Lynda Juall Carpenito : Handbook of Nursing Diagnosis

Handbook of Nursing Diagnosis by Lynda Juall Carpenito

Handbook of Nursing Diagnosis

Lynda Juall Carpenito RN MSN CRNP (Author)

Book Description

The ideal quick reference, this handbook offers practical guidance on nursing diagnoses and associated care. Sections cover Nursing Diagnoses, Health Promotion/Wellness Nursing Diagnoses, and Diagnostic Clusters—medical conditions with relevant collaborative problems and nursing diagnoses.

NEW! The newest nursing diagnoses approved by NANDA International for 2012–2014 are included in this edition.
NEW! Free eBook available on thePoint.
NEW! New resources such as medical and surgical care plans

Diseases and Disorders: A Nursing Therapeutics Manual by Marilyn Sommers

Diseases and Disorders: A Nursing Therapeutics Manual
by Marilyn Sommers

Book Description

Everything you need to know about caring for patients in one portable "must have" handbook! Often referred to as the "Merck Manual" for nurses by nurses, its quick access format makes it easy to find information on nearly 250 diseases and disorders. Clear, but comprehensive discussions of pathophysiology, with rationales in the medications and laboratory sections, explain the scientific basis for nursing care. Thoroughly revised and updated throughout, the 4th Edition incorporates the latest scientific advances and the practice of nursing today.

Read More : Diseases and Disorders: A Nursing Therapeutics Manual

Customer Reviews

This is a MUST HAVE book for all nursing student and health care professionals. The book is easy to read and provides all the essential details needed to properly care for patients. I utilize this book in all my classes. This is one of the best reference books that I have invested in.

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Mosby's Textbook for Nursing Assistants

Mosby's Textbook for Nursing Assistants

Author : Sheila A. Sorrentino RN MSN PhD

Reviews :

This is a very inclusive book for anyone going into the Nursing Assistant field. The book includes numerous charts and tables that are very easy to understand, very well organized, and great reference tools. I would strongly recommend it to anyone going into the field.

Book Description

Comprehensive in scope, yet easy to read, this trusted resource is all you need to prepare for success in nurse assisting. This engaging text highlights the teamwork and communication vital to your role on the nursing team while detailing over 100 skills you need to provide safe, effective care.

Read More : Mosby's Textbook for Nursing Assistants

Disturbed Body Image - Nursing Diagnosis for Scoliosis

Nursing Care Plan for Scoliosis - Nursing Diagnosis and Interventions for Scoliosis

Scoliosis is an abnormal curving of the spine. Your spine is your backbone. It runs straight down your back. Everyone's spine curves naturally a tiny bit. But people with scoliosis have a spine That curves too much. The spine Might look like the letter "C" or "S."

Symptoms

Usually there are no symptoms. But symptoms can include:

Backache or low-back pain
Tired feeling in the spine after sitting or standing for a long time
Uneven hips or shoulders (one shoulder may be higher than the other)
Spine curves more to one side.

Nursing Diagnosis for Scoliosis : Disturbed Body Image related to a posture that is tilted laterally.

Purpose: Improve the image of the body.

Nursing Interventions for Scoliosis:

1. Suggest to express their feelings and problems.
Rational: The expression of emotion helps the patient begin to accept reality

2. Give realistic expectations and goals for the short term to facilitate the achievement.
Rational: unrealistic expectations lead to patients experiencing failure and reinforces feelings of helplessness.

3. Give rewards for tasks done.
Rational: Strengthening Positive self-esteem and encourages repetition of behavior that is expected.

4. Give a boost to take care of the appropriate tolerances.
Rationale: Increasing self-reliance.

Nursing Care Plan for Scoliosis

Nursing Care Plan for Scoliosis

Analysis of data

Subjective Data:

Patients say back pain.
Patients say fatigue in the spine after sitting or standing for long.
Patients say trouble breathing.

Objective Data:

Shoulder, did not seem as high.
Visible protrusion of the scapula is not the same.
Looks are not the same hip.

Nursing Diagnosis for Scoliosis

Ineffective Breathing Pattern related to the suppression of pain.
Acute Pain: back related to the position of lateral body tilt.
Impaired Physical Mobility related to postural imbalance.
Disturbed Body Image related to kelateral tilted posture.

Nursing Interventions for Scoliosis

1. Ineffective Breathing Pattern related to the suppression of pain.

Purpose: The pattern of breathing effectively.

Plan of action:

Assess respiratory status every 4 hours.
Help and teach the patient to breath in any one hour. Rationale: Increasing the maximum ventilation and oxygenation.
Adjust bed semi-Fowler position to improve lung expansion. Rational: Sitting height allowing easier breathing and lung expansion.
Monitor vital signs every 1 hour. Rational: general indicators, circulation status and adequacy of perfusion.

2. Acute pain: back related to the position of lateral body tilt.

Purpose: Pain is reduced or lost

Plan of action:

Assess the type, intensity and location of pain. Rational: Influencing choice / control the effectiveness of interventions can influence the level of anxiety to pain.
Teach relaxation and distraction techniques. Rational: To divert attention, thereby reducing pain.
Teach and encourage use of the brace. Rational: To reduce pain during activity.
Collaboration in the provision of analgesia. Rational: To relieve pain.

Disturbed Body Image - Nursing Care Plan for Acne

Nursing Diagnosis for Acne: Disturbed Body Image

Acne

Acne is an infection of the skin, caused by changes in the sebaceous glands. The most common form of acne is called acne vulgaris, which means common acne. The redness comes from the inflammation of the skin in response to the infection.

Oils from the glands combine with dead skin cells to block hair follicles. Under the blocked pore, oil builds up. Skin bacteria can then grow very quickly. This infection makes the skin become swollen and red, which becomes visible.

The face, chest, back, and upper arms are most common places for acne to happen.

Acne is common during puberty, when a person is turning from a child into an adult, because of high levels of hormones. Acne becomes less common as people reach adulthood.

Disturbed Body Image Definition :

Confusion in mental picture of one's physical self Defining Characteristics: Nonverbal response to actual or perceived change in structure and/or function; verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function; verbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function; behaviours of avoidance, monitoring, or acknowledgment of one's body.

Nursing Interventions and Rational - Disturbed Body Image - Nursing Care Plan for Acne :

1. Encourage clients to express their feelings and perceptions about the effects of the disease.
Rational: By expressing feelings, can reduce the psychological burden.

2. Encourage individuals to ask the problem, management, development and health prognosis.
Rational: To assess patients' knowledge level and can provide new inputs that are beneficial to recovery

3. Provide reliable information and confirmed the information given.
Rational: Increasing patient knowledge, so that a healthy behavior and prevent the development of more severe disease.

4. Encourage you to share with the people about the values and things that are important to them
Rational: By expressing, sharing, can reduce the psychological burden.

Nursing Care Plan for Acne: Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity

Acne

Acne, a common skin condition affecting millions worldwide, is more than just a cosmetic concern. This article explores the intricacies of acne, shedding light on its causes, available treatments, and preventive measures to promote clearer, healthier skin.

Causes of Acne:

Excess Sebum Production: Overproduction of sebum, the skin's natural oil, can lead to clogged pores, creating an ideal environment for acne development.
Clogged Hair Follicles: When dead skin cells and sebum accumulate in hair follicles, they can form comedones (whiteheads and blackheads), providing a breeding ground for acne-causing bacteria.
Bacterial Infection: Propionibacterium acnes, a type of bacteria, thrives in clogged pores, causing inflammation and contributing to the development of inflammatory acne.
Hormonal Fluctuations: Changes in hormonal levels, especially during puberty, menstruation, pregnancy, or when using certain contraceptives, can trigger acne breakouts.
Genetic Factors: A family history of acne may increase an individual's susceptibility to developing the condition.

Prevention of Acne:

Regular Cleansing: Gentle cleansing with a mild, non-comedogenic cleanser helps remove excess oil, dirt, and dead skin cells from the skin's surface.
Avoiding Skin Irritants: Harsh skincare products, excessive scrubbing, and picking at acne lesions can exacerbate inflammation and worsen acne. Choose products labeled as "non-comedogenic" and be gentle with your skin.
Healthy Diet: A well-balanced diet rich in fruits, vegetables, and whole grains can contribute to overall skin health. Some studies suggest a link between dairy consumption and acne, so individual dietary choices may impact skin condition.
Hydration: Drinking an adequate amount of water helps maintain skin hydration and may contribute to clearer skin.
Stress Management: Chronic stress can exacerbate acne, so practicing stress-reducing activities like meditation, yoga, or deep breathing can be beneficial.

Impaired skin integrity

Impaired skin integrity refers to a condition in which the skin's protective barrier is compromised, leading to a breakdown of its structural integrity and functionality. This impairment can manifest in various forms, including wounds, lesions, or alterations in the skin's texture and appearance. The causes of impaired skin integrity are diverse, ranging from pressure and friction-related injuries to moisture-related damage and skin tears.

Understanding the concept involves recognizing that the skin serves as the body's first line of defense against external threats such as infections, chemicals, and physical trauma. When the skin's protective barrier is compromised, it becomes more susceptible to damage and may lose its ability to prevent the entry of harmful microorganisms.

Assessment of impaired skin integrity involves careful observation and documentation of changes in the skin, including color, temperature, texture, and the presence of wounds or lesions. Various scales and tools, such as the Braden Scale or Norton Scale, may be used to assess the risk of pressure ulcers and guide preventive measures.

Impaired Skin Integrity

Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis).

Nursing Diagnosis: Impaired Skin Integrity related to the destruction of skin tissue characterized by papules, pustules, nodes and lesions.

Nursing Interventions for Acne :

1. Encourage clients to avoid all forms of friction (touched, scratched by hand) on the skin.
Rational: Preventing the spread of bacteria that can worsen the infection in the skin lesions.

2. Instruct the patient to be able to treat the skin with a clean and correct.
Rational: the right skin care reduces the risk of accumulation of dirt on the skin.

3. Motivation of patients to keep taking the drugs and foods that contain enough nutrients.
Rational: To expedite the healing process.

4. Observations of erythema and palpated for warmth around the area.
Rational: The warmth is a sign of infection.

5. Collaboration of topical antibiotics.
Rational: To inhibit the growth of bacteria

Nursing Assessment for Skin Cancer

Nursing Assessment of Skin Cancer

1. Activity / Rest.

Symptoms: Stress fatigue or weariness.
Changes in the pattern of hours of rest and sleep habits at night, the factors that affect sleep, such as pain, anxiety, night sweats.

2. Circulation.

Symptoms: palpitations, chest pain in labor deployment.
Habits: changes in blood pressure.

3. Ego Integrity

Symptoms: stress factors (financial, employment, changes in the role) and how to change the stress (eg, smoking, drinking alcohol, looking for treatment delay, religious beliefs).
Concerns about changes in appearance, eg alopecia, lesions, defects, surgery.
Deny the diagnosis, feelings of helplessness, hopelessness, inadequacy, not significant, loss of control, depression.
Signs: Denial, withdrawal, anger.

4. Elimination.

Symptoms: A change in bowel habit, eg, blood in stool, pain on defecation.
Changes in urinary elimination, eg, pain / burning sensation during urination, hematuri, frequent urination.
Symptoms: Changes in bowel sounds, distended common.

5. Food / liquid.

Symptoms: poor dietary habits (eg, low fiber, high in fat, additives, preservatives), anorexia, nausea / vomiting, food intolerance, changes in body weight, severe weight loss, kakeksia, reduced muscle mass.
Mark: The changes in moisture / skin turgor, edema.

6. Neuro-sensory.

Symptoms: Dizziness, sincope.

7. Pain / Comfort.

Symptoms: No pain, or the degree of pain varies, eg, mild discomfort to severe pain (associated with the disease).

8. Breathing.

Symptoms: Smoking (tobacco, marijuana, living with someone who smokes), exposure to asbestos.

9. Security.

Symptoms: Exposure to toxic chemicals, carcinogens, sun exposure time / too much.
Symptoms: Fever, skin rash, ulceration.

10. Sexuality.

Symptoms: Sexual problems eg: impact on relationships, changes in levels of satisfaction, nuligravida greater than age 30 years, multigravida, multiple sex partners, early sexual activity, genital herpes.

11. Social interaction.

Symptoms: The lack adequatan / weaknesses of the support system, history perkawinaan (with respect to satisfaction at home, support or assistance), the problem of the function / role responsibilities.

Acute Pain and Anxiety NCP for Peritonitis

Acute Pain and Anxiety : Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis: Acute Pain related to chemical irritation of the peripheral peritoneum.

Goal: reduce / eliminate the pain

Nursing Intervention:
a. Review the report of pain, record the location, duration, intensity (scale 0-10) and characteristics (shallow, sharp, constant).
Rational: the change in location / intensity is not common but may indicate the occurrence of complications.

b. Maintain semi-Fowler position as indicated
Rational: to facilitate drainage of fluids / injured because of gravity and helps minimize the pain due to movement.

c. Provide comfort measures, eg the back massage, deep breathing, relaxation exercises / visualization.
Rational: increase relaxation and may increase the patient's coping abilities by refocusing attention.

d. Give frequent mouth care. Eliminate unpleasant environmental stimuli.
Rational: reduce nausea / vomiting, which can increase the pressure / intra-abdominal pain.

Nursing Diagnosis for Peritonitis: Anxiety or fear related to the threat of death / change in health status.

Goal: to reduce or eliminate anxiety

Nursing Intervention:
a. Evaluation of anxiety levels, record verbal responses and non-verbal patients. Encourage the free expression of emotions.
Rational: fear can occur because of severe pain, increasing pain, it is important to the diagnostic procedures and possible surgery.

b. Provide information about the disease process and the anticipated action
Rational: knowing what is expected to reduce anxiety.

c. Schedule adequate rest and sleep periods stop
Rational: limiting weaknesses, save energy, and can enhance coping abilities.

Deficient Fluid Volume Nursing Care Plan for Peritonitis

Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

Risk for Infection Nursing Care Plan for Peritonitis

Pathophysiology of Peritonitis

Pathophysiology of Peritonitis

The initial reaction of peritoneum to invasion by bacteria is a discharge of exudate fibrinosa. Pockets of pus (abscess) formed between fibrinosa adhesions, which stick together with the surrounding surface and limit the infection. Attachment usually disappears when the infection disappeared, but may persist as fibrous bands, which later can lead to intestinal obstruction.

Cause inflammation and fluid accumulation due to capillary membrane leak. If the fluid deficit is not corrected quickly and aggressively, it can cause cell death. The release of various mediators, such as interleukins, could start hyperinflammatory response, thus bringing to the subsequent development of many organ failure. Because the body tries to compensate by way of fluid and electrolyte retention by the kidneys, waste products also accumulate. Tachycardia initially improve cardiac output, but it soon failed so happens hypovolemia.

Organs including the peritoneal cavity in the abdominal wall edema experienced. Edema caused by capillary permeability organs is rising. Collection of fluid in the peritoneal cavity, and intestinal lumen and lumen-whole organ edema, intra-peritoneal and abdominal wall edema, including the retroperitoneal tissue causing hypovolemia. Hypovolemia increases with the increase in temperature, there is no input, and vomiting.
Entrapped liquid in the peritoneal cavity and intestinal lumen, further increasing intra-abdominal pressures, making full efforts into breathing difficult and cause a decrease in perfusion.

If the material is spread to infect the peritoneal surface or if the infection spreads, general peritonitis may arise. With the development of general peritonitis, peristaltic activity is reduced to arise paralytic ileus; intestine then becomes Atoni and stretch. Lost fluids and electrolytes into the intestinal lumen, resulting in dehydration, shock, circulatory disorders and oliguria. Adhesions can form between the arches are stretched intestines and can interfere with the recovery of bowel movements and cause intestinal obstruction.

4 Nursing Interventions for Gastritis

Nursing Interventions for Gastritis

1. Nursing Diagnosis: Acute Pain

Purpose: Pain is gone / no pain

Nursing Interventions:
• Review the level of pain.
• Provide information about the different strategies chosen to reduce pain.
• Encourage clients to use the chosen strategy to reduce pain.
• Encourage clients to avoid eating foods that stimulate an increase in stomach acid.
• Collaboration with the medical team for the administration of anti-analgesic.

Rational:
• In order to determine the level of pain experienced by the client.
• Able to learn methods of pain reduction and can do it.
• Assist in menurunhkan experienced pain threshold.
• In order for clients to find foods that stimulate stomach acid and does not consume them.
• Reduce the level of pain experienced by the client.

2. Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements

Purpose: Nutrition balanced.

Nursing Interventions:
• Describe the client and family about the importance of food for the body.
• Monitor the amount of food intake.
• Monitor and record the number of vomiting, frequency and color
• Provide a varied diet according to his diet to stimulate appetite.
• Provide food in small portions but frequently.
• Collaboration with the medical team for the administration of anti-emetic drugs.

Rational
• Clients and families can learn the importance of
• To know the food is consumed.
• As the data to perform nursing actions and subsequent treatment.
• To klirn be motivated and stimulates appetite.
• To reduce the feelings and needs food for patients.
• As a therapy for inhibiting / stimulating nausea and vomiting.

3. Nursing Diagnosis: Risk for Fluid Volume Deficit

Purpose: volume of body fluids are met

Nursing Interventions:
· Assess the possibility of signs of dehydration and record intake and output.
· Assess the balance of fluids and electrolytes every 24 hours.
· Encourage clients to keep the peroral intake is to eat and drink a little but often.
· Encourage clients to avoid consuming foods and beverages that contain caffeine.

Rational:
· Detecting the early signs of dehydration.
· Detecting early indicator of fluid and electrolyte imbalance.
· In order for the client's body fluid balance can be maintained.
· Caffeine is a central nervous system stimulant that can increase the activity of gastric and pepsin secretion leading to increased secretion of gastric acid that can cause reactions of nausea and vomiting.

4. Nursing Diagnosis: Anxiety

Purpose: No Anxiety

Nursing Interventions:
• Assess the client's anxiety.
• Give the client an opportunity to express his anxiety.
• Explain to clients that can challenge dijalankankan diet after recovery.
• Explain to the client about medical procedures / treatments will be done and encouraged cooperative therein.
• Provide motivation to the client about his recovery.

Rational:
• As the initial data to determine the client's anxiety level.
• In order to determine the cause of anxiety is experienced as well as reduce the psychological burden of the client.
• The client can adhere to diet and avoid disease relapse again.
• Able to understand and accept all the measures taken to cure the disease process.
• Clients and families are optimistic for the healing of disease and comply with all recommended clients are given.

Nursing Management Book

Nursing Management

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Details : Nursing Management

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Nursing Care Plan for COPD

Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath. In clinical practice, COPD is defined by its characteristically low airflow on lung function tests. In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time. In England, an estimated 842,100 of 50 million people have a diagnosis of COPD; thus, approximately 1 person in 59 is diagnosed with COPD at some point in their lives.
wikipedia

Nursing Care Plan for COPD : Nursing Assessment for COPD

The assessment includes information about past symptoms and manifestations of the disease earlier. Here are some guidance questions to obtain data on the health history of the disease process:

How long patients have difficulty breathing?
Does the activity increase dyspnea?
How much restriction on the patient's activity tolerance?
When do patients complain most tired and shortness of breath?
Is eating and sleeping habits are affected?
History of smoking?
Drugs that are used every day?
Drugs used in acute attacks?
What patients know about the condition and the disease?

Additional data collected through observation and examination as follows:

Pulse rate and respiratory patients?
Is the same breathing without effort?
Is there a contraction of abdominal muscles during inspiration?
Is there any use of accessory respiratory muscles during breathing?
Barrel chest?
Do look cyanotic?
Is there a cough?
Is there peripheral edema?
Are the neck veins look bigger?
What color, number and consistency of sputum of patients?
How, the sensor status of patients?
Is there an increase stupor? Anxiety?

Source : http://nursing-assessment.blogspot.com/2011/05/nursing-assessment-for-copd.html

Nursing Care Plan for COPD : Nursing Diagnosis for COPD

1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.

3. Impaired Gas Exchange related to ventilation perfusion inequality.

4. Activity Intolerance related to imbalance between supply with oxygen demand.

5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

6. Disturbed Sleep Pattern related to discomfort, the setting position.

7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.

8. Anxiety related to threat to self-concept, the threat of death, unmet needs.

9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.

10. Knowledge Deficit related to lack of information, do not know the source of information.

Source : http://nandanursingdiagnosis.blogspot.com/2011/05/nursing-diagnosis-for-copd.html

Nursing Care Plan for Alzheimer's Disease

Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 60.

Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person’s daily life and activities. Estimates vary, but experts suggest that as many as 5.1 million Americans may have Alzheimer’s.
nia.nih.gov

Nursing Care Plan for Alzheimer's Disease : Assessment of Alzheimer's Disease

1. Activity / rest
Signs: anxiety, helplessness, sleep pattern disturbance, lethargy and impaired motor skills.
Symptoms: feeling melting

2. Circulation
Symptoms: History of cerebral vascular disease / systemic, hypertension, embolic episodes

3. Ego integrity
Signs: hide incompetence, sit down and
watch the other, the first activity might accumulate
objects are not moving and emotional stability
Symptoms: suspicious or afraid of the situation / person fantasies, misperceptions of the environment, loss of multiple.

4. Elimination
Signs: Incontinence of urine / feaces
Symptoms: The urge to urinate

5. Food / fluid
Signs: loss of ability to chew, avoiding / refusing to eat and looked increasingly thin.
Symptoms: Historical episodes of hypoglycemia, changes
in taste, appetite, weight loss.

6. Hygiene
Signs: a lack of personal habits, forget to go to the bathroom and less interested in eating time
Symptoms: Need help, depending on other people

7. Neuro Sensory
Symptoms: Improvement of symptoms that exist primarily
cognitive changes, loss of sensation and existence propriosepsi
history of cerebral vascular disease / systemic as well as seizure activity.

8. Comfort
Signs: ekimosis laceration and a sense of hostile / attack others
Symptoms: A history of serious head trauma,
accident trauma

9. Social Integrity
Signs: Loss of social control, inappropriate behavior
Symptoms: Feeling lost power
Source : http://nursing-assessment.blogspot.com/2011/05/nursing-assessment-for-alzheimers.html

Nursing Care Plan for Alzheimer's Disease : Nursing Interventions for Alzheimer's Disease

1. Nursing Diagnosis : Risk for Injury related to:

Unable to recognize / identify hazards in the environment.
Disorientation, confusion, impaired decision making.
Weakness, the muscles are not coordinated, the presence of seizure activity.

Nursing Intervention :

Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in visual perception.
Help the people closest to identify the risk of hazards that may arise.
Eliminate / minimize sources of hazards in the environment
Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.

Rational:

Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.
An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.
Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.

2. Nursing Diagnosis : Disturbed Thought Processes related to :

Irreversible neuro degeneration
Memory Loss
Psychological Conflict
Deprivation lie

Nursing Intervention :

Assess the level of cognitive disorders such as changes orientasiterhadap people, places and times, range, attention, thinking skills.
Talk with the people closest to the usual behavior change / length of the existing problems.
Maintain a nice quiet neighborhood.
Face-to-face when talking with patients.
Call patient by name.
Use a rather low voice and spoke slowly in patients.

Rational:

Provide the basis for the evaluation / comparison that will come, and influencing the choice of intervention.
Noise, crowds, the crowds are usually the excessive sensory neurons and can increase interference.
Cause concern, especially in people with perceptual disorders.
The name is a form of self-identity and lead to recognition of reality and the individual.
Increasing the possibility of understanding.

Source : http://nursinginterventions-diagnosis.blogspot.com/2011/05/nursing-intervention-for-alzheimers.html

Nursing Assessment for Alzheimer's Disease

Nursing Diagnosis for Alzheimer's Disease

Nursing Care Plan for Gastritis

Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter pylori, chronic bile reflux, stress and certain autoimmune disorders can cause gastritis as well. The most common symptom is abdominal upset or pain. Other symptoms are indigestion, abdominal bloating, nausea, and vomiting and pernicious anemia. Some may have a feeling of fullness or burning in the upper abdomen. A gastroscopy, blood test, complete blood count test, or a stool test may be used to diagnose gastritis. Treatment includes taking antacids or other medicines, such as proton pump inhibitors or antibiotics, and avoiding hot or spicy foods. For those with pernicious anemia, B12 injections are given. wikipedia

Nursing Care Plan for Gastritis : Nursing Diagnosis for Gastritis

1. Risk for Imbalanced Fluid Volume and Electrolytes : less than body requirements related to inadequate intake, vomiting

2. Imbalanced Nutrition: Less Than Body Requirements related to decreased nutrition intake.

3. Activity Intolerance related to physical weakness.

4. Deficient Knowledge: about diseases related to lack of information.

5. Acute Pain related to an increase in stomach acid.

Nursing Care Plan for Gastritis : Nursing Interventions for Gastritis

1. Risk for Imbalanced Fluid Volume and Electrolytes : less than body requirements related to inadequate intake, vomiting

Goal:
Disorders of fluid balance did not occur.

Expected results:
Moist mucous membranes, good skin turgor, electrolytes returned to normal, capillary filling pink, vital signs stable, the balance of input and output.

Nursing Intervention :

Assess signs and symptoms of dehydration, observation of vital signs, measuring intake and output, encourage clients to drink ± 1500-2500ml, observation of skin and mucous membranes, collaboration with doctor in the provision of intravenous fluids.

2. Imbalanced Nutrition: Less than Body Requirements: less than body requirements related to inadequate intake, anorexia

Goal:
Nutritional deficiencies resolved.

Expected results:
Normal albumin value, no nausea and vomiting, weight within normal limits, normal bowel sounds.

Nursing Intervention :

Assess food intake, body weight measured regularly, give oral care on a regular basis, encourage clients to eat little but often, give food in warm, auscultation bowel sounds, assess food preferences, check the laboratory, for example: Hemoglobin, hematocrit, albumin.

Source : http://nursinginterventions-diagnosis.blogspot.com/2011/05/nursing-care-plan-for-gastritis.html

Nursing Intervention for Low Self-Esteem

Self esteem is person’s personal judgment of one’s own worth, based on how well one’s behavior conforms to one’s self ideal (Stuart and Sundeen, 1998).

The frequency on reaching purposes will result on low self esteem or high self esteem. If the individual frequent to failure, then it tends to low self esteem. The Self esteem is gained from his/herself and others. Main aspect is being loved and accepting respect from others (Keliat, 1992).

In general, self esteem is vurneable being disturbed in youth and old senile. High self esteem related with low anxiety, effective in group and accepted by others. Low self esteem is related with worst interpersonal relationship and has risk for depression and schizophrenia.

Low self esteem is negative overview assessing toward self and capability which expressed in directly or indirectly (Schult and Videbeck, 1998).

Low self esteem is generally defined as rejecting of her/himself as valuable human being and has no responsible his / herself life. Mainly, it is failure to adapt for proper behavior and aspiration. Self esteem disturbance is drawn as negative feeling of his/ herself including loss of self confidence and occur the self esteem. Low self esteem can be happen situational (trauma) or chronically (prolonged negative self evaluation) and can be expressed either directly or not (real or not).

Nursing Intervention for Low Self-Esteem

a. Nursing strategic (client)

1) Goal:

a) Identify capabilities and the positive aspects of the client owned

b) Assess skills that can be used

c) Establish or choose activities according to ability

d) Coaching activities are selected according to ability

e) Planning activities that have been trained.

2) Outcome: The client can identify capability and positive aspect, assess her capability, choose the appropriate activities and increase her capability.

3) The first nursing strategic

a) Identifying capability and positive aspect on client

b) Helping client to assess her capability

c) Helping client to choose activity

d) Training to client to choose the appropriate activities

e) Giving proper praise toward patient succeeding.

f) Suggesting to patient to include schedule the daily activity.

4) The second nursing strategic

a) Evaluating the daily routine of patient

b) Training for second capability

c) Suggesting to patient to include schedule the daily activity.

Low Self-Esteem Definition, Causes, Signs and Symptoms

Definition, Causes, Signs and Symptoms of Low Self-Esteem

Definition of Low Self-Esteem

Low self-esteem is a personal assessment of the results achieved by analyzing how far the behavior of ideal self-fulfilling. (Stuart and Sundeen, 1998: 227).

According to Townsend (1998: 189) low self-esteem is a self-evaluation of sense of self, or the ability to self-negataif either directly or indirectly.

The same opinion was expressed by Carpenito, LJ (1998: 352) that low self-esteem is a condition in which individuals experience negative self-evaluation of self and self.

Of the opinions of the above conclusions can be made, low self-esteem is a negative sense of self, loss of confidence, and failed to achieve the goals expressed directly or indirectly, decreased self-esteem can be situational or chronic.

Causes of Low Self-Esteem

Low self esteem is often caused due to an ineffective individual coping due to the lack of positive feedback, lack of support systems, development of ego regression, a negative feedback loop, dysfunctional family systems, and fixed at the early developmental stage (Towsand, MC, 1998: 366 ).

According to Carpenito, LJ (1998: 82) Ineffective individual coping is a state where an individual having or at risk of experiencing an inability to handle internal or environmental stresos because tidaka dekuat with adequate resources (physical, psychological, behavioral or cognitive).

Meanwhile, according to Towsand, MC (1998: 312) Ineffective individual coping is adaptive behavior disorder and a problem-solving skills in meeting the demands of life and role.

Of the opinions above can be drawn a conclusion, individuals who have ineffective coping will show inability in adjusting or may not solve the problem of the demands of life and facing role.

The existence of an ineffective individual coping is often indicated by the behavior (Carpenito LJ, 1998: 83; Towsand, MC, 1998: 313) as follows:

Subjective data:

Reveals the inability to resolve the issue or ask for help.
Express feelings of fear and anxiety is prolonged.
Reveals the inability of roles.

Objective data:

Changes in community participation.
Increased dependence.
Manipulate everyone around them for the purposes of fulfilling their own desires.
Refuse to follow the rules and regulations.
Destructive behaviors directed at oneself and others.
Manipulate verbal and changes in communication patterns.
Inability to meet basic needs.
Drug abuse.

Signs and Symptoms of Low Self-Esteem

According to Carpenito, LJ (1998: 352); Keliat, BA (1994: 20); behavior related to low self-esteem, among others:

Subjective data:

Self-criticize themselves or others.
Sense of self is essential that excess overage.
Feelings of inadequacy.
Feel guilty.
Negative attitude to self-own.
Pessimistic attitude to life.
Complaints of physical pain.
The polarized outlook on life.
Rejecting self-ability.
Reduction of self or self-mocking.
Feelings of anxiety or fear.
Rationalize away the rejection of positive feedback.
Disclose a personal failure.
Inability to set goals.

Objective data:

Decreased productivity.
Self-destructive behavior on its own.
Destructive behavior in others.
Substance abuse.
Withdraw from social relationships.
Facial expressions of shame and guilt.
Showed signs of depression (difficulty sleeping and eating difficult).
Seem irritable or easily angered.

Source : http://careplannursing.blogspot.com/2012/07/low-self-esteem-definition-causes-signs.html

Nursing Management of Anxiety

Nursing Management of Anxiety

A. Nursing Process

1. Patient's condition:

patients seem to dreamily
patients often pacing
patients ask you things that are not important
patient was suspected

2. Nursing Diagnosis

Risk for Self-Directed or Other-Directed Violence related to Anxiety

3. Purpose

Patients are able to know anxiety
Patients can use adaptive coping mechanisms
Patients can use relaxation techniques

B. Strategies for the nursing actions

1. Orientation

Ttherapeutic greeting
Evaluation / Validation : Ask the patient's current feelings, Ask the patient how the current situation.
Contract : topic, place, time

2. work

Discuss the problem off.
Guiding the implementation schedule
Guiding the use of relaxation techniques

3. Termination
a. Evaluation

patients were able to express feelings.
patients are able to recognize the behavior and response.
patients can use adaptive coping mechanisms.
patients can use relaxation techniques.

b. Follow-up plan

Encourage clients to identify and describe feelings.

c. Contract

topic,
place,
time

Care Plan Nursing

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