Nursing Intervention for Atrial Septal Defect (ASD)

Nursing Intervention for Atrial Septal Defect (ASD)

Atrial septal defect (ASD) is one of the more commonly recognized congenital cardiac anomalies presenting in adulthood. Atrial septal defect is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium. Depending on the size of the defect, size of the shunt, and associated anomalies, this can result in a spectrum of disease from no significant cardiac sequelae to right-sided volume overload, pulmonary arterial hypertension, and even atrial arrhythmias.

With the routine use of echocardiography, the incidence of atrial septal defect is increased compared to earlier incidence studies using catheterization, surgery, or autopsy for diagnosis. The subtle physical examination findings and often minimal symptoms during the first 2-3 decades contribute to a delay in diagnosis until adulthood, the majority (more than 70%) of which is detected by the fifth decade. However, earlier intervention of most types of atrial septal defect is recommended.

Nursing Intervention for Atrial Septal Defect (ASD)

Nursing Diagnosis for Atrial Septal Defect (ASD)

1. Nursing Diagnosis : Risk for Decreased Cardiac Output related to the defect structure.


Client will demonstrate improved cardiac output.

Expected results:
  1. Heart frequency, blood pressure, and peripheral perfusion are in the normal range according to age.
  2. Adequate urine output (between 0.5 to 2 ml / kg body weight, depending on age)

Nursing intervention / rational for Atrial Septal Defect (ASD)
  1. Give digoxin based on the program, using the precautions made ​​to prevent toxisitas.
  2. Give afterload-lowering drugs based on the program
  3. Give diuretics according to courses

2. Nursing Diagnosis : Activity Intolerance related to disruption of oxygen transport system


Clients maintain adequate energy levels without additional stress.

Expected results:
  1. Children identify and conduct activities in accordance with ability.
  2. Children get a break / sleep right.

Nursing intervention / rational for Atrial Septal Defect (ASD)
  1. Provide frequent rest periods and sleep periods without interruption.
  2. Encourage quiet games and activities.
  3. Help child choose activities according to age, condition and capability.
  4. Avoid extreme temperature environments due to hyperthermia or hypothermia increases oxygen demand.
  5. Implement measures to reduce anxiety.
  6. Respond immediately to the cry or other expressions of distress.

Nursing Assessment Nursing Care Plan Atrial Septal Defect (ASD)

Nursing Diagnosis Nursing Care Plan Atrial Septal Defect (ASD)

Nursing Intervention for Dystocia

Dystocia (antonym eutocia) is an abnormal or difficult childbirth or labour. Approximately one fifth of human labours have dystocia. Dystocia may arise due to incoordinate uterine activity, abnormal fetal lie or presentation, absolute or relative cephalopelvic disproportion, or (rarely) a massive fetal tumor such as a sacrococcygeal teratoma. Oxytocin is commonly used to treat incoordinate uterine activity, but pregnancies complicated by dystocia often end with assisted deliveries, including forceps, ventouse or, commonly, caesarean section. Recognized complications of dystocia include fetal death, respiratory depression, Hypoxic Ischaemic Encephalopathy (HIE), and brachial nerve damage. A prolonged interval between pregnancies, primigravid birth, and multiple birth have also been associated with increased risk for labor dystocia.

Shoulder dystocia is a dystocia in which the anterior shoulder of the infant cannot pass below the pubic symphysis or requires significant manipulation to pass below it. It can also be described as delivery requiring additional manoeuvres after gentle downward traction on the head has failed to deliver the shoulders.

Nursing Intervention for Dystocia
  • Assess and monitor fetal heart rate and fetal distress
  • Monitor maternal temperature and heart rate
  • Monitor uterine contraction
  • Assist with pelvic examination, measurement, ultrasound or other procedures
  • Administer antibiotic and IV fluid as prescribed
  • Monitor intake and output
  • Assess for dehydration
  • Monitor color of amniotic fluid
  • Teach mother in breathing and relaxing techniques
  • Provide good rest and comforts
  • Assess for prolapse of the cord

Nursing Intervention for Uterine Inversion

Nursing Intervention for Uterine Inversion

Uterine inversion is a potentially life-threatening complication of childbirth. Normally, the placenta detaches from the uterus and exits the vagina around half an hour after the baby is delivered. Uterine inversion means the placenta remains attached, and its exit pulls the uterus inside-out.

In most cases, the doctor can manually detach the placenta and push the uterus back into position. Occasionally, abdominal surgery is required to reposition the uterus.

The rate of uterine inversion is estimated from one in 2,000 to one in several hundred thousand labours. Estimates vary widely - depending on the study. The mother’s survival rate is about 85 per cent. The cause of death includes massive bleeding (haemorrhage) and shock.

Nursing Intervention for Uterine Inversion
  • Monitor for signs of hemorrhage and shock and treat shock
  • Prepare patient to reposition the uterus to the correct position via the vagina or laparatomy if unsuccessful.

Nursing Intervention for Placenta Abruptio

Nursing Intervention for Placenta Abruptio

Placenta abruptio

Premature separation of placenta; Ablatio placentae; Abruptio placentae; Placental abruption

Placenta abruptio is the separation of the placenta (the organ that nourishes the fetus) from its attachment to the uterus wall before the baby is delivered.

  • Abdominal pain
  • Back pain
  • Frequent uterine contractions
  • Uterine contractions with no relaxation in between
  • Vaginal bleeding
Signs and tests

Tests may include:*
  • Abdominal ultrasound
  • Complete blood count
  • Fetal monitoring
  • Fibrinogen level
  • Partial thromboplastin time
  • Pelvic exam
  • Prothrombin time
  • Vaginal ultrasound

Nursing Intervention for Placenta Abruptio
  • Monitor maternal vital signs and fetal heart rate
  • Assess for excessive vaginal bleeding, abdominal pain, and increase in fundal height
  • Bed rest, oxygen, IV fluids, and blood products as prescribed
  • Monitor and report any uterine activity
  • Prepare for the delivery of the fetus as quickly as possible
  • Monitor for sings of disseminated intravascular coagulation in the postpartum period
  • Administer Rh immune globulin if the mother is Rh-negative and has not been given the injection at 28 weeks of gestation.

Nursing Intervention for Placenta Previa

Nursing Intervention for Placenta Previa

Placenta previa is a complication of pregnancy in which the placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix.

The placenta is the organ that nourishes the developing baby in the womb.

Nursing Diagnosis for Placenta Previa

Deficient Fluid volume: hypovolemia related to loss of vascular overload.

Expected results :
Demonstrating the stability / improvement of fluid balance as evidenced by stable vital signs, capillary filling fast. sensorium precise and specific gravity of urine output and adequate on an individual basis.

Nursing Intervention for Placenta Previa

1) Evaluation, report, and note the number and amount of blood loss. Perform calculations Weigh bandage bandage.
Rational: Estimated blood loss help differentiate the diagnosis, each gram increase in weight pads together with loss of approximately 1 ml of blood.

2) Make a bed rest. Ajurkan clients to avoid the Valsalva manover and coitus.
Rational: Bleeding can be stopped with a reduction of activity. Increased abdominal pressure or orgasm (which increases the activity of the uterus) can stimulate bleeding.

3) Position the client appropriately, supine position with hips elevated or semi - Fowler. Avoid Trendelenburg position.
Rational: To ensure adequate blood available to the brain, raising the pelvis to avoid compression of vena cava.

4) Record vital signs, capillary filling at the base of the nail, mucous membrane color / skin and temperature. Measure central venous pressure, if any.
Rational: To help determine the severity of blood loss, although cyanosis and changes in blood pressure, pulse is advanced signs of loss of circulation or the occurrence of shock.

5) Avoid rectal or vaginal examination
Rational: It can increase the hemorrhage, especially when marginal or total placenta previa occurs.

6) Give intravenous solution, plasma expander, complete blood count, or packaging cells, as indicated.
Rational: Increasing the volume of blood circulation and overcome the symptoms of shock.

7) Prepare for Caesarean section birth.
Rational: Hemorrhage stops when the placenta is removed and closed venous sinuses.

Nursing Intervention for Cataract

Nursing Intervention for Cataract

Risk for Injury related to damage vision or lack of knowledge.

Expected results:
Can reduce the risk of injury.

Nursing Intervention Nursing Care Plan for Cataract
  1. Help the patient when capable of performing the post-operative ambulation until stable and to achieve the vision and adequate coping skills.
    R /: reducing the risk of injury when a fall or stagger step or do not have the coping skills to damage eyesight.
  2. Help the patient set the environment
    R /: facilitating self-reliance and reduce the risk of injury
  3. Orient the patient in room
    R /: improve the security of mobility in the environment.
  4. Do not exert pressure on the affected eye trauma
    R /: pressure in the eye can cause serious damage further.
  5. Use appropriate procedures when delivering eye medication.
    R /: injury can occur if the container touch the eye medication.

Nursing Intervention for Colon Cancer (Colorectal Cancer)

Nursing Intervention for Colon Cancer (Colorectal Cancer)

Cancer of The Colon and Rectum

The colon is the part of the digestive system where the waste material is stored. The rectum is the end of the colon adjacent to the anus. Together, they form a long, muscular tube called the large intestine (also known as the large bowel). Tumors of the colon and rectum are growths arising from the inner wall of the large intestine. Benign tumors of the large intestine are called polyps. Malignant tumors of the large intestine are called cancers. Benign polyps do not invade nearby tissue or spread to other parts of the body. Benign polyps can be easily removed during colonoscopy and are not life-threatening. If benign polyps are not removed from the large intestine, they can become malignant (cancerous) over time. Most of the cancers of the large intestine are believed to have developed from polyps. Cancer of the colon and rectum (also referred to as colorectal cancer) can invade and damage adjacent tissues and organs. Cancer cells can also break away and spread to other parts of the body (such as liver and lung) where new tumors form. The spread of colon cancer to distant organs is called metastasis of the colon cancer. Once metastasis has occurred in colorectal cancer, a complete cure of the cancer is unlikely.

Nursing Intervention for Colon Cancer (Colorectal Cancer)

Maintaining Elimination.
Monitor the frequency and consistency of defecation. Laxatives and enemas given as prescribed. Patients who show signs of progress towards the obstruction totally prepared to undergo surgery.

Eliminate Pain.
Analgesic prescription. Environment is made conducive to relaxation with dim lights, turn off the television or radio, and limiting visitors and phone if desired by the patient. Measures additional convenience offered a change of position, rubbing his back, and relaxation techniques.

Increasing Tolerance Activities.
Assess the patient's activity tolerance. Activities changed and is scheduled to allow an adequate period of bed rest in an effort to reduce fatigue patients. Blood component therapy prescription if the patient is suffering from severe anemia. If blood transfusion is given, the general safety guidelines and institutional policies regarding security measures must be followed. Improved postoperative activity and tolerance monitored.

Providing nutritional measures.
If the patient's condition allows, a diet high in calories, protein, and carbohydrates and low in residue be given to preoperative period for a few days to provide adequate nutrition and minimize peristaltic cramps by lowering the excess. Total parenteral nutrition given to some patients to replace the depletion of nutrients, vitamins and minerals. Daily body weight were recorded and physicians are notified when a patient continues to experience weight loss when receiving parenteral nutrition.

Nursing Intervention for Glomerulonephritis

Nursing Intervention for Glomerulonephritis

Glomerulonephritis, also known as glomerular nephritis, abbreviated GN, is a renal disease (usually of both kidneys) characterized by inflammation of the glomeruli, or small blood vessels in the kidneys. It may present with isolated hematuria and/or proteinuria (blood or protein in the urine); or as a nephrotic syndrome, a nephritic syndrome, acute renal failure, or chronic renal failure. They are categorised into several different pathological patterns, which are broadly grouped into non-proliferative or proliferative types. Diagnosing the pattern of GN is important because the outcome and treatment differs in different types. Primary causes are ones which are intrinsic to the kidney, whilst secondary causes are associated with certain infections (bacterial, viral or parasitic pathogens), drugs, systemic disorders (SLE, vasculitis) or diabetes.

Nursing Diagnosis for Glomerulonephritis

Ineffective Tissue Perfusion related to water retention and hypernatremia

Expected Results :
Clients will demonstrate normal cerebral tissue perfusion is marked with blood pressure within normal limits, decreased water retention, no signs of hypernatremia.

Nursing Intervention for Glomerulonephritis
  1. Blood Pressure Monitor and record every 1-2 hours per day during the acute phase.
    Rational: to detect early symptoms of blood pressure changes and determine further intervention.
  2. Keep the airway hygiene, prepare suction
    Rational: n happen due to lack of oxygen to the brain perfusion.
  3. Set of anti-hypertension, monitor client reactions.
    Rationale: Anti-Hypertension can be due to uncontrolled hypertension can cause kidney damage.
  4. Monitor the status of the volume of liquid every 1-2 hours, monitor urine output (N: 1-2 ml / kg / hr).
    Rational: The monitor is very necessary because the expansion of the volume of fluid can cause blood pressure to rise.
  5. Assess neurological status (level of consciousness, reflexes, pupil response) every 8 hours.
    Rational: To detect early changes in neurological status, facilitate subsequent intervention.
  6. Set of diuretics: Esidriks, Lasix appropriate orders.
    Rational: Diuretic can increase the excretion of fluids.

Nursing Intervention for COPD

Nursing Intervention for Chronic obstructive pulmonary disease (COPD)

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

Nursing Intervention for COPD

Nursing Diagnosis for COPD

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

Achieving client airway clearance

Nursing Intervention for COPD

  1. Give the patient 6 to 8 glasses of fluid per day unless there is Cor pulmonale.
  2. Teach and give the use of diaphragmatic breathing and coughing techniques.
  3. Assist in the provision of a nebulizer action, measured dose inhalers.
  4. Perform postural drainage with percussion and vibration in the morning and at night as required.
  5. Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
  6. Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in color of sputum, sputum viscosity, increased shortness of breath, chest tightness, fatigue.
  7. Give antibiotics as required.
  8. Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.

Nursing Diagnosis for COPD

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

Improvement of breathing patterns

Nursing Intervention for COPD
  1. Teach client diaphragmatic breathing exercises and breathing lips sealed.
  2. Give encouragement to intersperse activity with periods of rest. Let the patient make decisions about treatment based on patient tolerance level.
  3. Give encouragement to use the muscles of breathing exercises if required.

Nursing Intervention for Osteoarthritis

Nursing Intervention for Osteoarthritis

Osteoarthritis is the most common form of arthritis. It causes pain, swelling and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine.

Osteoarthritis breaks down the cartilage in your joints. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage absorbs the shock of movement. When you lose cartilage, your bones rub together. Over time, this rubbing can permanently damage the joint. Factors that may cause osteoarthritis include
  • Being overweight
  • Getting older
  • Injuring a joint
Therapies that manage osteoarthritis pain and improve function include exercise, weight control, rest, pain relief, alternative therapies and surgery.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases

Nursing Diagnosis for Osteoarthritis

Acute / Chronic Pain related to distention of tissue by the accumulation of fluid / inflammatory process, Liquor joints.

Expected Results :
  1. Showing pain is reduced or controlled
  2. Looks relaxed, to rest, sleep and participate in activities based on ability.
  3. Following the therapy program.
  4. Using the skills of relaxation and entertainment activity in the pain control program.

Nursing Intervention for Osteoarthritis

  1. Assess complaints of pain; note the location and intensity of pain (scale 0-10). Write down the factors that accelerate and signs of non-verbal pain
  2. Give mat / hard mattress, small pillow. Elevate bed when a client needs to rest / sleep.
  3. Help the client take a comfortable position when sleeping or sitting in a chair. Depth of bed rest as indicated.
  4. Monitor the use of a pillow.
  5. Encourage clients to frequently change positions.
  6. Help the client to a warm bath at the time of waking.
  7. Help the client to a warm compress on the sore joints several times a day.
  8. Monitor temperature.
  9. Give a gentle massage.
  10. Encourage the use of stress management techniques such as progressive relaxation bio-feedback therapeutic touch, visualization, self hypnosis and imagination guidelines breath control.
  11. Engage in activities of entertainment that is suitable for individual situations.
  12. Give the drug prior to activity / exercise that is planned as directed.
  13. Assist clients with physical therapy.

Nursing Diagnosis for Osteoarthritis

Impaired Physical Mobility related to: skeletal deformities, pain, discomfort, decrease in muscle strength.

Expected Results :
  1. Maintaining a function of position with no presence / restrictions contractors
  2. Maintain or improve strength and function of the compensation part of the body
  3. Demonstrating techniques / behaviors that allow doing activities.

Nursing Intervention for Osteoarthritis
  1. Monitor the level of inflammation / pain in joints
  2. Maintain bed rest / sit if necessary
  3. Schedule of activities to provide a rest period of continuous and uninterrupted nighttime sleep.
  4. Assist clients with range of motion active / passive and resistive exercise and isometric if possible
  5. Slide to maintain an upright position and sitting height, standing, and walking.
  6. Provide a safe environment, for example, raise the chair / toilet, use a high grip and tub and toilet, the use of mobility aids / wheelchairs rescue
  7. Collaboration physical therapist / occupational and specialist vasional.

Nursing Intervention for Myocardial Infarction

Nursing Intervention for Myocardial Infarction

Myocardial infarction is a condition of cessation of blood flow from the coronary artery in the affected area which causes lack of oxygen (ischemia) and heart cells become dead (myocardial necrosis).

The most common cause is the rupture of atherosclerotic lesions in coronary arteries that lead to the formation of a thrombus that clog arteries and lead to interruption of the blood supply to the region of the heart supplied.

Clinical manifestations of myocardial infarction is typical chest pain described as heavy, pressing, tightness, and is settled.

In individuals who lack the vitamins and other essential nutrients, especially vitamin C in millions of vascular wall cells for many years will damage / weaken the function of blood vessels. This condition causes the formation of cracks that will be enlarged on the walls of the arteries, especially the coronary arteries.

Automatic mechanisms of the body to repair the damage done through the production of fat molecules (including cholesterol), sugar, clotting factors and other factors in the liver in greater numbers than usual, and then channeled through the bloodstream to the coronary artery wall.

Because coronary artery had suffered severe damage, then the required intensive treatment, or in other words an increase higher than these factors. A large number of these factors over time will be buried beneath the endothelium in many arteries of the body. When the pile is to penetrate the endothelium, this area will be invaded by fibrous tissue and often calcified, which led to the formation of atherosclerotic plaques that protrude into the lumen of the blood vessel.

These plaques prone to rupture due to the tension of the strain caused by blood flow. Plaque rupture causing exposure to subendothelial collagen and activation of the clotting cascade, which in turn triggers platelet aggregation resulting in ischemic state. The degree of coronary occlusion and myocardial damage is also influenced by endothelial damage due to plaque formation. Severe ischemia and long will cause a necrotic region that stretches across the myocardial wall thickness.

Nursing Diagnosis for Myocardial Infarction

Acute Pain related to tissue ischemic, secondary to clogged arteries.

Marked by :
  • Chest pain with or without spread
  • Facial grimacing
  • Nervous
  • Delirium
  • Changes in pulse, blood pressure.
Goal :
Pain reduced / no pain

Expected Outcome :
  • Chest pain is reduced, eg from scale 3 to 2, or from 2 to 1
  • Facial expression relaxed / calm, not tense
  • Not anxious
  • Pulse 60-100 x / min
  • Blood pressure 120/80 mmHg
Nursing Intervention for Myocardial Infarction
  • Observation of the characteristics, location, time, and the course of chest pain.
  • Instruct the client to stop activity and rest during an attack.
  • Help the client to do relaxation techniques, eg deep breathing, distraction behavior, visualization, or imagination guidance.
  • Maintain oxygenation with bicanul example (2-4 lt / min)
  • Monitor vital signs (pulse and blood pressure) every two hours.
  • Collaboration with the health team in providing analgesic.

Nursing Diagnosis for Myocardial Infarction

Risk for Decreased Cardiac Output related to changes in power factors, reduction miocard characteristics.

Goal :
Cardiac Output: improved / stable.

Expected Outcome
  • No edema
  • No dysrhythmias
  • Normal urine output
  • Vital Signs within normal limits

Nursing Intervention for Myocardial Infarction
  • Maintain bed rest during the acute phase
  • Assess and report any signs of decreased cardiac output, blood pressure
  • Monitor urine output
  • Assess and monitor vital signs every hour
  • Assess and monitor ECG every day
  • Give oxygen as needed
  • Auscultation of respiratory and heart every hour as indicated
  • Keep parenteral fluids and medications appropriate advice.
  • Provide appropriate food diet.
  • Avoid Valsalva maneuver, straining (use laxan).

Nursing Intervention for Respiratory Distress Syndrome (RDS)

Nursing Intervention for Respiratory Distress Syndrome (RDS)

Neonatal respiratory distress syndrome (RDS) is most commonly a complication seen in premature infants. The condition makes it difficult to breathe.

Symptoms of Respiratory Distress Syndrome (RDS)

The symptoms usually appear within minutes of birth, although they may not be seen for several hours. Symptoms may include:
  • Bluish color of the skin and mucus membranes (cyanosis)
  • Brief stop in breathing (apnea)
  • Decreased urine output
  • Grunting
  • Nasal flaring
  • Puffy or swollen arms or legs
  • Rapid breathing
  • Shallow breathing
  • Shortness of breath and grunting sounds while breathing
  • Unusual breathing movement -- drawing back of the chest muscles with breathing

Nursing Intervention for Respiratory Distress Syndrome (RDS)

Goal :
Signs and symptoms of respiratory disstres, deviation from the function and the risk of infant against Respiratory Distress Syndrome (RDS)can be identified.
  • Assess the infant is at risk for Respiratory Distress Syndrome (RDS), namely:

    • mothers with diabetes mellitus or bleeding placenta.
    • Prematurity baby.
    • Fetal Hypoxia.
    • births by caesarean section.

    Assessment of immediate intervention is needed to determine if the baby showed signs of disstres breath and especially to improve the prognosis.
  • Assess respiratory status changes include:

    • Tachypnoea (respiratory above 60 x per minute, maybe 80-100 x)
    • Breath grunting
    • Nasal flaring
    • Intercostal retraction, suprasternal or Substernal with the use of auxiliary respiratory muscles
    • Cyanosis
    • Episodes of apnea, decreased breath sounds and presence crakles.

    These changes indicate the RDS has occurred, call a doctor for immediate action

    • Respiratory infants increased due to increased oxygen demand
    • Voice is a voice taps ekhalasi closing glottis to stop the air by pressing the vocal cords
    • Represents the state to lower the resistance of respiration with wide open airway
    • Retraction indicates inadequate lung expansion during inspiration
    • CNS occurs as a sign-up with PO2 below 40 mmHg
    • Episode apneu and decreased breath sounds indicating increasingly severe respiratory distress

Nursing Intervention for Alzheimer's Disease

Nursing Intervention and Diagnosis for Alzheimer's Disease

Alzheimer's disease is not contagious, but rather a syndrome similar to apoptosis of brain cells at the same time, so that the brain seemed to shrink. Alzheimer's disease is also said to be synonymous with the parents.

Risk for Alzheimer's disease, increases with age. Starting at the age of 65 years, someone has a five percent risk of developing the disease and will be doubling every five years, said a doctor. According to him, even if the disease is associated with a parent, but history proves that the first disease that is known for sure is that women suffer from this disease in the early 50's age.

Risk Factors
  •      People with hypertension who reach the age of 40 years and over
  •      People with diabetes
  •      Lack of exercise
  •      High cholesterol levels
  •      Heredity - the family has this disease in the 50s.

Nursing Diagnosis for Alzheimer's Disease

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

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

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

Nursing Diagnosis for Alzheimer's Disease

Disturbed Thought Processes related to :
  • Irreversible neuro degeneration
  • Memory Loss
  • Psychological Conflict
  • Deprivation lie

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

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

Nursing Assessment for Alzheimer's Disease

Nursing Diagnosis for Alzheimer's Disease

Nursing Intervention for Hepatitis

Hepatitis is an inflammation of the liver due to toxins, such as chemicals or drugs or agents that cause infections. Hepatitis that lasts less than 6 months of so-called "acute hepatitis", hepatitis lasting more than 6 months of so-called "chronic hepatitis".

Hepatitis usually occurs due to a virus, especially one of the five hepatitis viruses, A, B, C, D or E. Hepatitis can also occur due to other viral infections, such as infectious mononucleosis, yellow fever and cytomegalovirus infection. Causes of non-viral hepatitis is the main alcohol and drugs.

Hepatitis A usually resolves itself without becoming chronic. Once cured, it will be immune to hepatitis A, but not immune to other types of hepatitis.
5 percent of patients with chronic hepatitis B will be, because it is not handled properly.

Nursing Diagnosis for Hepatitis

Activity Intolerance related to fatigue and generalized malaise.

Expected outcome :

Exhibits increased ability to carry out desired activities and allow sufficient periods for rest and relaxation.

Nursing Intervention for Hepatitis
  • Encourage the patient to limit activity when fatigue
  • Assist the patient in planning periods of rest and activity when symptoms begin to subside.
  • Encourage gradual resumption of activities and mild excercise during recovery.

Abdominal pain related to tender, enlarged liver.

Expected outcome :

Report a decrease or absence of abdominal pain and tenderness;restrict activities if pain occurs;participates in planned activities when free of pain; take prescribed analgesic if necessary.

Nursing Intervention for Hepatitis
  • Asses and record presence or absence of abdominal pain or tenderness, hepatomegally and splenomegally.
  • Encourage the patient to maintain bedrest or restrict activities if abdominal pain or tenderness is present.
  • Administer analgesic as prescribed.
  • Notify the physian of sudden occuraence or increase in pain or tenderness.

Nursing Intervention for Neonatal Sepsis

Neonatal sepsis is a form of the disease are described with systemic bacterial infection in the first month of life which marked a positive blood culture results. Another definition is a clinical syndrome characterized systemic symptoms and accompanied by bacteremia that occurred in the first month of life.

The incidence of neonatal sepsis vary from 1-4 / 1000 live births in developed countries with large fluctuations over time and geographical space. The diversity of the incident from the hospital to another hospital can be connected with the number of prematurity, prenatal care, delivery execution, and environmental conditions in the treatment room.

Figures neonatal sepsis increased significantly, in infants with low birth weight and maternal risk factors if any (obstetric) or signs corioamnionitis, such as rupture of time (over 18 hours), maternal intrapartum fever (more than 37.5 ° C), maternal leukocytosis (more than 18000 / mm3), softening of the uterus and fetal tachycardia (more than 180 beats / min). Host risk factors include male gender, acquired immune defects or congenital galactosemia (Escherichia coli) administration of intramuscular iron preparations (E. coli), congenital anomalies (urethra, asplenia, myelomeningocele, sinus tract), omphalitis and twins (especially the second twin fetuses infected). Prematurity is a risk factor for both the beginning and advanced sepsis.

Nursing Diagnosis for Neonatal Sepsis

Risk for Injury related to neonatal sepsis

Expected results:
  • Infants receiving therapy
  • The baby suffered repeated culture after medical measures showed no 'growth' or other complication.
  • Infants have a normal body temperature

Nursing Intervention for Neonatal Sepsis
  • Maintain isolation: isolation treatment
  • Change position every 2 hours
  • Observation of vital signs every 2 hours, tell your doctor and report changes as needed
  • Monitor vital signs
  • Maintain a neutral environmental temperature
  • Check the temperature every 2 hours
  • Keep the hand washing procedure
  • Teach the technique of washing hands to the baby parent's, before holding the baby
  • Give oxygen to order
  • Plan periods of rest, avoid holding unnecessary.

Nursing Intervention for Neonatal Sepsis

Nursing Intervention for Meningitis

Meningitis is an inflammation of the protective membranes that envelop the brain and spinal cord, which as a whole is called the meninges. Inflammation can be caused by infection by viruses, bacteria, or other microorganisms as well, and although rarely can be caused by certain medications. Meningitis can cause death due to inflammation that occurs in the brain and spinal cord; so the condition is classified as a medical emergency.

Common symptoms of meningitis are headache and stiff neck accompanied by fever, confusion or altered consciousness, vomiting, and sensitivity to light (photophobia) or loud noises (phonophobia). Children usually only show nonspecific symptoms, such as irritability and drowsiness. Red rash may provide clues cause of meningitis; for instance, meningitis caused by meningococcal bacteria can be shown by a red rash.

Meningitis is often caused by infection by microorganisms. Most infections are caused by viruses, bacteria, fungi, and protozoa as the next most frequent cause. This disease can also be caused by a variety of non-infectious causes of aseptic meningitis term refers to a case of meningitis can not be proved the involvement of bacterial infection. This type of meningitis is usually caused by a virus, but this situation can also occur when a bacterial infection has been partially treated before, when the bacteria disappeared from the meninges, or pathogen infects an area close to the meninges (eg sinusitis). Endocarditis (infection of the heart valves that deploy small clusters of bacteria through the bloodstream) may cause aseptic meningitis. Aseptic meningitis can also arise from a spirochete infection, a type of bacteria that include Treponema pallidum (causes syphilis) and Borrelia burgdorferi (known for causing Lyme disease). Meningitis can be found in cerebral malaria (malaria infecting the brain) or amoebic meningitis, meningitis caused by amoeba infections such as; Naegleria fowleri, which is obtained from a source of fresh water.

Nursing Diagnosis for Meningitis

Impaired Tissue Perfusion related to increased intracranial pressure

  • Patients returned to the state of neurological status prior to illness.
  • Increased awareness and sensory function.

Expected results:
  • Vital signs within normal limits
  • Head pain is reduced
  • Increased awareness
  • There is an increasing cognitive
  • There are no signs or loss of the increased intracranial pressure.

Nursing Intervention for Meningitis
  1. Patients total bed rest with supine sleeping position without a pillow
    Rational: intacranial pressure changes, will be able to cause the risk for brain herniation
  2. Monitor signs of neurological status with GCS.
    Rational: It can reduce further brain damage.
  3. Monitor vital signs such as blood pressure, pulse, temperature, and caution in systolic hypertension.
    Rational: In normal circumstances, autoregulation maintains a state of systemic blood pressure changed by fluctuations. Autoreguler failure will lead to cerebral vascular damage that can be manifested by an increase followed by a decrease in systolic and diastolic pressure. While the increase in temperature to describe the journey of infection.
  4. Monitor intake and output
    Rational: hyperthermia can cause increased IWL and increase the risk of dehydration, especially in patients who are not aware, the nausea that reduce oral intake.

Nursing Intervention for Meningitis

Nursing Intervention for Gastritis

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

Nursing Diagnosis for Gastritis

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

Disorders of fluid balance did not occur.

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

Nursing Intervention for Gastritis

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

Nursing Diagnosis for Gastritis

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

Nutritional deficiencies resolved.

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

Nursing Intervention for Gastritis

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

Nursing Interventions for Hypertension

Hypertension is a chronic medical condition with increased blood pressure in the arteries. This increase causes the heart to work harder than normal to circulate blood through the blood vessels. Blood pressure involves two measurements, systolic and diastolic, depending on whether the heart muscle contraction (systole) or relaxation between beats (diastole). Normal blood pressure at rest is in the range of systolic (top reading) 100-140 mmHg and diastolic (bottom reading) of 60-90 mmHg. High blood pressure occurs when the constant is at 140/90 mmHg or more.

Hypertension is divided into primary hypertension (essential) or secondary hypertension. Approximately 90-95% of cases classified as "primary hypertension", which means high blood pressure without a clear medical cause. Other conditions that affect the kidneys, arteries, heart, endocrine system or other causes 5-10% of cases (secondary hypertension).

Hypertension is a major risk factor for stroke, myocardial infarction (heart attack), heart failure, arterial aneurysm (eg aortic aneurysm), peripheral arterial disease, and causes of chronic kidney disease. Even a modest increase in arterial blood pressure associated with a shorter life expectancy. Changes in diet and lifestyle can improve blood pressure control and reduce the risk of health-related complications. However, the drug is often required in some people if lifestyle changes alone proved ineffective or insufficient and drug usually must be taken for life until the doctor decides no longer need to take medication. Someone who has had high blood pressure, under normal conditions can be returned and the blood pressure is to be aware, many cases of stroke occurs when a person off drugs. And many people do not think that someone who usually have low blood pressure at one time may also have high blood pressure. Therefore, control of blood pressure on a regular basis to be conducted.

Nursing Diagnosis for Hypertension

Decreased Cardiac Output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy

Nursing Intervention for Hypertension
  • Monitor blood pressure
  • Note the central and peripheral pulse quality
  • Auscultation of heart and breath sounds
  • Observe skin color, moisture, temperature and capillary filling time
  • Observe the general edema
  • Provide quiet environment, comfortable
  • Suggest to reduce activity.
  • Maintain restrictions on activities such as recess ditemapt bed / chair
  • Help perform self-care activities as needed
  • Perform actions such as a comfortable back and neck massage
  • Encourage relaxation techniques
  • Give fluid restriction and sodium diet as indicated.

Nursing Diagnosis for Hypertension

Risk for Ineffective Tissue perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary related to impaired circulation

Nursing Intervention for Hypertension

  • Maintain bed rest, elevate head of bed
  • Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if available
  • Maintain fluid and drugs.
  • Observe the sudden hypotension.
  • Measure inputs and expenditures
  • Monitor electrolytes, BUN, creatinine.
  • Ambulation according to ability; avoid fatigue

NANDA Nursing

Care Plan Nursing