tag:blogger.com,1999:blog-27768403637969573502024-03-13T23:44:07.102+07:00Nursing InterventionsNursing Care Plan : Nursing InterventionsNew Bloggerhttp://www.blogger.com/profile/14577688728460634036noreply@blogger.comBlogger66125tag:blogger.com,1999:blog-2776840363796957350.post-67872494035835664872015-11-01T15:02:00.002+07:002015-11-01T15:02:36.624+07:00Nursing Interventions for ARDS (Acute Respiratory Distress Syndrome)<br />
<b>Nursing Care Plan for ARDS</b><br />
<br />
<b>Nursing Diagnosis : </b>Ineffective airway clearance<br />
related to:<br />
<br />
<ul>
<li>Loss of function of cilia airway (hypoperfusion).</li>
<li>Increasing the number / viscosity of pulmonary secretions.</li>
<li>Increased retention of the airway (interstitial edema).</li>
</ul>
Characterized by: <br />
<ul>
<li>Reports dyspnea. </li>
<li>Change the depth / respiratory rate, use of accessory muscles to breathe. </li>
<li>Cough (effective or ineffective) with / without sputum production. Anxiety / restlessness.</li>
</ul>
Expected outcomes: <br />
<ul>
<li>Stating / show loss of dyspnea. </li>
<li>Maintain a patent airway with breath sounds clean / no crackles. </li>
<li>Issued a secret without difficulty. </li>
<li>Show behavior to improve / maintain airway clearance.</li>
</ul>
<br />
<b>Intervention:</b><br />
<br />
Independent:<br />
<ul>
<li>Note the change of effort and breathing patterns.</li>
<li>Observations decrease in chest wall expansion and presence / increase fremitus.</li>
<li>Note the characteristic sound of the breath.</li>
<li>Note the characteristic cough (eg, cough settled, effective / ineffective) is also sputum production and characteristics.</li>
<li>Maintain the position of the body / head right and use the tools of the airway as needed.</li>
<li>Help with coughing / deep breath, reposition and exploitation as indicated.</li>
</ul>
<br />
Collaboration:<br />
Give moist oxygen, IV fluids, give proper humidity of the room.<br />
<ul>
<li>Give aerosol therapy, ultrasonic nebulizer.</li>
<li>Help with / provide chest physiotherapy, postural drainage example: chest percussion / vibration according to indications.</li>
<li>Give bronchodilators.</li>
<li>Keep an eye for adverse side effects of the drug, eg tachycardia, hypertension, tremors, insomnia.</li>
</ul>
<br />
<b>Rational:</b><br />
<br />
Independent:<br />
<ul>
<li>Intercostal muscle use / abdominal and nasal dilation showed increased respiratory effort.</li>
<li>Chest expansion is limited or not the same with respect to fluid accumulation, edema, and secret.</li>
<li>Consolidation of lung and fluid replenishment can increase fremitus.</li>
<li>Breath sounds indicate the flow of air through the tracheobronchial tree and is influenced by the presence of fluid, mucus, or other airflow obstruction. Wheezing can constitute evidence in connection with the narrowing of the airway edema. Crackles may be clear without coughing and showing the collection of mucus in the airways.</li>
<li>Cough characteristics may change depending on the cause / etiology of respiratory failure. Sputum, when there may be many, thick, bloody, or purulent.</li>
<li>Facilitate maintain a patent airway or if the patient's airway is affected ie., Disturbance of consciousness, sedation and maxillofacial trauma.</li>
<li>The collection of secretions interfere with ventilation or pulmonary edema and if the patient is not intubated, increase oral fluid intake can dilute / increase spending.</li>
</ul>
<br />
Collaboration:<br />
<ul>
<li>Humidity will remove and mobilize secretions and increase oxygen transport.</li>
<li>Treatment is made to deliver oxygen / bronchodilation / humidity firmly on the alveoli and to mobilize secret.</li>
<li>Improve drainage / elimination of pulmonary secretions into the central bronchi, which can be more readily coughed or sucked out.</li>
<li>Improve the efficiency of use of the breathing muscles and help the expansion of the alveoli.</li>
<li>Drug given to relieve bronchospasm, lowering the viscosity of secretions, improve ventilation and easier disposal secret.</li>
<li>Require a change in dose / drug options.</li>
</ul>
mas ckhttp://www.blogger.com/profile/05796738330565853948noreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-5842675812375186732015-10-13T10:14:00.001+07:002015-10-13T10:15:15.049+07:00Nursing Interventions for Cirrhosis<br />
Cirrhosis is severe scarring of the liver and poor liver function seen at the end of chronic liver disease. The scar tissue blocks the flow of blood through the liver and slows the processing of nutrients, hormones, drugs, and naturally produced toxins. It also slows the production of proteins and other substances made by the liver.<br />
<br />
According to the National Institutes of Health (NIH) cirrhosis is the 12th leading cause of death due to disease in America. It is more likely to affect men than women.<br />
<br />
Some of the symptoms include:<br />
<ul>
<li>decreased appetite</li>
<li>nose bleeds</li>
<li>small spider-shaped arteries underneath the skin</li>
<li>weight loss</li>
<li>weakness</li>
</ul>
More serious symptoms include:<br />
<ul>
<li>confusion and difficulty thinking clearly</li>
<li>yellow skin color (jaundice caused by buildup of bilirubin in the blood)</li>
<li>abdominal swelling (ascites)</li>
<li>swelling of the legs (edema)</li>
<li>impotence</li>
<li>males can start to develop breast tissue (gynecomastia)</li>
</ul>
<br />
<br />
<b>Nursing Interventions for Cirrhosis</b><br />
<br />
1. Imbalanced Nutrition Less Than Body Requirements related to anorexia.<br />
<br />
Goal: Nutrition clients are met.<br />
Expected outcomes: The client is able to exhibit a lifestyle to improve or maintain an appropriate body weight, showed weight gain goals with laboratory values, and freely sign of malnutrition.<br />
<br />
Interventions:<br />
<br />
1. Observation vital signs.<br />
Rationale: To determine the general state of the client.<br />
<br />
2. Provide oral care before meals.<br />
Rationale: Eliminate sense, it can not increase the appetite.<br />
<br />
3. Monitor dietary intake, or the number of calories and provide little in the frequency often.<br />
Rationale: Eat a lot harder when the client anorexia. Anorexia is also the worst during the day, make food intake difficult in the afternoon.<br />
<br />
4. Monitor blood glucose.<br />
Rationale: hyperglycemia or hypoglycemia can occur require changes in diet or insulin administration.<br />
<br />
5. Collaboration: Consultation with a dietitian to provide a diet in accordance with the client's needs with the input of fat and protein as tolerated.<br />
Rationale: Allows to create a diet program for individual needs. Protein restriction is indicated in severe diseases like hepatitis.<br />
<br />
<br />
<br />
2. Self-Care Deficit related to fatigue and the presence of ascites.<br />
<br />
Goal: The client is able to care for themselves.<br />
Expected outcomes: The client is able to show self-care activities.<br />
<br />
Interventions :<br />
<br />
1. Give the rest during the acute phase.<br />
Rationale: Increased rest and tranquility providing the energy that is used for healing.<br />
<br />
2. If the client is tired, limit visits of family or friends.<br />
Rationale: Increase rest and tranquility providing the energy that is used for healing.<br />
<br />
3. Give light activity during bed rest.<br />
Rationale: Bed rest time, can reduce the ability, this is precisely the case due to the limited activities that disrupt the rest period.<br />
<br />
<br />
<br />
3, Risk for Impaired tissue integrity related to bed rest, ascites and edema.<br />
<br />
Goal: Do not damage the integrity of the skin.<br />
<br />
Expected outcomes: Identify the risk factors and shows the behavior or technique to prevent skin damage.<br />
<br />
Interventions:<br />
<br />
1. Elevate the lower extremities.<br />
Rationale: Improves venous return and decrease edema in the extremities.<br />
<br />
<br />
2. Cut fingernails to short, and give the gloves if desired.<br />
Rationale: Prevent clients from injury to the skin, especially at bedtime.<br />
<br />
3. Keep the sheets dry and free of creases.<br />
Rational: Humidity increase pruritus and improve skin damage.<br />
<br />
4. Give the massage at bedtime.<br />
Rational: Beneficial to improve sleep by reducing skin irritation.<br />
<br />
Source :<br />
<a href="http://www.nandahealth.com/2015/09/nursing-diagnosis-and-interventions-for.html">http://www.nandahealth.com/2015/09/nursing-diagnosis-and-interventions-for.html</a> mas ckhttp://www.blogger.com/profile/05796738330565853948noreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-50434951162152428522015-10-13T10:03:00.002+07:002015-10-13T10:03:37.876+07:00Nursing Interventions for Atherosclerosis<b>Nursing Interventions for Atherosclerosis</b><br />
<br />
Atherosclerosis is a specific form of arteriosclerosis in which an artery wall thickens as a result of invasion and accumulation of white blood cells (WBCs) (foam cell) and proliferation of intimal smooth muscle cell creating a fibrofatty plaque.<br />
<br />
The spectrum of presentation includes symptoms and signs consistent with the following conditions:<br />
<ul>
<li>Asymptomatic state (subclinical phase)</li>
<li>Stable angina pectoris</li>
<li>Unstable angina (ie, ACS)</li>
<li>AMI</li>
<li>Chronic ischemic cardiomyopathy</li>
<li>Congestive heart failure</li>
<li>Sudden cardiac arrest</li>
</ul>
History may include the following:<br />
<ul>
<li>Chest pain</li>
<li>Shortness of breath</li>
<li>Weakness, tiredness, reduced exertional capacity</li>
<li>Dizziness, palpitations</li>
<li>Leg swelling</li>
<li>Weight gain</li>
<li>Symptoms related to risk factors</li>
</ul>
<br />
<b>Nursing Interventions for Atherosclerosis </b><br />
<br />
1. Acute Pain related to an impaired ability of blood vessels to supply oxygen to the tissues.<br />
<br />
Goal: reduced pain<br />
<br />
Expected outcomes: patient states chest pain disappear, or can be controlled, the patient did not seem grimace, demonstrate relaxation techniques.<br />
<br />
Intervention and Rational:<br />
<br />
1. Monitor characteristics of pain through verbal and hemodynamic responses (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).<br />
Rationale: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.<br />
<br />
2. Provide a comfortable environment, reduce the activity, limit visitors.<br />
Rationale:
Helps reduce external stimuli that can add to the tranquility so
patients can rest in peace and the power of the heart is not too hard.<br />
<br />
3. Assess the description of pain experienced by patients include: place, intensity, duration, quality, and distribution.<br />
Rationale: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other symptoms to obtain accurate data.<br />
<br />
4. Observation of vital signs before and after drug administration.<br />
Rationale: Knowing the patient's progress, after being given the drug. <br />
<br />5. Teach relaxation techniques with a sigh<br />
Rationale: Helps relieve pain experienced by patients psychologically which can distract the patient that is not focused on the pain experienced.<br />
<br />
<br /><br />
2. Ineffective Tissue Perfusion: Peripheral related to impaired circulation<br />
<br />
Goal: clients show improvement perfusion with<br />
<br />
Expected outcomes: a peripheral pulse / same, normal skin color and temperature, an increase in behaviors that increase tissue perfusion.<br />
<br />
Intervention and Rational:<br />
<br />
1. Observation of skin color on the sick.<br />
Rationale: The skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.<br />
<br />
2. View and examine the skin for ulceration, lesions, gangrene area.<br />
Rationale:
Lesions may occur from the size of a pin needle to involve all the
fingertips and can lead to infection or damage / loss of tissue
seriously.<br />
<br />
3. Note the decrease in pulse; traffic change skin (no color, glossy / tense).<br />
Rationale: This change indicates progress or chronic process.<br />
<br />
4. Advise for the proper nutrients and vitamins.<br />
Rationale: The balance of a good diet includes protein and adequate hydration, necessary for healing of the sick.<br />
<br />
5. Encourage patients perform the exercises or exercises gradually extremities.<br />
Rationale: For circulation.<br />
<br />
65. Monitor signs of tissue perfusion adequacy.<br />
Rationale: To identify the early signs of impaired perfusion.<br />
<br />
Source :<br />
<a href="http://list-nanda-nursing-diagnosis.blogspot.co.id/2013/01/ineffective-tissue-perfusion-peripheral.html" target="_blank">http://list-nanda-nursing-diagnosis.blogspot.co.id/2013/01/ineffective-tissue-perfusion-peripheral.html </a><br />
<a href="http://list-nanda-nursing-diagnosis.blogspot.co.id/2013/01/acute-pain-ncp-atherosclerosis.html">http://list-nanda-nursing-diagnosis.blogspot.co.id/2013/01/acute-pain-ncp-atherosclerosis.html</a>mas ckhttp://www.blogger.com/profile/05796738330565853948noreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-38738746968859227552015-02-19T10:16:00.006+07:002015-02-19T10:16:56.299+07:00Nursing Interventions for Bronchiectasis<b>Nursing Care Plan for Bronchiectasis</b><br />
<br />
<b>Definition</b><br />
<br />
Bronchiectasis means a dilation that can not be recovered again from bronchial caused by recurrent episodes of pneumonitis and elongated, foreign body aspiration, or mass (ie. Neoplasm) that inhibit the bronchial lumen obstruction. (Hudak & Gallo, 1997).<br />
<br />
<br />
<br />
<b>Classification</b><br />
Based on bronchography and pathology, bronchiectasis can be divided into three, namely:<br />
<ul>
<li>Cylindrical bronchiectasis.</li>
<li>Fusiform bronchiectasis.</li>
<li>Saccular or cystic bronchiectasis.</li>
</ul>
<br />
<br />
<b>Etiology</b><br />
<ul>
<li>Infection.</li>
<li>Hereditary disorder or congenital abnormalities.</li>
<li>Mechanical factors that facilitate the onset of infection.</li>
<li>Often patients have a history of pneumonia as a complication of measles, whooping cough, or other infectious diseases in childhood.</li>
</ul>
<br />
<br />
<br />
<b>Signs and symptoms</b><br />
<ul>
<li>Chronic cough with sputum that is a lot, especially in the morning, after sleeping.</li>
<li>Cough with sputum accompanying cold cough for 1-2 weeks or no symptoms at all (mild Bronchiectasis)</li>
<li>Persistent cough with sputum that is much less than 200-300 cc, accompanied by fever, no appetite, weight loss, anemia, pleural pain, and weak body sometimes shortness of breath and cyanosis, sputum often contain blood spots, and coughing up blood.</li>
<li>Found finger-clubbing in 30-50% of cases.</li>
</ul>
<br />
<b><a href="http://nursingdiagnosis-careplan.blogspot.com/2012/09/bronchiectasis-care-plan-with-nursing.html" target="_blank">Nursing Care Plan for </a><a href="http://nursingdiagnosis-careplan.blogspot.com/2012/09/bronchiectasis-care-plan-with-nursing.html" target="_blank">Bronchiectasis </a></b><br />
<br />
<br />
<br />
<b><a href="http://nursing-diagnosis-nanda.blogspot.com/2011/04/nursing-diagnosis-for-bronchiectasis.html" target="_blank">Nursing Diagnosis for Bronchiectasis </a></b><br />
<br />
<br />
<br />
<b>Ineffective airway clearance</b> related to the increased production of secretions, thick secretions.<br />
<br />
Goal: retain patent airway with breath sounds clean / clear.<br />
<br />
Expected outcomes:<br />
Shows the behavior to improve airway clearance (effective cough, and issued a secret.<br />
<br />
Interventions:<br />
1. Assess / monitor respiratory frequency. Note the ratio of inspiration and expiration.<br />
R /: Tachipneu common to some degree can be found at the reception or immersion stress / acute infection process. Slowed breathing and elongated compared inspiration expiration frequency.<br />
<br />
2. Auscultation of breath sounds and record their breath sounds<br />
R /: The degree of bronchospasm occurs with airway obstruction and can / do not manifested their breath sounds.<br />
<br />
3. Assess the patient to a comfortable position, high headboard and sat at the back of the bed.<br />
R /: Elevation of the head of the bed easier for respiratory function by using gravity. And make it easier to breathe and helps reduce muscle weakness and can be as a tool chest expansion.<br />
<br />
4. Help abdominal breathing exercises or lips.<br />
R / To cope with and control dyspnea and lower air entrapment.<br />
<br />
5. Observe the characteristic cough and aid measures for the effectiveness of efforts to cough.<br />
R / Knowing the effectiveness of cough.<br />
<br />
6. Enter the liquid till 3000ml / day according to the tolerance of the heart, as well as provide a warm and fluid intake between as a meal replacement.<br />
R /: Hydration helps to lower the viscosity of the secret, warm facilitate discharge can reduce bronchospasm. Liquids between meals can increase gastric distension and pressures diaphragm.<br />
<br />
7. Give the drug as indicated.<br />
R /: Speed up the process of healing.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-32839044888408017042015-01-10T02:05:00.002+07:002015-01-10T02:05:21.361+07:00Anxiety and Disturbed Sleep Pattern - Nursing Interventions for Heart Failure<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDnf4dJGRxORFQCHueBGZDPw8WtuNvvR4OEVpt5I4k7Y7A84qSv33H9B5Q4BzBonezaYaVXeEswhnXix1Km0YhHV3lad2_i6lA0vbCi-GtZ1Bm_dTzF1vhuBCgQuQnCoHnH9GEkhw0ewU/s1600/Nursing+Diagnosis+and+Interventions+for+Heart+Failure.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/AVvXsEgDnf4dJGRxORFQCHueBGZDPw8WtuNvvR4OEVpt5I4k7Y7A84qSv33H9B5Q4BzBonezaYaVXeEswhnXix1Km0YhHV3lad2_i6lA0vbCi-GtZ1Bm_dTzF1vhuBCgQuQnCoHnH9GEkhw0ewU/s1600/Nursing+Diagnosis+and+Interventions+for+Heart+Failure.jpeg" /></a></div>
<b>Nursing Diagnosis for Heart Failure : Anxiety</b> related to tissue oxygenation disorders, stress due to difficulty in breathing and the knowledge that the heart is not functioning properly.<br />
characterized by; anxiety, fear, worry, stress-related illness, anxiety, anger, irritability.<br />
<br />
Goal: The patient does not feel anxious.<br />
with expected outcomes:<br />
<ul>
<li>The patient said that anxiety decreased to a level that can be overcome.</li>
<li>The patient demonstrated problem-solving skills and know the feeling.</li>
</ul>
<br />
Interventions:<br />
<ul>
<li>Provide the opportunity for the patient to express feelings.</li>
<li>Encourage friends and family to consider patients as before.</li>
<li>Tell patient medical programs that have been made to lower the impending attack and increase the stability of the heart.</li>
<li>Help the patient a comfortable position to sleep or rest, limit visitors.</li>
<li>Collaboration for the administration of sedatives and tranquiliser.</li>
</ul>
<br />
Rationale :<br />
<ul>
<li>Statement of the problem can reduce tension, classify the level of coping and facilitate understanding of feelings.</li>
<li>Reassure patients that role in the family and work unchanged.</li>
<li>Encourage the patient to control symptoms, improve confidence in the medical program and integrate capabilities in self-perception.</li>
<li>Creating an atmosphere that allows the patient to sleep.</li>
<li>Help the patient relax until physically able to make adequate coping strategies.</li>
</ul>
<br />
<b>Nursing Diagnosis for Heart Failure : </b>Disturbed Sleep Pattern related to waking up frequently secondary to respiratory disorders (tightness, cough).characterized by; lethargy, insomnia, shortness of breath and coughing during sleep.<br />
<br />
Goal: The patient can sleep more comfortably.<br />
<br />
Interventions :<br />
<ul>
<li>Raise the head of the bed 20 -30 cm. Chock forearm with a pillow.</li>
<li>In patients with orthopnea, the patient is seated on the side of the bed with both feet supported on the seat, head and put on the table bed and lumbosacral vertebrae supported by a pillow.</li>
</ul>
<br />
Rationale :<br />
<ul>
<li>Venous return to the heart is reduced, pulmonary congestion is reduced and the suppression of the liver to the diaphragm is reduced and reducing muscle fatigue shoulder.</li>
<li>Reduce difficulty breathing and reduces the flow back to the heart.</li>
</ul>
<br />
Source :<br />
<a href="http://nandacareplan.blogspot.com/2014/11/heart-failure-5-nursing-diagnosis-and.html" target="_blank">http://nandacareplan.blogspot.com/2014/11/heart-failure-5-nursing-diagnosis-and.html</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-76077157058423049542014-01-20T23:43:00.002+07:002014-09-17T20:32:41.163+07:00Nursing Interventions for Tetralogy of FallotNursing Diagnosis : Decreased Cardiac Output r / t ineffective circulation, secondary to the presence of cardiac malformations<br />
<br />
Goal: Children can maintain adequate cardiac output<br />
<br />
NOC:<br />
<br />
<ul>
<li>Vital signs are normal with age.</li>
<li>There is no dyspnea, rapid breathing and deep, cyanosis, anxiety / lethargy, tachycardia, murmurs.</li>
<li>Clients composmetis.</li>
<li>Akral warm.</li>
<li>Peripheral pulse strong and equal on both extremities.</li>
<li>Capillary refill time less than 3 seconds.<br />
</li>
<li>Urine output of 1-2 ml / kg / hour.</li>
</ul>
<br />
Intervention:<br />
<ol>
<li> Monitor vital signs, peripheral pulses, capillary refill by comparing measurements at both extremities while standing, sitting and lying down if possible.</li>
<li> Assess and record the apical pulse for 1 full minute.</li>
<li> Observation of cyanotic attacks.</li>
<li> Give a knee-chest position in children.</li>
<li> Observe for signs of decreased sensory: lethargy, confusion, and disorientation.</li>
<li> Monitor intake and output adequately.</li>
<li> Provide adequate rest time for children and accompany children during activity.</li>
<li> Serve foods that are easily digestible and reduce the consumption of caffeine.</li>
<li> Collaboration in the examination serial ECGs, chest radiographs, administration of anti dysrhythmias.</li>
<li> Collaboration of oxygen.</li>
<li> Collaboration IV fluid administration.</li>
</ol>
Source : <a href="http://nandacareplan.blogspot.com/2013/12/decreased-cardiac-output-tetralogy-of.html" target="_blank">http://nandacareplan.blogspot.com/2013/12/decreased-cardiac-output-tetralogy-of.html</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-56535046984556671072013-09-25T11:35:00.001+07:002024-01-05T07:51:36.454+07:00Nursing Interventions for Chronic PainPain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring, without an anticipated or predictable end and a duration >6 months (NANDA); a state in which an individual experiences pain that persists for a month beyond the usual course of an acute illness or a reasonable duration for an injury to heal, is associated with a chronic pathologic process, or recurs at intervals for months or years (Bonica, 1990)<br />
<br />
Defining Characteristics:<br />
<br />
Subjective<br />
Pain is always subjective and cannot be proved or disproved. The client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). Clients with cognitive abilities who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify their current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).<br />
<br />
Objective<br />
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in its assessment, especially in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite or the inability to ambulate, perform activities of daily living (ADLs), work, or sleep. Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, and increase or decrease in respiratory rate and depth may be present but are usually not present with chronic pain that is relatively stable. Clients with chronic, cancer, or nonmalignant pain may experience threats to self-image; a perceived lack of options for coping; and worsening helplessness, anxiety, and depression. Chronic pain may affect almost every aspect of the client's daily life, including concentration, work, and relationships.<br />
<br />
<br />
Related Factors:<br />
Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; nerve injury (neuropathic pain)<br />
NOTE: The cause of chronic nonmalignant pain may not be known because pain is a new science and an area of diverse types of problems.<br />
<br />
NOC Outcomes (Nursing Outcomes Classification)<br />
<br />
Suggested NOC Labels<br />
<br />
Pain Level<br />
Pain Control<br />
Comfort Level<br />
Pain: Disruptive Effects<br />
<br />
Client Outcomes<br />
<br />
Uses pain rating scale to identify current level of pain intensity, determines a comfort/function goal, and maintains a pain diary (if client has cognitive abilities)<br />
Describes the total plan for drug and nondrug pain relief, including how to safely and effectively take medicines and integrate nondrug therapies<br />
Demonstrates ability to pace self, taking rest breaks before they are needed<br />
Functions on an acceptable ability level with minimal interference from pain and medication side effects (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)<br />
<br />
NIC Interventions (Nursing Interventions Classification)<br />
<br />
Suggested NIC Labels<br />
<br />
Pain Management, Analgesic Administration<br />
<br />
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-67850811791974874952013-09-25T11:32:00.004+07:002024-01-05T07:52:15.184+07:00Nursing Interventions for Acute Pain Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months (NANDA)<br />
<br />
Defining Characteristics:<br />
<br />
Subjective<br />
<br />
Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).<br />
<br />
Objective<br />
<br />
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.<br />
<br />
Related Factors:<br />
<br />
Actual or potential tissue damage (mechanical [e.g., incision or tumor growth],<br />
thermal [e.g., burn],<br />
or chemical [e.g., toxic substance])<br />
<br />
<br />
<br />
NOC<br />
<br />
Suggested NOC Labels<br />
<br />
Pain Level, Pain Control, Comfort Level<br />
Pain: Disruptive Effects<br />
<br />
Client Outcomes<br />
<br />
Uses a pain rating scale to identify current level of pain intensity and determines a comfort/function goal (if client has cognitive abilities)<br />
Describes how unrelieved pain will be managed<br />
Reports that the pain management regimen relieves pain to a satisfactory level with acceptable or manageable side effects<br />
Performs activities of recovery with a reported acceptable level of pain (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)<br />
States an ability to obtain sufficient amounts of rest and sleep<br />
Describes a nonpharmacological method that can be used to control pain<br />
<br />
<br />
NIC<br />
<br />
Suggested NIC Labels<br />
<br />
Conscious Sedation<br />
Patient-Controlled Analgesia (PCA) Assistance<br />
<br />
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-77835367498350379152013-01-06T21:32:00.001+07:002014-09-17T20:33:21.136+07:002 Nursing Interventions for Encephalitis <b>Nursing Care Plan for Encephalitis</b> <br />
<br />
Encephalitis is irritation and swelling (inflammation) of the brain, most often due to infections.<br />
<br />
Some patients may have symptoms of a cold or stomach infection before encephalitis symptoms begin.<br />
<br />
When a case of encephalitis is not very severe, the symptoms may be similar to those of other illnesses, including:<br />
<ul>
<li>Fever that is not very high</li>
<li>Mild headache</li>
<li>Low energy and a poor appetite</li>
</ul>
<br />
Other symptoms include:<br />
<ul>
<li>Clumsiness, unsteady gait</li>
<li>Confusion, disorientation</li>
<li>Drowsiness</li>
<li>Irritability or poor temper control</li>
<li>Light sensitivity</li>
<li>Stiff neck and back (occasionally)</li>
<li>Vomiting</li>
</ul>
<br />
Symptoms in newborns and younger infants may not be as easy to recognize:<br />
<ul>
<li>Body stiffness</li>
<li>Irritability and crying more often (these symptoms may get worse when the baby is picked up)</li>
<li>Poor feeding</li>
<li>Soft spot on the top of the head may bulge out more</li>
<li>Vomiting</li>
</ul>
<br />
Emergency symptoms:<br />
<ul>
<li>Loss of consciousness, poor responsiveness, stupor, coma</li>
<li>Muscle weakness or paralysis</li>
<li>Seizures</li>
<li>Severe headache</li>
<li>Sudden change in mental functions: <ul>
<li>"Flat" mood, lack of mood, or mood that is inappropriate for the situation</li>
<li>Impaired judgment</li>
<li>Inflexibility, extreme self-centeredness, inability to make a decision, or withdrawal from social interaction</li>
<li>Less interest in daily activities</li>
<li>Memory loss (amnesia), impaired short-term or long-term memory</li>
</ul>
</li>
</ul>
<br />
<b>Nursing Interventios for Encephalitis</b><br />
<br />
High risk of infection associated with lower body resistance to infection<br />
<br />
Goal :<br />
no infection<br />
<br />
Expected results :<br />
Healing on time with no evidence of spread of infection endogenous<br />
<br />
Nursing Intervention :<br />
Defense aseptic technique and proper hand washing techniques either nurses or visitors. Monitor and limit visitors.<br />
R /. reduce the risk of patients exposed to secondary infection. control the spread of the source of infection.<br />
Measure the temperature on a regular basis and clinical signs of infection.<br />
R /. Detecting early signs of infection<br />
Give antibiotics as indicated<br />
R /. Drugs are selected depending on the type of infection and sensitivity of the individual.<br />
<br />
High risk of injury associated with seizure activity<br />
<br />
Goal :<br />
There was no trauma<br />
<br />
Results expected :<br />
Not having a seizure<br />
No trauma<br />
<br />
Nursing Intervention :<br />
Give safety to patients by giving bearings, fixed the bed barriers and give a booster attached to the mouth, the airway remains free.<br />
R /. Protect patients in case of seizure, booster mouth somewhat tongue is not bitten.<br />
Note: enter the booster mouth when the mouth just relaxation.<br />
Maintain bed rest in the acute phase.<br />
R /. Lowering the risk of falling / injury during the vertigo.<br />
Collaboration<br />
Give the drug as an indication as delantin, valum, etc..<br />
R /. An indication for treatment and prevention of seizures.<br />
Observation of vital signs<br />
R /. Early detection of seizures for possible further action.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-40290832818740109272012-09-21T07:13:00.005+07:002014-09-17T20:33:41.850+07:00Hyperthyroidism - 2 Nursing Diagnosis and Interventions<b>Hyperthyroidism - 2 Nursing Diagnosis and Interventions</b><br />
<br />
1. <b>Knowledge Deficit</b> related to lack of information about the disease process and treatment at home.<br />
<br />
Purpose:<br />
Saying understanding of the condition / disease processes and actions.<br />
<br />
Intervention:<br />
<br />
1. Describe the process of individual disease<br />
R / Reduce anxiety and can lead to participation in the treatment plan.<br />
<br />
2. Instruct to breathing exercises, effective cough and exercise general conditions.<br />
R / Breath lip and abdominal breathing helps minimize airway collapse and increased activity tolerance.<br />
<br />
3. Discuss the factors that increase the individual's condition as air, pollen, tobacco smoke.<br />
R / environmental factors can cause bronchial irritation and increased production of airway secretions.<br />
<br />
<br />
2. <b>Ineffective airway clearance</b> related to increased production of secretions.<br />
<br />
Purpose:<br />
Maintaining a patent airway.<br />
<br />
Intervention:<br />
1. Auscultation of breath sounds<br />
R / Some degree of bronchial spasms occur with airway obstruction and may be manifested by the presence of breath sounds.<br />
<br />
2. Assess / monitor respiratory frequency.<br />
R / Tachipnoe common to some degree and can be found during / due process of acute infection.<br />
<br />
3. Push / aids or lips abdominal breathing exercises<br />
R / Provides a way to overcome and control dispoe and reduce air entrapment.<br />
<br />
4. Observation of the characteristic cough<br />
R / cough may persist but ineffective, especially in the elderly, acute illness or infirmity<br />
<br />
5. Increase fluid intake to 3000 ml / day<br />
R / Hydration helps decrease the viscosity of secretions facilitate spending.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-62567796198386171002012-05-24T08:09:00.003+07:002014-09-18T23:07:26.486+07:00Nursing Interventions for Tetanus<span style="font-weight: bold;">Tetanus</span> is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the Gram-positive, rod-shaped, obligate anaerobic bacterium Clostridium tetani. Infection generally occurs through wound contamination and often involves a cut or deep puncture wound. As the infection progresses, muscle spasms develop in the jaw (thus the name "lockjaw") and elsewhere in the body. Infection can be prevented by proper immunization and by post-exposure prophylaxis.<br />
<br />
<span style="font-weight: bold;">Prevention </span><br />
<br />
Unlike many infectious diseases, recovery from naturally acquired tetanus does not usually result in immunity to tetanus. This is due to the extreme potency of the tetanospasmin toxin; even a lethal dose of tetanospasmin is insufficient to provoke an immune response.<br />
<br />
Tetanus can be prevented by vaccination with tetanus toxoid. The CDC recommends that adults receive a booster vaccine every ten years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than three lifetime doses of the vaccine. The booster may not prevent a potentially fatal case of tetanus from the current wound, however, as it can take up to two weekhttp://www.blogger.com/img/blank.gifs for tetanus antibodies to form. In children under the age of seven, the tetanus vaccine is often administered as a combined vaccine, DPT/DTaP vaccine, which also includes vaccines against diphtheria and pertussis. For adults and children over seven, the Td vaccine (tetanus and diphtheria) or Tdap (tetanus, diphtheria, and acellular pertussis) is commonly used.<br />
<br />
The WHO certifies countries as having eliminated maternal or neonatal tetanus. Certification requires at least two years of rates < 1 case per 1000 live borns. In 1998 in Uganda, 3,433 tetanus cases were recorded in new-born babies; of these, 2,403 died. After a major public health effort Uganda in 2011 was certified as having eliminated tetanus.<br />
Source : <a href="http://en.wikipedia.org/wiki/Tetanus" target="_blank">wikipedia</a><br />
<br />
<a href="http://nursesnanda.blogspot.com/2012/01/nursing-care-plan-for-tetanus.html" target="_blank"><span style="font-weight: bold;">Nursing Interventions for Tetanus</span></a><br />
<br />
<a href="http://nandanursingdiagnosis.blogspot.com/2011/07/nursing-diagnosis-for-ineffective.html" target="_blank">Ineffective airway clearance</a> related to the accumulation of sputum in the trachea and respiratory muscle spasm<br />
<br />
<span style="font-style: italic;">Characterized by:</span><br />
<br />
Ronchi, cyanosis, dyspnea, cough accompanied by sputum ineffective or lenders, the results of laboratory tests showed: abnormal blood gas analysis (respiratory acidosis)<br />
<br />
Objectives:<br />
<br />
Effective airway<br />
<br />
Criteria:<br />
<br />
Clients are not crowded, no lender or sleam<br />
Breathing 16-18 times / minute<br />
No nostril breathing<br />
No additional respiratory muscle<br />
The results of laboratory blood gas analysis of blood within normal limits (pH = 7.35 to 7.45; PCO2 = 35-45 mmHg, PO2 = 80-100 mmHg)<br />
<br />
Tetanus Nursing Interventions and Rational:<br />
<br />
A. Clear the airway by adjusting the position of head extension.<br />
Rational: the anatomy of the head position of the extension is a way to align the respiratory cavity so that the process of respiration is still running smoothly by removing the blockage of the airway.<br />
<br />
2. Physical examination by auscultation of breath sounds heard (there Ronchi) every 2-4 hours.<br />
Rational: Ronchi show an upper respiratory problems due to fluid or a secret that covered most of the respiratory tract that need to be removed to optimize the airway.<br />
<br />
3. Clean the mouth and respiratory tract of mucus with a secret and do section.<br />
Rational: section is an act of assistance to issue a secret, thus simplifying the process of respiration.<br />
<br />
4. Oxygenation according to physician instructions.<br />
Rational: the provision of adequate oxygen can supply and provide backup oxygen, thus preventing hypoxia.<br />
<br />
5. Observation of vital signs every 2 hours.<br />
Rational: dyspnea, cyanosis is a sign of breathing disorder which is accompanied by decreased cardiac work arising tacikardi reffil time and capillary length / time.<br />
<br />
6. Observation of the onset of respiratory failure / apnea.<br />
Rational: the inability of the body in the respiratory process required critical interventions by using a breathing (mechanical ventilation)<br />
<br />
7. Collaboration in a secret-thinning medication (mukolotik).<br />
Rational: mukolitik drugs can thin the thick secretions so easy to remove and prevent viscosity.<br />
<br />
<a href="http://nursing-assessment.blogspot.com/2012/05/nursing-assessment-for-tetanus.html" target="_blank">Nursing Assessment for Tetanus</a><br />
<br />
<a href="http://nandanursingdiagnosis.blogspot.com/2012/05/nursing-diagnosis-for-tetanus.html" target="_blank">Nursing Diagnosis for Tetanus</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-36006674679864967552012-03-01T23:35:00.001+07:002014-09-17T20:34:02.620+07:00Nursing Interventions for Activity Intolerance<span style="font-weight: bold;">Activity Intolerance Definition</span> : Insufficient physiological or psychological energy to endure or complete required or desired daily activities<br />
<br />
Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert one's self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.<br />
<br />
Related Factors:<br />
<ul>
<li>Generalized weakness</li>
<li>Deconditioned state</li>
<li>Sedentary lifestyle</li>
<li>Insufficient sleep or rest periods</li>
<li>Depression or lack of motivation</li>
<li>Prolonged bed rest</li>
<li>Imposed activity restriction</li>
<li>Imbalance between oxygen supply and demand</li>
<li>Pain</li>
<li>Side effects of medications</li>
</ul>
Read More : <a href="http://nanda-nursinginterventions.blogspot.com/2012/02/nursing-interventions-for-activity.html">http://nanda-nursinginterventions.blogspot.com/2012/02/nursing-interventions-for-activity.html</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-2479671571171277532011-12-24T16:46:00.001+07:002014-09-18T23:09:10.044+07:00Nursing Diagnosis and Interventions for Hyperthermia<b>Definition </b><br />
<br />
Hyperthermia is the general name given to a variety of heat-related illnesses.<br />
<br />
<b>Description</b><br />
<br />Warm weather and outdoor activity go hand in hand. However, it is important for older people to take action to avoid the severe health problems often caused by hot weather.<br />
<br />
<b>Diagnosis </b><br />
<br />
Diagnosis is based on the medical history (including symptoms) and physical exam.<br />
<br />
<b>Treatment </b><br />
<br />
If the victim is exhibiting signs of heat stroke, emergency assistance should be sought immediately. Without medical attention, heat stroke can be deadly.<br />
<br />
Heat exhaustion may be treated in several ways:<br />
<br />
get the victim out of the sun into a cool place, preferably one that is air conditioned<br />
<br />
offer fluids but avoid alcohol and caffeine - water and fruit juices are best<br />
<br />
encourage the individual to shower and bathe, or sponge off with cool water<br />
<br />
urge the person to lie down and rest, preferably in a cool place<br />
<br />
<b>Prevention </b><br />
<br />
Prevention hyperthermia is relatively straightforward: Use common sense in avoiding excessive activity in situations in which heat is present. Adequate intake of fluids before, during and after exercise in any situation also is essential.<br />
<br />
<b><br />
</b> <b>Nursing Care Plan for Hyperthermia</b><br />
<br />
Goal:<br />
Addressing the problem of increased body temperature to prevent the lack of fluids or other complications due to Hipertermi.<br />
<br />
Outcomes:<br />
Temperature 36 to 37.5 C, Complaints fever is gone, chills missing, elastic skin turgor, vital signs within normal range (blood pressure, pulse, CVP and JVP)<br />
<br />
<b>Nursing Diagnosis for Hypertermia</b><br />
<ul>
<li>Deficient Fluid Volume</li>
<li>Altered Body Temperature</li>
<li>Hyperthermia related to increased metabolism, medication, anesthesia</li>
<li>Hyperthermia related to dehydration</li>
</ul>
<b>Nursing Interventions for Hyperthermia</b><br />
<ul>
<li>Monitor body temperature</li>
<li>Monitor blood pressure, respiratory rate and pulse</li>
<li>Monitor intake and output every 8 hours</li>
<li>Encourage a lot of drinking in the absence of contraindications</li>
<li>Maintain adequate ventilation in the room</li>
<li>Give a warm compress</li>
<li>Use clothes that are thin and absorbs perspiration</li>
<li>Encourage clients to total bedrest</li>
<li>Monitor client hydration status</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-58559131525280063312011-12-24T16:44:00.000+07:002014-09-17T20:35:13.216+07:00Nursing Interventions for Leukemia<b>Leukemia</b><br />
<br />
<b>Definition</b><br />
<br />
Leukemia is a neoplasm of acute or chronic blood-forming cells in bone marrow and spleen (Reeves, 2001). The other characteristic of leukemia is the proliferation of irregular or accumulation of white blood cells in bone marrow, replace normal bone marrow elements. Proliferation also occurs in the liver, spleen, and lymph nodes. The invasion of non-haematological organs such as the meninges, gastrointestinal tract, kidney, and skin.<br />
<br />
Acute lymphocytic leukemia (ALL) often occurs in children. Leukemia classified as acute if there is proliferation of the blastocyst (young blood cells) from bone marrow. Acute leukemia is a malignant primary bone marrow resulting in normal blood components late decision by abnormal blood components (blastocyst), accompanied by the spread of other organs. Leukemia is classified as chronic if found cell expansion and accumulation of old and young cells (Tejawinata, 1996).<br />
<br />
In addition to acute and chronic, there is also a congenital leukemia is leukemia were found in infants aged 4 weeks or younger infants.<br />
<br />
<br />
<b>Etiology</b><br />
<br />
The cause of ALL until now not clear, but most likely due to a virus (oncogenic viruses).<br />
<br />
Other factors that play a role include:<br />
<ol>
<li>Exogenous factors such as X rays, radioactive rays, and chemicals (benzol, arsenic, sulfate preparations), infections (viruses and bacteria).</li>
<li>Endogenous factors such as race</li>
<li>Constitutional factors such as chromosomal abnormalities, hereditary (sometimes encountered cases of leukemia in siblings or twins one egg).</li>
</ol>
<br />
Predisposing factors:<br />
<ol>
<li>Genetic factors: a certain virus causes changes in gene structure (T cell leukemia-lymphoma virus / HTLV)</li>
<li>Ionizing radiation: the work environment, prenatal care, previous cancer treatment</li>
<li>Exposure to chemicals such as benzene, arsenic, chloramphenicol, phenylbutazone, and anti-neoplastic agents.</li>
<li>Immunosuppressive medications, drugs carcinogens such as diethylstilbestrol</li>
<li>Hereditary factors such as the twins one egg</li>
<li>Chromosomal abnormalities</li>
</ol>
<br />
If the cause of leukemia is caused by a virus, the virus will easily fit into the human body if the structure of the viral antigen is consistent with the structure of the human antigen. The structure of the human antigen is formed by the antigen structure of various organs, especially the skin and mucous membranes located on the surface of the body (tissue antigen). By WHO, tissue antigens defined by the term HL-A (human leucocyte locus A).<br />
<br />
<br />
<b>Signs and Symptoms</b><br />
<br />
1. Anemia<br />
Caused by red blood cell production is less a result of the failure of the bone marrow to produce red blood cells. Characterized by reduced hemoglobin concentration, a decrease in hematocrit, red blood cell count less. Children with leukemia have pale, tiredness, shortness of breath sometimes.<br />
<br />
2. High body temperature and easy to infections<br />
Due to a decrease in leukocytes, it will automatically lower the body resistance due to leukocytes serves to maintain the immune system can not work optimally.<br />
<br />
3. Bleeding<br />
Signs of bleeding can be viewed and analyzed from the presence of mucosal bleeding such as gums, nose (epistaxis) or bleeding under the skin which is often called petechiae. Bleeding may occur spontaneously or due to trauma. If very low levels of platelets, bleeding can occur spontaneously.<br />
<br />
4. Decreased consciousness<br />
Due to infiltration of abnormal cells to the brain can cause a variety of disorders such as seizures to coma.<br />
<br />
5. Decrease in appetite<br />
<br />
6. Weakness and physical exhaustion.<br />
<br />
<br />
<br />
<b>Clinical Manifestation</b><br />
<br />
Typical symptoms of pale (may occur suddenly), body heat, and bleeding accompanied by splenomegaly and sometimes hepatomegaly and lymphadenopathy. Bleeding can be diagnosed ecchymoses, petekia, epistaxis, bleeding gums, etc..<br />
Symptoms are not typical is joint pain or bone pain can be mistaken for rheumatic diseases. Other symptoms can arise as a result of infiltration of leukemic cells in organs such as purpuric lesions on the skin, pleural effusion, cerebral seizures in leukemia.<br />
<br />
<br />
<div style="text-align: center;">
<b>2 Nursing Diagnosis and Interventions for Leukemia</b></div>
<br />
1. <b>Risk for Fluid Volume Deficit </b><br />
<br />
related to<br />
<ul>
<li>fluid intake and output,</li>
<li>excessive loss: vomiting, bleeding, diarrhea</li>
<li>decrease in fluid intake: nausea, anorexia</li>
<li>increased need for fluids: fever, hypermetabolic.</li>
</ul>
<br />
Purpose : the volume of fluid being met<br />
<br />
Expected outcomes:<br />
<ul>
<li>Adequate fluid volume</li>
<li>The mucosa moist</li>
<li>Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit</li>
<li>Pulse palpated</li>
<li>Urine output 30 ml / hour</li>
<li>Capillaries and refill less than 2 seconds</li>
</ul>
Intervention:<br />
<ul>
<li>Monitor fluid intake and output</li>
<li>Monitor body weight</li>
<li>Monitor BP and heart frequency</li>
<li>Evaluation of skin turgor, capillary refill and mucous membrane conditions</li>
<li>Give fluid intake 3-4 L / day</li>
<li>Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive.</li>
<li>Implement measures to prevent tissue injury / bleeding</li>
<li>Limit oral care to wash mouth when indicated</li>
<li>Give diet a smooth</li>
<li>Collaboration:<ul>
<li>Give IV fluids as indicated</li>
<li>Supervise laboratory tests: platelet count, Hb / Ht, freezing</li>
<li>Provide HR, platelets, clotting factors</li>
<li>Maintain a central vascular access device external (sub-clavicle artery catheter, tunneld, implantable ports)</li>
</ul>
</li>
</ul>
Read More : <a href="http://nursing-care-plan.blogspot.com/2011/12/2-nanda-nursing-diagnosis-and.html" style="font-style: italic; font-weight: bold;" target="_blank">http://nursing-care-plan.blogspot.com/2011/12/2-nanda-nursing-diagnosis-and.html</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-81083312325883332352011-12-24T16:38:00.001+07:002014-09-17T20:35:23.595+07:00Nursing Interventions for Epistaxis<b>Nursing Diagnosis</b><br />
<br />
<b>1. Risk for Bleeding</b><br />
<br />
Goal: minimize bleeding<br />
<br />
Expected Outomes: No bleeding, vital signs within normal limits, no anemis.<br />
<br />
<b>Interventions</b>:<br />
<ul>
<li>Monitor the patient's general condition</li>
<li>Monitor vital signs</li>
<li>Monitor the amount of bleeding patients</li>
<li>Monitor the event of anemia</li>
<li>Collaboration with the doctor about the problems that occur with bleeding: transfusion, medication.</li>
</ul>
(Diagnosis NANDA, NIC, NOC)<br />
<br />
<br />
<b>2. Ineffective airway clearance</b><br />
<br />
Goal: to be effective airway clearance<br />
<br />
Expected Outcomes: Frequency of normal breathing, no additional breath sounds, do not use additional respiratory muscles, dyspnoea and cyanosis does not occur.<br />
<br />
<i>Independent</i><br />
<ul>
<li>Assess the sound or the depth of breathing and chest movement.<br />Rational: Decreased breath sounds may lead to atelectasis, Ronchi, and wheezing showed accumulation of secretions.</li>
<li>Note the ability to remove mucous / coughing effectively<br />Rational: bright lumpy or bloody sputum may result from damage to lungs or bronchial injury.</li>
<li>Give Fowler's or semi-Fowler position.<br />Rational: Positioning helps maximize lung expansion and reduce respiratory effort.</li>
<li>Clean secretions from the mouth and trachea<br />Rational: To prevent obstruction / aspiration.</li>
<li>Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated.<br />Rational: Helping dilution of secretions.</li>
</ul>
<br />
<i>Collaboration </i><br />
<ul>
<li>Give medication in accordance with the indications mucolytic, expectorant, bronchodilator.<br />Rational: Mucolytic to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce bronchial spasms and analgesics are given to reduce discomfort.</li>
</ul>
Read More : <a href="http://nursing-care-plan.blogspot.com/2011/12/3-nursing-diagnosis-for-epistaxis-with.html" style="font-style: italic; font-weight: bold;" target="_blank">http://nursing-care-plan.blogspot.com/2011/12/3-nursing-diagnosis-for-epistaxis-with.html</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-16669149106835053292011-12-13T00:19:00.001+07:002014-09-17T20:35:38.752+07:00Nursing Intervention and Implementation of LBP - Low Back Pain<b>Intervention and Implementation of Low Back Pain</b><br />
<br />
<b>1. Relieves Pain</b><br />
<br />
To reduce pain nurses can encourage patients to bed rest and modification of the position is determined to improve lumbar flexion. Patients are taught to control and adjust the pains that go through the respiratory diaphragm and relaxation can help reduce muscle tension that contributes to lower back pain. Distract patients from pain with other activities such as reading books, watching TV and with imagination.<br />
<br />
Massage of the soft tissue, gently is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. When given the drug the nurse should assess the patient's response to each drug.<br />
<br />
<b>2. Improving physical mobility</b><br />
<br />
Physical mobility is monitored through continuous assessment. Nurses assess how patients move and stand. Once back pain is reduced, self-care activities may be performed with minimal strain on the injured structure. Change of position should be done slowly and assisted if necessary. Circular motion and sway should be avoided. Patients are encouraged to switch activities lying, sitting and walking around for a long time. Nurses need to encourage patients comply with exercise programs according to established, that one just does not exercise effective.<br />
<br />
<b>4. Health education</b><br />
<br />
Patients must be taught how to sit, stand, lie down and lifting objects properly.<br />
<br />
<b>5. Improving the performance of the role</b><br />
<br />
Responsibilities associated with the role may have changed since the occurrence of lower back pain. Once the pain healed, patients can return to his role of responsibility again. But when the activity is impacting on the bottom of back pain occurs again, it may be difficult to return to the original responsibility without bearing the risk of chronic low back pain with disability and depression caused.<br />
<br />
<b>6. Changing nutrition and weight loss</b><br />
<br />
Weight loss through eating way of adjustment can prevent recurrence of back pain, by means of the rational nutrition plan that includes changes in eating habits to maintain a desired weight.<br />
<br />
Read More :<br />
<br />
<a href="http://nursing-care-plan.blogspot.com/2011/11/nursing-care-plan-for-low-back-pain.html" style="font-weight: bold;" target="_blank">http://nursing-care-plan.blogspot.com/2011/11/nursing-care-plan-for-low-back-pain.html</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-7070428604075892542011-12-11T23:01:00.000+07:002014-09-17T20:36:25.744+07:00Nursing Diagnosis and Interventions for Stevens Johnson Syndrome - SJS<b>Nursing Diagnosis 1.</b><br />
<br />
<b>Impaired skin integrity</b> related to inflammatory dermal and epidermal<br />
<br />
Expected Outcomes:<br />
<br />
Shows the skin and skin tissue intact.<br />
<br />
<b>Intervention:</b><br />
<br />
1. Observation of skin turgor circulation daily notes and sensory as well as other changes that occur.<br />
Rational: determining a baseline by which changes in status can be compared and appropriate intervention<br />
<br />
2. Use a thin clothing and soft loom.<br />
Rational: reduce irritation and pressure from the suture line of clothes, leave the incision open to air increases the healing process and reduce the risk of infection<br />
<br />
3. Keep loom is used.<br />
Rationale: to prevent infection<br />
<br />
<br />
<b>Nursing Diagnosis 2.</b><br />
<br />
<b><a href="http://nanda-list.blogspot.com/2011/09/nanda-nursing-care-plan-imbalanced.html" target="_blank">Imbalanced Nutrition Less Than Body Requirements</a></b> related to difficulty swallowing<br />
<br />
Expected Outcomes:<br />
<br />
Demonstrate stable weight / weight gain<br />
<br />
<b>Intervention:</b><br />
<br />
1. Assess food habits are preferred / not preferred.<br />
Rational: give the patient / significant others a sense of control, increasing participation in treatment and may improve revenue<br />
<br />
2. Give portions to eat little but often.<br />
Rational: helps prevent gastric distension / discomfort<br />
<br />
3. Serve in warm food.<br />
Rationale: increased appetite<br />
<br />
4. Collaboration with a dietitian.<br />
Rational: calories, protein and vitamins to meet the increased metabolic demands, maintain weight and promote tissue regeneration.<br />
<br />
<br />
<b>Nursing Diagnosis 3. </b><br />
<br />
<b>Acute pain</b> related to inflammation of the skin<br />
<br />
Expected Outcomes:<br />
<ul><li>Reported reduced pain</li>
<li>Facial expressions / body posture relaxed</li>
</ul><br />
Intervention:<br />
<br />
1. Assess complaints of pain, note the location and intensity.<br />
Rational: pain is almost always present in some degree of severity of tissue involvement<br />
<br />
2. Provide basic comfort measures ex: massage at an area hospital.<br />
Rational: increase relaxation, reduce muscle tension and general fatigue<br />
<br />
3. Monitor vital signs.<br />
Rational: IV method is often used in early to maximize the effects of the drug<br />
<br />
4. Give analgesics as indicated.<br />
Rational: to relieve pain<br />
.<br />
<br />
<b>Nursing Diagnosis 4 </b><br />
<b><br />
</b> <b><a href="http://nanda-list.blogspot.com/2011/09/nanda-activity-intolerance.html" target="_blank">Activity Intolerance</a></b>related to physical weakness<br />
<br />
Expected Outcomes:<br />
<br />
<ul><li>Clients reported increased activity tolerance</li>
</ul><b>Intervention:</b><br />
<br />
1. Assess the individual response to the activity.<br />
Rational: determine the level of the individual's ability to fulfill their daily activities.<br />
<br />
2. Assist clients in meeting their daily activities with the limitations of the client.<br />
Rational: the energy expended is more optimal<br />
<br />
3. Explain the importance of energy restriction.<br />
Rational: vital energy to help the body's metabolic processes<br />
<br />
4. Involve the family in fulfilling client's activities.<br />
Rationale: The client has the support of family psychology.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-90890743114274395892011-11-01T23:57:00.003+07:002014-09-17T20:37:13.644+07:00Nursing Interventions for Anorexia Nervosa - Mental Disorder Patients<center style="text-align: left;">
<div style="background-color: rgb(fff, fff, fff); color: rgb(000, 000, 000); font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px; text-align: justify;">
<span style="font-weight: bold;">Anorexia nervosa</span> is an eating disorder that involves an inability to stay at the minimum body weight considered healthy for the person's age and height.<br />
<br />
Persons with this disorder may have an intense fear of weight gain, even when they are underweight. They may use extreme dieting, excessive exercise, or other methods to lose weight.<br />
<br />
<br />
<span style="font-weight: bold;">Causes</span><br />
<br />
The exact causes of anorexia nervosa are unknown. Many factors probably are involved. Genetics and hormones may play a role. Social attitudes that promote unrealistically thin body types may also contribute.<br />
<br />
More and more evidence points away from the idea that conflicts within a family may contribute to this or other eating disorders. Most mental health organizations no longer support this theory.<br />
<br />
Risk factors include:<br />
<br />
* Being a perfectionist<br />
* Feeling increasing concern about, or attention to, weight and shape<br />
* Having eating and digestive problems during early childhood<br />
* Having a mother or father with anorexia or addictions<br />
* Having parents who are concerned about weight and weight loss<br />
* Having a negative self-image and a high level of negative feelings in general<br />
* Undergoing a stressful life change, such as a new job or move, or events such as rape or abuse<br />
<br />
Anorexia usually begins in adolescence or young adulthood. It is more common in females, but may also be seen in males. The disorder is seen mainly in Caucasian women who are high academic achievers and who have a goal-oriented family or personality.<br />
<a href="http://www.nlm.nih.gov/medlineplus/ency/article/000362.htm" style="color: #feb22b; text-decoration: none;" target="_blank">www.nlm.nih.gov</a></div>
<div>
<br /></div>
<div>
Nursing Diagnosis for Anorexia Nervosa</div>
<div>
<br /></div>
<div>
<a href="http://nandanursingdiagnosis.blogspot.com/2011/06/nursing-diagnosis-for-imbalanced.html">Imbalanced Nutrition : Less Than Body Requirements</a></div>
<div>
<br /></div>
<div>
Expected Outcomes:</div>
</center>
<ul>
<li>Expressing understanding of nutritional needs</li>
<li>Establish a diet with adequate caloric intake to obtain the ideal body weight</li>
<li>Indicating weight gain in the range expected</li>
</ul>
<b><a href="http://nursinginterventions-diagnosis.blogspot.com/2011/10/nursing-interventions-for-typhoid-fever.html">Nursing Interventions</a> for Anorexia Nervosa</b>:<br />
<br />
1. Determine the minimum weight goals and daily nutritional needs.<br />
R: Malnutrition is a condition that changes the natural feelings that cause depression and agitation as well as affect cognitive function / decision-making. Improvements in nutritional status improve security thinking, and psychological work can begin.<br />
<br />
2. Involve the client with a team in managing / implementing behavior modification programs. Give rewards for appropriate weight gain is determined on an individual basis; ignore the weight loss.<br />
R: Providing a structured meal stimulation because the client is made to control the choice. Behavior modification may be effective only in cases of mild or penungkatan weight in the short term.<br />
<br />
3. Use a consistent approach. Sitting with a client when eating; give or take food without persuasion and / or comments. Give a pleasant environment and record food intake.<br />
R: The client detects the interest and reaction to pressure. Any comments which may appear as a force to focus on food. If a staff member to respond to it consistently, the client can begin to trust the response. An area when the client feels train strength and control, and he may experience guilt or to rebel if forced to eat. Structuring of time eating and reduce the discussion of food will lower the client's efforts to survive and avoid manipulative demand.<br />
<br />
4. Create a selective menu and ask the client to control the choice, as much as possible.<br />
R: Clients who gain confidence and feel in control of the environment is more likely to eat foods that are desired.<br />
<br />
5. Beware if clients choose to eat low-calorie foods; hoard food; throw the food at various places such as garbage bags or baskets.<br />
R: The client will try to avoid eating high-calorie foods that are considered and may avoid eating for a long time.<br />
<br />
Collaboration<br />
6. Consult with dietitian / nutritional therapy team<br />
R: Useful in determining the needs of individual meals and resources accordingly.<br />
<br />
7. Avoid using laxatives<br />
R: The use of laxatives to be counter productive because laxatives are used by clients to dispose of food / calories.<br />
<br />
8. Give a substitute for diet and snack foods that are preferred if available<br />
R: Presenting a variety of foods allows the client to have a potentially preferred food choices.<br />
<br />
9. Refer for dental care<br />
R: Periodontal Disease and the exhaustion of the tooth enamel causing tooth caries and loss of fillings require immediate intervention to improve nutrition and health inputs in general.<br />
<br />
10. Prepare / assist in elektrokonvulsif therapy (ECT) when indicated. Discuss the reasons for the use and help clients to understand that this therapy is not a punishment<br />
R: In the case of a complicated and rarely when there is severe malnutrition / life-threatening, short ECT series allows clients to start eating and access to psychotherapyUnknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-83600280304935528442011-10-30T12:18:00.003+07:002014-09-17T20:37:36.078+07:00Nursing Interventions for Organophosphate Insecticide IntoxicationAn insecticide is a pesticide used against insects. They include ovicides and larvicides used against the eggs and larvae of insects respectively. Insecticides are used in agriculture, medicine, industry and the household. The use of insecticides is believed to be one of the major factors behind the increase in agricultural productivity in the 20th century. Nearly all insecticides have the potential to significantly alter ecosystems; many are toxic to humans; and others are concentrated in the food chain.<br />
The classification of insecticides is done in several different ways:<br />
<ul>
<li>Systemic insecticides are incorporated by treated plants. Insects ingest the insecticide while feeding on the plants.</li>
<li>Contact insecticides are toxic to insects brought into direct contact. Efficacy is often related to the quality of pesticide application, with small droplets (such as aerosols) often improving performance.</li>
<li>Natural insecticides, such as nicotine, pyrethrum and neem extracts are made by plants as defenses against insects. Nicotine based insecticides are still being widely used in the US and Canada though they are barred in the EU.</li>
<li>Plant-incorporated protectants (PIPs) are insecticidal substances produced by plants after genetic modification. For instance, a gene that codes for a specific Baccilus thuringiensis biocidal protein is introduced into a crop plant's genetic material. Then, the plant manufactures the protein. Since the biocide is incorporated into the plant, additional applications at least of the same compound, are not required.</li>
<li>Inorganic insecticides are manufactured with metals and include arsenates, copper compounds and fluorine compounds, which are now seldom used, and sulfur, which is commonly used.</li>
<li>Organic insecticides are synthetic chemicals which comprise the largest numbers of pesticides available for use today.</li>
<li>Mode of action—how the pesticide kills or inactivates a pest—is another way of classifying insecticides. Mode of action is important in predicting whether an insecticide will be toxic to unrelated species, such as fish, birds and mammals.</li>
</ul>
<a href="http://en.wikipedia.org/wiki/Insecticide" target="_blank">en.wikipedia.org</a><br />
<div>
<br /></div>
<div>
<b>Nursing Interventions for Organophosphate Insecticide Intoxication</b></div>
<br />
First aid performed included: common actions aimed at the safety of life, preventing absorption and detoxification (antidotum) which includes resuscitation: Water way, breathing, elimination circulasi to inhibit the absorption through the stomach kumbah pencernaaan way, emesis, or catharsis and shampooing the hair.<br />
<br />
Provide antidotum, according to doctors advice a minimum of 2 x 24 hours of giving SA.<br />
<br />
Supportive Care; include maintaining the patient was not until the fever or chills, monitor physical changes such as rapid changes in pulse, respiratory distress, cyanosis, diaphoresis, and other signs of vascular collapse and possible fatal or death. Monitir vital signs every 15 minutes to several hours and report changes immediately to the doctor. Note the signs such as vomiting, nausea, and abdominal pain and vomiting will monitor all the blood. Observation of feces and urine as well as maintain intravenous fluids according to physician orders.<br />
<br />
If respiratory depression, give oxygen and suction do. Ventilator may be needed.<br />
<br />
If poisoning as an attempt to commit suicide then do safety precautions. Consultation psychiatry or clinical psychiatric nurse. Consider also the problem of personality disorder, depressive reactions, psychosis, neurosis, mental retardation and others.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-18206596086854457352011-10-06T23:01:00.002+07:002014-09-17T20:37:57.363+07:00Nursing Interventions for Typhoid Fever<b>Typhoid fever</b>, also known as typhoid, is a common worldwide illness, transmitted by the ingestion of food or water contaminated with the feces of an infected person, which contain the bacterium Salmonella enterica, serovar Typhi. The bacteria then perforate through the intestinal wall and are phagocytosed by macrophages. The organism is a Gram-negative short bacillus that is motile due to its peritrichous flagella. The bacterium grows best at 37°C / 98.6°F – human body temperature.<br />
<div>
<br /></div>
<div>
<br /></div>
<b>Nursing Diagnosis for Typhoid Fever</b><br />
<br />
<b>Increased body temperature</b> related to the infection process: salmonella thypi.<br />
<br />
Goal: Normal body temperature<br />
<br />
<b>Nursing Interventions for Typhoid Fever</b><br />
<br />
1. Observation of the client's body temperature<br />
R / Knowing the changes in body temperature.<br />
<br />
2. Give compress with warm water (water) on axila area, groin, temporal when heat<br />
R / Smooth blood flow in blood vessels.<br />
<br />
3. Encourage families to put on clothing that can absorb sweat like cotton<br />
R / Maintain cleanliness of body<br />
<br />
4. Collaboration with doctors in the provision of anti piretik:<br />
R / Lower heat to cure.<br />
<br />
<br />
<b>Nursing Diagnosis for Typhoid Fever</b><br />
<br />
<b>Imbalanced Nutrition: Less Than Body Requirements</b> related to inadequate intake<br />
<br />
Goal: Nutrition your body needs are met<br />
<br />
<b>Nursing Interventions for Typhoid Fever</b><br />
<br />
1. Assess client's nutritional patterns<br />
R / Knowing eating patterns, eating habits, regular meals.<br />
<br />
2. Assess eating likes and dislikes<br />
R / Improving the status of preferred food and avoid feeding that is not preferred.<br />
<br />
3. Encourage bed rest / activity restrictions during the acute phase:<br />
R / saving energy, reducing body of work.<br />
<br />
4. Measure weight every day<br />
R / Knowing a decrease or increase in weight.<br />
<br />
5. Encourage clients to eat little but often<br />
R / Reduce the gut works, avoid boredom eating.<br />
<br />
6. Collaboration with a dietitian for a diet providing<br />
R / Knowing what foods are recommended and the food should not be consumed.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-41992924779560012672011-09-19T23:13:00.002+07:002014-09-17T20:38:19.032+07:00Nursing Interventions for Uterine FibroidA <b>uterine fibroid</b> (also<b> uterine leiomyoma, myoma, fibromyoma, leiofibromyoma, fibroleiomyoma, and fibroma</b>) (the plural of myoma is myomas or myomata) is a benign (non-cancerous) tumor that originates from the smooth muscle layer (myometrium) and the accompanying connective tissue of the uterus.<br />
<br />
Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. While most fibroids are asymptomatic, they can grow and cause heavy and painful menstruation, painful sexual intercourse, and urinary frequency and urgency. Some fibroids may interfere with pregnancy although this appears to be very rare.<br />
In the US, symptoms caused by uterine fibroids are a very frequent indication for hysterectomy. Fibroids are often multiple and if the uterus contains too many leiomyomata to count, it is referred to as diffuse uterine leiomyomatosis. The malignant version of a fibroid is extremely uncommon and termed a leiomyosarcoma.<br />
<div>
<i>(wikipedia)</i></div>
<div>
<i><br />
</i></div>
<div>
<i><br />
</i></div>
<div>
<b>Nursing Interventions for Uterine Fibroid</b></div>
<br />
<i><b>Impaired Urinary Elimination</b></i>: Retention related to the suppression by the neoplastic tissue mass in the surrounding area, impaired sensory / motor.<br />
<br />
Goal:<br />
Clients urinate a normal amount and pattern of regular or no interference<br />
<br />
Results Criteria:<br />
The amount of urine 1500 ml/24 hours and regular pattern, no bladder distention and edema<br />
<br />
<b>Impaired Urinary Elimination Nursing Interventions for Uterine Fibroids </b>:<br />
<ul>
<li>Monitor inputs and outputs as well as the characteristics of urine</li>
<li>Determine the client's normal voiding pattern and note the variations</li>
<li>Encourage clients to increase fluid intake</li>
<li>Check all the urine, note the presence of stones and send output to a laboratory for analysis</li>
<li>Investigate complaints of a full bladder: suprapubic palpation to distention. Note the decrease in urine output, edema periorbital / dependent</li>
<li>Observations of changes in mental status, behavior or level of consciousness</li>
<li>Supervise laboratory tests, samples of electrolytes, BUN creatinine</li>
<li>Take a urine for culture and sensitivity</li>
<li>Give the drug as indicated, for example:</li>
<li>Note the catheter patency was settled, when using</li>
<li>Irrigation with acidic or alkaline solution as indicated</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-58794678611441754592011-09-12T23:35:00.002+07:002014-09-17T20:38:47.425+07:00Nursing Interventions for Scabies<b>Scabies</b> is a fairly common infectious disease of the skin caused by a mite. Scabies mites burrow into the skin producing pimple-like irritations or burrows.<br />
<br />
<b>Scabies</b> infestations can affect people from all socioeconomic levels without regard to age, sex, race or standards of personal hygiene. Clusters of cases, or outbreaks, are occasionally seen in nursing homes, institutions and child care centers.<br />
<br />
The most prominent symptom of scabies is intense itching particularly at night. The areas of the skin most affected by scabies include the webs and sides of the fingers, around the wrists, elbows and armpits, waist, thighs, genitalia, nipples, breasts and lower buttocks.<br />
<br />
<b><a href="http://nandanursingdiagnosis.blogspot.com/2011/07/nursing-diagnosis-risk-for-infection.html">Risk for infection</a></b> related to tissue damage and invasive procedures<br />
<br />
Goal:<br />
<ul><li>No infection</li>
</ul>Expected Result:<br />
<ul><li>Clients are free from signs and symptoms of infection</li>
<li>Demonstrate the ability to prevent infection</li>
<li>Demonstrate healthy behavior</li>
<li>Describe the process of transmission of the disease, factors that influence the transmission and management</li>
</ul><b>Nursing Interventions Risk for infection for Scabies</b><br />
<ul><li>Monitor for signs and symptoms of infection</li>
<li>Monitor susceptibility to infection</li>
<li>Limit visitors when necessary</li>
<li>Instruct visitors to wash their hands when visiting remedy and after leaving the patient</li>
<li>Maintain aseptic environment during the installation of equipment</li>
<li>Give skin care in the area epidema</li>
<li>Inspection of skin and mucous membranes of the redness, heat</li>
<li>Inspection of the wound condition</li>
<li>Provide antibiotic therapy if necessary</li>
<li>Teach how to avoid infection</li>
</ul><br />
<b><a href="http://nandanursingdiagnosis.blogspot.com/2011/08/nursing-diagnosis-for-impaired-skin.html">Impaired Skin Integrity</a></b> related to edema<br />
<br />
Goal:<br />
<ul><li>layer of the skin looks normal</li>
</ul>Expected Result:<br />
<ul><li>A good skin integrity can be maintained (sensation, elasticity, temperature)</li>
<li>No injuries or lesions on the skin</li>
<li>Able to protect skin and keep skin moist and natural treatments</li>
<li>Good tissue perfusion</li>
</ul><b>Impaired Skin Integrity Nursing Interventions for Scabies</b><br />
<ul><li>Instruct the patient to wear loose</li>
<li>Keep the skin clean to keep them clean and dry</li>
<li>Monitor the skin will be reddish</li>
<li>Bathe the patient with warm water and soap</li>
</ul>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-46542096403226091332011-09-12T23:04:00.002+07:002014-09-17T20:39:47.316+07:00Nursing Interventions for Cholera<b>Nursing Interventions for Cholera</b><br />
<br />
<br />
Deficient fluid volume related to excessive fluid loss through the stool or emesis<br />
<br />
Goal :<br />
<br />
Maintain adequate hydration<br />
<br />
Expected outcomes:<br />
<br />
No signs of dehydration: elastic skin turgor, sunken fontanel not, the patient is not agitated, mucous membranes moist, no weight loss.<br />
<br />
Nursing Interventions and Rational:<br />
<br />
1) Record Intake Output every 24 hours.<br />
<br />
R / Knowing the status of dehydration and evaluate the effectiveness of interventions.<br />
<br />
2) Measure the child's weight every day.<br />
<br />
R / observe dehydration.<br />
<br />
3) Measure vital signs and evaluation of skin turgor, mucous membranes, mental status.<br />
<br />
R / observe dehydration.<br />
<br />
4) Tell the family to give the child a drink gradually.<br />
<br />
R / improve hydration.<br />
<br />
collaboration:<br />
<br />
5) Give oral rehydration solution (ORS).<br />
<br />
R / rehydration and replacement of fluid loss through the stool.<br />
<br />
6) Provide and monitor IV fluids as indicated (collaboration).<br />
<br />
R / replacement fluid loss.<br />
<br />
7) Observe the results of the electrolyte.<br />
<br />
R / know the level of hydration and the effectiveness of interventions.<br />
<br />
Imbalanced Nutrition: Less Than Body Requirementsrelated to loss of fluids through diarrhea, inadequate intake<br />
<br />
Goal :<br />
<br />
consume adequate nutrition intake.<br />
<br />
Expected outcomes:<br />
<br />
No weight loss (weight stable)<br />
Eating out 1 serving.<br />
No nausea, vomiting.<br />
<br />
Nursing Interventions and Rational:<br />
<br />
1) Evaluation of nutritional status and weight loss<br />
<br />
R / Identifying the need for further intervention.<br />
<br />
2) Notify and motivation of mothers / families to continue breast-feeding.<br />
<br />
R / breast milk reduces the severity and duration of disease and provide additional nutrients.<br />
<br />
3) Tell the mother to give the child to eat small meals but often<br />
<br />
R / increase food intake.<br />
<br />
4) Observe and record the response to feeding.<br />
<br />
R / know the tolerance of feeding.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-41511750803644775552011-09-12T22:59:00.002+07:002024-01-05T07:54:22.537+07:00Nursing Intervention For Heart Failure<b>Nursing Intervention for Heart Failure</b><br />
<br />
<ol style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="background-color: white; font-family: verdana, Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">Assess cardiovascular status, vital sign and hemodynamic variable to detect signs of reduced cardiac output.</span></li>
<span class="Apple-style-span" style="background-color: white; font-family: verdana, Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Assess respiratory status to detect increasing fluid in the lungs and respiratory failure.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Keep the client in semi-fowler's position to increase chest expansion and improve ventilation.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Administer medication as prescribed, to enhance cardiac performance and reduce excess fluids.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Administer oxygen to enhance arterial oxygenation.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Measure and record intake and output, Intake greater than output may indicated fluid retention.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Monitor laboratory test result to detect electrolyte imbalances, renal failure, and impaired cardiac circulation.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Provide suctioning, if necessary assist with turning and encourage coughing and deep breathing to prevent pulmonary complication.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Restrict oral fluid to avoid worsening the client's condition.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Weigh the client daily to detect fluid retention. A weight gain of 2lb (0,9 kg) in 1 day or 5 lb (2,3 kg) in 1 week indicates fluid gain.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Measure and record the client's abdominal girth. An increased in abdominal girht suggests worsening fluid retention and right-sided heart failure.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Make sure the client maintains a low-sodium diet to reduce fluid accumulation.</li>
<li style="list-style-image: none; list-style-position: outside; list-style-type: decimal; margin-bottom: 0px; margin-left: 20px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">Encourage the client to express feelings, such as a fear of dying to reduce anxiety.</li>
</span></ol>
<br />
Source : http://articlesofnursing.blogspot.comUnknownnoreply@blogger.comtag:blogger.com,1999:blog-2776840363796957350.post-68323704949556524842011-08-20T12:04:00.003+07:002014-09-17T20:42:14.034+07:00Nursing Interventions for CRF<b>Nursing Interventions for Chronic Renal Failure CRF</b> <br />
<br />
<br />
Chronic renal failure (CRF) is the progressive loss of kidney function. The kidneys attempt to compensate for renal damage by hyperfiltration (excessive straining of the blood) within the remaining functional nephrons (filtering units that consist of a glomerulus and corresponding tubule). Over time, hyperfiltration causes further loss of function. <br />
<br />
Chronic loss of function causes generalized wasting (shrinking in size) and progressive scarring within all parts of the kidneys. In time, overall scarring obscures the site of the initial damage. Yet, it is not until over 70% of the normal combined function of both kidneys is lost that most patients begin to experience symptoms of kidney failure. <br />
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<br />
<span style="font-weight: bold;">Nursing Interventions for Chronic Renal Failure</span> <br />
<br />
<b>Nursing Diagnosis</b> <br />
<ul>
<li>Ineffective tissue perfusion (renal)</li>
<li>Excess fluid volume</li>
<li>Risk for infection</li>
<li>Risk for deficient fluid volume.</li>
</ul>
<br />
Planing and Goal<br />
<ul>
<li>The client will have normal fluid and electrolyte levels</li>
<li>The client will experience no preventable complication</li>
<li>The client will understand the means by which His/Her family members will implement health teaching after discharge.</li>
</ul>
<br />
<br />
Intervention<br />
<ol>
<li>Observe the client for metabolic acidosis to identify complication of renal failure.Observe the fluid and electrolyte balance hourly.</li>
<li>Insert an indwelling urinary catheter and measure output and specific gravity hourly. These action allow the nurse to monitor the kidneys, which have the major role in regulating fluid and electolyte balance. High potassium levels can occur.</li>
<li>Provide only enough fluid intake to replace urine output to avoid an edema caused by excessive fluid intake.</li>
<li>Monitor the client's diet to provide high carbohydrates, adequate fats, and low protein. If client receives high calories from fat and carbohydrate metabolism, the body doesn't break down protein for energy. Protein is thus available for growth and repair.</li>
<li>Reduce the client's potassium intake to help prevent elevated potassium levels. Protein catabolism causes potassium release from cells into the serum.</li>
<li>Observe for the arrhytmias and cardiac arrest to identify complications of high serum potassium.</li>
<li>Provide frequent oral hygiene to avoid tissue irritation and sometime ulcer formation caused by urea and other acid waste products excreted through the skin and mucous membranes.</li>
<li>Provide the client with hard candy and chewing gum to stimulate saliva flow and decrease thirst.</li>
<li>Maintain skin care with cool water to relive pruritus and remove uremic frost (white crystal formed on skin from excretion of urea).</li>
<li>Administer stool softeners to prevent colon irritation from high levels urea and organic acids.</li>
<li>Provide emotional reassurance to the client and family members to help decrease anxiety levels caused by the fact that the client has an acute illness with unknown prognosis.</li>
<li>Explain treatments and progress to the client to help reduce anxiety.</li>
<li>Provide hemodialysis or peritoneal dialysis as ordered.</li>
</ol>
Unknownnoreply@blogger.com