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NANDA NURSING

Saturday, July 21, 2012

Nursing Diagnosis and Intervention for Scoliosis

Nursing Diagnosis and Intervention for Scoliosis

Scoliosis Causes a sideways curve of your backbone, or spine. Often these curves are S-or C-shaped. Scoliosis is most common in late childhood and the early teens, when children grow fast. Girls are more Likely to have it than boys. It can run in families. Symptoms include Leaning to one side and having uneven shoulders and hips.

Sometimes the curve is temporary. It Might be due to muscle spasms, inflammation or having different leg lengths. A birth defect, tumor or another disease, Might cause the spine to have a curve That is not temporary. People with mild scoliosis Might only need checkups to see if the curve is getting worse. Others Might need to wear a brace or have surgery.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases
(www.nlm.nih.gov)


Nursing Diagnosis and Intervention for Scoliosis

1. Ineffective Breathing Pattern related to the suppression of pain.

Purpose: The pattern of breathing Effectively.

Plan of action:
  • Assess respiratory status every 4 hours.
  • Help and teach the patient to breath in any one hour. Rationale: Increasing the maximum ventilation and oxygenation.
  • Adjust bed semi-Fowler position to improv lung expansion. Rational: Sitting height allowing Easier breathing and lung expansion.
  • Monitor vital signs every 1 hour. Rational: general indicators, circulation status and adequacy of perfusion.

2. Acute Pain: back related to the position of lateral body tilt.

Purpose: Pain is reduced or lost

Plan of action:
  • Assess the type, intensity and location of pain. Rational: Influencing choice / control the effectiveness of Interventions can influence the level of anxiety to pain.
  • Teach relaxation and distraction techniques. Rational: To divert attention, thereby reducing pain.
  • Teach and Encourage use of the brace. Rational: To Reduced pain during activity
  • Collaboration in the provision of analgesia. Rational: To relieve pain.

Thursday, May 10, 2012

Nursing Diagnosis and Nursing Interventions for Appendicitis

Nursing Diagnosis for Appendicitis

Nursing Diagnosis Nursing Care Plan for Appendicitis
The appendix is a small, tube-like organ attached to the first part of the large intestine, also called the colon. It is located in the lower right area of the abdomen. It has no known function. A blockage inside of the appendix causes appendicitis. The blockage leads to increased pressure, problems with blood flow and inflammation. If the blockage is not treated, the appendix can break open and leak infection into the body.

Symptoms may include

  • Pain and/or swelling in the abdomen
  • Loss of appetite
  • Nausea and vomiting
  • Constipation or diarrhea
  • Inability to pass gas
  • Low fever
Not everyone with appendicitis has all these symptoms.

Appendicitis is a medical emergency. Treatment almost always involves removing the appendix. Anyone can get appendicitis. It happens most often to people between the ages of 10 and 30.

National Institute of Diabetes and Digestive and Kidney Diseases

nlm.nih.gov

Nursing Diagnosis for Appendicitis
  1. Ineffective Breathing Pattern related to the act of anesthetics.

  2. Acute Pain related to the surgical incision.

  3. Risk for Fluid Volume Deficit associated with vomiting.

  4. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

  5. Risk of Infection related to surgical incision.


Nursing Diagnosis for Appendicitis

High risk of infection related to an inadequate primary defenses, perforation, peritonitis secondary to inflammatory processes

Nursing Interventions for Appendicitis
  1. Assess and record the quality, location and duration of pain. Beware of the pain becomes severe.
  2. Monitor and record vital signs of the increase in temperature, pulse, breathing fast and shallow existence.
  3. Assess the abdomen against the rigidity and distention, decreased bowel sounds.
  4. Perform wound care with aseptic technique.
  5. See incision and bandage. Record the drainage characteristics of the wound / drain, erythema.
  6. Collaboration: antibiotics

Nursing Diagnosis for Appendicitis

Pain associated with distention of intestinal tissue by inflammation, a surgical incision

Nursing Interventions for Appendicitis
  1. Assess pain. Record the location, characteristics of pain.
  2. Keep the rest in semi-Fowler position.
  3. Suggest to early ambulation.
  4. Teach diaphragmatic breathing techniques to slow to help release muscle tension.
  5. Avoid pressure popliteal area.
  6. Give antiemetic, analgesic according to the program.

Source : http://nursinginterventions-diagnosis.blogspot.com

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