed sensory perception related to altered sensory reception, transmission, and/or integration
 Impaired swallowing
 Total urinary incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating
 Disturbed thought processes related to brain damage, confusion, or inability to follow instructions
 Impaired verbal communication related to brain damage
 Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility
 Interrupted family processes related to catastrophic illness and caregiving burdens

Nursing Diagnosis for Hemorrhagic Stroke:


 Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm
 Disturbed sensory perception related to medically imposed restrictions (aneurysm precautions)
 Anxiety related to illness and/or medically imposed restrictions (aneurysm precautions)

Nursing Diagnosis for Altered Level of Consciousness


 Ineffective airway clearance related to altered LOC
 Risk of injury related to decreased LOC
 Deficient fluid volume related to inability to take fluids by mouth
 Impaired oral mucous membrane related to mouth-breathing, absence of pharyngeal reflex, and altered fluid intake
 Risk for impaired skin integrity related to immobility
 Impaired tissue integrity of cornea related to diminished or absent corneal reflex
 Ineffective thermoregulation related to damage to hypothalamic center
 Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control
 Bowel incontinence related to impairment in neurologic sensing and control and also related to changes in nutritional delivery
methods
 Disturbed sensory perception related to neurologic impairment
 Interrupted family processes related to health crisis

Nursing Diagnosis for Patient with Increased Intracranial Pressure


 Ineffective airway clearance related to diminished protective reflexes (cough, gag)
 Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement)
 Ineffective cerebral tissue perfusion related to the effects of increased ICP
 Deficient fluid volume related to fluid restriction
 Risk for infection related to ICP monitoring system (fiberoptic or intraventricular catheter)
Nursing Diagnosis for Craniotomy
 Ineffective cerebral tissue perfusion related to cerebral edema
 Risk for imbalanced body temperature related to damage to the hypothalamus, dehydration, and infection
 Potential for impaired gas exchange related to hypoventilation, aspiration, and immobility
 Disturbed sensory perception related to periorbital edema, head dressing, endotracheal tube, and effects of ICP
 Body image disturbance related to change in appearance or physical disabilities

Nursing Diagnosis for Epilepsy


 Risk for injury related to seizure activity
 Fear related to the possibility of seizures
 Ineffective individual coping related to stresses imposed by epilepsy
 Deficient knowledge related to epilepsy and its control

Nursing Diagnosis for Brain Injury


 Ineffective airway clearance and impaired gas exchange related to brain injury
 Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures
 Deficient fluid volume related to decreased LOC and hormonal dysfunction
 Imbalanced nutrition, less than body requirements, related to increased metabolic demands, fluid restriction, and inadequate
intake
 Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage
 Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain
 Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness
 Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain
injury
 Disturbed sleep pattern related to brain injury and frequent neurologic checks
 Interrupted family processes related to unresponsiveness of patient, unpredictability of outcome, prolonged recovery period, and
the patient’s residual physical disability and emotional deficit
 Deficient knowledge about brain injury, recovery, and the rehabilitation process

These are individualized nursing care plans for various nursing diagnoses.

 Activity Intolerance
 Acute Confusion
 Acute Pain
 Anxiety
 Caregiver Role Strain
 Constipation
 Chronic Pain
 Decreased Cardiac Output
 Deficient Fluid Volume
 Deficient Knowledge
 Diarrhea
 Disturbed Body Image
 Disturbed Thought Processes
 Excess Fluid Volume
 Fatigue
 Hyperthermia
 Hypothermia
 Imbalanced Nutrition: Less Than Body Requirements
 Imbalanced Nutrition: More Than Body Requirements
 Impaired Gas Exchange
 Impaired Oral Mucous Membrane
 Impaired Physical Mobility
 Impaired Swallowing
 Impaired Tissue (Skin) Integrity
 Impaired Urinary Elimination

 – Functional Urinary Incontinence

 – Reflex Urinary Incontinence

 – Stress Urinary Incontinence

 – Urge Urinary Incontinence


 Impaired Verbal Communication
 Ineffective Airway Clearance
 Ineffective Breathing Pattern
 Ineffective Coping
 Ineffective Therapeutic Regimen Management
 Ineffective Tissue Perfusion
 Latex Allergy Response
 Powerlessness
 Risk for Aspiration
 Risk for Falls
 Risk for Infection
 Risk for Injury
 Risk for Unstable Blood Glucose Level
 Self-Care Deficit
 Urinary Retention
HYPOTHERMIA

Assessment is required in order to distinguish possible problems that may have lead to Hypothermia.

Assessment Rationales

Causative factors guide the appropriate treatment. Older patients have a decreased
Assess for precipitating situations and
metabolic rate and reduced shivering response; therefore the effects of cold may
risk factors.
not be immediately manifested.

For alert patients, oral temperature is regarded as more reliable than tympanic or
Note and monitor patient’s
axillary. For hypothermic patients, core temperature can be monitored using a
temperature.
temperature-sensitive pulmonary artery catheter or bladder catheter.

Monitor the patient’s HR, heart HR and BP drop as hypothermia progresses. Moderate to severe hypothermia
rhythm, and BP. increases the risk for ventricular fibrillation, along with other dysrhythmias.

Evaluate the patient for


drug abuse use,
These groups of drugs contribute to vasodilation and heat loss.
including antipsychotics, opioids, and
alcohol.

Evaluate the patient’s nutrition and Poor nutrition contributes to decreased energy reserves and restricts the body’s
weight. ability to generate heat by caloric consumption.

Hypothermia initially precipitates peripheral vascular constriction as a


compensatory mechanism to minimize heat loss from extremities. The patient’s skin
Assess the patient’s peripheral
will look pale and cool to the touch with delayed capillary refill. As hypothermia
perfusion at frequent intervals.
advances, vasodilation transpires, furthering heat loss. The patient’s skin becomes
warm and less pale. The patient may start to remove clothing and bed covers.

Decreased output may indicate dehydration or poor renal perfusion. Avoid fluid
Monitor fluid intake and urine output
overload to prevent pulmonary edema, pneumonia, and taxing an already
(and/or central venous pressure).
compromised cardiac and renal status.
Check for electrolytes,
arterial blood gases, and oxygen Acidosis may emerge from hypoventilation and hypoxia.
saturation by pulse oximetry.

Evaluate for the presence of


frostbite, if the patient has had Severe hypothermia generates ice crystals to form inside cells. The cells eventually
prolonged exposure to a cold burst and die.
environment.

Assess the patient’s readiness to


reach a toileting facility, both This allows the nurse to plan for assistance.
independently and with assistance.

Assess the patient’s typical pattern of


urination and occurrence This information is the source for an individualized toileting program.
of incontinence.

Nursing Interventions

The following are the therapeutic nursing interventions for Hypothermia:

Interventions Rationales

Regulate the environment temperature or relocate These methods provide for a more gradual warming of the body.
the patient to a warmer setting. Keep the patient Rapid warming can induce ventricular fibrillation. Moisture promotes
and linens dry. evaporative heat loss.

Body temperature should be raised no more than a few degrees per


Control the heat source according to the patient’s hour. Vasodilation occurs as the patient’s core temperature increases
physical response. leading to a decrease in BP. Hypotension, metabolic acidosis, and
dysrhythmias are complications of rewarming.

Give extra covering (passive warming), such as


clothing and blankets; cover postoperative patients Warm blankets provide a passive method for rewarming.
with heat-retaining blankets.
Give heated oral fluids for alert patients. Warm fluids produce a heat source.

Provide extra heat source:

 Heat lamp, radiant warmer


 Warming pads, mattress, or blankets These measures raise the core temperature and improve circulation.
Core warming is indicated when body temperature is below 30 °C (86
 Submersion in a warm bath
°F).
 Heated, moisturized oxygen
 Warmed intravenous fluids or lavage
fluids

Avoid manually rubbing, scrubbing, or massaging


Rubbing can further damage frozen tissue.
areas of frostbite.

Explain all procedures and treatment to the patient


Repeated explanations are needed to avoid confusion.
and SO.

Ineffective Breathing Pattern

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.

May be related to

 Ascending paralysis
 Decrease lung

Possibly evidenced by

 Altered chest expansion


 Cyanosis
 Respiratory depth changes
 Abnormal ABGs

Desired Outcomes

 Client will maintain effective breathing pattern.


Nursing Interventions Rationale

Assess frequency, symmetry, and depth of


Progressive weakness of both the inspiratory and the expiratory muscles
breathing. Observed for increased work of
may lead to respiratory distress that may necessitate the need
breathing and evaluate skin color, temperature,
for mechanical ventilation.
capillary refill.

Observe for signs of respiratory fatiguesuch as


May indicate neuromuscular respiratory failure or decrease lung
shortness of breath, decreased attention span,
capacity.
and impaired cough.

Pooling of secretions and increased airway resistance may impede


Auscultate lung sounds for any changes and
the diffusion of gases resulting in airway complications such
notifies the physician immediately.
as pneumonia.

Assess oxygen saturation and review client’s Determines oxygenation status and provides information about the
arterial blood gases results. effectiveness of ventilation given or the need to adjust the parameters.

Increases lung expansion and cough effort minimizes the work of


Keep the head of bed elevated at around 35-45°
breathing and the risk of aspiration of secretions.

Perform chest physiotherapy which includes


postural drainage, chest percussion, chest
Facilitates mobilization and clearance of airway secretions.
vibration, turning, deep breathing and coughing
exercises.

Mechanical ventilation may be required for an extended period to


Anticipate the need for mechanical ventilation as support pulmonary function and adequate oxygenation. Weaning from
ordered. mechanical ventilation happens when the respiratory muscles can
sustain spontaneous respiration and keep adequate tissue oxygenation.

Suction secretions as appropriate, especially if


the client is intubated or undergone Promotes adequate clearance of secretions and prevents aspiration.
a tracheostomy.

Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of
such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6
months.
May be related to

 Biologic injuring agent (inflammation of nerves)

Possibly evidenced by

 Communication of pain descriptors of discomfort in the extremities


 Guarding behavior
 Autonomic responses of diaphoresis
 Alteration in muscle tone
 Tachypnea, Tachycardia

Desired Outcomes

 Child rates pain as less than (specify pain rating and scale used).

Nursing Interventions Rationale

Determines the extent of pain or presence


Assess level of pain and ability to engage in activities.
of progressive paralysis.

Identify the child’s perception of the word “pain” and inquire family members
Facilitates better communication between
what word the child uses at home; Utilize pain scale appropriate for the child’s
the child/family and nurse.
age and developmental level.

Administer analgesics based on pain assessment and respiratory status; Eliminates or controls pain and provides
Monitor side effect after administration. comfort.

Provide support to extremities and maintain clean, comfortable bed using egg-
Increases comfort and decreases risks for
crate mattress and padding to bony prominences as needed; Reposition client
skin impairment.
every 2 hours, use good postural alignment, assist with passive ROM.

Promotes circulation to the area and


Apply a moist warm compress to painful areas as needed.
relieves pain.

Reassure parents and child that pain Provides information about the length of
diminishes as motor function slowly time pain might be anticipated to
improve or resolved. continue.

Identify pain preventive measures around the clock; observe for behavioral and Promotes immediate identification of pain
physiological signs of pain. which enhances efficient relief of pain.
Impaired Physical Mobility

Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

May be related to

 Neuromuscular impairment

Possibly evidenced by

 Paralysis
 Inability to purposefully move within physical environment including bed mobility, transfer and ambulation
 Limited ROM
 Decreased muscle strength and control
 Trauma from falls

Desired Outcomes

 Client will have an improved strength and function of the affected extremity.
 Client will demonstrate the use of adaptive devices to increase mobility.

Nursing Interventions Rationale

Understanding the particular level guides the design of best possible


Assess motor strength or functional level of mobility.
management plan.

Monitor nutritional needs as they associate with Good nutrition also gives required energy for participating in an
immobility. exercise or rehabilitative activities.

Place the client in a position of comfort. Provide Promotes relaxation and prevent the development of decubitus
frequent position changes as tolerated. ulcers.

Low ̶ molecular-weight heparin (LMWH) is administered in the


Administer heparin as ordered.
prophylaxis of deep vein thrombosis.

Provide padding to bony prominences such as elbow Maintain extremity in a physiological position, reduces the risk
and heels. of pressure ulcers.

Perform active, passive and isotonic range of motion Improves joint mobility, stimulates circulation and enhance muscle
exercises as appropriate. tone.

Evaluate the need for assistive devices and provide a


Correct utilization of wheelchairs, canes, transfer bars, and other
safe environment e.g., bed in low position and side
assistance can promote mobility and reduces the risk of falls.
rails up.

Provide rest periods in between activities. Consider


Rest periods are essential to conserve energy and avoid fatigue.
energy-saving techniques.

Assist client and their families to establish goals in


Enhances a sense of anticipation of progress or improvement and
participation with activities, exercise and position
promotes independence.
changes.

Formulates a course of treatment with specific interventions to


Consider the need for home assistance (e.g., physical
improve muscle function and to retrain in performing activities of
therapy and occupational therapy).
daily living (ADLs).

Impaired Urinary Elimination

Impaired Urinary Elimination: Disturbance in urinary elimination.

May be related to

 Neuromuscular impairment

Possibly evidenced by

 Urinary retention
 Paralysis

Desired Outcomes

 Client will establish routine urinary elimination patterns.

Nursing Interventions Rationale

Assess progressive degree of paralysis and effect on urinary Provides data on the effect of motor dysfunction that
elimination. travels upward from extremities.

Monitor intake and output every 4 to 8 hours Provides monitoring of I&O ratio and presence of urinary
and palpate bladder every 2 hours; assess for cloudy, foul- retention or infectionas paralysis progresses.
smelling urine.

If needed, insert an indwelling urinary catheter to maintain


Relieves bladder distention and urinary retention.
elimination.

Assist client in urinary elimination rehabilitation program; Promotes urine elimination and return to a normal pattern
perform Crede’s maneuver in a gentle manner if indicated. as soon as possible.

Supports urinary elimination and return to baseline


Educate parents in the program to restore urinary function. pattern without retention and possible
urinary bladder infection.

Instruct parents to maintain fluid intake and monitor output Maintains I&O balance and adequate intake to promote
in connection to intake. urinary output.

Instruct to report any reduction or absence of urinary Avoids complication of neuromuscular impairment of
elimination. disease and effect on urinary bladder function.

Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

 Change in health status and threat to self-concept.

Possibly evidenced by

 Increased apprehension as the condition worsens and paralysis spreads


 Expressed concern and worry about permanent effects of the disease
 Treatments during hospitalization
 Expressed feeling of increased helplessness and uncertainty

Desired Outcomes

 Parents and child verbalize decreased feelings of anxiety.


Nursing Interventions Rationale

Determines the extent of anxiety and need for interventions,


Assess source and level of anxiety,
sources may include fear and uncertainty about treatment and
how anxiety is manifested and need
recovery, guilt about the presence of illness, possible loss of
for information that will relieve it.
parental role and responsibility during hospitalizations.

Facilitate expression of concerns and an opportunity to


Provides an opportunity to release feelings, secure
ask inquiries regarding the condition and rehabilitation
information needed to overcome anxiety.
of the ailing child.

Allows for care and support of child instead of increasing anxiety


Encourage parents to stay with the child and in the
that is caused by absence and lack of knowledge about child’s
care of the child.
condition.

Therapeutically communicate with parents and child


Promotes an environment of support.
and answer questions in a calm and honest manner.

Assist parents and child to recognize improvements


Promotes a positive attitude and optimistic outlook for recovery.
resulting from treatments.

Allow the child to participate in own care depending


Promotes independence and control and preserves
on ability and degree of paralysis; allow to make
developmental status.
informed choices about ADL as soon as possible.

Teach parents and child about disease condition and Provides information to relieve anxiety by knowledge of what to
manifestation. expect.

Discuss each procedure or type of may


therapy, effects of any diagnostic tests to parents and Reduces fear of the unknown which increase anxiety.
child as appropriate to age.

Teach parents and child that degree of severity varies


but motor weakness and paralysis start
Provides information about the usual course of disease and length
with extremities and move upward with the peak
of illness.
reached in 3 weeks and improvement seen by 4 to 8
weeks.

Clarify any information and answer questions in lay


Prevents unnecessary anxiety resulting from incorrect knowledge
terms and utilize visual aids for reinforcement
or beliefs or inconsistencies in information.
if helpful.

Risk for Altered Parenting


Risk for Altered Parenting: At risk for the inability of the primary caretaker to create, maintain, or regain an environment that
promotes the optimum growth and development of the child.

May be related to

 Illness

Possibly evidenced by

 Verbalization of decreased interactions with hospitalized child and inability to provide care
 Lack of control over the situation
 Request for information about parenting skills for long recovery period or permanent residual disability

Desired Outcomes

 Parents will participate in child’s care.

Nursing Interventions Rationale

Assess for presence of permanent


disability or possibility of long-term recovery and effect on Identifies factors associated with long recovery period.
parents.

Identifies potential for social deprivation of parents


Encourage parents to express feelings and unmet needs
and development of strategies to achieve realistic
and ability to meet and develop self-expectations.
expectations.

Encourage and praise positive parental behaviors; support


any participation in care or decision-making on behalf of Reduces anxiety for and enhances learning about child’s needs
the and care.
child.

Encourage touching and play activities


Enhances comfort and positive parental behaviors.
between parents and child.

Teach about physical therapy program Facilitates muscle recovery and prevents contractures
including ROM, exercises, gait training, bracing (refer and permanent disability, promotes a sense of confidence and
as indicated). control.

Continue to inform and support parents during the Provides reassurance that recovery is slow and conserves
recovery period (provide telephone numbers). parental emotional reserves.
Refer to Guillain-Barre Syndrome
Provides information and support from those with experience
Support Group for assistance or community agencies for
with the disease.
support.

Ineffective Tissue Perfusion (Cerebral)

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level

May be related to

 Increased intracranial pressure


 Cerebral edema

Possibly evidenced by

 Delirium, hallucinations
 Drowsiness
 Hypercapnia

Desired Outcomes

 Child will have vital signs return to normal; child is alerted and oriented: motor, cognitive, and sensory function are
within acceptable parameters for the child’s age; normal specific urine gravity.

Nursing Interventions Rationale

Increasing systolic blood pressure accompanied by


Monitor vital signs and neurological status. decreasing diastolic bloodpressure is an ominous sign
of increased ICP.

Signs and symptoms that indicate an increase in ICP


Observe for any signs of increased intracranial pressure. include headache, drowsiness, decreased alertness,
vomiting, bulging fontanelle (infants).

Assess for nuchal rigidity, twitching, increased restlessness, and These are signs of meningeal irritation, which may
irritability. happen because of infection.

Observe for increasing restlessness, moaning, and guarding


These nonverbal cues may indicate increasing ICP
behaviors.
or pain. Unrelieved pain can potentiate increased
ICP.

Determines presence of hypoxia and indicates


Monitor arterial blood gases (ABGs) and oxygen saturation.
therapy needs.

Turning head to one side compresses the jugular


Maintain head or neck in midline position, provide small pillow for
veins and inhibits venous drainage, thereby
support.
increasing ICP.

During reposition, avoid bending of the knee and pushing heels These activities increase intra-thoracic and
against the mattress. intrabdominal pressures, thereby increasing ICP.

Produces relaxing effect which decreases adverse


Provide comfort measures and Decrease external stimuli such as
physiologic response and promotes rest to maintain
quiet environment, soft voice, and gentle touch.
or lower ICP.

Promotes venous drainage from head, thereby


Elevate the head of the bed 30°, and avoid neck flexion and
reducing cerebral congestion and edema and risk of
hip flexion.
increased ICP.

Reduces hypoxia which can increase blood volume,


Administer oxygen as needed.
promotes cerebral vasodilation and elevate ICP.

Administer medications as indicated:

Used to treat cerebral edema by promoting cerebral


 Osmotic diuretic: Mannitol (Osmitrol) blood flow

 Anticonvulsants: Diazepam (Valium) Used to control seizures related to increased


intracranial pressure.
or phenytoin (Dilantin)

Hyperthermia

Hyperthermia: Body temperature elevated above normal range.

May be related to

 Infection
 Abnormal temperature regulation

Possibly evidenced by
 Body temperature above the normal range
 Hot, flushed skin
 Increased heart rate
 Increased respiratory rate
 Seizures

Desired Outcomes

 Child will regain and maintain body temperature within a normal range.

Nursing Interventions Rationale

A history of aseptic viral meningitis usually begins with an onset


Assess the child’s vital signs closely. of fever up to 104°F. As hyperthermia progresses, HR and BP
increase also.

Assess for signs of dehydration such as dry mouth,


Elevated body temperature increases the metabolic rate, hence
sunken eyes, sunken fontanelle, low
increases the insensible fluid loss.
concentrated urine output.

Shivering can happen from rapid reduction of temperature which


Gradually decrease temperature. can result to rebound effect and increase the temperature instead
lower the temperature.

Decreases temperature by liberating heat by conduction and


Perform tepid sponge.
convection.

Prevents dehydration; Avoid fluid overload because of the risk of


Maintain adequate fluid intake as tolerated.
cerebral edema.

Antibiotics are given to treat the underlying causes of inflammation


Administer antibiotics as indicated.
and thus prevent the occurrence of seizure activity.

Antipyretics decrease fever and lessen brain oxygen demand as


Administer antipyretics as indicated.
fever increases cerebral metabolic demand.

Disturbed Sensory Perception

Disturbed Sensory Perception: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated,
distorted, or impaired response to such stimuli
May be related to

 Decreased LOC
 Cerebral edema
 Increased ICP
 Hydrocephalus

Possibly evidenced by

 Altered sensorium

Desired Outcomes

 Child will maintain normal LOC.

Nursing Interventions Rationale

Glasgow coma scale is a reliable and objective way of measuring the


Assess level of consciousness using pediatric
motor, verbal and sensory cues related to LOC. Neurological
Glasgow coma scale.
assessment aids in determining the extent of damage in meningitis.

Additional or changes in the treatment may be required once the


LOC furtherly decreases. Change in mentation, seizures,
Observe and notify physician for persistent
increased blood pressure (BP), bradycardia, or respiratory
deterioration in LOC.
abnormalities may indicate increasing ICP with decreased cerebral
perfusion pressure.

Assess for signs of cerebral edema such as Anoxia, vasodilation, or vascular stasis can lead to cerebral edema
dizziness, headache, irregular breathing, neck pain, due to the increased intracellular and extracellular fluid in
nausea or vomiting. the brain as the symptoms progress.

Assess ability to follow simple or complex Impaired cognitive function occurs with cerebral hemisphere
commands. involvement.

Evaluate presence or absence of protective reflexes:


Absence of reflexes is a late sign indicative of increasing ICP.
swallow, gag, blink, cough.

Assess for signs of meningeal irritation such as Meningeal signs are a result of meningeal and spinal root
headache, photobia, nuchal rigidity, opisthotonic inflammation, and/or pooling of infectious exudates and are cardinal
position, Kernig’s sign, Brudzinki’s sign. features of meningeal irritation.
Elevate head of bed up to 30° to 45° with the client’s
Promotes venous outflow from the brainand help decrease ICP.
head in neutral position.

Frequent reality orientation is important to promote cognitive


Reorient the client to the environment, as needed.
function.

Assist with diagnostic testing:

 Electroencephalogram
 Lumbar puncture for CSF The following diagnostic exam are done to evaluate cerebral
pressure and identify the presence of infectious organisms.
 Magnetic resonance imaging (MRI),
computed tomography (CT), or
ventriculogram

Initiate seizure precautions: observe and provide Providing appropriate and precise care during a seizure prevents
care during seizure. complication and further brain damage.

Maintain a quiet environment and keep the lights Prevents stimulation that can cause or precipitate an episode of
dim. convulsion.

Assess pupil size every 3 hours during the first 24 Increased intracranial pressure (ICP) will result in uneven pupil sizes,
hours and consequently every 6 hours. fixed dilated pupil.

Changes in seizure pattern signify the need for additional


neurological evaluation, anticonvulsant medications, and
Observe and document pattern and frequency reevaluation of treatment. Seizure usually happens prior an increase
of seizure. Notify physician of seizure activity. in intracranial pressure (ICP). Adequate treatment of infection will
mitigate further deterioration and maintain intracranial pressure
within normal limits.

Allow parents to participate in the child’s care. Support better coping and decrease anxiety.

Anticonvlsants are both used as prophylaxis and treatment. Therapy


Administer and monitor anticonvulsantsdrug levels. involves keeping therapeutic blood levels to avoid the occurrence of
seizures.

Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

 Lack of exposure to information.


Possibly evidenced by

 Request for information about medications, signs and symptoms and behaviors to report
 General care during convalescence of infant/child

Desired Outcomes

 Parents verbalize understanding of cause and treatment plan.

Nursing Interventions Rationale

Assess knowledge of disease and method


Promotes plan of instruction that is realistic to ensure compliance
to control and resolve disease; willingness and
with medical regimen; prevents a repetition of information.
interest of parents to implement care.

Provide information and explanations in clear


language that is understandable; use Ensures understanding based on readiness and ability to learn; visual
pictures, pamphlets, video tapes, model in aids reinforce learning.
teaching about disease.

Teach about administration of medications including


Provides information for compliance in medication therapy to
(specify: action of drugs, dosages times frequency,
prevent or treat infection and seizure activity resulting from
side effects, expected results, methods to give
the disease; bacterial meningitis is treated with antibiotics, and viral
medications); provide written instructions and
meningitis may be treated with antibiotics until diagnosis
schedule to follow and inform to administer full
is established.
course of antibiotic to child.

Assist to plan feedings and/or develop menus to


include nourishing fluids, Promotes optimal nutrition in a progressive manner as tolerable.
caloric and basic four groups for age group.

Reinforce to parents follow up to assess for Promotes identification of hearing loss (injury to 8th cranial
potential hearing impairment. nerve caused by meningitis).

Inform parents as to the benefits of routine May prevent the disease; data suggests the incidence of this form of
immunizations with H. influenzae(type B) vaccine, meningitis has decreased since the vaccine was introduced;
beginning at 2 months of age for a total of 3 doses. may decrease the spread of infection to unvaccinated infants.

Teach to promote adequate rest and Rest important for convalescence and stimulating activities needed
activities that provide age-appropriate play and for continued development or to promote stimulation if
stimulation (specify). developmental lag is present.

Teach to isolate other children in the family for 24 Prevents transmission of bacteria to others in the family.
hours if respiratory infection present or until the
culture is negative.

Teach to report elevated temperature, poor feeding


or anorexia, irritability or other changes in behavior Reveals signs and symptoms of presence of or spread of infection.
or level of consciousness, decrease in hearing acuity.

Administer antibiotics as prescribed


Manages existing infection and prevents further spread of infection
(specify) as soon as ordered based
(action of drug).
on analysis of CSF, throat cultures.

Provide stool softeners or mild laxative, avoid use of Prevents constipation and lessen the risk of increased ICP due to
restraints and prevent or reduce crying episodes. straining from defecation.

Risk for Injury

Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive
resources, which may compromise health.

May be related to

 Internal factor of altered neurologic regulatory function.

Possibly evidenced by

 [not applicable]

Desired Outcomes

 Child will not experience injury

Nursing Interventions Rationale

Assess neurologic status to include VS pattern, changes in Provides information that offers clues to possible
consciousness, behavior patterns and pupillary/ocular responses change in intracranial pressure caused
appropriate for age (measure head circumference in infant) (specify by inflammation of the brain and associated
when). edema.

Increased intracranial pressure will


Attach cardiac and respiratory monitor to assess for bradycardia
decrease pulse and respirations, widen the pulse
and hypoxia.
pressure with pulse becoming irregular and
respirations rapid and shallow as ICP progresses
and the body attempts to decrease blood flow to
brain.

Note any seizure activity including onset, frequency, duration and type
Prevents injury during seizure which is a
of movements before, during, or after seizure; pad bed and remove
complication of meningitis.
objects/toys from bed and administer any ordered anticonvulsants.

Provide a quiet environment free from bright lighting, minimize gentle


handling and care of infant/child, allow for rest periods between care Promotes comfort and rest and reduces irritability.
or procedures, restrict visiting if irritable.

Stay with infant/child and sit near Provides limited stimulation to infant/child during
and speak in a low voice. acute stage of disease.

Decreases intracranial pressure by allowing blood


Position with head elevated up to 30 degrees and maintain head
flow from brain by gravity or any obstruction
alignment with sandbag.
of jugular drainage.

Reposition q 2h, positioning child to optimize comfort with HOB


slightly elevated, no pillow in bed, side-lying position if nuchal rigidity Maintains airway patency and prevents obstruction
present; avoid sudden movements such as lifting the head; have by secretion which increases CO2 retention
oxygen and suctioning equipment on hand to be administered when and ICP.
needed.

Explain causes of increased ICP and


Allows for understanding of increased ICP and life-
importance of preventing any further
threatening nature of such a complication.
increases in ICP.

Inform parents of changes in condition, reasons for physical Promotes knowledge about possible
and mental changes and effects of the disease. manifestations of the disease and causes.

Provides knowledge of seizure complications and


Inform of reason for seizure activity and other signs and symptoms of
actions and responsibility in prevention and/ or
the disease and treatment necessitated by them.
treatment of this activity.

Inform parents of risk for complications and need for monitoring for Allows for ongoing care and responsibility in
increased ICP; review signs and symptoms of increased ICP. preventing change in neurologic status.

Administer antibiotics as prescribed


Manages existing infection and prevents further
(specify) as soon as ordered based on
spread of infection (action of drug).
analysis of CSF, throat cultures.

Administer stool softeners, avoid use of restraints and prevent or Prevents Valsalva’s maneuver that will increase
reduce crying episodes. ICP.
Risk for Trauma or Suffocation

Risk for Trauma: The state in which an individual is at risk of accidental tissue injury (e.g., wound, burns, fracture).

Risk factors may include

 Weakness, balancing difficulties; reduced muscle, hand or eye coordination


 Poor vision
 Reduced sensation
 Cognitive limitations or altered consciousness
 Loss of large or small muscle coordination
 Emotional difficulties

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

 Verbalize understanding of factors that contribute to the possibility of trauma and or suffocation and take steps to
correct the situation.
 Identify actions or measures to take when seizure activity occurs.
 Identify and correct potential risk factors in the environment.
 Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
 Modify environment as indicated to enhance safety.
 Maintain treatment regimen to control or eliminate seizure activity.
 Recognize the need for assistance to prevent accidents or injuries.

Nursing Interventions Rationale

Influences scope and intensity of


Determine factors related to individual situation, as listed in Risk Factors, and extent
interventions to manage threat to
of risk.
safety.

Note client’s age, gender, developmental age, decision-making ability, level of


Affects client’s ability to protect self and
cognition or competence.
others, and influences choice of
Nursing Interventions Rationale

interventions and teaching.

Alcohol, various drugs, and other stimuli


(loss of sleep, flashing lights, prolonged
television viewing) may
Ascertain knowledge of various stimuli that may precipitate seizure activity.
increase brainactivity, thereby
increasing the potential for seizure
activity.

Such may result in or exacerbate


Review diagnostic studies or laboratory tests for impairments and imbalances. conditions, such as confusion, tetany,
pathological fractures, etc.

Enables patient to protect self from


injury and recognize changes that
Explore and expound seizure warning signs (if appropriate) and usual seizure pattern. require notification of physician and
Teach SO to determine and familiarize warning signs and how to care for patient further intervention. Knowing what to
during and after seizure attack. do when seizure occurs can prevent
injury or complications and decreases
SO’s feelings of helplessness.

Prevents or minimizes injury


when seizures (frequent or generalized)
Use and pad side rails with bed in lowest position, or place bed up against wall and occur while patient is in bed. Note: Most
pad floor if rails not available or appropriate. individuals seize in place and if in the
middle of the bed, individual is unlikely
to fall out of bed.

May cause burns if cigarette is


Educate patient not to smoke except while supervised. accidentally dropped during aura or
seizure activity.

Use of helmet may provide added


Evaluate need for or provide protective headgear. protection for individuals who suffer
recurrent or severe seizures.

Reduces risk of patient biting and


Avoid using thermometers that can cause breakage. Use tympanic thermometer breaking glass thermometer or suffering
when necessary to take temperature. injury if sudden seizure activity should
occur.

Uphold strict bedrest if prodromal signs or aura experienced. Explain necessity for Patient may feel restless or need to
these actions. ambulate or even defecate during aural
phase, thereby inadvertently removing
Nursing Interventions Rationale

self from safe environment and easy


observation. Understanding importance
of providing for own safety needs may
enhance patient cooperation.

Do not leave the patient during and after seizure. Promotes safety measures.

Helps maintain airway patency and


reduces risk of oral trauma but should
not be “forced” or inserted when teeth
Turn head to side and suction airway as indicated. Insert plastic bite block only if jaw are clenched because dental and soft-
relaxed. tissue damage may result.
Note: Wooden tongue blades should not
be used because they may splinter and
break in patient’s mouth.

Supporting the extremities lessens


the risk of physical injury when patient
lacks voluntary muscle control. Note: If
Support head, place on soft area, or assist to floor if out of bed. Do not attempt to
attempt is made to restrain patient
restrain.
during seizure, erratic movements may
increase, and patient may injure self or
others.

Note pre seizure activity, presence of aura or unusual behavior, type of seizure
activity (location or duration of motor activity, loss of consciousness, incontinence,
eye activity, respiratory impairment or cyanosis), and frequency or recurrence.
Helps localize the cerebral area of
involvement.
Note whether patient fell, expressed vocalizations, drooled, or had automatisms (lip-
smacking, chewing, picking at clothes).

Documents postictal state and time or


Provide neurological or vital sign check after seizure (level of consciousness,
completeness of recovery to normal
orientation, ability to comply with simple commands, ability to speak; memory of
state. May identify additional safety
incident; weakness or motor deficits; bloodpressure (BP), pulse and respiratory rate).
concerns to be addressed.

Patient may be confused, disoriented,


and possibly amnesic after the seizure
Reorient patient following seizure activity.
and need help to regain control and
alleviate anxiety.

Allow postictal “automatic” behavior without interfering while providing May display behavior (of motor or
environmental protection. psychic origin) that seems inappropriate
or irrelevant for time and place.
Nursing Interventions Rationale

Attempts to control or prevent activity


may result in patient becoming
aggressive or combative.

May be result of repetitive muscle


contractions or symptom of injury
Investigate reports of pain.
incurred, requiring further evaluation or
intervention.

This is a life-threatening emergency that


if left untreated could cause metabolic
acidosis, hyperthermia, hypoglycemia,
arrhythmias, hypoxia, increased
intracranial pressure, airway
obstruction, and respiratory arrest.
Detect status epilepticus (one tonic-clonic seizure after another in rapid succession).
Immediate intervention is required to
control seizure activity and prevent
permanent injury or
death. Note: Although absence seizures
may become static, they are not usually
life-threatening.

Specific drug therapy depends on


seizure type, with some patients
Carry out medications as indicated:
requiring polytherapy or frequent
medication adjustments.

AEDs raise the seizure threshold by


stabilizing nerve cell membranes,
reducing the excitability of the neurons,
or through direct action on the limbic
system, thalamus, and hypothalamus.
Goal is optimal suppression of seizure
 Antiepileptic drugs (AEDs): phenytoin(Dilantin), primidone
activity with lowest possible dose of
(Mysoline), carbamazepine (Tegretol), clonazepam(Klonopin), valproic drug and with fewest side effects.
acid (Depakene), divalproex (Depakote), acetazolamide Cerebyx reaches therapeutic levels
within 24 hr and can be used for
(Diamox), ethotoin (Peganone), methsuximide (Celotin), fosphenytoin
nonemergent loading while waiting for
(Cerebyx); other agents to become effective.
Note: Some patients require polytherapy
or frequent medication adjustments to
control seizure activity. This increases
the risk of adverse reactions and
problems with adherence.

Adjunctive therapy for partial seizures or


 Topiramate (Topamax), ethosuximide(Zarontin), lamotrigine an alternative for patients when seizures
are not adequately controlled by other
Nursing Interventions Rationale

drugs.
(Lamictal), gabapentin (Neurontin)

Potentiates and enhances effects of


 Phenobarbital (Luminal) AEDs and allows for lower dosage to
reduce side effects.

Used to abort status seizure activity


because it is shorter acting than Valium
 Lorazepam (Ativan) and less likely to prolong post seizure
sedation.

May be used alone (or in combination


with phenobarbital) to suppress status
seizure activity. Diastat, a gel, may be
 Diazepam (Valium, Diastat rectal gel) administered rectally, even in the home
setting, to reduce frequency of seizures
and need for additional medical care.

May be given to restore metabolic


 Glucose, thiamine balance if seizure is induced
by hypoglycemia or alcohol.

Standard therapeutic level may not be


Monitor and document AED drug levels, corresponding side effects, and frequency of optimal for individual patient if
seizure activity. untoward side effects develop or
seizures are not controlled.

Identifies factors that aggravate or


Monitor CBC, electrolytes, glucose levels.
decrease seizure threshold.

Vagal nerve stimulator, magnetic beam


therapy, or other surgical intervention
(temporal lobectomy) may be done for
intractable seizures or well-localized
epileptogenic lesions when patient is
Prepare for surgery or electrode implantation as indicated. disabled and at high risk for serious
injury. Success has been reported with
gamma ray radio surgery for the
treatment of multiple seizure activity
that has otherwise been difficult to
control.

Risk for Ineffective Airway Clearance


Risk for Ineffective Airway Clearance: At risk for the inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway.

Risk factors may include

 Neuromuscular impairment
 Tracheobronchial obstruction
 Perceptual or cognitive impairment

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 effective respiratory pattern with airway patent or aspiration prevented.

Nursing Interventions Rationale

Ensure patient to empty mouth of dentures or foreign


Lessens risk of aspiration or foreign bodies lodging
objects if aura occurs and to avoid chewing gum and sucking
in pharynx.
lozenges if seizures occur without warning.

Maintain in lying position, flat surface; turn head to side Helps in drainage of secretions; prevents tongue from
during seizure activity. obstructing airway.

Loosen clothing from neck or chest and abdominal areas. Aids in breathing or chest expansion.

If inserted before jaw is tightened, these devices may


prevent biting of tongue and facilitate suctioning or
Provide and insert plastic airway or soft roll as indicated and
respiratory support if required. Airway adjunct may be
only if jaw is relaxed.
indicated after cessation of seizure activity if patient is
unconscious and unable to maintain safe position of tongue.

Reduces risk of aspiration or asphyxiation. Note: Risk


Suction as needed. of aspiration is low unless individual has eaten within the last
40 min.

Supervise supplemental oxygen or bag ventilation as needed May lessen cerebral hypoxia resulting from decreased
postictally. circulation or oxygenation secondary to vascular spasm
during seizure. Note: Artificial ventilation during general
Nursing Interventions Rationale

seizure activity is of limited or no benefit because it is not


possible to move air in or out of lungs during sustained
contraction of respiratory musculature. As seizure abates,
respiratory function will return unless a secondary problem
exists (foreign body or aspiration).

Presence of prolonged apnea postictally may


Get ready for or assist with intubation, if indicated.
need ventilatory support.

Low Self-Esteem

Situational Low Self-Esteem: Development of a negative perception of self-worth in response to current situation.

May be related to

 Stigma associated with condition


 Perception of being out of control
 Social role changes
 Feelings of abandonment
 Inconsistent behavior

Possibly evidenced by

 Verbalization about changed lifestyle


 Fear of rejection; negative feelings about body
 Change in self-perception of role
 Change in usual patterns of responsibility
 Lack of follow-through or nonparticipation in therapy
 Expressions of helplessness or uselessness
 Evaluation of self as unable to deal with situations or events

Desired Outcomes

 Identify feelings and methods for coping with negative perception of self.
 Verbalize increased sense of self-esteem in relation to diagnosis.
 Verbalize realistic perception and acceptance of self in changed role or lifestyle.
 Express positive self-appraisal
 Demonstrate behaviors to restore positive self-esteem.
 Participate in treatment regimen or activities to correct factors that precipitated crisis.

Nursing Interventions Rationale

Determine individual situation related to low self-esteem in Verbalization of concerns about future implications can help
the present circumstances. patient begin to accept or deal with situation.

Reactions vary among individuals, and previous knowledge


Explore feelings about diagnosis, perception of threat to self.
or experience with this condition affects acceptance of
Encourage expression of feelings.
therapeutic regimen.

Provides opportunity to problem-solve response, and


provides measure of control over situation. Concealment is
Analyze possible or anticipated public reaction to condition.
destructive to self-esteem (potentiates denial), blocking
Encourage patient to refrain from concealing problem.
progress in dealing with problem, and may actually increase
risk of injury or negative response when seizure does occur.

Concentrating on positive aspects can help alleviate feelings


Discuss with patient current and past successes and
of guilt and self- consciousness and help patient begin to
strengths.
accept manageability of condition.

Participation in as many experiences as possible can


Refrain from over protecting the patient; encourage
lessen depression about limitations. Observation and
activities, providing supervision and monitoring when
supervision may need to be provided for such activities as
indicated.
gymnastics, climbing, and water sports.

Contradictory or unfavorable expectations from SO may


Know the attitudes or capabilities of SO. Help individual
affect patient’s sense of competency and self-esteem and
realize that his or her feelings are normal; however, guilt and
interfere with support received from SO, limiting potential
blame are not helpful.
for optimal management and personal growth.

Tension and anxiety among caregivers is contagious and can


Elaborate the positive effect of staff and SO remaining calm
be conveyed to the patient, increasing or multiplying
during seizure activity.
individual’s own negative perceptions of situation or self.

Provides opportunity to gain information, support, and ideas


for dealing with problems from others who share similar
Refer patient and SO to support group (Epilepsy Foundation
experiences. Note: Some service dogs have ability to sense
of America, National Association of Epilepsy Centers,
or predict seizure activity, allowing patient to institute safety
and Delta Society’s National Service Dog Center).
measures, increasing independence and personal sense of
control.

Talk over and explain referral for psychotherapy with patient Seizures have a profound effect on personal self-esteem, and
Nursing Interventions Rationale

and SO. patient or SO may feel guilt over perceived limitations and
public stigma. Counseling can help overcome feelings of
inferiority and self-consciousness.

12 Spinal Cord Injury Nursing Care Plans

A spinal cord injury (SCI) is damage to any part of the spinal cord or nerves at the end of the spinal canal. The condition often causes
permanent changes in strength, sensation, and other body functions below the site of the injury.

Motor vehicle accidents, acts of violence, and sporting injuries are the common causes of spinal cord injury (SCI). The mechanism of
injury influences the type of SCI and the degree of neurological deficit. Spinal cord lesions are classified as a complete (total loss of
sensation and voluntary motor function) or incomplete (mixed loss of sensation and voluntary motor function).

Physical findings vary, depending on the level of injury, degree of spinal shock, and phase and degree of recovery, but in general, are
classified as follows:

 C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.


 C-4 to C-5: Tetraplegia with impairment, reduced pulmonary capacity, complete dependency for ADLs.
 C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs.
 C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence.
 T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles.
 L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction.

Nursing Care Plans

Nursing care planning and goals for patients with spinal cord injuries includes: maximizing respiratory function, preventing injury to
the spinal cord, promote mobility and/or independence, prevent or minimize complications, support psychological adjustment of
patient and/or SO, and providing information about the injury, prognosis, and treatment.

Here are 12 nursing care plans for patients with spinal cord injury:

1. Risk for Ineffective Breathing Pattern


2. Risk for Trauma
3. Impaired Physical Mobility
4. Disturbed Sensory Perception
5. Acute Pain
6. Anticipatory Grieving
7. Situational Low Self-Esteem
8. Constipation
9. Impaired Urinary Elimination
10. Risk for Autonomic Dysreflexia
11. Risk for Impaired Skin Integrity
12. Deficient Knowledge
13. Other Possible Nursing Care Plans