Showing posts with label Nursing Assessment. Show all posts

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.

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:

Hemophilia A: Disorders of the factor VIII (Anti - hemophilic factor)
Hemophilia B: Disorders of the factor IX (Christmas factor)
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)

Early symptoms, including pain
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.

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.

Nursing Assessment for Dizziness Vertigo

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

Nursing Assessment Nursing Care Plan for Dizziness Vertigo

1. Activity / Rest

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

2. Circulation

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

3. Ego Integrity

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

4. Food and Fluid

Nausea / vomiting, anorexia (for pain)
Weight loss

5. Neuro-Sensory

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

6. Pain / Comfort

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

7. Security

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

8. Social Interaction

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

9. Guidance / learning

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

Nanda Nursing Diagnosis for Dizziness Vertigo