12 Nursing Diagnosis for Diabetes Mellitus

Diabetes Mellitus

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.
www.medicinenet.com


12 Nursing Diagnosis for Diabetes Mellitus

1. Imbalanced Nutrition: Less/More than Body Requirements

2. Ineffective Tissue Perfusion: Renal, cardiopulmonary, peripheral

3. Impaired Urinary Elimination

4. Disturbed sensory perception: Visual, tactile

5. Activity Intolerance

6. Ineffective Coping

7. Sexual Dysfunction

8. Fear

9. Deficient Knowledge

10. Risk for Impaired Skin Integrity

11. Risk for Injury

12. Risk for Infection

Nursing Care Plan for Diabetes Mellitus

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6 Nursing Diagnosis and Interventions for Gastritis

Assessment - Nursing Care Plan for Gastritis:

1. Does the patient complains of heartburn, can not eat, nausea and vomiting?
2. When the occurrence of symptoms, whether before eating, after eating, after ingesting spicy foods, certain drugs or alcohol?
3. What are the symptoms associated with anxiety, Stress, allergies, eating and drinking too much or eating too fast?
4. What are the symptoms diminish or disappear?
5. Is there a history of previous gastric disease?
6. Does the patient have vomiting blood?
7. Is there any abdominal tenderness?
8. Dehydration or change in skin turgor or dry mucous membranes?

Diagnosis - Nursing Care Plan for Gastritis:

1. Acute pain
2. Imbalanced Nutrition Less Than Body Requirements
3. Hyperthermia
4. Risk for fluid volume deficit
5. Anxiety
6. Knowledge deficit

Intervention - Nursing Care Plan for Gastritis :

1. Relief of pain:

• Encourage clients to learn relaxation techniques
• Encourage clients to avoid foods and beverages that irritate the stomach, such as alcohol
• Encourage clients to use diet pd regular intervals.

2. Maintaining adequate nutrition remains

• Provide eat small but frequent meals and do not irritate.
• Give solid foods as soon as possible
• Provide a drink that contains no caffeine

3. Hyperthermia

• Monitor vital signs every 2 hours
• Apply a cold compress
• Management of giving antipyretics as indicated

4. Maintain body fluid volume

• Observation of fluid intake and output
• Observe for signs of dehydration

5. Reduce anxiety

• Encourage clients to express their problems and fears
• Help clients identify situations that cause anxiety
• Teach stress management strategies

6. Increase the client's knowledge about the disease

• Assess client's level of knowledge
• Provide the required information by using the right words and the corresponding time
• Reassure the client that the disease can be overcome.

6 Nursing Diagnosis and Interventions for Gastritis

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Gastritis - Imbalanced Nutrition Less Than Body Requirements

Nursing Diagnosis for Gastritis Imbalanced Nutrition Less Than Body Requirements related to anorexia, vomiting

Nursing Interventions for Gastritis:

1. Allow clients to choose foods (low-calorie foods are not allowed)
2. Make mealtime structure with a time limit (eg 40 minutes)
3. Eliminate distractions (eg conversation, watching television) during the meal.
4. Specify the time to eat, serve food, and eating time limit; inform the client that if the food is not eaten during the time that has been provided, will be the replacement of other feeding methods.
5. When food is not eaten, do feeding through a tube, NGT to order.
6. Perform a replacement feeding method each time the client refuses to eat by mouth.
7. Keep your attention during the meal if the client refuses to eat.
8. Reduce attention while eating.

Behavior Modification Therapy

1. Clients achieve increased body weight every day because of the desire of the client.
2. Separation from family for some time would be very helpful.
3. Switch on a fun activity.
4. Nursing interventions are technical limitations.
5. Social isolation.
6. Useful communication.
7. Give the award to the client only when he is likely to gain weight.
8. Consistent action should be maintained.
9. Each staff member must have a final report per shift on a decision
10. Measure weight accurately;

Expected outcome:

1. Clients indicate hydration, necessary to adequately.
2. Balance between inputs and outputs.

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Acute Lymphocytic Leukemia - Risk for Infection Nursing Diagnosis and Interventions

Acute lymphocytic leukemia (ALL) is a fast-growing cancer of a type of white blood cells called lymphocytes. These cells are found in the bone marrow and other parts of the body.

Acute lymphocytic leukemia (ALL) makes you more likely to bleed and develop infections. Symptoms include:

• Bone and joint pain
• Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
• Feeling weak or tired
• Fever
• Loss of appetite and weight loss
• Paleness
• Pain or feeling of fullness below the ribs
• Pinpoint red spots on the skin (petechiae)
• Swollen glands (lymphadenopathy) in the neck, under arms, and groin
• Night sweats

Note: These symptoms can occur with other conditions. Talk to your doctor about the meaning of your specific symptoms.www.nlm.nih.gov

Nursing Diagnosis for Acute Lymphocytic Leukemia : Risk for Infection related to changes in maturity of red blood cells, increased number of immature lymphocytes, immunosuppression

Goal : no infection.

Expected outcomes are:
Clients will:

• Identify the risk factors that can be reduced
• State the signs and symptoms of early infection
• No signs of infection

Nursing Interventions Acute Lymphocytic Leukemia : Risk for Infection

1. Take action to prevent exposure to known or potential sources of infection:

• Keep the protective insulation, according to institutional policy
• Maintain a careful hand washing technique
• Give good hygiene
• Limit visitors who were fever, flu or infections
• Give two times daily perianal hygiene and each bowel movement
• Limit fresh flowers and fresh vegetables
• Use the oral care protocol
• Hospitalized with neutropenic clients first.

Rational: Vigilance, minimizing client exposure to bacteria, viruses, and fungal pathogens either endogenous or exogenous.

2. Report if there are changes in vital signs
Rationale: Changes in vital signs is an early sign of sepsis, especially if there is an increase in body temperature.

3. Get culture of sputum, urine, diarrhea, abnormal blood and body secretions as recommended
Rational: The culture can confirm infection and identify the causative organism.

4. Explain the reasons for vigilance and abstinence
Rational: The culture can confirm infection and identify the causative organism.

5. Reassure the client and his family that the increased susceptibility to infection while only
Rational: granulocytopenia may persist 6-12 weeks. The notion of a temporary nature can help prevent anxiety granulocytopenia clients and their families

6. Minimize invasive procedures
Rational: certain procedures may cause tissue trauma, increased susceptibility of infection.

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Mesothelioma Prevention and Risk Factors

Mesothelioma is a rare form of cancer that occurs in the thin tissue that lines most of the internal organs. Asbestos is the cause of about 90 percent of all mesothelioma cases. Asbestos is a mineral found in the neighborhood. Asbestos fibers are strong and resistant to heat makes it very useful to be applied to a variety of needs. People who work in environments polluted many asbestos fibers have a greater risk of exposure mesothelioma.

When asbestos split, asbestos dust is formed. If dust is inhaled or swallowed asbestos fibers will then settle in the lungs or in the stomach and can cause irritation that causes mesothelioma.

Some people who over many years exposed to asbestos pollution can not have mesothelioma, while others the opposite. This indicates that other factors may be related, namely the hereditary factors do you have a family history of cancer in some people is a condition that increases the risk.

Mesothelioma Prevention and Risk Factors

Many people who experienced mesothelioma exposed to asbestos fibers while working at places such as:
• Mine
• Factory worker
• Manufacturing of electronic components
• Construction of rail
• Shipbuilding
• Construction workers
• Mechanics

Prevention :
• Beware if you work in an environment with asbestos
• Follow standard safety regulations
• Do not use objects that contain asbestos in your neighborhood

Risk factors that may increase the risk of mesothelioma such as:
• Exposure to asbestos fiber dust pollution
• Living with someone who works in an environment with asbestos (the asbestos fibers are attached to their clothing or skin)
• Smoking
• SV40 virus is found in many primates
• X-ray radiation
• Family history with mesothelioma

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Schizophrenia Mental Health Diagnosis And Daily Functioning

People are generally afraid of the idea of schizophrenia and there are a lot of misconceptions. There are over two million Americans with this mental illness and a number of medications to help treat it. It often can appear in the late teens or twenties for individuals and is very difficult for the whole family as well as the individual that suffers from it.

There is a beautiful video by Jill Taylor who discusses her own stroke as well as her interest in becoming a brain researcher in order to understand schizophrenia due to her brother's diagnosis with this illness. She is an innovator in understanding the way the brain and mind function.


Symptoms can include confusion, delusions and hallucinations. There can be isolating tendencies and withdrawal habits from others.Depression and anxiety may be quite high and it is easy to get overwhelmed. Cognitive problems can manifest in the areas of decision making, attention and the capacity to learn. Delusions can be chronic and one may think that an electronic gadget is communicating with them through waves or that they are constantly being watched by someone. It is painful to see someone shaping their behavior based on delusions that dominate the mind. Some people with medication are able to lessen these disturbing thoughts and not believe them to the degree that they had in the past.

Sometimes people with this diagnosis can show little affect and have a type of flat tone with little excitement. Dr. Laing worked with schizophrenics in the UK and had a radical approach with this population. He saw many aspects of our society and environment as insane and that believed it could be worked with as a journey into the inner self. His views were seen as controversial but many in the seventies appreciated his spiritual and existential approach to this problem. He saw the patient is resorting to this behavior as a coping mechanism and that it grew from an inner despair.

Most people with schizophrenia are not able to work and many qualify for disability in the United States. The intrusion of audio or visual hallucinations, problematical thought patterns and mood liability makes daily functioning a challenge and work responsibilities can often be impossible to sustain with any regularity. There have been many advances in medications and counseling is often used to help identify underlying triggers. Family support is important and there may also be hospitalizations required when symptoms are intense or there is lack of medication compliance.

Source : http://www.copyandpastearticles.com/

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Impaired Gas Exchange NANDA NOC NIC

Impaired Gas Exchange NANDA : NOC, NIC

Impaired Gas Exchange Definition: Excess or lack of oxygenation and or removal of carbon dioxide in the alveolar capillary membrane.

Defining characteristics:

• Impaired vision
• Reduction in CO2
• Tachycardia
• Hypercapnia
• Fatigue
• Somnolence
• Irritability
• Hypoxia
• Confusion
• Dyspnoe
• Nasal pharyngeal
• Normal blood gas analyzer
• Cyanosis
• Abnormal skin color (white, black)
• Hypoxemia
• Hypercarbia
• Headache when waking
• Abnormal breathing frequency and depth

Related factors:

• Ventilation perfusion imbalance
• Alveolar-capillary membrane changes

NOC:

• Respiratory Status: Gas exchange
• Respiratory Status: Ventilation
• Vital Sign Status

Results Criteria:

• Demonstrate improved ventilation and adequate oxygenation
• Maintain cleanliness of the lungs and free of signs of respiratory distress
• Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
• Vital signs within normal range

NIC:
1. Airway Management

• Open the airway, using chin lift technique or jaw thrust if necessary
• Position the patient to maximize ventilation
• Identification of patients need the installation of an artificial airway device
• Replace the mayo if necessary
• Perform chest physiotherapy if necessary
• Remove secretions by coughing or suctioning
• Auscultation of breath sounds, record the presence of additional noise
• Do the suction on the mayo
• Give bronchodilators if necessary
• Give your humidifier
• Adjust fluid intake to optimize the balance
• Monitor respiration and oxygen status

2. Respiratory Monitoring

• Monitor on average, the depth, rhythm and respiratory effort
• Note the movement of the chest, observe the symmetry, the use of additional muscle, supraclavicular and intercostal muscle retraction
• Monitor breath sounds, such as snoring
• Monitor breathing patterns: bradipena, takipenia, Kussmaul, hyperventilation, Cheyne stokes, Biot
• Note the location of the trachea
• Diagfragma monitor muscle fatigue (paradoxical movement)
• Auscultation of breath sounds, noting areas of decreased / no ventilation and additional sound
• Determine the need for suction by mengauskultasi crakles and ronkhi main airway
• Auscultation of lung sounds after the action for the results.

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Anxiety NIC NOC

Anxiety related to lack of knowledge and hospitalization

Definition:
Unexplained anxiety or fear of discomfort accompanied by autonomic responses (non-specific sources or not known by the individual); feelings of concern because of the anticipation of danger. This is a warning signal of a threat that will come and allow individuals to take action to approve the actions.


Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks.

Characterized by:

• restless
• insomnia
• restless
• fear
• sad
• Focus on self
• concerns
• anxious

NOC:

• Anxiety control
• coping

Expected outcomes are:

• Clients are able to identify and express symptoms of anxiety
• Identify, disclose and demonstrate techniques for controlling anxiety
• Vital signs within normal limits
• Posture, facial expressions, body language and activity levels showed reduced anxiety

NIC:

• Anxiety Reduction (decreased anxiety)
• Use a calm approach
• Clearly the hope of the offender patients
• Explain all procedures and what is felt during the procedure
• Accompany the patient to provide security and reduce fear
• Give factual information about the diagnosis, prognosis action
• Encourage the family to accompany the child
• Do a back / neck rub
• Listen attentively
• Identification of the level of anxiety
• Help the patient recognize situations that cause anxiety
• Encourage patients to express their feelings, fears, perceptions
• Instruct the patient to use relaxation techniques
• Give medications to relieve anxiety

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Activity Intolerance related to Fatigue

Activity intolerance related to fatigue

Definition: Insufficient physiological or psychological energy to continue or complete the requested activity or daily activities.

Defining characteristics:

• Verbal report of fatigue or weakness.
• Abnormal response of blood pressure or pulse of activity
• ECG changes indicating ischemia or arrhythmia
• Presence of dyspnea or discomfort on exertion.

Related factors:

• Bed rest or immobilization Baring
• Overall weakness
• Imbalance between oxygen suplei needs
• Lifestyle is maintained.

NOC:

• Energy conservation
• Self Care: ADLs

Expected Result:
Participate in physical activity without an accompanying increase in blood pressure, pulse and respiration
Able to perform daily activities (ADLs) independently

NIC:

Energy Management

• Observation of client restrictions in activities
• Encourage the child to express feelings of limitations
• Assess the factors that cause fatigue
• Monitor nutrition and adequate sources of energy
• Monitor the patient's physical and emotional exhaustion are excessive
• Monitor cardiovascular response to activity
• Monitor sleep patterns and duration of sleep / rest patients

Activity Therapy

• Collaborate with the Medical Rehabilitation Workers dalammerencanakan progran appropriate therapy.
• Help clients to identify activities that can be done
• Helps to choose activities consistent with the ability yangsesuai physical, psychological and social
• Helps to identify and obtain resources needed for the desired activity
• Mendpatkan auxiliary aids for activities such as wheelchairs, crick
• Bantu untu identify a preferred activity
• Help clients to exercise their free time schedule
• Help the patient / family to identify deficiencies in the activity
• Provide positive reinforcement for active move
• Help the patient to develop self-motivation and reinforcement
• Monitor physical response, EMOI, social and spiritual

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Nursing Interventions for Typhoid Fever

Nursing Interventions Nursing care Plan for Typhoid Fever

Typhoid fever is a generalized disease caused by bacteria called E. typhosa. This disease is primarily associated with poor hygiene and is more common in areas with poor sanitation. It is transmitted by water, milk and contaminated food. About 3% of patients who have it become carriers; that is, they harbor the virulent germs in their bodies and contaminate food, water and even articles they touch.

Typhoid Fever is caused by the bacteria species known as Salmonella enterica. These bacteria are transmitted into the victim through contaminated water in most cases of infection. If the water or even food contaminated with fecal wastes from an infected person is consumed by a person, he or she could get infected with the typhoid bacteria found in the feces.

Symptoms:
The first symptoms of typhoid are much like influenza. Fever, headache, back-ache, loss of appetite, chilliness with occasional nose-bleed, diarrhea or constipation are the common complaints. When these conditions continue for a length of time typhoid is suspected. The temperature gradually gets higher and higher, often reaching 104 F. The pulse, which usually is accelerated by increased temperature, is exceptionally slow. During the first week or ten days the temperature climbs and holds steady for another equal period, and then gradually falls to normal by the end of the fourth week. The actual diagnosis is made by laboratory study of the blood, urine and stool.

Nursing Interventions for Typhoid Fever

1. Maintain the temperature within normal limits

• Review knowledge of the client and family about hyperthermia.
• Observations of temperature, pulse, blood pressure, respiration.
• Give drink enough
• Provision of anti-pyrexia
• Parenteral fluids (IV) is adequate

2. Improve nutrition and fluid

• Assess the nutritional status of children.
• Allow the child to eat foods that can be tolerated,
• Plan to improve the nutritional quality at the child's appetite increases.
• Give the food is accompanied by a nutritional supplement to improve the quality of nutritional intake.
• Advised the parents to provide food with a small portion technique, but often.
• Measure weight every day at the same time, and with the same scale.
• Maintaining a child's oral hygiene.
• Explain the importance of adequate intake of nutrients for healing diseases.
• Collaboration for parenteral feeding through feeding through oral if you do not meet the nutritional needs of children

3. Prevent the lack of fluid volume

• Observation of vital signs (body temperature) at least every 4 hours
• Monitor the increasing signs of dehydration: inelastic turgor, sunken fontanel, decreased urine production, mucosal memberan dry, chapped lips
• Observe and record the weight at the same time and with the same scale.
• Monitor the provision of intravenous fluids per hour.
• Reduce the loss of fluid that is not visible (Insensible Water Loss / IWL) to give a cold compress or a tepid sponge.
• Give antibiotics as a program

DISCHARGE PLANNING

1. Patients should be reassured wash hands with soap after defecation.
2. They are known as a career to manage food avoided
3. Flies have prevented food and drink descend.
4. Patients need a break. Diet software that does not stimulate and low in fiber.
5. Provide information about the need conduct activities in accordance with the developmental level and physical condition of children.
6. Describe a given therapy: dosage, and side effects.
7. Explaining the symptoms of disease recurrence and things to be done to address these symptoms.
8. Emphasize the appropriate time to perform the specified control.

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Nursing Management of Hypertension

Hypertension management aims to prevent morbidity and mortality from cardiovascular complications associated with the achievement and maintenance of blood pressure below 140/90 mmHg.

Nursing Management of Hypertension

Without drug therapy

Without drug therapy, are used as measures for mild hypertension and as a supportive action in moderate and severe hypertension. Without drug therapy include:

Diet

The recommended diet for people with hypertension are:

• Moderate salt restriction of 10 g / day to 5 g / day
• Diets low in cholesterol and low saturated fatty acid
• Weight loss
• Decrease in ethanol intake
• Stop smoking
• Diets high in potassium

Physical Exercise
Physical exercise or sports are organized and directed that recommended for patients with hypertension is a sport that has four principles:

• Various forms of exercise that is isotonic and dynamic as running, jogging, cycling, swimming etc.
• A good exercise intensities between 60-80% of aerobic capacity or 72-87% of maximum pulse rate, called the exercise zone. Maximum pulse rate can be determined by the formula 220 - age.
• The duration of training ranged from 20-25 minutes in the training zone
• Training frequency should be 3 x per week, and most preferably 5 x per week.

Psychological Education
Provision of psychological education for hypertensive patients include:
1. Biofeedback techniques
Biofeedback is a technique used to show the signs on the subject of a state body that is consciously by the subjects considered normal.
The application of biofeedback is mainly used to cope with somatic disorders such as headaches and migraines, as well as for psychological disorders such as anxiety and tension.

2. Relaxation techniques
Relaxation is a procedure or technique that aims to reduce tension or anxiety, by training people to be able to learn to make the muscles in the body become relaxed

Health Education (Counseling)
The purpose of health education is to improve patients' knowledge about hypertension and its management so that patients can maintain life and prevent further complications.

Risk for Decreased Cardiac Output related to Hypertension
 
Pathophysiology of Hypertension

Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions

Nursing Care Plan for Hypertension in Pregnancy

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Prevent and Treat a Productive Cough

Coughing is a natural process that is important to keep the throat and airways clear. On a productive cough or cough with phlegm, a person suffering may have complaints, such as the discomfort caused by phlegm in the respiratory ropes and breathing difficulty that often leads to stress. Most people always assume cough is a mild disease that can heal itself. Nevertheless, it is not impossible cough that lasts longer than a very disturbing and annoying and can even be transmitted, can also cause secondary infection of the respiratory tract.

The cause of the cough is due to stimulation of infection varies among which include inflammation of the lining mucosa / mucus in respiratory tract diseases such as influenza, bronchitis caused by bacteria or viruses, and excessive smoking. Due to mechanical stimulation caused by the entry of small particles such as dust particle, or due to suppression / voltage respiratory tract such as tumor suppression, decreased elasticity of lung tissue caused by abdominal tissue, or pulmonary edema / fluid in the lungs.

As a result of chemical stimuli into a gas that is irritant such as cigarette smoke or chemical gases. The most common cause of cough is an infection / inflammation of the respiratory tract due to viral or bacterial microorganisms. Coughing is usually accompanied by a runny nose, and nasal congestion. Coughing is allowed to drag on without an action can lead to complications. Complications of cough is composed of three kinds, namely a sudden attack that can cause syncope (fainting / loss of consciousness while), coughing very strong or intense can cause rupture of the alveoli (air cavities) in the lung and broken ribs. To that end before the cough becomes more dangerous need for prevention efforts and efforts to overcome them.

Here are some ways to Prevent and Treat a Productive Cough :

1. Drink water at least 8 glasses a day to thin mucus.

2. Bath of warm water will help thin phlegm / mucus so it is more easily removed.

3. Avoid alcohol or caffeine consumption may increase the frequency of urination, so multiply the discharge of bodily fluids. Body fluids is necessary to keep the phlegm / mucus remains weak.

4. Quitting smoking, avoiding exposure to dust, the environment is too dry or too cold.

5. Keep the body warm, and adequate rest.

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Benefits of Exercising at Night

It's hard to get up early or do not have time to exercise in the morning? Take the time to exercise in the afternoon or evening, after work. Several studies have shown that exercise in the morning to burn calories more effectively than the afternoon or evening. But, there are four benefits you get if you close the day with exercise.

Here are some of the Benefits of Exercising at Night :

Sleep more soundly
If you include people who actually have more energy at night, just do exercises at home, or cardio exercise with a treadmill. So also when it is difficult to sleep. Exercise will make you sleep easier and when you wake up refreshed in the morning.

Reduce levels of stress after work
Piles of work and deadlines are always stressful. Exercise is the best way to reduce stress levels. So, after a weary work, turn your mind to focus your energy to exercise.

More consistent
Have tried to exercise the morning but could not be consistent? Try to change the sport. With exercise the right time and make you comfortable, exercise also tend to be done more consistently.

Healthy choices and saving
Aerobics class or dancing after work, is the right choice and healthy. It keeps you distracted from the activity that it is not healthy. Like, have a drink, dinner out, or watch television for hours after work.

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Nursing Care Plan for Varicella Zoster virus

Assessment for Varicella Zoster virus

• Subjective symptoms: complaints of headache, anorexia and malese.
• On the skin and mucous membrane: lesions in various stages of development: from erythematous macules that appear for 4-5 days and then quickly become vesicles and crusting that began in the body and spread sentrifubal prominent and extremities. Lesions may also occur in the mucosa, palate and konjunctiva.
• Temperature: fever may occur between 38-39 C

Nursing Diagnosis for Varicella Zoster virus

1. Impaired skin integrity related to trauma

2. Acute pain related to damage to the skin / tissue

3. Risk for Infection related to damage skin protection

4. Knowledge deficient related to incorrect interpretation of information


Nursing interventions for Varicella Zoster virus

DX 1

Impaired skin integrity related to trauma

Intervention:

• Encourage regular bathing
• Avoid scratching the lesions
• Use a soft clothes

DX2

Acute pain related to damage to the skin / tissue

Intervention:

• Use a powder analgesic and anti-pruritic.
• Keep the room temperature is still cool with adequate moisture.

DX3

Risk for Infection related to damage skin protection

Intervention:

• Perform isolation (strict isolation):

Strict isolation procedures:

• Single room: the door should always be closed. Clients who become infected by the same organism can be placed in the same room.
• Use masks, special clothing, and gloves for all those who come into the room.
• Always wash your hands after touching the client or objects that may be contaminated, and before giving the action to other clients.
• All contaminated items disposed of or put into a special place and labeled prior to decontamination or reprocessed back

DX4

Knowledge deficient related to incorrect interpretation of information

• Teach the parents in the treatment of children in ruamah on things above.
• Explain that fever d apat treated with tepid sponge bath did.
• Explain that the use of medication must be in accordance with doctor's instructions.

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Menstrual Pain / Dysmenorrhea Symptoms, Causes and Treatment

Menstrual Pain

For some women, menstruation sometimes create anxiety arises when the unspeakable pain when menstruation comes. This condition is known as "menstrual pain" or dysmenorrhea, namely "menstrual pain" that forced her to break or result in decreased performance and reduced daily activities.

The incidence (prevalence) Menstrual pain ranged 45-95% (USA, November 2006) among women of childbearing age. Although generally harmless, but often disturbing for women who experience it. Degree of pain and interference levels are not necessarily the same for every woman. There are still able to work (occasional grimace), those that could not move because of pain.

By type, dysmenorrhea consists of:

1.  Primary dysmenorrhea, (also called dysmenorrhea idiopathic, essential, intrinsic) is menstrual pain without abnormalities of the reproductive organs (without gynecologic disorders).
2.  Secondary dysmenorrhea, (also known as dysmenorrhea extrinsic, acquired) is menstrual pain that occurs because of gynecologic disorders, such as endometriosis (mostly), fibroids, adenomyosis.

Primary Dysmenorrhea Symptoms:

• There was a time or 6-12 months after the first menstruation (menarche)
• The pain arising prior to menstruation, or at the beginning of menstruation. Lasted several hours, but sometimes several days.
• The coming pain: intermittent, stabbing. Generally in the lower abdomen, sometimes spreading to surrounding areas (hips, quads)
• Occasionally accompanied by nausea, vomiting, headache, diarrhea. (Sssttt, sometimes ngamukan also know)

Causes

The exact cause of primary dysmenorrhea has yet clearly known (idiopathic), but several factors identified as triggers of Painful menstruation, including:

• Psychological factors. Women who are not emotionally stable (easily anxious), more prone to menstrual pain.
• Endocrine factors. Presumably because the onset of menstrual pain contractions of the womb (uterus) is excessive.
• Prostaglandin factors. This theory states that menstrual pain arises due to the increased production of prostaglandins (the lining of the uterus) during menstruation. This assumption underlies the antiprostaglandin treatment to relieve menstrual pain.

Treatment

The women who used to have menstrual pain in general already know the initial action when it comes menstrual pain. In fact rarely able to treat themselves based on experience during doctor visits. The most important thing to remember is the understanding that primary dysmenorrhea is not dangerous.

Hormonal drugs. Hormonal treatment with drugs intended to suppress ovulation and its use only on the advice of a doctor.

In addition, if the pain feels very annoying, you should rest and can also use compresses (warm) to reduce pain.

The medical action of a specific nature is the last option is based on the results of examination by the obstetrician.

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Orchitis - Causes, Symptoms and Treatment

 Orchitis

Orchitis is an infection of one or both testes (testicles).

Causes of Orchitis, among others:

• Some diseases associated with mumps orchitis (mumps, parotitis). Mentioned that 30% of patients may experience Mumps Orchitis on day 4 to day 7. This occurs because the propagation of infection through the lymph flow.
• Other viruses such as coxsackievirus berbungan with Orchitis, varicella, and echovirus.
• Bacteria. Orchitis by the spread of bacteria in general is epididymitis, which is infection of the epididymis (the sperm ducts are attached at the top of the testes). Infection by bacteria may also occur without an infection of the epididymis. Orchitis-causing germs such as Neisseria gonorrhoeae, Chlamydia trachomatis, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus and Streptococcus

Symptoms of Orchitis

Complaints and symptoms in patients Orchitis, among others:

• Swelling in one or both testicles, with a reddish color.
• Pain, mild to very painful. Sometimes feel pain spreading to the lower abdomen. Kesenggol little pain is just unbearable.
• Fever, chills.
• Occasionally accompanied by muscle pain, weakness, nausea, headaches.

On examination of the testes appear enlarged, soft (sometimes hardened), red, enlarged epididymis (curved bump formed on the testis), scrotal skin to stretch.

Treatment of Orchitis

Basically, treatment is based on the cause. If the suspected cause is a virus, medication with symptomatic medications (to relieve complaints), ie, fever and pain relief medication (non-steroidal anti-inflammatory drugs).

Meanwhile, if suspected because of germs, it needs antibiotics for at least 7-14 days.

In addition, to reduce complaints recommended:

• Rest. (Except for the light and at ease pain)
• Avoid tight pants and panties.
• Avoid excessive activity.

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Nursing Diagnosis and Interventions for Sinusitis

Nursing Diagnosis for Sinusitis

1 Acute Pain: head, throat, sinus related to inflammation of the nose

Goal : Pain is reduced or lost

Expected outcomes are:

• Clients express the pain diminished or disappeared
• Clients do not grimace in pain

Interventions:
1. Assess client's level of pain
R :/ Knowing the client's level of pain in determining further action

2. Explain the causes and effects of pain on the client and family
R :/ With the causes and consequences of pain the client is expected to participate in treatment to reduce pain

3. Teach relaxation techniques and distractions
R :/ The client knows the distraction and relaxation techniques can be practiced so as if in pain

4. Observation of vital signs and client complaints
R :/ Knowing the general state and development of the client's condition.


2. Anxiety related to lack of client knowledge about diseases and medical procedures (sinus irrigation / operation)

Goal: Anxiety is reduced / lost

Expected outcomes are:

• Clients will describe the level of anxiety and coping patterns.
• The client knows and understands about his illness and its treatment.

Interventions:
1. Assess client's level of anxiety
R :/ Determining the next action

2. Give comfort and ketentaman on the client:

• Show empathy (it comes with a touch client)

R :/ Facilitate client's receipt of the information provided

3. Give an explanation to clients about the illness slowly, quietly and use of clear sentences, short easy to understand
R :/ Increase client understanding about the disease and therapies for the disease so that the client more cooperative

4. Get rid of excessive stimulation such as:

• Place the room quieter client
• Limit contact with others / other clients are likely to experience anxiety

R :/ By removing the stimulus that will enhance the peace of the client concerned.

3. Ineffective Airway Clearance related to the obstruction (nasal secret buildup) secondary to inflammation of the sinuses

Goal: Effective airway, after a secret (seous, purulent) issued

Expected outcomes are:

• Clients no longer breathe through the mouth
• Airway back to normal, especially the nose

Interventions:
1. Assess the existing build-secret
R :/ Knowing the severity and subsequent action

2. Observation of vital signs
R :/ Knowing the client's development prior to surgery

3. Collaboration with the medical team for cleaning discharge
R :/ cooperation to eliminate the buildup of secret / problem

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Pediatric Nursing Care Plan for Diaper Rash

Pediatric Nursing Care Plan for Diaper Rash 

Definition of Diaper Rash

Diaper rash is a skin irritation on baby's buttocks area. This can happen if the diaper is wet, too late to be replaced, the diaper is too coarse and does not absorb sweat, fungal or bacterial infections or even eczema

Diaper rash is a skin problem in genital area is characterized by the emergence of baby patches of red skin, usually occurs in babies who have sensitive skin and prone to irritation. These spots will disappear within a few days when washed with warm water, and spread with a special lotion or diaper rash cream, diapers, or by removing some of the time.

Diaper rash is a common disorder found in infants. This disorder is a lot of babies aged less than 15 months, especially in the age range of 8-10 months.

Etiology of Diaper Rash

Rashes caused by roseola and erythema infectiosum (fith disease) is not harmful and usually subside without treatment. The rash caused by measles, rubella, and chickenpox become common for children to get the vaccine.

Some of the factors causing diaper rash (diaper rash, diaper dermatitis, napkin dermatitis), among others:

• Irritation or friction between the skin with diaper.
• Humidity factor.
• Lack of maintaining hygiene. infrequently changed diapers too long or not be replaced after a pee or have a bowel (feces).
• Infection of micro-organisms (mainly fungi and bacterial infections)
• Allergy diaper material.
• Disorders of sweat glands in the diaper-covered area.

Clinical Symptoms of Diaper Rash

Symptoms include red rash or blisters on the skin in the diaper area covered. In addition, the baby usually looks fussy, especially when replacing the diaper. Babies may also cry when the skin in the diaper area covered is washed or touched.
There are patches of redness on the buttocks due to irritation of the diaper.

Treatment of Diaper Rash

1. Frequently change the diaper. Do not let the diaper was wet, because it holds a lot of urine for long wear baby. Prolonged contact of urine or feces by the baby's skin can cause diaper rash.
2. When cleaning your baby, pat the area normally covered with diapers (buttocks, thighs, groin, and genital area of ​​a baby) gently with a clean towel. Try to avoid rubbing the area hard.
3. Occasionally let the baby butt is open (no diaper) for a while. This may be useful to keep the diaper area dry and clean.
4. Be careful in choosing diapers, because some types of diapers, diaper rash can be stimulating. If that happens, change the diapers of other brands that are more suitable.
5. If your baby is wearing cloth diapers are used repeatedly, wash the cloth diapers to detergent formula is not too hard. Avoid using fabric softener, because the perfume in softener can irritate baby's skin. Be sure to rinse well so that the diaper detergent is left in the diaper.
6. Avoid installing the diaper is too strong. Keep the diaper with no space between the baby's skin.

Pediatric Nursing Care Plan for Diaper Rash

Assessment for Diaper Rash

The identity of the patient and family, the pattern of sensory, physical examination (general health status, head to toe examination, investigation), checking vital signs and history of drug use.

Nursing Diagnosis for Diaper Rash

Impaired Physical Mobility related to decubitus

Risk for Infection related to incontinensia

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Nursing Care Plan for Decubitus Ulcer

Definition of Decubitus Ulcer

Decubitus ulcer is damage or death of tissue under the skin until the skin even through the muscle to the bone, because of the emphasis on an area on an ongoing basis, resulting in impaired blood circulation.

Decubitus ulcers are ulcers that result from the strong pressure by the weight on the bed.

Etiology

1. Pressure
2. Humidity
3. Friction

Pathophysiology

Pressure immobilization a long time, will result in pressure sores, if one part of the body is on a gradient (the difference between the two pressure points). Deeper tissue near the bone, especially muscle tissue with good blood supply will shift towards a lower gradient, while the skin is maintained at the contact surface by increasing friction with the presence of moisture, this situation led to stretching and angulation of blood vessels (micro circulation) in blood and tissue shear forces experienced in, it will be able to experience ischemia and necrosis before moving on to the skin.

Clinical Manifestations and Complications

1. Initial injury is a sign of redness that does not disappear when pressed thumb.
2. On a more serious injury encountered skin ulcers.
3. Can arise pain and signs of systemic inflammation, including fever and increased white blood cell count.
4. Infection can occur as a result of weakness and hospitalization is prolonged even in a small ulcer.

Diagnostic Examination

1. Culture: artificial growth of microorganisms or tissue cells.
2. Serum albumin: a major protein in plasma and other serous fluids.

Medical Management

1. Changing the position of the patient who is bed rest.
2. Relieving pressure on the skin reddened and placement of the pads are clean and thin when they have been shaped decubitus ulcers.
3. Systemic: broad-spectrum antibiotic

Nursing Care Plan for Decubitus Ulcer

Assessment - Nursing Care Plan for Decubitus Ulcer

a) Activity / rest
Signs: decreased strength, endurance, limited range of motion in the area of ​​pain disorders, such as muscle buds change.

b) Circulation
Signs: hypoxia, decreased peripheral pulses distal to the injured limb, general peripheral vasoconstriction with loss of pulse, white and cold, the formation of tissue edema.

c) elimination
Signs: decreased urine output is the absence of the emergency phase, the color may be reddish black, in the event, identify potentially damage the muscle.

d) Food / fluid
Signs: tissue edema, anorexia, nausea and vomiting.

e) Neuro-sensory
Symptoms: The area of ​​numbness / tingling

f) Respiratory
Symptoms: decreased function of the spinal cord, cord edema, neurologic damage, abdominal and respiratory muscle paralysis.

g) The integrity of the ego
Symptoms: family problems, employment, finances, disability.
Signs: anxiety, crying, dependency, self mmenarik, angry.

h) Security
Signs: a fracture due to location (fall, accident, tetanik muscle contraction, up to an electric shock).

Nursing Diagnosis - Nursing Care Plan for Decubitus Ulcer

1.Impaired Skin Integrity related to tissue destruction secondary to mechanical pressure, friction and factions.

2.Impaired Physical Mobility related to restriction of movement required, the conditioned status, loss of motor control due to changes in mental status.

3. Imbalanced Nutrition Less Than Body Requirements related to the inability of oral intake.

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Impaired Skin Integrity - Nursing Diagnosis Interventions for Marasmus

Marasmus is a form of protein deficiency which can cause fatigue, wasting of the muscles, low energy levels and weight loss. Like kwashiorkor, it can also weaken the immune system and increase the risk of infection amongst sufferers.

Marasmus can occur at any age, but that is often found in infants who are not getting enough milk and are not fed often attacked his successor or diarrhea. Marasmus may also occur due to various other diseases such as infections, gastrointestinal disorders or congenital heart disease, malabsorption, metabolic disorders, chronic kidney disease and disorders of the central nervous

The main causes of marasmus are less calorie protein that may occur due to: insufficient diet, eating habits are not exactly like the parent-child relationship with a disturbed, because of metabolic disorders, or congenital malformations. (Nelson, 1999).



Nursing Diagnosis Impaired Skin Integrity related to changes in nutritional status.

NOC: Tissue Integrity: Skin and mucous membranes.

Expected outcomes are:

1. A good skin integrity can be maintained.
2. No injuries / lesions on the skin.
3. Good tissue perfusion.
4. Show understanding of the process of skin repair and prevent recurring injury.
5. . Able to protect skin and keep skin moist and natural treatments.

Rating Scale:

1. do not ever show
2. rarely show
3. sometimes shows
4. often show
5. always show

NIC: Tissue Integrity: Skin and mucous.
Nursing Interventions - Impaired Skin Integrity for Marasmus

1. Monitor the skin will turn pink.
2. Apply lotion to a depressed area.
3. Mobilization of the patient every 2 hours.
4. Keep your skin clean and dry to keep them clean.

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3 Nursing Diagnosis Interventions for Hemophilia

Nursing Diagnosis and Nursing Interventions for Hemophilia

1. Nursing Diagnosis: Ineffective Tissue Perfusion related to active bleeding
characterized by decreased consciousness, bleeding.

Objectives / Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved

Nursing Interventions

1. Assess the cause of bleeding
2. Assess skin color, hematoma, cyanosis
3. Collaboration in the provision of adequate IVFD
4. Collaboration in the provision of blood transfusion.

Rational:

1. By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
2. Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
3. Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
4. Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion.

2. Nursing Diagnosis: Deficient Fluid volume related to loss due to bleeding
characterized by: a dry oral mucosa, skin turgor is slow again.

Objectives / Expected outcomes: Indicates repairs fluid balance, moist oral mucosa, skin turgor quickly returned less than 2 seconds

Nursing Interventions:

1. Monitor vital signs
2. Monitor output and income
3. Estimate the wound drainage and the loss of a visible
4. Collaboration in the provision of adequate fluid

Rational

1. Changes in vital signs may indicate the direction of abnormal fluid loss due to an increase in bleeding / dehydration
2. Need to determine kidney function, fluid replacement needs and to help evaluate the fluid status
3. Provide information about the degree of hypovolemia and help determine intervention
4. Maintain fluid balance due to bleeding

3. Nursing Diagnosis : Risk for Injury related to weakness of the defense secondary to hemophilia
characterized by frequent injuries

Objectives / Expected outcomes: injury and complications can be avoided / did not happen.

Nursing Interventions

1. Maintain security of client's bed, put a safety on the bed
2. Avoid injury, light - weight
3. Keep an eye on every move that allows the occurrence of injury
4. Encourage the parents to bring children to the hospital immediately in case of injury
5. Explain to parents the importance of avoiding injury.

Rational

1. Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma
2. Patients with hemophilia are at risk of spontaneous bleeding was controlled so that the required monitoring every move that allows the occurrence of injury
3. Early identification and treatment can limit the severity of complications
4. Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications.
5. Lower the risk of injury / trauma.

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Assessment, Physical Examination and Nursing Care Plan for Hemophilia

Hemophilia

Hemophilia is a bleeding disorder caused by deficiency and hereditary factors essential for blood coagulation (Wong, 2003).

Hemophilia is a congenital blood clotting disease caused by deficiency of blood clotting factors, ie factor VIII and factor IX. Factor VIII and factor IX is a plasma protein that is a component needed for blood clotting, these factors are required for fibrin clot formation in the area of ​​trauma. (Hidayat, 2006).

Hemophilia is a congenital coagulation disorders the most frequent and serious. The disorder is associated with a deficiency of factor VIII, IX or XI is determined genetically (Nelson, 1999).

Hemophilia is a hereditary or acquired coagulation disorders are most common, manifest as intermittent episodes of bleeding (Price & Wilson, 2005)

Hemophilia there are 3 kinds:

1. Hemophilia A: Disorders of the factor VIII (Anti - hemophilic factor)
2. Hemophilia B: Disorders of the factor IX (Christmas factor)
3. Van Willebrand disease

Clinical symptoms:
1. Infant (for diagnosis)

• Prolonged bleeding after circumcision
• Subcutaneous ecchymoses over the bumps of bone (at the age of 3-4 months)
• Large hematoma after infection
• Bleeding from the oral mucosa
• Soft tissue bleeding

2. Bleeding episodes (during the life span)

1. Early symptoms, including pain
2. After the pain, the swelling, warmth, and decreased mobility

3. Long-term sequelae

• Prolonged bleeding in the muscle can cause nerve compression and muscle fibrosis.

Pathophysiology of Hemophilia
Bleeding due to clotting disorder usually occurs in such a network that is located in muscles, joints, and other disorders because they can occur in the first, second and third, here the only disturbance will be discussed at the first stage, wherein the first stage is exactly what is the mechanism of interference freezing found in hemophilia A and B. Easy bleeding occurs in hemophilia, due to clotting disorder, at the start when a person is ± 3 months old or moments will begin to crawl the initial bleeding will occur due to minor injuries, followed by subsequent complaints.

Hemophilia can also cause cerebral hemorrhage, and fatal. Rationale is that when bleeding, there is a vascular injury (ie a channel where blood flows through the body) → blood out of the vessel. Blood vessels to shrink / shrank → Platelet (platelets) will close the wound on the vessel → Lack of a specific amount of blood clotting factors, resulting in wound closure webbing is not fully formed blood → did not stop flowing out → bleeding vessels (normal: blood clotting factors work to make webbing (fibrin strands) which will close the wound so that the blood stops flowing vessels).

Assessment and Physical Examination for Hemophilia

1. Assessment

• Family history of bleeding disorder
• Ask an unusual bleeding (bleeding that is difficult to stop a long time)
• Spontaneous bleeding (hemorrhage without trauma)

2. Physical examination
a. Activity
Symptoms: Muscle weakness
Symptoms: fatigue, malaise, inability to perform activities.
b. Circulation
Symptoms: skin, mucous membranes pale, cerebral nerve deficit / signs of cerebral hemorrhage
Symptoms: Palpitations
c. Elimination
Symptoms: Hematuria
d. Ego integrity
Symptoms: Depression, withdrawal, anxiety, anger.
Symptoms: Feelings of hopelessness and helplessness.
e. Nutrition
Symptoms: Anorexia, weight loss.
f. Painful
Mark:. Cautious behavior, anxiety, irritability.
Symptoms: Pain in the bones, joints, central tenderness, muscle cramps
g. Security
Signs: hematoma
Symptoms: mild trauma history.
- There was spontaneous bleeding in joints and muscles over and over accompanied by pain and swelling occurs.
- Recurrent joint bleeding caused by hemophilia Atropati give rise to joint space, bone crest and limited joint movement.
- Usually found in the Gastrointestinal bleeding also, excessive hematuria, and brain hemorrhage.
- There was hematoma at the extremities.
- Limitations and joint pain continued to hemorrhage

3. Psychology
- Assess the patient's self-concept à body image, roles, etc.
- Assess the patient and family understanding about the condition and action
- Assess the impact on lifestyle lung condition

Nursing Care Plan for Hemophilia

Nursing Management for Hemophilia

People with hemophilia should be aware of circumstances that can cause bleeding. They should really pay attention to teeth care to not have to undergo a tooth extraction. Rest of the body where there are injuries. When the leg is bleeding, use a tool such as a cane. Compressed injured body part and the surrounding area with ice or other soft material and frozen / cold. Press and tie, so the bleeding body part can not be moving (immobilization). Use an elastic bandage but keep in mind, do not press too hard and tie. Put these body parts in a higher position than the position of the chest and place it on a soft object like a pillow.

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Parkinson's Disease Nursing Care Plan - Diagnosis Interventions

Parkinson's disease is a progressive neurodegenerative disorder that affects movement control, impacting millions of people worldwide. This article explores the key aspects of Parkinson's disease, including its causes, symptoms, and current management strategies.

Causes of Parkinson's Disease:

1. Neurodegeneration: Parkinson's disease is characterized by the gradual loss of dopamine-producing neurons in the substantia nigra, a region of the brain involved in movement control.
2. Genetic Factors: While most cases of Parkinson's are sporadic, some have a genetic component. Mutations in specific genes, such as LRRK2 and SNCA, are associated with an increased risk of developing the condition.
3. Environmental Factors: Exposure to certain environmental toxins, such as pesticides and herbicides, has been linked to an elevated risk of Parkinson's disease.

Symptoms of Parkinson's Disease:

1. Tremors: Involuntary shaking or trembling, typically starting in the hands, is a hallmark symptom of Parkinson's.
2. Bradykinesia: Slowed movement and a gradual reduction in the ability to initiate and complete physical activities.
3. Muscle Rigidity: Stiffness and resistance to movement in the muscles, leading to reduced flexibility.
4. Postural Instability: Difficulty maintaining balance and an increased risk of falls.
5. Changes in Handwriting: Micrographia, or the shrinking of handwriting, is a common early sign.

Parkinson's Disease Nursing Care Plan

1. Nursing Diagnosis Impaired physical mobility related to the stiffness and muscle weakness.

Goal: The client is able to perform physical activity according to ability.

Expected results: the client can participate in training programs, joint contractures did not occur, increased muscle strength and the client indicates an act to increase the mobility

Nursing Interventions for Parkinson's Disease :

1. examine existing mobility and observation of an increase in damage
2. do an exercise program increases muscle strength.
3. encourage hangan bath and massage the muscle
4. help clients perform ROM exercises, self-care according to tolerance
5. collaboration physiotherapists for physical exercise

2. Nursing Diagnosis Self care deficit related to neuromuscular weakness, decline in strength, loss of muscle control / coordination.

Goal: self-care clients are met

Expected results: the client can indicate a change of life for the needs of taking care of themselves, clients are able to do self-care activities in accordance with the level of ability, and identify personal / community that can help.

Nursing Interventions for Parkinson's Disease :

1. assess the ability and the rate of decline and the scale of 0-4 to perform ADL
2. avoid what not to do the client and help if needed.
3. collaborative provision of laxatives and consult a doctor of occupational therapy
4. teach and support the client during the client's activities
5. environmental modifications

3. Nursing Diagnosis Impaired Verbal Communication related to the decline in speech and facial muscle stiffness

characterized by:

• Subjective Data: client / family says the difficulty in talking
• Objective data: the words are difficult to understand, face rigid.

Goal: maximize the ability to communicate.

Nursing Interventions for Parkinson's Disease:

1. Keep the complications of treatment.
2. Refer to speech therapy.
3. Teach clients to use facial exercises and breathing methods to correct the words, volume, and intonation.
4. Breath deeply before speaking to increase the volume and number of words in sentences of each breath.
5. Practice speaking in short sentences, reading aloud in front of the glass or into a voice recorder (tape recorder) to monitor progress.

 

Bibliography:

1. Olanow, C. W., Stern, M. B., & Sethi, K. (2009). The scientific and clinical basis for the treatment of Parkinson disease (2009). Neurology, 72(21 Suppl 4), S1–S136. doi: 10.1212/WNL.0b013e318198db1d
2. Dorsey, E. R., Bloem, B. R., & Okun, M. S. (2020). The past, present, and future of Parkinson's disease: A special essay on the 200th Anniversary of the Shaking Palsy. Movement Disorders, 35(6), 795–801. doi: 10.1002/mds.27986
3. Schapira, A. H., Chaudhuri, K. R., & Jenner, P. (2017). Non-motor features of Parkinson disease. Nature Reviews Neuroscience, 18(7), 435–450. doi: 10.1038/nrn.2017.62

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Nursing Assessment - Physical Examination for Appendicitis

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.

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Risk for Deficient Fluid Volume - Nursing Interventions for Appendicitis

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.

Pediatric Nursing Care Plan – Fluid Volume Deficit related to Diarrhea

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Nursing Care Plan for Acute Respiratory Infections (ARI)

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:

1. History: fever, cough, runny nose, anorexia, weakness / listlessness, respiratory disease history, treatment done at home and accompanying diseases.
2. Physical signs: fever, dyspnea, tachypnea, use of additional respiratory muscles, enlarged tonsils, painful swallowing.
3. Growth factor: General, level of development, daily habits, coping mechanisms, ability to understand the action taken.
4. 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

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