tag:blogger.com,1999:blog-68233192373018558452024-02-20T13:39:42.527+07:00Nanda Nurse DiaryNanda - Nursing Care Planyanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comBlogger100125tag:blogger.com,1999:blog-6823319237301855845.post-35033597733951814422017-02-02T12:36:00.000+07:002017-02-02T12:36:11.088+07:00Nursing Care Plan - Risk for Violent BehaviorViolence can be defined as the use of physical force with the intent to injure another person or destroy property, while aggression is generally defined as angry or violent feelings or behavior. A person who is aggressive does not necessarily act out with violence.<br />
<br />
<b>Risk for Violent Behavior</b><br />
<br />
General goals :<br />
The client can control violent behavior<br />
<br />
Specific goals :<br />
<br />
1. The client can build a trusting relationship<br />
<br />
Expected outcomes:<br />
The client shows signs of believing in the nurse:<br />
Bright face, smiling.<br />
Want to get acquainted.<br />
No eye contact.<br />
Willing to share feelings.<br />
<br />
Nursing Inerventions :<br />
Develop a relationship of trust with:<br />
Greet each interaction.<br />
Introduce the names, nicknames nurses and nurses interact purposes.<br />
Ask and call the name of the client's favorite.<br />
Show empathy, honesty and keeping promises whenever interacting.<br />
Ask the client's feelings and problems faced by the client.<br />
Create a clear interaction contract.<br />
Listen attentively to client's expression of feelings.<br />
<br />
2. The client can identify the causes of violent behavior accomplishments<br />
Expected outcomes:<br />
The client tells the causes of violent behavior is doing; tells cause annoyance / upset either of themselves or their environment<br />
<br />
Nursing Intervetions :<br />
Help clients express feelings of anger:<br />
Motivation client to tell the cause of resentment or annoyance<br />
Listen without interrupting or give an assessment of each client's expression of feelings<br />
<br />
3. The client can identify signs of violent behavior<br />
Expected outcomes:<br />
The client tells the signs of violent behavior occurs when:<br />
Physical signs: red eyes, hands clenched, tense expression, and others.<br />
Signs of emotional: feelings of anger, resentment, spoke harshly.<br />
Social sign: hostile experienced during a violent behavior.<br />
<br />
Nursing Interventions :<br />
Help the client revealed signs of violent behavior that happened:<br />
Motivation of the client communicating the physical condition (physical signs) when the violent behavior happened<br />
Motivation of the client to share his emotional condition (signs of emotional) during a violent behavior<br />
Motivation of the client to tell the condition of relationship with others (social signals) during a violent behavior<br />
<br />
4. The client can identify the type of violent behavior has ever done<br />
Expected outcomes:<br />
The client explained:<br />
The types of anger expression that had been done<br />
Felt when violence<br />
<br />
Nursing Interventions :<br />
Discuss with the client violent behavior is usually done:<br />
Motivation of the client to tell the kinds of violence that had been done.<br />
Motivation of the client communicating the client's feelings after the incident of violence occurred<br />
Discuss whether the acts of violence that can overcome the problems experienced.<br />
<br />
5. The client can be identified as a result of violent behavior<br />
Expected outcomes:<br />
The client explained that due to the violence that is done<br />
Self: wounds, shunned friends, etc.<br />
Another person / family: wound, irritability, fear, etc.<br />
Environment: goods or broken objects, etc.<br />
The effectiveness of the methods used in solving problems<br />
<br />
Nursing Interventions :<br />
Discuss with the client due to the negative (losses) on how that is done:<br />
Self<br />
Others / family<br />
Environment<br />
<br />
6. The client can identify constructive ways of expressing anger<br />
Expected outcomes:<br />
Explaining healthy ways of expressing angry<br />
<br />
Nursing Interventions :<br />
Discuss with the client:<br />
Does the client want to learn a new way of expressing anger that healthy<br />
Explain the various alternative options to express angry besides the known violent behavior by the client.<br />
Explain healthy ways to express angry:<br />
Ø physical way: a deep breath, hit a pillow or mattress, sports.<br />
Ø Verbal: revealed that he was upset to others.<br />
Ø Social: assertiveness training with others.<br />
Ø Spiritual: prayer, meditation, etc according their religious beliefs<br />
<br />
7. The client can demonstrate how to control violent behavior<br />
Expected outcomes:<br />
The client demonstrates how to control violent behavior:<br />
Physical: take a deep breath, hit the pillow / mattress<br />
Verbal: express the feeling irritated / annoyed at others without hurting<br />
Spiritual: prayer, meditation accordance religion<br />
<br />
Nursing Interventions :<br />
Discuss ways that may be selected and encourage clients choose the possible ways to express anger.<br />
Train showcase selected clients: demonstrate how to implement the chosen method, explain the benefits of this way, encourage clients imitating the demonstration that has been done, give reinforcement to the client, correct way is still not perfect.<br />
Encourage clients to use tools already trained when angry / annoyed<br />
<br />
8. The client has a family support to control violent behavior<br />
Expected outcomes:<br />
Explain how to care for a client with violent behavior<br />
Expressed pleasure in caring for the client<br />
<br />
Nursing Interventions :<br />
Discuss the importance of the role of the family as a supporter of the client to address violent behavior.<br />
Discuss potential families to help the client resolve violent behavior<br />
Explain the meaning, causes, consequences and how to care for the clients of violent behavior that can be carried out by the family.<br />
Demonstrate how to care for the clients (to handle violent behavior)<br />
Give the family the opportunity to demonstrate again.<br />
Give praise to the family after the demonstration<br />
<br />
9. The client uses the appropriate therapy program that has been set<br />
Expected outcomes:<br />
The client explained:<br />
Benefits of taking medication<br />
Losses do not take medication<br />
Medicine name<br />
The shape and color of drugs<br />
The dose given<br />
time usage<br />
How to use<br />
Effects felt<br />
<br />
Nursing Interventions:<br />
Explain the benefits of using the medication regularly and damages if the client does not use medication<br />
Explain to the client: the type (name, color and form of the drug), the dose is right for the client, time of use, how to use, the effect will be felt by the client.<br />
Advise the client: Ask for and use of medication on time, Report to the nurse / physician if the client is experiencing unusual effects, Give praise to discipline the client using the drug, Ask the family feeling after trying ways trained.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-24917569540982283412017-02-02T10:48:00.001+07:002017-02-02T10:48:16.920+07:00Types of Conflict and Conflict Management<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7srcX1lZRXH8oRSWT2sp7aGu5Io0ePeCcN7Ayr8pnIxri9MSj6IKtvtjTWjVL2vDCK2azkxSGTGbN551crWQa_54bzNiTQkv1mXWDisQXDzPoS5uHitSnHa8zO0HSHdAsL6LrbdmgDCs/s1600/Types+of+Conflict+and+Conflict+Management.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="220" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7srcX1lZRXH8oRSWT2sp7aGu5Io0ePeCcN7Ayr8pnIxri9MSj6IKtvtjTWjVL2vDCK2azkxSGTGbN551crWQa_54bzNiTQkv1mXWDisQXDzPoS5uHitSnHa8zO0HSHdAsL6LrbdmgDCs/s320/Types+of+Conflict+and+Conflict+Management.jpg" width="320" /></a></div>
Conflict is basically divided into two parts: the internal conflict and external conflict. Internal conflicts occur at the individual, while the external conflict is a conflict that arises between two or more people and is known for interpersonal conflict, for example; conflicts within the couple.<br />
<br />
Conflicts according Winardi (1994) is divided into four, including:<br />
<br />
a. Conflict within the individual's own<br />
Every conflict can be devastating for the person or people who are related, among conflicts are more worried about potentially be called conflicts involving individual itself. Conflicts can arise due to excessive load role (role overlads) and the inability of the relevant role (role person- incompatibilities) in this case the husband and wife.<br />
<br />
b. Interpersonal conflicts<br />
Interpersonal conflicts between one or more individuals. For example the marital relationship.<br />
<br />
c. Conflicts between groups<br />
Another conflict situations arise in the organization, as a network of groups that are intertwined.<br />
<br />
d. Conflicts between organizations<br />
This conflict between the organizations.<br />
<br />
This study focused on interpersonal conflicts or conflicts from individual to individual (interpersonal conflict) is the conflict in the marriage happens to husband and wife.<br />
<br />
<br />
According to Thomas and Kilmann (in Wirawan, 2010) conflict is an objective condition mismatch between the values or goals, such as the behavior that intentionally disrupt efforts to achieve goals, and emotionally-containing atmosphere of hostility. They developed a taxonomy of conflict management styles based on two dimensions: the first collaboration is an attempt to satisfy others when dealing with conflict. Both assertiveness is an attempt of people to satisfy themselves when dealing with conflict. Based on these two dimensions Thomas and Kilmann offers five types of conflict management styles. The five types of conflict management styles are as follows:<br />
<br />
1. Competition. Conflict management styles with high assertiveness level and low level of cooperation. This style is a style oriented power, where someone would use the power it has to win the conflict with persecuted his opponents.<br />
<br />
2. Collaborating. Conflict management styles with a high degree of assertiveness and cooperation. The goal is to find an alternative, a common ground, and fully meet the expectations of both parties involved in the conflict.<br />
<br />
3. compromising. Central conflict management style, in which the level of assertiveness and cooperation being. By using the strategy of giving and taking (give and take), both parties to the conflict seek alternative midpoint satisfying as they desire.<br />
<br />
4. Avoiding. Conflict management styles with the same level of assertiveness and low employment. In the style of management of this conflict, both sides are trying to avoid conflict. According to Thomas and Kilmann dodge shapes could include: (a) keep away from the subject matter; (B) the subject matter of delay until the right time; or (c) withdrawing from the conflict which threaten and harm.<br />
<br />
5. Accomodating. Conflict management styles with a low level of assertiveness and a high level of cooperation. A neglect its own interests and seek to satisfy the interests of the opponent.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-36974351016873324532017-01-29T18:20:00.002+07:002017-01-29T18:20:21.627+07:00Neonatal Nurse Salary Range (powerpoint)Neonatal nursing is a subspecialty of nursing care for newborn infants up to 28 days after birth. The term neonatal comes from neo, "new", and natal, "pertaining to birth or origin". Neonatal nursing requires a high degree of skill, dedication and emotional strength as the nurses care for newborn infants with a range of problems, varying between prematurity, birth defects, infection, cardiac malformations and surgical problems. Neonatal nurses are a vital part of the neonatal care team and are required to know basic newborn resuscitation, be able to control the newborn's temperature and know how to initiate cardiopulmonary and pulse oximetry monitoring. (<i>wikipedia</i>)<br />
<br />
<iframe allowfullscreen="" frameborder="0" height="485" marginheight="0" marginwidth="0" scrolling="no" src="//www.slideshare.net/slideshow/embed_code/key/qFqCEVNJXNPYMh" style="border-width: 1px; border: 1px solid #ccc; margin-bottom: 5px; max-width: 100%;" width="595"> </iframe> <br />
<div style="margin-bottom: 5px;">
<b> <a href="https://www.slideshare.net/neonatalnurses/neonatal-nurse-salary-range-16466705" target="_blank" title="Neonatal Nurse Salary Range">Neonatal Nurse Salary Range</a> </b> from <b><a href="https://www.slideshare.net/neonatalnurses" target="_blank">neonatalnurses</a></b> </div>
yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-64615951998362155182016-07-24T11:53:00.000+07:002016-07-24T11:53:14.315+07:00Guillain-Barré Syndrome - Definition, Etiology and ClassificationGuillain-Barre syndrome is a cause of paralysis is fairly common in young adults. Guillain-Barre syndrome is often caused concerns for patients and their families because it occurs in the productive age, especially in some circumstances can cause death, although it generally has a good prognosis.<br />
<br />
Some names are called by some experts for this disease, namely idiopathic polyneuritis, acute febrile polyneuritis, acute infectious polyneuritis, acute postinfectious polyneuritis, Acute inflammatory demyelinating Polyradiculoneuropathy, Landry's ascending paralysis and Landry-Guillain-Barré Syndrome.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHy_TPqKME3UM0jzfpjpvGisqUx28NEc9_Tuxkf8Ncb_o3Imh5-75Ot4dvW0DC5jdo1f7d-UAyZ7YgI2_za2V2rmjIXJEmU2NuOSKquCgBVH5XfSDBOXq2T5PC-YWEN5UkaNMJXoatk8w/s1600/Guillain-Barr%25C3%25A9+Syndrome+-+Definition%252C+Etiology+and+Classification.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHy_TPqKME3UM0jzfpjpvGisqUx28NEc9_Tuxkf8Ncb_o3Imh5-75Ot4dvW0DC5jdo1f7d-UAyZ7YgI2_za2V2rmjIXJEmU2NuOSKquCgBVH5XfSDBOXq2T5PC-YWEN5UkaNMJXoatk8w/s320/Guillain-Barr%25C3%25A9+Syndrome+-+Definition%252C+Etiology+and+Classification.jpg" width="320" /></a></div>
<br />
<b>Definition</b><br />
<br />
Guillain-Barre syndrome or acute inflammatory demyelinating polyneuropathy is an acute inflammation that causes nerve cell damage without an obvious cause. This syndrome was found in 1916 by Georges Guillain, Jean-Alexandre Barré and Strohl André. They discovered the syndrome in two soldiers who suffered from abnormality increased production of cerebrospinal fluid protein. Diagnosis of Guillain-Barre syndrome can be done by analyzing cerebrospinal fluid and electrodiagnostic. Indications of infection is the increase in white blood cells in the cerebrospinal fluid. Whereas when using electrodiagnostic, can through conduction studies nerve cells. (Nugrahanti, 2010)<br />
<br />
Parry said that, Guillain-Barre syndrome is a polyneuropathy that is ascending and acute that often occurs after 1 to 3 weeks after acute infection. According to Bosch, Guillain-Barre syndrome is a clinical syndrome characterized by flaccid paralysis that occurs acutely associated with the autoimmune process in which the target is peripheral nerves, nerve roots and cranial nerves.<br />
<br />
<br />
<b>Etiology</b><br />
<br />
Guillain-Barre syndrome is still not known with certainty the cause and is still a matter of debate. Some state / illness that precedes and may be an association with the occurrence of Guillain-Barre syndrome, among others:<br />
<ul>
<li>Infection</li>
<li>Vaccination</li>
<li>Surgery</li>
<li>Systemic disease: malignancy, systemic lupus erythematosus, thyroiditis, Addison's disease</li>
<li>Pregnancy or during childbirth</li>
</ul>
<br />
Guillain-Barre syndrome is often associated with acute non-specific infections. The incidence of cases of Guillain-Barre syndrome associated with these infections approximately between 56% - 80%, which is 1 to 4 weeks before neurological symptoms arise, such as upper respiratory infections or gastrointestinal infections.<br />
<br />
Previously the syndrome is thought to be caused by a viral infection, but recently revealed that in fact the virus is not the cause. Scientists have theorized today is an abnormality Immunobiology, either primary immune response and immune-mediated process.<br />
<br />
In general, this syndrome is often preceded by influenza infection or upper respiratory tract or gastrointestinal tract. The cause of viral infections in general, of the herpes group. This syndrome can also be preceded by vaccination, bacterial infections, endocrine disorders, surgery, anesthesia, and so on.<br />
<br />
<br />
<b>Classification</b><br />
<br />
Some variant of Guillain-Barre syndrome can be classified as follows:<br />
<ul>
<li>Acute inflammatory demyelinating polyradiculoneuropathy</li>
<li>Subacute inflammatory demyelinating polyradiculoneuropathy</li>
<li>Acute of motor axonal neuropathy</li>
<li>Acute of motor and sensory axonal neuropathy</li>
<li>Fisher's syndrome</li>
<li>Acute pandysautonomia</li>
</ul>
yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-24845998994642989062016-07-21T10:56:00.000+07:002016-07-21T10:56:01.376+07:00Risk for Infection - Nursing Assessment and Nursing Diagnosis<br />
Infection is an invasion of the body by pathogens or microorganisms capable of causing illness (Potter and Perry, 2005).<br />
<br />
Some of the factors that trigger the risk of infection in patients by Potter and Perry (2005) are:<br />
<br />
1) Agent<br />
The agent causing the infection, the microorganism can enter because the agent itself or because the toxins are released.<br />
<br />
2) Host<br />
The hosts were infected, so even if there is an agent, if no one can be charged, there is no infection. Hosts are usually people or animals in accordance with the needs of the agent to survive or breed.<br />
<br />
3) Environment<br />
Environment, the environment around the agent and the host, such as temperature, humidity, sunlight, oxygen and so on. There are certain agents that can only survive or infect certain environmental conditions as well.<br />
<br />
<br />
<b>Signs and Symptoms</b><br />
<br />
Signs and symptoms are common in infections (Smeltzer, 2002) as follows:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1_4_pGO82F-5hnW69dPFQPDDMn6fci4JqNWggflafYS7nEyAe9kagfgJZ55rY18YQj4LzkHer3x-HKs2Ogmt4AC1ForUNUejmzQ3aI-z9DVDIAw8elk2roWpN7qGSt-EnUryhU8FDJcY/s1600/90df94e873f50a8df9d65c6eebf5e671.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="172" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1_4_pGO82F-5hnW69dPFQPDDMn6fci4JqNWggflafYS7nEyAe9kagfgJZ55rY18YQj4LzkHer3x-HKs2Ogmt4AC1ForUNUejmzQ3aI-z9DVDIAw8elk2roWpN7qGSt-EnUryhU8FDJcY/s320/90df94e873f50a8df9d65c6eebf5e671.jpg" width="320" /></a></div>
<br />
<br />
1. Rubor<br />
Rubor or redness is first seen in areas that become inflamed. When inflammatory reactions arise, dilation of the arterioles that supply blood to areas of inflammation. So that more blood flows to local microcirculation and capillary stretch quickly filled with blood. This condition is called hyperemia or congestion, causing local red color because of acute inflammation.<br />
<br />
2. Calor<br />
Calor occur simultaneously with redness of acute inflammatory reactions. Calor is also caused by increased blood circulation. Because blood has a temperature of 37 degrees Celsius is channeled to the body surface inflamed to the area more than normal.<br />
<br />
3. Dolor<br />
Changes in local pH or local concentration of certain ions can stimulate nerve endings. Spending substances such as histamine or other bioactive can stimulate nerves. The pain is caused also by the pressure was rising due to swelling of inflamed tissue.<br />
<br />
4. Tumor<br />
Swelling partly due to hyperemia and mostly caused by the delivery of fluid and cells from the blood circulation into the interstitial tissues.<br />
<br />
5. Functio Laesa<br />
Functio laesa is a loss of function or a disturbance of function. <br />
<br />
<br />
<b>Diagnostic</b><br />
<br />
Laboratory tests are directly related to the infection include a complete blood count that includes: hemoglobin, leukocytes, hematocrit, erythrocytes, platelets, MCH, MCHV, basophils, eosinophils, stem segments, lymphocytes, and monocytes, erythrocyte sedimentation rate (ESR), random blood glucose, and albumin.<br />
<br />
<br />
<b>Medical Management</b><br />
<br />
1. Aseptic<br />
Actions taken in health care. This term is used to describe all the work done to prevent the entry of microorganisms into the body that are likely to lead to infection. The end goal is to reduce or eliminate the number of microorganisms, both on the surface of animate objects and inanimate objects so that medical equipment can be safely used.<br />
<br />
2. Antiseptic<br />
Efforts to prevent infection by killing or inhibiting the growth of microorganisms on the skin and other body tissues.<br />
<br />
3. Decontamination<br />
Actions taken so that an inanimate object can be handled safely by health workers, particularly medical clearance officer before washing done. An example is the examination table, medical equipment and gloves contaminated with blood or body fluids when actions are performed.<br />
<br />
4. Washing<br />
The removal of all blood, body fluids, or any foreign objects such as dust and dirt.<br />
<br />
5. Sterilization<br />
The removal of all microorganisms (bacteria, fungi, parasites and viruses), including bacterial endospore of inanimate objects.<br />
<br />
6. Disinfection<br />
The removal of most (not all) of disease-causing microorganisms from inanimate objects. High-level disinfection is done by boiling or using chemical solutions. This action can eliminate all microorganisms except some bacterial endospore.<br />
<br />
<br />
<b>Nursing Assessment</b><br />
<br />
1. Identity<br />
Getting the patient identity data, including name, age, education, occupation, address, registration number, and medical diagnostics.<br />
<br />
2. Health history<br />
<ul>
<li>The main complaints: Complaints are most felt by the patient to seek help.</li>
<li>Health history now: What is being felt now.</li>
<li>Past medical history : Is the possibility of patients had never had this disease or have ever been.</li>
<li>Family health history: Covering hereditary diseases or non-communicable diseases.</li>
</ul>
<br />
3. The need for Bio-Psycho-Social-Spiritual.<br />
Needs Bio-Psycho-Social-Spiritual include breathing, eating, drinking, elimination, motion and activity, rest - sleep, personal hygiene, temperature control, security and comfort, socialization and communication, achievement and productivity, knowledge, recreation and worship.<br />
<br />
4. Physical Examination<br />
a. General State<br />
The general state include: general impression, awareness, posture, skin color, skin turgor, and personal hygiene.<br />
b. Cardinal Symptoms<br />
Cardinal symptoms include: temperature, pulse, blood pressure, and respiration.<br />
c. Physical State<br />
Includes examining the physical state of the head to the lower extremities.<br />
<ul>
<li>Inspection: examine the skin, mucous membrane color, general appearance, adequacy systemic circulation, breathing pattern, chest wall movement.</li>
<li>Palpation: local tenderness, feeling a lump or axilla and breeast tissue, peripheral circulation, the peripheral pulse, skin temperature, color and capillary refill.</li>
<li>Percussion: knowing abnormal fluid, the air in the lungs, or the working diaphragm.</li>
<li>Auscultation: abnormal sounds, murmurs, as well as friction sound, or the sound of an extra breath.</li>
</ul>
<br />
<br />
<b>Nursing Diagnoses</b><br />
<br />
<a href="http://www.nandanursediary.top/2012/12/risk-for-infection-ncp-anemia.html"><b>Risk for Infection</b></a><br />
<br />
Definition: Having an increased risk of pathogenic organisms<br />
<br />
Risk Factor:<br />
<br />
Chronic Diseases<br />
<ul>
<li>Diabetes mellitus</li>
<li>Obesity</li>
</ul>
Knowledge is not enough to avoid pathogen exposure.<br />
Defence inadequate primary body.<br />
<ul>
<li>Impaired peristaltic</li>
<li>Damage to skin integrity (intravenous catheterization, an invasive procedure)</li>
<li>Changes in pH secretion</li>
<li>Decrease in work ciliary</li>
<li>Premature rupture of membranes</li>
<li>Smoking</li>
<li>Static body fluids</li>
<li>Tissue trauma network (ie., trauma, tissue destruction)</li>
</ul>
Inadequate secondary defenses<br />
<ul>
<li>Decrease in hemoglobin</li>
<li>Immunosuppression (ie., Immunity acquired is inadequate, pharmaceutical agents including immunosuppressants, steroids, monoclonal antibodies, immunomodulators)</li>
<li>Leukopenia</li>
<li>Suspension inflammatory response</li>
</ul>
Vaccination inadequate<br />
Exposure to environmental pathogens which increased<br />
<ul>
<li>outbreak</li>
</ul>
Invasive procedures<br />
Malnutritionyanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-64108727426223152022015-10-05T11:54:00.000+07:002019-02-13T14:05:16.762+07:00Hyperthermia and Ineffective Airway Clearance related to Bronchitis<b>Nursing Diagnosis and Interventions for Bronchitis:</b><br />
<br />
1. Ineffective airway clearance related to increased production of secretions.<br />
<br />
Goal: The client does not feel shortness of breath and no sputum.<br />
<br />
Expected outcomes:<br />
<ul><li>Maintain a patent airway with breath sounds clean or clear.</li>
<li>Shows behavior to improve airway clearance, for example: an effective cough.</li>
</ul>Interventions:<br />
<ul><li>Assess the respiratory function, breath sounds, the speed of the rhythm.</li>
<li>Assess a comfortable position for a client.</li>
<li>Suggest to cough effectively.</li>
<li>Collaboration: Provision mukolitik, Give the drug as an indication.</li>
</ul>Rationale:<br />
<ul><li>Assist the breathing pattern changes.</li>
<li>Breathing can facilitate the circulation in the body.</li>
<li>Cough teach effectively so patients independently.</li>
<li>To lower airway spasm.</li>
<li>Lowering the mucosal edema and smooth muscle spasm.</li>
</ul><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpU6mQc7rX2TxOQrCryG4urtFIwbGikE26FIn9_eM7wi8w81a5mlHkuvFJwn7WWg9HH1gPm5wlGom4UTnP7bRW18wOH5jIBu7WH4ikD3X97CMhGvuRVMyM52ubFa547siZYFM6yvz4WOY/s1600/Hyperthermia-and-Ineffective-Airway-Clearance-related-to-Bronchitis.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpU6mQc7rX2TxOQrCryG4urtFIwbGikE26FIn9_eM7wi8w81a5mlHkuvFJwn7WWg9HH1gPm5wlGom4UTnP7bRW18wOH5jIBu7WH4ikD3X97CMhGvuRVMyM52ubFa547siZYFM6yvz4WOY/s1600/Hyperthermia-and-Ineffective-Airway-Clearance-related-to-Bronchitis.jpeg" /></a></div>2. Hyperthermia related to the inflammatory process.<br />
<br />
Goal: The client can reach the normal temperature.<br />
<br />
Expected outcomes:<br />
<ul><li>Normal body temperature (36.5 to 37.5 0C-0C)</li>
</ul>Interventions:<br />
<ul><li>Give a warm compress or cold pack in accordance with the client's approval.</li>
<li>Encourage clients to use clothing that is thin and absorbs perspiration.</li>
<li>Dressing damp or wet with sweat that much.</li>
<li>Give a thin blanket.</li>
<li>Collaboration: Give antipyretics.</li>
</ul>Rationale:<br />
<ul><li>Warm compresses help dilate the pores of the skin surface so as to accelerate heat dissipation.</li>
<li>Clothing that is thin, does not hinder the body's heat loss.</li>
<li>Clothes are damp / wet will cause inconvenience to the client.</li>
<li>Thick blanket that will hinder the body's heat loss.</li>
<li>Can help you lose body heat.</li>
</ul>yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-57542755393562794652015-10-05T11:34:00.002+07:002015-11-11T20:43:32.569+07:00Acute and Chronic Bronchitis - Causes, Risk Factors, Symptoms and Prevention<br />
There are two types of bronchitis is acute bronchitis and chronic bronchitis.<br />
<br />
General conditions of acute bronchitis often develops from a cold or other respiratory infection. Acute bronchitis usually improves within a few days without leaving the effect, although you can continue to cough within weeks.<br />
<br />
While chronic bronchitis is a more serious condition, this condition is irritation or inflammation constantly on bronchial pipes and is often caused by smoking. However if you have recurrent bronchitis condition, you may be experiencing chronic bronchitis. Chronic bronchitis is one of the conditions associated with chronic obstructive pulmonary disease (COPD).<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7QL68mRTakCUjr1h1MyCMz22ic9-4fmKHUTFTJBoZsm1si9i5c6ISUqnIoWdkZnSnvc2ItgW_gKrKBhhGF441v8xi5Oekjie-NCXKW7fcgqCTx55dOZ8_jU9-885dDtoib1IDu7yt5dA/s1600/Acute+and+Chronic+Bronchitis+-+Causes%252C+Risk+Factors%252C+Symptoms+and+Prevention.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7QL68mRTakCUjr1h1MyCMz22ic9-4fmKHUTFTJBoZsm1si9i5c6ISUqnIoWdkZnSnvc2ItgW_gKrKBhhGF441v8xi5Oekjie-NCXKW7fcgqCTx55dOZ8_jU9-885dDtoib1IDu7yt5dA/s320/Acute+and+Chronic+Bronchitis+-+Causes%252C+Risk+Factors%252C+Symptoms+and+Prevention.jpg" width="320" /></a></div><b>Causes of of Acute and Chronic Bronchitis</b><br />
<br />
<b>Acute Bronchitis</b><br />
Cold viruses often cause acute bronchitis. But you can also experience non-infectious bronchitis because of exposure to cigarette smoke and other pollutants such as dust.<br />
<br />
Bronchitis can also occur when stomach acid rises into the esophagus, a condition known as gastroesophageal reflux disease (GERD). And workers exposed to dust or fumes can suffer bronchitis particular. Acute bronchitis generally disappear when no longer exposed to the irritant.<br />
<br />
<br />
<b>Chronic Bronchitis</b><br />
Sometimes the inflammation and bronchial wall thickening pipe becomes permanent, a condition known as chronic bronchitis. You generally consider that you have chronic bronchitis if you cough every day lost after three months of the year in two consecutive years.<br />
<br />
Unlike acute bronchitis, chronic bronchitis persists and is a serious illness. Smoking is the biggest cause, but air pollution and dust or toxic gases in the environment or workplace also can contribute to this disease.<br />
<br />
<br />
<b>Risk Factors of Bronchitis</b><br />
<br />
Factors that increase the risk of bronchitis, among others:<br />
<ul><li>Smoking. Smoking was the source of various diseases. Therefore, stop smoking because it is very detrimental to health.</li>
<li>Weak immune system, may be due to recovering from illness or other conditions that make the immune system becomes weak.</li>
<li>The condition in which stomach acid up into the esophagus (gastroesophageal reflux disease).</li>
<li>Exposed to irritants, such as pollution, smoke or dust.</li>
</ul><br />
<br />
<b>Symptoms of Acute and Chronic Bronchitis</b><br />
<br />
Here are some of the symptoms of acute and chronic bronchitis need to know:<br />
<ul><li>Cough.</li>
<li>The presence of mucus, either colorless, white or yellow-green.</li>
<li>Shortness of breath, worsening even while exerting little effort.</li>
<li>Tired.</li>
<li>Mild fever and chills.</li>
<li>Discomfort in the chest.</li>
</ul><br />
If you have acute bronchitis, you may have a cough that persists in a few weeks after recovering from bronchitis. However bronchitis symptoms can be confusing. You can not have mucus when you have bronchitis, and children often swallow the mucus so that parents may not know it. There can experience chronic bronchitis without acute bronchitis beforehand. As well as many smokers who have to clean up the mucus in the throat in the morning when waking from sleep, which, if it continues for more than three months, may have chronic bronchitis.<br />
<br />
If you have chronic bronchitis, the inflammation in the long term lead pipe bronchila injured and produce too much mucus. Eventually the pipe wall will bronchial airways thicken and you may be injured. Signs and symptoms of chronic bronchitis also can be:<br />
<br />
Cough which worsened in the morning and in the humid weather.<br />
Frequent respiratory infections (such as colds and flu) with a worsening cough up phlegm.<br />
<br />
If you have chronic bronchitis, you may have a period in which signs and symptoms will worsen. At that time you can have a well-padded acute bronchitis due to bacterial or viral in addition to your chronic bronchitis.<br />
<br />
<br />
<b>Prevention of Bronchitis</b><br />
<br />
Measures that can help reduce the risk of bronchitis and protect your lungs in general are:<br />
<ul><li>Avoid smoking or exposure to cigarette smoke.</li>
<li>Avoid those who are sick colds or flu.</li>
<li>Wash your hands regularly.</li>
<li>Use a mask to reduce the risk of infection.</li>
</ul>yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-67719419323704911412015-07-09T23:48:00.001+07:002015-07-10T00:01:07.238+07:00Common Causes that Make a Person Loss of Appetite for DaysEveryone must have experienced the condition appetite decreased or disappeared at a time. In medical terms, decreased appetite termed anorexia.<br />
<br />
In many cases, loss of appetite caused by the disease, which means that the condition is just a symptom of a disease. Appetite will return to normal once the disease is gone. The condition was not too worried unless lasted for more than one or two days.<br />
<br />
Other circumstances such as stress, sadness and anxiety-whichever common nowadays, - can also affect the normal appetite. It often occurs in adolescents and adults.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDcMbrcYkWDHLNlWnIuTkrZdLk2Qtvu3ZAXz14H-l5cWBrjg5hIEIEiYUrbz-9U04CPZgRXjmZ8N9yu21FLSQocIFWcg7n3T6PygN2nMs8XV0TVcVVRO6GMdh1Aoh6CixwRi53qG2LBYM/s1600/common-causes-that-make-a-person-loss-of-appetite-for-days.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDcMbrcYkWDHLNlWnIuTkrZdLk2Qtvu3ZAXz14H-l5cWBrjg5hIEIEiYUrbz-9U04CPZgRXjmZ8N9yu21FLSQocIFWcg7n3T6PygN2nMs8XV0TVcVVRO6GMdh1Aoh6CixwRi53qG2LBYM/s1600/common-causes-that-make-a-person-loss-of-appetite-for-days.jpg" /></a></div>
<b>What happens to the body so that appetite decreased?</b><br />
<br />
Basically, the appetite is an internal regulatory system that aims to meet the energy and nutritional needs of the body. The loss of your normal appetite would be a problem if the condition persists. It could be a symptom of a more serious disease. If these conditions persist, a person at risk of malnutrition or lack of nutrients.<br />
<br />
<br />
<b>Causes of lost appetite or decreased</b><br />
<br />
Apart from the pain, appetite can also be reduced because of the effects of medical drugs that are being consumed by a person, or as well as weight loss diet program that is being executed.<br />
<br />
Decreased appetite also almost always occur in the elderly, for no apparent reason could be found. However, factors such as sadness, depression, and excessive anxiety is a common cause of these conditions, and decrease the weight, especially in the elderly.<br />
<br />
Cancer can also cause a decrease in appetite drastically. Cancers that make appetite disappeared, among others:<br />
<ul>
<li>colon cancer</li>
<li>ovarian cancer</li>
<li>pancreatic cancer</li>
<li>stomach cancer</li>
</ul>
In addition, below are some other common causes that make a person lose appetite for days: <br />
<ul>
<li>Infection, for example; pneumonia, hepatitis, HIV, influenza, or kidney infection called pyelonephritis.</li>
<li>Heart disease, kidney, and liver were serious. For example is chronic renal failure, cirrhosis, or congestive heart failure can cause loss of appetite.</li>
<li>Blockage in the stomach, known as intestinal obstruction.</li>
<li>Inflammation of the stomach or intestine, as occurs in patients with pancreatitis, inflammation of the pancreas, irritable bowel, or appendix.</li>
<li>Endocrine problems, such as diabetes mellitus, or a condition that causes low thyroid hormone levels (hypothyroidism).</li>
<li>An autoimmune disorder, a condition in which a person's immune system attacks the body itself. Examples include rheumatoid arthritis and scleroderma.</li>
<li>Psychiatric conditions, such as depression, schizophrenia, or an eating disorder called anorexia nervosa.</li>
<li>Pregnancy.</li>
<li>Dementia, such as Alzheimer's disease, a condition that causes decreased memory and other brain function decline.</li>
</ul>
<br />
<b>What long-term effects of a loss of appetite?</b><br />
<br />
Malnutrition, lack of food and nutrients your body needs, is a major serious problem of loss of appetite if it lasts for more than a few weeks. Other long-term effects associated with the cause. For example, diabetes can cause damage to various organs in the body, including the kidneys, eyes and nerves. Because of a lack of appetite, the body lacks essential nutrients to control diabetes.<br />
<br />
Other effects related to the cause was cancer, which can cause death.<br />
<br />
<br />
<b>How to Overcome Decreased Appetite</b><br />
<br />
The main thing is to find the cause of the loss of appetite. If caused by common ailments such as colds and fever, the appetite will improve after the disease is cured.<br />
<br />
Consuming a multivitamin appetite enhancer may be necessary as a first step to restore the lost appetite. You can also try your favorite dish to cope with the declining appetite.<br />
<br />
But if you can not detect a cause, and the condition lasts for several days, immediately consult a doctor for further diagnosis.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-37269190735774229392015-07-06T23:43:00.001+07:002015-07-06T23:43:38.387+07:00Tetanus - Causes, Symptoms, Complications, Diagnosis and Preventions<div dir="ltr" style="text-align: left;" trbidi="on">
<b>Tetanus</b><br />
<br />
Tetanus is a serious infectious disease that attacks the nervous system and is characterized severe muscle contractions (seizures). This disease usually occurs as a result of stab wounds in the body of contaminated dust, manure, soil and animal or human feces.<br />
<br />
<br />
<b>Causes of Tetanus</b><br />
<br />
The cause is the bacteria Clostridium tetani, a type of bacteria that can only grow and thrive in situations that are less oxygen environment (anaerobic).<br />
<br />
<br />
<b>Symptoms of Tetanus</b><br />
<br />
Incubation period between injury until symptoms occur, generally lasts approximately 8 days (5-21 days), starting with stiffness in the jaw so that the mouth becomes locked (lockjaw) followed by:<br />
<ul style="text-align: left;">
<li>Muscle stiffness in: the face, neck, chest, stomach, back up the spine arched (epistotonus), hands and legs</li>
<li>Difficulty in swallowing</li>
<li>Fever</li>
<li>Excessive sweating</li>
<li>High blood pressure</li>
<li>Rapid heart rate</li>
<li>Disturbance defecating and urinating</li>
</ul>
<br />
<br />
<b>Neonatal Tetanus</b><br />
<br />
Neonatal tetanus is the tetanus which attack newborns (neonates). This disease generally occurs due care less hygienic umbilical cord so contaminated by tetanus germs, and is characterized by fussy baby, stiff muscles, difficulty eating / drinking and death.<br />
<br />
<br />
<b>Complications of Tetanus</b><br />
<br />
Severe tetanus can lead to complications such as:<br />
<ul style="text-align: left;">
<li>A torn muscle</li>
<li>Vertebral fractures</li>
<li>Respiratory failure, until death due to respiratory muscle spasm</li>
<li>In infants will occur serious brain damage</li>
</ul>
<br />
<b></b><br />
<b>Diagnosing Tetanus</b><br />
<br />
Until now there is no specific laboratory tests to make sure someone is suffering from tetanus, so doctors rely on their history of injuries and the typical symptoms are found.<br />
<br />
Examination can be done to support the diagnosis is testing a spatula that is touching the wall of the throat with a spatula (a kind of scoop), tetanus response is biting the spatula and close the mouth while a normal person would react nausea.<br />
<br />
<br />
<b>Preventing Tetanus</b><br />
<br />
Several steps can be taken to prevent this disease are:<br />
<ul style="text-align: left;">
<li>Hygienic wound care</li>
<li>Tetanus vaccine (tetanus toxoid), both primary immunization in infants and children and repeated vaccination every 10 years or in the event of a serious injury.</li>
</ul>
</div>
yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-79850498904690305772015-07-06T23:30:00.001+07:002015-07-06T23:30:42.971+07:00The Characteristics of Patients with Bulimia Nervosa You Should Know<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEid73uAMwoqd08XkCcAUb9cvxTVJliIcK65OhmE3BKW9hfDfjUgzRdo5vnHTnffCEH4qfUA_lPXQMzzF4s7pKhohuYIqtrkWFFiWwpm0QTasNs6RbiFnbipEa5aSbTGt85JZnnLyX90vg8/s1600/The+Characteristics+of+Patients+with+Bulimia+Nervosa+You+Should+Know.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEid73uAMwoqd08XkCcAUb9cvxTVJliIcK65OhmE3BKW9hfDfjUgzRdo5vnHTnffCEH4qfUA_lPXQMzzF4s7pKhohuYIqtrkWFFiWwpm0QTasNs6RbiFnbipEa5aSbTGt85JZnnLyX90vg8/s1600/The+Characteristics+of+Patients+with+Bulimia+Nervosa+You+Should+Know.jpg" /></a></div>
Bulimia Nervosa is a disorder of eating, which is visible from the habit of overeating that occurs continuously. Bulimia is an eating disorder that often occurs in women. The disorder usually is a form of self-torture. The most frequently performed by more than 75% of people with bulimia nervosa is making herself vomit, sometimes called cleaning; fasting, and use of laxatives, enemas, diuretics, and excessive exercise are also a common feature.<br />
<br />
Bulimia is a disease caused by the psychology of the patient, resulting in eating disorders. Bulimia is a condition where a patient overeating repeatedly and then back out. Issued food eaten can be through vomiting usually induced by laxatives, but it is also by removing it through urination by using diuretics.<br />
<br />
Moreover, in addition to overeating, bulimia sufferers also tend to be very strict diet and excessive exercise. Characteristics of bulimia disease is certainly a habit of issuing food eaten very quickly, so it is very strange to ordinary people when back regurgitate after eating food.<br />
<br />
Cleaning or vomit estimated as action to reduce hatred or guilt because they binge. Patients obsessed to rid themselves of the food, so food intake did not get absorbed by the body.<br />
<br />
Cleaning action usually takes place immediately, but in some people with bulimia do cleaning at some period thereafter.<br />
<br />
As with anorexia, bulimia is always associated with a control diet or weight loss. People with bulimia are usually paid much attention to weight, always feel less confident with the weight that tend to excessive dieting. The difference with patients with anorexia, people with bulimia have more stable body weight so that the disease is rarely known by the general public.<br />
<br />
To detect the symptoms of bulimia in everyday life is hard. Process sometimes overeating is a common thing in society. Eating is a fun activity, can relieve stress or depression. In addition, each person also has a different appetite, so eat with the number of lots that sometimes is normal.<br />
<br />
In addition, people with bulimia are not always thin. Could have had a normal weight or even overweight. But there are some signs that can be considered as a symptom of bulimia, namely:<br />
<ul style="text-align: left;">
<li>Always to the bathroom after meals to throw up (of course done many times).</li>
<li>Excessive exercise.</li>
<li>There is a change such as swollen cheeks or jaw, broken blood vessels in the eye, damage to the tooth enamel so that it is obvious.</li>
<li>Too shackled with heavy affairs or body shape.</li>
</ul>
</div>
yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-45808286198440238302015-06-23T09:53:00.001+07:002015-06-23T09:53:58.977+07:00Ineffective Individual Coping related to Bulimia Nervosa<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgC7R8MMbTfWKKgplGCSKeYCHQm2F1ShzM8bhy2MmYpMzM2zzZGmnEOslqg1SxdXo23uleC1x9k1ATCAJLHtZQM-sgtHThX8vLtkkqcV7pWBeuhrI5P1Q8z6bhrIVTkd37AC-gRuuPZ3Z0/s1600/ineffective-individual-coping-related-to-bulimia-nervosa.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgC7R8MMbTfWKKgplGCSKeYCHQm2F1ShzM8bhy2MmYpMzM2zzZGmnEOslqg1SxdXo23uleC1x9k1ATCAJLHtZQM-sgtHThX8vLtkkqcV7pWBeuhrI5P1Q8z6bhrIVTkd37AC-gRuuPZ3Z0/s1600/ineffective-individual-coping-related-to-bulimia-nervosa.jpg" /></a></div>
<b>Nursing Care Plan for Bulimia Nervosa</b><br />
<br />
Bulimia nervosa is a disorder in eating habits. Eating disorders are a psychiatric syndrome that is characterized by eating patterns associated with aberrant psychological characteristics associated with eating, body shape and weight. eating disorders occur due to several reasons in eating behavior, such as consumption of less healthy foods or eating too much.<br />
<br />
Bulimia nervosa is a feast of food, followed by washing stomach or vomiting. Eating disorders usually occur together with other diseases such as depression, being part of a violent, and anxiety disorders. In this case, people who suffer from eating disorders can experience physical health complications further, including the problem of the working conditions of liver and kidney failure, which can lead to death. Many people with bulimia have a normal weight and seem to be no significant problems in life. Their regular people who look healthy, successful in his field, and tend ferfeksionis. However, behind it, have low self-esteem and often depressed.<br />
<br />
<br />
<b>Nursing Diagnosis : Ineffective individual coping</b><br />
<br />
Goal: ineffectiveness of individual coping can be met.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Identify methods that are not associated with less food in the face of stress or crisis.</li>
<li>Expressed feelings of guilt, anxiety, anger, or excessive need for control.</li>
<li>Shows a more satisfying interpersonal relationships.</li>
<li>Revealed more realistic body image.</li>
<li>Addressing an alternative method of dealing with stress or crisis.</li>
<li>Revealed an increase in self-esteem and confidence.</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Assess client's eating habits.</li>
<li>Encourage clients to eat with other clients or their families, if tolerated.</li>
<li>Encourage clients to express their feelings (anxiety and guilt about eating).</li>
<li>Encourage clients to keep a diary to write down the type and amount of food eaten, identify feelings experienced before and after eating, especially about excessive eating behavior and depletion.</li>
<li>Discuss the client's preferred food and reduce anxiety.</li>
<li>Help clients explore ways to overcome the emotions (anger, anxiety, and frustration).</li>
<li>Give positive feedback to the client.</li>
<li>Teach client about the use of problem-solving process.</li>
<li>Exploration with the client about personal power.</li>
<li>Discuss with the client about the idea of receiving underweight "ideal".</li>
<li>Encourage clients to express their feelings, about the family members and those closest, role and relationship with them.</li>
</ul>
<br />
Rationale :<br />
<ul>
<li>Preventing overeating behavior that includes eating secretly and swallow food, helps clients quickly and return to normal diet (three times daily).</li>
<li>Prevent secrecy about eating, though at first anxiety, the client may be too high to join the meal together.</li>
<li>Helps reduce feelings verbally can reduce anxiety and reducing the depletion of food behaviors.</li>
<li>Helping clients examine food intake and feelings they experienced.</li>
<li>Helping clients looking at using food to cope with feelings or make it comfortable.</li>
<li>Helping clients to separate emotional issues of food and eating behavior.</li>
<li>Increase efforts to clients in the face of anxiety, anger, and other emotions honestly and openly.</li>
<li>Helps clients improve self-esteem and confidence of clients.</li>
<li>Helping clients find strength.</li>
<li>Change the client's perception of ideal body weight may be unrealistic and unhealthy.</li>
<li>Helping clients identify, accept, and cope with their feelings in a proper way.</li>
</ul>
yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-48676143725683571472015-06-23T09:16:00.002+07:002015-06-23T09:16:43.746+07:00Pathophysiology and Early Symptoms of Dementia<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw4fPiMJ-3GIeYvxB834XoFbQ2nXy96U8uD4Gy3zK_dX1HdPObPfjOfqeSfDobubvd2ojU54Fycgu3JS_XwLZ1xQMiGTYH3F0g-n_8ObDLB5HgJZRZ0IplMSr8I9iKGRPT0rsRsNKOErk/s1600/pathophysiology-and-early-symptoms-of-dementia.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Pathophysiology and Early Symptoms of Dementia" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgw4fPiMJ-3GIeYvxB834XoFbQ2nXy96U8uD4Gy3zK_dX1HdPObPfjOfqeSfDobubvd2ojU54Fycgu3JS_XwLZ1xQMiGTYH3F0g-n_8ObDLB5HgJZRZ0IplMSr8I9iKGRPT0rsRsNKOErk/s1600/pathophysiology-and-early-symptoms-of-dementia.jpg" /></a></div>
Dementia is not a specific disease. Dementia is a term used to describe a collection of symptoms that can be caused by a variety of disorders that affect the brain. A person with dementia have impaired intellectual functioning and causes disruption in daily activities or relationships with people around. People with dementia also lose the ability to solve problems, control emotions, and can even experience personality changes and behavioral problems such as irritability and hallucinations. A person diagnosed with dementia when two or more brain functions, such as memory and language skills, decreased significantly without loss of consciousness.<br />
<br />
Pathophysiology of dementia usually begins gradually and increasingly worse, so that this situation did not at first realize. A decline in memory, the ability to remember the time and the ability to recognize people, places and objects. Patients have difficulty in finding and using the right words and the abstract thinking (eg in the use of numbers). Frequent changes in personality and behavior disorders.<br />
<br />
Early symptoms usually are oblivious to what just happened but it could also begin as depression, fear, anxiety, decreased emotion, or other personality changes. There is a change in the pattern of speaking lightly so people use words more simple, using words that are not appropriate or not being able to find the right words. Inability to interpret the signs could pose difficulties in driving. In the end, patients are unable to perform their social functions.<br />
<br />
Some people can hide their deficiencies well. They avoid complex activities (such as reading or working). Patients who do not succeed in changing his life may experience frustration because of inability to perform everyday tasks. Patients forget to perform the essential duties or wrong in doing the task.<br />
<br />
Dementia is quite common in the elderly, afflicts about 16% of the age group above 65 years of age and 32-50% in the age group above 85 years. In about 10-20% of cases of dementia are reversible or treatable. The most frequent cause of dementia is Alzheimer's disease. Causes of Alzheimer's disease is unknown, but is thought to involve genetic factors, because the disease seems to be found in some families and are caused or influenced by several specific gene abnormalities. In Alzheimer's disease, some parts of the brain decline, resulting in cell damage and reduced response to a chemical that transmits signals in the brain. In the brain found abnormal tissue (called senile plaques and irregular nerve fibers) and abnormal proteins, which can be seen at autopsy. Lewy Body dementia closely resembles Alzheimer's disease, but have differences in microscopic changes that occur in the brain.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-41358827919763523112015-06-18T00:48:00.001+07:002015-06-18T00:48:24.982+07:00Prompts for Patients with Hordeolum (Stye)<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGv60mVj1n1qDDuV9bhU3re41bisSpPH6njKT9-JXAhNTsCKZMl23h2HLBPT4NyUFjLGs5fdh4rELjttTcllz3DM6k6Rd7cQ-pHhxZ9RWne8VAOh0GiyKkkq940cWAvkPJJQJUWPc_lg8/s1600/prompts-for-patients-with-hordeolum-stye.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGv60mVj1n1qDDuV9bhU3re41bisSpPH6njKT9-JXAhNTsCKZMl23h2HLBPT4NyUFjLGs5fdh4rELjttTcllz3DM6k6Rd7cQ-pHhxZ9RWne8VAOh0GiyKkkq940cWAvkPJJQJUWPc_lg8/s320/prompts-for-patients-with-hordeolum-stye.jpg" width="320" /></a></div>
Hordeolum can affect anyone, from children to the elderly. Stated that the incidence in adults more than children. There is no difference in the incidence (incidence rate) between men and women. Sometimes a person is really experiencing hordeolum (recurring). Supposing, just recovered that one, then reappear somewhere else.<br />
<br />
Hordeolum is an infection or inflammation of the gland at the edge of the upper eyelid and the lower part caused by bacteria, usually by staphylococcus bacteria (Staphylococcus aureus).<br />
<br />
Hordeolum may arise in one or more of the eyelid glands. Eyelid glands include Meibomian glands, the glands of Zeis and Moll.<br />
Based on the place, hordeolum is divided into 2 types:<br />
<br />
Internal hordeolum, occurred on Meibomian glands. At this internal hordeolum bump leads to the conjunctiva (the inner lining of the eyelid).<br />
External hordeolum, occurred at Zeis glands and Moll glands. Lump visible from the outside on the outside of the eyelid skin.<br />
<br />
<br />
<b>Symptoms of Hordeolum</b><br />
<ul>
<li>Signs hordeolum is easily recognized, namely visible lump on the eyelid the top or bottom, reddish. Sometimes appear whitish or yellowish spots accompanied by swelling of the eyelids.</li>
<li>On the internal hordeolum, the lump will appear more clearly with open eyelid.</li>
<li>Complaints are often felt by people hordeolum, including lump on the eyelid flavor, tenderness and increasing pain when bent. Sometimes watery eyes and sensitive to light.</li>
<li>Hordeolum can form an abscess in the eyelid and broken by removing the pus.</li>
</ul>
<br />
<br />
<b>Prompts for Patients with Hordeolum (Stye)</b><br />
<ul>
<li>Avoid scratching or tapping hordeolum.</li>
<li>Do not squeeze the hordeolum. Let hordeolum broke by itself, then wipe with a sterile gauze when out pus or fluid from the hordeolum.</li>
<li>Close your eyes while cleaning hordeolum.</li>
<li>To temporarily stop using makeup on the eyes.</li>
<li>Remove contact lenses during the treatment period.</li>
</ul>
yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-11159498317208788622015-06-18T00:25:00.001+07:002015-06-18T00:25:58.244+07:00Causes and How to Prevent LBP (Low Back Pain)<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYUPYJhZ4LpSDRz0JnxDoUxNuaTCVKuhKsNCFlVwRwgiz3H03EvaF88nl_hxJiwo1ZDr9-nvgDAlO9eTlMBnbZ9S-OdpXkdJiuV8fTWqyN7sdjAcCU9fGzKk399t12-P6klN-SOqfv4DA/s1600/Causes+and+How+to+Prevent+LBP+%2528Low+Back+Pain%2529.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYUPYJhZ4LpSDRz0JnxDoUxNuaTCVKuhKsNCFlVwRwgiz3H03EvaF88nl_hxJiwo1ZDr9-nvgDAlO9eTlMBnbZ9S-OdpXkdJiuV8fTWqyN7sdjAcCU9fGzKk399t12-P6klN-SOqfv4DA/s1600/Causes+and+How+to+Prevent+LBP+%2528Low+Back+Pain%2529.jpg" alt="Causes and How to Prevent LBP Low Back Pain" /></a></div>Low Back Pain (LBP) is pain that occurs in the lower back and can spread to the foot, especially the rear and outer side. These complaints can be so severe that patients have difficulty in every movement and the patient should rest and hospitalized.<br />
<br />
LBP complaint turned out ranks the second most common after headache. From the data on patients who went to the clinic of Neurology shows that the number of patients over the age of 40 years who present with low back pain turned out to be quite a lot.<br />
<br />
Given that low back pain is actually just a symptom, then the most important thing is to find the causes, so that appropriate treatment can be given.<br />
<br />
<b>Causes of LBP</b><br />
<br />
Basically the onset of pain is due to pressure on the nervous edge of the lumbar region (pinched nerve). Pinching the nerves can occur due to disturbances in muscle and surrounding tissue, nerve disorders in themselves, spinal abnormalities and abnormalities in other places, such as an infection or kidney stones and others.<br />
<br />
Muscle spasms (muscle tension) is the most common cause of LBP. This spasm can occur due to movement of the waist is too sudden or excessive beyond the power of the muscle. For example during exercise with no we realize we move too sudden, and excessive time chasing or hitting the ball (badminton, tennis, golf, etc.). Likewise, when we lift things a bit heavy with the wrong position, such as moving a table, a chair, lifting luggage, pushing the car, even when we are very excited lift our children or grandchildren will be able to happen LBP. Calcification of the spine around the waist that can result in pinching of the nerves that lead to severe back pain.<br />
<br />
HNP (spinal disc herniation). This happens because the involuntary (trauma / accident) and the pain may spread to either the right or left foot (ischialgia). The other reason we need to consider are: tumors, infections, kidney stones, and others. All of which can lead to pressure on the nerve fibers.<br />
<br />
Should not be forgotten for mental stress, namely: a mental state that causes the patient to feel very depressed. The clinical symptoms of psychological stress transferred into LBP, although previously had no vulnerability factors of the composition of the organs in the back.<br />
<br />
<br />
<b>How To Prevent LBP</b><br />
<br />
Here's how to prevent LBP:<br />
<br />
1. Regular exercise where the frequency / number and intensity should be enough, do not overdo it. For those who usually LBP, recommended for swimming, and should not be jumping up and down.<br />
<br />
2. Set the food by avoiding foods that contain a lot of fat, uric acid, etc., in order to slow down the calcification of the spine. Besides, try not to happen overweight.<br />
<br />
3. Living in a healthy environment with clean air and avoid excessive pollution.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-49632976106617353602015-06-13T15:00:00.000+07:002015-06-13T15:00:25.821+07:00Nursing Care Plan for Kawasaki Disease<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJbLgCjrLMc01ZiN1GRpuJ_pV7u36lS6zy4GfBiXzp0KlzhOmKb_l1oL4gdaK1KIe2ClEYcwYZ1cFvWpk4cZ2vbW4TuyOur_3EyaVa2RW4N1xGYpOgkIoMTDl8eisVRul38Lh2qP4Oi_Y/s1600/nursing-care-plan-for-kawasaki-disease.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJbLgCjrLMc01ZiN1GRpuJ_pV7u36lS6zy4GfBiXzp0KlzhOmKb_l1oL4gdaK1KIe2ClEYcwYZ1cFvWpk4cZ2vbW4TuyOur_3EyaVa2RW4N1xGYpOgkIoMTDl8eisVRul38Lh2qP4Oi_Y/s320/nursing-care-plan-for-kawasaki-disease.jpg" width="320" /></a></div>
Kawasaki disease (mucocutaneous lymph node syndrome) is a form of vasculitis identified by an acute febrile illness with multiple systems affected. Kawasaki fever is a fever in children is associated with vasculitis especially coronary blood vessels and other systemic complaints.<br />
<br />
Kawasaki disease, also known as Kawasaki syndrome, lymph node syndrome, and mucocutaneous lymph node syndrome.<br />
<br />
Kawasaki disease was described by and named after Japanese pediatrician Tomisaku Kawasaki in 1967. It is also called mucocutaneous lymph node syndrome or Kawasaki syndrome. <br />
<br />
Kawasaki disease is largely seen in children under five years of age. Kawasaki disease affects many organ systems, mainly those including the blood vessels, skin, mucous membranes, and lymph nodes. Its rarest but most serious effect is on the heart, where it can cause fatal coronary artery aneurysms in untreated children.<br />
<br />
The exact cause of Kawasaki disease is still unknown. Some studies suggest that it may be caused by the immune system’s reaction to an infectious agent, such as a virus. The condition itself is not contagious. <br />
<br />
Early symptoms may include:<br />
<ul>
<li>High fever</li>
<li>Bloodshot eyes (also known as “conjunctivitis without discharge”)</li>
<li>Rash</li>
<li>Swollen lymph nodes</li>
<li>Swollen, bright red tongue</li>
<li>Swollen hands and feet</li>
<li>Red palms and soles of the feet</li>
</ul>
<br />
Later symptoms may include:<br />
<ul>
<li>Diarrhea</li>
<li>Peeling skin on the hands and feet </li>
<li>Vomiting</li>
<li>Pain in the joints</li>
</ul>
<br />
<b>Nursing Diagnosis for Kawasaki Disease :</b><br />
<br />
1. Chronic pain related to inflammation of the myocardium or pericardium.<br />
2. Risk for decreased cardiac output related to accumulation of fluid in the pericardial sac.<br />
3. Activity intolerance related to inflammation and degeneration of myocardial muscle cells.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-90213267949264653372015-06-12T23:35:00.002+07:002015-06-12T23:35:57.957+07:00Hyperthermia related to Urinary Tract Infections<br />
<b>Nursing Care Plan for Urinary Tract Infections</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUXRhxdHc0to0G5gJ3Yg7hYNrDBHHzCI7GUKaAykpV490FmRsjB3-RliCNK767qrL0Y97KyGa_qq0UQoYO3UOoFW9pF4_GzZJZFkEeQRejUawq3nMgizdFP8t8hhAYuZmM0ZzhAq2zRvo/s1600/hyperthermia-related-to-urinary-tract-infections.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Hyperthermia related to Urinary Tract Infections" border="0" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUXRhxdHc0to0G5gJ3Yg7hYNrDBHHzCI7GUKaAykpV490FmRsjB3-RliCNK767qrL0Y97KyGa_qq0UQoYO3UOoFW9pF4_GzZJZFkEeQRejUawq3nMgizdFP8t8hhAYuZmM0ZzhAq2zRvo/s320/hyperthermia-related-to-urinary-tract-infections.jpg" width="320" /></a></div>
A urinary tract infection (UTI) is an infection that affects part of the urinary tract. A urinary tract infection (UTI) (also known as acute cystitis or bladder infection). Urinary tract infections (UTIs) are very common – particularly in women, babies and the elderly. Around one in two women and one in 20 men will get a UTI in their lifetime. <br />
<br />
The infection can occur at different points in the urinary tract, including: <br />
<ul>
<li>Urethra. An infection of the tube that empties urine from the bladder to the outside is called urethritis. </li>
<li>Kidneys. An infection of one or both kidneys is called pyelonephritis or a kidney infection.</li>
<li>Ureters. The tubes that take urine from each kidney to the bladder are rarely the only site of infection.</li>
<li>Bladder. An infection in the bladder is also called cystitis or a bladder infection.</li>
</ul>
Some of the symptoms include:<br />
<ul>
<li>Burning pain or a ‘scalding’ sensation when urinating</li>
<li>Pain above the pubic bone</li>
<li>Wanting to urinate more often and urgently, if only a few drops</li>
<li>A feeling that the bladder is still full after urinating </li>
<li>Blood in the urine.</li>
</ul>
<br />
Most urinary tract infections are caused by bacteria that live in the digestive system. Bacteria that enter the urethra and then the bladder. Women tend to get them more often because their urethra is shorter and closer to the anus than in men. <br />
The most common culprit is a bacterium common to the digestive tract called Escherichia coli (E. coli).<br />
Other micro-organisms, such as mycoplasma and chlamydia, can cause urethritis in both men and women. <br />
<br />
<br />
<b>Nursing Care Plan for <a href="http://www.nandanursediary.com/2013/02/nursing-diagnosis-related-to-urinary.html">Urinary Tract Infections</a></b><br />
<br />
<b>Hyperthermia</b> related to infection.<br />
Goal: the patient's body temperature to normal.<br />
<br />
Expected outcomes:<br />
<ul>
<li>The patient's body temperature is normal.</li>
<li>Acral feel warm.</li>
<li>Patients calm / relaxed.</li>
</ul>
<br />
Interventions and Rationale :<br />
<br />
Independent<br />
<br />
1. Assess increase in body temperature through laboratory tests.<br />
R /: To determine the factors causing an increase in body temperature and to establish further therapy program.<br />
<br />
2. Perform a cold or warm compresses on the body.<br />
R /: Warm compresses can enhance vasodilation of blood vessels while cold compress increase vasoconstriction of blood vessels.<br />
<br />
Collaboration<br />
<br />
3. Implement treatment programs: Management of antipyretics as indicated.<br />
R /: Antipyretics reduce fever.<br />
<br />
Observation<br />
<br />
4. Monitoring of vital signs.<br />
R /: To know the state of the patient.<br />
<br />
5. Monitor fluid intake and output.<br />
R /: Intake and output were less able to stimulate the growth of bacteria in the urinary vesica.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-27649085140963536722015-06-11T09:18:00.000+07:002015-06-11T09:18:45.831+07:00Nursing Assessment for Hypertensive Heart DiseaseHypertensive heart disease is heart disease caused by hypertension. Hypertension that is not controlled for a long time causing the left ventricle hypertrophy (LVH).<br />
<br />
The main causes of hypertensive heart disease is chronic hypertension. Hypertension in adults is caused by several things including:<br />
Essential hypertension occurred in 90% of cases of hypertension in adults.<br />
Secondary hypertension 10% of cases of hypertension in adults is caused by abnormalities in the kidneys, endocrine disorders, increased ICT, etc.<br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhimGOms7Ot3-EppV6wRsKH6h8ZlgPQe1ZfXowNW2Ji98-KCUiFua1BUgrgtfuPsaiwFTXvipBQ5xXXRk9TlkWWSBxKJI5x0gi-WdCN0DwMZcdTMtdJYag-kJL5tW9_l9gfmFEz3RGUGkU/s1600/nursing-assessment-for-hypertensive-heart-disease.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhimGOms7Ot3-EppV6wRsKH6h8ZlgPQe1ZfXowNW2Ji98-KCUiFua1BUgrgtfuPsaiwFTXvipBQ5xXXRk9TlkWWSBxKJI5x0gi-WdCN0DwMZcdTMtdJYag-kJL5tW9_l9gfmFEz3RGUGkU/s320/nursing-assessment-for-hypertensive-heart-disease.jpg" width="320" /></a></div>In the early stages of hypertension, will appear the signs as a result of chronic sympathetic stimulation. Heart beat faster and stronger. Occurred hyper circulation that may result from increased activity and neurohumoral system accompanied by hipervolumia. At an advanced stage, there will be a compensation mechanism in the form of heart muscle hypertrophy of the left ventricle and increased peripheral vascular resistance. Will appear shortness of breath in patients by the presence of diastolic interference.<br />
<br />
The assessment focused on the physical and psychological disorders caused by HHD. The existence of a long history of hypertension and a history of hypertension and heart disease in the family.<br />
<br />
Data base assessment:<br />
<br />
1. Activity / rest<br />
Symptoms: There is weakness, fatigue, shortness of breath.<br />
Signs: Heart rate increases, changes in heart rhythm, tachypnea.<br />
<br />
2. Circulation<br />
Symptoms: A history of hypertension, atherosclerosis, coronary heart disease and cerebrovascular disease.<br />
Symptoms: Increased blood pressure, pulse clear the area of the carotid, jugular and radial. Femoral pulse slowed, while the pulse popliteal, tibial and dorsalis pedis becoming weaker.<br />
Arising tachycardia and dysrhythmias, audible voice S4 atrial gallop.<br />
Skin discoloration occurs in the extremities, cold temperatures, pale skin, cyanosis.<br />
<br />
3. Ego integrity <br />
Symptoms: The change of personality, anxiety, depression, anger, multiple stress factors.<br />
Symptoms: Restlessness, narrowing the field of attention, crying, facial muscle tension, increased speech patterns, often sighed.<br />
<br />
4. Elimination<br />
Symptoms: The presence of disorders of the kidneys.<br />
<br />
5. Food / liquids<br />
Symptoms: The habit of eating foods high in salt, fat and cholesterol. Feelings of nausea and vomiting, weight changes, use of diuretics.<br />
Signs: Normal weight or obese. Arising edema (general or specific).<br />
<br />
6. Neuro sensory<br />
Symptoms: The existence of complaints of dizziness, throbbing head, sub-occipital headache, weakness on one side of the body, impairments, and epistaxis may occur.<br />
<br />
7. Pain / discomfort<br />
Symptoms: There angina, intermittent pain in the legs as indications of arteriosclerosis, severe occipital headache, abdominal pain.<br />
<br />
8. Breathing<br />
Symptoms: dyspnoea associated with the activity, tachypnea, orthopnea, cough with or without sputum, a history of smoking.<br />
Signs: The use of accessory respiratory muscles, the additional breath sounds, cyanosis.<br />
<br />
9. Learning<br />
Symptoms: Risk factors family history of hypertension, atherosclerosis, heart disease, diabetes, cerebrovascular disease / kidney. Race factor, the use of drugs / alcohol.yanihttp://www.blogger.com/profile/10064708777472149200noreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-61223323201851397542013-05-22T22:35:00.002+07:002013-05-22T22:35:21.912+07:00Nursing Care Plan for Bone CancerTumor is the growth of new cells, abnormal, progressive, where the cells never become mature. The incidence of bone tumors when compared with other types of tumors are small, ie less than 1% of all tumors of human body. Malignant tumor, when tumor capable of spreading to other places (able to metastasize) and benign tumors say, if it is not able to metastasize. Lungs, is the organ most frequently seized by child spread of malignant tumors.<br />
<br />
There are many different types of cancer. Cancers are usually named based on the type of cell that is affected. For example, lung cancer is caused by cells that are beyond the control of the shape of the lung, and breast cancer by cells that form the breast. A tumor is a collection of abnormal cells which accumulate together. However, not all tumors are cancerous. A tumor can be benign (not cancerous) or malignant (cancerous).<br />
<br />
Benign tumors are usually less dangerous and not able to spread to other parts of the body. Malignant tumors are generally more serious and can spread to other areas in the body. The ability of cancer cells to leave their original location and moved to another location in the body is called metastasis. Metastasis can occur with cancer cells enter the blood stream or lymphatic system body to walk to other places in the body.<br />
<br />
When cancer cells metastasize to other parts of the body, they are still called by the type of origin of the abnormal cells. For example, if a group of cells into diseased breast cancer and metastasizes to the bones, it is called metastatic breast cancer. Many different types of cancer are able to metastasize to the bones.<br />
<br />
The types of the most common cancers that spread to the bones are lung, breast, prostate, thyroid, and kidney. Most of the time, when people have cancer in their bones, it is caused by cancer that has spread from elsewhere in the body to the bones. It is less common to have an original bone cancer, a cancer that arises from cells that make bone. It is important to determine whether the cancer is in the bone from elsewhere or from a cancer of the bone cells. The treatments for cancers that have metastasized to the bone based on the initial type of cancer.<br />
<br />
Causes <br />
<br />
Bone cancer is caused by a problem with the cells that form bone. More than 2,000 people are diagnosed in the U.S. each year with a bone tumor. Bone tumors occur most commonly in children and adolescents and are less common in the older adults. Cancer involving the bone in adults older are most commonly the result of metastatic spread from another tumor.<br />
<br />
Signs and Symptoms<br />
<br />
The most common symptom of bone tumors is pain. In most cases, the symptoms become gradually more severe with time. At first, the pain may only be present at night or with activity. Depending on the growth of tumor, those affected may have symptoms for weeks, months, or years before seeking medical advice. In some cases, a mass or lump may be felt in the bone or in the tissues surrounding the bone. Tumors in the leg, causing the patient to walk lame, whereas tumors in the arm cause pain when the arm is used to lift some object. Swelling of the tumor may feel warm and slightly flushed.<br />
<br />
Classification<br />
<br />
Based on the level of malignancy, there are 3 levels of malignant tumor stages, namely:<br />
<ol>
<li>Stage I, when a low degree of malignancy.</li>
<li>Stage II, meaning the tumor has a high degree of malignancy.</li>
<li>Stage III, which means the tumor has spread.</li>
</ol>
Diagnostic tests<br />
<ol>
<li>Physical examination</li>
<li>DPL</li>
<li>X-Rays</li>
<li>Ct-Scan</li>
<li>MRI</li>
<li>biopsy</li>
<li>bone scan</li>
</ol>
<br />
<b>Nursing Diagnosis for Bone Cancer</b><br />
<br />
1. Anxiety related to change in health status.<br />
2. <a href="http://nanda-nurse-diary.blogspot.com/2013/02/chronic-pain-and-body-image-disturbance.html">Chronic Pain</a> related to pathologic processes.<br />
3. Imbalanced Nutrition Less Than Body Requirements related to hypermetabolic status with regard to cancer, the consequences of chemotherapy, and radiation effects.<br />
4. Risk for <a href="http://nanda-nurse-diary.blogspot.com/2013/04/activity-intolerance-and-excess-fluid.html">Fluid Volume Excess</a> related to damage to fluid intake.<br />
5. <a href="http://nanda-nurse-diary.blogspot.com/2012/12/risk-for-infection-ncp-anemia.html">Risk for Infection</a> related to the inadequate immunosuppression, malnutrition and invasive procedures.<br />
6. Risk for Impaired skin integrity related to radiation effects and changes in nutritional status.<br />
<br />
<b>Nursing Interventions</b> <b>for Bone Cancer</b><br />
<ol>
<li>Encourage clients to express feelings and thoughts.</li>
<li>Increase a sense of calm and comfortable environment.</li>
<li>Determine history of pain.</li>
<li>Give a distraction relaxation techniques.</li>
<li>Monitor the nutrient intake every day.</li>
<li>Control of environmental factors and diet that will be provided.</li>
<li>Create a pleasant dining atmosphere.</li>
<li>Assess the factors that reduce appetite.</li>
<li>Monitor nausea and vomiting.</li>
<li>Monitor fluid input and output.</li>
<li>Assess vital signs.</li>
<li>Encourage increased fluid intake.</li>
<li>Increase rest.</li>
<li>Emphasize the importance of oral hygiene.</li>
<li>Assess the skin as often as possible.</li>
<li>Wash with warm water and mild soap.</li>
<li>Instruct the client to avoid any skin cream unless there is an indication of physicians.</li>
<li>Encourage the use of soft and loose clothing.</li>
</ol>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-71306341189471239232013-05-17T23:59:00.002+07:002013-05-17T23:59:48.925+07:00Dengue Hemorrhagic Fever - 5 Nursing Interventions<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMtqL8QmGXeCF6IzJiiO_ne6J6wFZupC4MdoFflKyigikTwf6BrtA-lQWmLgxwRgNaVD_lxpZQ4kG9uSprvy7ouSJ_vltPT0_9jhe9W6g2CXwDzz5T5OXZE0jYV5h4ikYo37viFUmFJF8/s1600/Dengue+Hemorrhagic+Fever+-+5+Nursing+Interventions.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMtqL8QmGXeCF6IzJiiO_ne6J6wFZupC4MdoFflKyigikTwf6BrtA-lQWmLgxwRgNaVD_lxpZQ4kG9uSprvy7ouSJ_vltPT0_9jhe9W6g2CXwDzz5T5OXZE0jYV5h4ikYo37viFUmFJF8/s320/Dengue+Hemorrhagic+Fever+-+5+Nursing+Interventions.jpg" /></a><br />
<br />
DHF is an acute arbovirus infection that enters the body through the bite of a mosquito species aides. The disease often strikes children, adolescents, and adults that is characterized by fever, muscle and joint pain.<br />
<br />
Symptoms such as headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue fever.<br />
<br />
Nursing Diagnosis and Interventions for Dengue Hemorrhagic Fever<br />
<br />
Nursing Diagnosis 1. : Hyperthermia related to the process of dengue virus infection.<br />
<br />
Goal: Normal body temperature<br />
Outcomes:<br />
Body temperature between 36-37 0 C<br />
Muscle pain disappeared<br />
<br />
Intervention:<br />
<br />
1. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated)<br />
Rational: To replace fluids lost due to evaporation.<br />
<br />
2. Instruct the patient to wear clothing that is thin and easy to absorb sweat.<br />
Rationale: Providing a sense of comfort and easy thin clothing absorbs sweat and does not stimulate an increase in body temperature.<br />
<br />
3. Observation of intake and output, vital signs (temperature, pulse, blood pressure) every 3 hours once or more often.<br />
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.<br />
<br />
4. Collaboration: intravenous fluids and appropriate drug delivery program.<br />
Rationale: Fluid replacement is essential for patients with a high body temperature. Particular drug to lower the patient's body temperature.<br />
<br />
<br />
Nursing Diagnosis 2. : Risk for Fluid Volume Deficit related to intravascular fluid into the extravascular migration.<br />
<br />
Objective: Not happening fluid volume deficit<br />
Outcomes:<br />
Input and output balanced<br />
Vital signs within normal limits<br />
There is no sign of pre-shock<br />
Capilarry refill less than 3 seconds<br />
<br />
Intervention:<br />
1. Monitor vital signs every 3 hours / more often.<br />
Rationale: Vital sign help identify fluctuations in intravascular fluid.<br />
<br />
2. Observation of capillary refill.<br />
Rational: Indications adequacy of peripheral circulation.<br />
<br />
3. Observation of intake and output. Note the color of urine / concentration.<br />
Rationale: Decrease in urine output concentrated suspected dehydration.<br />
<br />
4. Suggest to drink 1500-2000 ml / day (as tolerated).<br />
Rational: To consume body fluids orally.<br />
<br />
5. Collaboration: intravenous fluid administration.<br />
Rational: It can increase the amount of body fluid, to prevent shock hipovolemic.<br />
<br />
<br />
Nursing Diagnosis 3. : Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid into the extravascular migration.<br />
<br />
Objective: Not happening hypovolemic shock<br />
Hasl criteria:<br />
Vital signs within normal limits<br />
<br />
Intervention:<br />
1. Monitor patient's general condition.<br />
Raional: To monitor the condition of the patient during treatment, especially when there is bleeding. Nurses immediately know the signs of pre-shock / shock.<br />
<br />
2. Observation of vital signs every 3 hours or more<br />
Rationale: Nurses need to continue to observe the vital signs to ensure there is no pre-shock / shock.<br />
<br />
3. Explain to patients and families sign of bleeding, and immediately report if there is bleeding.<br />
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.<br />
<br />
4. Collaboration: intravenous fluid administration.<br />
Rationale: Intravenous fluids needed to cope with the severe loss of body fluids.<br />
<br />
5. Collaboration: examination: HB, PCV, platelets.<br />
Rationale: To determine the level of leakage of blood vessels experienced by patients and to take further action reference.<br />
<br />
<br />
<br />
Nursing Diagnosis 4. : Risk for imbalanced Nutrition Less Than Body Requirements related to inadequate nutritional intake due to nausea and decreased appetite.<br />
<br />
Goal: Not an interruption nutritional needs.<br />
Outcomes:<br />
There are no signs of malnutrition.<br />
Shows a balanced weight.<br />
<br />
Intervention:<br />
1. Assess nutritional history, including a preferred food.<br />
Rationale: Identify deficiencies, suspect the possibility of intervention.<br />
<br />
2. Observation and record the patient's food intake.<br />
Rationale: Observing caloric intake / lack of quality food consumption.<br />
<br />
3. Measure body weight per day (if possible).<br />
Rationale: Observing weight loss / observe the effectiveness of the intervention.<br />
<br />
4. Give food a little but often and or eat between meals.<br />
Rational: little food can reduce vulnerabilities and increase input also prevent gastric distention.<br />
<br />
5. Give and Help oral hygiene.<br />
Rationale: Increased appetite and oral input.<br />
<br />
6. Avoid foods that stimulate and gassy.<br />
Rational: Lowering distention and gastric irritation.<br />
<br />
<br />
Nursing Diagnosis 5. : Risk for Bleeding related to decreased blood clotting factors (thrombocytopenia)<br />
<br />
Goal: Not bleeding.<br />
Outcomes:<br />
Normal blood pressure.<br />
Normal pulse.<br />
There is no sign of further bleeding, platelets increased.<br />
<br />
Intervention:<br />
1. Monitor signs of decreased platelets accompanied by clinical signs.<br />
Rationale: Platelet decline is a sign of blood vessel leakage, which at some stage may cause clinical signs such as epistaxis, petechia.<br />
<br />
2. Monitor platelets every day.<br />
Rationale: With the platelets are monitored on a daily basis, it can be seen the level of vascular leak and possible bleeding experienced by the patient.<br />
<br />
3. Instruct the patient to a lot of rest (bed rest).<br />
Rational: patient activity can lead to uncontrolled bleeding.<br />
<br />
4. Provide information to clients and families to report any signs of bleeding such as: hematemesis, melena, epistaxis.<br />
Rational: The involvement of patients and families may help to early treatment if there is bleeding.<br />
<br />
5. Anticipation of bleeding: use a soft toothbrush, maintain oral hygiene, apply pressure take 5-10 minutes after each blood.<br />
Rationale: Prevent further bleeding.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-41378655273757251992013-05-13T09:44:00.000+07:002015-11-11T20:47:36.149+07:00NCP Thromboangiitis Obliterans - Nursing Diagnosis and Interventions<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpro04UBMaIqPxJGw60LZF4z2pF4C7Xa5HTqkAuoq7_OE5CpxXf_PndmO1cQgrWOkkjFkYCfUZauawOnVNXXJTiqEMvNagswVWvIDKyRuQVd4yX_ZOjDaB6qD0NhSA2Cky_YLwYi3OAUc/s1600/NCP+Thromboangiitis+Obliterans+-+Nursing+Diagnosis+and+Interventions.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpro04UBMaIqPxJGw60LZF4z2pF4C7Xa5HTqkAuoq7_OE5CpxXf_PndmO1cQgrWOkkjFkYCfUZauawOnVNXXJTiqEMvNagswVWvIDKyRuQVd4yX_ZOjDaB6qD0NhSA2Cky_YLwYi3OAUc/s320/NCP+Thromboangiitis+Obliterans+-+Nursing+Diagnosis+and+Interventions.jpg" /></a>1. Acute Pain / <a href="http://nanda-nurse-diary.blogspot.com/2013/02/chronic-pain-and-body-image-disturbance.html">Chronic Pain</a> related to vasospasm / reperfusion disorders, ischemic / tissue damage.<br />
<br />
Goal: Pain is reduced and tissue damage is not widespread.<br />
<br />
Intervention:<br />
<ul><li>Record the characteristics of pain and paresthesias.</li>
<li>Check the patient's vital signs.</li>
<li>Discuss with the patient, how and why the pain inflicted.</li>
<li>Help the patient identify trigger factor or situation example: smoking, exposure to cold and how to handle.</li>
<li>Encourage the use of stress management techniques, entertainment activities.</li>
<li>Soak the affected area in warm water.</li>
<li>Give the room a warm, draft-free air, for example ventilation, air-conditioning, keep doors closed as indicated.</li>
<li>Monitor drug effects and action.</li>
<li>Collaboration: the medications as indicated, prepare surgical intervention when necessary.</li>
</ul><br />
Rational:<br />
<ul><li>Knowing the pain level.</li>
<li>To monitor the general state of the client.</li>
<li>That patients understand how to process pain.</li>
<li>That patients understand the factors that influence pain.</li>
<li>Used to divert the attention of the client.</li>
<li>Warm water will make the blood vessels will dilate and blood flow.</li>
<li>Avoid infection and keep the air hot.</li>
<li>Determine the level of effectiveness of the drug.</li>
<li>Administration of drugs to relieve pain.</li>
</ul><br />
<br />
2. <a href="http://nanda-nurse-diary.blogspot.com/2013/01/ineffective-tissue-perfusion-cerebral.html">Ineffective Tissue Perfusion</a> is related to cessation of arterial blood flow<br />
<br />
Intervention:<br />
<ul><li>Observation of skin color on the sick.</li>
<li>Note the decrease in pulse.</li>
<li>Evaluation of pain sensation parts, for example: sharp / shallow, hot / cold.</li>
<li>View and examine the skin for ulceration, lesions, gangrene area.</li>
<li>Recommended for proper nutrition and vitamins.</li>
<li>Collaboration: the medications as indicated (vasodilator), example: drainage lesions for culture or sensitivity.</li>
</ul><br />
Rational:<br />
<ul><li>To see cyanosis or redness of the skin.</li>
<li>Identify the severity of the cessation of arterial blood flow.</li>
<li>Knowing levels, flavors, and forms of pain.</li>
<li>Seeing how big a part that had gangrene.</li>
<li>Proper nutrition and vitamin requirements are complete will increase the body's immune system.</li>
<li>Giving obta vasodilator make the arteries dilate and blood flow.</li>
</ul><br />
<br />
3. <a href="http://nanda-nurse-diary.blogspot.com/2013/02/knowledge-deficit-ncp-asthma-bronchiale.html">Knowledge Deficit:</a> the need to learn about the condition, treatment needs related to lack of knowledge / resources are not familiar with, wrong perception / misunderstood.<br />
<br />
Intervention:<br />
<ul><li>Provide information to patients about the disease.</li>
<li>Encourage clients to ask questions about the disease.</li>
<li>Instruct to avoid exposure to cold.</li>
<li>Preserve the environment at a temperature above 20.9 C eliminate cold flow.</li>
<li>Discuss the possibility of moving to a warmer climate.</li>
<li>Emphasize the importance of stopping smoking, provide information on local clinics / support group.</li>
<li>Help the patient to create a method to avoid or alter discuss stress relaxation techniques.</li>
<li>Emphasize the importance of viewing each day and do the right skin care.</li>
</ul><br />
Rational:<br />
<ul><li>Increase patients' knowledge about the disease.</li>
<li>Knowing the client's level of curiosity about the disease.</li>
<li>Cold temperatures make the constriction of the blood vessels and will aggravate the blockage of blood flow.</li>
<li>Hot temperature makes blood vessels to maintain a state of dilatation.</li>
<li>Avoid the severity of which will happen.</li>
<li>That patients know and understand that smoking is a major contributing factor to the occurrence trombongitis.</li>
<li>Distraction and relaxation techniques to make the patient more calm in responding.</li>
<li>Avoid skin injury.</li>
</ul><br />
4. Anxiety related to the action procedure to be performed<br />
<br />
Intervention:<br />
<ul><li>Describe the action procedure to be performed.</li>
<li>Explain the importance of actions to be taken.</li>
<li>Observation of vital signs.</li>
<li>Give comfort to the patient.</li>
<li>Reassure the patient that the action to be performed is the best course of action.</li>
<li>Reassure the patient that the procedure acts to be performed safely.</li>
<li>Collaboration with physicians for the provision of drugs.</li>
</ul>Rational:<br />
<ul><li>Increase patients' knowledge about action procedure.</li>
<li>In order for patients to understand why the need for that action.</li>
<li>Knowing the general state of the client.</li>
<li>Patients will feel calm and do not worry with action procedures to be performed.</li>
<li>Reduce the level of anxiety on the client.</li>
<li>Reduce negarif thinking about an act procedures.</li>
<li>To create a calm and reduce anxiety levels.</li>
</ul>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-37804686967018502692013-04-21T22:28:00.000+07:002014-09-11T02:26:18.503+07:00Assessment and Nursing Diagnosis for Malignant Lymphoma Lymphomas are a group of cancers in which cells of the lymphatic system become abnormal and start to grow uncontrollably. Because there is lymph tissue in many parts of the body, lymphomas can start in almost any organ of the body.<br />
<br />
Primary malignant lymphoma: The excessive proliferation of lymphocytes which forms part of the immune system. Primary cancers refer to the fact that the cancer originated in the lymph cells rather than having metastasized. More detailed information about the symptoms, causes, and treatments of Primary malignant lymphoma is available below. <br />
<br />
<br />
<b>Nursing Assessment for Malignant Lymphoma </b><br />
<br />
Assessment at the client's malignant lymphoma by Doenges, (1999) obtained the following data:<br />
<br />
1. Activity / rest<br />
<ul>
<li>Symptoms: fatigue, weakness, or general malaise, loss of productivity and decreased exercise tolerance.</li>
<li>Signs: decreased strength, shoulders slumped, walking slowly, and other signs that show fatigue.</li>
</ul>
<br />
2. Circulation<br />
<ul>
<li>Symptoms: palpitations, angina / chest pain.</li>
<li>Signs: tachycardia, dysrhythmias, cyanosis face and neck (venous drainage obstruction due to enlarged lymph nodes is a rare occurrence), scleral jaundice, and general jaundice, liver damage and in connection with bile duct obstruction by enlarged lymph nodes, pallor (anemia), diaphoresis , night sweats.</li>
</ul>
<br />
3. Ego integrity<br />
<ul>
<li>Symptoms: stress factor, fear / anxiety in connection with the diagnosis and possible fear of death, diagnostic tests and treatment modalities (chemotherapy and radiation therapy).</li>
<li>Signs: various behaviors, such as angry, withdrawn, passive.</li>
</ul>
<br />
4. Elimination<br />
<ul>
<li>Symptoms: changes in urine and stool characteristics, history of intussusception obstruction, or malabsorption syndrome (infiltration of retro-peritoneal lymph nodes)</li>
<li>Signs: tenderness in the right upper quadrant on palpation and enlargement (hepatomegaly), tenderness in the left upper quadrant on palpation and enlargement (splenomegaly), decreased urine output, dark urine, anuria (urethral obstruction / fail ginja), bowel dysfunction, and bladder.</li>
</ul>
<br />
5. Food / fluid<br />
<ul>
<li>Symptoms: anorexia / loss of appetite, dysphagia (esophageal pressure) weight loss.</li>
<li>Signs: swelling of the face, neck, jaw, or right hand (secondary to superior vena cava compensated by enlarged lymph nodes), lower extremity edema in relation to the inferior vena cava obstruction of intra-abdominal lymph node enlargement (non-Hodgkin), ascites (obstruction in vena cava inferior with respect to intra-abdominal lymph node enlargement)</li>
</ul>
<br />
6. Neurosensory<br />
<ul>
<li>Symptoms: nerve pain (neuralgia) indicates nerve root compression by enlarged lymph nodes in the brachial, lumbar, and sacral plexus, muscle weakness, paresthesias.</li>
<li>Signs: mental status; lethargy, withdrawal, lack of interest in the general vicinity, paraplegia (spinal stem compression from vertebral tubauh, discus involvement in compression / degeneration or compression of the blood supply to the spinal rod)</li>
</ul>
<br />
7. Pain / comfort<br />
<ul>
<li>Symptoms: tenderness / pain on the affected lymph nodes, eg at about mediastinum, chest pain, back pain (vertebral compression) general bone pain (bone involvement limfomatus), pain in the affected area immediately after drinking alcohol.</li>
<li>Mark: a focus on self, cautious behavior.</li>
</ul>
<br />
8. Breathing<br />
<ul>
<li>Symptoms: dyspnea at work or rest; chest pain</li>
<li>Symptoms: dyspnea; tachycardia, dry non-productive cough, respiratory distress signal; increased respiratory rate and depth, use of accessory muscles, stridor, cyanosis, husky / laryngeal paralysis (pressure of enlarged nodes in laryngeal nerve).</li>
</ul>
<br />
9. Security<br />
<ul>
<li>Symptoms: a history of frequent / infection, mononukleus history, history of ulcer / perforation gastric bleeding, fever, night sweats without chills, redness / general pruritus</li>
<li>Symptoms: fever settled without any symptoms of infection, lymph node symmetric, no pain, swollen / enlarged, enlarged tonsils, general pruritus, most areas of melanin pigmentation loss (vitilago).</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis for Malignant Lymphoma </b><br />
<br />
Once the data is collected, followed by analysis of the data to determine nursing diagnoses.<br />
<br />
According Doenges (1999), nursing diagnoses in clients with postoperative laparotomy + biopsy, with an indication of malignant lymphomas as follows:<br />
<br />
1. <a href="http://nanda-nurse-diary.blogspot.com/2012/12/risk-for-infection-ncp-anemia.html">Risk for Infection</a> related to invasive procedures, the surgical incision.<br />
<br />
2. Risk for <a href="http://nanda-nurse-diary.blogspot.com/2013/01/fluid-volume-deficit-related-to.html">Fluid Volume Deficit</a> related to excessive loss, ie: vomiting, bleeding, diarrhea.<br />
<br />
3. Acute Pain related to the surgical incision.<br />
<br />
4. <a href="http://nanda-nurse-diary.blogspot.com/2013/04/activity-intolerance-and-excess-fluid.html">Activity Intolerance</a> related to general weakness, decreased energy reserves, increase the metabolic rate of the production of massive leukocytes.<br />
<br />
5. Constipation or <a href="http://nanda-nurse-diary.blogspot.com/2013/01/pathophysiology-and-clinical.html">Diarrhea</a> related to decreased dietary input, change the digestive process.<br />
<br />
6. Risk for <a href="http://careplannursing.blogspot.com/2012/01/impaired-skin-integrity-nanda-nursing.html" target="_blank">Impaired Skin Integrity</a> related to decreased blood and nutrients to the tissues, secondary surgery.<br />
<br />
7. Knowledge Deficit related to lack of accurate information about home care.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-45948765495234000512013-04-21T15:40:00.002+07:002015-11-11T20:47:55.472+07:00Powerlessness and Ineffective Therapeutic Regimen Management - NCP Diabetes Mellitus<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhd_Yl3E290Zya12NPFKMZdOhc8WNa-Fl9Jf_ufMyv2jpwedWDCk0jIsOZ7-6l-1RXw-hPDAryhyphenhyphen4aKU_3Rd6U1Ea-JQ4l7ziqK5vadv9mAwiIboU2RVjKKRloSCFuiQPHEmOxLqdejlPU/s1600/Powerlessness+and+Ineffective+Therapeutic+Regimen+Management+-+NCP+Diabetes+Mellitus.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhd_Yl3E290Zya12NPFKMZdOhc8WNa-Fl9Jf_ufMyv2jpwedWDCk0jIsOZ7-6l-1RXw-hPDAryhyphenhyphen4aKU_3Rd6U1Ea-JQ4l7ziqK5vadv9mAwiIboU2RVjKKRloSCFuiQPHEmOxLqdejlPU/s320/Powerlessness+and+Ineffective+Therapeutic+Regimen+Management+-+NCP+Diabetes+Mellitus.jpg" /></a><br />
<br />
Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.<br />
<br />
Type 1 diabetes is a chronic illness characterized by the body’s inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas. It is most common in juveniles, but it can also develop in adults in their late 30s and early 40s. <br />
<br />
The classic symptoms of type 1 diabetes are:<br />
<ul><li>polyuria, </li>
<li>polydipsia, </li>
<li>polyphagia, </li>
<li>unexplained weight loss. </li>
</ul>Other symptoms may include:<br />
<ul><li>fatigue, </li>
<li>nausea, </li>
<li>blurred vision.</li>
</ul><br />
Type 2 diabetes consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion.<br />
<br />
Many patients with type 2 diabetes are asymptomatic. Clinical manifestations include the following:<br />
<ul><li>Classic symptoms: Polyuria, polydipsia, polyphagia, and weight loss</li>
<li>Blurred vision</li>
<li>Lower-extremity paresthesias</li>
<li>Yeast infections (eg, balanitis in men)</li>
</ul><br />
<br />
<a href="http://nanda-nurse-diary.blogspot.com/2013/04/nursing-care-plan-for-diabetes-mellitus.html"><b>Nursing Care Plan for Diabetes Mellitus</b></a><br />
<br />
<b>Nursing Diagnosis and Interventions for Diabetes Mellitus</b><br />
<br />
<b>Powerlessness</b> related to long-term disease / progressive untreatable.<br />
<br />
Goal: The feeling of powerlessness is reduced during treatment.<br />
<br />
Expected Outcomes:<br />
<ul><li>acknowledge feelings of hopelessness,</li>
<li>identify healthy ways to deal with feelings,</li>
<li>assist in planning their own care.</li>
</ul><br />
Intervention:<br />
<br />
a) Instruct patient / family to express feelings about hospitalization and illness as a whole.<br />
<br />
b) Provide opportunities for families to express concern and discuss how they can help the patient fully.<br />
<br />
c) Determine goals / expectations of the patient / family.<br />
<br />
d) Determine whether there are changes related to people nearby.<br />
<br />
e) Provide support to patients to participate in self-care.<br />
<br />
<br />
<b>Ineffective Therapeutic Regimen Management </b>related to insufficiency of knowledge about diabetes.<br />
<br />
Goal: Client following diabetes education.<br />
<br />
Expected Outcomes:<br />
<ul><li>Clients can mention names, dosage, mode of action and time to drink regularly.</li>
</ul><br />
Interventions:<br />
<br />
a) Explain to the client and family about the etiology and treatment of diabetes.<br />
<br />
b) Encourage clients to frequently monitor blood sugar levels.<br />
<br />
c) Explain the importance of adhering to a diet and exercise program is recommended.<br />
<br />
d) Teach the client to use insulin (dose, timing, injection site).<br />
<br />
e) Teach the importance of achieving and maintaining a normal body weight.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-44212565984663884692013-04-20T10:19:00.000+07:002013-04-20T10:19:19.301+07:00HHD Hypertensive Heart Disease - 5 Nursing Diagnosis Interventions<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_sxmfZ2PJ8JKAnEY3g4aLXCc3lJGwG8i96U8GdpVsEZIWFh7cq2OH29EdPI-K7TUgrlX30OamSTLFfUKI50h4yVyJGQhZ5pE_uMkYfDjjZiB8q36mS_iZJLdQf3kBJESVJH5SyWF_xgI/s1600/HHD+Hypertensive+Heart+Disease+-+5+Nursing+Diagnosis+Interventions.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_sxmfZ2PJ8JKAnEY3g4aLXCc3lJGwG8i96U8GdpVsEZIWFh7cq2OH29EdPI-K7TUgrlX30OamSTLFfUKI50h4yVyJGQhZ5pE_uMkYfDjjZiB8q36mS_iZJLdQf3kBJESVJH5SyWF_xgI/s320/HHD+Hypertensive+Heart+Disease+-+5+Nursing+Diagnosis+Interventions.jpg" /></a>Hypertensive heart disease refers to heart problems that occur because of high blood pressure. These problems include:<br />
<ul>
<li>Coronary artery disease and angina</li>
<li>Heart failure</li>
<li>Thickening of the heart muscle (called hypertrophy)</li>
</ul>
<br />
HHD can not only be caused by high blood pressure, but it can also lead to heart disease, stroke, thickened blood vessels, and heart attack. It can also cause sudden death.<br />
<br />
Symptoms of HHD include:<br />
<ul>
<li>Shortness of breath</li>
<li>Fatigue</li>
<li>Irregular pulse</li>
<li>Weight gain</li>
<li>Nausea</li>
<li>Bloating</li>
<li>Swelling of feet</li>
<li>Chest pain</li>
<li>Dizziness</li>
<li>Sweating</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis and Interventions for HHD Hypertensive Heart Disease</b><br />
<br />
1. <a href="http://nanda-nurse-diary.blogspot.com/2013/01/acute-pain-nursing-care-plan-for.html"><b>Acute Pain:</b></a> Chest pain related to tissue ischemia due to decreased oxygen supply.<br />
<br />
Goal:<br />
<ul>
<li>Chest pain is gone.</li>
<li>Calm face expression.</li>
<li>Vital signs within normal limits.</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Adjust the position of the patient semi-fowler</li>
<li>Collaboration with a physician for treatment</li>
<li>Give analgesics according to the medical program</li>
<li>Assess chest pain after a given action</li>
<li>Observation of vital signs</li>
</ul>
<br />
<br />
2. <a href="http://nanda-nurse-diary.blogspot.com/2013/01/ineffective-tissue-perfusion-cerebral.html"><b>Ineffective Tissue Perfusion: cerebral </b></a>related to decreased supply of oxygen and nutrients in the brain due to hypertension.<br />
<br />
Goal:<br />
<ul>
<li>The patient does not feel dizzy</li>
<li>The patient does not look uneasy</li>
<li>There is no sign of change in mental status are lacking.</li>
<li>Normal vital signs</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Observation of vital signs</li>
<li>Assess history of hypertension</li>
<li>Observation of changes in sensory and motor</li>
<li>Instruct the patient to bedrest</li>
<li>Collaboration of anti-hypertensive therapy</li>
</ul>
<br />
<br />
3. <a href="http://nanda-nurse-diary.blogspot.com/2012/11/ineffective-breathing-pattern-related_22.html"><b>Ineffective Breathing Pattern</b></a> related to increased compensation body to increase oxygen supply to the tissues.<br />
<br />
Goal:<br />
<ul>
<li>Patient does not feel shortness of breath</li>
<li>Normal breathing frequency</li>
<li>Regular breathing rhythm</li>
<li>No increase in chest retraction</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Assess the patient's level of anxiety</li>
<li>Observation of vital signs</li>
<li>Give oxygen as needed</li>
<li>Atue sitting with semi-Fowler position</li>
</ul>
<br />
4. <a href="http://nanda-nurse-diary.blogspot.com/2013/02/disturbed-sleep-pattern-and-anxiety-ncp.html"><b>Disturbed Sleep Pattern</b></a> related to the feeling of dizziness.<br />
<br />
Goal:<br />
<ul>
<li>Patient can sleep as needed</li>
<li>Patient does not look lethargic</li>
<li>Normal vital signs</li>
<li>Normal blood pressure within 3 days of treatment</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Assess the patient's ability to adapt to headache</li>
<li>Assess the patient's ability to rest and sleep needs</li>
<li>Teach relaxation techniques</li>
<li>Create a calm atmosphere</li>
<li>Limit visitors</li>
<li>Collaboration with physicians for the provision of medicines</li>
</ul>
<br />
5. <b>Anxiety </b>related to lack of knowledge about the disease, treatment program and maintenance actions to be performed and experienced.<br />
<br />
Goal:<br />
<ul>
<li>Patient look calm</li>
<li>Patients cooperative in care and treatment programs</li>
<li>Increase patients' knowledge about the disease, the signs and the conditions experienced, as well as the complications that may occur.</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Assess the patient's anxiety</li>
<li>Provide an opportunity for patients to express anxiety</li>
<li>Provide a description of the information about: disease condition, food on abstinence and the reason, care and treatment programs will be carried out, break relations with the condition of the disease</li>
<li>Provide an opportunity for patients to explain the re-explanation.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-22165540342832889152013-04-18T11:16:00.000+07:002014-09-11T02:20:56.389+07:00Nursing Care Plan for Diabetes Mellitus - 5 Diagnosis Interventions<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9pIfPV6Jzx6JdnTkY_9naECgKZSRUYRxf7DxrgD1vvWi3UntpKTRG1QdsC61ipDvFT_5Ks2GFnjkLVYYq1q4DfosKP37GW9mmW9_IEtdU_z9n2ZDE-yCDtfMZ_0UkTaGLBW-ZotTcY3c/s1600/Nursing+Care+Plan+for+Diabetes+Mellitus+-+5+Diagnosis+Interventions.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9pIfPV6Jzx6JdnTkY_9naECgKZSRUYRxf7DxrgD1vvWi3UntpKTRG1QdsC61ipDvFT_5Ks2GFnjkLVYYq1q4DfosKP37GW9mmW9_IEtdU_z9n2ZDE-yCDtfMZ_0UkTaGLBW-ZotTcY3c/s320/Nursing+Care+Plan+for+Diabetes+Mellitus+-+5+Diagnosis+Interventions.jpg" /></a><b>Assessment for Diabetes Mellitus</b><br />
<br />
Assessment is the first step in the nursing process and basic overall.<br />
<br />
Assessment of patients with diabetes mellitus (Doenges, 1999) include:<br />
<br />
a. Activity / Rest<br />
Symptoms: weakness, fatigue, difficulty moving / walking, muscle cramps, decreased muscle tone.<br />
Signs: decreased muscle strength.<br />
<br />
b. Circulation<br />
Symptoms: ulcers on the legs, a long healing process, tingling / numbness in the extremities.<br />
Signs: skin hot, dry and reddish.<br />
<br />
c. Ego integrity<br />
Symptoms: depend on others.<br />
Signs: anxiety, sensitive stimuli.<br />
<br />
d. Elimination<br />
Symptoms: changes in the pattern of urination (polyuria), nocturia<br />
Signs: dilute urine, pale dry, poliurine.<br />
<br />
e. Food / fluid<br />
Symptoms: loss of appetite, nausea / vomiting, do not follow the diet, weight loss.<br />
Symptoms: dry skin / scaly, ugly turgor.<br />
<br />
f. Pain / comfort<br />
Symptoms: pain in the ulcer wound<br />
Signs: face grimacing with palpitations, looks very carefully.<br />
<br />
g. Security<br />
Symptoms: dry skin, itching, skin ulcers.<br />
Symptoms: fever, diaphoresis, damaged skin, lesion / ulceration<br />
<br />
h. Counseling / learning<br />
Symptoms: family risk factors diabetes, heart disease, stroke, hypertension, long healing. The use of drugs such as steroids, diuretics (thiazides): diantin and phenobarbital (may increase blood glucose levels).<br />
<br />
<br />
<b>Nursing Diagnosis for Diabetes Mellitus</b><br />
<br />
Nursing diagnoses in patients with diabetes mellitus (Doenges, 1999) are:<br />
<br />
<ol>
<li><a href="http://nanda-nurse-diary.blogspot.com/2013/01/fluid-volume-deficit-related-to.html">Fluid Volume Deficit </a>related to osmotic diuresis, gastric loss, excessive diarrhea, nausea, vomiting, limited input, mental mess.</li>
<li><a href="http://nanda-nurse-diary.blogspot.com/2012/11/imbalanced-nutrition-less-than-body.html">Imbalanced Nutrition, Less Than Body Requirements</a> related to insulin insufficiency, decreased oral input: anorexia, nausea, a full stomach, abdominal pain, change in consciousness: hypermetabolism status, the release of stress hormones.</li>
<li><a href="http://nanda-nurse-diary.blogspot.com/2012/12/risk-for-infection-ncp-anemia.html">Risk for Infection</a> related to inadequate peripheral defense, changes in circulation, high blood sugar levels, invasive procedures and skin damage.</li>
<li>Fatigue related to decreased metabolic energy production, changes in blood chemistry, insulin insufficiency, increased energy demand, hypermetabolism status status / infection.</li>
<li><a href="http://nanda-nurse-diary.blogspot.com/2013/02/knowledge-deficit-ncp-asthma-bronchiale.html">Knowledge Deficit</a>: about condition, prognosis and treatment needs related to misinterpretation of information / do not know the source of information.</li>
</ol>
<br />
<br />
<b>Nursing Intervention and Implementation </b><br />
<b>for Diabetes Mellitus</b><br />
<br />
Intervention is planning nursing actions that will be implemented to address the problem in accordance with the nursing diagnoses.<br />
<br />
Implementation is the realization of management and nursing plans that had been developed at the planning stage.<br />
<br />
Nursing Intervention and implementation in patients with diabetes mellitus (Doenges, 1999) include:<br />
<br />
<i><b>1). Fluid Volume Deficit </b></i><br />
<br />
Expected outcomes:<br />
Patients showed an improvement in fluid balance,<br />
the criteria; spending adequate urine (normal range), vital signs stable, clear peripheral pulse pressure, good skin turgor, capillary refill well and mucous membranes moist or wet.<br />
<br />
Intervention / Implementation:<br />
1. Monitor vital signs, note the presence of orthostatic blood pressure.<br />
R: Hypovolemia can be manifested by hypotension and tachycardia.<br />
<br />
2. Assess breathing and breath patterns.<br />
R: The lungs secrete carbonic acid is produced through respiration compensated respiratory alkalosis, the state of ketoacidosis.<br />
<br />
3. Assess temperature, color and moisture.<br />
R: Fever, chills, and diaphoresis is common in the infection process. Fever with skin redness, dry, maybe a picture of dehydration.<br />
<br />
4. Assess peripheral pulses, capillary refill, skin turgor and mucous membranes.<br />
R: Is an indicator of the level of dehydration or adequate circulating volume.<br />
<br />
5. Monitor intake and output. Record the urine specific gravity.<br />
R: Provide the estimated need for fluid replacement, renal function and the effectiveness of a given therapy.<br />
<br />
6. Measure body weight every day.<br />
R: Provide the best results of the assessment of the status of ongoing fluid and further in giving replacement fluids.<br />
<br />
7. Collaboration fluid therapy as indicated<br />
R: Type and amount of fluid depends on the degree of dehydration and individual patient response.<br />
<br />
<br />
<i><b>2). Imbalanced Nutrition, Less Than Body Requirements</b></i><br />
<br />
Goal: weight can be increased with normal laboratory values and no signs of malnutrition.<br />
<br />
Expected outcomes:<br />
Patients are able to express an understanding of substance abuse, decrease the amount of intake (diet on nutritional status).<br />
Demonstrate behaviors, lifestyle changes to improve and maintain a proper weight.<br />
<br />
Intervention / Implementation:<br />
<br />
1. Measure body weight per day as indicated.<br />
R: Knowing eating adequate income.<br />
<br />
2. Determine the diet program and diet of patients compared with food that can be spent on the patient.<br />
R: Identify deviations from the requirements.<br />
<br />
3. Auscultation of bowel sounds, record the presence of abdominal pain / abdominal bloating, nausea, vomiting, keep fasting as indicated.<br />
R: Influence of intervention options.<br />
<br />
4. Observation of the signs of hypoglycemia, such as changes in level of consciousness, cold / humid, rapid pulse, hunger and dizziness.<br />
R: Potentially life-threatening, which must be multiplied and handled appropriately.<br />
<br />
5. Collaboration in the delivery of insulin, blood sugar tests and diet.<br />
R: It is useful to control blood sugar levels.<br />
<br />
<br />
<i><b>3). Risk for Infection</b></i><br />
<br />
Goal: Infection does not occur.<br />
<br />
Expeected outcomes:<br />
Identify individual risk factors and potential interventions to reduce infection.<br />
Maintain a safe aseptic environment.<br />
<br />
Intervention / Implementation<br />
<br />
1. Observation for signs of infection and inflammation such as fever, redness, pus in the wound, purulent sputum, urine color cloudy and foggy.<br />
R: incoming patients with infections that normally might have been able to trigger a state ketosidosis or nosocomial infections.<br />
<br />
2. Increase prevention efforts by performing good hand washing, each contact on all items related to the patient, including his or her own patients.<br />
R: prevention of nosocomial infections.<br />
<br />
3. Maintain aseptic technique in invasive procedures (such as infusion, catheter folley, etc.).<br />
R: Glucose levels in the blood will be the best medium for the growth of germs.<br />
<br />
4. Attach catheter / perineal care do well.<br />
R: Reduce the risk of urinary tract infection.<br />
<br />
5. Give skin care with regular and earnest. Massage depressed bone area, keep skin dry, dry linen and tight (not wrinkled).<br />
R: peripheral circulation can be impaired which puts patients at increased risk of damage to the skin / eye irritation and infection.<br />
<br />
6. Position the patient in semi-Fowler position.<br />
R: Makes it easy for the lung to expand, lowering the risk of hypoventilation.<br />
<br />
7. Collaboration antibiotics as indicated.<br />
R: penenganan early can help prevent the onset of sepsis.<br />
<br />
<i><b>4. <a href="http://nanda-nurse-diary.blogspot.com/2013/01/fatigue-ncp-diabetes-mellitus.html">Fatigue - NCP Diabetes Mellitus</a></b></i><br />
<br />
<i><b>5. Knowledge Deficit</b></i><br />
<br />
Goal: patient expressed understanding of the conditions, procedures and effects of the treatment process.<br />
<br />
Expected outcomes:<br />
Perform the necessary procedures and explain the rationale of an action.<br />
Initiate the necessary lifestyle changes and participate in treatment regimen.<br />
<br />
Intervention / Implementation:<br />
1. Assess the level of knowledge of the client and family about the disease.<br />
R: Find out how much experience and knowledge of the client and family about the disease.<br />
<br />
2. Give an explanation to the client about diseases and conditions now.<br />
R: By knowing the diseases and conditions now, clients and their families will feel calm and reduce anxiety.<br />
<br />
3. Encourage clients and families to pay attention to her diet.<br />
R: Diet and proper diet helps the healing process.<br />
<br />
4. Ask the client and reiterated family of materials that have been given.<br />
R: Knowing how much understanding of clients and their families and assess the success of the action taken.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-6823319237301855845.post-42286562892092261042013-04-16T22:27:00.002+07:002013-04-16T22:27:25.384+07:00Activity Intolerance and Excess Fluid Volume related to CHF<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPHmHXiO1MjdgGbDqW2AqEoN77bUtXSkZacW1Bx07ppHcXAILVlz0HFLwxFyoaszed0r4EGfXACKgHgVtO_dYMv8s3FkAn5VSUZCKdDMzQ58TlqAx6k4GATNhBwPYkacioik-i9jDgrZc/s1600/Activity+Intolerance+and+Excess+Fluid+Volume+related+to+CHF.gif" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhPHmHXiO1MjdgGbDqW2AqEoN77bUtXSkZacW1Bx07ppHcXAILVlz0HFLwxFyoaszed0r4EGfXACKgHgVtO_dYMv8s3FkAn5VSUZCKdDMzQ58TlqAx6k4GATNhBwPYkacioik-i9jDgrZc/s320/Activity+Intolerance+and+Excess+Fluid+Volume+related+to+CHF.gif" /></a>Congestive heart failure (CHF) occurs when the heart isn't able to pump blood normally. As a result, there is not enough blood flow to provide the body's organs with oxygen and nutrients. The term "heart failure" does not mean that the heart stops beating completely, but that the heart is not working as efficiently.<br />
<br />
There are two basic problems in congestive heart failure:<br />
<ul>
<li>systolic dysfunction occurs when the heart can't pump enough blood to supply all the body's needs</li>
<li>diastolic dysfunction occurs when the heart cannot accept all the blood being sent to it</li>
</ul>
<br />
<br />
<b>Nursng Diagnosis for CHF</b> : <b><a href="http://nanda-nurse-diary.blogspot.com/2012/12/activity-intolerance-related-to-pain-of.html">Activity Intolerance</a></b> related to<br />
<ul>
<li>Imbalance between oxygen supply.</li>
<li>General weakness.</li>
<li>Prolonged bed rest / immobilization.</li>
</ul>
Characterized by:<br />
<ul>
<li>weakness</li>
<li>fatigue</li>
<li>changes in vital signs</li>
<li>presence of dysrhythmias, dyspnea, pallor, sweating.</li>
</ul>
Goals / expected outcomes:<br />
<br />
Client will:<br />
<ul>
<li>participate in desired activities,</li>
<li>meet self-care,</li>
<li>achieve increased tolerance activity can be measured</li>
</ul>
evidenced by the decrease in weakness and fatigue.<br />
<br />
<b>Nursing Intervention</b><br />
<br />
1. Check vital signs before and immediately after the activity, especially if the client is using vasodilators, diuretics and beta blockers.<br />
Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), displacement fluid (diuretics) or influence cardiac function.<br />
<br />
2. Note the cardiopulmonary response to activity, noted tachycardia, dysrhythmias, dyspnea, sweating and pale.<br />
Rationale: Decrease / inability of the myocardium to increase the volume, as long as the activity can lead to an immediate increase in heart rate and oxygen demand is also increasing fatigue and weakness.<br />
<br />
3. Evaluation of increased activity intolerance.<br />
Rational: It can show an increase in cardiac decompensation rather than excess activity.<br />
<br />
4. Implementation of cardiac rehabilitation programs / activities (collaboration).<br />
Rational: gradual increase in activity, avoiding cardiac work / oxygen consumption is excessive. Strengthening and improvement of cardiac function under stress, when the heart is unable to function better again.<br />
<br />
<br />
<b>Nursng Diagnosis for CHF : Fluid Volume Excess</b> related to<br />
<ul>
<li>Decline in glomerular filtration rate (decreased cardiac output)</li>
<li>Increased ADH production and retention of sodium / water</li>
</ul>
characterized by: Orthopnea, S3 heart sound, oliguria, edema, weight gain, hypertension, respiratory distress, abnormal heart sounds.<br />
<br />
Goals / expected outcomes:<br />
<br />
Client will:<br />
<ul>
<li>demonstrate stable fluid volume with the balance of inputs and outputs,</li>
<li>breath sounds clean / clear,</li>
<li>vital signs within acceptable range,</li>
<li>stable weight and no edema,</li>
<li>expressed an understanding of individual fluid restriction.</li>
</ul>
<b>Nursing Intervention:</b><br />
<br />
1. Monitor urine output, record the number and color of the time in which diuresis occurs.<br />
Rational: urine output may be few and concentrated, due to decreased renal perfusion. Supine position so that helps diuresis of urine may be increased during bed rest.<br />
<br />
2. Monitor / count balance input and output for 24 hours.<br />
Rational: diuretic therapy may be caused by a sudden loss of fluid / redundant (hypovolemia) although edema / ascites is still there.<br />
<br />
3. Keep sitting or bed rest with semifowler position during the acute phase.<br />
Rational: The position is increasing kidney filtration and reduce the production of ADH to increase diuresis.<br />
<br />
4. Monitor BP and CVP (if any)<br />
Rationale: Hypertension and increased CVP showed excess fluid and may indicate an increase in pulmonary congestion, heart failure.<br />
<br />
5. Assess bowel sounds. Record complaints anorexia, nausea, abdominal distension and constipation.<br />
Rational: visceral congestion (occurring in chronic heart failure) can interfere with the function of gastric / intestinal.<br />
<br />
6. Administration of drugs as indicated (collaboration)<br />
<br />
7. Consult with a dietitian.<br />
Rationale: The need to provide an acceptable diet that meets the client's needs calories in sodium restriction.Unknownnoreply@blogger.com