Colon Cancer Nursing Diagnosis

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

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

Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. It is common for people with colon cancer to experience no symptoms in the earliest stages of the disease. However, when the cancer grows, symptoms include:

• Diarrhea or constipation
• Changes in stool consistency
• Narrow stools
• Rectal bleeding or blood in the stool
• Pain, cramps, or gas in the abdomen
• Pain during bowel movements
• Continual urges to defecate
• Weakness or fatigue
• Unexplained weight loss
• Irritable bowel syndrome (IBS)
• Iron deficiency (anemia)

9 Nursing Diagnosis for Colon Cancer

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

Nursing Interventions : Impaired Physical Mobility - Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis: Impaired Physical Mobility

related to:

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

Can be evidenced by:

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

The expected outcomes / evaluation criteria, patients will:

• Maintaining a function of position in the absence / restrictions contractures.
• Maintain or improve strength and function of and / or compensation of the body.
• Demonstrate techniques / behaviors enabling activities.

Nursing Interventions : Impaired Physical Mobility - Rheumatoid Arthritis

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

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

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

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

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

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

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

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

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

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

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

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

Preeclampsia Nursing Diagnosis

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




7 Nursing Diagnosis for Preeclampsia

1. Acute pain
reated to post Caesarean section incision

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

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

4. Risk for Fluid Volume Deficit
related to the bleeding

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

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

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

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

Nursing Diagnosis and Interventions for Patent Ductus Arteriosus (PDA)

Nursing Diagnosis for Patent Ductus Arteriosus (PDA)

1. Decreased Cardiac Output related to malformations of the heart.
2. Impaired Gas Exchange related to pulmonary congestion.
3. Activity Intolerance related to imbalance between oxygen consumption by the body and oxygen supply to the cells.
4. Delayed Growth and Development related to an inadequate supply of oxygen and nutrients to the tissues.
5. Imbalanced Nutrition Less than Body related to fatigue at mealtime and increased caloric needs.
6. Risk for Infection related to decreased health status.

Nursing Interventions for Patent Ductus Arteriosus (PDA)
1. Maintain adequate cardiac output:

• Observation of the quality and strength of heart rate, peripheral pulses, skin color and warmth.
• Enforce the degree of cyanosis (circumoral, mucous membranes, clubbing).
• Monitor signs of CHF (restlessness, tachycardia, tachypnea, spasms, fatigue, periorbital edema, oliguria, and hepatomegaly).
• Collaboration of drugs in accordance with the order, using toxicity hazard prevention techniques.
• Provide treatment to reduce afterload.
• Give diuretics as indicated.

2. Reduce the increase in pulmonary vascular resistance:

• Monitor the quality and rhythm of breathing.
• Adjust the position of the child with Fowler position.
• Avoid children from an infected person.
• Give adequate rest.
• Provide optimal nutrition.
• Give oxygen if indicated.

3. Maintaining adequate levels of activity:

• Allow the child to rest frequently, and avoid disturbances during sleep.
• Encourage to engage in play and light activity.
• Help child to choose activities appropriate to the age, condition and abilities.
• Avoid the ambient temperature is too hot or too cold.
• Avoid the things that cause fear / anxiety in children.

4. Provide support for the Growth and Development :

• Assess the level of development of the child.
• Give the stimulation of growth and development, play activities, gaming, watching TV, puzzles, drawing, and others according to the condition and age of the child.
• Involve the family in order to continue to provide stimulation during care.

5. Maintaining growth in weight and height appropriate:

• Provide a balanced diet, high nutrients for adequate growth.
• Monitor height and weight, documented in the form of graphs to determine the trend of growing children.
• Measure weight every day with the same weight and the same time.
• Record intake and output correctly.
• Provide food with small portions but often to avoid fatigue during meals.
• Children who receive diuretics are usually very thirsty, and therefore not restricted fluid.

6. Children will not show signs of infection:

• Avoid contact with infected individuals.
• Give adequate rest.
• Provide optimal nutritional needs.

Source : http://fundamentalsnursing.com/

Perichondritis - Nursing Diagnosis and Interventions

Nursing Diagnosis and Interventions:

Nursing Diagnosis 1.

Acute Pain related to inflammation
Goal: pain can be reduced.
Expected outcomes:

• Reported pain reduced / controlled.
• Facial expression / posture relaxed.

Interventions and Rationale :
1. Assess the level of pain with a pain scale
R /: Giving info to assess the response to intervention.
2. Assess and record the patient’s response to intervention
R: Assist in providing interventions.
3. Collaboration give analgesic preparations
R /: Reduce pain.
4. Replacing the fuse when experiencing auditory canal edema
R /: To keep the canal open.

Nursing Diagnosis 2.

Anxiety related to lack of knowledge about the disease, the cause of infection and preventive actions.
Goal: reduce anxiety
Expected outcomes:

• Clients do not show signs of restlessness
• Clients look calm

Interventions and Rationale:
1. Listen carefully to what the client is saying about the disease and actions.
R /: Listening enables the detection and correction of the misconceptions and misinformation.
2. Provide an explanation of the causative organism; targeted treatment; schedule follow-up
R /: Knowledge of specific diagnoses and actions to improve compliance.
3. Give the client a chance to ask and discuss.
R /: Questions client signifies a problem that needs to be clarified.

Nursing Diagnosis 3.

Knowledge Deficit related to lack of exposure to information about the disease, treatment.
Goal: increased knowledge about the condition and treatment is concerned.
Expected outcomes :
Reported understanding of disease experienced.
Inquire about the treatment options that are clues readiness to learn.
Nursng Diagnosis and Interventions:
1. Assess the patient’s level of knowledge.
R /: Knowing the patient’s level of understanding and knowledge about the disease and indicators in intervention.
2. Provide information to patients about the course of their illness.
R /: Improve understanding of the client’s health condition.
3. Provide a description of the patient on any given act of nursing.
R /: Reduce levels of anxiety and help promote cooperation in support of a given therapy program.

Source : http://fundamentalsnursing.com