tag:blogger.com,1999:blog-83671714870108525902024-02-07T21:14:29.585-08:00Nursing Diagnosis - Nursing InterventionsNursing Diagnosis and Nursing InterventionsNew Bloggerhttp://www.blogger.com/profile/14577688728460634036noreply@blogger.comBlogger53125tag:blogger.com,1999:blog-8367171487010852590.post-77487992394086786902015-11-12T02:01:00.001-08:002015-11-12T02:01:38.677-08:00Nursing Diagnosis and Interventions for Bronchiectasis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBVw6jmzX5C_rUwWbi_L4QO3itRtc_LA96Plz7_0hsYPE2ScAqtb7Vxt0ihGNy6xahpUa_8G9Ofkbzqmah_okW4qLf8hutk6IoS01W3_Cpcq4XpYVqTEaqBpAz9JpFTcj-7p7ThvOoF6U/s1600/Bronchiectasis-NUrsing-Diagnosis-and-Interventions.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBVw6jmzX5C_rUwWbi_L4QO3itRtc_LA96Plz7_0hsYPE2ScAqtb7Vxt0ihGNy6xahpUa_8G9Ofkbzqmah_okW4qLf8hutk6IoS01W3_Cpcq4XpYVqTEaqBpAz9JpFTcj-7p7ThvOoF6U/s1600/Bronchiectasis-NUrsing-Diagnosis-and-Interventions.jpg" /></a></div>
Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Bronchiectasis may result from a number of infective and acquired causes, including pneumonia, tuberculosis, immune system problems, and cystic fibrosis. <br />
<br />
The cause in 10-50% of those without cystic fibrosis is unknown. <br />
<br />
Symptoms typically include a chronic cough productive of mucus. Other symptoms include shortness of breath, coughing up blood, and chest pain. Wheezing and nail clubbing may also occur. Those with the disease often get frequent lung infections.<br />
<br />
The mechanism of disease is breakdown of the airways due to an excessive inflammatory response. Involved bronchi become enlarged and thus less able to clear secretions. These secretions increase the amount of bacteria in the lungs, result in airway blockage and further breakdown of the airways.<br />
<b><br /></b>
<b>Nursing Diagnosis and Interventions for Bronchiectasis</b><br />
<br />
<b>Ineffective Airway Clearance</b> related to the production of mucus and a decreased ability to cough effectively.<br />
<br />
Goal: The airway re-effective, eliminating the quantity of sputum viscosity to improve pulmonary ventilation and gas exchange.<br />
<br />
Expected outcomes: Clients can:<br />
<ul>
<li>demonstrate effective cough,</li>
<li>mention ways to lower the viscosity of secretions,</li>
<li>no additional breath sounds, and</li>
<li>normal breathing (16-20 x / min) without the use of accessory muscles of breath.</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Assess color, viscosity, and the amount of sputum.</li>
<li>Adjust the position of the semi-Fowler.</li>
<li>Teach how to cough effectively.</li>
<li>Assist clients in the breathing exercises.</li>
<li>Maintain fluid intake at least 2500 ml / day unless otherwise indicated.</li>
<li>Perform chest physiotherapy with postural drainage techniques, percussion, and chest vibrations.</li>
<li>Collaboration of bronchodilators: Nebulizer (via inhalation) Collaboration of mucolytic agent and expectorant.</li>
<li>Collaboration of corticosteroids.</li>
</ul>
<br />
Rationale :<br />
<ul>
<li>Sputum characteristics can indicate the severity of the obstruction.</li>
<li>Improve chest expansion.</li>
<li>Cough controlled and effective spending can facilitate the embedding secret airway.</li>
<li>Maximum ventilation opening the airway lumen and increase the movement of secretions in the airway to be issued.</li>
<li>Adequate hydration help thin secretions and make effective airway clearance. In addition, to increase fluid intake is the tendency of clients to breathe through the mouth which increases water loss. Inhalation of vaporized water is also helpful because this steam can humidify bronchial branching.</li>
<li>Postural drainage with percussion and vibration using the help of gravity to help raise secretions that can be removed or sucked easily. Clients are instructed to breathe and cough effectively to help remove secretions. Postural drainage is usually done when the client wakes up, to get rid of secretions that have accumulated throughout the night, and before the rest, to improve the quality and quantity of sleep.</li>
<li>Administration of bronchodilators via inhalation will go directly to the bronchial area, which experienced a spasm so more quickly dilated.</li>
<li>Mucolytic agents decrease the viscosity and pulmonary adhesions secret for easy cleaning.</li>
<li>Expectorant agent will facilitate secret escape from adhesions airway.</li>
<li>Corticosteroids are useful in the broad engagement with hypoxemia and decrease the inflammatory reaction due to mucosal edema and bronchus wall.</li>
</ul>
mas ckhttp://www.blogger.com/profile/05796738330565853948noreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-10213844047448007922015-11-01T01:33:00.000-07:002015-11-01T01:33:02.351-07:00Nursing Diagnosis and Interventions for Acute Respiratory Distress Syndrome (ARDS)<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1Cih8f1u46v9pAF6Ik-kMeaBSPU6ImDFWaCv7G_C6bxEkatn31JyoftaOdmcf05HAWPaKYbAegDJqadJ5Jx7yeQTUJlRPfdyJIkS3CT5tRZ3xmAp1AlRMqMhNx_dEL2l-gcyAWhiZ93k/s1600/nursing-care-plan-acute-respiratory-distress-dyndrome-ards.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1Cih8f1u46v9pAF6Ik-kMeaBSPU6ImDFWaCv7G_C6bxEkatn31JyoftaOdmcf05HAWPaKYbAegDJqadJ5Jx7yeQTUJlRPfdyJIkS3CT5tRZ3xmAp1AlRMqMhNx_dEL2l-gcyAWhiZ93k/s1600/nursing-care-plan-acute-respiratory-distress-dyndrome-ards.jpg" /></a></div>
Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood. Infants can also have respiratory distress syndrome.<br />
<br />
<b>Causes</b><br />
<br />
ARDS can be caused by any major direct or indirect injury to the lung. Common causes include:<br />
<ul>
<li>Breathing vomit into the lungs (aspiration)</li>
<li>Inhaling chemicals</li>
<li>Lung transplant</li>
<li>Pneumonia</li>
<li>Septic shock (infection throughout the body)</li>
<li>Trauma </li>
</ul>
<br />
<b>Symptoms</b><br />
<br />
Symptoms usually develop within 24 to 48 hours of the injury or illness. Often, people with ARDS are so sick they cannot complain of symptoms. Symptoms can include any of the following:<br />
<ul>
<li>Difficulty breathing</li>
<li>Low blood pressure and organ failure</li>
<li>Rapid breathing</li>
<li>Shortness of breath</li>
</ul>
<a href="https://www.nlm.nih.gov/medlineplus/ency/article/000103.htm" target="_blank">(nlm.nih.gov</a>)<br />
<br />
<br />
<b>Acute Respiratory Distress Syndrome (ARDS)</b><br />
<br />
<b>Nursing Diagnosis</b><br />
<br />
<b>Excess Fluid Volume </b><br />
related to:<br />
<ul>
<li>Interference mechanisms of regulation.</li>
<li>Excess fluid intake.</li>
<li>Excess sodium intake.</li>
</ul>
<br />
Characterized by: <br />
<ul>
<li>Edema. </li>
<li>Electrolyte disturbances. </li>
<li>Changes in breathing patterns. </li>
<li>Intake exceeds output. </li>
<li>Pleural effusion. </li>
<li>Dyspnea.</li>
</ul>
Expected outcomes:<br />
<br />
<ul>
<li>Demonstrating a stable fluid volume with the balance of the input / output, stable weight, vital signs within normal limits and no edema.</li>
</ul>
<br />
<br />
Intervention:<br />
<br />
Independent:<br />
<br />
<ul>
<li>Monitor input / output. Calculate the fluid balance, record losing invisible. measuring the weight as indicated.</li>
<li>Evaluation of skin turgor, mucous membranes humidity, presence of dependent edema / general.</li>
<li>Monitor vital signs (blood pressure, pulse, respiratory rate). Auscultation of breath, note the crackles.</li>
<li>Review the fluid needs.</li>
<li>Eliminate the danger signs and know of the environment.</li>
<li>Encourage the patient to drink and eat slowly as indicated.</li>
</ul>
Collaboration:<br />
<ul>
<li>Give IV fluids, as indicated.</li>
<li>Give antiemetic medicines, as indicated.</li>
<li>Monitor laboratory tests as indicated, eg, hemoglobin / hematocrit, BUN / creatinine, plasma proteins, electrolytes.</li>
</ul>
<br />
Rational:<br />
Independent:<br />
<ul>
<li>Evaluator direct fluid status.</li>
<li>A sudden change in body weight was suspected loss / fluid retention.</li>
<li>Direct indicator of fluid status / repair balance.</li>
<li>Lack of fluid may be the symptoms of hypotension and tachycardia, because the heart tries to maintain cardiac output.</li>
<li>Excess liquid / failure may be manifested by hypertension, tachycardia, tachypnea, crackles, respiratory distress.</li>
<li>Depending on the situation, the liquid is restricted or given continuously.</li>
<li>Provision of information involving patients in scheduling with individual preferences and increase the sense of control and cooperation in the program.</li>
<li>Stimulation can reduce the vomiting center.</li>
<li>Can reduce the occurrence of vomiting when nausea.</li>
</ul>
Collaboration:<br />
<ul>
<li>Fluids may be required to prevent dehydration, though fluid restriction may be necessary when patients CHF.</li>
<li>May help reduce nausea / vomiting, increased fluid intake / food.</li>
<li>Satus evaluate hydration, kidney function and cause / effect imbalance.</li>
</ul>
mas ckhttp://www.blogger.com/profile/05796738330565853948noreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-49667183572262740012015-09-13T21:40:00.001-07:002015-09-13T21:46:44.823-07:00Nursing Diagnosis and Interventions for Acute Otitis Media (AOM)<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyWvf-HQotkmTSlOO4K4I3a2CqJnhO9YKbSXsMWVxFOPDNWicqHDXAHLjfgQAoCtgmkSawJVEPMCZdH2OlIA7xCvJfXM2poAby8VG-Z-60Fbn97S_3aVYa7cuJkOdDXUXLyCXPHksHzGk/s1600/Nursing+Diagnosis+and+Interventions+for+Acute+Otitis+Media+%2528AOM%2529.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Interventions for Acute Otitis Media (AOM)" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyWvf-HQotkmTSlOO4K4I3a2CqJnhO9YKbSXsMWVxFOPDNWicqHDXAHLjfgQAoCtgmkSawJVEPMCZdH2OlIA7xCvJfXM2poAby8VG-Z-60Fbn97S_3aVYa7cuJkOdDXUXLyCXPHksHzGk/s1600/Nursing+Diagnosis+and+Interventions+for+Acute+Otitis+Media+%2528AOM%2529.jpg" /></a></div>
<b>Acute Otitis Media (AOM)</b> is an infection of abrupt onset that usually presents with ear pain. <br />
<br />
The cause of Acute Otitis Media (AOM) is related to childhood anatomy and immune function. <br />
<br />
Infants and children may have one or more of the following symptoms:<br />
<ul>
<li>crying</li>
<li>irritability</li>
<li>sleeplessness</li>
<li>pulling on the ears</li>
<li>ear pain</li>
<li>headache</li>
<li>neck pain</li>
<li>a feeling of fullness in the ear</li>
<li>fluid drainage from the ear</li>
<li>fever</li>
<li>vomiting</li>
<li>diarrhea</li>
<li>irritability</li>
<li>lack of balance</li>
<li>hearing loss</li>
</ul>
<br />
<b>Nursing Diagnosis and Interventions for Acute Otitis Media (AOM)</b><br />
<br />
1. Disturbed Sensory Perception: auditory conductive disorder related to the sound of the organ.<br />
<br />
Purpose: to improve communication<br />
<br />
Intervention:<br />
<ul>
<li>Reduce noise in the client environment.</li>
<li>Looking at the client when speaking.</li>
<li>Speaking clearly and firmly on the client without the need to shout.</li>
<li>Provide good lighting when the client relies on the lips.</li>
<li>Using the signs of non-verbal (eg facial expressions, pointing, or body movement) and other communications.</li>
<li>Instruct family or the people closest to the client on how techniques of effective communication so that they can interact with clients.</li>
<li>If the client wants, the client can use hearing aids.</li>
</ul>
<br />
<br />
2. Acute Pain related to inflammation of the middle ear tissue.<br />
<br />
Purpose: The reduction in pain.<br />
<br />
Intervention:<br />
<ul>
<li>Assess the level of intensity of the client and client's coping mechanisms.</li>
<li>Give analgesics as indicated.</li>
<li>Distract the patient by using relaxation techniques: distraction, guided imagination, touching, etc..</li>
</ul>
<br />
Source : <i><a href="http://nursing-diagnosis-intervention.blogspot.co.id/2012/07/nursing-care-plan-for-acute-otitis-media.html" target="_blank">http://nursing-diagnosis-intervention.blogspot.co.id/2012/07/nursing-care-plan-for-acute-otitis-media.html</a></i>mas ckhttp://www.blogger.com/profile/05796738330565853948noreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-56854281680676689792015-04-12T21:54:00.005-07:002015-09-13T21:56:17.012-07:00Nursing Diagnosis and Interventions for Dermatitis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgj8caz99TG9TMWDyMQcy_Djg_sabf1scW-yZYBCUIjKGjbcS3XwcJ77YZonPWkGnfgGaPsAqlH42463PEvzcpPQHKUKTdxwkr_72AqoWLME0BFUctgNEHETQiAEdqYHReBCJCgf5zA68I/s1600/Nursing-Diagnosis-and-Interventions-for-Dermatitis.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Interventions for Dermatitis" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgj8caz99TG9TMWDyMQcy_Djg_sabf1scW-yZYBCUIjKGjbcS3XwcJ77YZonPWkGnfgGaPsAqlH42463PEvzcpPQHKUKTdxwkr_72AqoWLME0BFUctgNEHETQiAEdqYHReBCJCgf5zA68I/s320/Nursing-Diagnosis-and-Interventions-for-Dermatitis.jpg" /></a></div>
Eczema or dermatitis is a severe inflammation that causes the formation of small blisters or bubbles (vesicles) on the skin until finally burst and eject the liquid. The term eczema is also used for a group of conditions that cause changes in the pattern of the skin and cause specific changes in the surface.<br />
<br />
The main symptoms of the onset of mild eczema is an area of smooth, slightly flushed dry, scaly, can cause itching or not, and is usually found in the legs or arms. In patients with acute eczema, skin will experience intense itching, usually occurs in the front of the elbows, behind the knees, and face. However, any area of skin may be affected. Furthermore, the skin becomes more sensitive to scratchy fabrics, especially wool. In the winter, the eczema will become more severe because the indoor air is very dry.<br />
<br />
<b>Impaired Skin Integrity</b> related to changes in skin barrier function.<br />
<br />
Purpose: Patients will maintain the integrity of the skin during the treatment.<br />
<br />
Outcomes: no drought and thickening.<br />
<br />
Nursing actions:<br />
<br />
1. Protect your skin healthy to the possibility of maceration (excessive hydration of the stratum corneum) when installing wet bandage.<br />
R /: Maceration on healthy skin can cause rupture of the skin and the expansion of the primary abnormality.<br />
<br />
2. Avoid the risk of thermal injury due to the use of warm compresses the temperature is too high.<br />
R /: Patients with dermatitis may experience a decrease in sensitivity to heat.<br />
<br />
3. Apply lotions and creams skin immediately after bathing.<br />
R /: Hydration effective in preventing disruption of the stratum corneum layer of the skin barrier.<br />
<br />
4. Keep the nails are always cut short.<br />
R /: Cutting the nail will reduce skin damage due to scratching.<br />
<br />
<br />
<b>Impaired sense of comfort (pain and itching) </b>related to an inflammatory process of the skin.<br />
<br />
Purpose: Patients will maintain the level of comfort during the treatment.<br />
<br />
Outcomes: The patient will show reduced pain and itching after nursing actions 1 x 24 hours.<br />
<br />
Nursing actions:<br />
<br />
1. Assess the causes of disturbance sense of comfort.<br />
R /: As a basis for nursing intervention plan.<br />
<br />
2. Control irritant factors.<br />
R /: Itching can be aggravated by heat, chemical and physical.<br />
<br />
3. Maintain humidity of approximately 60%.<br />
R /: With low humidity skin will lose water.<br />
<br />
4. Maintain a cold or cool environment.<br />
R /: Coolness reduce itching.<br />
<br />
5. Use a mild soap or special soap for sensitive skin.<br />
R /: These include the absence of a solution of detergent, dye or reinforcement material.<br />
<br />
5. Wash bed linens and clothes with a mild soap.<br />
R /: harsh soaps can cause irritation to the skin.<br />
<br />
6. Compress Air with cold water in order to relieve the itching.<br />
R /: Aspiration water from the gauze pack will gradually cooling the skin and relieve pruritus.<br />
<br />
7. Apply lotions and creams skin immediately after bathing.<br />
R /: Hydration effective in preventing disruption of the stratum corneum layer of the skin barrier.<br />
<br />
8. Use of topical therapy as prescribed by a doctor.<br />
R /: This action helps relieve symptoms.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-11997941421416118122015-04-07T11:04:00.001-07:002019-02-13T21:54:06.671-08:00Nursing Diagnosis and Intervention for Hypothermia - Hyperthermia<b>Hypothermia</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOeT4UyVnlb2Nvny2AGBiyh77MkuXftA6LPtckQ3Yup4q3DuGNkhrvumH9fvkndXn4b-C6WVoYPgm5zjJjDBaxL2MJKbN5jfSbxwzmfSiiUN-3uEEeN5jXkjNW3K_1UIthXAwPuYV-Gc8/s1600/Nursing+Diagnosis+and+Intervention+for+Hypothermia+-+Hyperthermia1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Intervention for Hypothermia - Hyperthermia" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOeT4UyVnlb2Nvny2AGBiyh77MkuXftA6LPtckQ3Yup4q3DuGNkhrvumH9fvkndXn4b-C6WVoYPgm5zjJjDBaxL2MJKbN5jfSbxwzmfSiiUN-3uEEeN5jXkjNW3K_1UIthXAwPuYV-Gc8/s320/Nursing+Diagnosis+and+Intervention+for+Hypothermia+-+Hyperthermia1.jpg" /></a></div>Hypothermia is a condition where the body's mechanism for temperature regulation difficulties to overcome pressure cold temperatures. Hypothermia can also be defined as the temperature of the inside of the body below 35 ° C. The human body is able to regulate the temperature in termonetral zone, which is between 36.5 to 37.5 ° C. Outside this temperature, the response of the body to regulate temperature will be active balancing heat production and heat loss in the body.<br />
<br />
Symptoms of mild hypothermia is patient speaks slurred, the skin becomes slightly gray, lower heart rate, decreased blood pressure, and muscle contraction occurs as the body's attempt to generate heat. In patients with moderate hypothermia, heart rate and respiration weakened until it reaches just 3-4 breaths in one minute. In patients with severe hypothermia, the patient is unconscious self, the body becomes very stiff, dilated pupils, hypotension, acute and very slow breathing to subtle (invisible).<br />
<br />
Hypothermia occurs when the core body temperature decreases below 35 ° C (95 ° F). At this temperature, the body's physiological compensatory mechanisms fail to maintain body heat.<br />
<br />
<br />
<b>Hyperthermia</b><br />
<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrGN3FtJ5Nacd1ihS09R_BQ4AKj4KXmXNJ7rxr-D0bTfBIfeNSiyHWAlY2yyLaRG_qfwtEQh45hysKZT3qpMK9pRvlOTZ1zR18WJUK6o5Uvb4kHWYkA9rV5Rekhncjq4fIVedJ_JKQfFo/s1600/Nursing+Diagnosis+and+Intervention+for+Hypothermia+-+Hyperthermia.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Intervention for Hypothermia - Hyperthermia" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhrGN3FtJ5Nacd1ihS09R_BQ4AKj4KXmXNJ7rxr-D0bTfBIfeNSiyHWAlY2yyLaRG_qfwtEQh45hysKZT3qpMK9pRvlOTZ1zR18WJUK6o5Uvb4kHWYkA9rV5Rekhncjq4fIVedJ_JKQfFo/s1600/Nursing+Diagnosis+and+Intervention+for+Hypothermia+-+Hyperthermia.jpg" /></a></div>Hyperthermia is an increase in the core temperature of the human body that usually occurs due to infection. Hyperthermia can also be defined as a body temperature that is too hot or tall. Generally, people will sweat to lower body temperature. However, in certain circumstances, the temperature may rise rapidly up sweating does not provide sufficient effect. Hyperthermia tend to be more common in infants and children under 4 years of age and older people aged 65 years and above. Selan, people who are overweight, are sick, or in certain treatments also have a greater risk for experiencing hyperthermia. Body temperature that is too high can damage the brain and other vital organs. In patients with severe hyperthermia, symptoms will arise include the mental state of fatigue, anxiety, seizures body, and can lead to coma.<br />
<br />
<b>Nursing Diagnosis and Intervention for <a href="http://ncp-blog.blogspot.com/2015/04/hypothermia-clinical-signs-etiology-and.html" target="_blank">Hypothermia</a> - <a href="http://nursing-diagnosis-nanda.blogspot.com/2015/04/nursing-assessment-for-hypothermia-and.html" target="_blank">Hyperthermia</a></b><br />
<br />
<b>Altered Body Temperature</b> related to abnormal births, exposure to environmental temperature, cold or hot.<br />
<br />
<b>Purpose 1: </b>Identifying infants at risk or actual body temperature instability.<br />
<br />
Interventions:<br />
<br />
1. Assess the factors related to the risk of fluctuations in body temperature in infants, such as; prematurity, sepsis and infection, asphyxia or hypoxia, CNS trauma, fluid and electrolyte imbalance, the ambient temperature is too hot or cold, birth trauma and maternal history of drug abuse.<br />
<br />
2. Assess the potential and actual hypothermia or hyperthermia:<br />
<ul><li>Monitor body temperature, do measurements on a regular basis.</li>
<li>Monitor the temperature of the environment.</li>
<li>Prevent conditions that cause heat loss in infants such as baby clothes are not wet or dry, exposure to outside air or air conditioning.</li>
<li>Check the respiratory rate (tachypnea), depth and pattern.</li>
<li>Observe the color of the skin.</li>
<li>Monitor irritability, tremors and seizures activity.</li>
<li>Monitor the presence of flushing, respiratory distress, apnea episodes, moisture, and fluid loss.</li>
</ul><br />
<b>Purpose 2: </b>Prevent conditions that can trigger fluctuations in body temperature.<br />
<br />
Interventions:<br />
1. Protect the wall incubator with:<br />
<ul><li>Laying incubator right place.</li>
<li>Room temperature maintenance / operating room maintained.</li>
<li>Use protective pads or heat in the incubator.</li>
</ul>2. Dry the newborn immediately below the heater.<br />
3. The water bath above 37 ° C and bathing the baby, after the baby is stable and 6-12 hours postnatally, dry immediately.<br />
4. Use a mat on the table resuscitation or heating.<br />
5. Close surface resuscitation table with a warm blanket, first warmed incubator.<br />
6. Keep the skin temperature from 36 to 36.5 ° C.<br />
7. As little as possible to open the incubator.<br />
8. Warm always incubator before use.<br />
9. Hold the baby with skin attached to the mother's skin (kangaroo method).<br />
10. Give a hat and wrap in a blanket.<br />
<br />
<br />
<b>Purpose 3: </b>Preventing complications cold.<br />
<br />
Interventions:<br />
1. Assess signs of cold stress on the baby:<br />
<ul><li>Decrease in body temperature to less than 32.2 ° C.</li>
<li>Weakness and irritability.</li>
<li>Poor feeding and lethargy.</li>
<li>Pallor, cyanosis of central or mottling.</li>
<li>Cold clammy skin.</li>
<li>The redness of the skin.</li>
<li>Bradycardia.</li>
<li>Slow breathing, irregular accompanied by grunting.</li>
<li>Decreased activity and reflexes.</li>
<li>Distesi abdomen and vomiting.</li>
</ul>2. Give the actual treatment or risk of injury due to cold as follows:<br />
<ul><li>Give heat therapy slowly and record body temperature every 15 minutes.</li>
<li>Consider administration of plasma proteins (plasmanate) after 30 minutes.</li>
<li>Give oxygen that is set humidity.</li>
<li>Monitor serum glucose.</li>
<li>Give sodium bicarbonate for metabolic acidosis.</li>
<li>To replace the intake of food and fluids, give dextrose 10% to temeperatur rises above 35 ° C.</li>
</ul>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-83928157285392253842012-07-20T19:02:00.002-07:002015-09-13T22:06:39.179-07:00Nursing Diagnosis and Intervention for Scoliosis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg41Hjt8n533KAMcJiSzdGisCYmY_Wy-HcFEZsMiBHrLLWrdZ4_g-llGONYGon9g9u2NBDRfF9EFbf10kgK_7F8s-fFm8j5KcIXFe__BdLBhmt5vQpUHEN2jvAgAKibL_DhuBFY_vvmErE/s1600/Nursing+Diagnosis+and+Intervention+for+Scoliosis.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Intervention for Scoliosis" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg41Hjt8n533KAMcJiSzdGisCYmY_Wy-HcFEZsMiBHrLLWrdZ4_g-llGONYGon9g9u2NBDRfF9EFbf10kgK_7F8s-fFm8j5KcIXFe__BdLBhmt5vQpUHEN2jvAgAKibL_DhuBFY_vvmErE/s320/Nursing+Diagnosis+and+Intervention+for+Scoliosis.jpg" /></a></div>
Scoliosis is a disorder in which the body frame in the form of spinal curvature. As many as 75-85% of scoliosis cases are idiopathic, the disorder of unknown cause. While the other 15-25% of scoliosis cases are the side effects caused due to suffering from specific disorders, such as muscular dystrophy, Marfan syndrome, Down syndrome, and other diseases. The disorder causes various muscles or nerves around the spinal cord does not function perfectly and causing the spine becomes curved shape.<br />
<br />
<a href="http://careplannursing.blogspot.co.id/2012/07/nursing-care-plan-for-scoliosis.html" target="_blank"><span style="font-weight: bold;">Nursing Diagnosis and Intervention for Scoliosis</span></a><br />
<br />
<br />
1. <span style="font-weight: bold;">Ineffective Breathing Pattern</span> related to the suppression of pain.<br />
<br />
Purpose: The pattern of breathing Effectively.<br />
<br />
Plan of action:<br />
<ul>
<li> Assess respiratory status every 4 hours.</li>
<li> Help and teach the patient to breath in any one hour. Rationale: Increasing the maximum ventilation and oxygenation.</li>
<li> Adjust bed semi-Fowler position to improv lung expansion. Rational: Sitting height allowing Easier breathing and lung expansion.</li>
<li> Monitor vital signs every 1 hour. Rational: general indicators, circulation status and adequacy of perfusion.</li>
</ul>
<br />
2. <span style="font-weight: bold;">Acute Pain</span>: back related to the position of lateral body tilt.<br />
<br />
Purpose: Pain is reduced or lost<br />
<br />
Plan of action:<br />
<ul>
<li> Assess the type, intensity and location of pain. Rational: Influencing choice / control the effectiveness of Interventions can influence the level of anxiety to pain.</li>
<li> Teach relaxation and distraction techniques. Rational: To divert attention, thereby reducing pain.</li>
<li> Teach and Encourage use of the brace. Rational: To Reduced pain during activity</li>
<li>Collaboration in the provision of analgesia. Rational: To relieve pain.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-42416702018246229672012-05-10T08:24:00.002-07:002015-09-13T22:20:00.003-07:00Nursing Diagnosis and Nursing Interventions for Appendicitis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVd1ePcqrDgULzBxIwkMwJkuK1RM8xAYgteKYOoQNKQB5sV3Y9ZaR9QGlFiKg8UO8ocjb-sIjZctLY8zhvTm789EmFjTZ0KY9fX-QXB1z5EPoX0ReJmkgYkOh2BVFuG5pQ-s4br_AZD_M/s1600/Nursing+Diagnosis+and+Nursing+Interventions+for+Appendicitis.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Interventions for Appendicitis" border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVd1ePcqrDgULzBxIwkMwJkuK1RM8xAYgteKYOoQNKQB5sV3Y9ZaR9QGlFiKg8UO8ocjb-sIjZctLY8zhvTm789EmFjTZ0KY9fX-QXB1z5EPoX0ReJmkgYkOh2BVFuG5pQ-s4br_AZD_M/s320/Nursing+Diagnosis+and+Nursing+Interventions+for+Appendicitis.JPG" width="320" /></a></div>
<b>Acute appendicitis</b> is the most common cause of acute inflammation in the lower right quadrant of the abdominal cavity, the most common causes of emergency abdominal surgery (Smeltzer, 2001).<br />
<br />
Appendicitis is a condition in which infection occurs in the appendix. In mild cases may recover without treatment, but many cases require laparotomy with removal of the infected appendix. If untreated, the mortality rate is quite high, due to peritonitis and shock when an infected appendix destroyed. (Anonymous, Appendicitis, 2007)<br />
<br />
<b>Nursing Diagnosis for Appendicitis</b><br />
<br />
<ol>
<li><span class="Apple-style-span"><b><a href="http://nandanursingdiagnosis.blogspot.com/search/label/Nursing%20Diagnosis%20for%20Ineffective%20Breathing%20Pattern" target="_blank">Ineffective Breathing Pattern</a></b> related to the act of anesthetics.</span></li>
<span class="Apple-style-span">
<li><b><a href="http://nandanursingdiagnosis.blogspot.com/search/label/Nursing%20Diagnosis%20for%20Acute%20Pain" target="_blank">Acute Pain</a></b> related to the surgical incision.</li>
<li><b>Risk for Fluid Volume Deficit</b> associated with vomiting.</li>
<li><b><a href="http://nandanursingdiagnosis.blogspot.com/search/label/Nursing%20Diagnosis%20for%20Imbalanced%20Nutrition%20%3A%20Less%20Than%20Body%20Requirements" target="_blank">Imbalanced Nutrition: Less than Body Requirements</a></b> related to anorexia.</li>
<li><b><a href="http://nandanursingdiagnosis.blogspot.com/search/label/Nursing%20Diagnosis%20Risk%20for%20Infection" target="_blank">Risk of Infection</a></b> related to surgical incision.</li>
</span></ol>
<span class="Apple-style-span"><br />
</span> <b>Nursing Diagnosis for Appendicitis</b><br />
<br />
Risk for infection related to an inadequate primary defenses, perforation, peritonitis secondary to inflammatory processes.<br />
<br />
<b>Nursing Interventions for Appendicitis</b><br />
<ol>
<li>Assess and record the quality, location and duration of pain. Beware of the pain becomes severe.</li>
<li>Monitor and record vital signs of the increase in temperature, pulse, breathing fast and shallow existence.</li>
<li>Assess the abdomen against the rigidity and distention, decreased bowel sounds.</li>
<li>Perform wound care with aseptic technique.</li>
<li>See incision and bandage. Record the drainage characteristics of the wound / drain, erythema.</li>
<li>Collaboration: antibiotics</li>
</ol>
<br />
<br />
<b>Nursing Diagnosis for Appendicitis</b><br />
<br />
Acute Pain related to distention of intestinal tissue by inflammation, a surgical incision<br />
<br />
<br />
<b>Nursing Interventions for Appendicitis</b><br />
<ol>
<li>Assess pain. Record the location, characteristics of pain.</li>
<li>Keep the rest in semi-Fowler position.</li>
<li>Suggest to early ambulation.</li>
<li>Teach diaphragmatic breathing techniques to slow to help release muscle tension.</li>
<li>Avoid pressure popliteal area.</li>
<li>Give antiemetic, analgesic according to the program.</li>
</ol>
Source : <a href="http://nursinginterventions-diagnosis.blogspot.com/2011/03/nursing-interventions-for-appendicitis.html" style="font-style: italic; font-weight: bold;" target="_blank">http://nursinginterventions-diagnosis.blogspot.com</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-46989026515468545672012-03-28T18:29:00.004-07:002015-09-13T22:08:49.391-07:00Nursing Diagnosis and Interventions for Depression<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-T1yih-5A1tAFxSnUMbYiZLcWEerQYrYpjNM_rO7u16m5O1kB3Gl5528GokiRgoSEMeLb1AR8iIGu-3B0XiEAeWEZHnthTBDvbhLXVt3U1X8K3H1qS7MnCUndLXPKXc9MwA4_0H1DYzY/s1600/Nursing+Diagnosis+and+Interventions+for+Depression.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-T1yih-5A1tAFxSnUMbYiZLcWEerQYrYpjNM_rO7u16m5O1kB3Gl5528GokiRgoSEMeLb1AR8iIGu-3B0XiEAeWEZHnthTBDvbhLXVt3U1X8K3H1qS7MnCUndLXPKXc9MwA4_0H1DYzY/s1600/Nursing+Diagnosis+and+Interventions+for+Depression.jpg" /></a></div>
<a href="http://nursesnanda.blogspot.com/2012/02/nanda-depression.html" target="_blank"><span style="font-weight: bold;">Nursing Diagnosis for Depression</span></a><br />
<br />
1. Risk for Self-Mutilation and Other<br />
<br />
2. Depression<br />
<br />
<a href="http://careplannursing.blogspot.com/2011/11/depression-nursing-diagnosis-and.html" target="_blank"><span style="font-weight: bold;">Nursing Interventions for Depression</span></a><br />
<br />
<ol>
<li>The general objective: There was no violence for Self-Directed or Other-Directed</li>
<li>Specific objectives<ul>
<li>Clients can build a trusting relationship<br />
<br />
<u>Action:</u><br />
<br />
<ul>
<li> Introduce yourself to the patient</li>
<li> Do interactions with patients as often as possible with empathy</li>
<li> Listen to the notice of the patient with empathy and patient attitude more use non-verbal language. For example: a touch, a nod.</li>
<li> Note the patient talks and give a response in accordance with her wishes</li>
<li> Speak with a low tone of voice, clear, concise, simple and easy to understand</li>
<li> Accept the patient is without comparing with others.</li>
</ul>
</li>
<li>Clients can use adaptive coping<br />
<br />
<u>Action:</u><br />
<br />
<ul>
<li> Give encouragement to express feelings and say that nurses understand what patients perceived.</li>
<li> Ask the patient the usual way to overcome feeling sad / painful</li>
<li> Discuss with patients the benefits of commonly used coping</li>
<li> Together with patients looking for alternatives, coping.</li>
<li> Give encouragement to the patient to choose the most appropriate coping and acceptable</li>
<li> Give encouragement to patients to try coping that have been selected</li>
<li> Instruct the patient to try other alternatives in solving problems.</li>
</ul>
</li>
<li>Clients are protected from violent behavior to self and others.<br />
<br />
<u>Action:</u><br />
<br />
<ul>
<li> Monitor carefully the risk of suicide / violence themselves.</li>
<li> Keep and store the tools that can be used by patients for violent behavior, self / others, in a safe place and locked.</li>
<li> Keep materials that endanger the patient's appliance.</li>
<li> Supervise and place the patient in the room that easily monitored by peramat / officer.</li>
</ul>
</li>
<li> Clients can improve self-esteem</li>
<u>Action:</u><ul>
<li> Help to understand that the client can overcome despair.</li>
<li> Assess and mobilize internal resources of individuals.</li>
<li> Help identify sources of hope (eg, peer relationships, beliefs, things to be resolved).</li>
</ul>
<li>Clients can use the social support<br />
<br />
<u>Action:</u><br />
<br />
<ul>
<li> Review and make use of individual external sources (the people closest to, the health care team, support groups, religion).</li>
<li> Assess support system beliefs (values, past experiences, religious activities, religious beliefs).</li>
<li> Make referrals as indicated (eg, counseling, religious leaders).</li>
</ul>
</li>
<li>Clients can use the drug correctly and precisely<br />
<br />
<u>Action:</u><br />
<br />
<ul>
<li> Discuss about the drug (name, dosage, frequency, effect and side effects of taking medication).</li>
<li> Help using the drug with the principle of 5 correct (right patient, medication, dose, manner, time).</li>
<li> Encourage talking about effects and side effects are felt.</li>
<li> Give positive reinforcement when using the drug properly. </li>
</ul>
</li>
</ul>
</li>
</ol>
<span style="font-weight: bold;"><a href="http://nursingdiagnosis-nursinginterventions.blogspot.com/2012/03/nursing-diagnosis-and-interventions-for_29.html">Nursing Diagnosis and Interventions for Depression</a></span>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-78375879171308548462012-03-28T10:26:00.001-07:002015-09-13T22:21:08.893-07:00Nursing Diagnosis and Interventions for Ischemic Heart Disease<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuADr8W5BqMnuyVfYBhYd6yRONd83-XUeYjVGNqsbzRdRNNpGSV_7NS4kNmePtzqbzgf9i2rYzmHTaY0BvGcZOnySYPkhpYPFMKMronPjEBEbd-hL-nIOWxoPgh8ZjvSz6tlYBCDYWbhU/s1600/Ischemic+Heart+Disease.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Interventions for Ischemic Heart Disease" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuADr8W5BqMnuyVfYBhYd6yRONd83-XUeYjVGNqsbzRdRNNpGSV_7NS4kNmePtzqbzgf9i2rYzmHTaY0BvGcZOnySYPkhpYPFMKMronPjEBEbd-hL-nIOWxoPgh8ZjvSz6tlYBCDYWbhU/s1600/Ischemic+Heart+Disease.jpg" /></a></div>
<b>Ischaemic (or ischemic) heart disease</b> is a disease characterized by reduced blood supply to the heart.<br />
<br />
Most ischaemic heart disease is caused by atherosclerosis, usually present even when the artery lumens appear normal by angiography.<br />
<br />
The narrowing or closure is predominantly caused by the covering of atheromatous plaques within the wall of the artery rupturing, in turn leading to a heart attack (Heart attacks caused by just artery narrowing are rare).<br />
<br />
<br />
<span style="font-weight: bold;">Nursing Diagnosis for Ischemic Heart Disease</span><br />
<br />
1. <span style="font-weight: bold;">Acute pain</span> related to an imbalance of oxygen supply to myocardial demands.<br />
<br />
2. <span style="font-weight: bold;">Decreased cardiac output</span> related to electrical factors (dysrhythmias), decrease in myocardial contraction, structural abnormalities (papillary muscular dysfunction and ventricular septal rupture)<br />
<br />
3. <span style="font-weight: bold;">Anxiety</span> related to the needs of the body is threatened.<br />
<br />
4. <span style="font-weight: bold;">Activity intolerance</span> related to insufficient oxygen for life activities secondary to cardiac ischemia.<br />
<br />
<br />
<span style="font-weight: bold;">Nursing Interventions for ischemic Heart Disease</span><br />
<br />
1. Acute pain related to an imbalance of oxygen supply to myocardial demands.<br />
<br />
Outcome: The patient will express pain decreased<br />
<br />
Intervention:<br />
• Assess pain location, duration, radiation, occurrence, a new phenomenon.<br />
• Review of previous activities that cause chest pain.<br />
• Create a 12 lead ECG during anginal pain episodes.<br />
• Assess signs of hypoxemia, give oxygen therapy if necessary.<br />
• Give analgesics as directed.<br />
• Maintain a rest for 24-30 hours during episodes of illness<br />
• Check vital signs, during periods of illness.<br />
<br />
2. Decreased cardiac output related to electrical factors (dysrhythmias), Decrease in myocardial contraction, structural abnormalities (papillary muscular dysfunction and ventricular septal rupture)<br />
<br />
Outcome: The patient will demonstrate a stable cardiac condition or better.<br />
<br />
Intervention:<br />
• Maintain bed rest with head elevation of 30 degrees during the first 24-48 hours<br />
• Assess and monitor vital signs and hemodynamic per 1-2 hours<br />
• Monitor and record ECG continue to assess the rate, rhythm, and order to each change per 2 or 4 hours.<br />
• Review and report signs of CO reduction.<br />
<br />
3. Anxiety related to the needs of the body is Threatened.<br />
<br />
Objectives: The patient will demonstrate reduced anxiety after nursing actions.<br />
Intervention:<br />
• Assess signs and verbal expressions of anxiety<br />
• Take action to reduce anxiety by creating a calm environment<br />
• Accompany patient during periods of high anxiety<br />
• Provide an explanation of procedures and treatments<br />
• Encourage patients to express feelings<br />
• Refer to the spiritual adviser if necessaryUnknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-85615338658982032362012-02-28T17:41:00.001-08:002015-09-13T22:27:43.694-07:00Nursing Diagnosis and Nursing Interventions for Hallucination<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWvIVJOTflGyXYnsr1zgqcnfCjMroWYJd1DvjF8MoH7JdT9wRmjxqcBphwhhJ0vTfM6Bosm2BJUAXeAHIMhMXiMnPAG6HIkxVM1ReYKruFgGnXbJfnjrX81cBQwDH2fi1lC0ypgAv30fw/s1600/Nursing+Diagnosis+and+Nursing+Interventions+for+Hallucination.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Interventions for Hallucination" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWvIVJOTflGyXYnsr1zgqcnfCjMroWYJd1DvjF8MoH7JdT9wRmjxqcBphwhhJ0vTfM6Bosm2BJUAXeAHIMhMXiMnPAG6HIkxVM1ReYKruFgGnXbJfnjrX81cBQwDH2fi1lC0ypgAv30fw/s1600/Nursing+Diagnosis+and+Nursing+Interventions+for+Hallucination.jpg" /></a></div>
<b>Hallucinations</b> are perceptions in the conscious state without apparent stimulation of the senses. The quality of the perception felt by people with very clear, substantial and in fact came from outside the room. This definition can distinguish hallucinations with dreams, visions, illusions and pseudo-hallucinations (not the same as real perception, but not under controlled conditions). Examples of this phenomenon is that a person experiencing visual impairment, where he thought he saw an object, but other people's sense of vision can not capture the same object.<br />
<br />
Hallucinations can be divided based on the senses that react when these perceptions are formed, namely<br />
<ul>
<li>visual hallucinations</li>
<li>auditory hallucinations</li>
<li>olfactory hallucinations</li>
<li>hallucinations gustatori</li>
<li>tactile hallucinations</li>
</ul>
<br />
<span style="font-weight: bold;"> <a href="http://nursingdiagnosis-nursinginterventions.blogspot.com/2012/02/nursing-diagnosis-and-nursing.html">Nursing Diagnosis for Hallucination</a></span><br />
<br />
1. Risk for Injury: self, others and the environment related to auditory hallucinations.<br />
<br />
2. Disturbed Sensory Perception: hallucinations related to the withdrawal.<br />
<br />
3. Social isolation: withdrawal related to low self esteem.<br />
<br />
4. Self-care deficit related to activity intolerance.<br />
<br />
<span style="font-weight: bold;">Nursing Interventions for </span><span style="font-weight: bold;">Hallucination</span><br />
<br />
<span style="font-style: italic; font-weight: bold;">Creating a therapeutic environment</span><br />
<br />
To reduce the level of anxiety, panic and fear in patients affected by hallucinations, preferably at the beginning of the approach is done on an individual basis and keep your eye contact, if possible the patient in touch or hold. Patients should not in isolation either physically or emotionally. Each nurse entered the room or close to the patient, talk with patients. So also when the patient should be told to leave. The patient was told the action would be undertaken.<br />
In that room should be provided the means to stimulate interest and encourage patients to get in touch with reality, such as clocks, picture or wall hangings, magazines and games.<br />
<br />
<span style="font-style: italic; font-weight: bold;">Implement physicians therapy program</span><br />
<br />
Often patients refuse medication that is given with respect to stimulation hallucinations in receipt. The approach should be persuasive but instructive. Nurses must observe in order to give the right drug at the telannya, as well as drug reactions are given.<br />
<br />
<span style="font-style: italic; font-weight: bold;">Explores the problems of patients and help resolve existing problems</span><br />
<br />
Once the patient is more cooperative and communicative, nurses can explore the patient’s problem which is causing hallucinations as well as help overcome existing problems. The collection of this data can also be through the information the patient’s family or others close to the patient.<br />
<br />
<span style="font-style: italic; font-weight: bold;">Giving activity in patients</span><br />
<br />
Patients in whom enable themselves to perform physical movement, such as exercising, playing or conducting. This activity can help steer patients to the real-life and cultivate relationships with others. Patients in whom scheduling of activities and choose appropriate activities.<br />
<br />
<span style="font-style: italic; font-weight: bold;">Involving family and other officers in the process of care</span><br />
<br />
Patient’s family and other officers should tell about the patient data in order to have unity of opinion and continuity in the nursing process, for example from a conversation with the patient in the know when it is alone, he was often heard men who mock. But if there is someone else nearby voices were not heard clearly. Nurses advised patients not to be alone and busied himself in the game or activity that exists. This conversation should be in to tell the patient’s family and other officers not to leave the patient alone and advice that is given is not contradictory.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-71027315824697324832012-01-28T17:57:00.001-08:002015-09-13T22:41:06.972-07:00Nursing Diagnosis and Nursing Interventions for Pleural Effusion<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4VxoO5ZVKoxIKwuyA4awDpRQTw24H8JmN8PN8edqUU6_wUijGRRbaUqX2SRjbyUEzdG33Zd6g2vmORNyzDEqjqC-q4D5bj5OhBdX60mC5scbSslZKDElmFa3N8ib7kPmbFaU6kmcAK0g/s1600/Nursing+Diagnosis+and+Nursing+Interventions+for+Pleural+Effusion.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Interventions for Pleural Effusion" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4VxoO5ZVKoxIKwuyA4awDpRQTw24H8JmN8PN8edqUU6_wUijGRRbaUqX2SRjbyUEzdG33Zd6g2vmORNyzDEqjqC-q4D5bj5OhBdX60mC5scbSslZKDElmFa3N8ib7kPmbFaU6kmcAK0g/s320/Nursing+Diagnosis+and+Nursing+Interventions+for+Pleural+Effusion.jpg" /></a></div>
<b>Pleural effusion</b> is a health condition where the amount of excess fluid accumulates in the pleural cavity. This limits the ability of the lungs to grow and therefore the patient's difficulty in breathing. Below, we examine the root causes, symptoms and available treatments for pleural effusion.<br />
<br />
There is a thin layer of fluid between the lung and the chest wall, in the human body. This liquid is very important because it acts as a lubricant between the chest wall and lungs when we breathe. Cavity or space between the chest wall and the lungs, where it accumulates fluid, called the pleura and the liquid is called pleural fluid. An abnormal increase in the number of pleural fluid causes the chest wall separate from the lungs. This condition is known as pleural effusion.<br />
<br />
Possible signs of pleural effusion:<br />
<ul>
<li>The emphasis on the lungs</li>
<li>Chest pain (does not occur in all patients)</li>
<li>Difficulty breathing.</li>
<li>Cough and fever with empyema (if the pneumonia was caused effusion)</li>
<li>Hiccups.</li>
<li>Dyspnea (shortness of breath)</li>
</ul>
<br />
<br />
<a href="http://nandanursingdiagnosis.blogspot.com/2011/08/nursing-diagnosis-for-pleural-effusion.html" target="_blank"><span style="font-weight: bold;">Nursing Diagnosis for Pleural Effusion</span></a><br />
<br />
1. Ineffective breathing pattern related to decreased lung expansion secondary to accumulation of fluid in the pleural cavity (Susan Martin Tucleer, et al, 1998).<br />
<br />
2. Imbalanced Nutrition : Less Than Body Requirements related to an increased metabolism, decreased appetite due to shortness of breath secondary to suppression abdominal structures (Barbara Engram, 1993).<br />
<br />
3. Anxiety related to the threat of death imaginable (inability to breathe).<br />
<br />
4. Sleep pattern disturbance related to a persistent cough and shortness of breath and change of atmosphere.<br />
<br />
5. Self-care deficit related to fatigue (physical state of the weak)<br />
<br />
6. Deficient Knowledge about conditions, treatment of the rules related to less exposure to information.<br />
<br />
<span style="font-weight: bold;"><br />
Nursing Interventions for Pleural Effusion<br />
<br />
<span style="font-style: italic;">1. Ineffective breathing pattern</span></span><span style="font-style: italic;"> </span>related to:<br />
<ul>
<li>Decrease in lung expansion (fluid accumulation)</li>
<li>Musculuskeletal disorders</li>
<li>Pain / anxiety</li>
<li>Inflammatory process</li>
</ul>
characterized by:<br />
<ul>
<li>dyspnea, tachipnea</li>
<li>changes in depth </li>
<li>use of accessory muscles, nasal dilation</li>
<li>impaired development of the chest and cyanosis, abnormal blood gas analysis</li>
</ul>
<br />
Expected outcomes / evaluation criteria, the client will:<br />
<ul>
<li>Showed a normal breathing pattern / blood gas analyzer effectively with the normal range</li>
<li>There was no cyanosis</li>
<li>No signs / symptoms of hypoxia.</li>
</ul>
<a href="http://nanda-nursinginterventions.blogspot.com/2012/03/nursing-interventions-for-ineffective.html" target="_blank"><span style="font-weight: bold;">Nursing Interventions for ineffective breathing pattern - Pleural effusion</span></a>:<br />
<br />
1. Identifying the etiology / triggers factor <br />
Rational: understanding the causes of lung collapse necessary for the proper installation of the chest tube and choose another teraupetik action.<br />
<br />
2. Evaluation of respiratory function.<br />
Rational: respiratory distress and changes in vital signs may occur due to physiological stress and may indicate the occurrence of pain or shock.<br />
<br />
3. Auscultation of breath sounds<br />
Rational: The sound of the breath can be decreased or no lobe, lung segment or the entire lung.<br />
<br />
4. Assess fremitus<br />
Rational: Sound and tactile fremitus (vibration) decreases in fluid-filled tissue / consolidation.<br />
<br />
5. Collaboration in the assessment of radiographic series<br />
Rational: hemathorak improvement and monitor progress of lung expansion.<br />
<br />
6. Collaboration in the provision of supplemental oxygen through a cannula / mask as indicated.<br />
Rational: A tool in reducing the work of breath, increased respiratory distress and cyanosis relief with respect to hypoxemia.<br />
<br />
<span style="font-style: italic; font-weight: bold;">2. Ineffective airway clearance</span> related to weakness and poor cough effort.<br />
<br />
NOC:<br />
<br />
• Demonstrate effective airway clearance and respiratory status evidenced by, gas exchange and ventilation are not dangerous:<br />
<ul>
<li>Having a patent airway</li>
<li>Removing secretions effectively.</li>
<li>Having a rhythm and respiratory frequency in the normal range.</li>
<li>Having a pulmonary function within normal limits.</li>
</ul>
<br />
• Demonstrate adequate gas exchange, characterized by:<br />
<ul>
<li>Easy to breathe</li>
<li>There is no anxiety, cyanosis and dyspnea.</li>
<li>O2 saturation within normal limits</li>
<li>Chest X-ray within the expected range.</li>
</ul>
<br />
NIC:<br />
<br />
• Assess and document<br />
<ul>
<li>The effectiveness of the administration of oxygen and other treatments.</li>
<li>The effectiveness of treatment.</li>
<li>Trends in arterial blood gases.</li>
</ul>
<br />
• Auscultation of the anterior and posterior chest to find a decrease or absence of ventilation and the presence of noise barriers.<br />
<br />
• Sucking airway<br />
<ul>
<li>Determine the need for oral suction / tracheal.</li>
<li>Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.</li>
</ul>
<br />
• Maintain adequacy of hydration to decrease viscosity of secretions.<br />
<br />
• Explain the use of ancillary equipment properly, such as oxygen, suction equipment lenders.<br />
<br />
• Inform the patient and family that smoking is an activity that is prohibited in the treatment room.<br />
<br />
• Instruct the patient about the coughing and deep breathing techniques to facilitate the discharge of secretion.<br />
<br />
• Negotiate with the respiratory therapist as needed.<br />
<br />
• Give oxygen that has been humidified.<br />
<br />
• Tell your doctor about the results of an abnormal blood gas analysis.<br />
<br />
• Assist in the delivery of aerosol. Nebulizer and another lung treatment in accordance with institutional policies and protocols.<br />
<br />
• Encourage physical activity to improve the movement of secretions.<br />
<br />
• If the patient is unable to ambulate, the patient lies sleeping position changed every 2 hours.<br />
<br />
• Inform the patient before beginning the procedure to reduce anxiety and increase self-control.<br />
<br />
<a href="http://nursingdiagnosis-nursinginterventions.blogspot.com/2012/01/nursing-diagnosis-and-nursing.html"><span style="font-weight: bold;">Nursing Diagnosis and Nursing Interventions for Nursing Diagnosis for Pleural Effusion </span></a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-29681218419519450962011-12-24T02:00:00.001-08:002015-09-13T22:41:40.616-07:00Nursing Diagnosis and Interventions - Diabetes Mellitus with Gangrene<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyaBkKpA-df6stdVBoM6MY8Xo-nVCpHQJlaHHzZ2FDiD_olh8tP0nUgPhNNtTE3-tV8ef0l4T3XrGXviNlRgJMWI61x-U3lrgTz9VbReRWkkFZMmJmntWDT1qPgLmAC3OjYbHf3Qy5Y58/s1600/Nursing+Diagnosis+and+Interventions+-+Diabetes+Mellitus+with+Gangrene.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Interventions - Diabetes Mellitus with Gangrene" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyaBkKpA-df6stdVBoM6MY8Xo-nVCpHQJlaHHzZ2FDiD_olh8tP0nUgPhNNtTE3-tV8ef0l4T3XrGXviNlRgJMWI61x-U3lrgTz9VbReRWkkFZMmJmntWDT1qPgLmAC3OjYbHf3Qy5Y58/s320/Nursing+Diagnosis+and+Interventions+-+Diabetes+Mellitus+with+Gangrene.png" /></a></div>
<b>Diabetes Mellitus (DM)</b> is a metabolic disorder characterized by increased levels of glucose in the blood or hyperglycemia, which cause a variety of chronic complications caused by abnormalities in insulin secretion, insulin action or both. Diabetes Mellitus is also often referred to as the great imitator because the disease may affect all organs of the body and cause a variety of complaints and symptoms are highly variable. Often people consider Diabetes Mellitus is caused by heredity, even though the main factor causing diabetes is precisely the unhealthy lifestyle such as eating high-calorie foods, obesity, low in fiber and rarely exercise.<br />
<br />
<b>Nursing Diagnosis and Interventions - Diabetes Mellitus with Gangrene</b><br />
<br />
<b>Impaired tissue perfusion</b> related to the weakening / decreased blood flow to the area of gangrene due to obstruction of blood vessels.<br />
<br />
Objective: to maintain peripheral circulation remain normal.<br />
<br />
Outcomes Criteria:<br />
<ul>
<li>Palpable peripheral pulse is strong and regular</li>
<li>The color of the skin around the wound is pale / cyanotic</li>
<li>The skin around the wound felt warm.</li>
<li>Edema does not occur and injuries from getting worse.</li>
<li>Sensory and motor function improved</li>
</ul>
<br />
Action plan:<br />
<br />
1. Teach the patient to mobilize<br />
Rational: the mobilization improves blood circulation.<br />
<br />
2. Teach about the factors that can increase blood flow:<br />
Elevate the legs slightly lower than the heart (elevation position at rest), avoid penyilangkan feet, avoid tight bandage, avoid using a pillow, behind the knees and so on.<br />
Rational: to increase blood flow through so that does not happen edema.<br />
<br />
3. Teach about the modification of risk factors such as:<br />
Avoid high-cholesterol diet, relaxation techniques, stop smoking, and drug use vasoconstriction.<br />
Rationale: High cholesterol can accelerate the occurrence of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.<br />
<br />
4. Cooperation with other health team in the provision of vasodilators, regular blood sugar checks and oxygen therapy.<br />
Rational: vasodilator administration will increase the dilation of blood vessels so that tissue perfusion can be improved, while the regular blood sugar checks can be up to date and state of the patient, to improve the oxygenation of the ulcer / gangrene.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-17411943682541629652011-12-24T01:56:00.001-08:002015-09-13T22:57:39.398-07:00Nursing Diagnosis and Interventions for Stevens Johnson Syndrome - SJS<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4PX9FBgbMh4DDjfrXvOcGYNu7O92M05xqPnlBE1v3EdqbvnOb3PgPSJ6pMFqpXsWjxn1QQPSKX7nwLZnHY8LjIdlB1yXGmaKmsmHU5npnPaRDufHqu6C3C_IPaWroQRNVIpL2NPGX2cc/s1600/Nursing+Diagnosis+and+Interventions+for+Stevens+Johnson+Syndrome+-+SJS.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4PX9FBgbMh4DDjfrXvOcGYNu7O92M05xqPnlBE1v3EdqbvnOb3PgPSJ6pMFqpXsWjxn1QQPSKX7nwLZnHY8LjIdlB1yXGmaKmsmHU5npnPaRDufHqu6C3C_IPaWroQRNVIpL2NPGX2cc/s1600/Nursing+Diagnosis+and+Interventions+for+Stevens+Johnson+Syndrome+-+SJS.jpg" /></a></div>
<b>Stevens–Johnson syndrome</b>, a form of toxic epidermal necrolysis, is a life-threatening skin condition, in which cell death causes the epidermis to separate from the dermis. The syndrome is thought to be a hypersensitivity complex that affects the skin and the mucous membranes. The most well-known causes are certain medications, but it can also be due to infections, or more rarely, cancers.<br />
<br />
SJS usually begins with fever, sore throat, and fatigue, which is commonly misdiagnosed and therefore treated with antibiotics. Ulcers and other lesions begin to appear in the mucous membranes, almost always in the mouth and lips, but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children who develop SJS. A rash of round lesions about an inch across arises on the face, trunk, arms and legs, and soles of the feet, but usually not the scalp.<br />
<br />
<b>Nursing Diagnosis and Interventions for Stevens Johnson Syndrome - SJS</b><br />
<br />
<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><br />
<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-8367171487010852590.post-56428119779770868572011-12-11T06:52:00.001-08:002015-09-13T23:04:20.710-07:00Nursing Diagnosis and Nursing Interventions for Pain<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjASmWYO-mGkZATxjQB7cYZaVcQesFMTnIQ1Ra1h8jCxhNs82cp2-Bl_xPp0wmj3TSBJ_Bw1W4YHA2jiz-T0GjETnoSnWAlrbkC-sI2U6A2cG3VoIq_okvTB8dX9BZILhDx15Nh8mPrTZY/s1600/Nursing+Diagnosis+and+Nursing+Interventions+for+Pain.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Interventions for Pain" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjASmWYO-mGkZATxjQB7cYZaVcQesFMTnIQ1Ra1h8jCxhNs82cp2-Bl_xPp0wmj3TSBJ_Bw1W4YHA2jiz-T0GjETnoSnWAlrbkC-sI2U6A2cG3VoIq_okvTB8dX9BZILhDx15Nh8mPrTZY/s320/Nursing+Diagnosis+and+Nursing+Interventions+for+Pain.jpg" /></a></div>
<b>Pain</b> is a sensory and emotional experience unpleasant result of tissue damage that is actual or potential. Pain is the main reason for a person to seek medical assistance. Pain occurs along with many disease processes, or simultaneously with multiple diagnostic examination or treatment. Pain is very disturbing and difficult for a lot more people than any disease (Smeltzer, 2001).<br />
<br />
<b>According to Smeltzer (2001),</b> the pain can be classified as follows:<br />
<br />
<b>1. <a href="http://nandanursingdiagnosis.blogspot.co.id/2011/07/nursing-diagnosis-for-acute-pain.html" target="_blank">Acute pain</a></b><br />
Acute pain is usually a sudden onset and is generally associated with specific injuries. Acute pain indicates that damage or injury has occurred. It drew attention to the fact that the pain is really happening and teaches us to avoid a similar situation potentially cause pain. If the damage is not longer the case and there is no systematic diseases, acute pain usually decreases with healing occurs; This pain generally occurs in less than six months and usually less than one month. For purposes of definition, acute pain can be described as pain that lasts from a few seconds up to six months.<br />
<br />
<b>2. <a href="http://nandanursingdiagnosis.blogspot.co.id/2011/03/nursing-diagnosis-for-chronic-pain.html" target="_blank">Chronic pain</a></b><br />
Chronic pain is constant or intermittent pain that persist throughout a period of time. This pain lasts beyond the expected healing time and often can not be attributed to a specific cause or injury. Chronic pain may not have onset defined by fixed and often difficult to treat because normally this pain does not respond to treatments directed at the cause. Although acute pain may be a very important signal that something is not working as it should, chronic pain is usually a problem by itself.<br />
<br />
<br />
<b>Nursing Diagnosis and Nursing Interventions for Pain </b><br />
<br />
<b>Nursing Diagnosis for Pain</b><br />
<ol>
<li><b>Acute Pain</b><br />
related to physical injury, reduction of blood supply, process of giving birth</li>
<li><b>Chronic Pain</b><br />
related to the malignancy</li>
<li><b>Anxiety </b><br />
related to pain that is felt</li>
<li><b>Ineffective individual coping </b><br />
related to chronic pain</li>
<li><b>Impaired physical mobility </b><br />
related to musculoskeletal pain</li>
<li><b>Risk for injury </b><br />
related to lack of perception of pain</li>
</ol>
<b>Nursing Interventions for Pain</b><br />
<br />
Nurses develop a plan of nursing diagnoses that have been made. Nurses and clients together to discuss realistic expectations of action to overcome the pain, the degree of recovery of the expected pain, and the effects that must be anticipated in the client's lifestyle and function. Expected outcomes and goals of nursing and nursing diagnoses were selected based on the client's condition. The general objective of nursing care with pain are as follows:<br />
<ul>
<li>Clients feel healthy and comfortable</li>
<li>Clients retain the ability to perform self-care</li>
<li>Clients maintain physical function and psychological currently owned</li>
<li>Client describes the factors that cause pain</li>
<li>Clients use the therapy given safely at home</li>
</ul>
Read More :<br />
<a href="http://nursing-care-plan.blogspot.com/2011/11/nursing-care-plan-for-pain-assessment.html" style="font-weight: bold;" target="_blank">Nursing Diagnosis and Nursing Interventions for Pain</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-54951233806810265422011-09-19T18:59:00.003-07:002015-09-13T23:11:47.505-07:00Nursing Diagnosis and Nursing Interventions for DHF<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVhoMwTiXPaCSzKAsqx6V7HmYEcghPNzAJUuOqoKw4mpZoB0CwWrV1Niv5pCHfqidLAutJ6aLjMw11a2T-qTNk7wiLCBFX1OhmDYm4Yr3cWGQvkoL-dJxcRTEj0zsRUZlsoxYyMvlB6VQ/s1600/Nursing+Diagnosis+and+Nursing+Interventions+for+DHF.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Interventions for DHF" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVhoMwTiXPaCSzKAsqx6V7HmYEcghPNzAJUuOqoKw4mpZoB0CwWrV1Niv5pCHfqidLAutJ6aLjMw11a2T-qTNk7wiLCBFX1OhmDYm4Yr3cWGQvkoL-dJxcRTEj0zsRUZlsoxYyMvlB6VQ/s320/Nursing+Diagnosis+and+Nursing+Interventions+for+DHF.jpg" /></a></div>
<b>Dengue Hemorrhagic Fever</b><br />
<br />
Dengue hemorrhagic fever is a severe febrile disease that is often lethal, caused by a virus, characterized by capillary permeability, abnormalities of hemostasis and in severe cases, shock syndrome protein loss. (Nelson, 2000: 1134)<br />
<br />
<b>Symptoms of Dengue Fever</b><br />
<ul>
<li>High fever for 5-7 days.</li>
<li>Nausea, vomiting, no appetite, diarrhea, constipation.</li>
<li>Bleeding, especially bleeding under the skin, ptechie, echymosis, hematoma.</li>
<li>Epistaxis, hematemesis, melena, hematuria.</li>
<li>Muscle pain, joint, abdoment, and heartburn.</li>
<li>Headache.</li>
<li>Swelling around the eyes.</li>
<li>Enlargement of the liver, spleen, and lymph nodes.</li>
<li>Signs of shock (cyanosis, clammy skin, decreased blood pressure, anxiety, capillary refill more than two seconds, rapid and weak pulse).</li>
</ul>
<br />
<b>Nursing Diagnosis and Nursing Intervention for DHF</b><br />
<div>
<b><br />
</b></div>
<div>
<b>1. Imbalanced Body Temperature</b></div>
<div>
<b><br />
</b></div>
<div>
<b>related to :</b></div>
<div>
<b><br />
</b></div>
<div>
<b></b></div>
the disease (viremia)<br />
<br />
<div>
<u>Goal :</u><br />
<div>
<ul>
<li>Normal body temperature (36-37 C).</li>
<li>Patients were free from fever.</li>
</ul>
<br />
<b>Nursing Interventions and Rational for DHF </b>:<br />
<br />
1. Assess the onset of fever.<br />
Rational: to identify patterns of fever patients.<br />
<br />
2. Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.<br />
Rational: vital signs is a reference to determine the patient's general condition.<br />
<br />
3. Instruct patient to drink plenty<br />
Rationale: Increased body temperature resulting in increased evaporation of the body so it needs to be balanced with a lot of fluid intake.<br />
<br />
4. Give a warm compress.<br />
Rational: With vasodilation can increase evaporation which accelerate the decline in body temperature.<br />
<br />
5. Advise not to wear a thick blanket and clothing.<br />
Rational: thin clothing helps reduce the evaporation of the body.<br />
<br />
6. Give intravenous fluid therapy and medications according to physician programs.<br />
Rational: infusion of fluids is very important for patients with a high temperature.</div>
</div>
<br />
<br />
<div>
<b>2. Activity Intolerance</b> </div>
<div>
<br /></div>
<div>
<b>related to</b> </div>
<div>
<br /></div>
<div>
weak body condition<br />
<br />
<u>Goal :</u><br />
<ul>
<li>Patients are able to independently after fever-free.</li>
<li>Activities of daily needs are met</li>
</ul>
<b>Nursing Interventions and Rational for DHF:</b><br />
<br />
1. Assess the patient's complaint.<br />
Rationale: To identify patient's problems.<br />
<br />
2. Review of the things that are not capable or able to be done by the patient.<br />
Rationale: To determine the level of dependency of patients in meeting their needs.<br />
<br />
3. Help the patient to meet their daily activities according to the limitations of the patient.<br />
Rationale: The provision of assistance is needed by the patient at the time his condition is weak and nurses have a responsibility in fulfilling their daily needs without dependence on patient care.<br />
<br />
4. Put the items in places easily accessible by patients.<br />
Rationale: Will assist patients to meet their own needs without help from others.</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-28073158297340043192011-07-22T09:29:00.002-07:002015-09-13T23:15:36.524-07:00Nursing Diagnosis and Nursing Intervention for Meningitis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhC_eZsvSzMM3Eb5VZh2lW3F-4pX9VYNMklKuFXzSiAg-maUFJDNJa9HUR3pDHY5GWOM6TR0_V-WrdQOyNwHSOe6s83CgTcNsYXMNpubrhwBMgeq3DxynPGxgDCfoPyKxqQfL5eUUVpxuo/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Meningitis.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Intervention for Meningitis" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhC_eZsvSzMM3Eb5VZh2lW3F-4pX9VYNMklKuFXzSiAg-maUFJDNJa9HUR3pDHY5GWOM6TR0_V-WrdQOyNwHSOe6s83CgTcNsYXMNpubrhwBMgeq3DxynPGxgDCfoPyKxqQfL5eUUVpxuo/s320/Nursing+Diagnosis+and+Nursing+Intervention+for+Meningitis.jpg" /></a></div>
<b>Meningitis</b> is an inflammation of the protective membranes that envelop the brain and spinal cord, which as a whole is called the meninges. Inflammation can be caused by infection by viruses, bacteria, or other microorganisms as well, and although rarely can be caused by certain medications. Meningitis can cause death due to inflammation that occurs in the brain and spinal cord; so that this condition is classified as a medical emergency.<br />
<br />
Common symptoms of meningitis are headache and stiff neck accompanied by fever, confusion or altered consciousness, vomiting, and sensitivity to light (photophobia) or loud noises (phonophobia). Children usually shows only nonspecific symptoms, such as irritability and drowsiness. Red rash may provide clues to the cause of meningitis; for instance, meningitis caused by meningococcal bacteria may be indicated by a red rash.<br />
<br />
<b>Nursing Diagnosis and Nursing Intervention for Meningitis</b><br />
<br />
<b>1. Acute pain</b><br />
<br />
<b>related to</b><br />
<ul>
<li>infection process</li>
<li>toxin in the circulation</li>
</ul>
<b>Nursing Intervention for Meningitis:</b><br />
<ul>
<li>Place the ice bag on his head, cool clothing above the eyes, provide a comfortable head position a little bit high, range of motion exercises and active or passive masage neck muscles.</li>
<li>Support to find a comfortable position (head rather high-).</li>
<li>Give range of motion exercises active / passive.</li>
<li>Use a warm moisturizer, neck or hip.</li>
</ul>
<div>
<br /></div>
<b>2. Impaired Physical Mobility</b><br />
<br />
<b>related to</b><br />
<ul>
<li>neuromuscular damage.</li>
</ul>
<b>Nursing Intervention for Meningitis:</b><br />
<ul>
<li>Assess the degree of immobilization of the patient.</li>
<li>Assistive range of motion exercises.</li>
<li>Give skin care, massage with moisturizer.</li>
<li>Check the area experiencing tenderness, give air mattresses or water body alignment are functionally notice.</li>
<li>Provide training programs and the use of mobilization.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-31249610384940787882011-07-18T07:52:00.002-07:002015-09-13T23:18:38.477-07:00Nursing Diagnosis and Nursing Intervention for Schizophrenia<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS1OrS3zwtELZsKZSbNPn5xWjwp-It3SLcRoIkIvJdBuGpyvzd7NjGOzG9ZqS6si5IeShmhPsO5Y3WPpTcMsCDjI6tJrk4tj2JDh0ct0Zq-AtzuMySU_yTgolMuAnKJKk7JXO-OnrtPvw/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Schizophrenia.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Intervention for Schizophrenia" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiS1OrS3zwtELZsKZSbNPn5xWjwp-It3SLcRoIkIvJdBuGpyvzd7NjGOzG9ZqS6si5IeShmhPsO5Y3WPpTcMsCDjI6tJrk4tj2JDh0ct0Zq-AtzuMySU_yTgolMuAnKJKk7JXO-OnrtPvw/s320/Nursing+Diagnosis+and+Nursing+Intervention+for+Schizophrenia.jpg" /></a></div>
<b>Schizophrenia</b> is a mental disorder often characterized by abnormal social behavior and failure to recognize what is real. Common symptoms include false beliefs, unclear or confused thinking, auditory hallucinations, reduced social engagement and emotional expression, and lack of motivation. Diagnosis is based on observed behavior and the person's reported experiences.<br />
<br />
<b>Nursing Diagnosis and Nursing Intervention for Schizophrenia</b><br />
<br />
<div>
<b> Impaired Verbal Communication</b> </div>
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
<ul>
<li>changes in thought processes (delusions).</li>
</ul>
<span class="Apple-style-span" style="font-family: Arial, georgia, Verdana, sans-serif; font-size: 13px; line-height: 20px;"><b>Criteria for outcome</b></span><br />
Can Perform verbal communication<br />
<b><br />
</b></div>
<div>
<b>Nursing Intervention for Schizophrenia</b><br />
<ol>
<li>Trusting relationship with clients.</li>
<li>Do not argue and support the client's delusions.<ul>
<li>Tell the nurse received: I accept your beliefs, accompanied by expressions received.</li>
<li>Tell the nurse does not support: conscious for me to trust him with expressions of doubt and empathy.</li>
<li>Not discuss the content of delusional clients.</li>
</ul>
</li>
<li>Make sure clients are safe and protected.<ul>
<li>Use the openness and honesty</li>
<li>Do not leave the client alone</li>
<li>Clients are assured a safe place, not alone.</li>
</ul>
</li>
<li>Clients can identify capabilities that owned<ul>
<li>Give credit to the appearance and the reality of the client's ability.</li>
<li>Discuss with the client's capabilities in the past and present realistic.</li>
<li>Ask what you can do (activities of daily living)</li>
<li>If the client is always talking about delusions, delusions listen to nothing.</li>
</ul>
</li>
<li>Clients can identify unmet needs :<ul>
<li>Observation of the daily needs of clients</li>
<li>Discussion unmet needs of clients both at home during / at the hospital.</li>
<li>Relationship unmet needs and the emergence of delusions.</li>
<li>Increase activities that can meet the needs of the client (the client for scheduled events).</li>
</ul>
</li>
<li>Clients can connect with reality:<ul>
<li>Talking with clients in the context of the reality (other people, places, times)</li>
<li>Include the client in a therapeutic group activity: reality orientation</li>
<li>Give credit to the positive activities undertaken each client.</li>
</ul>
</li>
</ol>
</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-29876558047721273852011-07-08T07:37:00.003-07:002015-09-17T03:38:56.219-07:00Nursing Diagnosis and Nursing Intervention for Angina Pectoris<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHnJS1D4FWF938aLHUMrLZzoZHMurx2eZIHODKbng992yLSADaar-pXMW8-qwDEImjectOvH8Jc5ZiXL7envcWzSuHeF15VU70cyZ9l2ZP5EsakCiYGOlc-BCKbGFnvslx6Ehwxzuldhg/s1600/Nursing-Diagnosis-and-Nursing-Intervention-for-Angina-Pectoris.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Intervention for Angina Pectoris" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHnJS1D4FWF938aLHUMrLZzoZHMurx2eZIHODKbng992yLSADaar-pXMW8-qwDEImjectOvH8Jc5ZiXL7envcWzSuHeF15VU70cyZ9l2ZP5EsakCiYGOlc-BCKbGFnvslx6Ehwxzuldhg/s320/Nursing-Diagnosis-and-Nursing-Intervention-for-Angina-Pectoris.jpg" /></a></div>
Angina pectoris is the sensation of chest pain, pressure, or squeezing, often due to ischemia of the heart muscle from obstruction or spasm of the coronary arteries.<br />
<br />
Angina pectoris is the medical term for chest pain or discomfort due to coronary heart disease. It occurs when the heart muscle doesn't get as much blood as it needs. This usually happens because one or more of the heart's arteries is narrowed or blocked, also called ischemia.<br />
<br />
Angina often occurs when the heart muscle itself needs more blood than it is getting, for example, during times of physical activity or strong emotions. Severely narrowed arteries may allow enough blood to reach the heart when the demand for oxygen is low, such as when you're sitting. But, with physical exertion—like walking up a hill or climbing stairs—the heart works harder and needs more oxygen.<br />
<br />
<br />
<span style="font-weight: bold;">Nursing Diagnosis and Nursing Intervention for Angina Pectoris</span><br />
<br />
<div>
<b>Decreased Cardiac Output</b> </div>
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
<ul>
<li>Inotropic changes, such as transient or prolonged myocardial ischemia and effects of medications; </li>
<li>alterations in rate, rhythm, and electrical conduction.</li>
</ul>
<span class="Apple-style-span" style="font-size: 13px; line-height: 20px;"><b>Criteria for outcome</b></span></div>
<div>
<ul>
<li>Cardiac Pump Effectiveness</li>
<li>Demonstrate increased activity tolerance.</li>
<li>Report or display decreased episodes of dyspnea, angina, and dysrhythmias.</li>
<li>Participate in behaviors and activities that reduce the workload of the heart.</li>
</ul>
</div>
<br />
<span style="font-weight: bold;">Nursing Intervention for Angina Pectoris</span><br />
<ol>
<li>Monitor vital signs, eg heart rate, blood pressure.<br />
Rationale: Tachycardia can occur because of pain, anxiety, hypoxemia, and decreased cardiac output. Changes also occur in blood pressure (hypertension or hypotension) due to cardiovascular response.</li>
<li>Record the color and the presence / quality of the pulse.<br />
Rationale: decreased peripheral circulation when cardiac output falls, making skin color pale or gray (depending on the level of hypoxia) and decreased strength of peripheral pulses.</li>
<li>Maintain bed rest in a comfortable position during the acute episode.<br />
Rationale: Lowering the oxygen consumption / demand, lowering employment and risk of myocardial decompensation.</li>
<li>Provide supplemental oxygen as needed<br />
Rationale: Increase the supply of oxygen to the need to improve myocardial contractility, decrease ischemia, and lactic acid levels.</li>
</ol>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-14906824109058773362011-07-08T07:06:00.005-07:002015-09-17T03:44:13.887-07:00Nursing Diagnosis and Nursing Intervention for Sepsis<span class="Apple-style-span"><span style="font-weight: bold;"><a href="http://nursingdiagnosis-nursinginterventions.blogspot.com/2011/07/nursing-diagnosis-and-nursing_08.html">Nursing Diagnosis and Nursing Intervention for Sepsis</a></span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr_7nidhyphenhyphenskoGR0PsZgt7bq6unkCoriTR2o4cd8_IBHzZMLXBOvibGLA66H7VY6hXdmstZlyxFrKXC2ATDwLDHwZZKsuBmaLx3eSQ6i8jmdBuE4bdRinW7Y3wc1G5VZVdQ7EAV9fxMN9c/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Sepsis.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr_7nidhyphenhyphenskoGR0PsZgt7bq6unkCoriTR2o4cd8_IBHzZMLXBOvibGLA66H7VY6hXdmstZlyxFrKXC2ATDwLDHwZZKsuBmaLx3eSQ6i8jmdBuE4bdRinW7Y3wc1G5VZVdQ7EAV9fxMN9c/s320/Nursing+Diagnosis+and+Nursing+Intervention+for+Sepsis.jpg" /></a></div>
<b>Risk for Infection</b><br />
<br />
Nursing Intervention for Sepsis<br />
<br />
1. Examine client for possible source of infection, such as sore throat, sinus pain, burning with urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive catheters, or lines. Rationale: Respiratory tract and urinary tract infection are the most frequent causes of sepsis, followed by abdominal and soft tissue infections. The use of intravascular devices is also a well-known cause of hospital-acquired sepsis.<br />
<br />
2. Investigate reports of pain out of proportion to visible signs.<br />
Rationale: Pressurelike pain over area of cellulitis may indicate development of necrotizing fasciitis due to group A beta hemolytic streptococci (GABS), necessitating prompt intervention.<br />
<br />
3. Maintain sterile technique when changing dressings, suctioning, and providing site care, such as an invasive line or a urinary catheter. Rationale: Medical asepsis prevents or limits introduction of bacteria and reduces the risk of nosocomial infection.<br />
<br />
4. Wash hands with antibacterial soap before and after each care activity, even when gloves are used.<br />
Rationale: Hand washing and hand hygiene reduce the risk of crosscontamination. Note: Methicillin-resistant Staphylococcus aureus (MRSA) is most commonly transmitted via direct contact with healthcare workers who fail to wash hands between client contacts.<br />
<br />
5. Encourage client to cover mouth and nose with tissue when coughing or sneezing. Place in private room if indicated. Wear mask when providing direct care as appropriate. Rationale: Appropriate behaviors, personal protective equipment, and isolation prevent spread of infection via airborne droplets.<br />
<br />
6. Encourage or provide frequent position changes, deep-breathing, and coughing exercises.<br />
Rationale: Good pulmonary toilet may reduce respiratory compromise.<br />
<br />
7. Provide isolation and monitor visitors, as indicated.<br />
Rationale: BSI should be used for all infectious clients. Wound and linen isolation and hand washing may be all that is required for draining wounds. Clients with diseases transmitted through air may also need airborne and droplet precautions. Reverse isolation and restriction of visitors may be needed to protect the immunosuppressed client.<br />
<br />
<br />
8. Limit use of invasive devices and procedures when possible. Remove lines and devices when infection is present and replace if necessary.<br />
Rationale: Reduces number of possible entry sites for opportunistic organisms.<br />
<br />
9. Inspect wounds and sites of invasive devices daily, paying particular attention to parenteral nutrition lines. Document signs of local inflammation and infection and changes in character of wound drainage, sputum, or urine.<br />
Rationale: Catheter-related bloodstream infections (CR-BSIs) are increasing where central venous catheters are used in both acute and chronic care settings. Clinical signs, such as local inflammation or phlebitis, may provide a clue to portal of entry, type of primary infecting organism(s), as well as early identification of secondary infections.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-55591563378035343222011-07-06T23:31:00.001-07:002015-09-17T03:48:21.560-07:00Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbrwe3uz2EyTTeJ0kCgde8ZtTg8OzV2puPNN1Ce13QHFzPK4lDlW0Rl6F11Cj5AbZXxZtfhnjydA_44sFQnZhHQEcSJJoxvaB1vClH9W8HzGOmljjCt5xQ9RptLdtqULI7Ho2xE3r_0r0/s1600/Nursing-Diagnosis-and-Nursing-Intervention-for-Cesarean-Section-Postoperative.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="258" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbrwe3uz2EyTTeJ0kCgde8ZtTg8OzV2puPNN1Ce13QHFzPK4lDlW0Rl6F11Cj5AbZXxZtfhnjydA_44sFQnZhHQEcSJJoxvaB1vClH9W8HzGOmljjCt5xQ9RptLdtqULI7Ho2xE3r_0r0/s320/Nursing-Diagnosis-and-Nursing-Intervention-for-Cesarean-Section-Postoperative.jpg" width="320" /></a></div>
A Caesarian section is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies.<br />
<br />
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><span style="font-weight: bold;">Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative</span><br />
<b> </b></span><br />
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><b>1. Risk for infection</b></span><br />
<div>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><br />
</span></div>
<div>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><b>Related to :</b></span></div>
<div>
<ul>
<li><span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;">bleeding,</span></li>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;">
<li>postoperative wound</li>
</span></ul>
</div>
<div>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"> </span> <span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><u>Goal :</u></span><br />
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;">There were no infections, bleeding and wounds, after surgery.</span><br />
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><br />
</span> <span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><b>Nursing Intervention for Cesarean Section Postoperative</b></span><br />
<ol>
<li><span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;">Assess the condition of output / dischart out; number, color, and odor from the operation wound.<br />
R / recording the changes in output. The existence of a darker color with a bad smell may be a sign of infection.</span></li>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;">
<li>Tell the client the importance of wound care during the postoperative period.<br />
R / Infection can arise from lack of cleanliness of the wound.</li>
<li>Have a general culture in the output.<br />
R / Various bacteria can be identified through the output.</li>
<li>Perform wound care.<br />
R / Incubation germs in the wound area can cause infection.</li>
<li>Tell the client how to identify signs of infection.<br />
R / Various clinical manifestations can be nonspecific sign of infection, fever and increased pain may be symptoms of infection.</li>
</span></ol>
</div>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><br />
<span style="font-family: 'trebuchet ms';">2. </span><b>Acute Pain</b></span><br />
<div>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><br />
</span></div>
<div>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><b>Related to</b></span></div>
<ul>
<li><span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;">postoperative wound</span></li>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"> </span></ul>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"><u>Goal :</u><br />
Pain is reduced / no pain<br />
<br />
<b>Nursing Intervention for Cesarean Section Postoperative</b><br />
</span><br />
<ol><span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;">
<li>Assess the condition of pain experienced by the client.<br />
R / Measurement of the level of pain can be performed with pain scales.</li>
<li>Tell the client suffered pain and its causes.<br />
R / Improving coping clients, in dealing with pain.></li>
<div>
<br />
<li>Teach relaxation techniques.<br />
R / Reduced perception of pain.</li>
</div>
<div>
<br />
<li>Collaboration of analgesics.<br />
R / Reduced pain can be done by giving oral or systemic analgesics, in a broad spectrum / specific.</li>
</div>
</span></ol>
<span class="Apple-style-span" style="font-family: 'trebuchet ms'; font-size: 13px; line-height: 16px;"> </span>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-6292851764795572832011-07-05T05:37:00.002-07:002015-09-17T03:54:16.925-07:00Nursing Diagnosis and Nursing Intervention for Hepatitis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg957VXS7YoLvA5m7iT3oZhzD_m3MArrFia6glExB-uWf26xIOgFZy82ZzaXnRaFmb2hUgjg_N_tMdYqDK2cKGZVYPaNaxWr3ScIy3F2By7qp8-GfH4C4kn_h2a5MjA41nkp3fdlwjCfrE/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Hepatitis.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg957VXS7YoLvA5m7iT3oZhzD_m3MArrFia6glExB-uWf26xIOgFZy82ZzaXnRaFmb2hUgjg_N_tMdYqDK2cKGZVYPaNaxWr3ScIy3F2By7qp8-GfH4C4kn_h2a5MjA41nkp3fdlwjCfrE/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Hepatitis.jpg" /></a></div>
Hepatitis is a medical condition defined by the inflammation of the liver and characterized by the presence of inflammatory cells in the tissue of the organ.<br />
<br />
Causes<br />
<ul>
<li>Immune cells in the body attacking the liver.</li>
<li>Infections from viruses (such as hepatitis A, hepatitis B, or hepatitis C), bacteria, or parasites.</li>
<li>Liver damage from alcohol or poison.</li>
<li>Medicines, such as an overdose of acetaminophen.</li>
</ul>
Symptoms <br />
<ul>
<li>Jaundice (yellowing of the skin or eyes)</li>
<li>Fatigue</li>
<li>Dark urine and pale or clay-colored stools</li>
<li>Loss of appetite</li>
<li>Pain or bloating in the belly area</li>
<li>Nausea and vomiting</li>
<li>Low fever</li>
<li>Itching </li>
<li>Weight loss</li>
</ul>
<br />
<span style="font-weight: bold;">Nursing Diagnosis and Nursing Intervention for Hepatitis</span><br />
<br />
1. <b>Acute Pain</b> : abdominal <br />
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
<ul>
<li>tender </li>
<li>enlarged liver</li>
</ul>
</div>
<div>
<br /></div>
<div>
<b>Expected outcome</b><br />
Report a decrease or absence of abdominal pain and tenderness;restrict activities if pain occurs;participates in planned activities when free of pain; take prescribed analgesic if necessary.<br />
<br /></div>
<div>
<b>Nursing Intervention for Hepatitis</b><br />
<ul>
<li>Asses and record presence or absence of abdominal pain or tenderness, hepatomegally and splenomegally.</li>
<li>Encourage the patient to maintain bedrest or restrict activities if abdominal pain or tenderness is present.</li>
<li>Administer analgesic as prescribed.</li>
<li>Notify the physian of sudden occuraence or increase in pain or tenderness.</li>
</ul>
</div>
<br />
<br />
<b>2. Activity Intolerance</b> <br />
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
<ul>
<li>fatigue </li>
<li>generalized malaise.</li>
</ul>
</div>
<div>
<b>Expected outcome</b><br />
Exhibits increased ability to carry out desired activities and allow sufficient periods for rest and relaxation.<br />
<br /></div>
<div>
<b>Nursing Intervention for Hepatitis</b><br />
<ul>
<li>Encourage the patient to limit activity when fatigue</li>
<li>Assist the patient in planning periods of rest and activity when symptoms begin to subside.</li>
<li>Encourage gradual resumption of activities and mild excercise during recovery.</li>
</ul>
</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-5799423089138423602011-07-03T18:59:00.003-07:002015-09-17T04:00:54.917-07:00Nursing Diagnosis and Nursing Intervention for Dengue Fever<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgb_v_N7U7rF5W8PBRKJQ7nbpBlTBSsXXfPC3Ay0sEfaE3PiFzAKbDhvF_6dy6vt3qNAk3fDlI7tZbF3BpH-ZKxaWn5gaop8AyVJC-Elc6BNGmicNiejhrn5JG2DH44n9LJm64j6BTo2Y/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Dengue+Fever.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="170" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgb_v_N7U7rF5W8PBRKJQ7nbpBlTBSsXXfPC3Ay0sEfaE3PiFzAKbDhvF_6dy6vt3qNAk3fDlI7tZbF3BpH-ZKxaWn5gaop8AyVJC-Elc6BNGmicNiejhrn5JG2DH44n9LJm64j6BTo2Y/s320/Nursing+Diagnosis+and+Nursing+Intervention+for+Dengue+Fever.jpg" width="320" /></a></div>
Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles.<br />
<br />
Dengue is transmitted by several species of mosquito within the genus Aedes, principally A. aegypti. <br />
<br />
Symptoms<br />
<ul>
<li>Sudden, high fever</li>
<li>Fatigue</li>
<li>Nausea</li>
<li>Vomiting</li>
<li>Severe joint and muscle pain</li>
<li>Severe headaches</li>
<li>Pain behind the eyes </li>
<li>Skin rash, which appears two to five days after the onset of fever</li>
<li>Mild bleeding (such a nose bleed, bleeding gums, or easy bruising)</li>
</ul>
<br />
<b>Nursing Diagnosis and Nursing Intervention for Dengue Fever</b><br />
<br />
1. <span class="Apple-style-span" style="font-family: arial, sans-serif; line-height: 16px;"><i style="font-style: normal; font-weight: bold;"><span class="Apple-style-span">Deficient Fluid volume</span></i></span> : less than body requirements related to increased capillary permeability, bleeding, vomiting and fever.<br />
<br />
<b>Goal:</b><br />
<ul>
<li>Body fluid volume adequat</li>
</ul>
<b>Expected outcomes:</b><br />
<ul>
<li>Body fluid volume returned to normal</li>
</ul>
<b>Nursing Intervention for Dengue Fever</b><br />
<ul>
<li>Assess the general state and condition of the patient</li>
<li>Observation of vital signs (temperature, pulse, respiratory rate)</li>
<li>Observation for signs of dehydration</li>
<li>Observation drip infusion and intravenous needle insertion site</li>
<li>Balance of fluid (the fluid input and out put)</li>
<li>Give the patient and family encourage patients to drink a lot</li>
<li>Instruct the patient's family to replace the patient's clothing is wet with sweat.</li>
</ul>
<br />
2. <span style="font-weight: bold;">Hyperthermia</span><br />
<div>
<br />
<span style="font-weight: bold;">Related to</span><br />
<ul>
<li>dengue virus infection process</li>
</ul>
<b>Goal :</b><br />
<ul>
<li>Hypertermia can be resolved</li>
</ul>
</div>
<div>
<b>Expected outcomes</b><br />
<ul>
<li>Body temperature returned to normal</li>
</ul>
<b>Nursing Intervention for Dengue Fever</b><br />
<ul>
<li>Observation of vital signs, especially temperature</li>
<li>Give a cold compress (plain water) on the forehead and armpits</li>
<li>Change clothes soaked with sweat</li>
<li>Encourage the family to put on clothing that can absorb sweat like cotton.</li>
<li>Encourage the family to provide drinking lots of approximately 1500 to 2000 cc per day.</li>
<li>Collaboration with doctors in the provision Therapy, febrifuge.</li>
</ul>
</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-77410530719613311562011-07-03T17:52:00.002-07:002015-09-18T19:00:32.807-07:00Nursing Diagnosis and Nursing Intervention for Typhoid Fever<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghATMyfnhmlUiVDmN9Nwwg6_CMwYbn23VZbdeUmEZQiR-sGFyuIXRd-WGFxuqbf4Bxa_KHJ61dXQyklHoegdowAKsrPhmV23YgvCZLYKc0oUo-zaY_LDVSpN00ePrwF73z7rq3Qp7dffM/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Typhoid+Fever.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghATMyfnhmlUiVDmN9Nwwg6_CMwYbn23VZbdeUmEZQiR-sGFyuIXRd-WGFxuqbf4Bxa_KHJ61dXQyklHoegdowAKsrPhmV23YgvCZLYKc0oUo-zaY_LDVSpN00ePrwF73z7rq3Qp7dffM/s1600/Nursing+Diagnosis+and+Nursing+Intervention+for+Typhoid+Fever.jpg" /></a></div>
Typhoid fever is a bacterial infection of the intestinal tract and occasionally the bloodstream. It is most commonly due to a type of bacterium called Salmonella typhi ( S. typhi ). <br />
<br />
Anyone can get typhoid fever but the greatest risk exists to travelers visiting countries where the disease is common. Occasionally, local cases can be traced to exposure to a person who is a chronic carrier. Outbreaks are rare.<br />
<br />
Early symptoms include fever, general ill-feeling, and abdominal pain. High fever (103°F, or 39.5°C) or higher and severe diarrhea occur as the disease gets worse.<br />
<br />
Other symptoms :<br />
<ul>
<li>Abdominal tenderness</li>
<li>Weakness </li>
<li>Chills</li>
<li>Agitation</li>
<li>Bloody stools</li>
<li>Severe fatigue</li>
<li>Confusion</li>
<li>Difficulty paying attention (attention deficit)</li>
<li>Delirium</li>
<li>Fluctuating mood</li>
<li>Hallucinations</li>
<li>Nosebleeds</li>
<li>Slow, sluggish, lethargic feeling</li>
</ul>
<br />
<div>
<br />
<div>
<b>Nursing Diagnosis and Nursing Intervention for Typhoid Fever</b></div>
</div>
<br />
<br />
<b>1. Hyperthermia </b><br />
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
<ul>
<li>salmonella thypi infection process</li>
</ul>
<b>Goal: </b><br />
<br />
Hyperthermia is resolved<br />
<br />
<b>Expected outcomes</b><br />
<ul>
<li>Temperature, pulse and respiration within normal limits, free from cold and no complications associated with typhoid problem. </li>
</ul>
<br />
<b>Nursing Intervention for Typhoid Fever</b><br />
<ul>
<li>Observation of the client's body temperature, </li>
<li>encourage families to limit the activities of the client, </li>
<li>give compress with cold water (plain water) in axila area, groin, temporal when heat, </li>
<li>encourage families to put on clothing that can absorb sweat like cotton, </li>
<li>collaboration with doctors in the provision of anti piretik. </li>
</ul>
<br />
<span class="Apple-style-span" style="font-weight: bold;"><br />
</span></div>
<div>
<span class="Apple-style-span" style="font-family: arial, 'times New Roman', helvetica; font-size: 14px; line-height: 22px;"><b>2. Risk for Imbalanced Nutrition: Less than body requirements</b></span> </div>
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
<ul>
<li>inadequate intake </li>
</ul>
<br />
<b>Goal :</b><br />
<ul>
<li>adequate nutrition</li>
</ul>
<b>Expected outcomes </b><br />
<ul>
<li>Appetite increased, </li>
<li>indicating stable weight / ideal, </li>
<li>the value of bowel / intestinal peristalsis normal, </li>
<li>normal laboratory values,</li>
<li>conjunctiva and mucous membranes are not pale lips.</li>
</ul>
</div>
<div>
<br />
<b>Nursing Intervention for Typhoid Fever</b><br />
<ul>
<li>Assess client's nutritional patterns,</li>
<li>review of eating in the client likes and dislikes,</li>
<li>recommend bed rest / activity restrictions during the acute phase, balanced body weight each day.</li>
<li>Encourage clients to eat little but often,</li>
<li>record or report such things as nausea, vomiting, stomach pain and distension,</li>
<li>collaboration with a nutritionist for dietary administration,</li>
<li>collaboration in laboratory tests such as hemoglobin, hematocrit and albumin,</li>
<li>collaboration with physicians in the provision of anti-emetics such as (ranitidine).</li>
</ul>
</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-51103894408847658752011-06-30T12:03:00.002-07:002015-09-18T19:09:21.260-07:00Nursing Diagnosis and Nursing Intervention for Marasmus<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQvn9RgbQQZZO7igrTaYnUTC9juBNNGqkZlpdg9QiwOJbqyASLsnWqSon_-w6THeuino4OwtZgv4WgE5EdbXd2XNNL58Y6ZiDtQ78JUwRtEi1uSnJVBv6ilp67TFAlinY1AKL4Dfkv9ds/s1600/Nursing-Diagnosis-and-Nursing-Intervention-for-Marasmus.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Diagnosis and Nursing Intervention for Marasmus" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQvn9RgbQQZZO7igrTaYnUTC9juBNNGqkZlpdg9QiwOJbqyASLsnWqSon_-w6THeuino4OwtZgv4WgE5EdbXd2XNNL58Y6ZiDtQ78JUwRtEi1uSnJVBv6ilp67TFAlinY1AKL4Dfkv9ds/s1600/Nursing-Diagnosis-and-Nursing-Intervention-for-Marasmus.jpg" /></a></div>
Marasmus is a form of severe malnutrition characterized by energy deficiency. Marasmus occurrence increases prior to age 1. Marasmus is one of the gravest types of protein-energy malnutrition in the world. Characterized by chronic wasting of fat, muscle, and other body tissues. Body weight is reduced to less than 60% of the normal (expected) body weight for the age. <br />
<br />
Symptoms can be rather severe:<br />
<ul>
<li>Chronic, persistent diarrhea.</li>
<li>Tiredness.</li>
<li>Faintness.</li>
<li>Inexplicable loss of weight.</li>
</ul>
Symptoms of marasmus that point towards a serious problem include:<br />
<ul>
<li>An alteration in the level of consciousness; lassitude and sluggishness; giddiness.</li>
<li>Complete or partial paralysis of the legs.</li>
<li>Loss of bowel / bladder control.</li>
<li>Long drawn out periods of diarrhea and vomiting.</li>
</ul>
<br />
<b>Nursing Diagnosis and Nursing Intervention for Marasmus</b><br />
<br />
<div>
<b>1. Imbalanced Nutrition : Less Than Body Requirements</b> </div>
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
inadequate food intake (appetite).<br />
<br />
<b>Goal:</b><br />
Patients receive adequate nutrition<br />
<br />
<b>Expected outcomes:</b><br />
improving oral inputs.<br />
<br />
<b>Nursing Intervention for Marasmus</b><br />
<ul>
<li>Get a diet history</li>
<li>Encourage parents or other family members for feeding the child or there while eating</li>
<li>Ask the children to eat over the kitchen, in a group and make mealtime a pleasant</li>
<li>Use a familiar cutlery</li>
<li>Nurses should be there at mealtime to provide assistance, prevent disruption, and praised the child to eat them</li>
<li>Serve eat little but often</li>
<li>Serve small portions of food and give each portion separately</li>
</ul>
<div>
<br /></div>
<b>2. Deficit Fluid Volume </b></div>
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
diarrhea<br />
<br />
<b>Goal:</b><br />
Prevent dehydration<br />
<br />
<b>Expected outcomes:</b><br />
<ul>
<li>Lip mucosa moist,</li>
<li>there was no increase in temperature,</li>
<li>good skin turgor.</li>
</ul>
<br />
<b>Nursing Intervention for Marasmus</b><br />
<ul>
<li>Monitor vital signs and signs of dehydration</li>
<li>Monitor the number and type of fluid intake</li>
<li>Measure urine output accurately</li>
</ul>
</div>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-8367171487010852590.post-23566873300163833122011-06-30T11:48:00.003-07:002015-09-18T19:15:17.473-07:00Nursing Diagnosis and Nursing Intervention for Atrial Septal Defect<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhvQc6bTLj_A0C1ILKVlrDF8z7nLyPOH7drLQeAA6bpH6wCyZhJ5O7bdMwcpjQtYBnea7sMUVxBXuEvB2TBmKQNyzL2D-5qQkE53H9Be8iRKeI7-xvqW-eBjobnGhzNxNzGYtvojHMOm0M/s1600/Nursing-Diagnosis-and-Nursing-Intervention-for-Atrial-Septal-Defect.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhvQc6bTLj_A0C1ILKVlrDF8z7nLyPOH7drLQeAA6bpH6wCyZhJ5O7bdMwcpjQtYBnea7sMUVxBXuEvB2TBmKQNyzL2D-5qQkE53H9Be8iRKeI7-xvqW-eBjobnGhzNxNzGYtvojHMOm0M/s1600/Nursing-Diagnosis-and-Nursing-Intervention-for-Atrial-Septal-Defect.jpg" /></a></div>
Atrial septal defect (ASD) is a congenital heart defect in which blood flows between the atria (upper chambers) of the heart. As a baby develops in the womb, a wall (called the interatrial septum) forms that divides the upper chamber into a left and right atrium. An abnormal formation of this wall can result in a hole that remains after birth. This is called an atrial septal defect, or ASD. Normally, the atria are separated by a dividing wall, the interatrial septum. <br />
<br />
<br />
Symptoms that do occur may begin at any time after birth through childhood.<br />
<ul>
<li>Difficulty breathing (dyspnea)</li>
<li>Frequent respiratory infections in children</li>
<li>Feeling the heart beat (palpitations) in adults</li>
<li>Shortness of breath with activity </li>
</ul>
<br />
Possible Complications<br />
<ul>
<li>Arrhythmias, particularly atrial fibrillation</li>
<li>Heart failure</li>
<li>Heart infections (endocarditis)</li>
<li>High blood pressure in the arteries of the lungs (pulmonary hypertension )</li>
<li>Stroke</li>
</ul>
<br />
<b>Nursing Diagnosis and Nursing Intervention for Atrial Septal Defect</b><br />
<br />
<div>
<b>1. Risk for Decreased Cardiac Output</b> </div>
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
<br /></div>
<div>
defect structure<br />
<br />
<b>Goal:</b><br />
The client will demonstrate improved cardiac output.<br />
<br />
<b>Expected outcomes:</b><br />
<ul>
<li>Heart frequency, blood pressure, and peripheral perfusion are at the normal age-appropriate.</li>
<li>Adequate urine output (between 0.5 to 2 ml / kg, depending on age)</li>
</ul>
<b>Nursing Intervention for Atrial Septal Defect</b><br />
<ul>
<li>Give medication according to the program, using the precautions designed to prevent toxisitas.</li>
<li>Give afterload-lowering drugs according to program</li>
<li>Give diuretics according to courses</li>
</ul>
<div>
<br /></div>
<b>2. Risk for Infection</b> </div>
<div>
<br /></div>
<div>
<b>Related to</b> </div>
<div>
weakness physical status<br />
<br />
<b>Goal:</b><br />
Clients do not show evidence of infection<br />
<br />
<b>Expected outcomes:</b><br />
Children are free from infection.<br />
<br />
<b>Nursing Intervention for Atrial Septal Defect</b><br />
<ul>
<li>Avoid contact with infected individuals</li>
<li>Give adequate rest</li>
<li>Give optimal nutrition to support the body's natural defenses.</li>
</ul>
</div>
Unknownnoreply@blogger.com