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Nursing Diagnosis Risk for Infection - NCP Impetigo

Nursing Care Plan Risk for Infection - Impetigo

Nursing Diagnosis Risk for infection - NCP Impetigo

Nursing Diagnosis Risk for Infection related to decreased immune system, malnutrition, inflammation, and invasive procedures.

Expected outcomes are:
  • Clients are free from signs and symptoms of infection.
  • Showed the ability to prevent infection.
  • Demonstrate healthy behavior.
  • Describe the process of transmission of the disease, factors that influence transmission.

Nursing Interventions - Nursing Care Plan for Impetigo :
  • Monitor for signs and symptoms of infection.
  • Monitor susceptibility to infection.
  • Limit the visitor when necessary.
  • Instruct patient visitors to wash their hands during a visit and after leaving the patient.
  • Maintain aseptic environment during ongoing treatment.
  • Give skin care in the area epidema.
  • Inspection of skin and mucous membrane of the redness, heat.
  • Inspection of the condition of the wound.
  • Give antibiotic therapy if necessary.
  • Teach how to avoid infection.

Nursing Diagnosis for Knowledge Deficit - NCP Impetigo

Nursing Interventions for Impetigo

Nursing Diagnosis of Knowledge Deficit - Nursing Care Plan for Impetigo 

Nursing Diagnosis: Knowledge Deficit: the disease, prognosis and treatment needs.

Patients showed an understanding of disease processes and treatment procedures,

with the expected outcomes: the patient can explain the status of the disease, treatment, care understand that done.

Nursing Interventions ;

Teach About the Disease:
  • Determine the level of knowledge of patients and families related to disease processes.
  • Describe the pathophysiology of the disease and connect with the anatomy and physiology.
  • Describe the signs and symptoms of the disease.
  • Describe the disease process.
  • Identification of possible causes.
  • Provide information about the patient's condition.
  • Provide information about the diagnostic measures.
  • Describe the rationality of therapy / treatment given.
  • Describe complications.
  • Talk about lifestyle changes in patients who may be required.
  • Discuss treatment options.
  • Take time to explore a second opinion.
  • Instruct patients and families to recognize signs and symptoms to report.
  • Clarification of information provided by other health team prior to the information provided.

Rational:
  • To facilitate the client and the appropriate use of health services.
  • Assist clients in understanding the information related to the occurrence of disease in particular.
  • Clients know what foods are recommended.
  • Clients understand the handling done / recommended.
  • Clients experiencing what activities to do.

Knowledge Deficit related to Tuberculosis

Nursing Care Plan for Impetigo - Impaired Skin Integrity

Nursing Care Plan for Impetigo - Impaired Skin Integrity

Nursing Care Plan for Impetigo - Nursing Diagnosis and Interventions : Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity related to lesions and mechanical injury (scratching the itchy skin)

Expected outcomes are:
  • A good skin integrity can be maintained (sensation, elasticity, temperature)
  • No injuries or lesions on the skin.
  • Able to protect skin and keep skin moist and natural treatments.
  • Good tissue perfusion.

Nursing Interventions:

1. Instruct the patient to use, loose clothing.
Rational: a loose shirt, shirt will reduce friction on the skin lesions.

2. Cut nails and keep the client's hand hygiene.
Rational: the nail that will reduce the short and avoid scratching the impetigo lesion severity.

3. Keep clean skin, to keep them clean and dry.
Rational: the skin clean and dry, will reduce the spread or proliferation of bacteria.

4. Monitor skin color, the existence of redness.
Rational: to know the progression of the disease and the effectiveness of actions taken.

5. Bathe the patient with warm water and soap (antiseptic).
R: warm water will kill bacteria and reduce the rash. Anti-septic soap can reduce or kill the bacteria on the skin.

6. Collaboration for the administration of topical antibiotics on the client.
Rational: topical antibiotic may discontinue or inhibit the growth of bacteria.

7. Give the knowledge of the client not to scratch the wound.
Rational: the knowledge of patients on the treatment process can accelerate the success of the nursing process.

Nursing Interventions Risk for Decreased Cardiac Output in Hypertension

Nursing Interventions Hypertension

Nursing Interventions Risk for Decreased Cardiac Output in Hypertension

Nursing Diagnosis: Risk for Decreased Cardiac Output - Nursing Care Plan for Hypertension

Risk for Decreased Cardiac Output related to vasoconstriction

Expected outcomes are:
  • Clients participating in activities that lower blood pressure / load
  • cardiac work, maintaining blood pressure within an acceptable range of individuals, showing stable norms and cardiac frequency in the normal range.

Nursing Intervention:

1. Observation of blood pressure (the ratio of pressure to give an overview more complete, the involvement / field of vascular problems).

2. Note the presence, quality of the central and peripheral pulsation (throbbing carotid, jugular, radial and femoral probably observed / palpation.

3. Auscultation of heart and breath sounds tone. (S4 commonly heard in patients with severe hypertension due to atrial hypertrophy, the development of S3 showed ventricular hypertrophy and malfunction, the presence of crackles, wheezing may indicate the occurrence of pulmonary congestion secondary to
or chronic heart failure).

4. Observe skin color, moisture, temperature, and capillary refill time. (a pale, cold, moist skin and slow capillary refill time reflect decompensation / decrease in cardiac output).

5. Note the presence of fever, general / specific. (may indicate a failure heart, kidney or vascular damage).

6. Provide a comfortable, quiet, reduce the activity / fray environment, limit the number of visitors and length of stay. (helping to decrease sympathetic stimulation, increased relaxation).

7. Encourage relaxation techniques, imagination and distraction guide. (can stimuli that lead to lower stress, create a calming effect, that will lower blood pressure).

8. Collaboration with physicians in the delivery of anti-hypertensive therapy, deuritik. (lowers blood pressure).

Risk for Decreased Cardiac Output related to Hypertension

Nursing Care Plan for Hypertension in Pregnancy

Nursing Interventions for Hyperemesis Gravidarum

Nursing Care Plan for Hyperemesis Gravidarum
Nursing Interventions for Hyperemesis Gravidarum

1. Assess for signs of dehydration
Rational: improve fluid balance, and maintain a homeostatic mechanism, is the basis for the mother and fetus to maintain balance.

2. Assess vital signs
Rational: temperature, pulse rate increased and decreased BP are signs of dehydration and hypovolemia.

3. Give parenteral fluids: electrolytes, glucose and vitamins according to program
Rational: This fluid will provide or meet the needs of the body's acid-base balance, electrolytes and hypoavitaminosis.

4. Provide nutrition in small but frequent portions.
Rational: feeding gradually or slowly may help.

5. Monitor the provision of fluids and food in 24 hours as well as expenditures and recorded fluid intake.
Rational: the provision of fluids and electrolytes is a way to deal with persistent vomiting, this recording will be able to assess the balance of electrolytes are given, while the number of how many calories can already be given.

6. Review of edema in the legs or elsewhere.
Rational: the edema may also occur due to lack of albumin or renal failure.

7. Assess the presence of ketones in the urine.
Rational: presence of ketones in the urine indicates maternal fat supplies for energy use due to inadequate caloric intake.

8. Do collaborations with other teams for the administration of antiemetic drugs.
Rational: usually to cope with vomiting.

9. Give the food a light, when it is allowed in small portions and frequent (liquid and solid)
Rational: the provision of solid and liquid foods in small portions and often may reduce vomiting.

10. Increase feeding of this, if the client is able to accept (tolerance).
Rational: an increase in feeding demonstrate efficacy in the treatment.

11. Monitor FHR and fetal activity.
Rational: FHR and fetal movement is an indication that the fetal / fetus in good condition.

12. Monitor symptoms of morning sickness.
Rational: hormonal changes, maternal Hypoglycemia and decreased gastric motility, emotional and cultural factors.

13. Examine the skin: the texture and turgor.
Rational: dry skin and poor turgor is a sign of dehydration.

14. Encourage clients to multiply the rest.

15. Create a comfortable environment.

Nursing Assessment for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%

Nursing Diagnosis for Hyperemesis Gravidarum

1. Fluid and electrolyte imbalances related to excessive vomiting or lack of fluid intake.

2. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting or lack of nutritional intake.

3. Anxiety related to hyperemesis influence on the health of the fetus.

4. Knowledge deficit related to lack of information about the treatment of hyperemesis.

5. Sleep pattern disturbance related to persistent vomiting.

6. Activity Intolerance related to weakness.

Nursing Assessment for Hyperemesis Gravidarum

Nursing Assessment for Hyperemesis Gravidarum

Nursing Care Plan for Hyperemesis Gravidarum : Nursing Assessment for Hyperemesis Gravidarum

1. Main complaint:
  • Severe vomiting
  • Nausea, vomiting in the morning and after meals
  • Epigastric pain
  • Feeling thirsty
  • No appetite
  • Vomiting of food / liquid acid

2. Predisposing factors
  • Maternal age <20 years
  • Multiple gestation
  • Obesity
  • Trophoblastic Disease

3. Physical Examination
  • Metabolic acidosis is characterized by headache, disorientation
  • Tachycardia, hypotension, vertigo
  • Conjunctival jaundice
  • Impaired consciousness, delirium

Signs of dehydration:
  • Dry skin, mucous membranes dry lips
  • Slow return of skin turgor
  • Sunken eyelids
  • Weight loss
  • Increase in body temperature
  • Oliguria, ketonuria
  • Concentrated urine

Laboratory data:
  • Proteinuria
  • Ketonuria
  • Urobilinogen
  • Decreased levels of potassium, sodium, chloride, and protein
  • Decreased levels of vitamin
  • Increased Hb and Ht
Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Assessment for Epilepsy - ABCDE

Nursing Assessment for Epilepsy - ABCDE

Airway
In the ictal phase, the client usually found clenched his teeth so that obstruct the airway, the client bite the tongue, mouth foaming, and the postictal phase, usually found injury to the tongue and gums due to the bite.

Breathing
In the ictal phase, the client breathing down / speed, increased mucus secretion, and skin was pale even cyanosis. In phase posiktal, clients have apnea.

Circulation
In the ictal phase pulse and cyanosis increase, the client usually unconscious.

Disability
Clients can be realized or not depends on the type of attacks or characteristics of epilepsy suffered. Usually the patient was confused, and do not remember the incident when the seizures.

Exposure
Client's clothing was opened to thoracic examination, whether there are additional injuries due to seizures.

Nursing Diagnosis for Epilepsy

Nursing Diagnosis and Interventions Risk for Injury - Seizures

Social Isolation related to Low Self-esteem

Social isolation related to low self-esteem

Objectives:
  • Clients can build a trusting relationship.
  • Clients can positively identify the capabilities they have.
  • Clients can assess the capability of being used.
  • Clients can (set) to plan activities in accordance with the capabilities.
  • Clients can perform activities according to the condition of pain and ability.
  • Clients can take advantage of existing support systems.


Nursing Interventions:
  • Construct a trusting relationship with therapeutic communication:
    • Therapeutic greet.
    • Introduce yourself.
    • Explain the purpose of interaction.
    • Create a calm environment.
    • Create a clear contract.
    • Stay on time.
  • Discuss the capability and the positive aspects of the client owned.
  • Every meeting with clients avoid from giving negative ratings.
  • Polar realistic praise.
  • Discuss with the client the ability to still be used for ill.
  • Discuss with the client capabilities that can be shown to the user.
  • Plan activities with clients who may be continued every day according to ability:
    • Work independently.
    • Activities that require total assistance.
  • Increase activity in accordance with the tolerance of the client's condition.
  • Give examples of how implementation of the activities that the client did.
  • Give the client a chance to try activities that are planned
  • Give credit for the success of the client.
  • Discuss the possible implementation of the home.
  • Give health education to families about how to treat clients with dignity help families provide support for clients cared for, help prepare the family home environment.

Nursing Diagnosis for Congestive Heart Failure - CHF related to

Nursing Diagnosis for CHF - Congestive Heart Failure

1 Decreased Cardiac Output
related to
  • changes in left ventricular contractility,
  • rhythm frequency changes,
  • electrical conduction
2. Ineffective Tissue Perfusion
related to
  • decrease in cardiac output
  • tissue hypoxemia,
  • acidosis and,
  • the possibility of thrombus or emboli.
3. Ineffective Airway Clearance
related to
  • decrease in lung volume,
  • hepatomegaly,
  • splenomegaly
4. Activity Intolerance
related to
  • imbalance between myocardial oxygen supply and demand of the body, the ischemic / necrotic myocardial tissue
5. Excess Fluid Volume
related to
  • Systemic fluid overload,
  • interstitial fluid permeation in the systemic secondary to decreased cardiac output, right heart failure
6. Imbalanced Nutrition: Less Than Body Requirements
related to
  • anorexia,
  • dyspnoea,
  • nausea, vomiting,
  • side effects of drugs,
  • sputum production
7. Sleep pattern disturbance
related to
  • paroxysmal nocturnal disease,
  • hospitalization,
  • crowded
8. Anxiety
related to
  • fear of death,
  • decline in health status,
  • crisis situations,
  • changes in consciousness.

Nursing Assessment for Congestive Heart Failure

Nursing Assessment for Congestive Heart Failure

Nursing Assessment for Congestive Heart Failure

1. Activity / rest
Symptoms: fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
Symptoms: Anxiety, mental status changes such as lethargy, changes in vital signs of activity.

2. Circulation
Symptoms: history of hypertension, acute myocardial infak, previous episodes of Chronic Heart Failure, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
Signs: blood pressure; may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia, apical pulse; PMI may spread and change in an inferior position to the left, heart murmurs; S3 (gallops) is diagnostic, S4 may, occur, S1 and S2 may be weakened, systolic and diastolic murmur, Color: blue, pale gray, cyanotic, nail backs; pale or cyanotic with a filling, capillary slow, Liver; enlargement / can be palpated, breath sounds ; crackles, rhonchi, edema; may be dependent, general or pitting especially on the extremities.

c. Ego integrity
Symptoms: Anxiety, worry and fear. Stress-related illness / financial concerns (job / cost of medical care).
Signs: A variety of behavioral manifestations, such as anxiety, anger, fear and irritability.

d. Elimination
Symptoms: Decreased urination, dark colored urine, nighttime urination (nocturia), constipation / diarrhea.

e. Food / fluid
Symptoms: Loss of appetite, nausea / vomiting, significant weight gain, swelling of the lower extremities, clothes / shoes feel tight, high-salt diet / food that has been processed and the use of diuretics.
Symptoms: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, stress and pitting).

f. Hygiene
Symptoms: fatigue / weakness, fatigue during activities of self care.
Signs: Appearances indicate negligence personal care.

g. Neurosensory
Symptoms: weakness, dizziness, fainting episodes.
Symptoms: Lethargy, tangled thought, oriented, behavioral changes and irritability.

h. Pain / Comfort
Symptoms: Chest pain, acute or chronic angina, upper right abdominal pain and muscle pain.
Signs: No quiet, insecure, narrow focus and behavior to protect themselves.

i. Breathing
Symptoms: Dyspnea on exertion, sleeping, sitting or with several pillows, cough with less / no sputum formation, history of chronic disease, use of rescue breathing.
Signs: Respiratory: tachypnea, shallow breathing, use of accessory respiratory muscles. Cough: Dry / loud / or non productive cough may be continuous with / without sputum formation. Sputum; Perhaps blood Flushed, pink / frothy (pulmonary edema). Breath sounds; may not be heard. Mental function; may decrease, anxiety, lethargy. Skin color; Pallor and cyanosis.

j. Security
Symptoms: Changes in mental function, loss of strength / muscle tone, skin abrasions.

k. Social interaction
Symptoms: Decreased participation in social activities are wont to do.

l. Learning / teaching
Symptoms: use / forgot to use heart medications, such as calcium channel blockers.
Symptoms: Evidence of lack of success to increase.

Diagnostic Examination for CHF

Diagnostic Examination for CHF
Diagnostic Examination for CHF

1. Thoracic X-ray: may reveal an enlarged heart, edema or pleural effusion which confirmed the diagnosis of CHF.

2. ECG: reveals tachycardia, ventricular hypertrophy and ischemia, an echocardiogram.

3. Laboratory examination: includes electrolytes, serum sodium levels revealed a low blood hemodilution that results from the presence of excess water retention, potassium, sodium, chloride, urea and blood sugar.

4. Sonogram (echocardiogram) to indicate the dimensions of ventricular enlargement, changes in the function / structure of the valve or area decreased ventricular contractility.

5. Cardiac catheterization: an indication of abnormal pressure and helps to distinguish right and left heart failure and valvular stenosis or insufficiency. Also assess patency of coronary arteries. Contrast agent is injected into the ventricles show abnormal size and ejection fraction / change in contractility.

6. Ultrasonography (USG): get an overview of free fluid in the abdominal cavity, and the picture of the liver and spleen enlargement. Enlarged liver and spleen is sometimes difficult to be checked manually when accompanied by ascites.

Constipation / Diarrhea related to Anemia

Constipation / Diarrhea related to Anemia

Nursing Diagnosis: Constipation / Diarrhea related to a reduction in dietary inputs, changes in digestion, the side effects of oral therapy.

Signs :
  • frequency change
  • characteristics and the amount of feces
  • nausea / vomiting
  • anorexia
  • sudden abdominal pain
  • impaired bowel sounds.

Expected outcomes are:
  • normal bowel function
  • behavioral changes necessary to live as the cause.

Nursing Intervention:
  • Observation of color, consistency, frequency, amount.
  • Auscultation of bowel sounds
  • Supervise the input / output
  • Encourage input 2500-3000 ml
  • Consult with a nutritionist: high-fiber diet
  • Give an enema as indicated
  • Give anti-diarrheal medications as indicated.

Imbalanced Nutrition: Less Than Body Requirements - Anemia Nursing Diagnosis and Interventions

Imbalanced Nutrition: Less Than Body Requirements - Anemia Nursing Diagnosis and Interventions

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Signs:
  • weight loss,
  • oral mucosal changes,
  • loss of muscle tone

Expected outcomes are: weight gain / stable with normal laboratory values​​, no sign of malnutrition.

Nursing Intervention:
  • Observation and record food intake
  • Measure weight every day
  • Observation of nausea / vomiting, flatulence and other symptoms
  • Give and good oral hygiene aids
  • Give your dessert is diluted when the oral mucosa injury
  • Monitor lab results: Hb / HMT, protein, iron, B12, folic acid and serum electrolytes
  • Give the drug as interuksi: vitamins, minerals, oral iron
  • Give soft diet, low in fiber, did not stimulate.
Source : http://nanda-nursing-care-plan.blogspot.com/2012/07/imbalanced-nutrition-less-than-body_14.html

    Activity Intolerance - Anemia Nursing Diagnosis and Intervention

    Activity Intolerance - Nursing Diagnosis and Intervention for Anemia

    Nursing Diagnosis: Activity Intolerance
    Symptoms: weakness, plenty of rest, palpitations, tachycardia, increased BP, dyspnea.

    Expected outcomes are:
    increase in activity tolerance; pulse, respiration and blood pressure normal.

    Nursing Intervention:
    • Assess the ability to perform the task, record the presence of fatigue and difficulty performing tasks
    • Assess the running balance disorders and muscle weakness
    • Monitor vital signs during and after activity
    • Change position slowly, monitor for dizziness
    • Give assistance activity / ambulation if necessary
    • Encourage to stop activity when palpitations, chest pain, shortness of breath, weakness and dizziness.

    Impaired Social Interaction related to Self-concept Disturbance

    Impaired Social Interaction related to Self-concept Disturbance

    Impaired Social Interaction related to Self-concept Disturbance

    Goal:
    • Shows the appearance of a role
    • Indicate the involvement of social

    Expected outcomes are:
    • Social interaction skills: the use of effective social interaction behavior.
    • Social engagement: social interaction of individuals who are with other people, groups.

    Nursing Interventions:
    • Increase socialization.
    • Assess the interaction patterns among patients with other people.
    Rational:
    • To improve patient interactions with others.
    • To determine the pattern of patient interaction with others.

    Urinary Incontinence related to Pelvic Muscle Degenerative

    Nursing Diagnosis: Urinary incontinence related to pelvic muscle degenerative

    Goal:
    • Showed urinary continence.
    • Adequacy of time to reach a small room between urgency and urinary output.
    • Underwear stays dry all day
    • Able to urinate on their own.
    Expected outcomes are:
    • Urinary continence. Maintain the frequency of urination over 2 hours.

    Nursing Interventions Urinary Incontinence:
    • Perform pelvic floor muscle exercises
    • Perform treatment of urinary incontinence
    • Identification of the multifactorial causes of incontinence
    Rational:
    • Muscle strengthening volunteer pubotogsigeal with repeated contractions.
    • To improve urinary continence and to maintain intregitas perineal skin.
    • To find out the cause of urinary incontinence.

    Nursing Interventions Risk for Social Isolation

    Nursing Interventions Risk for Social Isolation

    Nursing Care Plan for Risk for Social Isolation - Nursing Diagnosis for Risk for Social Isolation

    Risk factors may include, changes in health conditions, changes in physical appearance or sexual perception of social behavior is unacceptable, inadequate resources and or the fear of losing their personal resources.

    Desired outcomes / evaluation criteria:
    • Identification of a stable support system.
    • Use of resources for appropriate help.
    • Reveal an increase in self-esteem.

    Nursing Interventions Risk for Social Isolation:

    1. Determine the client's response to the conditions, feelings about self, concerns or worries about the other person's response, his ability to control the situation, and a sense of hope.
    Rational: How to receive individual and relate to the situation will help determine treatment plans and interventions.

    2. Assess the coping mechanisms and methods of dealing with the problems of life previously.
    Rational: Assessing reveals successful techniques that can be used in the current situation.

    3. Discuss concerns about work and leisure involvement. Note the potential for problems involving finance, insurance, and housing.
    Rationale: Clients with a potentially terminal disease, which carries a stigma, faced a big problem with the possibility of losing their jobs, health insurance, housing, and they become unable to care for themselves independently.

    4. Identification of the availability and stability of family and community support systems.
    Rational: This information is very important to help clients plan for future care.

    5. Encourage honesty in the appropriate relationship.
    Reason: As a rule, do not need to be told acquaintances about the client's health status. However, information should be shared with a close relationship such as SO, family, and sexual partners. Honesty can help identify the stable support.

    6. Encourages contact with family and friends.
    Rational: Many clients are afraid to say SO, family, and friends for fear of rejection, and some clients withdrew because of the tumultuous feelings. Contact promote a sense of support, concern, involvement, and understanding. Supporting a loved one when they learned of the diagnosis is useful and can provide long-term optimism.

    7. Helping clients to solve the problem of isolation for short-term solutions, such as acts of infectious disease or immune system is threatened.
    Rational: anticipatory planning can ease the sense of isolation and loneliness that can accompany this situation.

    8. Help clients distinguish between isolation and loneliness or solitude, which may be by choice.
    Rational: To provide an opportunity for clients to achieve the control he must make a decision about the choice to take care of themselves on this issue.

    9. Alert to verbal cues and nonverbal, such as withdrawal, a statement of despair, and sense of loneliness. Determine the presence and level of risk for suicidal thoughts.
    Rational: Indicators of despair and suicide may be present. When the signal is recognized, the clients are usually willing to express their thoughts and feeling of alienation and despair.

    10. Identifying community resources, self-help groups, and drug rehabilitation program or termination, as shown. Reason: To provide an opportunity to resolve any problems that may contribute to a sense of loneliness and isolation, the risk of transmission, and guilt.

    Nursing Interventions for Hepatitis B

    Nursing Interventions for Hepatitis B

    Setting energy use to treat or prevent fatigue and optimize function. Regular physical exercise to maintain fitness and health.

    Anxiety reduction and minimize anxiety, fear or anxiety associated with unknown source or anticipated danger.

    Teaching people about the disease, diagnosis and treatment. Facilitation of Learning: Promoting the ability to process and understand information. Increased Readiness Learning: Improving the ability and willingness to receive information.

    Infection Protection: Prevention and early detection of infection in patients at risk. Infection Control, Minimizing the acquisition and transmission of infectious agents. Supervision: purposeful and ongoing acquisition.

    Surveillance and safety. purposeful and ongoing collection and analysis of information about the client and the environment to be used in promoting and maintaining client safety. Analysis of potential risk factors, determining the health risk, risk reduction strategies and priorities for an individual or group.

    5 Nursing Diagnosis for Hepatitis B

     Hepatitis B
    • Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease.
    • The virus is transmitted through contact with the blood or other body fluids of an infected person.
    • Two billion people worldwide have been infected with the virus and about 600 000 people die every year due to the consequences of hepatitis B.
    • The hepatitis B virus is 50 to 100 times more infectious than HIV.
    • Hepatitis B is an important occupational hazard for health workers.
    • Hepatitis B is preventable with the currently available safe and effective vaccine.
    Most people do not experience any symptoms during the acute infection phase. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

    In some people, the hepatitis B virus can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer.

    There is no specific treatment for acute hepatitis B. Care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.

    Some people with chronic hepatitis B can be treated with drugs, including interferon and antiviral agents. Treatment can cost thousands of dollars per year and is not available to most people in developing countries.

    Liver cancer is almost always fatal and often develops in people at an age when they are most productive and have family responsibilities. In developing countries, most people with liver cancer die within months of diagnosis. In high-income countries, surgery and chemotherapy can prolong life for up to a few years.

    People with cirrhosis are sometimes given liver transplants, with varying success.

    5 Nursing Diagnosis for Hepatitis B
    1. Activity intolerance
    2. Anxiety
    3. Knowledge Deficit
    4. Risk for infection
    5. Risk for injury

    Imbalanced Nutrition: Less Than Body Requirements of Gastritis

    Nursing Diagnosis Imbalanced Nutrition: Less Than Body Requirements of Gastritis

    Nursing Diagnosis and Nursing Interventions : Imbalanced Nutrition: Less Than Body Requirements of Gastritis

    Gastritis is a common name for all kinds of inflammation of the inner lining of the stomach, which is known as the mucosa. It is characterized by severe stomach ailments like cramps in the stomach, diarrhea and constipation and even blood with the stools.

    Symptoms of Gastritis

    1. Upper abdominal pain or dyspepsia
    2. Nausea
    3. Vomiting
    4. Belching
    5. Acid reflux
    6. Bloating
    7. Indigestion
    8. Loss of appetite
    9. Bad breath
    10. Feeling of fullness in upper abdomen
    11. Concentrated burning sensation in upper abdomen
    12. Passing of blood in stool
    13. Blood vomiting
    14. Passing black, tarry stool.

    Nursing Diagnosis for Gastritis : Imbalanced Nutrition: Less Than Body Requirements related to the lack of food intake.

    Goal:
    After the patient's nutritional needs of nursing actions are met.

    Expected outcomes are:
    • General condition is quite
    • Good skin turgor
    • Increased weight
    • Difficulty swallowing is reduced
    Nursing Interventions :
    • Instruct patient to eat small meals but frequently.
    • Give soft foods.
    • Perform oral hygiene.
    • Measure weight basis.
    • Texture observation, the patient's skin turgor.
    • Observations of nutritional intake and output.
    Rationale:
    • Keeping the patient remained stable nutritional prevent nausea and vomiting.
    • To facilitate the patient to swallow.
    • Oral hygiene can stimulate the appetite of the patient.
    • Knowing the development of nutritional status of patients.
    • Knowing a patient's nutritional status.
    • Knowing a patient's nutritional balance.
    Source : http://nursesnanda.blogspot.com/2012/07/sample-of-nursing-diagnosis.html

      Acute Pain related to Gastritis

      Nursing Diagnosis : Acute Pain - NCP Gastritis

      Gastritis is basically an erosion of the stomach lining, which can occur suddenly due to certain factors or happen gradually over a longer period of time. Inflammation or irritation of the lining of the stomach is also a form of gastritis.

      Gastritis can occur in adults and in children, which when left untreated can give rise to other gastrointestinal problems. There can be a number of different causes that give rise to gastritis. An infection caused by Helicobacter pylori (H. pylori) or other bacteria and viruses living in the mucous lining of the stomach could be one of the causes. A back flow of bile from the bile tract into the stomach, which is known as bile reflux could give rise to gastritis. Pernicious anemia, which is the stomach's inability to properly digest vitamin B12 could be another cause.

      Acute Pain Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

      Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

      Nursing Care Plan for Gastritis

      Nursing Diagnosis: Acute pain related to irritation of the gastric mucosa secondary to psychological stress.

      Goal:
      After the act of nursing, pain can be reduced, patients can rest and generally good condition.

      Expected outcomes are:
      • Clients express the pain diminished or disappeared.
      • The client does not grimace in pain.
      • Vital signs are within normal limits.
      • The pain intensity was reduced (reduced pain scale 1-10).
      • Demonstrate relax, rest, sleep, increased activity quickly.

      Nursing Interventions:
      • Investigate complaints of pain, note the location, intensity of pain, and pain scale.
      • Instruct patient to report pain as soon as it began.
      • Monitor vital signs.
      • Explain the causes and effects of pain on the client and his family.
      • Encourage rest during the acute phase.
      • Encourage relaxation techniques.
      • Provide an environment conducive situation.
      • Collaboration with the medical team in the delivery of the action.

      Rationale:

      • To find out where the pain and facilitate interventions to be performed.
      • Early intervention to facilitate recovery of muscle control pain by decreasing muscle tension.
      • Autonomic responses include, changes in blood pressure, pulse, respiration, associated with pain relief.
      • With the causes and consequences of pain the client is expected to participate in treatment to reduce pain.
      • Reduce pain that was exacerbated by movement.
      • Decrease muscle tension, increase relaxation, and increased sense of control and coping abilities.
      • Provide support (physical, emotional, increased sense of control, and coping skills).
      • Eliminate or reduce the client's complaints of pain.
      Source : http://nursesnanda.blogspot.com/2012/07/sample-of-nursing-diagnosis.html

      Pathophysiology of Osteomyelitis

      Pathophysiology of Osteomyelitis

      Pathophysiology of Osteomyelitis

      Staphylococcus aureus is the cause of 70-80 percent of bone infection. Other pathogenic organisms commonly found in osteomyelitis include: Proteus, Pseudomonas and E.coli. There is an increased incidence of penicillin-resistant infections, nosocomial, gram negative and anaerobic.

      Onset of osteomyelitis after orthopedic surgery can occur within the first 3 months (acute fulminant stage I) and is often associated with accumulation of hematoma or superficial infection. Late onset infection (stage 2) occurred between 4 and 24 months after surgery. Osteomyelitis long onset (stage 3) is usually due to haematogenous spread and occurred 2 years or more after surgery.

      Initial response to infection is one of inflammation, increased Vascularization and edema. After 2 or 3 days, thrombosis in blood vessels occurs in the area, resulting in ischemia with bone necrosis associated with an increased and can spread to soft tissue or joints in the vicinity, unless the infection process can be controlled, then the bone will form an abscess.

      Abscess formed in the walls forming the dead tissue, but as in the abscess cavity in general, the bone tissue dies (sequestrum) is not easy to melt and flow out. Cavity can not be deflated and healed, as occurs in soft tissues. New bone growth occurs (involukrum) and surrounds the sequestrum. Although there appeared to be healing, but the sequestrum remains vulnerable to infectious chronic recurrent abscesses issue.

      Source : http://nanda-nursing-care-plan.blogspot.com/2012/07/pathophysiology-of-osteomyelitis.html

      Nursing Management of Diabetic Ulcers

      Nursing Management of Diabetic Ulcers

      Diabetic ulcers are sores, or pain that occurs at the foot of the person who has suffered from diabetes mellitus.

      Meanwhile, according to Askandar (2001) Diabetic Ulcers are sores on the feet of red-black and foul smelling due to the blockage that occurred in medium or large vessels in the legs.

      The cause of diabetic ulcers

      Diabetic ulcers occur because of complications of diabetes mellitus called sensory neuropathy. People with diabetes also have poor blood circulation, thereby causing injury to the toe easily or toes which can lead to ulcer / gangrene.

      Diabetic ulcer wound care
      • Dressing and wound control and help protect the wound from further damage.
      • Keep the circulation in the legs with active passive movement.
      • Control blood sugar levels.
      • If necessary, collaboration with medical debridement for action.

      Prevention to avoid diabetic ulcers
      • For patients with diabetes mellitus are at risk for diabetic ulcers should consult immediately to health care. If you experience itching, blisters, blisters between the toes or on the skin around the toes. Pale-colored toes, aching or tingling, skin cracks and breaks, signs of inflammation.
      • Clean your feet every day with water that is not too cold or hot and use a soft cloth to clean your toes.
      • Use a moisturizing cream on dry skin. Not be used in between the toes.
      • Prevent skin irritation on the foot.
      • Maintenance / cut nails should be done with caution. Cut nails straight and smooth after immersion for 20 minutes in water, so that the nail is not hard.
      • Wear clean socks every day. Socks should not be too tight so that air circulation is not obstructed.
      • Avoid using tight shoes to prevent blisters.
      Source : http://nanda-nursing-care-plan.blogspot.com/2012/07/nursing-management-of-diabetic-ulcers.html