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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.

Intervention:
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

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.

5 Nursing Management for Hallucinations

According May Thomas Durant (2004) hallucinations can generally be found in patients with psychiatric disorders such as: skizoprenia, depression, delirium and conditions associated with alcohol use, and environmental substances. Based on the assessment results of mental hospital patients found 85% of patients with hallucinations. So I feel compelled to write the case with the provision of nursing care ranging from assessment to evaluation.

1. Creating a therapeutic environment

To reduce the level of anxiety, panic and fear in patients affected by hallucinations, preferably at the beginning of the approach, carried out on an individual basis and keep the eye contact occurs, if the patient can touch or hold. Patients not in isolation either physically or emotionally. Each nurse came into the room or close to the patient, talk with the patient. So also when it will leave the patient should be notified. The patient was told that action will be undertaken. In that room should provide a means in which to stimulate attention and encourage patients to get in touch with reality, such as wall clocks, pictures or wall hangings, magazines and games.

2. Implement treatment programs doctor

Often patients refuse medication that is given with respect to the stimuli received hallucinations. The approach should be persuasive but instructive. Nurses must observe in order to provide correct drug ingested, as well as drug reactions is given.

3. Explores the problems of patients and help overcome existing problems.

Once the patient is more cooperative and communicative, nurses can explore issues that are causing the patient's hallucinations and help resolve any problems. This data collection can also be through the patient's description of the family or others close to the patient.

4. Giving activity in patients.

Patients were invited to enable themselves to perform physical movements, such as exercising, playing or doing activities. This activity can help steer patients to real life and cultivate relationships with other people. Patients in whom draw up a schedule of activities and choose appropriate activities.

5. Involving the family and other officers in the care process.

The patient's family and other officials should be notified about the patient data so that there is unity and continuity in the opinion of the nursing process, for example from a conversation with the patient in the know when it is alone, he often heard the man mocked. But if there are others nearby voices were not audible. The nurse suggested that the patient should not be alone and get busy in a game or activity there. This conversation should be in the patient's family and let petugaslain not to let the patient alone and advice that is given is not contradictory.

Nursing Diagnosis and Interventions for Low Self-Esteem

Definition of Low Self-Esteem

Low Self-Esteem is a self-resisted as something precious and can not be responsible for their own lives.


Process of Low Self-Esteem

Self-concept is defined as all the thoughts, beliefs, and beliefs that make a person knows about themselves and affect relationships with others (Stuart & Sunden, 1995). The concept of self is not formed since birth but learned.

One component is the concept of self-esteem, self-esteem which is about the attainment of individual self-assessment by analyzing how far the behavior in accordance with the ideal self (Keliat, 1999). While low self esteem is rejected him as something of value and not responsible for her own life. If an individual often fails then tend to low self esteem. Low self esteem if the loss of love and appreciation of others. Self-esteem derived from self and others, the main aspect was accepted and received the award from someone else.

Low self esteem disorder described as feeling negative about themselves, including loss of self-confidence and self-esteem, feeling failed to reach the desire, self-criticism, reduced productivity, destructive directed at other people, feelings of inadequacy, irritable and withdrawn socially.

Factors affecting self-esteem include parental rejection, parental expectations are not realistic, repeated failures, have less personal responsibility, dependence on others and the ideal self is not realistic. While the originator stressors may result from internal and external sources such as :
  1. Trauma such as sexual abuse and psychological or witnessing events that threaten.
  2. Tensions related to the role or roles expected position in which the individual experiencing frustration.

Disorders of self-esteem or low self esteem can occur:
  1. Situational, which occurred a sudden trauma, for example, should the operation, accident, her husband divorced, dropping out of school, working breakup, etc.. In patients treated low self esteem can occur because of privacy that less attention: the indiscriminate physical examination, the installation of equipment that is not polite (catheter, perianal inspection checks etc..), Hope for the structure, shape and function of the body that is not achieved because in-patient / illness / disease, treatment of workers who do not appreciate.
  2. Chronic, that negative feelings toward themselves have lasted long.

Nursing Diagnosis

  1. Risk for social isolation: withdrawal related to low self esteem.
  2. Self-concept Disturbance: low self-esteem related to dysfunctional grieving.

Nursing Interventions

1. Clients can build a trusting relationship with caregivers
action:
1.1. Construct a trusting relationship: therapeutic greetings, self-introduction, explain the purpose, creating a quiet environment, create a clear contract (time, place and topic of conversation).
1.2. Give the client a chance to express feelings.
1.3. Take time to listen to clients.
1.4. Tell the client that he is someone who is valuable and responsible and able to help themselves.

2. Clients can identify capabilities and positive aspects possessed.
action:
2.1. Discuss capabilities and positive aspects of client owned.
2.2. Avoid giving a negative assessment of each meeting client, focusing on realistic compliment.
2.3. Clients can assess the capabilities and positive aspects possessed.

3. Clients can assess the capabilities that can be used.
action:
3.1. Discuss with the client the ability to still be used.
3.2. Discuss also the ability to continue after returning home.

4. Clients can assign / plan activities appropriate capabilities.
action:
4.1. Plan with client activity to do each day according to ability.
4.2. Increase activity according to the tolerance of the client's condition.
4.3. Give examples of how the implementation of activities that the client should do.

5. Clients can perform activities according to the conditions and capabilities
action:
5.1. Give a chance to try activities that have been planned.
5.2. Give praise / reward for success.
5.3. Discuss the possibility of implementation at home.

Nursing Diagnosis and Interventions for Constipation

Constipation is a little defecation frequency, stool is not sufficient in number, in the form of hard and dry (Oenzil, 1995).

Constipation is a decrease in frequency of defecation, stool followed by spending long or hard and dry. There was an effort straining during defecation is a sign associated with constipation. If the small intestine motility slowed, a longer period of exposure to feces on the intestinal wall and most of the absorbed water content in the feces. A small amount of water left out to soften and lubricate the stool. Spending dry and hard stools can cause pain in the rectum. (Potter & Perry, 2005).

1. Constipation related to irregular defecation pattern

Goal : Patients can defecate regularly (every day)

Outcomes:
  • Defecation can be done once a day.
  • Soft stool consistency.
  • Faecal elimination without excessive straining.
Nursing Interventions:

Independent:
1. Determine the pattern of defecation and trained to do so.
Rationale: To restore the regularity of defecation pattern.

2. Set the right time for defecation, such as after meals.
Rationale: To facilitate defecation reflex.

3. Provide coverage in accordance with the indications of nutritional fiber.
Rationale: Nutrition high fiber to launch fecal elimination.

4. Give fluids if not contraindicated 2-3 liters per day.
Rationale: To soften the stool elimination.

Collaboration:
5. Provision of laxatives or enemas as indicated.
Rationale: To soften the stool.


2. Imbalanced Nutrition, Less Than Body Requirements related to loss of appetite

Goal: demonstrate good nutritional status

Outcomes:
  • Tolerance to dietary needs.
  • Maintain body mass and body weight in the normal range.
  • Laboratory values ​​within normal limits.
  • Reported adequacy of energy levels.
Nursing Interventions:

Independent :
1. Make meal planning to put in a feeding schedule.
Rationale : Keeping the patient's diet, so patients eat regularly.

2. Support family members to bring favorite foods from the patient's home.
Rationale : The patient feels comfortable with food brought from home and can improve the patient's appetite.

3. Offer large meals during the day when the high appetite.
Rationale : By giving a large portion can maintain adequacy of nutrient intake.

4. Ensure that the diet meets the needs of the body as indicated.
Rationale : High carbohydrate, protein, and calories needed or required for treatment.

5. Make sure that the patient's diet is liked or disliked.
Rationale : To support the improvement of the patient's appetite.

6. Monitor input and expenditure and body weight periodically.
Rationale : Knowing the balance of food intake and output.

7. Assess the patient's skin turgor.
Rationale : As the data supporting a change in nutrition less than the requirement.

Collaboration:

8. Monitor laboratory values​​, such as hemoglobin, albumin, and blood glucose levels.
Rationale: In order to determine the level of Hb content deficiencies, albumin, and glucose in the blood.

9. Teach method for meal planning.
Rationale: Clients are accustomed to eating in a planned and orderly.

10. Health Education: Teach patients and families about nutritious food and not expensive.
Rational: Maintain the required nutrition adequacy.

Pathophysiology of Constipation

Defecation as well on urination is a physiological process that includes working smooth muscles, and fiber latitude, central and peripheral innervation, coordination of the reflex system, good awareness and physical ability to reach a place of defecation. The difficulty of diagnosis and management of constipation is because of the many mechanisms involved in the normal process of defecation (urge to defecate normally stimulated by rectal distension through four stages, among others: the stimulus baffle recto-anal reflex, muscle relaxation of the internal sphincter, external sphincter muscle relaxation and muscles in the pelvic region, and an increase in intra-abdominal pressure).

Disruption of one of these mechanisms can result in constipation. Defecation starting peristalsis of the large intestine to the rectum to deliver feces removed. Feces enter and stretch the ampulla of the rectum followed by relaxation of the internal anal sphincter. To avoid spontaneous spending stool, occurring reflex contraction of the external anal sphincter and pelvic floor muscle contraction that is innervated by the pudendal nerve. The brain receives stimuli desire for defecation and external anal sphincter relaxation was ordered to, so the rectum expel its contents with the help of muscle contractions of the abdominal wall. This contraction will raise the pressure in the stomach, and muscle relaxation of the sphincter ani elevators. Both sympathetic and parasympathetic innervation involved in the process of defecation.

The pathogenesis of constipation varied, multiple causes, including several overlapping factors. Although constipation is a lot of complaints in the elderly, colonic motility was not affected by age. Normal aging process does not result in a slowing of gastrointestinal trip. Pathophysiological changes that cause constipation not due to age but is particularly the case for those with constipation.

Study with radiopaque sign ingested by healthy elderly people who do not get a change of the total time of bowel movements, including motor activity of the colon. About time bowel movements by following the radiopaque markers are swallowed, normally less than 3 days already incurred. In contrast, studies in older people who suffer from constipation, bowel movements showed an extended time of 4-9 days. In those treated or bedridden, can be extended to 14 days. Radioactive markers used mainly slow the course of the left colon and the slowest time of the expenditure of the sigmoid colon. Electrophysiological examination to measure motor activity of the colon of patients with constipation showed reduced motor responses of the sigmoid due to reduced intrinsic innervation because myentericus plexus degeneration. Found also reduced nerve stimulation in circular smooth muscle that can lead to an increased time bowel movements.

Individuals over the age of 60 years are also shown to have plasma levels of beta-endorphins are increased, accompanied by an increase in endogenous opiate binding to receptors in the gut. This is evidenced by the effect of dosage opiate constipation that can cause relaxation of colonic tone, reduced motility, and inhibits gastric-colonic reflex.

In addition, there is a tendency of decrease in sphincter tone and strength of smooth muscles associated with age, particularly in women. Patients with constipation have a greater difficulty to remove the small, hard stools that attempts to push harder and longer. This can result in pressure on the pudendal nerve, causing further weakness.

Causes and Risk Factors of Colon Cancer

The cause of the Colon cancer is unknown. Diet and reduction in circulation time in the large intestine (flow front feces) that includes the causative factor. Appropriate precautionary instructions recommended by the American Cancer Society, the National Cancer Institute, and other cancer organizations.

Risk factors for colon cancer:
  • Age over 40 years.
  • Blood in the stool.
  • History of rectal polyps or colon polyps.
  • Adematosa polyps or adenomas villus.
  • Family history of colon cancer or polyposis in the family.
  • History of chronic inflammatory bowel disease.
  • Diets high in fat, protein, meat and low in fiber.
Some groups recommend a diet that had the little animal fat and high in vegetables and fruits (eg Mormons, Seventh Day Adventists).

Foods to avoid:
  • Red meat.
  • Animal fats.
  • Fatty foods.
  • Meat and fish fried or grilled.
  • Carbohydrates are filtered (example: the filtered juice)
Foods should be consumed:
  • Fruits and vegetables, especially Craciferous Vegetables from the cabbage group (such as broccoli, brussels sprouts).
  • Whole grain rice.
  • Enough fluids, especially water.
Since most colon tumors produce adenomas, the main factors that endanger the colon, causing adenomas.

There are three types of colon adenomas: tubular, villous and tubulo villous. Although most colon cancers originate from adenomas, only 5% of all adenomas Colon became manigna, villous adenomas have a high potential to be manigna.

People who have had ucerative colitis or Crohn's disease also have a risk of Colon cancer. The addition of a risk at the beginning of a younger age and a higher level of involvement of the colon. Colon cancer risk would be 2/3 times greater if a family member suffering from the disease.

Tests and Investigations for Colon Cancer

Colon is a muscular, tube-shaped organ located at the lower part of your digestive system. The organ has a key role in helping the body taking in nutrients, water, and minerals. It also helps in removing waste of the body in the form of stool.

Colon cancer is the growth of malignant tumor in the tissue of the colon (in the inner wall of the organ).

Colon cancer symptoms aggravate as the malignancy heads toward the later stage. The asymptomatic illness suddenly becomes filled with disturbing manifestations, particularly abdominal pain that is present even during the earlier stage of Colon cancer.

It is important to note that most of colon cancer cases start as small, noncancerous clumps of cells known as polyps. By time some of these polyps could become cancers.

Signs and Symptoms
  • Slimmer size of feces
  • Feeling of abdominal fullness or incomplete bowel emptying
  • Abrupt weight reduction
  • Abdominal flatulence
  • Feeling of incomplete elimination of fecal matter or stool
  • Feeling of need to throw up (nausea) and actual vomiting
  • Bowel movement disturbances like loose bowel movement (diarrhea) or difficulty of passing hardened stool (constipation)
  • Gastrointestinal bleeding manifested by bloody stool (melena or hematochezia)


Tests and Investigations for Colon Cancer

1. Endoscopy

Endoscopic examination needs to be done, either sigmoidoscopy or colonoscopy. Typical picture of carcinoma or ulcer can be seen clearly on endoscopy, and to establish the diagnosis a biopsy is necessary.

2. Radiology

Radiological examination can be done include: breast and colon (barium enema).

Barium enema examination may be able to clarify the state of the tumor and identify its location. This test illustrates the possible existence of a deadlock on the contents of the stomach, where a reduction in tumor size in the lumen. Small wounds may not be identified by this test. Barium enema is generally done after sigmoidoscopy and colonoscopy.

Computer Tomography (CT) help clarify the broad masses and the presence of disease. Chest X-ray and liver scan may be able to find a place that is distant metastatic.

Chest examination is useful in addition to see whether there is metastasis to the lung cancer can also be used in preparation for surgery. In colon photo can be seen a filling defect in a place or a stricture.

3. Ultrasonography (USG).

This examination is useful for detecting the presence or absence of metastatic cancer in the lymph nodes in the abdomen and liver.

4. Histopathology

In addition to performing endoscopy, biopsy should be done in a few places for histopathological examination to confirm the diagnosis. Histopathological picture of colorectal carcinoma is adenocarcinoma, and differentiation of cells need to be determined.

5. Laboratory

There is no distinctive marker for colorectal carcinoma, however any patient who experienced bleeding needs to be checked Hb.

Tumor markers commonly used are CEA. CEA levels over 5 mg / ml is usually found already advanced colorectal carcinoma.

Based on research, the CEA can not be used for the early detection of colorectal carcinoma, because the titer was found more than 5 mg / ml only in one third of cases of stage III. Patients with mucous bloody bowel movements, stool should be examined in bacteriological against shigella and amoeba.

6. Scan (for example, MRI. CZ: gallium) and ultrasound:

Performed for diagnostic purposes, the identification of metastatic, and evaluation of response to treatment.

7. Biopsy (aspiration, excision, needle)

Done for the appeal and describe the diagnostic and treatment can be done through the bone marrow, skin, organs and so on.

8. Complete blood counts

With differential and platelets: Can indicate anemia, changes in red blood cells and white blood cells: platelets increases or decreases.

9. Chest X-ray:

Investigate metastatic or primary lung disease.

The Concept of Adolescence - Definition, Categorization and Characteristics

Definition of Adolescence

The term adolescence is derived from the noun "adolescenta", which means teenagers, which means it grows into an adult (Hurlock, 2001).

Adolescence means gradually toward physical maturity, intellect, mental, social and emotional. This suggests the general nature, namely that growth does not move from one phase to the other phase abruptly, but the growth was taking place step by step.

Adolescent is a period of transition between childhood and adolescence, teens are often faced with a confusing situation, on the one hand we need to behave like an adult and the other side can not be said to be an adult.

Changes of puberty in girls is occurring menarche (first menstruation). This suggests that the reproductive organs begin to mature.


Categorization of Adolescence

The World Health Organization set a limit on Adolescence in 2 parts:

1) The period of early adolescence
This period ranges from age 10 to 12 years. The period of adolescence is a period of transition from children's to adult period. This period is considered as the days are very important in one's life, especially in the formation of individual personality.

2) The period of late adolescence
The period between ages 15 to 20 years. The period of adolescence is a period of consolidation of identity. His understanding of "who I am" is influenced by the views of those around him as well as his personal experiences to determine patterns of behavior as adults. Stabilization of self-identity is not always run smoothly, but often through a long and turbulent process. Therefore, many experts call this period as a time-period of storm and stress (Latifah, 2008).


Categorizing of Adolescents (Hurlock, 2001):

1) Adolescence boy
Adolescence boy puberty between the ages of 14-17 years.

2) Adolescent girls
Adolescent girls experiencing puberty at age 12-15 years.


Characteristics of Adolescence

Adolescence has certain characteristics that distinguish the periods before and after, these characteristics include:

1. Adolescence is a critical period
The existence of a direct effect on attitudes and behavior as well as the long -term consequences make the adolescent period is more important than any other period. In addition to the physical development of rapid and important accompanied by the rapid mental development, especially in early adolescence, which all lead to the need for the development of mental adjustment and shape attitudes, values and new interest (Hurlock, 2001).

2. Adolescence is a transitional period
The transition does not mean disconnected with what happened before, but the transition from one stage of development to the next stage. Meaning that happened before will leave its mark on what is happening now and in the future (Hurlock, 2001).

3. Adolescence is a time of change
When a physical change occurs rapidly, changes in behavior and attitudes are also taking place rapidly, that decreased physical changes, the changes in behavior and attitudes decreased as welll.

4. Adolescence is a period of identity search
Conformity with the standards group is considered much more important for adolescents than individuality, and if not adjust the teen group will be expelled from the group. But gradually they began to search for identity and no longer satisfied together with his friends in every way, as before.

5. Adolescence as a troubled age
Problems in adolescence is often a difficult problem to overcome either by adolescent boys and girls (Hurlock, 2001). And many teens are aware that the completion of which he passes himself did not always correspond with their expectations.

Nursing Assessment and Physical Examination for Pre and Postoperative Appendectomy

Appendectomy is the removal of the inflamed appendix with procedures or endoscopic approach.

Complaints that often arise in post appendectomy is the verbal communication of pain that is felt, behavior too cautious, behavioral aberrations, (moaning, crying, restlessness), the face shows pain (eyes gloomy, sullen, restricting movement).

Nursing Assessment for Appendicitis

Assessment is the process whereby data relating to clients systematically collected. This process is dynamic and organized process that involves three basic activities, ie systematically collect, sort and organize the collected data and document data in a format that can be opened again. Assessment is used to recognize and identify health problems and needs of the client and the client's nursing physical, mental, social and environmental.

This Assessment contains:

1) Identity.
The identity of the client Appendicitis Post Operative on which to base the assessment, include: name, age, gender, education, occupation, religion, address, medical diagnosis, medical treatment, medical record number, date of entry, date of surgery and the date of assessment.
The identity of the person in charge, include: name, age, gender, education, occupation, religion, address, relationship with the client and resource costs.

2) The scope of health problems containing the main complaint when assessed client, the client post appendectomy usually complain of pain in the surgical wound and activity limitations.


History of Disease.

1) History of present illness.
History of present illness found during the assessment, which is described from start to enter care facilities to do the assessment. Complaints are now assessed using PQRST (palliative and provocative, quality and quantity, region and radiation, the severity scale and timing). Clients who have undergone appendectomy surgery generally complain of pain at the surgical site will increase when moved or pressed and generally decreases after being given the drug and rested. The pain is felt just as tingling with pain scale of more than five (0-10). The pain will be localized in the area of ​​operation can also be spread throughout the abdomen and right thigh and generally persists throughout the day. Pain may be able to interfere with the activity of the corresponding tolerance range of each client.

2) Formerly medical history.
Contains previous illness experience, whether it impinges on the illness now and if ever experienced before surgery.

3) Family health history.
Keep in mind if there are other family members who suffer from the same illness as clients, also examined the presence of infectious disease in the offspring or family.

4) Psychological History.
In general, clients with post appendectomy, do not undergo psychological aberration function. Nevertheless, you still need to be done on the fifth concept of client self (body image, self-identity, role function, ideal self and self-esteem.

5) Social History.
Clients with post appendectomy is not impaired in social relationships with other people, but still have to compare the social relationship between the client before and after surgery.

6) Spiritual History.
In general, clients who underwent treatment will experience limitations in activities as well as in religious activities. Need to be assessed against sickness client confidence and motivation for recovery.

7) Daily Habit.
Clients who underwent surgical removal of the appendix is generally experienced difficulties in the move, because of acute pain and weakness. Clients may experience a disruption in self-care (bathing, brushing teeth, shampoo and nail clippers), as activity intolerance, impaired.

Clients will experience a restriction digestion oral input to the function back into the normal range. Possible clients will experience nausea, vomiting and constipation in the early postoperative period due to the influence of anesthesia. Oral intake can be started after the digestive functions back into the normal range. Clients can also experience decreased urine output because of the restriction of oral input. Urine output would gradually to normal after an increase in oral input. The pattern can be disturbed ataupu break client is not compromised, depending on client's tolerance to pain is felt.


Physical Examination

Physical examination includes:

General state
Post-appendectomy clients achieve full consciousness after a few hours back from the operating table, the appearance suggests a state of mild pain to severe depending on the period of acute pain. Generally stable vital signs but will experience instability in clients who experienced perforation of the appendix.

Respiratory System
Clients will post appendectomy decreased or increased respiratory rate (tachypnea) and shallow breathing, according to the range tolerated by the client.

Cardiovascular system
Generally clients experience tachycardia (as a response to stress and hypovolemia), had hypertension (as a response to pain), hypotension (weakness and bed rest). Usually normal capillary refill, also examined the state of the conjunctiva, and the presence of cyanosis, auscultation of heart sounds.

Digestive system
The presence of pain at the surgical site in the lower right abdomen when palpated. Clients post appendectomy usually complain of nausea and vomiting, constipation in early postoperative and decreased bowel sounds. Will appear the surgical wound in the lower right abdominal incision surgery.

urinary system
Early postoperative client will experience a decrease in the amount of urine output, this happens because of the restriction of oral intact during the initial period of post-appendectomy. Normal urine output would gradually with increasing oral intake.

Musculoskeletal system
In general, the client may experience weakness due to postoperative bed rest and stiffness. Muscle strength gradually improved with increasing activity tolerance.

Integumentary system
Will appear the surgical wound in the lower right abdomen for surgical incision with redness (usually in early onset). Skin turgor will improve with an increase in oral intake.

Nerve system
Generally clients with post appendectomy is not experiencing irregularities in neural function. Assessment persafan functions include: level of consciousness, cranial nerves and reflexes.

Hearing system
Assessment conducted include: ear shape and symmetry, presence or absence of inflammation and auditory function.

Endocrine system
Generally clients post appendectomy, no abnormal endocrine function. But still need to be assessed adequacy endocrine function (thyroid, etc.).

Measles Nursing Diagnosis and Interventions

Measles is a highly contagious viral infection, which is characterized by fever, cough, conjunctivitis (inflammation of the lining of connective eye / conjunctiva) and skin rash. The disease is caused by infection of measles virus, Paramixovirus class. Transmission of the infection occurs because of inhaling spray saliva from patients with measles. Patients can transmit the infection within 2-4 days before the onset of skin rash and 4 days after the rash there. Before the widespread use of measles vaccination, measles outbreaks occur every 2-3 years, especially in children aged pre-school and elementary school children. If someone has had measles, then the rest of his life he normally would be immune to this disease.

Symptoms begin to appear within 7-14 days after infection, which are: body heat, sore throat, runny nose, cough, muscle pain, red eyes (conjuctivitis). And 2-4 days later, small white spots appear on the inside of the mouth. Rash (redness of skin) that feels a bit itchy appear 3-5 days after the onset of the above symptoms. This could take the form of macular rash (rash reddish flat) and papules (red rash that stands out). At first the rash appears on the face, which is in front of and below the ears and on the neck next to the side. Within 1-2 days, the rash spreads to the trunk, arms and legs, while a rash on the face began to fade. At the peak of the disease, the patient was very ill, and the rash extends his body temperature reached 40 ° Celsius. At 3-5 days later his temperature dropped, the patient begins to feel well and left immediately rash disappeared. Fever, lethargy, runny nose, cough and red eyes and inflammation for several days followed by a red blotchy rash that started on the face and spread to the body and there for 4 days to 7 days.

1. Impaired social interaction related to isolation from friends.

Expected results:
  • Children demonstrate an understanding of the restrictions.
  • Appropriate child activities and interact.

Intervention:
1. Explain the reason for the isolation and use of special vigilance.
Rational: to increase children's understanding of the discussion.

2. Let the children play the gloves and masks.
Rational: to facilitate positive coping.

3. Provide diversion activities.
Rational: the right to perform activities and interact.

4. Encourage parents to stay with their children during hospitalization.
Rational: to reduce separation and provide proximity.

5. Prepare children for changes perampilan friends physically.
Rationale: to encourage the acceptance of friends.


2. Risk for impaired skin integrity related to raking pruritus.

Expected results: the skin remains intact

Intervention:
1. Keep nails short and clean.
Rational: to minimize the trauma and secondary infection.

2. Wear gloves or elbow restrein.
Rational: to prevent scratching.

3. Give clothes are thin, loose, and not to irritate.
Rationale: because excessive heat can increase itching.

4. Close area of ​​pain (long sleeves, long pants, underwear layer).
Rational: to prevent scratching.

5. Give lotion that softens (very little on the open lesions).
Rationale: because the open lesions to reduce drug absorption increased pruritus.

6. Avoid exposure to sunlight or heat.
Rationale: cause rashes.