Care Plan Nursing

Nursing Assessment - Physical Examination for Appendicitis

2012-03-06T01:28:00.000+07:00

Physical Examination for Appendicitis

Interview

Get a thorough medical history, especially regarding:
The main complaint: the client will get a pain around the epigastrium radiating to the lower right abdomen. Complaints arising under the right abdominal pain may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. Pain is felt continuously, may be lost or attributable to, pain in a long time. Complaints which usually accompanies a client complaining of nausea and vomiting, the body heat.
Past medical history of health problems usually associated with a client right now.
Diet, eating foods low in fiber.
Elimination habits.

Physical examination

Physical examination of the general state of ill clients seem mild / moderate / severe.
Circulation: tachycardia.
Respiratory: Tachypnea, shallow breathing.
Activity / rest: Malaise.
Elimination: Constipation in early onset, sometimes diarrhea.
Abdominal distension, tenderness / pain off, stiffness, decreased or absent bowel sounds.
Pain / comfort, epigastric and abdominal pain around the umbilicus, the increased severe and localized to the point Mc. Burney, an increase of walking, sneezing, coughing or breathing deeply. Pain in the lower right quadrant because the position of the right leg extension / seated upright position.
Fever over 38 ° c.
Psychological data, appear restless.
There are changes in pulse rate and breathing.
On rectal toucher palpable lump and the patient will feel pain in the pro-lithotomy.
Weight as an indicator to determine the drug.

Examination Support

Signs of peritonitis, lower right quadrant. Line drawings of air fluid level in the cecum or ileum.
Erythrocyte sedimentation rate (ESR) is increased in the state of appendicitis infiltrates.
Routine urinalysis is important to see what there is infection in the kidney.
The increase of leukocytes, Neutrophilia, without eosinophils.
Appendix on barium enema is not filled.
Ultrasound: fekalit non-calcified, non-perforated appendix, appendix abscess.

Risk for Deficient Fluid Volume - Nursing Interventions for Appendicitis

2012-03-06T01:08:00.000+07:00

Appendicitis

The main complaint in patients with appendicitis is pain around the epigastrium radiating to the lower right abdomen. Complaints arising under the right abdominal pain may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. Nature of the complaints of persistent pain is felt, may be lost or there is pain in a long time. Complaints which usually accompanies a client complaining of nausea and vomiting, loss of heat.

Risk for Deficient Fluid Volume

Definition: The decrease intravascular fluid, interstitial, and / or intrasellular. This leads to dehydration, loss of fluids with sodium expenditure.

Characteristics :

Weakness
Thirst
Decreased skin turgor / tongue
Mucous membrane / dry skin
Increased pulse rate, decreased blood pressure, decrease in volume / pulse pressure
Completion of decreased venous
Changes in the mental position
The concentration of urine increased
Increased body temperature
Elevated hematocrit
Weight loss immediately (except on third spacing)

Nursing Diagnosis Interventions for Appendicitis

Risk for deficient Fluid Volume related to a sense of nausea and vomiting,
characterized by:

Sometimes diarrhea.
Abdominal distension.
Tense abdomen.
Decreased appetite.
There is a sense of nausea and vomiting.

Purpose: Maintaining the balance of fluid volume

Results Criteria:

The client is not diarrhea.
A good appetite.
The client no nausea and vomiting.

Nursing Intervention for Appendicitis :

1) Monitor vital signs.
Rational: This is an early indicator of hypovolemia.

2) Monitor intake and urine output and concentration.
Rational: Decreased urine output and concentration will improve the sensitivity / sediment as one the impression of dehydration and require increased fluids.

3) Give fluid little by little but often.
Rationale: To minimize the loss of fluids.

Nursing Care Plan for Acute Respiratory Infections (ARI)

2012-03-06T00:26:00.002+07:00

Acute respiratory infections are respiratory tract infection that lasts up to 14 days. Respiratory tract includes the organs from the nose to the lungs, along with the surrounding organs such as the sinuses, middle ear space and the pleura.

Acute Respiratory infection is a disease that often occurs in children, because the immune system of children is still low.

Terms of ARI include three elements namely : infections, respiratory tract, and acute, where the notion as follows:

1. Infection

Is the entry of germs or microorganisms into the human body and multiply, causing symptoms of the disease.

2. Respiratory tract

Is the organ, from the nose to the alveoli, along with the sinuses, middle ear cavity and the pleura.

3. Acute infections

Acute infection is a direct infection of up to 14 days. limit of 14 days is taken to indicate an acute process although for some diseases that can be classified in a process may take more than 14 days.

Assessment - Nursing Care Plan for Acute Respiratory Infections (ARI) for Acute Respiratory Infection

Things that need to be assessed in patients with Upper Respiratory Infection:

History: fever, cough, runny nose, anorexia, weakness / listlessness, respiratory disease history, treatment done at home and accompanying diseases.
Physical signs: fever, dyspnea, tachypnea, use of additional respiratory muscles, enlarged tonsils, painful swallowing.
Growth factor: General, level of development, daily habits, coping mechanisms, ability to understand the action taken.
Knowledge of the patient / family: the experience of respiratory diseases, respiratory diseases and knowledge about the action taken.

Nursing Diagnosis for Acute Respiratory Infection

1. Hyperthermia related to the invasion of microorganisms

2. Risk for Imbalanced Nutrition: Less Than Body Requirements related to painful swallowing, decreased appetite secondary to acute respiratory tract infections.

3. Knowledge deficient: on the management of Acute Respiratory Infections related to lack of information

4. Ineffective breathing pattern related to decreased lung expansion

Tips to Overcome Heart Palpitations

2012-02-20T01:22:00.000+07:00

Heart palpitations or tachycardia is a condition when the heart rate over 100 beats per minute. Many things can cause palpitations as blood circulation problems, hypertension or cholesterol, potassium deficiency and arrhythmias.

Symptoms of palpitations include discomfort in the chest, difficulty breathing, irregular heartbeat, chest pain, and the head feels light. In a serious condition needs immediate medical treatment, but prior to the doctor or the symptoms are mild you can do the following:

Avoid stimulants

Stimulants can stimulate the heart rate by speeding up metabolism and releases adrenaline. So, definitely avoid coffee, caffeinated tea, soft drinks, energy drinks, and medicines that contain caffeine.

Eat Fiber

If you are experiencing tachycardia caused by high blood pressure or other circulatory system problems then you should start eating foods high in fiber. This will erode the fiber layer of fat in blood vessels causing high blood pressure. Also drink enough water and avoid eating too much saturated fat.

Simple Exercise

Simple exercise done in stages is great for strengthening the heart muscles. But remember, do not exercise that much because it was not even good for the heart and prone to heart attacks.

Avoid Anxiety

Anxiety also makes the body releases adrenaline which causes the heart beat faster.

Meditation

Meditation is the ability to control the mind and body function by concentrating on one of them in order to reach things that are soothing. By learning how to relax, then you also learn to lower the heart rate.

Simple Tips to Prevent Heart Disease

2012-02-20T00:56:00.001+07:00

Simple Tips to Prevent Heart Disease - The heart is the main organ that is essential for humans, because the heart is required to pump blood throughout the body, allowing the body to get oxygen and nutrients needed for metabolism. The heart needs to be maintained in order to perform its functions properly. One is to avoid coronary heart disease which is one of the dangerous diseases that can cause heart attacks. To do so, we need to know how to keep our heart healthy, what to avoid and what to do to maintain heart health.

Know your blood pressure, and do whatever, that reached number 115/75 mmHg.

Your blood pressure may be even more important than your cholesterol. And, you can reduce this pressure alone. The best way? Regular exercise, and reduce fat in the abdomen. Why? because fat is covering the vital organs, so that these organs could work better, it takes the blood pressure more. So, when the reduced abdominal fat, blood pressure required would decrease drastically.

Simple Exercise - Walking for 30 minutes every day

Walking a half hour each day, lowering the risk of heart attack by about 30 percent. It's kind of a test for you, if you successfully do this, chances are you'll start doing other activities, then call it with others. This step is very important, because it will strengthen your commitment, try to call your female counterparts, because they will be more supportive of you.

Simple Exercise can Lower Blood Cholesterol Levels

2012-02-20T00:34:00.000+07:00

Levels of cholesterol in the blood depends on what you eat and how the body makes cholesterol in the liver. Having too much cholesterol in the blood is not a disease, but can lead to hardening and narrowing of the arteries (atherosclerosis) in the cardiovascular system.

Here is a simple exercise that can lower blood cholesterol levels :

1. Start by warming up before exercise. Stretching is simple enough to do. If you have a disease such as diabetes, asthma, or heart disease, you should consult with a physician.

2. Start moving. Do a 20-30 minute walk, three to four times a week. After 8 weeks of practice is done on foot, could proceed by foot up to one hour as much as 6-7 times a week.

3. If you have previously made walking on the road is flat, trying to do on the road uphill to increase physical capabilities. If not, can also use a kind of treadmill that can simulate the ground uphill or down.

4. If you have a chance, join aerobics classes. In addition to instructions during a workout, aerobics classes bring joy to own that could push back the exercise.

5. Consider adding an exercise like yoga. This exercise makes you more disciplined, positive thinking and relaxation are helpful to reduce stress.

Note:

Exercise 20-30 minutes per day can be considered to have much lower cholesterol.
Another benefit of regular exercise is a useful weight loss can also increase HDL cholesterol, and lowers LDL cholesterol. Especially if done by reducing the fat around the waist and abdomen.
To prevent injury do not forget to always wear shoes.

Nursing Interventions Acute Pain related to Uterine Fibroids

2012-02-20T00:17:00.001+07:00

Nursing Diagnosis Acute Pain related to inflammation due to the addition of mass in the uterus

Objectives:

Pain can be reduced or lost

Expected outcomes are:

Pain scale (1-10) = 1-3.
Respiration = 16-24 beats / minute.
Pulse = 60 -100 beats / min.
Expression showed no signs of pain and seemed to relax.

Nursing Interventions Acute Pain related to Uterine Fibroids

1. Observation of a pain scale (1-10)

Rational: Observation of a pain scale is necessary for us to know the level of pain experienced by the client so that we can provide appropriate interventions for clients.

2. Find the area, location, and intensity of pain

Rational: To determine the location of pain, pain in the abdomen may indicate the likelihood of complications

3. Give a sitting position while hugging a pillow or a position in the sense of comfort by the client

Rational: It can provide comfort to the client.

4. Give instruction in relaxation techniques and deep breathing techniques

Rational: relaxation and deep breathing techniques to increase comfort and reduce the level of pain experienced by the client

5. Encourage clients to use a warm compress

Rational: Warm compresses can increase vasodilation of blood vessels at the site of pain so that pain can be reduced.

6. Collaboration in the delivery of analgesics and antiemetics, as indicated when necessary.

Rational: The provision of analgesia is necessary if the client is a pain scale of 7-10, this analgesic increase relaxation, decrease attention to pain, and control the adverse action.

7. Provide information about the use of analgesics that are prescribed or not prescribed

Rational: The specific instructions about the use of drugs, increasing awareness of safe use and side effects.

8. Evaluation of vital signs.

Rational: To determine the condition of clients after the intervention so that it can be done to determine further action.

Disturbed Sleep Pattern Nursing Care Plan for Stroke

2012-02-12T00:44:00.001+07:00

Sleep is one of the basic human needs. Bed rest depending on the age and habits of each individual. Babies and children need more sleep than adults. In adults, bed rest, relax as well as much needed other than the actual sleep.

Get the quality and quantity of good sleep is one important part of the healing process of patients with stroke. However, sleep disturbance itself is a problem that often arises in patients with stroke. Sleep disorders can lead to frustration. Sleep disorders can make the patient tired and disturbed.

Disturbed Sleep Pattern Definition :

Disturbed Sleep pattern Time-limited disruption of sleep
Disturbed Sleep pattern

Characteristics:

Prolonged awakenings, sleep maintenance insomnia, self-induced impairment of normal pattern, sleep onset more than 30 minutes, early morning insomnia, awakening earlier or later than desired, verbal complaints of difficulty falling asleep, verbal complaints of not feeling well-rested, increased proportion of Stage 1 sleep, dissatisfaction with sleep, less than age-normed total sleep time, three or more nighttime awakenings, decreased proportion of Stages 3 and 4 sleep, decreased ability to function.

Nursing Diagnosis Disturbed Sleep Pattern Nursing Care Plan for Stroke

Disturbed Sleep Pattern related to the environment and the lack of privacy

Goal:

Patients can meet the need for sleep

Expected Outcomes:

Patients often wake up at night.
Patients find it easy to fall asleep without difficulty.
Patients can get up in the morning with a fresh and not tired.

Nursing Interventions

1. Assess patients' sleep patterns to plan treatment

2. Observation of patient medication and diet

3. Help the patient reduce the pain before sleep and the client with a comfortable position to sleep

4. Keep quiet environment, such as lowering the volume of radio & television

Rational:

Sleep habits are individual. Data collected in a comprehensive and holistic needed to decide the etiology of sleep disorders

Difficulty sleeping can be a side effect of medication

Clients say an uncomfortable position and pain are all factors that are often the cause of sleep disorders

Excessive crowd cause sleep disturbance.

Deficient Knowledge Nursing Care Plan for Stroke

2012-02-12T00:20:00.001+07:00

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

Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)Knowledge deficient related to less access to health information.

Stroke is a medical emergency that occurs when the blood flow to the brain is interrupted. This typically occurs when a blood clot blocks the flow of blood, thereby preventing the brain from getting the oxygen that it needs. Without oxygen, the brain cannot function properly and could be permanently damaged.

Nursing Diagnosis for Stroke Deficient Knowledge

Goal:
Increased knowledge of clients

Expected Outcomes:

Clients and families understand about the disease Stroke, care and treatment

Nursing Interventions Nursing Care Plan for Stroke :

1. Assessing the client's readiness and ability to learn

2. Assessing knowledge and skills of previous clients about the disease and its impact on the desire to learn.

3. Give the most important material on the client

4. Identify the main source of support and note the client's ability to learn and support the necessary behavior changes.

5. Assess the family desires to support the client's behavior change.

6. Evaluation of learning outcomes through demonstration and mentions again the material being taught.

Rational:

The learning process depends on the particular situation, social interaction, cultural and environmental values

New information is absorbed and the fact meallui previous assumptions and biases influence the transformation process

Information will be more striking if the concept is explained from the simple to the complex

Family support is needed to support changes in patient

Hyperthermia Nursing Care Plan for Tetanus

2012-02-04T00:45:00.000+07:00

Nursing Care Plan for Tetanus - Nursing Diagnosis : Hyperthermia and Interventions

Hyperthermia

Definition: The body temperature rises above the normal range.

Characteristics :

Increase in body temperature above the normal range
Attacks or convulsions (seizures)
Skin redness
Increase respiratory rate
Tachycardia
Hands felt warm to the touch

Tetanus is an infectious disease which is caused due Clostridium tetani bacterium.

Tetanus is transmitted through the environment and not from person to person contact. It is also known as lockjaw as it causes spasms that lock the muscles of the jaw. In severe cases, respiratory muscles get locked due to spasm and the person dies due to lack of oxygen to the brain and other parts of the body.

The chief tetanus symptoms generated by the neurotoxins include lockjaw and other contraction of the skeletal muscles of the face and upper body. Highly painful spasms become evident, accompanied by the voluntary muscles becoming increasingly rigid. The limbs and trunk follow, along with an arching of the back that is technically called opisthotonos. As the symptoms progress, so generally do the severity of the spasms, especially the masseter muscle contributing to lockjaw.

Nursing Diagnosis for Tetanus

Hyperthermia related to efeks toxin (bacteremia)

characterized by :
body temperature 38-40 ° C,
hyper-hydration,
white blood cells more than 10,000 / mm3

Purpose: Normal body temperature

Results Criteria:

Temperature :36-37 ° C,
Laboratory results: white blood cells (WBCs) between 5.000-10.000/mm3

Nursing Interventions - Hyperthermia Nursing Care Plan for Tetanus :

1. Set the ambient temperature, which is convenient.

Rational: The climate and environment can affect an individual's body temperature as a process of adaptation through the process of evaporation and convection.

2. Monitor body temperature every 2 hours

Rasioanl: Identify the symptoms progress to the shock.

3. Provide adequate hydration or drinking adequat

Rationale: Fluids help refresh the body and the compression of the body.

4. Take action on aseptic technique and antiseptic treatment of wounds.

Rational: wound care eliminate the possibility of a toxin that is located around the wound.

5. Implement programs and antipieretik antibiotic treatment.

Rational: These drugs may have antibacterial properties to treat a broad spectrum of gram-positive bacteria or gram negative bacteria. Antipyretic worked as a process of thermoregulation, heat anticipation.

6. Collaborative laboratory examination of leukocytes.

Rational: The results of leukocytes increased by more than 10,000 / mm 3 indicates the presence of infection and to keep abreast of the prescribed treatment.

Acute Pain / Chronic Pain - Rheumatoid Arthritis Nursing Care Plan

2012-02-01T00:01:00.000+07:00

Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammation of the joints. This disease is categorized as an autoimmune disease because people suffering from this condition have antibodies in their blood that target their own body tissues.

Rheumatoid arthritis can attack various organs and tissues in the human body. However, it mainly attacks synovial joints in the hands, wrists, ankles, and knees.

There are, typically, three distinctive types of discomfort which go along with chronic RA. The foremost of these types of discomfort is often called "flair up pain." It is caused by the inflammation of the joints which goes along with periods when your RA is flaring and active.

The next type of rheumatoid pain is often simply called joint pain. It is caused by damage to the joints, which is a consequence of the inflammation. This is the everyday discomfort which is present, even while your RA is not active.

Finally, the very last rheumatoid aspect of the pain equation might be called "emotional pain." It involves the emotions, your psychological well being, and your stress level. The tiredness which you will feel is a part too. This aspect of RA really makes "everything hurt worse."

Management / Treatment of Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis : Acute Pain / Chronic Pain

related to:

Tissue distension by accumulation of fluid / inflammatory process
Destruction of joints.

Can be evidenced by:

Complaints of pain, discomfort, fatigue.
Focusing on self / narrowing of focus
Behavior distraction / autonomic response
Behavior that is care / protect

Expected results / patient evaluation criteria will be:

Showed pain relief / control
Looks relaxed, able to sleep / rest and participate in activities according to ability.
Follow the program prescribed pharmacological
Combining the skills of relaxation and entertainment activities into a program of pain control.

Nursing Interventions and Rational - Nursing Care Plan for Rheumatoid Arthritis

1. Record complaints of pain, record the location and intensity (scale 0-10). Write down the factors that accelerate and signs of pain - non-verbal.

Rational: To assist in determining the need for pain management and program effectiveness.

2. Give a hard mattress, a small pillow. Elevate the bed linen as needed.

Rational: a soft mattress, pillow that would prevent maintenance of proper body alignment, placing stress on the joints that hurt. Elevation of the bed linen lowering the pressure in the inflamed joints / pain.

3. Place / monitor the use of pillows, sandbags, splint, brace.

Rational: Resting sore joints and maintain a neutral position. The use of the brace can reduce pain and can reduce damage to the joints.

4. Advise to change position frequently. Help to move in bed, prop joint pain above and below, avoid jerky movements.

Rationale: Prevent the occurrence of general fatigue and joint stiffness. Stabilize joints, reduce the movement / pain in the joints.

5. Instruct the patient to a warm bath or shower at the time awake and / or at bedtime. Provide a warm washcloth compress for sore joints several times a day. Monitor the temperature of the water compresses, baths, and so on.

Rational: The heat increases muscle relaxation, and mobility, reduce pain and stiffness in the morning release. Sensitivity to heat can be removed and dermal wound can be healed.

6. Give a gentle massage

Rationale: Increase relaxation / reducing pain.

7. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeed back, visualization, guidelines imagination, self hypnosis, and breath control.

Rationale: Increase relaxation, provide a sense of control and may enhance coping abilities.

8. Engage in activities appropriate entertainment for individual situations.

Rationale: Focusing attention back, providing stimulation, and increased self-confidence and feeling healthy.

9. Give drug before the activity / planned exercise as directed.

Rationale: Increasing realaksasi, reduce muscle tension / spasm, making it easier to participate in therapy.

10. Collaboration: Give medications as directed.

Rational: As an anti-inflammatory and mild analgesic effect in reducing stiffness and increasing mobility.

11. Give ice-cold compress if needed

Rational: The cold can relieve pain and swelling during the acute period

Management / Treatment of Rheumatoid Arthritis

2012-01-31T23:26:00.000+07:00

Management / Treatment of Rheumatoid Arthritis

Therefore, the exact cause of rheumatoid arthritis is unknown, there is no causative treatment that can cure this disease. This should really be explained to patients so that it knows that the treatment is given aimed at reducing complaints / symptoms slow the progression of disease.

The main objective of the program management / treatment of Rheumatoid Arthritis, as follows:

To relieve pain and inflammation
To maintain joint function and the maximum capability of the patient
To prevent and or correct deformity that occurs in the joints
Maintain independence so it does not depend on others.

There are a number of ways that management deliberately designed to achieve the objectives mentioned above, namely:

1. Education

The first step of this management program is to provide adequate education about the disease to the patient, family and anyone associated with the patient. Education will include understanding the pathophysiology (disease course), the cause and the estimated trip (prognosis) of this disease, all components of program management including complex drug regimens, sources of help to overcome this disease and effective method of management provided by health team . This education process should be carried out continuously.

2. Rest

Is important because of rheumatism, usually accompanied by severe fatigue. Although fatigue may arise every day, but there are times where patients feel better or heavier. Patients should be split into several times a day time activity time, followed by a period of rest.

3. Physical exercise and Thermoterapy

Specific exercises can be helpful in maintaining joint function. This exercise includes active and passive movements in all joints are sore, at least two times a day. Medication for pain relief should be given before starting the exercise. Hot compresses on the sore and swollen joints may reduce pain. Exercise and Thermoterapy is best regulated by the health workers who have received special training, such as a physical therapist or occupational therapist. Excessive exercise can damage the structure supporting the joints that are already weakened by the disease.

4. Diet / Nutrition

Rheumatic Patients do not require a special diet. There are a number of ways giving a diet with a variety of variations, but all of which has not been proven true. The general principle for obtaining a balanced diet is important.

5. Drugs

Drug delivery is an important part of the program management of rheumatic diseases. Drugs used to reduce pain, relieve inflammation and to try to change the course of the disease.

Pathophysiology of Hypertension

2012-01-31T23:04:00.001+07:00

Pathophysiology of Hypertension

Mechanisms that control the constriction and relaxation of blood vessels located in the vasomotor center, the medulla in the brain. Of the vasomotor center, the sympathetic nerve pathway begins, which continues down the spinal cord and the spinal cord out of the column to the sympathetic ganglia in the thorax and abdomen. Central vasomotor stimulation delivered in the form of impulse which moves downward through the sympathetic nervous system to the sympathetic ganglia. At this point, preganglionic neurons, releasing acetylcholine, which will stimulate post-ganglion nerve fibers to blood vessels, where the release of norepinephrine resulting in constriction of blood vessels. Various factors such as anxiety and fear can affect the response to stimuli vasoconstriction of blood vessels.

Individuals with hypertension is very sensitive to norepinephrine, although it is not clear why this could occur.

At the same time in which the sympathetic nervous system stimulates the blood vessels in response to emotional stimuli, the adrenal glands are also stimulated, resulting in additional vasoconstriction activity. Adrenal medulla secretes epinephrine, which causes vasoconstriction. Adrenal cortex to secrete cortisol and other steroids, which can strengthen the vasoconstrictor response of blood vessels. Vasoconstriction resulting in decreased flow to the kidneys, causing the release of renin. Renin stimulates the formation of angiotensin I is then converted into angiotensin II, a powerful vasoconstrictor, which in turn stimulates the secretion of aldosterone by the adrenal cortex. This hormone causes retention of sodium and water by kidney tubules, causing increased intra-vascular volume. All these factors tend to trigger a state of hypertension.

For consideration of Gerontology. Structural and functional changes in the peripheral vascular system are responsible for changes in blood pressure that occurs in the elderly. These changes include atherosclerosis, loss of elasticity of the connective tissue and a decrease in vascular smooth muscle relaxation, which in turn lowers the ability of distention and tensile strength of blood vessels. Consequently, the aorta and large arteries decreases its ability to accommodate the volume of blood pumped by the heart, resulting in decreased cardiac cheating and increased peripheral resistance. Pathophysiology of Hypertension (Brunner & Suddarth, 2002).

Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions

Acute Pain Nursing Care Plan for Pyelonephritis

2012-01-31T22:37:00.000+07:00

Pyelonephritis or a kidney infection usually caused by Escherichia Coli, a bacteria type that is found in the large intestine. This infection makes its way from the genital area through the urethra to the bladder, up the ureters and then it reaches the kidneys. Being more common in women than in men.

Pyelonephritis known that if a person has any physical obstruction to the flow of urine, like a kidney stone, an enlarged prostate, or the backflow of urine from the bladder into the ureters, it is very likely the risk of pyelonephritis to rise.

Persons with pyelonephritis might experience painful urination, tightly contraction of the abdomen muscles, one or both kidneys may be enlarged and tender, and cystitis symptoms can appear also. Usually, pyelonephritis starts suddenly, with pain in the lower part of the back on either side, fever, chills, nausea and vomiting, but very often, in children these symptoms are slight and difficult to recognize.

Nursing Care Plan for Pyelonephritis

Nursing Diagnosis for Pyelonephritis : Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

Evaluation criteria: no pain when urinating, no pain on percussion of the pelvis.

Nursing Interventions and Rational for Pyelonephritis

Independent

1. Monitor urine output to changes in color, odor and voiding pattern, input and output every 8 hours and monitor the results of repeated urinalysis.

Rational: To identify indications of progress or deviations from expected results.

2. Record the location, duration, intensity scale (1-10) the spread of pain.

Rational: To help evaluate the obstroksi and cause pain.

3. Provide comfort measures, such as back massage, environment, rest, sleep.

Rational: Increase relaxation, reduce muscle tension.

4. Help or encourage the use of focused relaxation breathing.

Rational: Helps to redirect attention and for muscle relaxation.

5. Give perianal care.

Rational: To prevent contamination of the urethra.

6. If mounted catheter, catheter care provided 2 times per day.

Rational: The catheter provides a way for bacteria to enter the bladder and up into the urinary tract.

Collaboration

1. Consul doctor if: previous urine yellow, ivory, yellow urine, dark orange, hazy or cloudy. Micturition pattern changes, frequent urination in small amounts, feeling the urge to urinate. Persistent pain or increasing pain.

Rational: These findings could signal further tissue damage and needs extensive examination.

2. Give analgesics as needed and evaluate its success.

Rational: Analgesic block the path of pain, thereby reducing pain.

3. Giving antibiotics. Create a variety of drink preparations, including fresh water. Provision of water to 2400 ml / day.

Rational: As a result of urine output makes it easy to urinate often and help flush urinary tract.

Ineffective Airway Clearance Nursing Care Plan for Tetanus

2012-01-30T02:16:00.000+07:00

Tetanus is caused by gram positive, obligate anaerobic bacteria: Clostridium tetani which affects skeletal muscles."Gram positive" means that the bacteria has a thick cell wall, while "obligate anaerobe" means that the bacteria can't survive in the presence of oxygen and survive using anaerobic respiration (without oxygen).

Causes:
Bacterium Clostridium tetani.
Contamination of a puncture wound, e.g.: a piercing.
Ear infections as bacteria may enter through ear.
Using unsterile equipment in surgery or other similarly invasive procedures such as tattooing and body piercing.

Ineffective Airway Clearance related to the accumulation of sputum in the trachea and the respiratory muscles spame

Characterized by:
Ronchi,
Cyanosis,
Dyspneu,
Ineffective cough accompanied by sputum or phlegm, lab test results, Abnormal Blood Gas Analysis (respiratory acidosis)

Objective: Airway clearance is effective

Criteria:

- Clients are not congested, mucus, or none sleam
- Respiratory 16 -18 x / minute
- No breathing nostril
- No additional respiratory muscle
- The results of laboratory examination of blood: Blood Gas Analysis in the normal range (pH = 7.35 to 7.45; PCO2 = 35-45 mmHg, pO 2 = 80-100 mmHg)

Nursing Interventions Ineffective Airway Clearance Nursing Care Plan for Tetanus:

1. Clear the airway by adjusting the position of head extension
Rational: The anatomy of the head position of the extension is a way to align the respiratory cavity so that the process of respiration remains smooth to get rid of airway obstruction.

2. Physical examination by auscultation listening to breath sounds (there Ronchi) every 2-4 hours.
Rational: Ronchi indicate a problem caused by upper respiratory fluids or secretions that covered most of the respiratory tract that is necessary to issue, to optimize the airway.

3. Clean the mouth and airways of secretions and mucus by suction
Rational: Suction is an act of assistance to remove secretions, thus simplifying the process of respiration.

4. oxygenation
Rationale: The provision of oxygen in adequat can supply and provide backup oxygen, thus preventing the occurrence of hypoxia.

5. Observation of vital signs every 2 hours
Rational: Dyspneu, cyanosis is a sign of breathing disorder which is accompanied by decreased cardiac work and capilary tachycardia arising refill time prolonged / long.

6. Observation of the onset of respiratory failure.
Rational: The inability of the body in the process of respiration required critical interventions using tools breathing (mechanical ventilation)

7. Collaboration in drug delivery thinning secretions
Rational: Drug-thinning secretions could dilute the thick secretions that facilitate spending and prevent viscosity.

Auditory Hallucinations Definition Causes and Symptoms

2012-01-16T22:46:00.002+07:00

Definition of Auditory hallucinations

Auditory hallucinations are false sensory perception of external stimuli that are not able to hear in the identification.

Auditory hallucinations are the hearing of individual sensory perception in the absence of real external stimuli.

Signs and symptoms of Auditory hallucinations

Patients the observed behavior is as follows

1. Eyes glanced to the left and right like to find who or what he was talking.

2. Listening attentively to others who are not speaking or to inanimate objects such as furniture, walls etc..

3. Involved conversations with inanimate objects or with someone who does not appear.

4. Move the mouth like he was speaking or being the voice replied.

Causes of Auditory hallucinations

Social isolation withdrawn

1. understanding

Pulling himself a nuisance by withdrawing and others are on the mark with self isolation (withdrawing) and self-care is lacking.

2. cause

a. development

Touch, attention, warmth of the family that resulted in solitary individual, the ability to relate to inadequate client ended by withdrawing.

b. Low self esteem

Signs and symptoms of Auditory Hallucinations

Signs symptoms of withdrawal can be viewed from various aspects, among others

a. physical aspects

1) Appearance self-less.

2) Sleep less.

3) Courage less.

b. aspects of emotion

1) Talk is not clear.

2) Feeling ashamed.

3) Easy to panic.

c. social aspects

1) Sit outs

2) There was daydreaming

3) No matter the environment

4) Avoidance of others

d. aspects of intellectual

1) Feeling hopeless

2) Lack of confidence

4 Steps To Treat Gastroenteritis

2012-01-16T22:45:00.000+07:00

Sometimes we as humans fail to health of our bodies, so it can not shy away from unhygienic food of all kinds of seeds and disease germs. If we are not hygienic food then we could be attacked by digestive disease that one result is gastroenteritis or diarrhea. Besides gastroenteritis can be caused by chemicals in food poisoning, colds, dehydration (lack of body fluids) and others.

Gastroenteritis is a condition in which a person defecate many times in one day which exceeds the normal limits and the stool or feces that comes out of a thin or thick with wind / fart from the stomach.

Here below are the 4 Steps To Treat Gastroenteritis:

1. Drink Plenty of Water White
Frequently drinking lots of water because of the frequent bowel movements the body will lose a lot of fluid that should always be replaced with new fluid. Each after defecation drink one or two glasses of water or mineral water is clean and has been cooked. Drink oral rehydration salt sugar solution which is to assist the formation of energy and withstand gastroenteritis / diarrhea after bowel movement out. Avoid drinking coffee, tea, etc. are able to stimulate gastric acid.

2. Eating Special Foods
Avoid eating fibrous foods such as gelatin, vegetable and fruit because fibrous foods will only prolong the gastroenteritis. Fibrous food is only good for people with a bowel obstruction. For patients with gastroenteritis should eat foods low in fiber and smooth like rice or rice porridge with toppings salted eggs. Here the rice will become sugar to provide energy, while the salted egg will provide protein and salts for diarrhea and as an agent holding a body builder. Avoid eating out at random and spicy foods containing chillies and pepper.

3. Enough Rest
It is inevitable that people who waste water will taste weak, weak, lethargic, less passionate, and so on. For that for those of you who already feel very weak should ask the permission of the school or office to avoid the possibility of the worst or embarrassing in public places.
Sleep as much as possible but do not forget the time eating food and drugs should be regularly, drinking lots, worship and pray and others.

4. Drinking Drugs With the Right Dose
There is a good idea to consult with your doctor and ask for the right medicine for you, because everyone has the characteristics of each in drug selection. Hospitals, physician practices, health centers or clinics other appropriate department of health license is the right choice because it has a good doctor with good medicine too. If you doubt just go to another doctor to get more information.
After getting the medicine medicinal drink according to the dose specified time. Usually the doctor will prescribe mules, diarrhea medications, vitamins and antibiotics. For drug mules and diarrhea should be taken if the stomach pains and gastro enteritis alone and stop if it stops mules and gastroenteritis. As for the antibiotics must be spent so that germs and other germs and do not form a death total resistance. For the vitamin up to you want to spend or not, but it would not hurt if spent because the vitamin is good for you as long as not excessive.

Imbalanced Nutrition Less Than Body Requirements Nanda Nursing Diagnosis for Hyperemesis Gravidarum

2012-01-12T22:32:00.000+07:00

Imbalanced Nutrition Less Than Body Requirements Nanda Nursing Diagnosis for Hyperemesis Gravidarum

Imbalanced Nutrition Less Than Body Requirements Definition: Intake of nutrients insufficient to meet metabolic needs.

Hyperemesis Gravidarum

Hyperemesis Gravidarum (HG) is a very severe form of morning sickness. It is described as extreme vomiting, dehydration, nutritional deficiencies, and electrolyte imbalances combined with a first trimester weight loss of aproximately 10% of normal body weight.

Morning sickness is a normal part of early pregnancy and it can also continue through out the pregnancy in some cases. But extreme pregnancy nausea can cause distressing effects for the mother and can also be harmful for your baby.

There are numerous theories regarding the etiology of HG, however, none are conclusive as of yet. The most commonly held belief is that the increase in HCG and estrogen hormones in early pregnancy is the cause.

Nursing Intervention - Imbalanced Nutrition Less Than Body Requirements - Hyperemesis Gravidarum

1. Restrict oral intake until the vomiting stops.
Rationale: Maintaining electrolyte balance fluid and prevent further vomiting.

2. Give the anti-emetic drugs are prescribed with a low dose.
Rationale: To prevent vomiting and to maintain fluid and electrolyte balance

3. Maintain fluid therapy can be saved.
Rational: Correction of hypovolemia and electrolyte balance.

4. Record intake and output.
Rationale: Determining hydration fluid through vomiting and spending.

5. Encourage to eat small meals but often
Rational: Can adequate intake of nutrients body needs.

6. Advise to avoid fatty foods
Rational: can stimulate nausea and vomiting

7. Recommended to eat a snack such as biscuits
Rational: snack can reduce or prevent nausea, vomiting, excessive excitatory

8. Record intake, if oral intake can not be given within a certain period.
Rational: To maintain a balance of nutrients.

9. Inspection of irritation on the mouth.
Rationale: To determine the integrity of the oral mucosa.

10. Assess oral hygiene and personal hygiene and the use of cleaning fluids mouth as often as possible.
Rational: To maintain the integrity of the oral mucosa

11. Monitor hemoglobin and hematocrit levels.
Rationale: Identify presence of anemia and potential decline in the capacity of oxygen carrier mothers. Clients with Hb levels <12 mg / dl or low hematocrit levels considered anemic in the first trimester.

12. Test urine of acetone, albumin and glucose
Rationale: Establish baseline data; done routinely to detect potential high-risk situations such as inadequate intake of carbohydrate, ketoacidosis diabetic and hypertension due to pregnancy.

13. Measure the enlargement of the uterus
Rational: maternal malnutrition affects fetal growth and aggravate the decline of complement in fetal brain cells, resulting in deterioration of fetal development and the possibilities further.

Physical, Mental, Psychosocial and Spiritual Changes In Elderly

2012-01-12T08:45:00.000+07:00

Physical Changes in Elderly

(1) Cells: fewer but larger size, reduced intra and extra cellular fluid.

(2) Nervous System: rapid decrease neural connections, slow in response time to react, diminishing the nervous system senses of hearing, presbiacusis, tympanic membrane atrophy, due to the increased occurrence of serum collection ceratin.

(3) Vision System: sclerosis arising pupillary sphincter and loss of response to the synapse, the cornea is more shaped speris, cloudy lens, increasing the threshold of observation of light, loss of accommodation, decreased visual field.

(4) Cardiovascular System. : Heart valves thicken and become stiff, the heart's ability to pump blood decreases 1% every year after age 20 years, causing contraction and decline in volume, loss of elasticity of blood vessels, blood pressure rises.

(5) Respiration System : respiratory muscles become stiff so that causes decreased activity of cilia. Lungs lose their elasticity so that the residual capacity increases, breath heavy. Depth of breathing decreased.

(6) Gastrointestinal System: loss of teeth, causing malnutrition, decreased sense of taste because of the mucous membrane and atrophy of the senses of taste up to 80%, then the loss of nerve sensitivity of taste for sweet and salty taste.

(7) Genitourinary System: kidney nephron shrink and become atrophic so that blood flow to the kidneys decreased to 50%, GFR decreased to 50%. Renal threshold for glucose is enhanced. Urinary vesicles, the muscles become weaker, its capacity is decreased to 200 cc so difficult urinary-derived vesicles in elderly men would result in retensia urine. Enlarged prostate, 75% experienced by men over 55 years. In the vulva occurs vaginal atrophy are going dry mucous membranes, decreased tissue elasticity, and reduced secretion becomes alkaline.

(8) Endocrine System: endocrine system on almost all hormone production decreases, whereas the parathyroid function and secretion did not change, decreased thyroid activity resulting in lower basal metabolic rate (BMR). Porduksi decreased sex cells such as progesterone, estrogen and testosterone.

(9) Integumentary System: skin becomes wrinkled due to loss of fat tissue, scalp and thinning hair becomes gray, whereas in the ear and nose hair thickened. Become hard and brittle nails.

(10) Musculoskeletal System: bones lose density and become more fragile kiposis, height is reduced vertebral discusine called thinning, the tendon fibers shrink and atrophy - muscle fibers, so that the elderly be slow moving. muscle cramps and tremors.

Mental Changes in Elderly

Factors that affect the mental changes are:

First of all the physical changes, particularly the organs of taste
Health
The level of education
Heredity
Environment

Psychosocial Changes

 Retirement: a value measured by productivity, identits associated with a role in job
 Sensing or aware of the death
 The change in the way of life, ie moving into a nursing home is more narrow.
• Impaired self-concept due to loss of losing office.
• The series of losses, namely loss of relationships with friends and family.
• Loss of physical strength and sturdiness, changes to the self-image, self-concept changes.

Spiritual Change

Religion or belief increasingly integrated in the life (Maslow, 1970) Elderly more mature in their religious life, this is seen in thinking and acting in everyday (Murray and Zentner, 1970)

Theory of Aging Process

2012-01-12T07:40:00.000+07:00

Biological Theories

(1) Genetic Theory And Mutation (Somatic Mutatie Theory)
According to this theory, aging is genetically programmed for certain species. Aging occurs as a result of biochemical changes that are programmed by the molecules / DNA and every cell in time will be the mutation. As a typical example is a mutation of sex cells (a decrease in functional ability of cells).

(2) Use and Damage
Excess effort and stress causes the body's cells are tired (damaged).

(3) Reaction of Immune Self (Auto Immune Theory)
In the process of metabolism, one time produced a special substance. There are certain tissues that are not resistant to these substances so that the tissues of the body becomes weak and ill.

(4) The theory of "Imunology Slow Virus Theory"
Imune system to be effective with increasing age and entry of virus into the body can cause organ damage.

(5) Theory of Stress
Aging occurs due to loss of cells commonly used by the body. Tissue regeneration can not maintain a stable internal environment, the extra effort and stress causes the body cells tired unused.

(6) Free Radical Theory
Free radicals can be formed in the wild, unstable free radicals (groups of atoms) of oxygen resulting in oxidation of organic materials such as carbohydrates and proteins. These free radicals can cause the cells can not regenerate.

(7) Cross Chain Theory
The cells are old or obsolete, the chemical reaction causes a strong bond, particularly the collagen network. This causes a lack of elastic bonding, chaos and loss of function.

(8) Theory Courses
Organism's ability to set the number of cells that divide after the cells die.
Theory of Social Psycho

(1) Activity Theory
- The provision will increase to a decrease in the number of activities directly. This theory states that the elderly are successful are those who are active and participate in many social activities.
- The optimum size (lifestyle) continued in the way of life of elderly.
- Maintaining the relationship between social systems and individuals to remain stable from middle age to elderly.
(2) Personality Continues (Continuity Theory) Basic personality or behavior does not change in elderly patients. This theory is a combination of the above theory. In this theory states that the changes that occur in the elderly person is strongly influenced by the type of personality they have.

(3) Disengagement Theory

This theory states that with increasing age, a person gradually began to break away from social life. This situation resulted in decreased elderly social interaction, both in quality and quantity so often lose terjaadi double (triple loss), namely:
- Losing Role
- Barriers of Social Contacts
- Reduction Commitment Contacts
Theory of Psychology

(1) Theory Development Task

Havigurst (1972) stated that the developmental tasks in old age include:
- Adjusting to decline in physical strength and health
- Adjusting to retirement and reduced income
- Adjusting to the death of a spouse
- Establish a relationship with people own age
- Establish a satisfactory physical living arrangements
- Adjusting to the social roles flexibly
In addition to the above developments tasks, there are specific developmental tasks that may arise as a result of demands:
- Physical Maturity
- Expectations and cultural community
- The individual's personal values and aspirations
According to this theory, every individual has a hierarchy of the self, the needs that motivate all human behavior (Maslow 1954).

Nursing Assessment for Dizziness Vertigo

2012-01-12T00:57:00.000+07:00

Dizziness is classified into three categories-vertigo, syncope, and nonsyncope nonvertigo. Each category has a characteristic set of symptoms, all related to the sense of balance. In general, syncope is defined by a brief loss of consciousness (fainting) or by dimmed vision and feeling uncoordinated, confused, and lightheaded. Many people experience a sensation like syncope when they stand up too fast. Vertigo is the feeling that either the individual or the surroundings are spinning. This sensation is like being on a spinning amusement park ride. Individuals with nonsyncope nonvertigo dizziness feel as though they cannot keep their balance. This feeling may become worse with movement.

Nursing Assessment Nursing Care Plan for Dizziness Vertigo

1. Activity / Rest

Fatigue, weakness, malaise
limitation of motion
Eye strain, difficulty reading
Insomnia, waking in the morning, accompanied by headache.
Severe headaches when changes in posture, activity (work) or because the weather changes.

2. Circulation

History of hypertension
Vascular pulsations, eg temporal region.
Pale, flushed face.

3. Ego Integrity

Emotional stress factors / specific environment
Changes in disability, despair, hopelessness depression
Worries, anxiety, receptors for headaches.

4. Food and Fluid

Nausea / vomiting, anorexia (for pain)
Weight loss

5. Neuro-Sensory

Dizziness, disorientation (for headache)
History of seizures, head injury had just happened, trauma, stroke.
Aura; facial, olfactory, tinnitus.
Visual changes, sensitive to light / sound harsh, epistaxis.
Parastesia, progressive weakness / paralysis one side tempore
Changes in the patterns of speech / thought patterns
Easily aroused, sensitive to the stimulus.
Decreased deep tendon reflexes
Papilledema.

6. Pain / Comfort

Characteristics of pain depends on the type of headache, eg migraine, muscle tension, cluster, brain tumors, post-traumatic, sinusitis.
Pain, redness, pale in the face.
The focus narrows
Focus on own
Emotional responses / behaviors like crying undirected, anxiety.
The muscles also tighten the neck area, frigidity vocals.

7. Security

History of allergy or allergic reactions
Fever (headache)
Gait disturbance, parastesia, paralysis
Purulent nasal drainage (sinus headache disorders).

8. Social Interaction

Changes in responsibility / role of social interaction associated with the disease.

9. Guidance / learning

History of hypertension, migraine, stroke, illness in family
Use of alcohol / other drugs, including caffeine. Oral contraceptives / hormone, menopause.

Nanda Nursing Diagnosis for Dizziness Vertigo

2012-01-12T00:28:00.000+07:00

Dizziness is the Third Most Frequent Reason People Seek Medical Attention

Dizziness is one thing, vertigo is another. Both involve potential feelings of unsteadiness and possible faintness, but vertigo will often also include disorientation. Both conditions can persist to be point of becoming disabling.

There are many reasons for causing dizziness. Infection in viral system is the main cause of dizziness which affects the air flow to the head or the ear. The low blood pressure can also cause dizziness due to reduction of blood supply to the brain. Mental anxiety and panic attacks, can lead to dizzy condition. Sudden low blood sugar is another possible cause, and is easily treated by taking some sugary foods.

The dizziness can be recognized with the following symptoms

Being fainted at the sight of blood or with emotional upset
Fainting in standing up too quickly or standing still too long
Weakness during a illness
Seasickness or motion sickness
Queasiness, nausea, or vomiting
Confusion in thinking
Fatigue feelings, tiredness or daytime sleepiness
Clumsy movement

Vertigo is usually due to an imperfection of the equilibratory apparatus of the semicircular canals of the ear. There may also be associated problems with the vestibule, 8th nerve, the semicircular canals, the eyes, or in the brainstem. Any of these structures can be affected by a variety of diseases and disorders, such as: otitis media, labyrinthitis, osteosclerosis, an obstruction of the Eustachian tube, or external auditory canal. Avery important element that may result in vertigo, is a disease called " Meniere's syndrome.

Nanda Nursing Diagnosis for Dizziness Vertigo

1. Pain (acute / chronic)

related to: stress and tension, irritation / nerve pressure, increased intracranial
characterized by : pain states that are influenced by such factors, changes in position, changes in sleep patterns, anxiety.

2. Ineffective individual coping

related to: inadequate relaxation, coping methods are not adequate, excess workload.

3. Deficient knowledge : (needs to learn) about the condition and treatment needs

related to : cognitive limitations, are not familiar information and less to remember.
characterized by the request information, Inadequate follow the instructions.

Nursing Assessment Nursing Care Plan for Dizziness Vertigo

Self-Care Deficit Nursing Care Plan for Stroke

2012-01-11T10:49:00.002+07:00

Self-Care Deficit Nursing Nanda Diagnosis Definition:

Impaired ability to perform or complete activities of daily living, Such as feeding, dressing, bathing, toileting.

The nurse may encounter the patient with a self-care deficit in the hospital or in the community.

Stroke Definition :

That stroke is a disease affects the blood vessels That blood supply to the brain. Without blood to supply oxygen and Nutrients and to remove waste products, brain cells begin to die Quickly. Stroke is Sometimes Called a "brain attack. Stroke is a medical emergency and can cause permanent neurological damage or even death if not promptly diagnosed and treated.

The cause of stroke is an interruption in the blood supply, with a resulting depletion of oxygen and glucose in the affected area. This reduces or abolishes IMMEDIATELY neuronal function, and also initiates the ischemic cascade the which Causes neurons to die or Be Seriously Damaged, Further impairing brain function.

Nanda Nursing Diagnosis Self-Care Deficit

related to weakness, neuromuscular disorders, decreased muscle strength, decreased muscle coordination, depression, pain, damage to the perception

Goal: The ability to care for self-rising

Expected outcomes:

a. Demonstrating changes in lifestyle to meet the needs of daily living

b. Perform self-care according to ability

c. Identify and utilize sources of aid

Nursing Interventions Self-Care Deficit Nursing Care Plan for Stroke

1. Monitor the client's skill level in caring for themselves

2. Provide assistance to the needs that really need it

3. Create an environment that allows clients to perform ADLs independently

4. Involve the family in helping clients

5. Client's motivation to perform ADLs according to ability

6. Provide aids themselves when possible

7. Collaboration: plug the DC if necessary, consultation with a occupational or physiotherapy.

Ineffective Airway Clearance Stroke Nursing Care Plan

2012-01-11T10:20:00.000+07:00

Ineffective Airway Clearance Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Stroke

Stroke is also Referred to as a brain attack, and it Occurs Pls a blood vessel leading to the brain ruptures or gets blocked due to plaque deposits. When plaque accumulates on the wall of arteries, it is known as arthrosclerosis.

Nanda Nursing Diagnosis Ineffective Airway Clearance

related to the buildup of sputum (due to weakness, loss of cough reflex)

Goal: Patient is able to maintain a patent airway.

Expected outcomes:

a. Vesicular breath sounds

b. Normal respiratory rate

c. No signs of cyanosis and pallor

d. There is no sputum

Nursing Interventions :

1. Auscultation of breath sounds

2. Measure vital signs

3. Give the semi-Fowler position in accordance with the requirements (not conflict with other nursing problems)

4. Perform the exploitation lenders and pairs of OPA if decreased consciousness

5. When it is possible to do chest physiotherapy and breathing exercises in

6. Collaboration:

Provision of oxygenation
Laboratory: blood gas analysis, complete blood etc.
Giving medication as needed

Basic Steps to Prevent Cancer

2012-01-11T08:21:00.002+07:00

One third of all cancer cases in the United States, China and the United Kingdom each year could be prevented if only people would do the basic steps for cancer prevention.

Prevention of cancer should not be anything complicated, some simple decisions in your daily life effectively enough to fend off the attack of cancer. But the point is to keep us stay on course a healthy lifestyle.
The American Institute for Cancer Research and the World Cancer Research Fund stated that cancer deaths could be prevented if we keep the weight remains the ideal, healthy and varied diet, physical activity and quitting smoking.

World Health Organization (WHO) declared lack of exercise are risk factors for breast cancer and colon cancer, 27 percent of causing diabetes and 30 percent of the causes of heart disease worldwide. WHO also recommends exercising at least 150 minutes per week, equivalent to walking or cycling for 30 minutes every day.

"There is no magic bullet to prevent cancer but we've got the opportunity and obligation to protect themselves from cancer as much as possible," said Peter Baldini from the World Lung Foundation.
source : http://health.kompas.com

Acute Pain Nursing Care Plan for Hepatitis

2012-01-09T07:31:00.003+07:00

Hepatitis is characterized by the destruction of a number of liver cells and the presence of inflammatory cells in the liver tissue caused by excessive alcohol drinking, disorders of the gall bladder or pancreas, including medication side effects, and infections.

A person can develop hepatitis if they contract one of the viruses that can cause liver inflammation, or as a result of exposure to substances that can cause hepatitis. There are two ways that can lead to hepatitis: it can either occur as a result of infections or from autoimmune processes.

Hepatitis can be divided into two subgroups:

1. Acute Hepatitis
Acute hepatitis caused by the below in result of inflammation that causes damaging to the liver's normal function and lasting less than six months. People having a weakened immune system and weaken liver, making them more susceptible to be infected by hepatitis.
a) Infectious viral hepatitis such as hepatitis A, B, C, D, E.
b) Inflammation of liver caused by Epstein-Barr virus and cytomegalovirus.
c) Inflammation of liver caused by other bacteria.
d) Medication overdose causing damage to liver tissues and cells such as tranquilizers, chemotherapeutic agents, antibiotics and anesthetics.
e) Excessive alcohol drinking.

2. Chronic Hepatitis:
Chronic hepatitis means active, ongoing inflammation of the liver persisting for more than six months. Chronic hepatitis, although much less common than acute hepatitis, can persist for years, even decades. In most people, it is quite mild and does not cause significant liver damage. It may be caused by hepatitis B and C viruses, drugs and excessive alcohol drinking. It can also result in cirrhosis, with an enlarged spleen and fluid accumulation in the abdominal cavity. In some people, continued inflammation slowly damages the liver, eventually resulting in severe scarring of the liver, liver failure and sometimes liver cancer.

In addition to common and everyday body aches that many people experience, Hepatitis patients also suffer from the virus's discomforting symptoms, such as headaches, liver pain and joint pain.

Prior to attempting pain management, it is imperative that you discuss your symptoms and available options with your doctor. A knowledgeable physician will be able to give sound advice in regard to which analgesic may be best for you. The manufacturer, as well as a doctor, can provide appropriate dosing recommendations.

Rather then self-treating pain with over-the-counter medications and possibly harming an already overexerted liver, many Hepatitis patients instead turn to non-medication options. Massage therapy, heat packs, topical pain relievers, and gentle stretching are some safe alternatives for pain management. Getting enough sleep is yet another safe way to aid in pain reduction.

Nursing Diagnosis Nursing Care Plan for Hepatitis

Acute Pain related to swelling of the inflamed liver and portal vein dam

Expected results:

Show signs of physical pain and behavior in pain (not to wince in pain, crying intensity and location)

Nursing Interventions Nursing Care Plan for Hepatitis

a. Collaboration with individuals to determine the method can be used to reduce the intensity of pain

R / pain associated with hepatitis very uncomfortable, because stretching the capsule of the liver, through the approach to individuals who experience pain comfort changes are expected to more effectively reduce the pain.

b. Indicate the client's acceptance of the client's response to pain

Acknowledge the pain
Listen attentively client's expression of pain

R / clients who have tried to convince health providers that he was experiencing pain

c. Provide accurate information

Explain the causes of pain
Indicate how long the pain will end, if known

R / clients are prepared to experience the pain through the explanation of the real pain will tend to be more peaceful than clients who receive an explanation less / not an explanation.

d. Discuss with your doctor the use of analgesics that do not contain hepatotoxic effects

R / likelihood of pain already can not be limited to techniques for reducing pain.

Pathophysiology of CHF - Congestive Heart Failure

2012-01-08T23:22:00.000+07:00

Congestive heart failure is a condition in which the heart becomes an inefficient or weak pump.

This heart condition is a long-term and chronic condition, which typically involves both sides of the heart. However, the condition may affect only the right side of the heart (right-sided heart failure) or the left side (left-sided heart failure). The condition occurs when your heart muscles are weak and cannot pump the blood out of the heart effectively (systolic heart failure) or when your heart muscles are stiff and do not fill up with blood easily (diastolic heart failure).

Pathophysiology of CHF - Congestive Heart Failure

Heart failure is often separated into two classifications: right sided or left-sided failure. In right-sided failure, the right ventricle is unable to pump blood into the pulmonary artery, resulting in less blood being oxygenated by the lungs and increased pressure in the right atrium and systemic venous circulation. Systemic venous hypertension causes edema on the extremities. In left-sided failure, the left ventricle is unstable to pump blood into the systemic circulation, resulting in increased pressure in the left atrium and pulmonary veins. The lungs become congested with blood, causing relevated pulmonary pressures and pulmonary edema.
Although, each type produces different systemic/pulmonary artery alterations, clinically it is unusual to observe solely right-or left-sided failure. Since both sides of the heart are dependent on adequate function of the other side, failure of one chamber causes a reciprocal change in the opposite chamber. For example, in left-sided failure increase in pulmonary vascular congestion will cause increased pressure in the right ventricle, resulting in right ventricular hypertrophy, decreased myocardial efficiency, and eventually pooling of blood in the systemic venous circulation.

Physical Examination for Congestive Heart Failure (CHF)

2012-01-08T23:16:00.001+07:00

Congestive heart failureor Heart failure is inability of the heart to pump an adequate amount of blood to the systemic circulation to meet the body's metabolic demands.

In most cases, heart failure is a process that occurs over time, when an underlying condition damages the heart or makes it work too hard, weakening the organ. Heart failure is characterized by shortness of breath (dyspnea) and abnormal fluid retention, which usually results in swelling (edema) in the feet and legs.

Common symptoms of congestive heart failure include:

Shortness of breath with exertion or when lying down
Cough
Swelling in legs, feet and ankles (pooling of blood)
Swelling of the abdomen
Weight gain
Loss of appetite, indigestion
Irregular or rapid pulse
Low blood pressure
Weakness and fatigue
Heart palpitations (feeling the heart beat)
Difficulty sleeping
Other symptoms may include:
Decreased in alertness or ability to concentrate
Decreased urine production
Nighttime urination (the need to get out of bed to go to the bathroom)
Nausea and vomiting

Physical Examination for Congestive Heart Failure (CHF)

GENERAL SITUATION
Obtained good or composmentis awareness and change according to the level of perfusion disorders involving the central nervous system

Breathing

Visible shortness
Frequency of breathing exceeds the normal

Bleeding

Inspection: the scar, complaints of physical weakness, edema of the extremities.
Palpation: weak peripheral pulses, thrill
Percussion: Shifting boundaries of heart
Auscultation: decreased blood pressure, extra heart sounds

BRAIN

Awareness is usually composmentis
Peripheral cyanosis
The face grimacing, crying, moaning, stretched and stretched.

Bladder

Oliguria
Extremity edema

Bowel

Nausea
Vomiting
Decrease in appetite
Weight loss

BONE

Weaknesses
Fatigue
Unable to sleep
Sedentary lifestyle
Schedule regular exercise could not

PSYCHOSOCIAL

The integrity of the ego: denial, fear of dying, anger, worry.
Social interaction: stress due to family, work, difficulties of economic cost, difficulty coping.

Ineffective Airway Clearance Nursing Care Plan for Epistaxis

2012-01-08T23:03:00.001+07:00

Epistaxis is defined as acute bleeding from the nostril, nasal cavity or nasopharynx. Anterior nosebleeds occur when the source of bleeding originates from Kiesselbach's plexus (Little's area) which is present in the anterior part of the nasal canal. Anterior epistaxis usually occurs in children and young adults.

However, posterior nosebleeds originates from the sphenopalatine artery which is present in the posterior part of the nasal canal. Posterior epistaxis usually presents in old individuals.

First-Aid at Home for Epistaxis

Remember to stay calm. Most nose bleeds are benign and will stop with simple measures.
Sit upright and lean your head forward. Tilting your head backward will cause you to swallow the blood.
Pinch your nose for about 10 minutes. This simple application of pressure should stop most bleeds.
Once the bleeding has stopped, try to prevent any further irritation to the nose for the next 24 hours. Avoid sneezing, blowing your nose, picking your nose or straining.
Avoid prolonged exposure to dry air. Using a humidifier and avoiding air-conditioned environments will help keep the nasal mucosa from drying out and triggering more bleeding.

Nursing Diagnosis Nursing Care Plan for Epistaxis

Ineffective Airway Clearance

Goal: to be effective airway clearance

Expected Outcomes: Frequency of normal breathing, no additional breath sounds, do not use additional respiratory muscles, dyspnoea and cyanosis does not occur.

Independent

Assess the sound or the depth of breathing and chest movement.
Rational: Decreased breath sounds may lead to atelectasis, Ronchi, and wheezing showed accumulation of secretions.
Note the ability to remove mucous / coughing effectively
Rational: bright lumpy or bloody sputum may result from damage to lungs or bronchial injury.
Give Fowler's or semi-Fowler position.
Rational: Positioning helps maximize lung expansion and reduce respiratory effort.
Clean secretions from the mouth and trachea
Rational: To prevent obstruction / aspiration.
Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated.
Rational: Helping dilution of secretions.

Collaboration

Give medication in accordance with the indications mucolytic, expectorant, bronchodilator.
Rational: Mucolytic to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce bronchial spasms and analgesics are given to reduce discomfort.

Deficient Fluid Volume Nursing Care Plan for Peritonitis

2012-01-08T00:19:00.001+07:00

Deficient Fluid Volume Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis Deficient Fluid Volume related to active fluid volume loss.

Deficient Fluid Volume NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium

Characteristics

Decreased urine output
Concentrated urine
Output greater than intake
Sudden weight loss
Decreased venous filling
Hemoconcentration
Increased serum sodium
Hypotension
Thirst
Increased pulse rate
Decreased skin turgor
Dry mucous membranes
Weakness
Possible weight gain
Changes in mental status

Goal:
To identify interventions to improve the balance of fluid and minimize the inflammatory process to improve comfort.

Expected outcomes:

Adequate urine output with normal specific gravity,
Stable vital signs
Mucous membranes moist
Good skin turgor
The capillary rise
Weight within the normal range.

Nursing Interventions Deficient Fluid Volume Nursing Care Plan for Peritonitis

Independent:

1. Monitor vital signs, note the presence of hypotension (including postural changes), tachycardia, tachypnea, fever. Measure CVP if any.
Rational: To assist in the evaluation of the degree of fluid deficit / effectiveness of fluid replacement therapy and response to treatment.

2. Maintain adequate intake and output and then connect with the body weight daily.
Rationale: Demonstrates overall hydration status.

3. Rehydration / resuscitation fluid
Rationale: To meet the need of fluid in the body (homeostasis).

4. Measure specific gravity of urine
Rationale: Demonstrates changes in hydration status and renal function.

5. Observation of skin / mucous membranes for dryness, turgor, note peripheral edema / sacral.
Rational: Hypovolemia, fluid displacement, and lack of nutrition aggravate skin turgor, adding tissue edema.

6. Eliminate the danger signs / smells from environment. Limit intake of ice cubes.
Rational: Lowering the gastric stimulation and vomiting response.

7. Change positions frequently give skin care with often, and keep the bed dry and free of folds.
Rational: tissue edema and circulatory disturbance tends to damage the skin.

Collaboration:

1. Monitor laboratory examinations, eg Hb / hematocrit, electrolytes, protein, albumin, BUN, creatinine.
Rationale: Provides information about hydration and organ function.

2. Give the plasma / blood, fluids, electrolytes.
Rational: Charge / maintain circulating volume and electrolyte balance. Colloid (plasma, blood) to help move the water into the area by increasing intravascular osmotic pressure.

3. Keep fasting with nasogastric aspiration / intestinal
Rational: Lowering intestinal hyperactivity, and loss from diarrhea.

The number 1 killer in the United States and how you can beat it

2012-01-08T00:13:00.000+07:00

Do you know what the number one killer in much of the developed world and especially the United States is? The answer is heart disease. With all the junk food that is available nowadays heart disease has turned in to the biggest killer today. So how can we beat this serial killer and add a few more years to our lives you ask? The answer is simple. We just need to eat healthier and the risk or contracting any sort of heart problem is greatly reduced. In fact you can add about 15 years to your life by just changing a few things in your diet.

The answer is really eating more raw foods and mostly vegetable foods. Raw vegetable foods contain zero cholestrol which is what causes heart disease in the first place.The reason people in the past sought to cook food so much is that it was often dirty and it would make us sick if we tried to consume it as it was. In African villages, people that do not have running water must go to the rivers and get it from there. Of course it is not clean so what do they do? They boil it first to kill the germs and then let it cool and then they will drink it. Nowadays the food we get from the stores is basically edible when we get it. We also wash the food at home so it is very safe for us to consume already. That means we are not taking any risks if we go raw with out diets, or at least replace some of our unhealthy eating habits with raw food.

Some people might be asking what is the main difference between raw and cooked food? Well the thing is when food is being cooked, the temperatures get so high that most of the nutrients present in the food will be destroyed! That means that we are not getting in as many nutrients as we would be led to believe. Many diseases that are prevalent today come about because people do not get as many nutrients as they should from the food they are eating.

When you eat raw clean food, you can rest assured that you will not miss out on any essential nutrients inside the food. Some people may also ask what the nutrients can do for them? Well the biggest thing is that they can easily prevent you from contracting any annoying niggling illnesses. Many people who have gone raw have not had any slight sign of the flu or cold in many years. Some even say it has been more than 15 years since they were last sick!

With all the advances in science and medicine, people in the developing world now have a life expectancy which is very high. Sometimes it is over 80 years old and that is despite people eating all of this unhealthy food. How many more years can we add to this if we all went raw? Maybe another 15 years! Japan has so many people living to an old age, probably because they eat so much raw food such as sushi, that it is actually becoming a huge problem for them!

Now going raw is a process and it is not going to happen overnight, but you have to take responsibility for your health. There are so many raw food recipes for beginners out there that you can try and they are very tasty. In fact you can save money and time because you do not have to stand around cooking food for so long. The many raw food recipes for beginners are easy to prepare and you will not regret as least incorporating a bit of raw food in your diet. There are also many other benefits you can get from raw food.

by: Anthony Muzonzini

The Risks Presented By GBS and Meningitis For Newborns

2012-01-08T00:06:00.000+07:00

According to the Center For Disease Control (CDC), Group B Strep is the major prevalent cause of sepsis and meningitis (a severe infection of the fluid of the spinal cord and the fluid surrounding the brain) in newborns. Group B Strep is a bacterial infection that may affect an infant if the mother is is colonized with the bacteria and transmits it during childbirth.

The bacteria normally germinates in the vagina and/or the lower intestine. It is found in about 1 out of every 4 adult women. However, it usually does not lead to an active infection or lead to symptoms. Transmission from expecting mother to the baby generally occurs during labor and delivery. The child may be exposed to group b strep, for instance, if the bacteria moves up from the mother's vagina into the uterus after the membranes (bag of water) rupture. The newborn may also come in contact with GBS while moving down through the birth canal. In this time, the newborn can swallow or inhale the bacteria.

Around 75% of cases of Group b strep in newborns take place during the seven days of life, and the majority show up inside of a few hours following birth. This is called "early onset." The rest develop a GBS infection at anytime from one week to several months after birth. This is called as "late onset." Statistically, approximately fifty percent of instances of late onset can be related to the baby's mother having had the bacteria. In the other cases of late onset, the cause of the infection is unknown.

After the infant is exposed to the bacteria, it may travel to the infant's bloodstream. This may induce sepsis (overpowering infection throughout the body), pneumonia, or meningitis. These are all severe conditions which can progress rapidly and leave the infant with lifelong disabilities or may even cause the newborn's death. Among the typical possible disabilities are: brain damage, cerebral palsy, blindness, deafness, and seizures.

The most common symptoms of meningitis include: a high fever, lethargy, unusual irritability, trouble feeding, stiffness, vomiting, and rashes. Since the infection can advance quickly quick treatment is needed to avoid significant harm to the newborn. For bacterial based meningitis (such as that caused by Group B Strep), treatment calls for the immediate administration of intravenous IV and antibiotics. A diagnosis of meningitis is established through a sample of spinal fluid through a spinal tap and growing the bacteria for correct identification. This is important so as to determine the right antibiotic for use. The outcome of the test might take several hours. In the time it takes for the results, the infection can result in lasting damage or kill the child. Because of the immediacy required, treatment normally begins ahead of a confirmed diagnosis if meningitis is a possible explanation for the baby's symptoms. Penicillin is the most commonly administered treatment.

If an infant died or suffers from permanent disabilities that were avoidable except for the failure on the part of a physician to diagnose GBS meningitis or to provide immediate treatment that doctor might be liable for malpractice. The mothers and fathers of children thus injured by GBS meningitis should consult with a birth injury attorney immediately as the law permits just a limited amount of time to pursue a birth injury claim.

by: Joseph Hernandez

Hyperthermia Nanda Nursing Diagnosis - Dengue Fever

2012-01-07T23:24:00.001+07:00

Nanda Nursing Diagnosis for Dengue Fever : Hyperthermia

Dengue hemorrhagic fever is an acute infectious disease manifested initially with fever. Dengue fever is one of the contagious viral diseases spread through the mosquito bite. The female Aedes aegypti mosquitoes thrive in stagnant water of surroundings and become the carriers of the virus. The disease is characterized by mild to high fever, headache, joint and muscle pains and rashes.

Signs and Symptoms

Mild to high fever about 105 F
Severe pain in the bone joints
Intense headache and backache
Loss of appetite
Appearance of rashes all over the body
Nausea followed by vomiting

Home Remedies for Dengue

1. One should reduce the exposure to mosquitoes as far as possible and not venture out in the dawn or dusk, when the mosquitoes are most prevalent.

2. Mosquito nets, mosquito repellant ointments and coils must be regularly used while sleeping at night, to prevent the mosquito bite.

3. Holy basil leaves are very useful in preventing and treating dengue. Drinking a decoction of basil leaves and cardamom powder, adding little salt and milk helps in reducing high fever.

4. Juice extracted from two raw papaya leaves helps in preventing Dengue.

5. Drinking few cups pf herbal tea prepared from basil leaves, ginger and cardamom powder is very effective in reducing the fever.

6. Orange juice is widely used for treating Dengue fever. Drinking orange juice helps in proper digestion to fight against the disease.

7. Plenty of water or diluted fruit juice must be administered to the patient to maintain the required water balance of the body.

Nursing Diagnosis and Interventions for Dengue Fever

Nursing Diagnosis Hyperthermia

related to :

the disease (viremia)

Goal :

Normal body temperature (36-37 C).
Patients were free from fever.

Nursing Interventions and Rational for DHF :

1. Assess the onset of fever.
Rational: to identify patterns of fever patients.

2. Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
Rational: vital signs is a reference to determine the patient's general condition.

3. Instruct patient to drink plenty
Rationale: Increased body temperature resulting in increased evaporation of the body so it needs to be balanced with a lot of fluid intake.

4. Give a warm compress.
Rational: With vasodilation can increase evaporation which accelerate the decline in body temperature.

5. Advise not to wear a thick blanket and clothing.
Rational: thin clothing helps reduce the evaporation of the body.

6. Give intravenous fluid therapy and medications according to physician programs.
Rational: infusion of fluids is very important for patients with a high temperature.

Impaired Skin Integrity Nanda Nursing Diagnosis - Stevens-Johnson Syndrome (SJS)

2012-01-07T23:03:00.000+07:00

Stevens Johnsons Syndrome is a dangerous problem of the skin. It is thought to be a hypersensitivity complex affecting the skin and the mucous membranes.

Stevens Johnson Syndrome (SJS) is a severe and deadly allergic reaction to certain drugs, some proscription and some over the counter, which causes the severe burning of skin and mucosal membranes from the inside out. 15% of people who develop Stevens Johnson Syndrome will die as a direct result. Many drugs which have been known to cause SJS do not have warning labels notifying users about the very real danger of Stevens Johnson Syndrome.

The skin rash of SJS consists of erythematous (red) papules, vesicles, bullae. There may also be iris lesions. The mucosal lesions include conjunctivitis as well as oral and genital ulcers. The most frequent complications of SJS are keratitis, uveitis, and perforation of the globe of the eye all of which may result in permanent visual impairment.

Nanda Nursing Diagnosis : Impaired skin integrity related to inflammatory dermal and epidermal

Expected Outcomes:

Shows the skin and skin tissue intact.

Intervention:

1. Observation of skin turgor circulation daily notes and sensory as well as other changes that occur.
Rational: determining a baseline by which changes in status can be compared and appropriate intervention

2. Use a thin clothing and soft loom.
Rational: reduce irritation and pressure from the suture line of clothes, leave the incision open to air increases the healing process and reduce the risk of infection

3. Keep loom is used.
Rationale: to prevent infection

Intellectual Disability Causes and Signs

2012-01-07T07:55:00.000+07:00

Doctors have found many causes of intellectual disabilities. The most common are:

Genetic conditions. Sometimes an intellectual disability is caused by abnormal genes inherited from parents, errors when genes combine, or other reasons. Examples of genetic conditions are Down syndrome, fragile X syndrome, and phenylketonuria (PKU).
Problems during pregnancy. An intellectual disability can result when the baby does not develop inside the mother properly. For example, there may be a problem with the way the baby’s cells divide as it grows. A woman who drinks alcohol or gets an infection like rubella during pregnancy may also have a baby with an intellectual disability.
Problems at birth. If a baby has problems during labor and birth, such as not getting enough oxygen, he or she may have an intellectual disability.
Health problems. Diseases like whooping cough, the measles, or meningitis can cause intellectual disabilities. They can also be caused by extreme malnutrition (not eating right), not getting enough medical care, or by being exposed to poisons like lead or mercury.

An intellectual disability is not a disease. You can’t catch an intellectual disability from anyone. It’s also not a type of mental illness, like depression. There is no cure for intellectual disabilities. However, most children with an intellectual disability can learn to do many things. It just takes them more time and effort than other children.

Signs of Intellectual Disability

There are many signs of an intellectual disability. For example, children with an intellectual disability may:

sit up, crawl, or walk later than other children;
learn to talk later, or have trouble speaking,
find it hard to remember things,
not understand how to pay for things,
have trouble understanding social rules,
have trouble seeing the consequences of their actions,
have trouble solving problems, and/or
have trouble thinking logically.

Pediatric Nursing Care Plan - Mental Retardation

2012-01-07T07:45:00.001+07:00

Pediatric Nursing Care Plan - Mental Retardation Nursing Assessment

Assessment can be done through:

Neuroradiology can find abnormalities in the structure of the cranium, such as classification or increased intracranial pressure.
Echoencephalography can show the tumor and hematoma.
A brain biopsy is only useful on a small number of children retardasii mentally. Not easy for parents to accept the role in brain tissue making even small amounts because they add to the brain damage is inadequate.
Bio-chemical research to determine the metabolic rates of various materials which are known to affect brain tissue if not found in large quantities or small, such as hyperglycemia in preterm neonates, accumulation of glycogen in muscles and neurons, fat deposits in the brain and high levels of phenylalanine.

Or can perform the following assessments:

Assessment of physical
Assessment for growing up
Family history assessment, especially regarding mental retardation and hereditary disorders in which mental retardation is one of the main species.
Medical history to obtain evidence of trauma to prenatal, perinatal, postnatal, or physical injury.
Prenatal maternal infection (eg, rubella), alcoholism, drug consumption.
Inadequate nutrition.
Environmental deviations.
Psychiatric disorders (eg, Autism).
Infections, particularly those involving the brain (eg, meningitis, encephalitis, measles) or high body temperature.
Chromosome abnormalities.
Assist with diagnostic tests such as: analysts chromosomes, metabolic dysfunction, radiography, tomography, electro ensephalography.
Perform or assist with intelligence tests. Stanford Binet, Wechsler intellence, Scale, American Assiciation of Mental Retardation Adaptive Behavior Scale.
Observation of an early manifestation of mental retardation:
- Not responsive to contact.
- Poor eye contact during breastfeeding.
- Decrease in spontaneous activity.
- Decreased awareness of sound vibrations.
- Sensitive stimuli.
- Breast-feeding is slow.

Pediatric Nursing Care Plan Mental Retardation Nursing Diagnosis and Interventions

1. Altered Growth and Development related to damage to cognitive function.

Expected results:

Children and families actively involved in infant stimulation program.
Families applying these concepts and continue the child care activities at home.
Children perform activities of daily living at optimal capacity. Family ~ find out about educational programs.

Nursing interventions :

Involve children and families in early infant stimulation program. Rational: to help maximize growth in children.
Assess the progress of the child's development with regular intervals, for which detailed records to distinguish subtle changes in function. Rational: so the treatment plan can be repaired as needed.
Help families set goals for the child's reality. Rationale: to encourage the successful achievement of goals and self-esteem.
Provide positive reinforcement / specific tasks to the behavior of children. Rational: as this can improve motivation and learning.
Provide information on adolescent social practices and codes of behavior that is concrete and well defined. Rational: because of the ease and lack of assessment of the child persuasion can make children are at risk of dangerous.

2. Altered family processes related to having a child with mental retardation.

Expected results:

Family expresses feelings and concerns about the birth of a child with mental retardation and its implications.
Family members indicate acceptance of the child.
Family members indicate acceptance of the child.

Nursing Interventions:

Provide information on the family as soon as possible during or after birth. Rational: In order for families able to receive the actual circumstances.
Encourage both parents to be present at the conference giving information. Rational: In order for parents to get lots of information about mental retardation.
Discuss with family members about the benefits of home care, give them a chance to investigate all residential alternatives before making a decision. Rationale: So that they can take the best decision for them and their children.
Encourage the family to meet with other families who have the same problem. Rational: so they can receive additional support.

Self-Care Deficit Nanda Nursing Diagnosis

2012-01-07T00:18:00.003+07:00

Self-care deficits

When an individual is very unable to meet their own self-care requisites, a "self-care deficit" occurs. It is the job of the Registered Nurse to determine these deficits, and define a support modality.

Self-care deficit nursing theory is a grand nursing theory that was developed between 1959 and 2001 by Dorothea Orem. It is also known as the Orem model of nursing. It is particularly used in rehabilitation and primary care settings where the patient is encouraged to be as independent as possible.

Self-Care Deficit

Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

Defining Characteristics:

Inability to feed self independently
Inability to dress self independently
Inability to bathe and groom self independently
Inability to perform toileting tasks independently
Inability to transfer from bed to wheelchair
Inability to ambulate independently
Inability to perform miscellaneous common tasks such as telephoning and writing

Related Factors :

Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
Musculoskeletal disorder such as rheumatoid arthritis
Cognitive impairment
Energy deficit
Pain
Severe anxiety
Decreased motivation
Environmental barriers
Impaired mobility or transfer ability

Expected Outcomes

Patient safely performs (to maximum ability) self-care activities.
Resources are identified which are useful in optimizing the autonomy and independence of the patient.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Self-Care: Eating
Self-Care: Bathing
Self-Care: Dressing
Self-Care: Grooming
Self-Care: Hygiene
Self-Care: Toileting

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Self-Care Assistance: Bathing/Hygiene
Self-Care Assistance
Dressing/Grooming
Self-Care Assistance: Feeding
Self-Care Assistance: Toileting
Environment Management

Impaired Physical Mobility Nanda Nursing Diagnosis

2012-01-07T00:02:00.003+07:00

Nanda Definition:

Impaired physical mobility a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities.

Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment.

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment.

Impaired physical mobility - Related factors arising from within the person include pain or fear of discomfort, anxiety or depression, and physical limitations due to neuromuscular or musculoskeletal impairment. External factors include enforced rest for therapeutic purposes, as in the case of immobilization of a fractured limb. The human body is designed for motion; hence, any restriction of movement will take its toll on every major anatomic system.

Defining Characteristics:

Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation
Reluctance to attempt movement
Limited range of motion (ROM)
Decreased muscle endurance, strength, control, or mass
Imposed restrictions of movement including mechanical, medical protocol, and impaired coordination
Inability to perform action as instructed

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Ambulation: Walking
Joint Movement: Active
Mobility Level

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Exercise Therapy: Ambulation
Joint Mobility
Fall Precautions
Positioning
Bed Rest Care

Expected Outcomes

Patient performs physical activity independently or with assistive devices as needed.
Patient is free of complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, and normal bowel pattern.

Imbalanced Nutrition More than Body Requirements Nanda Nursing Diagnosis

2012-01-06T23:52:00.003+07:00

Imbalanced Nutrition More than Body Requirements Definition :

Imbalanced nutrition : more than body requirements refers to a caloric intake / excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue. As the amount of stored fat increases, the individual becomes overweight or obese. A person is said to be overweight when BMI is between 25 and 29.9 kg/m2 and obese when BMI is >30 kg/m2 . Factors that affect weight gain include genetics, sedentary lifestyle, and emotional factors associated with dysfunctional eating. Medical conditions associated with this problem are as follows: diabetes mellitus, severe hypertension, and Cushing’s syndrome. Cultural or ethnic background also influences eating habits. Overall nutritional requirements of geriatric patients are similar to those of younger patients, except that calories should be reduced because of their leaner body mass. The major goals for this problem is to maintain or restore optimal nutrition status, promote healthy nutritional practices, prevent complication associated with malnutrition and decrease weight.

Related Factors :

Cultural preferences
Excessive intake in relation to metabolic need
Lack of knowledge of nutritional needs, food intake, and/or appropriate food preparation
Metabolic disorders
Poor dietary habits

Psychosocial factors

Sedentary lifestyle

Socioeconomic status

Use of food as coping mechanism

Nursing Interventions Classification (NIC)

Nutrition Counseling
Nutritional Monitoring
Weight Reduction Assistance

Nursing Outcomes Classification (NOC)

Nutritional Status: Food and Fluid Intake
Weight Control
Knowledge: Diet

Goal and Objectives

Patient will articulate actions essential to attain weight reduction.
- Patient will cemonstrate change in eating patterns and participation in individual exercise program.
Patient will commence an appropriate program of exercise.
Patient will demonstrate proper selection of meals or menu planning toward the goal of weight reduction.
Patient will exhibit weight loss with optimal continuation of health.

Patient will recognize inappropriate behaviors and consequences related with overeating or weight gain.

Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

2011-12-27T21:55:00.001+07:00

Nursing Diagnosis for Peritonitis : Imbalanced Nutrition, Less Than Body Requirements related to anorexia and vomiting.

Imbalanced Nutrition, Less Than Body Requirements NANDA Definition: Intake of nutrients insufficient to meet metabolic needs.

Characteristics :

Loss of weight
Lack of interest in food
Pale conjunctiva and mucous membranes
Poor muscle tone
Amenorrhea
Poor skin turgor
Edema of extremities
Electrolyte imbalances
Weakness
Constipation
Anemias

Goals

Client will gain 2 pounds per week for the next 3 weeks.
Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; constipation will be corrected; client will exhibit increased energy in participation in activities).

Nursing Interventions Imbalanced Nutrition, Less Than Body Requirements for Peritonitis

Independent:

1. Monitor bow NG tube, and note the presence of vomiting or diarrhea.
Rational: The large number of gastric aspiration and vomiting or diarrhea is suspected bowel obstruction, requiring further evaluation.

2. Measure body weight each day.
Rationale: Loss of or increase in early showed further changes in hydration but loss is suspected nutritional deficit.

3. Auscultation bowel sounds, record sounds nothing or hyperactive.
Rationale: Although there is no frequent bowel sounds, bowel inflammation or irritation may accompany intestinal hyperactivity, decreased water absorption, and diarrhea.

4. Record the required calorie needs.
Rational: The calories (energy sources) will accelerate the healing process.

5. Monitor Hb and albumin
Rational: Indications adequate protein to the immune system.

6. Assess abdomen with frequent return to the gentle sound, the appearance of normal bowel sounds, flatus smooth dam.
Rationale: Indicates the return to normal bowel function.

Collaboration:

1. Collaborative installation NGT if the client can not eat and drink orally.
Rational: In order to keep the client nutrients are met.

2. Collaboration with a dietitian in your diet.
Rational: A healthy body is not easy for infection (inflammation).

3. Provide information about the food substances which are very important to balance the body's metabolism
Rationale: Clients can strive to meet the needs of eating nutritious food.

Risk for Infection Nursing Care Plan for Peritonitis

2011-12-27T21:18:00.001+07:00

Nursing Diagnosis for Peritonitis : Risk for Infection related to tissue trauma

Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

Goal: Reduce infections, improve patient comfort.

Expected outcomes:

Increased healing in time, free of purulent drainage or erythema, no fever.
Stated understanding of the causes of individual / risk factors.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.

Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

Nursing Care Plan for Mitral Stenosis

2011-12-21T11:31:00.001+07:00

Mitral stenosis (MS) is a blockage of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral stenosis typically have mitral valve leaflets are thickened, komisura are fused, and the chordae tendineae are thickened and shortened. Transverse diameter of the heart are usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen. Here is a picture of mitral valve stenosis.

Mitral stenosis causes a change in shape of heart and changes in blood vessels of the lungs according to severity of Mitral Stenosis and heart conditions. Convexity left border of the heart indicates that the prominent stenosis. In most cases there are two disorders that mitral stenosis and mitral insufficiency, generally one of them stand out. Also very dilated left ventricle when the mitral insufficiency involved are very significant. Classical radiological signs of patients with Mitral stenosis is a double contour (double contour) which leads to an enlarged left atrium, and the presence of septum lines are localized.

This condition makes the pulmonary venous pressure increases, causing diversion of blood, chest X-ray look at the relative dilation of blood vessels compared to the top of the pulmonary blood vessels below the lungs. Narrowing of the mitral valve causes the valve does not open properly and blocks the flow of blood between the left heart chambers. When the mitral valve narrowing (stenosis), blood can not efficiently pass through the heart. This condition causes a person to become weak and become short of breath and other symptoms.

Mitral stenosis, a valve disorder most often caused by rheumatic heart disease. It is estimated that 99% mitral stenosis based on rheumatic heart disease. However, approximately 30% of patients with mitral stenosis can not find any previous history of the disease.

In all valvular heart disease, mitral stenosis most commonly found, namely ± 40% of all rheumatic heart disease, and affects women more than men, with a ratio of approximately 4: 1.

Myxoma (benign tumor in the left atrium) or blood clots can block blood flow as it passes through the mitral valve and cause the same effect as mitral valve stenosis.

Nursing Assessment - Nursing Care Plan for Mitral Stenosis

Anamnesa

Demographic Data
- Name
- Age
- Gender
- Interest / nation
- Religion
- Education
- Works
- Address
Main Complaints: patients with mitral stenosis is usually complain of shortness, cyanosis and coughing.
History of Disease Now: The client is usually taken to hospital after shortness of breath, cyanosis or coughing is accompanied by high fever / no.
History of past illness: The client had suffered from rheumatic fever disease, SLE (Systemic Lupus Erithematosus), RA (Rhemautoid arthritis), myxoma (benign tumor in the left atrium).
Family History of Disease: there are no hereditary factors that influence the occurrence of mitral stenosis.

ROS (Review of Systems)

B1 (Breath): Shortness / increased respiration, low tones at the apex by using a bell on his side to the left, shortness of breath and fatigue, cough, orthopnea in venous congestion there.

B2 (Blood): an increase in the jugular vein, odema leg, in the form of atrial arrhythmia atrial fibrillation (rapid heart rate and irregular), hemoptysis, embolism and thrombus, strength weakened pulse, tachycardia, peripheral edema (started happening right heart failure), BJ 1 harsh systolic murmur, palpitations, hemoptysis, apical diastolic murmurs.

B3 (Brain): chest pain and abdominal

B4 (Bladder): excess fluid imbalance, oliguria

B5 (Bowel): Dysphagia, nausea, vomiting, no appetite B6 (Bone): weakness, sweating, rapid fatigue.

Psychosocial assessment

Shortness of breath affects the interaction
Activities limited
Fear of facing surgery
Stress due to disease condition with a poor prognosis

Nursing Diagnosis Nursing Care Plan for Mitral Stenosis

Impaired tissue perfusion
Risk for excess fluid volume
Ineffective breathing pattern
Impaired gas exchange
Activity intolerance

Nursing Care Plan for Mitral Stenosis

Nursing Diagnosis and Interventions for Mitral Stenosis

Nursing Care Plan for Diabetes Mellitus

2011-11-15T09:10:00.000+07:00

Definition of Diabetes Mellitus

Diabetes mellitus is a heterogeneous group of disorders characterized by increased levels of glucose in the blood or hyperglycemia.

Diabetes Melllitus is a collection of symptoms that arise in a person caused by the presence of elevated levels of sugar (glucose) blood due to insulin deficiency both absolute and relative terms.

Signs and Symptoms of Diabetes Mellitus

A common complaint of patients with Diabetes Mellitus such as polyuria, polydipsia, polyphagia in Diabetes Mellitus is generally no. Instead the patient is often disturbing complaints from complications of chronic degenerative blood vessels and nerves. In Diabetes Mellitus elderly there are pathophysiological changes due to aging process, so that the clinical picture varies from asymptomatic cases to cases with extensive complications. A recurring complaint is the presence of impaired vision due to cataracts, tingling in the limbs and muscle weakness (peripheral neuropathy) and injuries to the legs which are difficult to recover with treatment prevalent.

According Supartondo, the symptoms caused by diabetes mellitus in the elderly are often found are:

Cataract
Glaucoma
Retinopathy
Itching around the body
Pruritus Vulvae
Bacterial infections of skin
Fungal infections in the skin
Dermatopati
Peripheral neuropathy
Visceral neuropathy
Amiotropi
Neurotrophic ulcer
Kidney disease
Peripheral vascular disease
Coronary disease
Cerebral vascular disease
Hypertension

Management of Diabetes Mellitus

The main goal of therapy of diabetes mellitus is trying to normalize the activity of insulin and blood glucose levels in an attempt to reduce vascular complications, and neuropathy. Therapeutic purposes in any type of diabetes is to achieve normal blood glucose levels.

There are 5 components in the management of diabetes:

Diet
Exercise
Monitoring
Therapy (if needed)
Education

Nursing Assessment of Diabetes Mellitus

1. Family Health History

Are there families who suffer from diseases such as client?

2. Patient Medical History and Previous Treatment

How long a client suffering from diabetes, how to handle, gets what type of insulin therapy, how to take her medicine whether regular or not, what is being done to address the client's illness.

3. Activity / Rest:

Tired, weak, difficult Moving / walking, muscle cramps, decreased muscle tone.

4. Circulation

Is there a history of hypertension, AMI, claudication, numbness, tingling in the extremities, foot ulcers are healing old, tachycardia, changes in blood pressure

5. Ego integrity

Stress, anxiety

6. Elimination

Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea

7. Food / fluid

Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, use of diuretics.

8. Neuro-sensory

Dizziness, headache, tingling, numbness in the muscle weakness, paresthesias, visual disturbances.

9. Pain / Leisure

Abdomen tense, pain (moderate / severe)

10. Breathing

Cough with / without purulent sputum (tergangung presence of infection / no)

11. Security

Dry skin, itching, skin ulcers.

Nursing Diagnosis for Diabetes Mellitus

Imbalanced Nutrition : Less Than Body Requirements
Deficient Fluid Volume
Impaired skin integrity
Risk for injury

Depression Nursing Diagnosis and Interventions

2011-11-14T08:40:00.002+07:00

Risk for Violence: Self-Directed or Other-Directed

Nursing Interventions for Depression

The general objective: There was no violence for Self-Directed or Other-Directed
Specific objectives
- Clients can build a trusting relationship
  
  Action:
  - Introduce yourself to the patient
  - Do interactions with patients as often as possible with empathy
  - Listen to the notice of the patient with empathy and patient attitude more use non-verbal language. For example: a touch, a nod.
  - Note the patient talks and give a response in accordance with her wishes
  - Speak with a low tone of voice, clear, concise, simple and easy to understand
  - Accept the patient is without comparing with others.
- Clients can use adaptive coping
  
  Action:
  - Give encouragement to express feelings and say that nurses understand what patients perceived.
  - Ask the patient the usual way to overcome feeling sad / painful
  - Discuss with patients the benefits of commonly used coping
  - Together with patients looking for alternatives, coping.
  - Give encouragement to the patient to choose the most appropriate coping and acceptable
  - Give encouragement to patients to try coping that have been selected
  - Instruct the patient to try other alternatives in solving problems.
- Clients are protected from violent behavior to self and others.
  
  Action:
  - Monitor carefully the risk of suicide / violence themselves.
  - Keep and store the tools that can be used by patients for violent behavior, self / others, in a safe place and locked.
  - Keep materials that endanger the patient's appliance.
  - Supervise and place the patient in the room that easily monitored by peramat / officer.
- Clients can improve self-esteem
- Clients can use the social support
  
  Action:
  - Review and make use of individual external sources (the people closest to, the health care team, support groups, religion).
  - Assess support system beliefs (values, past experiences, religious activities, religious beliefs).
  - Make referrals as indicated (eg, counseling, religious leaders).
- Clients can use the drug correctly and precisely
  
  Action:
  - Discuss about the drug (name, dosage, frequency, effect and side effects of taking medication).
  - Help using the drug with the principle of 5 correct (right patient, medication, dose, manner, time).
  - Encourage talking about effects and side effects are felt.
  - Give positive reinforcement when using the drug properly.

Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions

2011-11-13T08:40:00.002+07:00

Hypertension Nursing Assessment

Assessment is the main basis of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment - a careful collection of data about clients, their families, the data obtained through interviews, observation and examination.

The data collected can be divided into two (Kelliat, Budi Ana., 1995) :

Data base
Specific data relating to the current situation of the client which can be determined by the nurse, client or family.

The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).

Read More

Hypertension Nursing Diagnosis

Risk for Decreased Cardiac Output related to Increased afterload, vasoconstriction and myocardial ischemia.
Acute pain related to increased cerebral vascular pressure.

Read More

Hypertension Nursing Intervention

Nursing Diagnosis :

Risk for Ineffective Tissue Perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary related to impaired circulation

Nursing Intervention for Hypertension

Maintain bed rest, elevate head of bed

Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if available

Maintain fluid and drugs.

Observe the sudden hypotension.

Measure inputs and expenditures

Monitor electrolytes, BUN, creatinine.

Ambulation according to ability; avoid fatigue

Ineffective Breathing Pattern NIC NOC

2011-11-07T13:52:00.001+07:00

Nursing Diagnosis for Ineffective Breathing Pattern

Definition: The exchange of air inspiration and / or expiration inadequate.

Ineffective breathing pattern related to

Hyperventilation
Hypoventilation syndrome
Damage muskuloskletal
Neuromuscular Dysfunction
Fatigue muscles of respiration

Data:

Changes in chest movement
Bradipnea, tachypnea
Decrease in inspiratory and expiratory pressures
Breath nostril
The use of auxiliary respiratory muscles
Increased vital signs

Nursing Interventions for Ineffective Breathing Pattern
a. Airway Management:

Open the airway with headtilt, chinlift, jaw thrust
Set the position to maximize ventilation
Use tools airway
Perform chest physiotherapy
Teach breath deeply and cough effectively
Auscultation of breath sounds
Give bronchodilators (Collaboration)

b. Oxygen therapy

Provide humidification system of oxygen equipment
Monitor the flow of oxygen and the amount given
Monitor signs of oxygen toxicity

c. Monitoring of respiration

Monitor the frequency, rhythm and depth of breathing
Monitor the use of auxiliary respiratory muscles

d. Monitoring of vital signs

Monitor blood pressure, pulse, respiratory rate, temperature
Monitor blood pressure during sleep, sit, stand up if indicated
Monitor signs and symptoms of hypothermia or hyperthermia
Monitor rhythm and breath sounds

Ineffective Airway Clearance NIC NOC

2011-11-07T13:44:00.001+07:00

Ineffective Airway Clearance

Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

Ineffective airway clearance related to

The accumulation of secretions
Airway spasm

Data:

Cough
Discharge
Dyspneu
Cyanosis
Respiratory rate increased
Ronkhi
Wheezing

a. Airway Management:

Open the airway with headtilt, chinlift, jaw thrust
Set the position to maximize ventilation
Use tools airway
Perform chest physiotherapy
Teach breath deeply and cough effectively
Perform suction
Auscultation of breath sounds
Give bronchodilators (Collaboration)

b. Oxygenation therapy

Provide humidification system of oxygen equipment
Monitor the flow of oxygen and the amount given
Monitor signs of oxygen toxicity

Urinary Retention

2011-11-06T23:59:00.000+07:00

Urinary retention is the inability to empty the bladder. With chronic urinary retention, you may be able to urinate, but you have trouble starting a stream or emptying your bladder completely. You may urinate frequently; you may feel an urgent need to urinate but have little success when you get to the toilet; or you may feel you still have to go after you've finished urinating. With acute urinary retention, you can't urinate at all, even though you have a full bladder. Acute urinary retention is a medical emergency requiring prompt action. Chronic urinary retention may not seem life threatening, but it can lead to serious problems and should also receive attention from a health professional.

Male and female urinary tracts.
Anyone can experience urinary retention, but it is most common in men in their fifties and sixties because of prostate enlargement. A woman may experience urinary retention if her bladder sags or moves out of the normal position, a condition called cystocele. The bladder can also sag or be pulled out of position by a sagging of the lower part of the colon, a condition called rectocele. Some people have urinary retention from rectoceles. People of all ages and both sexes can have nerve disease or nerve damage that interferes with bladder function.
Source : http://kidney.niddk.nih.gov/kudiseases/pubs/UrinaryRetention/

NURSING DIAGNOSIS: Urinary retention

Related to:

stasis of urine in the kidney and bladder associated with prolonged horizontal positioning;
difficulty urinating associated with anxiety regarding use of bedpan or urinal;
incomplete bladder emptying associated with:
- horizontal positioning (the gravity needed for complete bladder emptying is lost)
- decreased bladder muscle tone resulting from the generalized loss of muscle tone that occurs with prolonged immobility.

Desired Outcome
The client will not experience urinary retention as evidenced by:

voiding at normal intervals
no reports of bladder fullness and suprapubic discomfort
absence of bladder distention and dribbling of urine
balanced intake and output.

Constipation

2011-11-06T23:53:00.000+07:00

Constipation means different things to different people. For many people, it simply means infrequent stools. For others, however, constipation means hard stools, difficulty passing stools (straining), or a sense of incomplete emptying after a bowel movement. The cause of each of these "types" of constipation probably is different, and the approach to each should be tailored to the specific type of constipation.

Constipation also can alternate with diarrhea. This pattern commonly occurs as part of the irritable bowel syndrome (IBS). At the extreme end of the constipation spectrum is fecal impaction, a condition in which stool hardens in the rectum and prevents the passage of any stool.

The number of bowel movements generally decreases with age. Ninety-five percent of adults have bowel movements between three and 21 times per week, and this would be considered normal. The most common pattern is one bowel movement a day, but this pattern is seen in less than 50% of people. Moreover, most people are irregular and do not have bowel movements every day or the same number of bowel movements each day.

Medically speaking, constipation usually is defined as fewer than three bowel movements per week. Severe constipation is defined as less than one bowel movement per week. There is no medical reason to have a bowel movement every day. Going without a bowel movement for two or three days does not cause physical discomfort, only mental distress for some people. Contrary to popular belief, there is no evidence that "toxins" accumulate when bowel movements are infrequent or that constipation leads to cancer.

It is important to distinguish acute (recent onset) constipation from chronic (long duration) constipation. Acute constipation requires urgent assessment because a serious medical illness may be the underlying cause (for example, tumors of the colon). Constipation also requires an immediate assessment if it is accompanied by worrisome symptoms such as rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary loss of weight. In contrast, the evaluation of chronic constipation may not be urgent, particularly if simple measures bring relief.

Sample of Nursing Care Plan

2011-11-06T23:17:00.000+07:00

Nursing care plan

A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Characteristics of the nursing care plan

Its focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.
It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
It focuses on client-specific nursing outcomes that are realistic for the care recipient
It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.
It is a product of a deliberate systematic process.
It relates to the future.

Elements of the nursing care plan

The nursing care plan consists of a nursing diagnosis with defining characteristics (subjective and objective data that support the diagnosis), related factors or risk factors, expected outcomes/goals, and nursing interventions.

from : http://en.wikipedia.org/wiki/Nursing_care_plan

Sample of Nursing Care Plan

Click Here

Schizophrenia Care Plan - Nursing Assessment, Diagnosis, Interventions and Implementation

2011-11-03T08:10:00.002+07:00

Schizophrenia Care Plan - Nursing Assessment

1. History. Review the history of the client to the originator stressors and significant data.
Biological-genetic vulnerability (family history)
Stressful life events
The results of the mental status examination
Psychiatric history and medication adherence in the past
History of treatment
The use of drugs and alcohol
Pendidkkan and employment history

2. Assess the client for the presence of characteristic symptoms

3. Assess the support system of family and community
Current living arrangements and level of supervision
The involvement and support of family
Case manager or therapist
Participation in community treatment programs

4. Assess the knowledge base of clients and families. Assess whether the client and his family have enough knowledge about:
schizophrenia disorders
Medication and treatment recommendations
Signs of recurrence
Measures to reduce stress

5. Assess the client for any side effects of antipsychotic medications
Pyramidal system effects (extrapyramidal system; ESE,). Use of certain tools, such as the AIMS scale or neurological Simpson scale, to perform the assessment.
Aphek anticholinergic
cardiovascular effects

Schizophrenia Care Plan - Nursing Diagnosis

1. Analysis of positive and negative symptoms

2. Analysis of strengths and weaknesses of clients, including:
Self-care ability
socialization
communication
reality-testing
job skills
support system

3. Analysis of factors that increase the risk of behavioral expression of the unconscious, including:
agitation
angry
suspicious
The existence of hallucinations that threaten

4. Establish and prioritize nursing diagnoses for clients and their families.
Low self esteem, chronic
Ineffective family coping: worsening
Impaired home maintenance management
Ineffective individual coping
Lack of knowledge (please specify)
Ineffective management of therapeutic progarm: family
Ineffective management of therapeutic progarm: Individual
noncompliance
Changes in role performance
Less self-care (specify)
Changes in sensory / perception: visual, auditory, kinesthetic, taste, touch, smell (please specify)
Changes in the process of thinking
The risk of violence to self / others

Schizophrenia Care Plan - Nursing Interventions

1. Set realistic goals with clients.
2. Specify the desired outcomes for clients with schizophrenia disorder.
3. Set criteria desired outcomes for families that have family members with schizophrenia.

Schizophrenia Nursing Interventions

Schizophrenia Care Plan - Nursing Assessment, Diagnosis, Interventions and Implementation

Family Counseling In Schizophrenia Patients

Nursing Diagnosis and Interventions Impaired Verbal Communication for Schizophrenia

Family Counseling In Schizophrenia Patients

2011-11-03T07:46:00.000+07:00

Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.3–0.7%. Diagnosis is based on observed behavior and the patient's reported experiences.

Symptoms

A person diagnosed with schizophrenia may experience hallucinations (most reported are hearing voices), delusions (often bizarre or persecutory in nature), and disorganized thinking and speech. The latter may range from loss of train of thought, to sentences only loosely connected in meaning, to incoherence known as word salad in severe cases. Social withdrawal, sloppiness of dress and hygiene, and loss of motivation and judgment are all common in schizophrenia. There is often an observable pattern of emotional difficulty, for example lack of responsiveness. Impairment in social cognition is associated with schizophrenia, as are symptoms of paranoia; social isolation commonly occurs. In one uncommon subtype, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation, all signs of catatonia.

Late adolescence and early adulthood are peak periods for the onset of schizophrenia, critical years in a young adult's social and vocational development. In 40% of men and 23% of women diagnosed with schizophrenia the condition manifested itself before the age of 19. To minimize the developmental disruption associated with schizophrenia, much work has recently been done to identify and treat the prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset of symptoms. Those who go on to develop schizophrenia may experience transient or self-limiting psychotic symptoms and the non-specific symptoms of social withdrawal, irritability, dysphoria, and clumsiness during the prodromal phase.

Family Counseling In Schizophrenia Patients

1. Teach families about schizophrenia

Schizophrenia is a brain disorder that affects all aspects of the functional. No single cause has been determined, but research suggests that the cause, including genetics, brain structure and chemistry changes, and various factors related to stress.

The symptoms may include hearing voices (hallucinations), mistaken beliefs (delusions), communicating in ways that are difficult to understand, as well as occupational and social function badly.

The symptoms may improve, but may also recur continue for life.

2. Teach the family about

Antipsychotic drugs are used; important for clients to take it as prescribed.

Many side effects occur and can be overcome if reported immediately to healthcare providers. (Provide specific information regarding the client's medication).

Follow up treatment with a therapist or care manager is very important.

3. Teach families about ways to overcome the symptoms of the client

Identify the events that typically disappointing clients and provide extra help as needed.

Note when the client became angry and do the actions to reduce anxiety.

Measures to reduce anxiety include rest, relaxation techniques, a balance between rest and activity, and proper diet.

Write down the symptoms that indicated the client when he was sick, and when this happens encourage clients to contact a health care provider (if he refuses, you should contact your own health care providers).

Client does not approve the statement of hallucinations or delusions; let me know about reality, but do not argue with the client.

Additional Information:
Teach families about self-care
Encourage families to talk about their feelings and concerns with health care providers.

Encourage families to want to consider joining a support group or community assistance.

Nursing Care Plan - Assessment, Diagnosis and Interventions for Acute Myocardial Infarction

2011-11-02T09:25:00.002+07:00

Acute Myocardial Infarction (AMI)

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation).

Every year, several million people in North America are diagnosed with an AMI, and approximately one-third of these patients die during the acute phase. Health Canada has identified cardiovascular disease or heart diseases as the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national healthcare system.

Clinical Manifestations of Myocardial Infarction

Pain

Chest pain that occurs suddenly and constantly not subside, usually above the sternal region and upper abdomen, this is the main symptom.
The severity of pain can increase settled until unbearable pain.
Pain is very ill, such as punctured-pin that can spread to the shoulder and continued down to the arm (usually the left arm).
The pain started spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and do not disappear with the help of rest or nitroglycerin (NTG).
Pain may spread to the jaw and neck.
Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.
Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompany diabetes can interfere neuroreseptor (collect the experience of pain).

Laboratory examination Examination of cardiac enzymes :

CPK-MB/CPK
Isoenzymes found in heart muscle increased by between 4-6 hours, peaks in 12-24 hours, returned to normal within 36-48 hours.
LDH / HBDH
Increases in the 12-24 hour time-consuming dams to return to normal
AST
Increases (less real / special) occurred within 6-12 hours, culminating in 24 hours, returning to normal within 3 or 4 days

ECG ECG changes that occur in the early phase of T wave height and symmetrical. After this there is ST segment elevation. Changes that occur later are the presence of a wave of Q / QS which indicate the presence of necrosis.

Pain scores according to White:

= Do not experience pain
= Pain on one side without disturbing activities
= More pain at one place and resulted in disruption of activities, such as difficulty getting out of bed, hard to bend the head and others.

Primary Assessment for Acute Myocardial Infarction Nursing Care Plan (AMI) :

Airways

Blockage or accumulation of secretions
Wheezing or crackles

Breathing

Shortness of breath with mild activity or rest
Respiration more than 24 x / min, irregular rhythm shallow
Ronchi, crackles
The expansion of the chest is not full
Use of auxiliary respiratory muscles

Circulation

Weak pulse, irregular
Tachycardia
Blood pressure increase / decrease
Edema
Nervous
Acral cold
Pale skin, cyanosis
Decreased urine output

Secondary Assessment Acute Myocardial Infarction (AMI) :

Activities
- Symptoms:
  - Weakness
  - Fatigue
  - Can not sleep
  - Settled lifestyle
  - No regular exercise schedule
- Signs:
  - Tachycardia
  - Dyspnea at rest or activity
Circulation
- Symptoms:
  - History of Acute Myocardial Infarction (AMI)
  - Coronary artery disease
  - Blood pressure problems
  - Diabetes mellitus.
- Signs:
  - Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or stand
  - Pulse: normal, full or not strong or weak / strong quality with slow capillary filling, irregular (dysrhythmias)
  - Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased contractility / complaints ventricle
  - Murmur: If there are shows valve failure or dysfunction of heart muscle
  - Friction: suspected pericarditis
  - Heart rhythm can be regular or irregular
  - Edema: juguler venous distention, edema dependent, peripheral, general edema, cracles may exist with heart failure or ventricular
  - Color: Pale or cyanotic, flat nail, on mucous membranes or lips
Ego integrity
- Symptoms: an important symptom or deny the existence of conditions of fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family
- Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain
Elimination
- Signs: normal, decreased bowel sounds.
Food or fluid
- Symptoms: nausea, anorexia, belching, heartburn, or burning
- Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes
Hygiene
- Symptoms or signs: difficulty perform maintenance tasks
Neuro Sensory
- Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)
- Signs: mental changes, weakness
Pain or discomfort
- Symptoms:
  - Sudden onset of chest pain (may or may not relate to activities), not relieved by rest or nitroglycerin (although most deep and visceral pain)
  - Location: Typical on the anterior chest, Substernal, precordial, can spread to the hands, jaw, face. No specific location such as epigastric, elbow, jaw, abdomen, back, neck.
  - Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.
  - Intensity: Usually 10 (on a scale of 1-10), may experience the worst pain ever experienced.
  - Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly
Respiratory:
- Symptoms:
  - Dyspnea with or without job
  - Nocturnal dyspnea
  - Cough with or without sputum production
  - History of smoking, chronic respiratory disease.
- Signs:
  - Increased respiratory rate
  - Shortness of breath / strong
  - Pallor, cyanosis
  - Breath sounds (clean, cracles, wheezing), sputum
Social interactions
- Symptoms:
  - Stress
  - Difficulty coping with the stressors that exist eg illness, treatment in hospital
- Signs:
  - Difficulty rest - sleep
  - Response too emotional (angry constantly, fear)
  - Withdraw

Nursing Diagnosis for Acute Myocardial Infarction (AMI)

Acute Pain
Decreased Cardiac Output related
Activity Intolerance
Imbalanced Nutrition: Less than Body Requirements
Ineffective Tissue Perfusion
Anxiety
Ineffective Coping
Ineffective Sexuality Patterns

Emergency Nursing Care Plan For Chest Pain - Heart Attack

2011-10-19T01:18:00.001+07:00

Chest pain and heart attack

Chest discomfort or pain is a key warning symptom of a heart attack. Heart attack symptoms include:

Chest pain or pressure, or a strange feeling in the chest.
Sweating.
Shortness of breath.
Nausea or vomiting.
Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or Both shoulders or arms.
Sudden weakness or lightheadedness.
A fast or irregular heartbeat.

Most people fear That chest pain always means something is wrong with the heart. This is not the case. Chest discomfort or pain, ESPECIALLY in People who are younger than age 40, can have many Causes.

Pain in the muscles or bones of the chest Often Occurs When You increase of your activities or add exercise to your schedule. This is Sometimes Called chest wall pain.
Burning chest pain, That Occurs When You cough may be Caused by an upper respiratory infection Caused by a virus.
Burning chest or rib pain, ESPECIALLY Appears just before a rash, may be Caused by shingles.
A broken rib can be quite painful, ESPECIALLY Pls you cough or try to take a deep breath.
Gastroesophageal reflux disease (GERD) can cause pain just below the breastbone. Many people say Will They have "heartburn." This pain is usually relieved by taking an antacid or eating.

Other, more serious problems That can cause chest pain include:

A collapsed lung (pneumothorax), the which usually Causes a sharp, stabbing chest pain and shortness of breath Occurs with.
A blood clot in the lung (pulmonary embolism), the which usually Causes deep chest pain with the rapid development of extreme shortness of breath.
Lung cancer, the which may cause chest pain, ESPECIALLY if the cancer cells spread to involve the ribs.
Diseases of the spine, the which can cause chest pain if the nervous in the spine are "pinched."

http://www.webmd.com/heart-disease/tc/chest-pain-topic-overview

Emergency Nursing Care Plan For Chest Pain - Heart Attack

Nursing Assessment For Chest Pain - Heart Attack

1. Primary Assessment
a. Airway
- How airway clearance?
- Is there a blockage / buildup of secretions in the airway?
- How is the sound of his breathing, is there any additional breath sounds?

b. Breathing
- How does the pattern of breathing? Frequency? The depth and rhythm?
- Does using a respirator muscles?
- Are there any additional breath sounds?

c. Circulation
- What about the peripheral arteries and carotid arteries? The quality (content and voltage)
- How capillary refill, cyanosis or oliguria?
- Is there a decrease in consciousness?
- How vital signs?

Secondary Assessment
The important points that need further examination during chest pain (coronary):
a. Location of pain
Where to start, propagation (coronary chest pain: from sternal spread to the neck, chin or shoulder to the left arm of the ulna)
b. Nature of pain
Feeling of fullness, heaviness such as seizures, squeezing, stabbing, choking / burning, etc..
c. Characteristics of pain
The degree of pain, duration, how many times arise in a certain period.
d. Chronology of pain
Beginning there is pain and progress sequentially
e. The situation at the time of attack
Whether arising at times / specific conditions
f. Factors that reinforce / relieve pain such as attitude / posture, movement, pressure, etc..
g. Other symptoms that may exist whether or not a relationship with chest pain.

Nursing Diagnosis For Chest Pain - Heart Attack

1. Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation
2. Ineffective Tissue Perfusion (heart muscle) related to decreased blood flow
3. Activity intolerance related to imbalance between oxygen supply and metabolic needs of the network

Nursing Intervention For Chest Pain - Heart Attack

The principles of action:
1. Bed rest with Fowler position / semi-Fowler
2. Perform 12 lead ECG, if necessary, 24 leads
3. Observation of vital signs
4. Collaboration: oxygen delivery and administration of drugs according to advice
5. Install a drip and give peace to the client
6. Taking blood samples
7. Reduce environmental stimuli
8. Be calm in the works
9. Observing signs of complications

Nursing Care Plan (NCP) for Cataract

2011-10-19T00:32:00.001+07:00

A cataract is a clouding of the lens in your eye. It affects your vision. Cataracts are very common in older people. By age 80, more than half of all people in the United States either have a cataract or have had cataract surgery.

Common symptoms are

* Blurry vision
* Colors that seem faded
* Glare
* Not being able to see well at night
* Double vision
* Frequent prescription changes in your eye wear

Cataracts usually develop slowly. New glasses, brighter lighting, anti-glare sunglasses or magnifying lenses can help at first. Surgery is also an option. It involves removing the cloudy lens and replacing it with an artificial lens. Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay cataracts.

NIH: National Eye Institute
nlm.nih.gov

Nursing Care Plan (NCP) for Cataract

Nursing Diagnosis for Cataract

Preoperatively:
Anxiety related to lack of knowledge of cataract surgery procedures

Intraoperative:
Acute pain related to surgery

Postoperative:
Risk for infection related to inflammation of postoperative wound

Nursing Outcome and Interventions Nursing Care Plan (NCP) for Cataract

Anxiety decreased after nursing actions, with expected outcomes:
1. the patient calm and relaxed
2. can reveal the cause of anxiety
3. patients were able to control anxiety
4. patients may explain the action operations

Interventions:
1. examine the patient's anxiety level, measuring vital signs
2. give patients the information needed prior to surgery
3. provide mental relaxation techniques as well as suport involving elements of religious
4. give patients the opportunity to express his feelings before surgery

Acute pain decreased after nursing actions, with expected outcomes:
1. patients expressed reduced pain
2. the patient's face looked relaxed

Interventions:

1. recommended for, uses management techniques of relaxation, visualization, and breathing in

Infections do not occur during nursing actions

Interventions:

1. Discuss the importance of washing hands before touching or treating the eye
2. Show the proper techniques to clean the eye from the inside out with a wet tissue / cotton ball for each swabs, bandages and anti-insert contact lenses when using
3. Emphasize not to touch or scratch the operated eye
4. Observation / discuss examples of signs of infection redness, eyelid swelling, purulent drainage.

Nursing Care Plan Tonsillectomy

2011-10-18T23:40:00.001+07:00

Tonsillectomy

Tonsillectomy is surgery to remove the tonsils. These glands are at the back of your throat. Often, tonsillectomy is done at the same time as adenoidectomy, surgery to remove the adenoid glands.

Etiology of Tonsillectomy

The cause of tonsillitis is viral and bekteri, mostly caused by a virus which is also a predisposing factor of bacterial infection.

Virus Type:

Adenovirus
Virus echo
The influenza virus

Bacteria Type:

Streptococcus
Mycrococcus
Corine bacterium diphterial

The degree of tonsillar enlargement:
a. Grade I (Normal)
Tonsils are behind tonsil pillars (soft structure, cut by the soft palatine).
b. Grade II
Tonsils are among the pillars and uvula.
c. Grade III
Touching tonsils uvula.
d. Grade IV
One or two tonsil extends ketengah uvofaring.

Nursing Assessment of Tonsillectomy

Assess difficulty swallowing, easy to choke.
Assess sore throat acute / chronic.
Assess the history of sore throats and influenza.
Assess allergy history.
Assess the bleeding by mouth.
Assess the presence of asthma, cystic fibrosis.

Nanda Nursing Diagnoses for Tonsillectomy

1. Risk for infection related to the factors of surgery

2. Pain related to surgical operations

3. Fluid Volume Deficit related to decreased fluid intake secondary to pain on swallowing

4. Imbalanced Nutrition Less Than Body Requirements related to reduced input secondary to pain on swallowing

5. Risks to the ineffectiveness of therapeutic management related to inadequate knowledge about the complications, pain, positioning and management activities.
http://nandanursingdiagnoses.blogspot.com/

Interventions Nursing Care Plan Tonsillectomy

Risk for infection related to the factors of surgery

Objectives:
- There is no infection.
- There were no complications.
Intervention:
- Monitor temperature every 4 hours, the state of injury when performing maintenance.
- Give an antibiotic is prescribed, give at least 2 liters of fluid every day while implementing antibiotic therapy.
- Give antipyretics are prescribed if there is fever.

Pain related to surgical operations

Objectives:
- The client states lost pain / controlled.
- The client indicates to relax, rest / sleep and increased activity appropriately.Iintervention:
- Monitor vital signs
- Provide comfort measures, eg changes in position, music, relaxation.
- If prescribed analgesics, analgesics are routinely set during the first 24 hours, not waiting for patients to ask for it.
- Tell your doctor if analgesics can not eliminate the pain.

Tuberculosis (TB) Nursing Diagnosis, Interventions, Implementation and Evaluation

2011-10-17T23:42:00.002+07:00

Tuberculosis (TB) is an infectious disease caused by bacteria whose scientific name is Mycobacterium tuberculosis. It was first isolated in 1882 by a German physician named Robert Koch who received the Nobel Prize for this discovery. TB most commonly affects the lungs but also can involve almost any organ of the body. Many years ago, this disease was referred to as "consumption" because without effective treatment, these patients often would waste away. Today, of course, tuberculosis usually can be treated successfully with antibiotics.

There is also a group of organisms referred to as atypical tuberculosis. These involve other types of bacteria that are in the Mycobacterium family. Often, these organisms do not cause disease and are referred to as "colonizers" because they simply live alongside other bacteria in our bodies without causing damage. At times, these bacteria can cause an infection that is sometimes clinically like typical tuberculosis. When these atypical mycobacteria cause infection, they are often very difficult to cure. Often, drug therapy for these organisms must be administered for one and a half to two years and requires multiple medic
ations.
http://www.medicinenet.com/tuberculosis/article.htm

Nursing Diagnosis and Interventions for Tuberculosis (TB)

1. Ineffective airway clearance related to increased production of secretions.

Plan objectives: to maintain patient airway, remove secretions without assistance, indicating the behavior to maintain / improve airway clearance.

Plan of action:
1) Assess respiratory function, eg, breath sounds, rhythms speed, depth and accessory muscle use.
Rational: the Ronchi, wheezing may indicate the accumulation of secretions / inability to clean Yuang airway can lead to the use of accessory respiratory muscles and increased work of breathing.

2) Record the ability to remove mucous or coughing effectively, record the character, amount of sputum, presence of hemoptysis.
Rational: spending will be difficult if the secretions are very thick, the sputum or coughing up blood caused by lung damage or brokeal requiring the evaluation / further intervention.

3) Give high semifowler position, help the patient to cough and deep breathing exercises.
Rational: breath in will increase lung expansion and reduce the effort and helps remove respiratory secretions.

4) Clean the mouth and trachea of secretions as indicated.
Rationale: prevent obstruction / aspiration.

5) Maintain the entry of fluid at least 2500 cc / day unless contraindicated.
Rational: help thin secretions.

6) Give the medication as indicated

Nursing Care Plan - Implementation
1. Increase / maintain adequate ventilation or oxygenation.
2. Preventing the spread of infection.
3. Behavioral supports to maintain health.
4. Enhance effective coping strategies.
5. Provides information about the disease process, prognosis and treatment needs.

Nursing Care Plan - Evaluation
1. Respiratory function is adequate to meet individual needs.
2. Complications prevented.
3. Lifestyle changes to prevent the spread of infection.
4. Disease process or prognosis and treatment programs is understood.

Privacy Policy

2011-10-10T09:36:00.001+07:00

Privacy Policy for careplannursing.blogspot.com

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Nursing Care Plan for Neonatal Hypoglycemia

2011-10-10T08:13:00.002+07:00

Neonatal hypoglycemia

Neonatal hypoglycemia is low blood sugar (glucose) in the first few days after birth.

Symptoms of Neonatal Hypoglycemia

Infants with hypoglycemia may not have symptoms. If they do occur, symptoms may include:

Bluish-colored skin (cyanosis)
Breathing problems
Decreased muscle tone (hypotonia)
Grunting
Irritability
Listlessness
Nausea, vomiting
Pale skin
Pauses in breathing (apnea)
Poor feeding
Rapid breathing
Problems with maintaining body heat
Shakiness
Sweating
Tremors
Seizures

Treatment of Neonatal Hypoglycemia

Infants with hypoglycemia may need to receive:

Feeding with breast milk or formula within the first few hours after birth, either by mouth or through a tube inserted through the nose into the stomach (nasogastric lavage)
A sugar solution through a vein (intravenously) if the baby is unable to feed by mouth, or if the blood sugar is very low

Treatment normally continues for a few hours or days to a week.

If the low blood sugar continues, the baby may also receive medication to increase blood glucose levels (diazoxide) or to reduce insulin production (ocreotide).

In rare cases, newborns with very severe hypoglycemia who don’t improve with treatment may need surgery to remove part of the pancreas (to reduce insulin production).

Installation and Catheter Care

2011-10-10T07:26:00.000+07:00

Installation and Catheter Care

A PRE-INTERACTION PHASE
- Assess patient and check the medical plan
- Define the procedure with a catheter directly or settle
- Determine the type and size of catheter
- Prepare the tool:
• Foley catheter
• Urine Bag
• Disposable Gloves
• sterile gloves
• Kom small, containing a liquid antiseptic
• Jelly
• Spuit 10cc
• Plaster
• Crooked
• Scissors bandage / plaster
• Sterile Tweezers
• Perlak
• perforated Duk
• Cotton sublimate

ORIENTATION PHASE

• Identification of patients
• Explain procedure and purpose of the act of catheterization

PHASES OF WORK

1 Put the cover
2 Put your tools to near patient
3 Set the lamp or torch
4 Adjust the position of
a child patient or the patient is unconscious with the help
b Female patients with a dorsal recumbent position
c Patients with a supine male

PHASES OF WORK

a Washing hands
b Wear disposable gloves
c Opening under clothing
d Attach waterproof below the buttocks
e Juxtapose bent close to the buttocks
f Put down a hole
g Clean the urethral meatus

CLIENTS IN WOMEN
a Use the dominant hand is not to open the labia majora with the thumb of the index finger.
b Then clean the meatus with an antiseptic fluid using tweezers from the top down, dilanjutkandengan labia minora and majora area further.

CLIENTS IN MEN
a Hold the penis by hand is not dominant
b Clean the meatus with an antiseptic liquid using the dominant hand using tweezers.
- Clean the meatus with a circular motion from the inside out
- When you clean the gland penis Peril proceed from top to bottom.

h Remove the disposable gloves
i Hold the tool with clients
j Open sets and keep the area sterile catheter in the catheter
k If the drainage is still a separate part, open and connect to the catheter
l Wear sterile gloves
m Connect the catheter;
CLIENTS FOR WOMEN
- Still using the hand that is dominant, go back to the labia majora to find the urethral meatus
- With the dominant hand, put the catheter in the urethral meatus -7.5 ± 5 cm or until the urine out.
CLIENTS FOR MEN
- Enforce the penis with the 90o position, insert the catheter with dominant hand ± 17.5 - 20 cm or until the urine out.

n If using a permanent catheter, insert aquabidest ± 20cc
o fixation catheter into the patient
- For men under the abdomen
- For women dipah or loose on the leg without fixation
p Fixation urine bag on the bed
q Adjust the position of the patient as comfortable as possible
r Wash hands

C PHASE TERMINATION
Evaluation by using the following criteria:
- Catheter fixed, drainage lancer or catheter directly into and release tanpaketidaknyamanan
- Patients feel comfortable
- Termination

D Documentation
1 Date and time
2 Type and size of catheter
3 Is specimen was filled
4 Number of urine
5 Description of urine
6 The response of patients to the procedure.

Hyperthermia Care Plan for Nurses

2011-10-09T23:49:00.000+07:00

Hyperthermia

DEFINITIONS:

Circumstances where an individual experiencing an increase in body temperature above peroral C 37.80 / 38.80 C per-rectal due to external factors (Carpenito, 1995)

PURPOSE:

Addressing the problem of increase in body temperature to prevent the lack of fluids or other complications due to hyperthermia.

CRITERIA:

Temperature 36 to 37.5 C, no complaints of fever, chills no, elastic skin turgor, vital signs within normal range (blood pressure, pulse, CVP and JVP)

NURSING DIAGNOSIS :

Deficient fluid volume
Altered Body Temperature
Hyperthermia

NURSING ACTION - Care Plan for Hypertermia:

Monitor body temperature
Monitor blood pressure, respiratory frequency, and pulse
Monitor intake and output every 8 hours
Encourage much to drink when there is no contraindication
Maintain adequate ventilation in the room
Give a warm compress
Use clothing that is thin and absorbs perspiration
Encourage clients to total bedrest
Monitor client's hydration status

HEALTH EDUCATION:

Teach how to properly compress
Explain the importance of fluid to maintain normal body temperature

Act of collaboration:

Maintain intravenous fluids according to program
Give antipyretics according to program
Give therapy, for the cause of fever according to program

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2011-09-10T01:03:00.000+07:00

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Ineffective Breathing Pattern Care Plan

2011-09-10T00:13:00.019+07:00

Ineffective breathing pattern

DEFINITIONS:

Inspiration and / or expiration that does not provide adequate ventilation

PURPOSE:

Addressing the problem of ineffective breathing pattern

CRITERIA:

There was no increased work of breathing
There is no use of accessory muscles / retractions and asymmetrical chest expansion
No dyspnoea and cyanosis
Blood Gas Analysis within normal limits
Vital signs within normal limits
No additional breath sounds

NURSING DIAGNOSIS INEFFECTIVE BREATHING PATTERN CARE PLAN :

Ineffective breathing pattern related to

Fatigue, changes in the ratio of O2 and CO2
Anxiety, hyperventilation, hypoventilation syndrome
Pain
Bone deformities, spinal cord injury
Neuromuscular dysfunction
Obesity

NURSING INTERVENTIONS INEFFECTIVE BREATHING PATTERN CARE PLAN

Review the causes of respiratory failure
Observations of breathing patterns
Auscultation of lung sounds periodically, note the quality of breath sounds, wheezing, expiratory lengthening and observation symmetry chest movement
Determine the location and extent of crackles in the sternum
Ensure breathing in tune with vgentilator and no resistance (Fighting)
Attach and fill the balloon with the proper ETT fixation
Have resuscitation equipment close to the client, perform manual ventilation if necessary

HEALTH EDUCATION:

Teach the client and family relaxation techniques to increase effective breathing pattern
Teach how to cough effectively
Talk about home-care plan

Act of collaboration:

Ventilator settings and adjust the ventilator pattern with the client's condition
Observation konsintrasi O2 (Fi O2) is given
Encourage deep breath through the abdomen during the period of respiratory distress
Record the pressure and the airway pressure waveform monitor
Ensure humidity and air temperature of inspiration and periodically checks
Set and check the ventilator alarm