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.