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Wednesday, January 22, 2014

Decreased Cardiac Output and Impaired Skin Integrity - NCP Chronic Kidney Disease

Nursing Care Plan for Chronic Kidney Disease

Chronic Kidney Disease (CKD) / CRF is a kidney disorder that is progressive and irreversible in which the ability of the body fails to maintain metabolism and fluid and electrolyte balance, causing uremia (retention of urea and other nitrogen garbage in the blood).

Causes of Chronic Kidney Diseas

CKD / CRF may be caused by systemic diseases are as follows:
  1. DM.
  2. Chronic Glomerulonefrtitis.
  3. Pyelonephritis.
  4. Toxic agents.
  5. Uncontrolled hypertension.
  6. Urinalysis tract obstruction.
  7. Vascular disorders.
  8. Infection.

Clinical manifestations of Chronic Kidney Disease
  1. Cardiovascular system: includes hypertension (due to fluid retention and sodium from activation of the renin-angiotensin-aldosterone system), congestive heart failure and pulmonary edema (due to excess fluid) and pericarditis (due to irritation of the pericardial layers by uremic toxins).
  2. Integrumenurum system: severe itching (pruritus). Granules is a penunpukkan uremic urine crystals in the skin, hair thin and rough.
  3. Gastrointestinal System: anorexia, nausea, vomiting.
  4. Neurovascular system: changes in the level of consciousness, inability to concentrate, and muscle spasms kedura.
  5. Pulmonary System: krekels, sputun thick, deep breath and kusmaul.
  6. Reproductive system: amenorrhea, testicular atrifi.

Nursing Diagnosis : Decreased Cardiac Output related to increased cardiac load

Goal: Decrease in cardiac output does not occur

Expected outcomes : maintain cardiac output and blood pressure with evidence of cardiac frequency in the normal range, strong peripheral pulses and capillary refill time is equal to.

1. Auscultation of heart and lungs.
R /: The presence of an irregular heart rate tachycardia.

2. Assess for hypertension.
R /: Hypertension may occur due to interference with the system of the renin-angiotensin-aldosterone system (caused by renal dysfunction).

3. Investigate complaints of chest pain, note the location, severity (0-10 scale).
R /: HT and CRF can cause pain.

4. Assess the level of activity, response to activity.
R /: Fatigue can also accompany CRF anemia.

Nursing Diagnosis : Impaired Skin Integrity related to pruritis

Goal : Skin integrity can be maintained

Expected outcomes :
Maintaining intact skin.
Shows the behavior / technique to prevent skin damage.

Intervention :
1. Inspection of the skin to change color, turgor, vascular, note any redness.
R / : Indicates areas poor circulation or damage that may lead to the formation of pressure sores / infections.

2. Monitor fluid intake and hydration of the skin and mucous membranes.
R / : Detecting the presence of dehydration or overhydration affecting circulation and tissue integrity

3. Inspection of the area depends on the edema.
R / : Tissue edema is more likely to be damaged / torn.

4. Change positions as often as possible.
R / : Lowering pressure on edema, poorly perfused tissue to reduce ischemia.

5. Give skin care.
R / : Reduce drying, skin tears.

6. Maintain a dry linen.
R / : Lowering dermal irritation and the risk of skin damage.

7. Instruct the patient to use a damp and cold compresses to put pressure on the area pruritis.
R / : Eliminate the discomfort and reduce the risk for injury.

8. Encourage wear loose cotton clothes.
R / : Prevent direct dermal irritation and improve skin moisture evaporation.


Nursing Management for Chronic Kidney Disease

Chronic kidney disease or end stage renal disease (ESRD) is a progressive disorder of renal function and the irreversible failure where the body's ability to maintain metabolism and fluid and electrolyte balance, causing uremia (retention of urea and other nitrogen garbage in the blood). (Brunner & Suddarth, 2001; 1448)

Clinical Manifestations of Chronic Kidney Disease

Clinical manifestations according Suyono (2001) is as follows:

a. Cardiovascular disorders
Hypertension, chest pain, and shortness of breath due to pericarditis, pericardial effusion and heart failure due to fluid retention, heart rhythm disturbances and edema.

b. Pulmonary disorders
Shallow breathing, Kussmaul breathing, cough with thick sputum and ripples, the sound crackles.

c. Gastrointestinal disorders
Anorexia, nausea, and fomitus associated with protein metabolism in the intestine, gastrointestinal tract bleeding, ulceration and bleeding mouth, ammonia breath odor.

d. Musculoskeletal disorders
Restless legs syndrome (RLS) (pains in the legs so that it always moved), burning feet syndrome (tingling and burning, especially on the soles of the feet), tremor, myopathy (weakness and hypertrophy of the muscles of the extremities).

e. Integumentary disorders
Skin pale from anemia and yellowish due to accumulation urokrom, itching caused by toxic, thin and brittle nails.

f. Endocrine disorders
Sexual disorders: decreased fertility and erection, menstrual disorder and amenorrhea. Glucose metabolic disorders, metabolic disorders of fat and vitamin D.

g. Disorders of fluid electrolyte and acid-base balance
Usually the retention of salt and water but can also occur sodium loss and dehydration, acidosis, hyperkalemia, hypomagnesemia, hypocalcemia.

h. hematological System
Anemia is caused by reduced production eritopoetin, so that the stimulus eritopoesis in reduced bone marrow, hemolysis due to reduced life span of erythrocytes in uremia toxic atmosphere, can also malfunction thrombosis and thrombocytopenia.

Nursing Management for CKD is divided into three, namely:

1. Conservative
  • Laboratory examination of blood and urine.
  • Observation of fluid balance.
  • Observe for edema.
  • Limit fluid intake.
2. Dialysis
  • Peritoneal dialysis: usually done in cases of emergency. While dialysis can be done anywhere that is not acute CAPD (Continuous Ambulatory Peritoneal Dialysis).
  • Hemodialysis: Namely; dialysis is performed via invasive action in the vein by using a machine. At first hemodiliasis performed through the femoral region, but to simplify it done: arteriovenous fistula: venous and arterial combine, Double lumen: directly on the heart area (vascularity to the heart).
3. Operation
  • Stone retrieval
  • Kidney transplant

Monday, January 20, 2014

Nursing Assessment for Hallucinations (Predisposing and Precipitating Factors)

At this stage the nurse explore the factors that exist below, namely:

1. Predisposing Factors

Are risk factors that affect the type and amount of resources that can be generated by individuals to cope with stress. Obtained either from the patient or his family, the cultural factors of social development, biochemical, psychological and genetic risk factors that affect the type and amount of resources that can be generated by individuals to cope with stress.
  • Development factors: If the developmental tasks encountered resistance, and impaired interpersonal relationships then the individual will experience stress and anxiety.
  • Sociocultural factors: A variety of factors can lead to a society ruled by a lonely feeling to the environment in which the client was raised.
  • Biochemical factors: Having an influence on the occurrence of mental disorders. With the excessive stress experienced by a person inside the body will then produce a hallucinogenic substance that can be Neurochemistry.
  • Psychological factors: Interpersonal relationships are not harmonious and the dual role conflicting and often accepted by the child will lead to high stress and anxiety disorders and ended with reality orientation.
  • Genetic factors: what influence gene in schizophrenia is unknown, but research suggests that family factors showed a highly influential on the disease.

2. Precipitating Factors

Namely; stimulus perceived by the individual as a challenge, a threat / demands that require extra energy for coping. The presence of environmental stimuli that often are as participation of clients in a group, far too long encouraged communication, objects that exist in the environment is also a quiet atmosphere / isolation is often a trigger hallucinations because it can increase the stress and anxiety that stimulates the body to secrete hallucinogenic substances.

3. Behavior

Client's response to the hallucinations may be suspicious, frightened, feeling insecure, anxious and confused, self-destructive behavior, lack of attention, not able to take decisions and can not distinguish the real and unreal situation. According to Rawlins and Heacock, 1993 tried to solve the problem of hallucinations based upon the nature of the existence of an individual as a creature that is built on the basis of the elements of the bio-psycho-socio-spiritual that hallucinations can be seen from the dimensions:
  • Physical dimensions : Man built by the sensory system to respond to external stimuli provided by the environment. Hallucinations can be caused by several physical conditions like fatigue tremendous, drug use, fever up to delirium, alcohol intoxication and difficulty to sleep in a long time.
  • Emotional dimensions : Feelings of anxiety are excessive on the basis of problems that can not be the cause of the hallucinations occur. The contents of hallucinations can be a force command and scary. Clients no longer able to oppose the order with the condition to the client to do something about these fears.
  • Intellectual dimension: In this intellectual dimension explains that individuals with hallucinations would show a decrease in the function of the ego. At first it is a hallucination of his own ego to resist the impulse to press, but it is something that raises awareness that can take all the attention of the client and often will control all client behavior.
  • Social Dimension : The social dimension in individuals with hallucinations showed a tendency to be alone. Individuals preoccupied with hallucinations, as if it is a place to meet the need for social interaction, self-control and self-esteem were not found in the real world. Fill hallucinations control system used by the individual, so if the command hallucinations in the form of a threat, the individual himself or others tend to it. Therefore, an important aspect in implementing nursing interventions to pursue a process of interpersonal interactions that lead to a satisfying experience, and not aloof mengusakan client so that the client always interacts with its environment and hallucinations did not last.
  • Spiritual Dimension: Humans as social beings, so that interaction with other human beings is a fundamental requirement. In these individuals tend to be aloof until the above process does not occur, the individual is not aware of the existence and hallucination into the control system of the individual. Hallucinations when an individual loses control over him his life.

4. Sources Coping

An evaluation of the person's choice of coping strategies. Individuals can cope with stress and anxiety by using coping resources in the environment. Coping as a capital source to solve the problem, social support and cultural beliefs, can help a person integrate stressful experience and adopt coping strategies that work.

5. Coping Mechanisms

Every effort is directed at the implementation of stress, including efforts to resolve the problem directly and defense mechanisms are used to protect themselves.