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Sunday, July 27, 2014

Nursing Management of Constipation

Examination begins with inspection of the abdominal area is there any enlargement of the abdomen, stretch or bulge. Further palpation on the surface of the abdomen to assess the strength of the abdominal muscles. Palpation over the faecal mass can be felt in the colon, the presence of a tumor or aneurysm of the aorta. On percussion, among others sought excessive gas gathering, organ enlargement, asietes, or the presence of faecal mass. Auscultation, among others, to listen to the sound of bowel movements, normal or excessive intestinal example on the bridge. Examination of the anal region provide an important clue, for example, is there any hemorrhoids, prolapse, fissures, fistulas, and tumor mass in the anal area can interfere with the process of defecation.

Digital rectal examination should be done, among others, to determine the size and condition of the rectum and the amount and consistency of stool.

Digital rectal can provide information about:
  • Rectal tone.
  • Sphincter tone and strength.
  • Pubo-rectal muscle strength and pelvic floor muscles.
  • Is there a mass pile of feces ?
  • Is there another mass (eg haemorrhoids) ?
  • Is there blood ?
  • Are there injury in the anus ?
Physical examination of constipation, most of the abnormalities found are not clear. However, careful examination and thorough needed to find abnormalities that could potentially affect the function of the colon in particular. Beginning with an examination of the oral cavity include gears, oral mucous membrane lesions and tumors that can disrupt a sense of taste and ingestion.

Laboratory tests associated with efforts to detect risk factors cause constipation, such as blood glucose, thyroid hormone levels, electrolytes, anemia associated with bleeding from the rectum, and so on. Other procedures such as anoscopy done routinely recommended in all patients with constipation to find there any fissures, ulcers, haemorrhoids and malignancy.

Abdominal plain radiography should be performed in patients with constipation, especially the occurrence of acute. This examination can detect there a fecal impaction and hard fecal masses that can cause blockage and perforation of the colon. If there were an estimated colonic obstruction, can be followed by barium enema to ensure a place and nature of the obstruction. Intensive examination is done selectively after 3-6 months of treatment of constipation is less successful and performed only at centers managing certain constipation.

Many kinds of drugs that are marketed for constipation, stimulating efforts to provide symptomatic treatment. Meanwhile, when possible, treatment should be directed at the cause of constipation. Long-term use of laxatives that are primarily stimulates intestinal peristalsis, should be limited. Treatment strategy is divided into:

1. Non-pharmacological treatment

Exercise colon: colon train is a suggested form of exercise behavior in patients with otherwise unexplained constipation. Patients are encouraged to hold a regular time each day to take advantage of large bowel movement. The recommended time is 5-10 minutes after eating, so it can take advantage of the gastro-colonic reflex to defecate. It is expected that this habit can cause sufferers to respond to the signs and induce bowel movements, and do not resist or postpone the urge to defecate.

Diet: The role of diet is important for constipation, especially in the elderly group. Epidemiological data indicate that a diet containing plenty of fiber reduces the incidence of constipation and various other gastrointestinal diseases, such as colorectal cancer and diverticular. Fiber increases stool weight and mass and shorten transit time in the gut. To support the benefits of fiber, adequate fluid intake is expected around 6-8 glasses a day, if there are no contraindications for fluid intake.

Sports: Pretty in activities or mobility and exercise help overcome constipation, walk or jog conducted in accordance with the age and ability of the patient, will invigorate the circulation and to strengthen the abdominal muscles of the abdominal wall, especially in patients with atony on the abdominal muscles .


2 Pharmacologic Treatment

If less successful behavior modification, pharmacological therapy is added, and is usually used class of laxative drugs. There are 4 types of laxative drug classes:

Enlarge and soften the stool mass.
Soften and lubricate the stool, this medicine works by lowering the surface tension of the stool, making it easier for water absorption.
Osmotic classes that are not absorbed, so it is quite safe to use, for example in patients with renal failure.
Stimulates peristalsis, thereby increasing the motility of the colon. This group is widely used. It should be noted that this class of laxatives can be used for long-term, can result in plexus mesentericus damage and colonic dysmotility.

When encountered severe chronic constipation and can not be solved by means of the above, surgery may be needed. Pasa generally, if not found a blockage due to the presence of a mass or volvulus, surgery was not performed.
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Saturday, July 26, 2014

Risk for Decreased Cardiac Output - NCP Acute Myocardial Infarction (STEMI)

Nursing Care Plan for AMI with ST elevation (STEMI)

Definition

Acute myocardial infarction is the destruction of tissue due to inadequate blood supply so that coronary blood flow is reduced. (Brunner & Suddath, 2002)

Acute myocardial infarction is the death of myocardial tissue caused by myocardial coronary blood damage, due to the inadequate blood flow. (Carpenito, 2000)

Acute myocardial infarction is ischemia or necrosis of the heart muscle caused by decreased blood flow through one or more coronary arteries. (Doengos, 2000)


Etiology

According to Noer, 1999; 103 caused by

a. Causal factors:

1. Oxygen supply to the heart is reduced due to:
a. Vascular factors: Atherosclerosis, spasm, arteritis.
b. Circulation Factor: hypotension, aortic stenosis, insufficiency.
c. Blood factors: anemia, hypoxemia, polycythemia.

2 Cardiac output increased
For example: Activity, emotional, eating too much, anemia, hyperthyroidism.

3. Increased myocardial oxygen demand at:
Myocardial damage, myocardial hypertrophy, diastolic hypertension.


b. Predisposing factors
1 Biological factors that can not be changed:
a. Age over 40 years.
b. Gender. The incidence is higher in men, whereas in women increases after menopause.
c. Heredity.
d. Race.

2 Risk factors that can be changed
a. Major; Hyperlipidemia, hypertension, heavy smoking, diabetes, obesity, a diet high in saturated fat.
b. Minor; physical activity, pattern type A personality (emotional, aggressive, ambitious, competitive).


Clinical Manifestations

Acute myocardial infarction usually occurs in men over 40 years and having artheriosklerosis. In the coronary vessels and is often accompanied by arterial hypertension. The attack also occurs in women and young men, early 30s or even 20s. Women who use the contraceptive pill and smoke have a very high risk. However, the overall incidence of myocardial infarction in men is higher than women at all ages.

Chest pain that lasted all of a sudden and continuous, located at the bottom of the sternum and upper abdomen is the main symptom that usually appears. Pain will be felt increasingly heavy can spread to the shoulder and arm, usually the left arm. Unlike the pain of angina pain arises spontaneously (not after heavy work or emotional disorders) and persist for several hours to several days and will not go away with rest or nitroglycerin. In some cases the pain may spread to the chin and neck, pain is often accompanied by shortness of breath, pallor, cold sweats, dizziness, light-headedness, nausea, vomiting (Brunner & Suddarth, 2002)


Pathogenesis

AMI with ST elevation (STEMI) usually occurs when coronary blood flow decreased abruptly after occlusion of thrombus on atherosclerotic plaque that already exists. STEMI occurs when a coronary artery thrombus occurs rapidly at the site of vascular injury, where the injury is triggered by factors such as smoking, hypertension, and lipid accumulation. In STEMI classical pathological picture consists of rich red fibrin thrombus, which is believed to be the basis of so STEMI respond to thrombolytic therapy. Furthermore, the location of plaque rupture, various agonists (collagen, ADP, epinephrine, serotonin) triggers platelet activity, which in turn will produce and release thromboxane A2 (potent vasoconstrictor local). In addition, platelet activation triggers a conformational change in the receptor glycoprotein IIb / IIIa. After experiencing a conversion function, the receptor has a high affinity for the amino acid sequence in soluble adhesion proteins (integrins) such as von Willebrand factor (vWF) and fibrinogen, both of which are multivalent molecules that can bind to two different platelets simultaneously, resulting in crosslinking of platelets and aggregation.

Coagulation cascade is activated by exposure of tissue factor on endothelial cells are damaged. Factor VII and X are activated, resulting in the conversion of prothrombin into thrombin, which then converts fibrinogen into fibrin. The coronary arteries are involved then will experience the occlusion by thrombus composed of platelets and fibrin aggregates. On rare occasions, STEMI may also be caused by occlusion of the coronary arteries caused by coronary embolism, congenital abnormalities, coronary spasm and systemic inflammatory diseases.



Nursing Care Plan for Acute Myocardial Infarction with ST Elevation (STEMI)

Nursing Diagnosis : Risk for Decreased Cardiac Output related to decreased constriction ventricular function, cardiac muscle degeneration.

Outcomes:
  • Lowering episodes of dyspnea, angina, and dysrhythmias.
  • Identify the behavior to decrease the heart's workload.

Nursing Interventions:

Independent

1. Monitor cardiac rhythm and frequency.
R /: Tachycardia and cardiac dysrhythmias may occur when attempting to increase cardiac output responds to fever. Hypoxia and acidosis due to ischemia.

2 Auscultation of heart sounds. Note the distance / tone heart, murmurs, S3 and S4 gallops.
R /: To provide early detection of complications such as CHF, cardiac tamponade.

3 Encourage bed rest in a semi-Fowler's position.
R /: Lowering cardiac workload, maximize cardiac output.

4 Provide comfort measures such as changes in position and back rub, and entertainment activity in cardiac tolerance.
R /: Improve relaxation and redirect the attention.

5. Encourage use of stress management techniques such as breathing exercises and guided imagery.
R /: This behavior can control anxiety, increase relaxation and decrease the work of the heart.

6 Evaluation of complaint fatigue, dyspnea, palpitations, chest pain continuously. Note the presence of breath sounds adventisius, fever.
R /: The clinical manifestations of CHF that can accompany endocarditis or myocarditis.


Collaborative

1 Give oxygen complement.
R /: Increase the availability of oxygen to myocardial function and decrease the effects of anaerobic metabolism, which occurs as a result of hypoxia and acidosis.

2 Give drugs in accordance with indications such as digitalis, diuretics.
R /: Can be given to increase myocardial contractility and decrease the workload of the heart in the presence of CHF (miocarditis).

3 Give Antibiotic / anti-microbial.
R /: Given to address the identified pathogens, prevent further heart damage.

4 Assist in emergency pericardiocentesis.
R /: The procedure was done in a bed can to lower the pressure in the fluid around the heart.

5. Prepare patients for surgery if indicated.
R /: Replacement valves may be required to improve cardiac output.
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Tuesday, July 15, 2014

COPD - Gordon's Functional Health Patterns


Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease that is progressive, meaning that the disease lasts a lifetime and is slowly getting worse from year to year. In the course of this disease are the phases of acute exacerbation. Various factors play a role in the course of the disease, among other risk factors are factors that cause or aggravate diseases such as smoking, air pollution, environmental pollution, infections, genetics and climate change.

The degree of airway obstruction occurs, and the identification of components that allow for reversibility. Phase course of the disease outside the lung and other diseases such as sinusitis and chronic pharyngitis. That ultimately these factors make further deterioration occurs sooner. To undertake the management of COPD should be considered these factors, so that the better treatment of COPD. Chronic obstructive pulmonary disease is a broad classification of disorders that includes chronic bronchitis, bronchiectasis, emphysema and asthma, which is an irreversible condition associated with dyspnea on exertion and a decrease in the flow of air in and out of the lungs.

Lately the disease is more interesting to talk about because of the prevalence and mortality rate continues to increase. The increasing age of human life and to overcome other degenerative diseases, COPD is very disturbing quality of life of advanced age. Industry that can not be separated by air pollution and the environment as well as the habit of smoking is a major cause.



COPD - Gordon's Functional Health Patterns

Health Perception-Health Function
1) Past medical history, history of productive cough more than 2 weeks.
2) Smokers, examine shelter, ventilation, sunlight, pollution sources around the home, contact with smokers.
3) Difficulty mobilization and expenditure sputum, presence haemoptoe.
4) inadequate treatment.


Nutritional Metabolic Pattern
1) Anorexia
2) Nausea
3) Weight loss
4) Difficulty in eating or digestion


Activity Exercise Pattern
1) Weakness
2) Muscle cramps
3) Shortness of breath, cough


Sleep-Rest Pattern
1) Disruption of sleep patterns
2) Shortness of breath at night


Cognitive-Perceptual Pattern
1) Headache


Role-Relationship Pattern
1) Changes in the role.
2) Depression


Sexuality-Reproductive Pattern
1) Decrease in sexual activity because of shortness of breath


Coping-Areas Management Pattern
1) Sometimes the negative emotions that arise because of shortness of breath
2) Manipulation.
3) Isolation
4) Increased dependency
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