Knowledge Deficit Definition and Related Factors

Nursing Diagnosis for Knowledge Deficit

Knowledge Deficit : About the Disease Process

Knowledge Deficit Definition:


The absence or lack of cognitive information in connection with a specific topic.

Defining characteristics:

verbalization of problems,
inaccuracies follow instructions,
inappropriate behavior.

Knowledge Deficit Related Factors:

cognitive limitations,
interpretations of misinformation,
lack of desire to seek information,
not knowing the sources of information.


NOC:

Kowlwdge: disease process
Kowledge: health behavior


Results Criteria:

Patients and families express an understanding of the disease, condition, prognosis and treatment programs
Patients and families are able to perform the procedure correctly explained
Patients and families are able to explain again what was described nurse / other health team


NIC:

Teaching: Disease Process

Give your assessment of the level of knowledge about the patient's specific disease process
Describe the pathophysiology of the disease and how it relates to anatomy and physiology, in a proper way.
Describe the usual signs and symptoms appear the disease, in a proper way
Describe the disease process, the proper way
Identify possible causes, dengna proper way
Provide information to patients about the condition, in a proper way
Avoid a hopeless
Provide information to families about the progress of patients in an appropriate manner
Discuss lifestyle changes that may be necessary to prevent complications in the future and controlling disease or process
Discuss the choice of therapy or treatment
Encourage the patient to explore or get a second view in a proper way or indicated
Exploration of possible sources or support, the proper way
Refer patients to the group or agency in the local community, in a proper way
Instruct the patient about the signs and symptoms to report on health care givers, in a proper way

Nursing Management of Low Back Pain

1. Relieves Pain

To reduce pain nurses can encourage patients to bed rest and modification of the position is determined to improve lumbar flexion. Patients are taught to control and adjust the pains that go through the respiratory diaphragm and relaxation can help reduce muscle tension that contributes to lower back pain. Distract patients from pain with other activities such as reading books, watching TV and with imagination.

Massage of the soft tissue, gently is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. When given the drug the nurse should assess the patient's response to each drug.

2. Improving physical mobility

Physical mobility is monitored through continuous assessment. Nurses assess how patients move and stand. Once back pain is reduced, self-care activities may be performed with minimal strain on the injured structure. Change of position should be done slowly and assisted if necessary. Circular motion and sway should be avoided. Patients are encouraged to switch activities lying, sitting and walking around for a long time. Nurses need to encourage patients comply with exercise programs according to established, that one just does not exercise effective.

4. Health education

Patients must be taught how to sit, stand, lie down and lifting objects properly.

5. Improving the performance of the role

Responsibilities associated with the role may have changed since the occurrence of lower back pain. Once the pain healed, patients can return to his role of responsibility again. But when the activity is impacting on the bottom of back pain occurs again, it may be difficult to return to the original responsibility without bearing the risk of chronic low back pain with disability and depression caused.

6. Changing nutrition and weight loss

Weight loss through eating way of adjustment can prevent recurrence of back pain, by means of the rational nutrition plan that includes changes in eating habits to maintain a desired weight.


Evaluation

1. Experienced pain relief

- Rest in comfort
- Change the position comfortably
- Avoidance of drug dependence

2. Shows the return of physical mobility

- Return to activity gradually
- Avoid positions that cause discomfort which causes muscle
- Plan rest breaks throughout the day

3. Demonstrate body mechanics that maintain back

- Improved posture
- Changing the position of its own to minimize back stress
- Demonstrating the use of good body mechanics
- Participate in training programs

4. Back to the responsibilities associated with roles

- Use techniques facing problems to adjust to stressful situations
- Shows the reduction in dependence on others for self care
- Back to work when the back pain has been healed
- Return to full productive lifestyle

5. Achieving the desired body weight

- Identify the need for weight loss
- Participate in the development of weight loss plan
- Faithful to the weight-loss program

Source : http://nursing-care-plan.blogspot.com/2011/11/nursing-care-plan-for-low-back-pain.html

LBP Low Back Pain Nursing Diagnosis

The lower back is an intricate structure of interconnected and overlapping elements:

• Tendons and muscles and other soft tissues
• Highly sensitive nerves and nerve roots that travel from the lower back down into the legs and feet
• Small and complex joints
• Spinal discs with their gelatinous inner cores.

An irritation or problem with any of these structures can cause lower back pain and/or pain that radiates or is referred to other parts of the body. Pain from resultant lower back muscle spasms can be severe, and pain from a number of syndromes can become chronic.

These lower back pain symptoms include any combination of the following:

• Difficulty moving that can be severe enough to prevent walking or standing
• Pain that does not radiate down leg or pain that also moves around to the groin, buttock or upper thigh, but rarely travels below the knee;
• Pain that tends to be achy and dull
• Muscle spasms, which can be severe
• Local soreness upon touch

Nursing Diagnosis of Low Back Pain

1. Acute pain associated with musculoskeletal problems.

2. Impaired physical mobility related to pain, muscle spasm, and reduced flexibility.

3. Deficient knowledge related to body mechanics techniques to protect the back.

4. Ineffective Role Performance related to impaired mobility and chronic pain.

5. Imbalanced Nutrition: more than body requirements related to obesity.

Anxiety Nursing Diagnosis

Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks.


Anxiety

Related to :

• Anesthesia
• Anticipated/actual pain
• Disease
• Invasive/noninvasive procedure:
• Loss of significant other
• Threat to self-concept

Evidenced by

• Physiological :
  • Increase in blood pressure, pulse, and respirations
  • Dizziness, light-headedness
  • Perspiration
  • Frequent urination
  • Flushing
  • Dyspnea
  • Palpitations
  • Dry mouth
  • Headaches
  • Nausea and/or diarrhea
  • Restlessness
  • Pacing
  • Pupil dilation
  • Insomnia, nightmares
  • Trembling
  • Feelings of helplessness and discomfort
  
  
• Behavioral :
  • Expressions of helplessness
  • Feelings of inadequacy
  • Crying
  • Difficulty concentrating
  • Rumination
  • Inability to problem-solve
  • Preoccupation
  
  

Outcome :

1. Demonstrate a decrease in anxiety A.E.B.:

• A reduction in presenting physiological, emotional, and/or cognitive manifestations of anxiety.
• Verbalization of relief of anxiety.

Nursing InterventionAssist patient to reduce present level of anxiety by :

• Provide reassurance and comfort.
• Stay with person.
• Don't make demands or request any decisions.
• Speak slowly and calmly.
• Attend to physical symptoms. Describe symptoms:

2. Discuss/demonstrate effective coping mechanisms for dealing with anxiety.

Nursing Intervention

• Discuss alternate strategies for handling anxiety. (Eg.: exercise, relaxation techniques and exercises, stress management classes, directed conversation (by nurse), assertiveness training)
• Set limits on manipulation or irrational demands.
• Help establish short term goals that can be attained.
• Identify and reinforce coping strategies patient has used in the past.
• Discuss advantages and disadvantages of existing coping methods.
• Give clear, concise explanations regarding impending procedures.
• Focus on present situation.
• Reinforce positive responses.
• Initiate health teaching and referrals as indicated 

Nursing Diagnosis Ineffective Airway Clearance

Nursing Diagnosis: Ineffective Airway Clearance

NANDA Definition : Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

Defining Characteristics: Abnormal breath sounds (crackles, rhonchi, wheezes)
* Changes in respiratory rate or depth
* Cough
* Hypoxemia/cyanosis
* Dyspnea
* Chest wheezing
* Fever
* Tachycardia

Related Factors: Decreased energy and fatigue
* Ineffective cough
* Tracheobronchial infection
* Tracheobronchial obstruction (including foreign body aspiration)
* Copious tracheobronchial secretions
* Perceptual/cognitive impairment
* Impaired respiratory muscle function
* Trauma

NOC Outcomes (Nursing Outcomes Classification)

* Respiratory Status: Airway Patency

NIC Interventions (Nursing Interventions Classification)

* Cough Enhancement
* Airway Management
* Airway Suctioning


Expected Outcomes Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.

Nursing Management of Rheumatoid Arthritis (RA)

The main objective of Nursing Management program are as follows:

• To relieve pain and inflammation
• To maintain joint function and the maximum ability of the patient
• To prevent and or correct deformity that occurs in joints
• Maintaining independence so as not to depend on others.

There are several ways the management to achieve the goals mentioned above, namely:

Education
The first step of this management program is to provide adequate education about the disease to patients, families and anyone associated with the patient. Education will include understanding the pathophysiology (disease course), the causes and estimated journey (prognosis) of the disease, all components of program management including complex drug regimens, sources of help to overcome this illness and effective method of management provided by health teams . This educational process must be done continuously.

Rest
It is important because rheumatic usually accompanied by severe fatigue. Although fatigue may arise every day, but there are times when patients feel better or heavier. Patients should be divided into several time a day time activity which was followed by a period of rest.

Physical Exercise
Specific exercises can be useful in maintaining joint function. This exercise includes active and passive movement on all the joints are sore, at least twice a day. Drugs for pain relief should be given before starting the exercise. Hot compresses on the sore and swollen joints may reduce pain. Paraffin bath with temperature can be regulated and shower with hot and cold temperatures can be done at home. Exercise and termoterapi is best regulated by the health workers who have received specialized training, such as a physical therapist or occupational therapist. Excessive exercise can damage the supporting structure of the joints that are already weakened by the disease.

Diet / Nutrition
Rheumatic Patients do not require a special diet. There are a number of ways with a variety of diets that vary, but all of them unsubstantiated. The general principle for obtaining a balanced diet is important.

Drugs
Administration of drugs is an important part of all rheumatic disease management programs. Drugs used to reduce pain, relieve inflammation and to try to change the course of the disease.

Source : http://all-nurses.blogspot.com/2011/06/nursing-management-of-patients-with.html

Nursing Assessment for Schizophrenia

Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.3–0.7%. Diagnosis is based on observed behavior and the patient's reported experiences.

Schizophrenia is associated with a wide variety of abnormal behaviors; therefore, assessment findings vary greatly, depending on both the type and phase of the illness. The individual may exhibit a decreased emotional expression, impaired concentration, and decreased social functioning, loss of function, or anhedonia. Individuals with these particular symptoms (present in one-third of the schizophrenic population) are associated with poor response to drug treatment and poor outcome.

Although behaviors and functional deficiencies can vary widely among patients and even in the same patient at different times, watch for the following characteristic signs and symptoms during the assessment interview:

1. ambivalence coexisting strong positive and negative feelings, leading to emotional conflict
2. apathy
3. clang associations words that rhyme or sound alike used in an illogical, nonsensical manner; for instance, It's the rain, train, pain.
4. concrete thinking inability to form or understand abstract thoughts
5. delusions false ideas or beliefs accepted as real by the patient. Delusions of grandeur, persecution, and reference (distorted belief regarding the relation between events and one's self; for example, a belief that television programs address the patient on a personal level) are common in schizophrenia. Also common are feelings of being controlled, somatic illness, and depersonalization.
6. echolalia meaningless repetition of words or phrases
7. echopraxia involuntary repetition of movements observed in others
8. flight of ideas rapid succession of incomplete and poorly connected ideas
9. hallucinations false sensory perceptions with no basis in reality. Usually visual or auditory, hallucinations may also be olfactory (smell), gustatory (taste), or tactile (touch).
10. illusions—false sensory perceptions with some basis in reality; for example, a car backfiring might be mistaken for a gunshot.
11. loose associations not connected or related by logic or rationality
12. magical thinking belief that thoughts or wishes can control other people or events
13. neologisms bizarre words that have meaning only for the patient
14. poor interpersonal relationships
15. regression return to an earlier developmental stage
16. thought blocking sudden interruption in the patient's train of thought
17. withdrawal disinterest in objects, people, or surroundings
18. word salad illogical word groupings; for example, She had a star, barn, plant. It's the extreme form of loose associations.

Sample of Nursing Care Plan Tuberculosis (TB)

Nursing Care Plan and Nursing Diagnosis for Tuberculosis (TB)

Pulmonary tuberculosis

Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs, but may spread to other organs.

Symptoms
The primary stage of TB usually doesn't cause symptoms. When symptoms of pulmonary TB occur, they may include:

• Cough (usually cough up mucus)
• Coughing up blood
• Excessive sweating, especially at night
• Fatigue
• Fever
• Unintentional weight loss

Other symptoms that may occur with this disease:

• Breathing difficulty
• Chest pain
• Wheezing

Prevention

TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers.

A positive skin test indicates TB exposure and an inactive infection. Discuss preventive therapy with your doctor. People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative.

Prompt treatment is extremely important in controlling the spread of TB from those who have active TB disease to those who have never been infected with TB.

Some countries with a high incidence of TB give people a BCG vaccination to prevent TB. However, the effectiveness of this vaccine is controversial and it is not routinely used in the United States.

People who have had BCG may still be skin tested for TB. Discuss the test results (if positive) with your doctor.

nlm.nih.gov

Nursing Care Plan Pulmonary Tuberculosis (TB)

Nursing Diagnosis Pulmonary Tuberculosis

1. Ineffective airway clearance

2. Impaired gas exchange

3. Risk for infection

4. Imbalanced Nutrition Less then Body Requirements

5. Knowledge deficit

Source : http://all-nurses.blogspot.com/2011/10/nursing-care-plan-pulmonary.html

Impaired Gas Exchange of Tuberculosis

 Nursing Diagnosis - Impaired Gas Exchange of Pulmonary Tuberculosis

Tuberculosis, MTB, or TB (short for tubercle bacillus) is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis typically attacks the lungs but can also affect other parts of the body. It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit their saliva through the air. Most infections are asymptomatic and latent, but about one in ten latent infections eventually progresses to active disease which, if left untreated, kills more than 50% of those so infected.

The classic symptoms of active TB infection are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss (the latter giving rise to the formerly prevalent term "consumption"). Infection of other organs causes a wide range of symptoms. Diagnosis of active TB relies on radiology (commonly chest X-rays) as well as microscopic examination and microbiological culture of body fluids. Diagnosis of latent TB relies on the tuberculin skin test (TST) and/or blood tests. Treatment is difficult and requires administration of multiple antibiotics over a long period of time. Social contacts are also screened and treated if necessary. Antibiotic resistance is a growing problem in multiple drug-resistant tuberculosis (MDR-TB) infections. Prevention relies on screening programs and vaccination with the bacillus Calmette–Guérin vaccine.

Nursing Diagnosis - Impaired Gas Exchange of Pulmonary Tuberculosis


related to:

• reduced effectiveness of the surface of the lung,
• atelectasis,
• alveolar capillary membrane damage,
• secretions are thick,
• bronchial edema.

with the expected outcomes:

• Reported dyspnea did not occur.
• Showed improvement adequate ventilation and oxygenation of tissues with blood gas analysis in the normal range.
• Free from symptoms of respiratory distress.

Nursing Interventions - Impaired Gas Exchange of Pulmonary Tuberculosis

a. Assess dyspnea, tachypnea, abnormal breath sounds. Increased respiratory effort, chest expansion limitations and weaknesses.

b. Evaluation of the level of consciousness-changing, noted signs of cyanosis and discoloration of the skin, mucous membranes, and nail color.

c. Demonstrate / encourage you to exhale with disiutkan lips, especially in patients with fibrosis or parenchymal damage.

d. Suggest to bedrest, limit and auxiliary activities as needed.

e. Monitor blood gas analysis.

f. Collaboration: Give oxygen as indicated.

Rational:

a. Pulmonary tuberculosis may lead to widespread coverage in the lungs that comes from bronchopneumonia which extends into inflammation, necrosis, pleural effusion and widespread fibrosis with symptoms of respiratory distress.

b. Secret accumulation can interfere with oxygenation in vital organs and tissues.

c. Increased resistance to air flow to prevent the collapse of the airway.

d. Reduce oxygen consumption in the period of respiration.

e. Decrease in oxygen saturation (PaO2) or increased PaC02 show the need for further treatment. Inadequate or changing therapy.

f. Help correct the hypoxemia that occurs secondary alveolar hypoventilation and decreased lung surface.

Sample of Nursing Care Plan for Heart Failure - Decreased Cardiac Output

Nursing Care Plan for Heart Failure 
 
Nursing Diagnosis : Decreased Cardiac Output 

NANDA Definition:

Inadequate blood pumped by the heart to meet metabolic demands of the body

Nursing Diagnosis:

Decreased cardiac output related to Altered heart rate and rhythm AEB bradycardia

characterized by:

• with pale conjunctiva, nail beds and buccal mucosa
• irregular rhythm of the pulse
• bradycardic
• pulse rate of 34 beats / min
• generalized weakness

Short-Term Objectives:
the patient Will Participate in activities That Reduced the workload of the heart.

Long-Term Objectives:
Will the patient be Able to display hemodynamic stability.

Nursing Interventions Decreased Cardiac Output Congestive Heart Failure:

1. Auscultation apical pulse; examine the frequency, the heart rhythm.
Rational: Usually tachycardia (even at rest) to compensate for the decrease in ventricular contractility.

2. Record the heart sounds.
Rational: S1 and S2 may be weak due to decreased pumping action. Gallop rhythm common (S3 and S4) is generated as the flow of blood to the porch of distension. Mur-mur may indicate incompetence / stenosis of the valve.

3. Palpation of peripheral pulses.
Rational: The decrease in cardiac output may show decreased radial artery, popliteal, dorsalis, pedis and posttibial. The pulse may disappear fast or irregular pulse to be palpable and alternan.

4. Monitor blood pressure.
Rational: In Congestive Heart Failure early, moderate or chronic blood pressure may increase. In Congestive Heart Failure-up body could no longer compensate and hypotension can not be normal again.

5. Assess against pale skin and cyanosis.
Rational: Pale, indicating reduced peripheral perfusion secondary to cardiac output adekutnya not; vasoconstriction and anemia. Cyanosis may occur as refrakstori Congestive Heart Failure. The area of ​​pain is often colored blue striped atu because of increased venous congestion.

6. Give supplemental oxygen by nasal cannula / mask and drugs as indicated (collaboration).
Rationale: Increased dosage of oxygen to the need to counter the effects of myocardial hypoxia / ischemia.

Activity Intolerance of CHF (Congestive Heart Failure)

Nursing Diagnosis for Congestive Heart Failure (CHF)

Activity Intolerance

related to imbalance between oxygen supply. General weakness, long bedrest / immobilized.

Characterized by:

• Weakness,
• fatigue,
• changes in vital signs,
• presence of dysrhythmias,
• dyspnea,
• pallor,
• sweating.

Goals / evaluation criteria:

Clients will participate in desired activities, meet self-care, achieve increased tolerance activity can be measured, evidenced by a decrease in weakness and fatigue.

Nursing Interventions Activity Intolerance related to Congestive Heart Failure (CHF) :

1. Check vital signs before and immediately after activity, especially when the client is using vasodilators, diuretics and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), the displacement of fluid (diuretics) or influence cardiac function.

2. Note the cardiopulmonary response to activity, note tachycardia, dysrhythmias, dyspnea sweaty and pale.
Rationale: Decrease / inability of the myocardium to increase the volume of activity during dpat sekuncup cause an immediate increase heart rate and oxygen demand is also increasing fatigue and weakness.

3. Evaluation of increased activity intolerant.
Rational: It can show increased activity of cardiac decompensation rather than excess.

4. Implementation of cardiac rehabilitation programs / activities (collaboration)
Rationale: Increasing gradual to avoid the activity of cardiac work / oxygen consumption is excessive. Strengthening and improvement of cardiac function under stress, if cardiac function can not be improved again.

Source : http://nursing-care-plan.blogspot.com/2011/12/nursing-diagnosis-activity-intolerance.html

Acute Pain of Leukemia

Nursing Diagnosis for Leukemia - Acute pain 

related to an agent of physical injury

Purpose: pain is resolved

Expected outcomes:

• The patient stated the pain disappeared or controlled
• Shows the behavior of pain management
• Looks relaxed and able to rest, sleep

Nursing Intervention for Leukemia :

• Assess complaints of pain, notice changes in the degree of pain (using a scale of 0-10)
• Monitor vital signs, note the non-verbal clues such as muscle tension, anxiety
• Provide quiet environment and reduce stressful stimuli.
• Place the client in a comfortable position and prop joints, extremities with pillows.
• Change the position of periodic and soft assistive range of motion exercises.
• Provide comfort measures (massage, cold compresses and psychological support)
• The review / enhance client comfort interventions
• Evaluate and support the client's coping mechanisms
• Encourage the use of pain management techniques. Example: relaxation exercises / breathing in, touch.
• Auxiliary therapeutic activity, relaxation techniques.
• Collaboration: Monitor levels of uric acid, give the medication as indicated.

Source : http://nursing-care-plan.blogspot.com/2011/12/2-nanda-nursing-diagnosis-and.html

Risk for Fluid Volume Deficit of Leukemia

Nursing Diagnosis for Leukemia

Risk for Fluid Volume Deficit

related to

• fluid intake and output,
• excessive loss: vomiting, bleeding, diarrhea
• decrease in fluid intake: nausea, anorexia
• increased need for fluids: fever, hypermetabolic.

Purpose : the volume of fluid being met

Expected outcomes:

• Adequate fluid volume
• The mucosa moist
• Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit
• Pulse palpated
• Urine output 30 ml / hour
• Capillaries and refill less than 2 seconds

Nursing Intervention for Leukemia :

• Monitor fluid intake and output
• Monitor body weight
• Monitor BP and heart frequency
• Evaluation of skin turgor, capillary refill and mucous membrane conditions
• Give fluid intake 3-4 L / day
• Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive.
• Implement measures to prevent tissue injury / bleeding
• Limit oral care to wash mouth when indicated
• Give diet a smooth
• Collaboration:
  • Give IV fluids as indicated
  • Supervise laboratory tests: platelet count, Hb / Ht, freezing
  • Provide HR, platelets, clotting factors
  • Maintain a central vascular access device external (sub-clavicle artery catheter, tunneld, implantable ports)

Source : http://nursing-care-plan.blogspot.com/2011/12/2-nanda-nursing-diagnosis-and.html

Nursing Assessment for Obesity

Nursing Care Plan for Obesity

Nursing Assessment for Obesity

Physical Examination

1. Activity / Rest
symptoms:
- Weakness, drowsiness trended
- Inability / lack of desire to be active or exercise regularly
- Dyspnea with work
signs:
- Increased heart rate / breathing with activity

2. circulation
symptoms:
- History of cultural factors / lifestyle affects food choices
- Weight loss can / can not be accepted as a problem
- Eating may relieve feelings of pleasure, such as loneliness, frustration, boredom
- Prisoners of the closest people to lose weight

3. Food / fluid
symptoms:
- Digesting food with excess / normal
- Experiment with different types of diet with little results
- History repeated and decreased weight gain
signs:
- Weight loss is not right with height
- Endormofik body type (soft / about)
- Failed to determine the input of food to reduce demand (eg, changes in lifestyle from active to not exercise, aging)

4. Pain / Comfort
Symptoms: Pain / discomfort in the joints that support weight loss or spine

5. Breathing
Symptoms: Dyspnea
Signs: cyanosis, respiratory distress

6. Sexuality
Symptoms: menstrual disorders, amenorrhea

7. Education / learning
symptoms:
- Problems can be either lifetime or in connection with life events
- Family history of obesity
- Health problems that accompany diabetes, including hypertension, gallbladder disease and cardiovascular disease, hypothyroidism.

Source : http://nursing-care-plan.blogspot.com/2012/02/nursing-care-plan-for-obesity.html

Sample of Nursing Care Plan for Myocardial Infarction

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation).

Every year, several million people in North America are diagnosed with an AMI, and approximately one-third of these patients die during the acute phase. Health Canada has identified cardiovascular disease or heart diseases as the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national healthcare system.




Clinical Manifestations of Myocardial Infarction

Pain

1. Chest pain that occurs suddenly and constantly not subside, usually above the sternal region and upper abdomen, this is the main symptom.
2. The severity of pain can increase settled until unbearable pain.
3. Pain is very ill, such as punctured-pin that can spread to the shoulder and continued down to the arm (usually the left arm).
4. The pain started spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and do not disappear with the help of rest or nitroglycerin (NTG).
5. Pain may spread to the jaw and neck.
6. Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.
7. Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompany diabetes can interfere neuroreseptor (collect the experience of pain).

Laboratory examination Examination of cardiac enzymes :

1. CPK-MB/CPK
   Isoenzymes found in heart muscle increased by between 4-6 hours, peaks in 12-24 hours, returned to normal within 36-48 hours.
2. LDH / HBDH
   Increases in the 12-24 hour time-consuming dams to return to normal
3. AST
   Increases (less real / special) occurred within 6-12 hours, culminating in 24 hours, returning to normal within 3 or 4 days

ECG ECG changes that occur in the early phase of T wave height and symmetrical. After this there is ST segment elevation. Changes that occur later are the presence of a wave of Q / QS which indicate the presence of necrosis.


Pain scores according to White:

1. = Do not experience pain
2. = Pain on one side without disturbing activities
3. = More pain at one place and resulted in disruption of activities, such as difficulty getting out of bed, hard to bend the head and others.

Nursing Care Plan for Myocardial Infarction

Primary Assessment for Acute Myocardial Infarction Nursing Care Plan (AMI) :

Airways

1. Blockage or accumulation of secretions
2. Wheezing or crackles

Breathing

1. Shortness of breath with mild activity or rest
2. Respiration more than 24 x / min, irregular rhythm shallow
3. Ronchi, crackles
4. The expansion of the chest is not full
5. Use of auxiliary respiratory muscles

Circulation

1. Weak pulse, irregular
2. Tachycardia
3. Blood pressure increase / decrease
4. Edema
5. Nervous
6. Acral cold
7. Pale skin, cyanosis
8. Decreased urine output

Secondary Assessment Acute Myocardial Infarction (AMI) :

1. Activities
   • Symptoms:
     
     • Weakness
     • Fatigue
     • Can not sleep
     • Settled lifestyle
     • No regular exercise schedule
   • Signs:
     • Tachycardia
     • Dyspnea at rest or activity
2. Circulation
   • Symptoms:
     
     • History of Acute Myocardial Infarction (AMI)
     • Coronary artery disease
     • Blood pressure problems
     • Diabetes mellitus.
   • Signs:
     
     • Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or stand
     • Pulse: normal, full or not strong or weak / strong quality with slow capillary filling, irregular (dysrhythmias)
     • Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased contractility / complaints ventricle
     • Murmur: If there are shows valve failure or dysfunction of heart muscle
     • Friction: suspected pericarditis
     • Heart rhythm can be regular or irregular
     • Edema: juguler venous distention, edema dependent, peripheral, general edema, cracles may exist with heart failure or ventricular
     • Color: Pale or cyanotic, flat nail, on mucous membranes or lips
3. Ego integrity
   • Symptoms: an important symptom or deny the existence of conditions of fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family
   • Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain
4. Elimination
   • Signs: normal, decreased bowel sounds.
5. Food or fluid
   • Symptoms: nausea, anorexia, belching, heartburn, or burning
   • Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes
6. Hygiene
   • Symptoms or signs: difficulty perform maintenance tasks
7. Neuro Sensory
   • Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)
   • Signs: mental changes, weakness
8. Pain or discomfort
   • Symptoms:
     
     • Sudden onset of chest pain (may or may not relate to activities), not relieved by rest or nitroglycerin (although most deep and visceral pain)
     • Location: Typical on the anterior chest, Substernal, precordial, can spread to the hands, jaw, face. No specific location such as epigastric, elbow, jaw, abdomen, back, neck.
     • Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.
     • Intensity: Usually 10 (on a scale of 1-10), may experience the worst pain ever experienced.
     • Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly
9. Respiratory:
   • Symptoms:
     
     • Dyspnea with or without job
     • Nocturnal dyspnea
     • Cough with or without sputum production
     • History of smoking, chronic respiratory disease.
   • Signs:
     
     • Increased respiratory rate
     • Shortness of breath / strong
     • Pallor, cyanosis
     • Breath sounds (clean, cracles, wheezing), sputum
10. Social interactions
    • Symptoms:
      • Stress
      • Difficulty coping with the stressors that exist eg illness, treatment in hospital
    • Signs:
      • Difficulty rest - sleep
      • Response too emotional (angry constantly, fear)
      • Withdraw

Source : http://careplannursing.blogspot.com/2011/11/nursing-care-plan-assessment-diagnosis.html

Risk for Injury of Hemophilia

Nursing Diagnosis : Risk for Injury related to weakness of the defense secondary to hemophilia
characterized by frequent injuries

Objectives / Expected outcomes: injury and complications can be avoided / did not happen.

Nursing Interventions

1. Maintain security of client's bed, put a safety on the bed
2. Avoid injury, light - weight
3. Keep an eye on every move that allows the occurrence of injury
4. Encourage the parents to bring children to the hospital immediately in case of injury
5. Explain to parents the importance of avoiding injury.

Rational

1. Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma
2. Patients with hemophilia are at risk of spontaneous bleeding was controlled so that the required monitoring every move that allows the occurrence of injury
3. Early identification and treatment can limit the severity of complications
4. Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications.
5. Lower the risk of injury / trauma.

Source : http://careplannursing.blogspot.com/2012/03/3-nursing-diagnosis-interventions-for.html

Ineffective Tissue Perfusion of Hemophilia

Nursing Diagnosis: Ineffective Tissue Perfusion related to active bleeding
characterized by decreased consciousness, bleeding.

Objectives / Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved

Nursing Interventions

1. Assess the cause of bleeding
2. Assess skin color, hematoma, cyanosis
3. Collaboration in the provision of adequate IVFD
4. Collaboration in the provision of blood transfusion.

Rational:

1. By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
2. Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
3. Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
4. Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion.

Source : http://careplannursing.blogspot.com/2012/03/3-nursing-diagnosis-interventions-for.html

Self-care deficit of Parkinson's disease

Nursing Diagnosis for Parkinson's disease -  Self-care deficit

Parkinson's disease is a common disorder that arises due to some imperfection that amends the normal functioning of the central nervous system. The disease results in the loss of the neurons or nerve cells that contain dopamine in the substantia niera, the part of the brain that controls movement.

Parkinson's disease (Paralysis agitans) as described by James Parkinson in 1817 is characterized by degeneration of central nervous tissues, affecting the motor skills of a person, thereby impairing his (rarely her) movements and speech.

The causes of the disease have not been proven, the following factors increase the risk of Parkinson's;

• Age
• Male
• Genetic link to a sufferer
• Stress
• Head trauma
• Environmental exposure to pesticides
• Rural living
• High fat diet

There are also three factors that have been associated with a decreased risk of Parkinson's, these are cigarette smoking, anti-oxidants being present in diet and having measles early in life.




Nursing Diagnosis for Parkinson's disease -  Self-care deficit  related to neuromuscular weakness, decline in strength, loss of muscle control / coordination.

Goal: self-care clients are met

Expected results: the client can indicate a change of life for the needs of taking care of themselves, clients are able to do self-care activities in accordance with the level of ability, and identify personal / community that can help.

Nursing Interventions for Parkinson's Disease :

• assess the ability and the rate of decline and the scale of 0-4 to perform ADL
• avoid what not to do the client and help if needed.
• collaborative provision of laxatives and consult a doctor of occupational therapy
• teach and support the client during the client's activities
• environmental modifications

Source : http://careplannursing.blogspot.com/2012/03/parkinsons-disease-nursing-care-plan.html

Nursing Management of Pheochromocytoma

A pheochromocytoma or phaeochromocytoma (PCC) is a neuroendocrine tumor of the medulla of the adrenal glands (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that failed to involute after birth and secretes excessive amounts of catecholamines, usually noradrenaline (norepinephrine), and adrenaline (epinephrine) to a lesser extent. Extra-adrenal paragangliomas (often described as extra-adrenal pheochromocytomas) are closely related, though less common, tumors that originate in the ganglia of the sympathetic nervous system and are named based upon the primary anatomical site of origin.


Nursing Management of Pheochromocytoma

• Monitor vital signs, especially blood pressure changes--> severe hypertension can precipitate a cerebrovascular accident and/or sudden blindness
• Administer antihypertensive medications as ordered
• Promote rest and decrease stressful stimuli--> acute attacks may be precipitated by emotional stress, physical exertion, and change in position
• Monitor urine tests for glucose and acetone--> clients with pheochromocytoma may present with manifestations of diabetes mellitus
• For clients on 24-hour VMA testing--> instruct to avoid vigorous and prolonged exercise and intake of coffee, tea, chocolate, bananas, and vanilla-flavored food at least two days prior to and during urine collection (note: clincians may also order client to stop taking medications like methyldopa, L-Dopa, paracetamol at least three days prior to urine collection as well)
• Provide high-calorie, well-balanced diet
• Instruct patient to avoid smokinga nd stimulants like coffee and tea--> may influence catecholamine release
• For clients with an adrenalectomy, observe for BP changes-- clients are at risk for shock due to a drastic drop in catecholamine levels
• Provide client teaching on possibility of lifeslong steroid replacement (for bilateral adrenalectomy)

Nursing Diagnosis for Acromegaly / Gigantism

Acromegaly is the overgrowth of the bones and soft tissues due to excessive secretion of the growth hormone.


Incidence

Acromegaly is uncommon; only three to four cases are diagnosed per million people each year. It develops very gradually and may not be recognized until it has been present for many years. hyperpituitarism occurs equally among men and women. The mean age at diagnosis is about 40-60 years.


It is caused by prolonged, excessive secretion of growth hormone (GH). The most common cause of acromegaly is a benign tumour (adenoma) of the somatotroph cells, which produce growth hormone. These cells are within the anterior pituitary gland, located in the middle of the head just below the brain.

Nursing Diagnosis for Acromegaly / Gigantism

1. Disturbed body image related to enlargement of body parts as manifested by enlarged hands, feet and jaw.

2. Disturbed sensory perception related to enlarged pituitary gland as manifested by protrusion of eye balls .

3. Fluid volume deficit related to polyuria as manifested by excessive thirst of the patient.

4. Disturbed sleeping pattern related to soft tissue swelling as manifested by verbalization of the patient about insomnia.

5. Anxiety related to change in appearance and treatment as manifested by verbalization of the patient about body appearance.

6. Ineffective coping related to change in appearance as manifested by verbalization of negative feeling about the change in appearance.

7. Knowledge deficit regarding development of disease and treatment as manifested by repeated questions by the patient regarding disease and treatment.

Source : http://studynursing.blogspot.in/search/label/Endocrine%20System

Nursing Interventions for Diabetes Insipidus

Interventions

1. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss.
Ø Assess the fluid level of the patient
Ø Monitor vital signs frequently
Ø Restrict oral fluid intake.
Ø Administer hypotonic saline intravenously.
Ø Administer medications if ordered.
 
2. Disturbed sleeping pattern, insomnia related to nocturia as manifested by verbalization of patient about interrupted sleep.
Ø Assess the sleeping pattern of the patient
Ø Give psychological support.
Ø Advice the patient to restrict oral fluids
Ø Provide calm and quiet environment.
 
3. Activity intolerance related to fatigue and frequent urination as manifested by fatigue and weakness of the patient.
Ø Assess the activity status of the patient
Ø Give psychological support to the patient.
 
4. Anxiety related to course of disease and frequent urination as manifested by verbalization of anxious questions.
Ø Assess the anxiety level of the patient.
Ø Explain the patient about the disease and treatment.
Ø Provide calm and quiet environment.
Ø Divert the attention of the patient by talking about different matter.
 
5. Ineffective coping related to frequent urination as manifested by verbalization of negative feeling by the patient.
Ø Assess the coping ability of the patient
Ø Explain the patient about the disease and treatment
Ø Give psychological support.
 
6.Risk for complications related to excessive loss of fluid from the body as manifested by hypotension and weight loss.
Ø Assess the fluid volume of the patient
Ø Monitor vital signs frequently.
Ø Take immediate measures to restore fluid volume such as IV fluid therapy
Ø Administer medications as ordered.
 
7. Knowledge deficit regarding management of diabetes insipidus as manifested by verbalization of doubts by the patient
Ø Assess the knowledge level of the patient.
Ø Explain the management of diabetes insipidus to the patient.

Nursing Diagnosis for Diabetes Insipidus

Nursing Diagnosis for Diabetes Insipidus

Diabetes insipidus (DI) is a condition which causes frequent urination. The reduction in production or release of ADH results in fluid and electrolyte imbalance caused by increased urinary output. Depending on the cause, Diabetes insipidus may be transient or life long condition. In its clinically significant forms, diabetes insipidus is a rare disease.
Clinical Manifestations

• Diabetes insipidus is characterized by increased thirst and increased urination. The primary character of DI is polyuria, excretion of large quantities of urine ( 5-20L per day)with a very low specific gravity(less than 1.005) and urine osmolality of < 100mmol/kg. In partial DI urine output may be lower(2-4L per day).
• Polydipsia (excessive intke of fluids) is also a characteristic feature of DI. Patient compensate for fluid loss by drinking great amount of water. The patient with central DI favours cold or iced drinks. Nocturia occurs due to frequent tendency to urinate which interrups sleep of the patient.
• Central DI usually occurs suddenly with excessive fluid loss. DI usually has a triphastic pattern: the acute phase with abrupt onset of polyuria, an interphase where urine volume apparently normalizes, and a third phase where DI is permanent.
• If fluid loss is not compensated, severe fluid volume de ficit results. This deficit is manifested by weight loss, hypotension, tachycardia with decreased cardiac output, poor tissue turgor, irritability, mental dullness. Hypovolemic shock may develop if fluid volume is not restored.

Nursing Diagnosis for Diabetes Insipidus

1. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss.

2. Sleeping pattern disturbances, insomnia related to nocturia as manifested by verbalization of patient about interrupted sleep

3. Activity intolerance related to fatigue and frequent urination as manifested by weakness and fatigue of the patient.

4. Anxiety related to course of disease and frequent urination as manifested by verbalization of anxious questions.

5. Ineffective coping related to frequent urination as manifested by verbalization of negative feeling by the patient.

6. Risk for complications related to excessive loss of fluid from the body as manifested by hypotension and weight loss.

7. Knowledge deficit regarding management of diabetes insipidus as manifested by verbalization of doubts by the patient.

Source : http://studynursing.blogspot.in/search/label/Endocrine%20System

Nursing Diagnosis for Gastrostomy

Gastrostomy is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube, called a "g-tube," is used for feeding or drainage.

Gastrostomy is performed because a patient temporarily or permanently needs to be fed directly through a tube in the stomach. Reasons for feeding by gastrostomy include birth defects of the mouth, esophagus, or stomach, and neuromuscular conditions that cause people to eat very slowly due to the shape of their mouths or a weakness affecting their chewing and swallowing muscles.
Gastrostomy is also performed to provide drainage for the stomach when it is necessary to bypass a longstanding obstruction of the stomach outlet into the small intestine. Obstructions may be caused by peptic ulcer scarring or a tumor.

Nursing Diagnosis for Gastrostomy

1. Imbalanced nutrition, less than body requirements, related to enteral feeding problems
2. Risk for infection related to presence of wound and tube
3. Risk for impaired skin integrity at tube site
4. Ineffective coping related to inability to eat normally
5. Disturbed body image related to presence of tube
6. Risk for ineffective therapeutic regimen management related to knowledge deficit about home care and the feeding procedur.

Sample of Nursing Diagnosis for Colostomy

Colostomy surgery is often a frightening prospect for most people. But it can dramatically improve a person's quality-of-life, especially in cases of serious disease.

Types of Colostomies

There are several different types of colostomies including ascending, transverse, and descending.

1. Ascending. This colostomy has an opening created from the ascending colon, and is found on the right abdomen. Because the stoma is created from the first section of the colon, stool is more liquid and contains digestive enzymes that irritate the skin. This type of colostomy surgery is the least common.
2. Transverse. This surgery may have one or two openings in the upper abdomen, middle, or right side that are created from the transverse colon. If there are two openings in the stoma, (called a double–barrel colostomy) one is used to pass stool and the other, mucus. The stool has passed through the ascending colon, so it tends to be liquid to semi-formed.
3. Descending or sigmoid. In this surgery, the descending or sigmoid colon is used to create a stoma, typically on the left lower abdomen. This is the most common type of colostomy surgery and generally produces stool that is semi-formed to well-formed because it has passed through the ascending and transverse colon.

Sample of Nursing Diagnosis for Colostomy

1. Risk for impaired Skin Integrity: risk factors may include absence of sphincter at stoma and chemical irritation from caustic bowel contents, reaction to product/removal of adhesive, and improperly fitting appliance.

2. Risk for Diarrhea/Constipation: risk factors may include interruption/alteration of normal bowel function (placement of ostomy), changes in dietary/fluid intake, and effects of medication.*

3. Deficient Knowledge [Learning Need] regarding changes in physiologic function and self care/treatment needs may be related to lack of exposure/recall, information misinterpretation, possibly evidenced by questions, statement of concern, and inaccurate follow-through of instruction/development of preventable complications.

4. Disturbed Body Image may be related to biophysical changes (presence of stoma; loss of control of bowel elimination) and psychosocial factors (altered body structure, disease process/associated treatment regimen, e.g., cancer, colitis), possibly evidenced by verbalization of change in perception of self, negative feelings about body, fear of rejection/reaction of others, not touching/looking at stoma, and refusal to participate in care.

5. Impaired Social Interaction may be related to fear of embarrassing situation secondary to altered bowel control with loss of contents, odor, possibly evidenced by reduced participation and verbalized/observed discomfort in social situations.

6. Risk for Sexual Dysfunction: risk factors may include altered body structure/function, radical resection/treatment procedures, vulnerability/psychologic concern about response of SO(s), and disruption of sexual response pattern (e.g., erection difficulty)

Impaired Physical Mobility of Parkinson's Disease

Parkinson's disease (also known as Parkinson disease, Parkinson's, idiopathic parkinsonism, primary parkinsonism, PD, or paralysis agitans) is a degenerative disorder of the central nervous system. The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain; the cause of this cell death is unknown. Early in the course of the disease, the most obvious symptoms are movement-related; these include shaking, rigidity, slowness of movement and difficulty with walking and gait. Later, cognitive and behavioural problems may arise, with dementia commonly occurring in the advanced stages of the disease. Other symptoms include sensory, sleep and emotional problems. PD is more common in the elderly, with most cases occurring after the age of 50.


Nursing Diagnosis for Parkinson's Disease : Impaired physical mobility related to bradykinesia, muscle rigidity and tremors

characterized by:
Subjective data: the client said it was difficult to do activities
Objective data: tremors while on the move

Outcome: improve the mobility

Nursing Interventions for Parkinson's Disease :

• Help clients make daily exercise such as walking, cycling, swimming, or gardening.
• Encourage clients to stretch and exercise as directed postural therapist.
• Bathe with warm water and the clients do sorting to help muscle relaxation.
• Instruct the client to rest on a regular basis in order to avoid weakness and frustration.
• Teach for postural exercise and walking techniques to reduce the stiffness when walking and the possibility of learning continues.
• Instruct the client to walk with your legs open.
• Create a client's hand with awareness raising, lifting the feet when walking, use the shoes for walking, and walking with step length.
• Tell the client to walk to the rhythm of music to help improve the sensory.

Evaluation: client sessions of physical therapy, facial exercise 10 minutes 2 times a day.

Source : http://nanda-list.blogspot.com/2011/12/3-nursing-diagnosis-for-parkinsons.html

5 Nursing Diagnosis Peritonitis

Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Peritonitis may be localised or generalised, and may result from infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process.


Treatment


Depending on the severity of the patient's state, the management of peritonitis may include:

• General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances.
• Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be targeted on them.
• Surgery (laparotomy) is needed to perform a full exploration and lavage of the peritoneum, as well as to correct any gross anatomical damage that may have caused peritonitis. The exception is spontaneous bacterial peritonitis, which does not always benefit from surgery and may be treated with antibiotics in the first instance.

5 Nursing Diagnosis Nursing Care Plan for Peritonitis

1. Acute Pain Nursing Care Plan for Peritonitis

2.Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

3. Risk for Infection Nursing Care Plan for Peritonitis

4. Deficient Fluid Volume Nursing Care Plan for Peritonitis

5.Ineffective Breathing Pattern Nursing Care Plan for Peritonitis

Source : http://nanda-list.blogspot.com/2011/12/nursing-care-plan-for-peritonitis-5.html

Peritonitis Definition and Clinical Manifestations

Peritonitis Definition

Peritonitis is inflammation of the peritoneum - the serous membrane lining the abdominal cavity and covers the viscera is dangerous complications that can occur in acute or chronic form or set of signs and symptoms, including tenderness and pain on palpation loose, defans muscular, and general signs of inflammation. Patients with peritonitis may experience symptoms of acute, mild illness and limited, or severe and systemic disease with septic shock.

Infectious peritonitis, are divided over the causes perimer (spontaneous peritonitis), secondary (associated with pathological processes in visceral organs), or tertiary cause (recurrent or persistent infection after adequate initial therapy). Infection of the abdomen are grouped into pertitonitis infection (common) and abdominal abscesses (local peritonitis infection is relatively difficult to enforce and very dependent of the underlying disease. The cause of peritonitis is spontaneous bacterial peritonitis due to chronic liver disease.

Other causes of secondary peritonitis is perforated appendicitis, peptic and duodenal ulcer perforation, perforation of the colon due to diverdikulitis, volvulus and cancer, and ascending colon strangulation. The cause of iatrogenic trauma generally comes from the upper gastrointestinal tract including pancreas, bile ducts and colon sometimes also can occur from trauma endoscopy. Stitching operation that is leaking is a common cause of peritonitis.

After surgery, abdominal effective for non-infectious etiology, incidence of secondary peritonitis (due to rupture of suture surgery should be less than 2%. Surgery for inflammatory diseases (eg appendicitis, divetikulitis, cholecystitis) without risk of perforation is less than 10% of secondary peritonitis and peritoneal abscess. Risk occurrence of secondary peritonitis and abscess higher with the involvement of the duodenum, pancreatic colonic perforation, peritoneal contamination, perioperative shock, and the passive transfusion.

Peritonitis Clinical Manifestations

The presence of blood or fluid in the peritoneum cavity will provide signs of stimulation peritoneum. Peritoneum stimuli cause tenderness and muscular defans, liver dullness may disappear due to free air under the diaphragm. Decreased peristaltic lost due to temporary paralysis of the intestines.

In case of bacterial peritonitis, the patient's body temperature will rise and there is tachycardia, hypotension and the patient seemed lethargic and shock. This stimulation causes pain on any movement that causes the shift of peritoneum. Pain is a subjective form of pain when the patient moves such as roads, breathing, coughing, or straining. Pain is a pain if the objective is moved such as palpation, tenderness loose, psoas test, or other tests.

Clinical diagnosis of peritonitis enforced by the presence of abdominal pain (Acute abdomen) with a dull pain and obscure location (visceral peritoneum) that more and more obvious location (parietal peritoneum). Relative signs of peritonitis with severe infection is high fever or sepsis patients who could be hypothermia, tachycardia, dehydration to be hypotensive. Severe abdominal pain which usually has a punctum maximum specific place as a source of infection.

The walls of the stomach will feel tight because the mechanism of anticipation patient unconsciously to avoid palpation painful or tense because of irritation of the peritoneum.

Deficient Fluid Volume Nursing Diagnosis

Nursing Diagnosis for Deficient Fluid Volume

Hypovolemia; Dehydration

Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances.

Deficient Fluid Volume related to

• Loss of active fluid volume
• Failure of regulatory mechanisms

Data:

• Decrease in mental status
• Decrease in vital signs
• Decrease in skin turgor
• Decrease in urine output
• Dry mucous membranes
• Ht increased
• Increased concentration of urine
• Thirst
• Weight loss suddenly

Nursing Interventions for Deficient Fluid Volume

a. monitoring of fluid

• Assess the history of the number and type of fluid intake and elimination patterns
• Assess the cause of lack of fluid volume: vomiting, diarrhea, hyperthermia, diaphoresis.
• Monitor weight, intake and output
• Monitor vital signs
• Monitor the mucous membrane, turgor, and thirst
• Monitor urine color and quality
• Monitor JVP, peripheral edema, ascites and weight gain

b. Management of fluid

• Monitor weight
• Maintain adequate intake
• Install catheter
• Monitor hydration status and hemodynamic
• Monitor laboratory results related to fluid retention: Increased BUN, Ht decrease
• Monitor the nutritional status
• Encourage clients oral intake
• Provision of IV therapy and NGT
• Collaboration transfusion

Nursing Care Plan for Pleura Effusion

Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.

Types of fluids

Four types of fluids can accumulate in the pleural space:

• Serous fluid (hydrothorax)
• Blood (haemothorax)
• Chyle (chylothorax)
• Pus (pyothorax or empyema)

Treatment

Treatment depends on the underlying cause of the pleural effusion.

Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain (either pigtail or surgical). When managing these chest tubes, it is important to make sure the chest tubes do not become occluded or clogged. A clogged chest tube in the setting of continued production of fluid will result in residual fluid left behind when the chest tube is removed. This fluid can lead to complications such as hypoxia due to lung collapse from the fluid, or fibrothorax, later, when the space scars down. Repeated effusions may require chemical (talc, bleomycin, tetracycline/doxycycline), or surgical pleurodesis, in which the two pleural surfaces are scarred to each other so that no fluid can accumulate between them. This is a surgical procedure that involves inserting a chest tube, then either mechanically abrading the pleura or inserting the chemicals to induce a scar. This requires the chest tube to stay in until the fluid drainage stops. This can take days to weeks and can require prolonged hospitalizations. If the chest tube becomes clogged, fluid will be left behind and the pleurodesis will fail.

Pleurodesis fails in as many as 30% of cases. An alternative is to place a PleurX Pleural Catheter or Aspira Drainage Catheter. This is a 15Fr chest tube with a one-way valve. Each day the patient or care givers connect it to a simple vacuum tube and remove from 600 cc to 1000 cc of fluid. This can be repeated daily. When not in use, the tube is capped. This allows patients to be outside the hospital. For patients with malignant pleural effusions, it allows them to continue chemotherapy, if indicated. Generally the tube is in for about 30 days and then it is removed when the space undergoes a spontaneous pleurodesis.

Nursing Care Plan for Pleura Effusion

Nursing Diagnosis

Ineffective airway clearance related to weakness and poor cough effort.

Nursing Intervention

NOC :

• Demonstrate effective airway clearance and proved with respiratory status, gas exchange and ventilation are not dangerous :
  • Having a patent airway
  • Removing the secretion effectively.
  • Having a rhythm and respiratory frequency in the normal range.
  • Having a lung function within normal limits.
• Show that adequate gas exchange is characterized by :
  • Easy to breathe
  • No anxiety, cyanosis and dyspnea.
  • Saturation of O2 in the normal range
  • Chest X-ray within the expected range.

NIC :

• Assess and document :
  • The effectiveness of oxygen and other treatments.
  • The effectiveness of treatment.
  • Trends in arterial blood gases.
• Anterior and posterior chest auscultated to determine the decrease or absence of ventilation and the presence of sound barriers.
• Suction airway
  • Determine the need for sucking oral / tracheal.
  • Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
• Maintain adequate hydration to reduce the viscosity of secretions.
• Explain the use of support equipment properly, such as oxygen, suction equipment lenders.
• Inform patients and families that smoking is an activity that is prohibited in the treatment room.
• Instruct patients about cough and deep breathing techniques to facilitate the release of secretion.
• Negotiate with respiratory therapists as needed.
• Tell your doctor about the results of an abnormal blood gas analysis.
• Assist in the provision of aerosols. Nebulizer and other pulmonary care according to institutional policies and protocols.
• Encourage physical activity to improve the movement of secretions.
• If the patient is unable to perform ambulation, the location of the patient sleeping position changed every 2 hours.
• Inform patients before starting the procedure to reduce anxiety and increase self-control.

2 Nursing Diagnosis Interventions for Hepatitis

Hepatitis

Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E.
Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids (e.g. from blood transfusions or invasive medical procedures using contaminated equipment). Hepatitis B is also transmitted by sexual contact.
The symptoms of hepatitis include jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.(who.int)

Nursing Interventions for Hepatitis
Ineffective breathing pattern related to the collection of intra-abdominal fluid, ascites, decreased lung expansion and accumulation of secretions.
Results :
Adequate breathing pattern
Intervention :

• Monitor the frequency, depth and respiratory effort
• Auscultation additional breath sounds
• Give the semi-Fowler position
• Provide training in breath and cough effectively
• Provide oxygen as needed

Acute Pain related to swelling of the liver, an inflamed liver.
Results :
Showed signs of physical pain and behavior in a pain (do not wince in pain, crying intensity and location)
Intervention :

• Collaboration with individuals to determine methods that can be used for pain intensity.
• Show on client acceptance of the client’s response to pain.
  • Acknowledge the pain
  • Listen attentively to the client expression of pain.
• Provide accurate information and explain the causes of pain, how long the pain will end, if known.
• Discuss with your doctor the use of analgesics that do not contain hepatotoksi effect.

Source : http://ncp-blog.blogspot.com

4 Nursing Diagnosis Interventions for Dengue Hemorrhagic Fever

Nursing Diagnosis and Interventions for Dengue Hemorrhagic Fever
1. Nursing Assessment

• Assess the patient’s medical history
• Assess the increase in body temperature, signs of bleeding, nausea, vomiting, no appetite, heartburn, muscle pain and signs of shock (rapid and weak pulse, hypotension, skin cold and moist, especially on the extremities, cyanosis, restlessness, decreased awareness).

2. Nursing Diagnosis for DHF – Dengue Hemorrhagic Fever

1. Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting, and fever.
2. Ineffective Peripheral Tissue Perfusion related to bleeding.
3. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting, no appetite.
4. Hyperthermia related to the process of viral infection.

3. Nursing Interventions for DHF – Dengue Hemorrhagic Fever
Goal:

• Show signs of liquid fulfillment
• Shows signs of adequate peripheral tissue perfusion
• Showed vital signs within normal limits
• The family suggests that adaptive coping

1. Deficient Fluid Volume

• Observation of vital signs at least every 4 hours
• Monitor the increasing signs of dehydration: inelastic turgor, sunken fontanel, decreased urine production
• Observation and recording intake and output
• Provide adequate hydration according to the needs of the body
• Monitor laboratory values​​: electrolyte / blood, urine specific gravity, serum body
• Maintain adequate intake and output
• Monitor and record the weight
• Monitor the provision of intravenous fluids per hour through

2. Ineffective Peripheral Tissue Perfusion

•  Assess and record vital signs (quality and frequency of pulse, blood pressure, capillary refill)
• Assess and record the circulation in the extremities (temperature, humidity and color)
• Assess the possibility of the death of tissue in the extremities such as cold, pain, swelling of the feet)

3. Imbalanced Nutrition Less Than Body Requirements

• Allow the child to eat foods that can be tolerated child. Plan to improve the nutritional quality at the child’s appetite increases.
• Give the food is accompanied by a nutritional supplement to improve the quality of nutritional intake
• Encourage parents to provide food with a small portion technique but often
• Measure weight every day at the same time and with the same scale
• Keep the patient’s oral hygiene
• Explain the importance of adequate intake nutirisi to cure disease

4. Hyperthermia

• Measure vital signs: body temperature
• Teach the family in the temperature measurement
• Perform wipe
• Increase fluid intake
• Provide therapy to lower the temperature

Nursing Management - Ineffective Cerebral Tissue Perfusion related to Hydrocephalus

Nursing Diagnosis for Hydrocephalus
Ineffective Cerebral Tissue Perfusion related to increased volume of cerebrospinal fluid.
NOC : circulation status
NOC – Expected outcomes:
1. Indicate the status of the circulation is characterized by the following indicators:

• Systolic and diastolic blood pressure within normal range
• No major vein noisy

2. Demonstrated cognitive abilities, characterized by the indicator:

• Communicate clearly and in accordance with the age and ability
• Show attention, concentration and orientation
• Demonstrated long-term memory and the current
• Process information
• Make the right decision

Hydrocephalus – Ineffective Cerebral Tissue Perfusion – NIC Interventions
1. Monitor the following matters:

• Vital signs
• Headache
• Level of awareness and orientation
• Inistagmus diplopia, blurred vision, visual acuity

2. Monitoring of ICT:

• ICT monitoring and neurological response of the patient care activities
• Monitor tissue perfusion pressure
• Note the change in the patient in response to stimulus

4. Management of peripheral sensation

• Monitor the presence of paresthesias: numbness or tingling
• Monitor the status of fluid intake and output including

5. Collaborative activity

• Keep the thermodynamic parameters within the range recommended
• Give the drugs to increase intravascular volume, as requested
• Give a drug which causes hypertension to maintain cerebral perfusion pressure according to demand
• Elevate the head of the bed 0 to 45 degrees, depending on the patient’s condition and medical demand
• Give loap and osmotic diuretics, according to demand.

Source : http://nursingdiagnosisinterventions.com/ineffective-cerebral-tissue-perfusion-related-to-hydrocephalus

Nursing Management of Hypertension

Nursing Assessment for Hypertension

Basic Nursing Assessment data by Doenges (1999) :

1. Activity / Rest
   • Symptoms: weakness, fatigue, shortness of breath, monotonous lifestyle.
   • Signs: The frequency of the heart increases, changes in heart rhythm, tachypnoea.
2. Circulation
   • Symptoms: History of hypertension, atherosclerosis, coronary heart disease / valve and cebrocaskuler disease, episodes of palpitations.
   • Signs: The increase in BP, pulse throbbing clear from the carotid, jugular, radial, tachycardia, valvular stenosis murmur, jugular venous distension, pale skin, cyanosis, cold temperature (peripheral vasoconstriction) filling the capillary may be slow / delayed.
3. Ego Integrity
   • Symptoms: History personality changes, anxiety, multiple stress factors (relationship, financial, work related).
   • Signs: Explosion mood, anxiety, continue narrowing of attention, tears burst, face muscles tense, breathing heaved, increased speech patterns.
4. Elimination
   • Symptoms: Impaired renal current or (such as obstruction or a history of kidney disease in the past).
5. Food / fluid
   • Symptoms: The preferred food that includes foods high in salt, fat and cholesterol, nausea, vomiting and changes in body weight lately (up / down) Historical use of diuretics.
   • Signs: normal weight or obese, the presence of edema, glikosuria.
6. Neuro Sensory
   • Genjala: Complaints of dizziness / headache, throbbing, headache, suboksipital (happens when you wake up and eliminate spontaneously after a few hours) Impaired vision (diplobia, blurred vision, epistaxis).
   • Signs: mental status, changes in waking, orientation, pattern / content of speech, effects, think the process, decreased hand grip strength.
7. Pain / discomfort
   • Symptoms: Angina (coronary artery disease / heart involvement), headache.
8. Respiratory
   • Symptoms: dyspnea related to the activities / work Tachypnoea, orthopnea, dyspnea, cough with or without the formation of sputum, history of smoking.
   • Signs: respiratory distress / respiratory accessory muscle use additional breath sounds (krakties / wheezing), cyanosis.
9. Security
   • Symptoms: Impaired coordination / gait, postural hypotension.

Nursing Diagnosis for Hypertension

1. Risk for Decreased Cardiac Output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy
2. Acute Pain: headache related to increased cerebral vascular pressure
3. Ineffective Tissue perfusion : cerebral, renal, cardiac related to circulatory disorder
4. Knowledge Deficit related to lack of information about the disease process and self-care.