Nursing Diagnosis and Interventions for Pediatric GERD

Gastroesophageal reflux disease (GERD) is a chronic digestive disease. GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid content of the stomach backs up into the esophagus.

The cause of GERD is complex and may involve multiple causes.

Like in adults with the condition, gastroesophageal reflux is the upward movement of stomach contents into the esophagus and sometimes into or out of the mouth.

According to the National Digestive Disease Information Clearinghouse, a child's immature digestive system is usually to blame. They add that most infants grow out of GERD by the time they are 1 year old.


Symptoms of Acid Reflux in Infants and Children

• Frequent or persistent cough
• Crying with feeding or after feeding
• Heartburn, gas, or abdominal pain
• Frequent or recurrent vomiting
• Refusing to eat or difficulty eating (choking or gagging with feeding)

Nursing Diagnosis for Gastroesophageal Reflux Disease (GERD)

1. Deficient Fluid Volume related to input, nausea and vomiting / excessive spending.
2. Acute pain related to inflammation of the esophagus lining.
3. Imbalanced Nutrition: less than body requirements related to anorexia, nausea, vomiting.
4. Risk for Impaired Gas Exchange
5. Risk for Impaired Home Maintenance
6. Risk for Aspiration related to barriers to swallow, decreased reflux larynx and glottis to liquid reflux.
7. Ineffective airway clearance related to fluid reflux into the larynx and throat.
8. Impaired swallowing related to narrowing / stricture of the esophagus due to gastroesophageal reflux disease.
9. Anxiety related to the disease process.

Nursing Interventions for Gastroesophageal Reflux Disease (GERD)

1. Increase fluid intake and adequate nutrition.

• Keep head of bed at a position 60 degrees for 30 minutes to 40 minutes.
• Give food a little but often 2 to 3 hours.
• Thicken the milk with cereal.
• Give dinner.
• Measure weight each morning.
• Monitor intake and output.

2. Observe and report any signs of respiratory distress, assess for changes in respiratory status.

3. Before the surgery is done to prepare the client and family for surgery.

4. Monitor the operating side to wholeness.

5. Prevent abdominal distension.

• Maintain patency of a nasogastric tube (NG) or gastrostomy, if installed.
• Check hose NG position.
• Auscultation bowel sounds.

6. Monitor for signs and symptoms of postoperative hemorrhage.

• Decreased blood pressure and increased pulse apex.
• Blood in NG drainage.
• Drainage like coffee grounds would exist in the first 24 hours.

7. Help the parents to express feelings or frustration because they feel responsible or not enough help.

8. Give the stimulation activity.

• Discharge planning and home care.
• Encourage parents about drug administration.
• Encourage parents about feeding.
• Encourage parents to report any vomiting or presence of fresh blood.

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NCP Cholera - 6 Nursing Diagnosis and Interventions

Nursing Care Plan for Cholera

Cholera, a severe diarrheal disease caused by the bacterium Vibrio cholerae, has plagued human populations for centuries. This waterborne illness poses significant public health challenges, particularly in regions with inadequate sanitation and limited access to clean water. This article explores the causes, symptoms, transmission, and global efforts in the prevention and management of cholera.

Causes and Transmission:

1. Vibrio cholerae, the bacterium responsible for cholera, typically thrives in contaminated water and food sources. The primary mode of transmission is through the ingestion of contaminated water or food, often via the consumption of raw or undercooked seafood, or contaminated fruits and vegetables.
2. Once ingested, the bacterium releases a toxin that affects the small intestine, leading to rapid and profuse watery diarrhea—a hallmark symptom of cholera. The severity of the disease can range from mild to severe, with severe cases potentially progressing to life-threatening dehydration without prompt intervention.

Symptoms:

1. Watery Diarrhea: Cholera is characterized by the sudden onset of profuse, painless, and watery diarrhea, often described as "rice-water stool."
2. Vomiting: Individuals with cholera may experience vomiting, contributing to fluid loss and dehydration.
3. Dehydration: Rapid fluid loss can lead to severe dehydration, accompanied by symptoms such as sunken eyes, dry mucous membranes, lethargy, and a rapid heart rate.
4. Muscle Cramps: Dehydration can cause muscle cramps and weakness.

Nursing Assessment for Cholera

1. Assess the status of dehydration (skin color, temperature, acral, skin turgor, mucous membranes, eyes, crown, body temperature, pulse, respiration, behavior, weight loss).
2. Observe for manifestations of acute diarrhea
   • A sudden attack of diarrhea
   • Fever
   • Anorexia, nausea, vomiting
   • Weight loss
   • Pain and abdominal cramps, abdominal distension
   • Increased bowel sounds / hyper-peristaltic
   • Malaise
   • Bowel movements more than 3 times a day, liquid stool consistency, with / or without mucus and blood
3. Assess the psychosocial status of families
4. Assess the level of knowledge of family
   • Knowledge of diarrhea at home
   • Knowledge of dietary
   • Knowledge about the prevention of recurrent diarrhea

Nursing Diagnosis for Cholera

1. Deficient fluid volume related to excessive fluid loss through the stool or emesis
2. Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake
3. Risk for infection related to microorganisms that penetrate the gastrointestinal tract.
4. Impaired Skin Integrity: perianal, related to irritation from diarrhea
5. Anxiety related to separation from parents, unfamiliar environment, a stressful procedure.
6. Interrupted Family Processes related to crisis situations, lack of knowledge about diseases, treatment of clients.

Nursing Interventions for Cholera


Deficient fluid volume related to excessive fluid loss through the stool or emesis

Goal :

• Maintain adequate hydration

Expected outcomes:

No signs of dehydration: elastic skin turgor, sunken fontanel not, the patient is not agitated, mucous membranes moist, no weight loss.

Nursing Interventions and Rational:
1) Record Intake Output every 24 hours.
R / Knowing the status of dehydration and evaluate the effectiveness of interventions.

2) Measure the child's weight every day.
R / observe dehydration.

3) Measure vital signs and evaluation of skin turgor, mucous membranes, mental status.
R / observe dehydration.
4) Tell the family to give the child a drink gradually.
R / improve hydration.

collaboration:
5) Give oral rehydration solution (ORS).
R / rehydration and replacement of fluid loss through the stool.

6) Provide and monitor IV fluids as indicated (collaboration).
R / replacement fluid loss.

7) Observe the results of the electrolyte.
R / know the level of hydration and the effectiveness of interventions.


Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake

Goal :

• consume adequate nutrition intake.

Expected outcomes:

• No weight loss (weight stable)
• Eating out 1 serving.
• No nausea, vomiting.

Nursing Interventions and Rational:

1) Evaluation of nutritional status and weight loss
R / Identifying the need for further intervention.

2) Notify and motivation of mothers / families to continue breast-feeding.
R / breast milk reduces the severity and duration of disease and provide additional nutrients.

3) Tell the mother to give the child to eat small meals but often
R / increase food intake.

4) Observe and record the response to feeding.
R / know the tolerance of feeding.

 

 

Bibliography:

1. Ali, M., Nelson, A. R., Lopez, A. L., & Sack, D. A. (2015). Updated global burden of cholera in endemic countries. PLoS Neglected Tropical Diseases, 9(6), e0003832. doi: 10.1371/journal.pntd.0003832
2. Clemens, J. D., Nair, G. B., Ahmed, T., Qadri, F., Holmgren, J., & Cholera Symposium Participants. (2017). Cholera. The Lancet, 390(10101), 1539-1549. doi: 10.1016/S0140-6736(17)30559-7

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2 Nursing Interventions for Malaria

1. Ineffective Tissue perfusion related to a decrease in the cellular components needed for the delivery of oxygen and nutrients in the body.

Nursing Intervention:

1. Maintain bed rest to help with maintenance activities.
Rational: reduce myocardial workload and oxygen consumption, maximizing the effectiveness of tissue perfusion.

2. Monitor the blood pressure trend, noting the development of hypotension and changes in pulse pressure.
Rational: hypotension will develop along with the germs that invade the blood.

3. Monitor the quality, the strength of peripheral pulses.
Rational: at the beginning of a strong rapid pulse due to an increase in cardiac output, pulse weak or slow due to ongoing hypotension, decreased cardiac output and peripheral vaso constriction.

4. Assess respiratory rate and depth of quality. Note the severe dyspnea.
Rationale: increased respiration occurs in response to the direct effects of the bacteria on the respiratory center. Breathing becomes shallow in the event of respiratory insufficiency, raises the risk of acute respiratory failure.

5. Give parenteral fluids.
Rational: to maintain tissue perfusion, a large amount of fluid may be required to support the circulation volume.

2. Deficient Knowledge: about the disease, prognosis and treatment needs related to lack of exposure / recall errors of interpretation of information, cognitive limitations.

Nursing Intervention:

1. Review the disease process and future expectations.
Rational: provides basic knowledge of where the patient can make a choice.

2. Provide information on the administration of drugs, drug interactions, side effects, and adherence to the program.
Rational: to increase understanding and enhance cooperation in healing and reducing recurrence of complications.

3. Discuss the need for proper nutritional intake and balanced.
Rationale: The need for optimal healing and general wellbeing.

4. Encourage periods of rest and activity scheduled.
Rational: energy savings and improve healing.

5. Review the need for personal hygiene and environmental cleanliness.
Rationale: Exposure control helps the environment by reducing the amount of the existing causes of disease.

6. Identify the signs and symptoms that require medical evaluation.
Rational: early recognition of progression / recurrence of infection.

7. Emphasize the importance of antibiotic treatment as needed.
Rational: the use of the prevention of infection.

Read More : http://screware.blogspot.com/2013/06/malaria-5-nursing-interventions.html

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5 Nursing Interventions for Dengue Hemorrhagic Fever

Nursing Diagnosis and Interventions for Dengue Hemorrhagic Fever

Nursing Diagnosis 1. : Hyperthermia related to the process of dengue virus infection.

Goal: Normal body temperature
Outcomes:
Body temperature between 36-37 0 C
Muscle pain disappeared

Intervention:

1. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated)
Rational: To replace fluids lost due to evaporation.

2. Instruct the patient to wear clothing that is thin and easy to absorb sweat.
Rationale: Providing a sense of comfort and easy thin clothing absorbs sweat and does not stimulate an increase in body temperature.

3. Observation of intake and output, vital signs (temperature, pulse, blood pressure) every 3 hours once or more often.
Rational: Detecting early dehydration and to know the balance of fluids and electrolytes in the body. Vital Signs is a reference to determine the patient's general condition.

4. Collaboration: intravenous fluids and appropriate drug delivery program.
Rationale: Fluid replacement is essential for patients with a high body temperature. Particular drug to lower the patient's body temperature.


Nursing Diagnosis 2. : Risk for Fluid Volume Deficit related to intravascular fluid into the extravascular migration.

Objective: Not happening fluid volume deficit
Outcomes:
Input and output balanced
Vital signs within normal limits
There is no sign of pre-shock
Capilarry refill less than 3 seconds

Intervention:
1. Monitor vital signs every 3 hours / more often.
Rationale: Vital sign help identify fluctuations in intravascular fluid.

2. Observation of capillary refill.
Rational: Indications adequacy of peripheral circulation.

3. Observation of intake and output. Note the color of urine / concentration.
Rationale: Decrease in urine output concentrated suspected dehydration.

4. Suggest to drink 1500-2000 ml / day (as tolerated).
Rational: To consume body fluids orally.

5. Collaboration: intravenous fluid administration.
Rational: It can increase the amount of body fluid, to prevent shock hipovolemic.


Nursing Diagnosis 3. : Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid into the extravascular migration.

Objective: Not happening hypovolemic shock
Hasl criteria:
Vital signs within normal limits

Intervention:
1. Monitor patient's general condition.
Raional: To monitor the condition of the patient during treatment, especially when there is bleeding. Nurses immediately know the signs of pre-shock / shock.

2. Observation of vital signs every 3 hours or more
Rationale: Nurses need to continue to observe the vital signs to ensure there is no pre-shock / shock.

3. Explain to patients and families sign of bleeding, and immediately report if there is bleeding.
Rationale: By involving the patient and family, then the signs of bleeding can be immediately identified and prompt action, and the right can be given immediately.

4. Collaboration: intravenous fluid administration.
Rationale: Intravenous fluids needed to cope with the severe loss of body fluids.

5. Collaboration: examination: HB, PCV, platelets.
Rationale: To determine the level of leakage of blood vessels experienced by patients and to take further action reference.

Read More : http://nanda-nurse-diary.blogspot.com/2013/05/dengue-hemorrhagic-fever-5-nursing.html

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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.

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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.

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COPD - Acute Pain Nursing Interventions

Nursing Care Plan for COPD - Nursing Interventions for Acute Pain

Acute pain related to the process of inflammation in the lining of the lungs

Goal: The pain is reduced / lost.

Expected outcomes are:

• Clients say the pain is reduced / lost.
• Relaxed facial expression.

Nursing Interventions - Acute Pain for COPD

1. Determine the characteristics of pain, for example; sharp, consistent, stabbed. Investigate changes in character / intensity of pain / location.
Rational: Chest pain is usually present in some degree of pneumonia, complications can arise such as pericarditis and endocarditis.

2. Monitor vital signs.
Rationale: Changes in heart rate or blood pressure showed that patients experience pain, especially when other reasons for changes in vital signs.

3. Provide comfort measures, for example: back massage, change of position, quiet music / conversation, relaxation / breathing exercises.
Rational: The act of non-analgesics administered with a gentle touch to relieve discomfort and increase the effects of analgesic therapy.

4. Offer a clean mouth often.
Rational: mouth breathing and oxygen therapy may irritate and dry the mucous memberan, potential public inconvenience.

5. Advise and assist the patient in the technique of chest compressions during episodes of coughing.
Rational: A tool to control chest discomfort while increasing the effectiveness of cough effort.

6. Give analgesic and antitussive according to indications.
Rational: This drug can be used to suppress non-productive cough / proximal or reduce excessive mucus, improve comfort / rest common.

COPD - Acute Pain Nursing Interventions

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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 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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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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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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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 Interventions Acute Pain related to Uterine Fibroids

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

Objectives:

• Pain can be reduced or lost

Expected outcomes are:

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

Nursing Interventions Acute Pain related to Uterine Fibroids

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

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

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

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

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

Rational: It can provide comfort to the client.

4. Give instruction in relaxation techniques and deep breathing techniques

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

5. Encourage clients to use a warm compress

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

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

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

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

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

8. Evaluation of vital signs.

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

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Depression Nursing Diagnosis and Interventions

Risk for Violence: Self-Directed or Other-Directed


Nursing Interventions for Depression

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

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

Acute Myocardial Infarction (AMI)

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

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

Clinical Manifestations of Myocardial Infarction

Pain

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

Laboratory examination Examination of cardiac enzymes :

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

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


Pain scores according to White:

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

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

Airways

1. Blockage or accumulation of secretions
2. Wheezing or crackles

Breathing

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

Circulation

1. Weak pulse, irregular
2. Tachycardia
3. Blood pressure increase / decrease
4. Edema
5. Nervous
6. Acral cold
7. Pale skin, cyanosis
8. Decreased urine output

Secondary Assessment Acute Myocardial Infarction (AMI) :

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

Nursing Diagnosis for Acute Myocardial Infarction (AMI)

1. Acute Pain
2. Decreased Cardiac Output
3. Activity Intolerance
4. Imbalanced Nutrition: Less than Body Requirements
5. Ineffective Tissue Perfusion
6. Anxiety
7. Ineffective Coping
8. Ineffective Sexuality Patterns

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