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Wednesday, May 22, 2013

Colon Cancer Nursing Diagnosis


Most colon cancers originate from small, noncancerous (benign) tumors called adenomatous polyps that form on the inner walls of the large intestine. Some of these polyps may grow into malignant colon cancers over time if they are not removed during colonoscopy. Colon cancer cells will invade and damage healthy tissue that is near the tumor causing many complications.

Colon cancer is not necessarily the same as rectal cancer, but they often occur together in what is called colorectal cancer. Rectal cancer originates in the rectum, which is the last several inches of the large intestine, closest to the anus.

Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. It is common for people with colon cancer to experience no symptoms in the earliest stages of the disease. However, when the cancer grows, symptoms include:
  • Diarrhea or constipation
  • Changes in stool consistency
  • Narrow stools
  • Rectal bleeding or blood in the stool
  • Pain, cramps, or gas in the abdomen
  • Pain during bowel movements
  • Continual urges to defecate
  • Weakness or fatigue
  • Unexplained weight loss
  • Irritable bowel syndrome (IBS)
  • Iron deficiency (anemia)
9 Nursing Diagnosis for Colon Cancer

1. Constipation related to obstructive lesions.
2. Acute Pain related to tissue compression secondary to obstruction.
3. Fatigue related to anemia and anorexia.
4. Imbalanced Nutrition, Less Than Body Requirements related to nausea and anorexia.
5. Risk for fluid volume deficit related to vomiting and dehydration
6. Anxiety related to cancer diagnosis and surgery planning
7. Knowledge Deficit: the diagnosis, surgical procedures, and self-care.
8. Impaired Skin Integrity related to surgical incision (abdominoperineal), stoma formation, and faecal contamination of the skin periostomal.
9. Disturbed body image related to colostomy.
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Saturday, May 4, 2013

Nursing Interventions : Impaired Physical Mobility - Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis: Impaired Physical Mobility

related to:

  • skeletal deformity
  • painful
  • discomfort
  • activity intolerance
  • decreased muscle strength.

Can be evidenced by:
  • Reluctance to try moving / inability to move in with their own physical environment.
  • Limiting the range of motion, coordination imbalances, decreased muscle strength / control and mass (advanced stage).

The expected outcomes / evaluation criteria, patients will:
  • Maintaining a function of position in the absence / restrictions contractures.
  • Maintain or improve strength and function of and / or compensation of the body.
  • Demonstrate techniques / behaviors enabling activities.

Nursing Interventions : Impaired Physical Mobility - Rheumatoid Arthritis

1. Keep the rest bed rest / activity schedule to sit if necessary to provide a continuous period and nighttime sleep uninterrupted.
Rationale: Systemic Rest is recommended during acute exacerbations, and all phases of the disease is important to prevent exhaustion maintain strength

2. Evaluation / continue monitoring the level of inflammation / pain in the joints.
Rationale: The level of activity / exercise depends on the development / resolution of inflammation peoses

3. Change positions frequently with sufficient amount of personnel. Demonstrate / aids removal techniques and the use of mobility assistance.
Rationale: Eliminates stress on the network and improves circulation. Memepermudah patient self-care and independence. Proper removal techniques to prevent tearing skin abrasion.

4. Assist with range of motion active / passive, and resistive exercise also demikiqan isometris if possible.
Rationale: Maintain / improve joint function, muscle strength and general stamina.

5. Position with pillows, sand bags.
Rationale: Increase stability (reducing the risk of injury) and required memerptahankan joint position and body alignment, reducing contractor

6. Encourage the patient to maintain an upright posture and sitting height, standing, and walking.
Rationale: To maximize joint function and maintain mobility.

7. Provide a safe environment, such as raising the chair, using the toilet railings, wheelchair use.
Rationale: Avoiding injury due to accidents / falls

8. Use a small pillow / thin below the neck.
Rationale: Preventing neck flexion.

9. Collaboration: consul with physiotherapy.
Rationale: Useful in formulating training programs / activities based on individual needs and identifying tools.

10. Collaboration: Provide foam mat / converter pressure.
Rationale: Reducing pressure on fragile networks to reduce the risk of immobility.

11. Collaboration: give medications as indicated (steroids).
System may be needed to suppress acute inflammation.

Source : http://nanda-nurse-diary.blogspot.com/2012/11/nursing-diagnosis-impaired-physical.html
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Preeclampsia Nanda Nursing Diagnosis

Nanda Nursing Diagnosis for Preeclampsia
Preeclampsia/eclampsia is a complex hypertensive disorder of pregnancy affecting multiple systems. Preeclampsia is a condition that pregnant women can get. Preeclampsia and eclampsia are complications of pregnancy. In preeclampsia, the woman has dangerously high blood pressure, swelling, and protein in the urine.




7 Nursing Diagnosis for Preeclampsia

1. Acute pain
reated to post Caesarean section incision

2. Alteration in Bowel Elimination: Constipation
related to decreased intestinal peristalsis.

3. Risk for Infection
related to tissue trauma / skin damage

4. Risk for Fluid Volume Deficit
related to the bleeding

5. Altered family processes
related to the preparation of infant acceptance.

6. Sleep pattern disturbance
related to the tension during the birth process, pain.

7. Knowledge Deficit: perawtan about babies, family planning, nutrition
related to inadequate information. 

Source : http://nanda-nurse-diary.blogspot.com/2012/11/nanda-7-nursing-diagnosis-for.html
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