tag:blogger.com,1999:blog-89648615454819546002024-02-24T09:02:56.098+07:00Blog Nursing Care PlanSi Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comBlogger1571100tag:blogger.com,1999:blog-8964861545481954600.post-59880317834598480652015-09-01T00:35:00.000+07:002015-09-01T00:35:23.127+07:00Ineffective Airway Clearance related to Pneumonia<b>Nursing Care Plan for Pneumonia</b><br />
<br />
Pneumonia is one of the diseases of respiratory tract infection is the most established and often a cause of death in almost all the world. <br />
<br />
Most are caused by microorganisms, but also by other ingredients, so it is known:<br />
<ul>
<li>Lipid pneumonia: therefore aspiration of mineral oil.</li>
<li>Chemical pneumonitis: inhalation of organic materials or chemical vapors such as beryllium.</li>
<li>Extrinsic allergic alveolitis: inhalation of material dust containing allergens, such as dust.</li>
<li>Drug Reaction pneumonitis.</li>
<li>Pneumonia due to X-ray radiation.</li>
<li>Pneumonia is not clear: desquamative interstitial pneumonia, eosinophilic pneumonia.</li>
<li>Microorganisms.</li>
</ul>
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The clinical picture is usually preceded by an acute infection of the upper respiratory tract for several days, followed by fever, body temperature sometimes exceeding 40 degrees C, sore throat, muscle and joint pain. Also accompanied by cough, sputum mucoid or purulent, sometimes bloody.<br />
<br />
<b>Nursing Diagnosis and Interventions</b><br />
<br />
<b>Ineffective airway clearance</b> related to tracheobronchial inflammation, edema formation, increased sputum production.<br />
<br />
Goal:<br />
<ul>
<li>Airway effectively with breath sounds clean and clear.</li>
<li>Patients can perform effective cough to remove secretions</li>
</ul>
Expected results :<br />
<ul>
<li>Maintain a patent airway with breath sounds clean / clear.</li>
<li>Show behavior to improve airway clearance.</li>
<li>Example: effective cough and remove secretions.</li>
</ul>
<br />
Intervention:<br />
<br />
1. Auscultation of breath sounds, note the breath sounds. For example: wheezing, crackles.<br />
Rationale: Airway clearance ineffective can be manifested in the presence of breath sounds adventisius.<br />
<br />
2. Assess / monitor respiratory rate, record the ratio of inspiration / expiration.<br />
Rational: Tachypnea usually exist in some degree and can be found at the reception or during stress / presence of acute infectious process. Breathing can be slowed, and the frequency of expiration elongated than inspiration.<br />
<br />
3. Provide a comfortable position for the patient, such as semi-Fowler position.<br />
Rationale: The position of the semi-Fowler will facilitate the patient to breathe<br />
<br />
4. Encourage / aids abdominal breathing exercises or lips.<br />
Rationale: Giving the patient a few ways to cope with and control dipsnea and lower air entrapment.<br />
<br />
5. Observe the characteristic cough, auxiliary measures to improve the effectiveness of efforts to cough.<br />
Rationale: A cough may persist, but ineffective. The most effective cough in high sitting position or head down after chest percussion.<br />
<br />
6. Provide warm water as tolerated heart.<br />
Rational: Hydration lowers the viscosity of secretions and facilitate spending.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-10713889175990706502015-08-24T22:24:00.000+07:002015-08-24T22:24:06.110+07:00Ineffective Breathing Pattern - Nursing Care Plan for Diabetic Ketoacidosis<b>Nursing Care Plan for Diabetic Ketoacidosis</b><br />
<br />
Diabetic ketoacidosis is a state of urgency, or acute from Type I diabetes, is caused by the increased acidity of body ketone bodies due to a lack or deficiency of insulin, with characteristic hyperglycemia, acidosis, and ketones due to a lack of insulin (Stillwell, 1992).<br />
<br />
Signs and symptoms<br />
<ol>
<li>Polyuria</li>
<li>Polydipsia</li>
<li>Blurred vision</li>
<li>Weak</li>
<li>Headache</li>
<li>Orthostatic hypotension (decrease in systolic blood pressure of 20 mmHg or more when standing)</li>
<li>Anorexia, Nausea, Vomiting</li>
<li>Abdominal pain</li>
<li>Hyperventilation</li>
<li>Changes in mental status (unconscious, lethargic, coma)</li>
<li>High blood sugar levels (over 240 mg / dl)</li>
<li>There are ketones in the urine</li>
<li>Breath smelling of acetone</li>
<li>Ileus can occur secondary to the loss of K + due to osmotic diuresis</li>
<li>Dry skin</li>
<li>Sweat</li>
<li>Kusmaul (rapid, deep) because of metabolic acidosis</li>
</ol>
<a href="http://blog-nursingcareplan.blogspot.com/2014/10/acute-pain-and-ineffective-breathing.html"><br /></a>
<b><a href="http://blog-nursingcareplan.blogspot.com/2014/10/acute-pain-and-ineffective-breathing.html">Ineffective Breathing Pattern</a> </b>related to a decreased ability to breathe<br />
<br />
Expected outcomes:<br />
<ul>
<li>Regular breathing pattern.</li>
<li>Respiration rate back to normal.</li>
<li>Easy to breathe.</li>
</ul>
<br />
Intervention:<br />
<ul>
<li>Assess respiratory status by detecting pulmonary.</li>
<li>Give chest physiotherapy including postural drainage.</li>
<li>Suction to discharge mucus.</li>
<li>Identification capability and provide confidence in breathing.</li>
<li>Collaboration in the provision of medical therapy.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-37352235344302844912015-08-14T07:56:00.003+07:002015-08-14T07:56:42.365+07:00Airway Management in Patients with Septic Shock<b>Nursing Care Plan for Septic Shock</b><br />
<br />
Sepsis is a condition when microorganisms invade the body and cause a systemic inflammatory response. The response generated often leads to a decrease in organ perfusion and organ dysfunction. If accompanied by hypotension it is called septic shock. (Linda D.U, 2006)<br />
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Microorganisms that cause septic shock is a gram-negative bacteria. When microorganisms invade body tissues, the patient will show an immune response. This immune response activation evoke various chemical mediators which have various effects that lead to shock, which increased capillary permeability, which leads to leakage of fluid from the capillaries and vasodilatation.<br />
<br />
Gram-negative bacteria causing systemic infection that resulted in cardiovascular collapse. Endotoxin gram-negative bacilli causing capillary vasodilation and peripheral arteriovenous bypass open relationship. In addition, there is increased capillary permeability. Increased capacity due to vasodilation of peripheral vascular causes relative hypovolemia, while the increase in capillary permeability causing interstitial to the intravascular fluid loss is seen as edema.<br />
<br />
Early signs of septic shock is often a decrease in mental alertness and confusion, which occurs within 24 hours or more before the blood pressure down. This phenomenon is caused by reduced blood flow to the brain.<br />
Outpouring of blood from the heart is increased, but the blood vessels widen so blood pressure drops. Breathing becomes fast, so that the lungs secrete excessive levels of carbon dioxide in the blood decreases.<br />
<br />
Early symptoms include shivering, body temperature rises very fast, warm and reddish skin, weak pulse and blood pressure fluctuated. Decreased urine production despite increased flow of blood from the heart. In later stages, the body temperature often drops to below normal.<br />
When the shock worsens, several organs fail:<br />
<ul>
<li>Kidneys: urine production decreases</li>
<li>Lungs: respiratory disorders and decreased levels of oxygen in the blood</li>
<li>Heart: fluid retention and swelling. May develop blood clots in the blood vessels.</li>
</ul>
<br />
<b>Airway Management in Patients with Septic Shock</b><br />
<br />
<a href="http://blog-nursingcareplan.blogspot.com/2014/10/acute-pain-and-ineffective-breathing.html">Ineffective breathing pattern</a> related to imbalance between supply and demand of oxygen, pulmonary edema.<br />
<br />
Goals and outcomes (NOC)<br />
<br />
After the act of nursing, the patient will be:<br />
<ul>
<li>Vital signs within normal ranges.</li>
<li>Indicates that a patent airway.</li>
<li>Demonstrating a clean breath sounds, no cyanosis and dyspnea.</li>
</ul>
Airway Management:<br />
<ul>
<li>Open the airway.</li>
<li>Position the patient to maximize ventilation (Fowler / semifowler).</li>
<li>Auscultation of breath sounds, record the additional sound.</li>
<li>Identification of patients need artificial airway installation tool.</li>
<li>Monitor respiration and oxygenation status.</li>
<li>Monitor vital signs.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-71139924501832347842015-08-12T10:19:00.000+07:002015-08-12T10:19:01.577+07:00Nursing Care Plan for Blepharitis<br />
Blepharitis is an inflammation of the eyelids. Inflammation is often on the eyelids and the edge of the eyelids. In some cases accompanied by ulcers or not at the edge of the eyelids. Usually involving hair follicles and glands. Blepharitis is characterized by the formation of excessive oil in the glands near the eyelid which is the preferred environment by bacteria that are normally found on the skin.<br />
<br />
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Usually, people often assume eyestrain, or gritty eyes, and feels glare and discomfort when exposed to sunlight or at the time was in a smoky environment, provides an overview in the form of red eyes, and as there is a foreign body in the eye. Additionally, blepharitis can also disrupt the patient's self-image.<br />
<br />
In general, the cause of blepharitis include:<br />
<ul>
<li>Infection or allergy that is usually chronic. Allergies can be caused by dust, smoke, chemicals irritating, or cosmetic ingredients.</li>
<li>Due to abnormalities of the meibomian glands.</li>
<li>Bacterial infections such as staphylococcus, Alpha-hemolytic streptococci, beta-hemolytic streptococci, pneumococcal (Streptococcus pneumoniae), pseudomonas, demodex folliculorum, until Pityrosporum ovale.</li>
<li>Infections caused by the herpes zoster virus, herpes simplex, vaccinia, and so on.</li>
<li>Pityrosporum ovale yeast infection, can cause superficial (systemic).</li>
</ul>
<br />
Clinical Manifestations<br />
<br />
Symptoms:<br />
<ul>
<li>Blepharitis causes redness, scales and can also form a scab or shallow open sores on the eyelids.</li>
<li>Blepharitis can cause the patient to feel there is something in the eye. Eyes and eyelids itchy, hot, and red. Eyelid swelling can occur and a few strands of eyelashes to fall out.</li>
<li>Eyes become red, watery and sensitive to bright light. It could also be formed scab firmly attached to the edge of the eyelid; if scab is released, bleeding can occur.</li>
<li>During sleep, eye secretions dried up, so that when you wake difficult eyelids open.</li>
</ul>
<br />
Signs :<br />
<ul>
<li>The scales on the eyelids.</li>
<li>Eyelid redness, swelling, pain, and itching.</li>
<li>Sticky exudate dependent on the eyelashes.</li>
<li>Dirty eyes and a burning sensation.</li>
<li>Oily exudate.</li>
<li>Hard eyes opened.</li>
<li>Reduced the number of lashes.</li>
</ul>
<br />
<b>Nursing Care Plan for Blepharitis</b><br />
<br />
<b>Assessment</b><br />
<br />
1. The history of health, environment, employment, lifestyle, use of drugs and cosmetics.<br />
<br />
2. Subjective Data:<br />
<ul>
<li>People with eye inflammation may complain of itching.</li>
<li>Pain (mild to severe) on the eyelids.</li>
<li>Lacrimation (watery eyes always).</li>
<li>Restless due to itching / pain.</li>
<li>Patients feel there is something in the eye.</li>
<li>Embarrassment and lack of confidence due to the effects of the disease (the lashes fall out and not replaced).</li>
<li>Eyes blurred and visual acuity decreased.</li>
</ul>
<br />
3. Objective Data :<br />
<ul>
<li>Eyelid redness.</li>
<li>Eyelid edema.</li>
<li>Presence of pus expenditure.</li>
<li>The eyelids can be a meeting when sleeping.</li>
<li>Decreasing the number of eyelashes (loss).</li>
</ul>
<br />
4. Supporting Data:<br />
Microbiological examination to determine the cause.<br />
<ul>
<li>Laboratory tests.</li>
<li>Radiography.<br />
<ul>
<li>Fluorescein angiography.</li>
<li>Computed tornografi (CT Scan).</li>
<li>With a slit lamp examination.</li>
</ul>
</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis for Blepharitis</b><br />
<ol>
<li><a href="http://blog-nursingcareplan.blogspot.com/2015/08/acute-pain-and-risk-for-infection.html">Acute pain</a> r / t inflammation due to bacterial infection.</li>
<li>Anxiety r / t visual impairment, damage to the eyelids.</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2014/10/risk-for-injury-and-disturbed-thought.html">Risk for injury</a> r / t the deficit of knowledge, blurred vision or decrease the sharpness of the eyes.</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2015/02/nursing-care-plan-for-knowledge-deficit.html">Knowledge Deficit</a> r / t less information about the disease.</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2015/01/nursing-care-plan-for-risk-for.html">Risk for infection</a> r / t invasive procedures.</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2014/12/impaired-sensory-perception-auditory.html">Disturbed Sensory perception</a> (visual) r / t disruption reception status sensory organs.</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-30432514711259037922015-08-12T09:44:00.003+07:002015-08-12T09:45:11.345+07:00Acute Pain and Risk for Infection related to Cystitis<b>Nursing Diagnosis and Interventions for Cystitis</b><br />
<br />
Cystitis is inflammation of the bladder is most often caused by the spread of infection of the urethra (Brunner & Suddarth, 2002).<br />
<br />
Causes of Cystitis include: (Lyndon Saputra, 2009).<br />
<ul>
<li>In women, most bladder infections caused by ascending infection originating from the urethra and often associated with seyual activity.</li>
<li>In men, it can be caused by ascending infection of the urethra or prostate but rather more often is secondary to anatomic abnormalities of the urinary tract.</li>
<li>May be associated with congenital anomalies genitourinary tract, such as "bladder neck obstruction", stasis of urine, ureteral reflux, and "neurogenic bladder".</li>
<li>Is more common in diabetics.</li>
<li>Can be increased in women who use contraceptives or diaphragm that is not installed properly.</li>
<li>Urinary catheterization may cause infection.</li>
</ul>
<br />
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Symptoms and Signs: (Lyndon Saputra, 2002)<br />
<ul>
<li>Dysuria (painful urination), pollakiuria (pee a little and often), nocturia (urination at night), a bad taste in the suprapubic area, tenderness on palpation in the suprapubic area.</li>
<li>Systemic symptoms such as pyrexia, sometimes shivering; often more pronounced in children, sometimes without symptoms or signs of local infection of the urinary tract.</li>
<li>Cloudy urine may smell bad and the leukocytes, erythrocytes, and organisms.</li>
</ul>
<br />
<br />
<h1 class="post-title entry-title">
<a href="http://blog-nursingcareplan.blogspot.com/2012/06/nursing-care-plan-for-cystitis.html"><span style="font-size: small;">Nursing Care Plan for Cystitis</span></a></h1>
<br />
<b>Nursing Diagnosis : <a href="http://blog-nursingcareplan.blogspot.com/2015/08/acute-pain-related-to-acute-coronary.html">Acute Pain</a></b> related to bladder infections<br />
<br />
Goal: There is no pain and a burning sensation during urination.<br />
<br />
Expected outcomes: reduced pain / no pain<br />
<br />
Interventions :<br />
<br />
1. Monitor:<br />
<ul>
<li>The bow of urine to discoloration, odor and voiding pattern.</li>
<li>Input and output every 8 hours.</li>
<li>Re urinalis results.</li>
</ul>
Rationale: To identify the indication, the progress or the storage of the expected results.<br />
<br />
2. Consul doctor if:<br />
<ul>
<li>Previous amber-yellow urine, dark orange, foggy or cloudy.</li>
<li>Voiding patterns change, for example, a burning sensation as burning when urinating, a sense of urgency when urinating.</li>
<li>Persistent pain or increased pain.</li>
</ul>
Rationale: These findings may provide further signs of tissue damage and need more extensive checks, such as radiology examinations if not previously done.<br />
<br />
3. Give analgesics as needed and evaluating success.<br />
Rationale: Analgesics block the path of pain, thus reducing pain.<br />
<br />
4. If the frequency becomes a problem, make it easy access to the bathroom, bedpan under the bed. Instruct the patient to urinate whenever there is desire.<br />
Rationale: Urinate frequently reduces static urine in the bladder and avoid the growth of bacteria.<br />
<br />
5. Give antibiotics. Create variations perfomed drinks, including fresh water beside the bed. Giving water to 2400 ml / day.<br />
Rationale: As a result of an increase in urine output facilitate frequent urination and help flush the urinary tract.<br />
<br />
<br />
<b>Nursing Diagnosis : <a href="http://blog-nursingcareplan.blogspot.com/2015/01/nursing-care-plan-for-risk-for.html">Risk for infection</a></b> related to nosocomial risk factors.<br />
<br />
Objective: There is no infection in the bladder.<br />
<br />
Expected outcomes: Clients can urinate clear, without inconvenience, urinalysis within normal limits, urine culture showed no bacteria.<br />
<br />
Interventions :<br />
<br />
1. Provide perineal care with soapy water every shift. If the patient's incontinence, perineal wash as soon as possible.<br />
Rationale: To prevent contamination of the urethra.<br />
<br />
2. If indwelling catheter, catheter care given two times a day (a part of a shower in the morning and at bedtime) and after defecation.<br />
Rationale: Catheter give way on the bacteria to enter the bladder and up into the urinary tract.<br />
<br />
3. Follow universal precautions (washing hands before and after direct contact, wearing gloves), when in contact with body fluids or blood which may have occurred (provide perineal care, emptying urine drainage bag, urine specimen shelter). Defense aseptic technique when catheterization, when taking a urine sample from indwelling catheters.<br />
Rationale: To prevent cross-contamination.<br />
<br />
4. Reposition the patient every two hours, and encourage fluid intake of at least 2400 ml / day (unless contraindicated). Do ambulation aids as needed.<br />
Rationale: To prevent static urine.<br />
<br />
5. Take action to maintain acidic urine.<br />
Rationale: Acid urine hinders the growth of bacteria.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-36492784662236258552015-08-08T11:17:00.001+07:002015-08-08T11:17:39.456+07:00Differences Between Right Chest Pain and Heart Attacks<br />
If you ever feel the pain right chest, do not panic and fear. Because it turns out that not all the causes of the pain is a symptom or sign of that harm your health. However, can not be denied that sometimes you feel pain in the chest is sometimes also indicate a serious disturbance in the body inside. Even some who sometimes assume pain in the right chest is a symptom or sign of a heart attack. Though medically heart is on the left, not the right. Conclusions about the heart attack is usually taken for pain in the right chest is sometimes indeed appear suddenly and can even cause pain that is unbearable in a long time. So what are the real causes of chest pain the upper right and what's the difference with a heart attack? <br />
<br />
<br />
<b>Differences Between Right Chest Pain and Heart Attacks</b><br />
<br />
For those of you who suspect or fear that you are feeling the pain is a symptom of heart disease or not, there are some signs or symptoms that you should know to differentiate these symptoms. In general, heart disease or heart attack can actually be easily recognized without any medical diagnosis. But apparently a sign of chest pain that does not mean you are affected by heart disease. Sometimes the chest pain can also signal other diseases, such as asthma, pneumothorax, and so on.<br />
<br />
Heart disease usually chest will feel heavy and makes it very difficult to breathe. Chest felt heavy when you inhale and as if by a rope tied very tight in the chest. Stomach feels queasy, emerging feelings of anxiety and usually your body will react with sweat.<br />
<br />
Not only in the chest, but also if your chest pain is caused due to a heart attack, the pain will usually spread to the neck, left arm, jaw, behind the stomach, until it feels in one of your shoulders. So not only the symptoms of pain you feel in one place. In addition, if you can feel it, your heart will beat faster than normal. And at the same time, a heart attack can make your body feel very weak. Such conditions usually experienced by people with heart disease after exercise, when not active, after a large meal, or when you're under stress. Well, then what are the causes and symptoms of chest pain on the right side? Consider the following information.<br />
<br />
<br />
<b>Various Causes of Chest Pain Symptoms in Section Right</b><br />
<br />
Once you know how the symptoms that the chest pain is a sign you have a heart attack, now we will discuss some of the causes of pain that usually happens in the right chest. Lots of cause or effect that can make you feel the pain, eg due to excessive physical activity, physical contact, even viral infections.<br />
<br />
1. Inflammation of the lining of the stomach<br />
<br />
Peritonitis or also called gastritis can make you feel pain in the upper right chest. Such conditions usually will you feel after you fast during the day or after you consume alcohol in portions too much. Abdominal pain that you feel could also trigger chest pain right.<br />
<br />
Although the right chest pain is not a heart attack symptoms, but still have to watch out because it could be an early symptom of a disease which if not prevented immediately be difficult to cure.<br />
<br />
2. Gall Bladder Disorders<br />
<br />
Another cause that can make you feel chest pain on the right side is due to interference with your gall bladder. The disorder usually occurs because you are eating too many fatty foods, or when a gallstone stuck in the bile duct. Well, the disorder can cause chest pain right which is quite disturbing. So you should immediately consult a medical condition to a doctor.<br />
<br />
3. Inflammation of the pleura<br />
<br />
The pleura is a tissue that is located surrounding the lungs. Well, if the part is impaired and causes inflammation of the pleural tissue, sometimes will feel the pain in the right chest. Condition or pain usually will you feel when you cough or when being inhaled.<br />
<br />
4. Virus Infection<br />
<br />
Right chest pain may be caused by the presence of a virus that infects your body. Let's say some kind of virus that causes the common cold or flu. Well, the virus also can sometimes cause pain in the chest. In fact, you could also feel pain when you are coughing or breathing. Thus, the emotion you cure the common cold or flu you have experienced.<br />
<br />
5. Gastrointestinal Disorders<br />
<br />
The fifth problem is usually also results in the upper right chest pain is due to the occurrence of gastrointestinal disorders in your body. When in your body digestive tract is being disrupted, it often involves the tightening of the throat and chest.<br />
<br />
6. Injury<br />
<br />
For the athletes, you may also often experience pain in the chest right or left. If you do not have a history of heart disease, the pain can occur due to injury. Perhaps because of a fall, because collisions with other athletes, or other accidents that occur in the field.<br />
<br />
7. Fatigue<br />
<br />
Right chest pain also can occur because you are too tired to perform the activity or activities of the day. The activities you do may require you to use your chest muscles. Therefore if you are too tired, there is a possibility you feel pain or pain in the chest. Especially if you are doing the movements wrong.<br />
<br />
8. Inflammation of the Heart<br />
<br />
Inflammation of the liver disease can also lead to the emergence of pain or pain in certain body parts. The pain can appear at the right clothes, even you can feel in the chest right. This usually occurs due to inflammation of the liver, therefore, you should perform further tests to physicians.<br />
<br />
Those are the eight causes of chest pain on the right that is often experienced by someone. Even the wrong sleeping position also can make you feel sick right chest. You also now better understand how to characterize or painful symptoms that bodes heart attack so you can distinguish between heart disease with symptoms of pain others.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-61977910050970930242015-08-08T10:59:00.000+07:002015-08-08T10:59:12.237+07:00Acute Pain related to Acute Coronary Syndrome<br />
<b>Nursing Care Plan for Acute Coronary Syndrome</b><br />
<br />
Acute coronary syndrome is a term used for any condition brought on by sudden, reduced blood flow to the heart. It is an emergency. It includes unstable angina and heart attack.<br />
<br />
<b>Symptoms of Acute Coronary Syndrome</b><br />
<br />
Chest pain or discomfort may immediately signal to you that something’s wrong with your heart. Other symptoms, however, may leave you unsure of what’s wrong. Take note of these common signs of an acute coronary syndrome:<br />
<ul>
<li>Chest pain or discomfort, which may involve pressure, tightness or fullness</li>
<li>Pain or discomfort in one or both arms, the jaw, neck, back or stomach</li>
<li>Shortness of breath</li>
<li>Feeling dizzy or lightheaded</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2014/10/some-causes-of-nausea-after-eating.html">Nausea</a></li>
<li>Sweating</li>
</ul>
Some additional heart attack symptoms include:<br />
<ul>
<li>Abdominal pain</li>
<li>Pain similar to heartburn</li>
<li>Clammy skin</li>
<li>Lightheadedness, dizziness or fainting</li>
<li>Unusual or unexplained fatigue</li>
<li>Feeling restless or apprehensive</li>
</ul>
<br />
<b>Nursing Care Plan for Acute Coronary Syndrome</b><br />
<br />
Nursing Diagnosis: <a href="http://blog-nursingcareplan.blogspot.com/2014/10/acute-pain-and-ineffective-breathing.html">acute pain</a> r / t tissue ischemia secondary to coronary artery blockage.<br />
<br />
Goal : Pain experienced by patients can be reduced.<br />
<br />
Expected outcomes:<br />
- The client states chest pain is gone / controlled.<br />
- Clients can demonstrate relaxation techniques.<br />
- Clients can indicate reduced tension, relaxed and easy to move.<br />
<br />
Interventions:<br />
<br />
1. Provide a comfortable environment, calm, and give slow activity.<br />
R: Reduce external stimuli where anxiety and heart strain and limited coping abilities and judgment of the current situation.<br />
<br />
2. Assist relaxation techniques, such as deep breathing / slow, distraction, visualization, guided imagery.<br />
R: Helps in reducing the pain response.<br />
<br />
3. Provide supplemental oxygen by nasal cannula or face mask as indicated.<br />
R: Increase the amount of oxygen available for the use of the myocardium and also reduces discomfort with respect to tissue ischemia.<br />
<br />
4. Give appropriate indications such as antianginal drugs, beta-blockers, analgesics.<br />
R: To control pain and increase the comfort of patients so that the healing process runs smoothly.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-22342874625966181012015-04-22T12:33:00.002+07:002015-04-22T12:33:51.085+07:00Pathophysiology of Hemorrhagic Stroke<b>Pathophysiology of <a href="http://blog-nursingcareplan.blogspot.com/2015/04/nursing-assessment-for-hemorrhagic.html">Hemorrhagic Stroke</a></b><br />
<br />
Cerebral hemorrhage including third of all cases the main cause of cerebral vascular disorders. Cerebral hemorrhage can occur outside the dura mater (extradural hemorrhage or epidural), under the dura mater, (subdural hemorrhage), in the subarachnoid space (subarachnoid hemorrhage) or in the substance of the brain (intracerebral hemorrhage). Extradural hemorrhage (epidural) is a neuro surgical emergency requiring immediate treatment. This is usually followed by a skull fracture rips meningeal artery with other arteries. Subdural hemorrhage (including acute subdural hemorrhage) is basically the same with epidural hemorrhage, subdural hematoma normally except that the bridge torn vein. Therefore, a longer period of hematoma formation (obviously longer intervention) and cause pressure on the brain. Some patients may experience chronic subdural hemorrhage without showing signs and symptoms. Subarachnoid hemorrhage can occur as a result of trauma or hypertension, but the most common cause is leaking aneurysm, in the area of the circle of Willis, and congenital arteriovenous malformation in the brain. Arteries in the brain may be a place aneurysm. Intracerebral hemorrhage is most common in patients with hypertension and cerebral atherosclerosis, due to degenerative changes due to this disease usually causes rupture of blood vessels. in people younger than 40 years, intracerebral hemorrhage is usually caused by arteriovenous malformations, haemangioblastoma and trauma, also caused by certain types of arterial pathology, brain tumors and the use of medications (oral anticoagulants, amphetamines and various drug additives). Bleeding is usually an artery, and occurs mainly around the basal ganglia. Usually sudden onset with severe headache. When hemorrhage enlarged, the more obvious neurological deficits that occur in the form of loss of consciousness and abnormalities in vital signs. Patients with extensive bleeding and hemorrhage decreased consciousness and abnormalities in vital signs.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-40268814411926125742015-04-22T12:24:00.002+07:002015-04-22T12:24:36.144+07:00Nursing Assessment for Hemorrhagic Stroke<br />
According to the WHO. (2007) Stroke is an acute neurological dysfunction caused by impaired blood flow that occur suddenly with signs and symptoms according to the focal area of the brain is disrupted.<br />
<br />
Stroke is a disorder of brain function that occurs anatomy suddenly and quickly, due to disturbance of brain haemorrhage. Stroke or Cerebral vascular Accident (CVA) is a loss of brain function caused by the cessation of blood supply to part of the brain (Brunner and Suddarth, 2008).<br />
<br />
<br />
<b>Assessment </b><br />
<br />
1. Primary Assessment<br />
<br />
Airway<br />
The blockage / obstruction of the airway by a buildup of secretions due to the weakness of the cough reflex.<br />
Breathing<br />
Weakness swallow / cough / protect the airway, breathing hard onset and / or irregular, audible breath sounds Ronchi / aspiration.<br />
Circulation<br />
Blood pressure may be normal or increased, hypotension occurs at an advanced stage, tachycardia, abnormal heart sounds at an early stage, dysrhythmias, skin and mucous membranes pale, cold, cyanosis at an advanced stage.<br />
<br />
2. Secondary Assessment<br />
<br />
1. Activity and rest<br />
Subjective Data:<br />
<ul>
<li>difficulties in the move; weakness, loss of sensation or paralysis.</li>
<li>tiredness, trouble breaks (pain or muscle spasms).</li>
</ul>
Objective data:<br />
<ul>
<li>Changes in the level of consciousness.</li>
<li>Changes in muscle tone (flaccid or spastic), paraliysis (hemiplegia), general weakness.</li>
<li>visual impairment.</li>
</ul>
<br />
2. Circulation<br />
Subjective data:<br />
<ul>
<li>A history of heart disease (heart valve disease, dysrhythmias, heart failure, bacterial endocarditis), polycythemia.</li>
</ul>
Objective data:<br />
<ul>
<li>Arterial hypertension.</li>
<li>Dysrhythmia, ECG changes.</li>
<li>Pulsation: varied possibilities.</li>
<li>Pulse carotid, femoral and iliac artery or abdominal aorta.</li>
</ul>
<br />
3. Ego integrity<br />
Subjective data:<br />
<ul>
<li>feeling helpless, hopeless.</li>
</ul>
Objective data:<br />
<ul>
<li>emotional instability and anger that are not appropriate, sadness, joy.</li>
<li>difficulty of self expression.</li>
</ul>
<br />
4. Elimination<br />
Subjective data:<br />
<ul>
<li>incontinence, anuria.</li>
<li>abdominal distention (very full bladder), absence of bowel sounds (paralytic ileus).</li>
</ul>
<br />
5. Eating / drinking<br />
Subjective data:<br />
<ul>
<li>loss of appetite.</li>
<li>nausea / vomiting indicate the presence of increased intracranial pressure.</li>
<li>loss of sensation of the tongue, cheeks, throat, dysphagia.</li>
<li>History of diabetes, Increased fat in the blood.</li>
</ul>
Objective data:<br />
<ul>
<li>problems in chewing (declining reflexes palate and pharynx).</li>
<li>obesity (risk factors).</li>
</ul>
<br />
6. Neuro-sensory<br />
Subjective data:<br />
<ul>
<li>dizziness / syncope (prior CVD / temporary for TIA).</li>
<li>headache: the intra-cerebral hemorrhage or subarachnoid hemorrhage.</li>
<li>weakness, tingling / numbness, affected side looks like a lame / death</li>
<li>reduced visibility.</li>
<li>touch: loss of sensors on the collateral of the extremities and the face of the ipsilateral (same side).</li>
<li>sense of taste and smell disorders.</li>
</ul>
Objective data:<br />
<ul>
<li>mental status; coma usually mark the bleeding stage, behavioral disturbances (such as lethargy, apathy, attack) and impaired cognitive function.</li>
<li>extremity: weakness / paraliysis (contralateral to all types of strokes, do not draw the hand grip, reduced tendon reflexes in (contralateral).</li>
<li>facial paralysis / parese (ipsilateral).</li>
<li>aphasia (damage or loss of function of language, expressive possibilities / difficulty saying words, receptive / trouble saying the word comprehensive, global / combination of both.</li>
<li>lose the ability to know or see, auditory, tactile stimuli.</li>
<li>apraxia: lose the ability to use the motor.</li>
<li>reaction and pupil size: unequal dilatation and not react on the ipsilateral side.</li>
</ul>
<br />
7. Pain / comfort<br />
Subjective data:<br />
<ul>
<li>headache that vary in intensity.</li>
</ul>
Objective data:<br />
<ul>
<li>unstable behavior, anxiety, muscle tension / facial.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-59813122213297811532015-04-21T02:05:00.002+07:002015-04-21T02:05:17.696+07:00Fluid Volume Deficit related to Diabetes Mellitus<b>Diabetes Mellitus</b><br />
<br />
<b>Fluid Volume Deficit</b><br />
<br />
Definition: Decreased intravascular fluid, interstitial, and / or intracellular. This leads to dehydration, loss of fluid with sodium output.<br />
<br />
Defining characteristics:<br />
<ul>
<li>Weakness.</li>
<li>Haus.</li>
<li>Decreased skin turgor / tongue.</li>
<li>Mucous membrane / dry skin.</li>
<li>Increased pulse rate, decreased blood pressure, decrease in volume / pulse pressure.</li>
<li>Charging vein decreased.</li>
<li>Changes in mental status.</li>
<li>Increased urine concentration.</li>
<li>Increased body temperature.</li>
<li>Hematocrit rises.</li>
<li>Losing weight immediately (except the third spacing).</li>
</ul>
<br />
Related factors :<br />
<ul>
<li>Loss of active fluid volume.</li>
<li>Failure of regulatory mechanisms.</li>
</ul>
<br />
<b>NOC:</b><br />
<ul>
<li>Fluid balance.</li>
<li>Hydration.</li>
<li>Nutritional Status: Food and Fluid Intake.</li>
</ul>
<br />
Expected outcomes:<br />
<ul>
<li>Maintain urine output in accordance with the age and weight, urine specific gravity of normal, normal hematocrit.</li>
<li>Blood pressure, pulse, body temperature within normal limits.</li>
<li>No signs of dehydration, the elasticity of the skin turgor; good, moist mucous membranes, no excessive thirst.</li>
</ul>
<br />
<b>NIC:</b><br />
<ul>
<li>Fluid management</li>
<li>Measure diapers / pads if necessary.</li>
<li>Maintain records accurate intake and output.</li>
<li>Monitor the status of hydration (moisture mucous membranes, adequate pulse, orthostatic blood pressure), if necessary.</li>
<li>Monitor vital signs.</li>
<li>Monitor input food / liquid and calculate daily calorie intake.</li>
<li>Collaborate IV fluid administration.</li>
<li>Monitor nutritional status.</li>
<li>Give IV fluids at room temperature.</li>
<li>Encourage oral input.</li>
<li>Give a nasogastric replacement in accordance with the output.</li>
<li>Encourage families to help patients eat</li>
<li>Offer a snack (fruit juice, fresh fruit).</li>
<li>Collaboration doctor if signs of excess fluid appears meburuk.</li>
<li>Set the possibility of transfusion.</li>
<li>Preparation for transfusion.</li>
</ul>
<br />
<br />
<a href="http://blog-nursingcareplan.blogspot.com/2015/01/fluid-volume-deficit-and-imbalanced.html" title="Fluid Volume Deficit and Imbalanced Nutrition - NCP for Bowel Obstruction">Fluid Volume Deficit and Imbalanced Nutrition - NCP for Bowel Obstruction</a> <br />
<br />
<a href="http://blog-nursingcareplan.blogspot.com/2015/02/nursing-care-plan-for-risk-for-fluid.html" title="Nursing Care Plan for Risk for Fluid Volume Deficit related to Hematemesis - Melena">Nursing Care Plan for Risk for Fluid Volume Deficit related to Hematemesis - Melena</a><br />
<br />
<a href="http://blog-nursingcareplan.blogspot.com/2010/07/nursing-care-plan-for-diabetes-mellitus.html">Nursing Care Plan for Diabetes Mellitus</a>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-83289907240999229762015-04-21T01:50:00.004+07:002015-04-21T01:50:42.100+07:00Nursing Management for DecubitusDecubitus management begins with vigilance to prevent pressure sores by getting to know people with a high risk of pressure sores, for example in patients immobilized.<br />
<br />
Attempts to determine the risk of pressure sores among others by using a scoring system Norton. Scores below 14 indicate a high risk for the occurrence of pressure sores. With evaluation scores can be seen the development of the patient.<br />
<br />
The next action is to maintain the cleanliness of the people, especially the skin, to bathe every day. After drained then rubbed with lotion, especially in the skin that exist in the bone protrusions. Should be given massase for blood circulation, all excreta / screta must be cleaned carefully agari not cause blisters on the skin of the patient.<br />
<br />
Further action is useful both for prevention and after the occurrence of pressure sores another antaral:<br />
<br />
1. Improving the health status of the patient;<br />
general; repair and maintain the general state of the patient, for example overcome anemia, hypoalbuminemia corrected, the nutrients and adequate hydration, vitamins (vitamin C) and minerals (Zn) is added.<br />
Special; trying to cope with / treat diseases that exist in people, eg DM.<br />
<br />
2. Reduce / equalize the pressure factors that interfere with blood flow;<br />
a. Switch position / switch lying / sleeping alternating least every two hours long. Objection to this approach is the reliance on nurses who sometimes have very less, and sometimes disturbing break sufferers, even painful.<br />
b. Special mattresses to more evenly press that occurs in the patient's body, for example; mattress with air bubbles press the up and down, the water mattress with adjustable water temperature. (mind this sophisticated equipment is expensive, the treatment should be good and can be damaged).<br />
c. Stretch the skin and skin folds that cause local blood circulation is interrupted, can be reduced, among others;<br />
Maintain the position of the patient, whether put to sleep flat on the bed, or been allowed to sit in a chair.<br />
Help support beam legs, small cushions to withstand the patient's body, "donut" to heel,<br />
So also look skin hyperemia in the patient's body, especially in places that often occur decubitus, above all efforts made with more care to improve the ischemia that occurs, because once tissue damage recovery efforts will be more complicated.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-78354608268536086342015-04-02T14:28:00.000+07:002015-04-02T14:28:38.322+07:00Coronary Heart Disease - Causes, Symptoms and Prevention<br />
<b>Coronary heart disease</b> is also called <b>coronary artery disease</b> or <b>ischemic heart disease</b>, this is a form of heart disease that is caused by narrowing of the coronary arteries. Coronary heart disease is the most common form of heart disease. Coronary heart disease causes almost all heart attack (<a href="http://blog-nursingcareplan.blogspot.com/2012/05/nursing-care-plan-for-myocardial.html">myocardial infarction</a>).<br />
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<b>What is a Coronary Heart Disease?</b><br />
<br />
Healthy coronary arteries have flexible walls that provide blood to the heart. However, over the years, the flexible walls can be damaged by substances such as fat, <a href="http://blog-nursingcareplan.blogspot.com/2015/04/7-foods-that-reduce-your-bad.html">cholesterol</a>, calcium, and platelets (small cells that are responsible for blood clotting). When the arterial wall is damaged, these substances can be "attached" arterial wall that will eventually narrowing of the coronary arteries. This condition is referred to as coronary <a href="http://ncp-blog.blogspot.com/2010/06/migraines-raise-heart-disease-risk.html" target="_blank">heart disease</a>.<br />
<br />
Buildup in the arterial wall is a process called <a href="http://blog-nursingcareplan.blogspot.com/2014/09/nursing-care-plan-for-atherosclerosis.html">atherosclerosis</a>. This process produces a substance known as plaque. Such as buildings, plaque like dirt that accumulates in the pipelines of your home. As the impact of the increasingly heavy dirt buildup, which flows through the pipe may be reduced or even completely stopped. Similarly, when your heart is not getting enough oxygen because of narrowed arteries, you may feel pressure in the chest or pain called angina. If the blood supply to part of the heart is completely halted because of this narrowing, the result is a heart attack.<br />
<br />
Every person has atherosclerosis as they age. For most of us, atherosclerosis begins early in life. Some people have a rapid increase in the buildup of atherosclerotic plaques after 30 years old and for some people, plaque buildup is not a problem until she was at 50 or 60 years.<br />
<br />
<br />
<b>Causes of Coronary Heart Disease</b><br />
<br />
Although we do not know for sure about the causes of coronary heart disease, why atherosclerosis occurs or even how this process begins. Some medical experts believe that atherosclerotic buildup in the inner lining of the arteries can be caused by several conditions, including:<br />
<ul>
<li>Increased levels of LDL (Low-density lipoprotein).</li>
<li>Low levels of HDL cholesterol (high-density lipoprotein).</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2011/05/nursing-care-plan-for-hypertension.html">High blood pressure</a>.</li>
<li>Tobacco smoke.</li>
<li>High levels of blood sugar (<a href="http://blog-nursingcareplan.blogspot.com/2010/07/nursing-care-plan-for-diabetes-mellitus.html">diabetes mellitus</a>).</li>
<li>Inflammation.</li>
</ul>
<br />
<b>Symptoms of Coronary Heart Disease</b><br />
<br />
Symptoms of heart disease is not always the same for every kind, among the various existing heart disease, the symptoms will be different for each despite the similarities between all of them remains. For coronary heart disease, the most common symptom is chest pain or called <a href="http://blog-nursingcareplan.blogspot.com/2014/10/decreased-cardiac-output-angina.html">Angina</a>. In addition, there are also minor symptoms for one type of heart disease, namely:<br />
<ul>
<li>hard to breathe</li>
<li><a href="http://nandanursingdiagnosis.blogspot.com/2011/06/nursing-diagnosis-fatigue.html" target="_blank">fatigue</a></li>
<li>weakness or dizziness</li>
<li>excessive sweating</li>
<li>palpitations (this is an irregular heartbeat)</li>
<li>rapid heart beat</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2014/09/nursing-care-plan-for-nausea-and.html" target="_blank">nausea</a> and sweating.</li>
</ul>
<br />
<br />
<b>Prevention of Coronary Heart Disease</b><br />
<br />
Below are four main guidelines for coronary heart disease but must demonstrate that both excessive drinking and frequent and / or high stress levels have been indirectly linked to coronary heart disease.<br />
<br />
1. Watch what you eat<br />
Saturated fat is the main culprit in the formation of arterial plaque. Reduce consumption of saturated fats not only can stop the progression of coronary heart disease but may be able to reverse the condition. According to the American Heart Association saturated fat intake should be no more than 10 percent of calories to maintain the status quo and less than 7 percent for the possibility of reducing existing plaque deposits.<br />
<br />
2. Stay away from cigarettes and cigarette smoke.<br />
Smoking or cigarette smoke will increase bad cholesterol, lower good cholesterol and lead to narrowed arteries. Smokers will have the possibility of 4 times greater than nonsmokers.<br />
<br />
3. Do not let yourself become inactive<br />
Physical activity will greatly help prevent heart disease and blood vessels. The stronger the greater the activity manfaatnya.Selalu a time to exercise to keep your body's overall condition.<br />
<br />
4. Watch your weight<br />
The increase in overweight could be the cause of someone having a heart attack or stroke. The more fat, the greater the risks. Being overweight also increases the amount of LDL (bad) cholesterol and other blood fats and reduce HDL (good cholesterol).Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-76087063423343930272015-04-02T13:57:00.000+07:002015-04-02T13:57:20.437+07:007 Foods That Reduce Your Bad Cholesterol Levels<br />
The word "cholesterol", may already no stranger to everyone. Did you know, cholesterol is one of the body fat, better known by the name of lipids. As body fat, cholesterol certainly have a variety of functions in the body. However, if the levels of bad cholesterol in the blood increased or high. Then this may be a serious problem for the health of the body. Various types of food shown to lower your cholesterol levels. So, what are the cholesterol-lowering foods .... ???.<br />
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Under normal circumstances, or stable, cholesterol does have several important functions in the human body. Several functions as the cholesterol that the body fat constituent structures at the cell membrane, protecting the skin from toxins and drought problems, the formation of vitamin D (along with UV light) and form bile acids in the intestine. However, the increase in the levels of bad cholesterol in the body can cause various health problems such as erectile dysfunction, kidney failure, <a href="http://blog-nursingcareplan.blogspot.com/2012/05/nursing-care-plan-for-myocardial.html">heart attack</a>, <a href="http://blog-nursingcareplan.blogspot.com/2012/01/nursing-care-plan-for-stroke-with.html">stroke</a> and increased risk of <a href="http://blog-nursingcareplan.blogspot.com/2014/10/risk-for-injury-and-disturbed-thought.html">Alzheimer's disease</a>.<br />
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Here are 7 foods that lower bad cholesterol in your body:<br />
<br />
1. Tomatoes.<br />
Although classified into fruits, consuming tomatoes may help reduce levels of bad cholesterol in the body. You can make a delicious tomato juice and drink two glasses of tomato juice every day.<br />
<br />
2. Pomegranate.<br />
The small round red fruit was also very good for lowering cholesterol levels in the body, especially serves to reduce the buildup of cholesterol plaque and be able to increase the production of nitric oxide, which can help in reducing plaque in the arteries.<br />
<br />
3. Avocado.<br />
Fruit with sightings oval and green colored fruit is one that can raise levels of good cholesterol in the body. This is because, there are two types of cholesterol in our body is the bad cholesterol (Low-density lipoprotein) and good cholesterol (high-density lipoprotein).<br />
<br />
4. Grapes<br />
Grapes are also very good to increase the levels of good cholesterol in the body. By regularly drank two glasses of grape juice every day can keep the good cholesterol in your body.<br />
<br />
5. Garlic.<br />
Although classified as spices or herbs one for every housewife. Garlic was also very effective in helping reduce levels of bad cholesterol in the body. Try to eat a clove of garlic a day to reduce levels of bad cholesterol in your body (you also can mix them into various types of cuisine you).<br />
<br />
6. Various processed soy (tofu and tempeh).<br />
Both types of food are also very good for lowering bad cholesterol levels in your body. Another benefit that can be obtained that contained a protein source in both types of food.<br />
<br />
7. Nuts.<br />
Nuts are referred to as peanuts, walnuts, almonds and edamame. The content of omega 3 and antioxidants in the beans are very good for lowering bad cholesterol levels in your body.<br />
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Read More :<br />
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<a href="http://www.amazon.com/gp/product/B00E408LNK/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00E408LNK&linkCode=as2&tag=carplanur-20&linkId=SR5KOJBHRKLLGY7B">Hidden Truth About Cholesterol Lowering Drugs How To Avoid Heart Disease Naturally Hidden Truth About Cholesterol Lowering Drugs</a><img alt="" border="0" src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=B00E408LNK" height="1" style="border: none !important; margin: 0px !important;" width="1" />Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-7663910877541780932015-02-25T14:02:00.000+07:002015-02-25T14:02:28.154+07:00How to Overcome Disturbed Sleep Pattern In ChildrenSleep is essential to the child's needs, as important as the nutritional needs. The need to sleep in children will be reduced in accordance with age. Sleep is a major activity throughout the early development of the child's brain. At the age of 2-5 years, children spend the same amount of time between waking and sleep. During childhood and adolescence, sleep accounted for an average of 40 percent in one day.<br />
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When the amount of time needed to sleep are not fulfilled, sleep disturbances may occur. Children who have difficulty sleeping or fussy all night will interfere, and it is complained of as a child by a family of sleep disorders. Overall sleep disturbances may occur in 20-30 per cent of children. Children who have problems with sleep and cause sleep disorders in children and will give an adverse impact on children and families. Most parents would bring their children to seek help when parents have felt the impact of sleep disorders in children, we should know the normal sleep patterns in children.<br />
<br />
Sleep disorders in children are caused by several factors that contribute to each other which is the basic mechanism, the duration of sleep that does not fit the age of the child (insufficient sleep quality), poor sleep quality and sleep time periods are not suitable in terms of circadian rhythm disorders.<br />
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Sleep disorders are grouped into two broad categories, namely dyssomnia and parasomnias. Dyssomnia is a disorder that occurs in children who have difficulty to sleep, in maintaining sleep at night, or experience excessive sleepiness during the day. Meanwhile parasomnias is a state of waking at night which is unusual.<br />
<br />
When stratified by age, Disturbed Sleep Pattern that occurs in children will vary based on the age of the child, namely:<br />
<br />
1. In the age of the baby; 2-12 months<br />
Often found in the form of sleep disorder waking at night excessive and rhythmic movements during sleep such as headings banging, body rocking and rolling body.<br />
<br />
2. In the age of the baby; 1-3 years old<br />
Frequently encountered is the problem of hours of sleep, wake up at night and rhythmic movements during sleep. This can continue until preschool.<br />
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3. In the age of the baby; 3-5 years old<br />
Sleep problems are often encountered is the sleep terrors, nightmares, trouble sleeping and waking hours during the night. Some children found instances running during sleep and sleep terrors.<br />
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4. In the age of the baby; 6-12 years old<br />
More of a sleep disorder that can be found that is running during sleep, sleep terrors, bruxim, enuresis, less sleep, sleep habits are unhealthy, and restles legs syndrome.<br />
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5. In adolescence<br />
In adolescence, sleep disorders which can be found as a less amount of sleep, insomnia, sleep late at night, restless legs syndrome, and narcolepsy.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-85141850751870626762015-02-25T13:44:00.007+07:002015-02-25T13:44:59.451+07:00Disturbed Sleep Pattern related to Anxiety in Patients with Preoperative<b>Disturbed Sleep Pattern related to Anxiety</b><br />
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Surgery is a treatment that uses the action invasive way by opening the body part to be handled. Before the surgery there are some important things should be prepared that preparation before surgery include physical and mental preparation, where it helps reduce the risk of the outcome of the surgery because surgery is very dependent on the state of the patient and preoperative preparation. Effendi, 2008: 121 says the success rate of surgery is very dependent on each stage experienced and interdependencies between related health team (surgeons, anesthetists and nurses), in addition to the role of cooperative patients during preoperative process.<br />
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The preoperative period prior to surgery, which began operation specified preparations and last until the patient is on the operating table. Preoperative patient may experience a variety of fears of procedures that must be patient surgery carried out, such as the fear of anesthesia, fear of pain, fear of surgery failure, fear of being disabled and the fear of death. This can cause anxiety. (Smeltzer, Suzanne C. and Brenda G Bare, 2004: 263)<br />
<br />
Anxiety in patients can be characterized by physiological changes caused by the activation of the endocrine system and the central nervous system, causing the disruption of sleep patterns. Disturbed Sleep Pattern in client preoperatively, because the impact of hospitalization and increased anxiety because the disease is usually characterized by increasing the amount of time awake, frequent waking and reduced REM sleep and bedtime. State of anxious patients will affect the need for sleep and rest. Potter & Perry, 2005: 257 says sleep is a very important requirement for humans. Each individual requires a different amount of rest and sleep. Physical and emotional health depends on the ability to meet basic human needs. No amount of rest and enough sleep, ability to concentrate, make decisions and participate in the daily activities will decrease and increase irritability in biochemical and biophysical processes in the human body.<br />
<br />
Biochemical and biophysical processes of the human body has a rhythm or activity that occurs with a consistent pattern in the daily cycle. When the rhythm is disturbed as disruption of sleep patterns in patients with preoperative can affect the biochemical and biophysical processes that can lead to deviations from the norm of life.<br />
<br />
Disturbed Sleep Pattern will decrease the immune system, may lead to a decrease in mental, emotional stability is disrupted and vital signs are increasing.<br />
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Anxiety can cause bottlenecks in tasks and everyday life client and cause various disorders including lethargy, fatigue, difficulty concentrating, eating disorders and sleep disorders that can provide appropriate nursing care.<br />
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According to Potter & Perry, 2005: 152. The identification and handling of clients sleep pattern disturbance is important to be known by the nurse, because it can help the client is in meeting the needs enough rest and sleep before surgery. For that a nurse must understand the nature of sleep, and the factors that influence sleep habits. Client requires an individualized approach based on their personal habits and sleep patterns and specific issues that affect their sleep. Nursing interventions can be effective in dealing with short-term sleep disorders and long-term.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-17504967926050910092015-02-22T10:26:00.002+07:002015-02-22T10:26:30.358+07:00Deficient Fluid Volume - Assessment, Nursing Diagnosis, Outcomes and Intervention<b>Deficient Fluid Volume</b><br />
<br />
<b>Assessment</b><br />
<ol>
<li>Intake-output.</li>
<li>Weight.</li>
<li>Breath sounds.</li>
<li>Edema.</li>
<li>Check the skin turgor.</li>
</ol>
<br />
<b>Nursing Diagnosis</b><br />
<ol>
<li>Fluid volume imbalance: less than body requirements related to diarrhea, gastric fluid loss, diaphoresis, polyuria.</li>
<li>Impaired oral mucous membrane related to lack of fluid volume.</li>
<li>Impaired skin integrity related to dehydration and or edema.</li>
</ol>
<br />
<b>Expected Outcomes</b><br />
<br />
Individuals will:<br />
<ol>
<li>Increase fluid intake of at least 2000 ml / day (unless there are contraindications).</li>
<li>Telling the need to increase fluid intake during stress or heat.</li>
<li>Maintain urine specific gravity within normal limits.</li>
<li>Showed no signs and symptoms of dehydration.</li>
</ol>
<br />
<b>Interventions</b><br />
<ol>
<li>Assess likes and dislikes; give a favorite drink in the diet limits.</li>
<li>Plan objectives for each turn of the fluid input (eg, 1000 ml during the morning, afternoon 800 ml, and 200 ml at night)</li>
<li>Assess the individual understanding of the reasons to maintain adequate hydration and methods to achieve the goal of fluid intake.</li>
<li>For children, the offer:<ul>
<li>Forms an attractive liquid (popsicle, cold juice, ice conical).</li>
<li>Unusual container (colored cups, straws).</li>
<li>A game or activity (send the child to drink if the child's turn).</li>
</ul>
</li>
<li>Encourage the individual to maintain a written report of fluid intake and urine output, if necessary.<br />
</li>
<li>Monitor input; make sure at least 1500 ml orally every 24 hours.<br />
</li>
<li>Monitor output; make sure at least 1000-1500 ml every 24 hours.</li>
<li>Monitor urine specific gravity.<br />
</li>
<li>Measure weight every day with the same kind of clothes, lose weight 2% -4% showed mild dehydration, 5% -9% moderate dehydration.<br />
</li>
<li>Teach that coffee, tea, and juice grapes cause diuresis and can increase fluid loss.<br />
</li>
<li>Consider additional fluid loss associated with vomiting, diarrhea, fever, drein hose.<br />
</li>
<li>Monitor blood levels of electrolytes, blood urea nitrogen, urine and serum osmolality, creatinine, hematocrit, and hemoglobin.<br />
</li>
<li>For wound drainage:<ul>
<li>Keep careful records of the number and type of drainage.</li>
<li>Weigh bandage, if necessary, to estimate fluid loss.</li>
<li>Wound bandage to minimize fluid loss.</li>
</ul>
</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-33569673827422885842015-02-22T10:05:00.001+07:002015-02-22T10:05:17.364+07:00Nursing Care Plan for Deficient Fluid Volume (Hypovolemia)<b>Deficient Fluid Volume (Hypovolemia)</b><br />
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<b>Definition</b><br />
<br />
<a href="http://blog-nursingcareplan.blogspot.com/2015/01/fluid-volume-deficit-and-imbalanced.html">Deficient volume</a> of extracellular or Hypovolemia (FVD) is isotonic fluid loss, which is accompanied by loss of sodium and water in relatively equal amounts. Isotonic volume deficits, often termed dehydration that should be used for conditions of relatively pure water loss resulting in hypernatremia.<br />
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<br />
<b>Causes</b><br />
<br />
Factors that affect the body's fluid and electrolyte balance, among others:<br />
<br />
Age:<br />
Fluid intake needs vary depending on age, because age will affect the surface area of the body, metabolism, and weight. Infant and children are more susceptible to interference than the fluid balance in adulthood. In old age often occurs due to fluid balance disorders renal dysfunction or heart.<br />
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Climate:<br />
People who live in areas of heat (high temperature) and low air humidity has increased loss of body fluids and electrolytes through sweat. While someone who activity in a hot environment can lose up to 5 liters of fluid per day.<br />
<br />
Stress :<br />
Stress can increase cell metabolism, blood glucose, and the breakdown of muscle glykogen. This mechanism can increase sodium and water retention so that when prolonged exposure may increase the blood volume.<br />
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Diet:<br />
One's diet affect the intake of fluids and electrolytes. When inadequate nutrient intake, the body will burn fat protein and serum albumin and so will the protein reserves will decline even though both are indispensable in the process fluid balance so that it will lead to edema.<br />
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During illness:<br />
During illness affects the condition of the body's fluid and electrolyte balance, for example:<br />
Trauma such as burns will increase water loss through IWL.<br />
Kidney and cardiovascular disease affect regulatory processes fluid and electrolyte balance of the body.<br />
Patients with decreased level of consciousness will be impaired because of the fulfillment of fluid intake to lose the ability to fulfill them independently.<br />
<br />
<br />
<b>Signs and symptoms</b><br />
<br />
Clinical signs and symptoms that may be obtained on the client with hypovolemia include: dizziness, weakness, <a href="http://blog-nursingcareplan.blogspot.com/2015/02/nursing-care-plan-for-risk-for-fatigue.html">fatigue</a>, syncope, <a href="http://blog-nursingcareplan.blogspot.com/2015/02/anorexia-nervosa-definition-clinical.html">anorexia</a>, <a href="http://blog-nursingcareplan.blogspot.com/2014/10/some-causes-of-nausea-after-eating.html">nausea</a>, <a href="http://blog-nursingcareplan.blogspot.com/2014/10/vomiting-definition-etiology-signs-and.html">vomiting</a>, thirst, mental confusion, <a href="http://blog-nursingcareplan.blogspot.com/2015/02/how-to-prevent-constipation-during.html">constipation</a>, oliguria. Depending on the type of fluid loss. Hypovolemia may be accompanied by acid-base imbalance, osmolar or electrolyte. Depletion (CES) in weight can lead to hypovolemic shock.<br />
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Compensatory mechanisms of the body on the condition of hypovolemia is can include increased stimulation of the sympathetic nervous system (increase in heart frequency, inotropic (heart contraction) and vascular resistance), thirst, antideuritik releasing hormone (ADH), and the release of aldosterone. Long hypovolemia conditions can cause acute renal failure.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-21839608841489161922015-02-22T09:21:00.001+07:002015-02-22T09:24:19.140+07:00How to Prevent Constipation During PregnancyDuring pregnancy, the mother's abdomen will adapt to the emergence of a baby in the womb, which led to a significant change. So pregnant women often suffer from constipation. Then how to cope with pregnant women with constipation?<br />
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First, we find out first what is constipation in pregnant women. Constipation experienced by a mother when she was pregnant due to increased hormone progesterone which then affect the muscles to relax, including the muscles in the digestive tract. These events make food to survive in the intestine in a longer period of time. In addition to an increase in the hormone progesterone, which urged the fetal development of the rectum of the mother is also a cause of maternal constipation. These conditions will get worse if the mother is eating foods that contain iron in amounts less.<br />
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Then, how to avoid constipation, so that pregnant women continue to feel comfortable? Let us refer to some of these tips.<br />
<br />
<b>1. Eat foods rich in fiber.</b><br />
<br />
Fiber content of foods that are able to make a bowel movement becomes smooth. Therefore, in order to avoid constipation, pregnant women are strongly encouraged to eat foods rich in fiber. Examples of foods rich in fiber are; cereals, wholemeal bread, vegetables, fresh fruit, brown rice and beans.<br />
<br />
<b>2. Drink plenty of water</b><br />
<br />
In normal conditions, humans are required to drink 2 liters of water a day. This is in contrast to pregnant women, where the researchers already mentioned that to prevent pregnant women from constipation, pregnant women need to increase the amount of water they drink at least one glass. To get maximum results, drink warm water in the morning.<br />
<br />
<b>3. Regular exercise</b><br />
<br />
In addition to good health of the mother and fetus, sports activities also can prevent pregnant women from the risk of constipation. Perform light exercise such as walks, swimming, yoga, pregnancy exercise, and mild exercise that other woods.<br />
<b><br />
</b> <b>4. Do not delay defecation</b><br />
<br />
Do not delay if you feel the urge to defecate. If delayed, likely will make pregnant women suffer from constipation. If you want to defecate when preformance trip, you can ask your husband or driver to stop at the nearest gas station.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-35201442106148437992015-02-22T00:04:00.002+07:002015-02-22T00:04:19.715+07:00Nursing Care Plan for Risk for Fatigue related to Asthma<br />
Asthma is a respiratory tract circumstances narrowed due to hyperactivity to certain stimuli, which causes inflammation. Early symptoms of asthma is shortness of breath, coughing, and wheezing sound becomes.<br />
<br />
This disease can affect anyone, both children and adults. Asthma is very susceptible to stimuli such as dust, feathers, smoke, cold air, and exercise. And more details about the cause of Asthma read the following.<br />
<br />
<br />
<b>Nursing Diagnosis for Asthma </b>: <b>Risk for Fatigue</b> related to CO2 retention, hypoxemia, emotion focused on breathing and sleep apnea.<br />
<br />
Goal:<br />
The client will be met needs rest to maintain energy levels while awake.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Being able to discuss the causes of fatigue.</li>
<li>The clients can sleep and rest in accordance with the needs of the body.</li>
<li>The client can be relaxed and bright face.</li>
</ul>
<br />
Interventions:<br />
<ul>
<li>Explain the causes of fatigue in individuals.</li>
<li>Avoid disturbances during sleep.</li>
<li>Jointly analyze the level of fatigue by using scale Rhoten (1982).</li>
<li>Indentivikasi important activities and adjust the activity with rest.</li>
<li>Teach effective breathing techniques.</li>
<li>Keep extra O2 when training.</li>
<li>Avoid the use of sedatives and hypnotics.</li>
</ul>
<br />
Rational<br />
<ul>
<li>Knowledgeable causative factors, it is expected to avoid it.</li>
<li>Sleep is an attempt to restore the conditions that have decreased after the activity.</li>
<li>Rhoten scale to determine the level of fatigue experienced by the client.</li>
<li>Fatigue occurs because of an imbalance between the needs of the activities and needs a break.</li>
<li>Respiratory effectively help Unfulfilled O2 in tissues.</li>
<li>Oxygen is used for combustion of glucose into energy.</li>
<li>Sedatives and hypnotics weaken the muscles, especially the respiratory muscles.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-5037724143485753752015-02-21T23:48:00.002+07:002015-02-21T23:48:34.765+07:00Nursing Care Plan for Knowledge Deficit related to Diabetic Foot Ulcers<br />
<b>Nursing Care Plan for <a href="http://blog-nursingcareplan.blogspot.com/2015/02/impaired-tissue-integrity-ncp-for.html">Diabetic Foot Ulcers</a> </b><br />
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<b>Nursing Diagnosis : <a href="http://blog-nursingcareplan.blogspot.com/2014/12/ncp-for-knowledge-deficit-related-to.html">Knowledge Deficit</a> </b>(about the disease, diet, care, and treatment) related to a lack of information.<br />
<br />
Goal: The patient obtain clear and correct information about the disease. <br />
<br />
Expected outcomes:<br />
<ul>
<li>The patients know about the disease, diet, care and treatment and can explain it if asked.</li>
<li>The patient can perform self-care based on the knowledge acquired.</li>
</ul>
<br />
<b>Interventions:</b><br />
<br />
1. Assess the level of knowledge of the patient / family about the disease of diabetes and gangrene.<br />
Rationale: To provide information to the patient / family, the nurse needs to know the extent to which information or knowledge that is known to the patient / family.<br />
<br />
2. Assess the patient's educational background.<br />
Rationale: In order for nurses to provide explanations by using words and phrases that can understand the patient as the patient's level of education.<br />
<br />
3. Explain the process of disease, diet, care and treatment in the patients with language and words that are easy to understand.<br />
Rationale: In order information can be received easily and precisely so as to avoid misunderstandings.<br />
<br />
4. Explain the procedure to be performed, the benefits to the patient and involve the patient in it.<br />
Rationale: With explanatory and there and participate directly in the action taken, the patient will be more cooperative and reduced anxiety.<br />
<br />
5. Use pictures to give an explanation (if there is / possible).<br />
Rational: images may help to remember the explanation has been given.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-44769142041690565422015-02-19T00:15:00.002+07:002015-02-19T00:15:50.060+07:00Anorexia Nervosa - Definition, Clinical Manifestations, Etiology and Complications<div class="separator" style="clear: both; text-align: center;">
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<b>Definition of Anorexia Nervosa</b><br />
<br />
Anorexia nervosa is an eating disorder characterized by refusal to maintain weight within the limits of the normal minimum. Characteristics are losing weight on purpose, driven and or maintained by the patient.<br />
<br />
<br />
<b>Clinical Manifestations of Anorexia Nervosa</b><br />
<ul>
<li>Sudden weight loss, without any obvious cause.</li>
<li>Look emaciated, loss of subcutaneous fat.</li>
<li>Changes in eating habits, meal times are not uncommon.</li>
<li>Exercise and excessive physical activity.</li>
<li>Amenorrhoea.</li>
<li>Dry scaly skin.</li>
<li>Lanugo on the extremities, back and face.</li>
<li>The skin turns yellowish.</li>
<li>Sleep disorders.</li>
<li>Constipation.</li>
<li>Erosion of the esophagus.</li>
<li>Natural feelings of depression.</li>
<li>Excessive focus on achieving high results.</li>
<li>Excessive attention to food and body image.</li>
<li>Erosion of enamel and dentin.</li>
</ul>
<br />
<b>Etiology of Anorexia Nervosa</b><br />
<br />
Various psychological factors associated with the development of the typical behavior of Anorexia Nervosa. Low self-esteem is often instrumental in the emergence of this disease. Weight loss is seen as an achievement and self-esteem depend on the size and weight. There is also a relationship between eating disorders with mood disorders. Family dynamics can also play a role in the development of symptoms of anorexia nervosa. Parents may be too in control and too protect children. Other factors also play a role in the emergence of this disorder is the ideal slimness society that seeks equaled or even exceeded by the teens. Individuals affected by this disorder have a distorted body image consider themselves obese or obsess about the size and shape of certain body parts.<br />
<br />
<br />
<b>Complications of Anorexia Nervosa</b><br />
<ul>
<li>Cardiac: bradycardia, tachycardia, arrhythmia, hypotension, heart failure.</li>
<li>Gastrointestinal: esophagitis, peptic ulcer, hepatomegaly.</li>
<li>kidney; serum urea and electrolyte abnormalities.</li>
<li>Skeletal; osteoporosis, pathologic factors.</li>
<li>Endocrine; reduced fertility, increased levels of cortisol and growth hormone, increased gluconeogenesis.</li>
<li>Metabolic; decrease in BMR, body temperature regulation disorders.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-58011143346617157952015-02-18T23:45:00.000+07:002015-02-18T23:45:03.234+07:00Nursing Care Plan for Risk for Fluid Volume Deficit related to Hematemesis - MelenaGastrointestinal tract bleeding is an emergency that requires immediate treatment. The incidence of gastrointestinal bleeding reached approximately 100 cases in 100,000 population per year, predominantly from the upper gastrointestinal tract.<br />
<br />
Upper gastrointestinal bleeding appears 4 times more often than bleeding at the bottom, and is a major cause of morbidity and mortality in cases of gastrointestinal disorders. Mortality from upper gastrointestinal bleeding was found as much as 6-10% of all cases.<br />
<br />
Gastrointestinal tract bleeding can occur in five types of manifestations, namely hematemesis, melena, hematochezia, occult GI bleeding which can be detected even though not found bleeding on stool examination, as well as signs of anemia such as syncope and dyspnea.<br />
<br />
Hematemesis is vomiting blood. Blood can be in the form of fresh (clot or clots or bright red liquid) or changed due to enzymes and stomach acid, to brown and shaped like a coffee granules. Can hematemesis due to the injury or bleeding in the upper gastrointestinal tract.<br />
<br />
Melena is black stool and stink because the product mix blood from the gastrointestinal tract. The presence of melena shows that blood has been in the gastrointestinal tract within at least 14 hours and usually occur in the upper gastrointestinal tract, although sometimes melena may also occur as a result of bleeding from the colon.<br />
<br />
<b>Nursing Diagnosis for Hematemesis - Melena : Risk for Fluid Volume Deficit </b>related to bleeding<br />
<br />
Subjective data:<br />
<ul>
<li>The client fasting, thirst, frequent sweating.</li>
</ul>
Objective data:<br />
<ul>
<li>Mucosa dry mouth, vomiting blood often (3 times) in the hospital, dysentery mixed urinary maroon.</li>
</ul>
<br />
Goal: fluid requirements are met.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Vital signs within normal limits.</li>
<li>Normal skin turgor.</li>
<li>Mucous membranes moist.</li>
<li>Urine production output balance.</li>
<li>Blood vomiting and defecating blood stopped.</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Measure and record intake and expenditure.</li>
<li>Monitor vital signs.</li>
</ul>
Collaboration:<br />
<ul>
<li>Monitor parenteral fluids.</li>
<li>Monitor the laboratory; Hb, Hct.</li>
</ul>
<br />
<br />
Rationale :<br />
<ul>
<li>Accurate documentation helps to identify the loss of fluid or fluid needs and affect subsequent action.</li>
<li>Hypotension, tachycardia, increased respiration is an indication of lack of fluids.</li>
<li>Excessive bleeding can cause hipovelemia, circulatory collapse.</li>
<li>Volume depletion petensial for dehydration, cardiovascular collapse, fluid and electrolyte imbalance.</li>
<li>Anemia, low HCT occurs due to fluid loss during blood vomiting and defecating blood.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-53736682247954244662015-02-18T23:25:00.003+07:002015-02-18T23:25:52.436+07:00Assessment - Nursing Care Plan for Hematemesis and Melena<b>Nursing Care Plan for Hematemesis and Melena</b><br />
<br />
<b>Physiological Assessments</b><br />
<br />
<b>1. Oxygen</b><br />
<br />
Assess:<br />
<ul>
<li>The number and color of blood hematemesis.</li>
<li>Brownish color: blood from the stomach may still lagging behind, potential aspirations.</li>
<li>Sleeping position: to prevent vomiting into the airway, preventing shock.</li>
<li>Signs of shock: can occur when blood counts more than 500 cc and occurs continuously.</li>
</ul>
The amount of bleeding: observation hemodynamic signs, namely; blood pressure, pulse, respiration, temperature. Usually blood pressure (systolic) 110 mmHg, rapid breathing, pulse 110 beats / min, the temperature between 38-39 degrees Celsius, cold skin pale or cyanosis of the lips, the tip of the extremities, reduced blood circulation to the kidneys, causing reduced urine.<br />
<br />
<br />
<b>2. Fluids</b><br />
<br />
Circumstances which need to be assessed on the client with hematemesis and melena associated with fluid needs that amount of bleeding that occurs. Blood will determine the amount of fluid replacement.<br />
<br />
Assess: various bleeding / blood spending way to determine the location of bleeding and the type of a ruptured blood vessel. Bleeding that occurs suddenly, the color of fresh red blood, as well as continuous discharge describe bleeding that occurs in the upper gastrointestinal tract and ruptured arteries. If the emergency phase is over, the next phase of doing an assessment of:<br />
<ul>
<li>Balance intake - output. This assessment is done on the client hematemesis and melena caused by rupture of esophageal varices as a result of cirrochis liver, which often have ascites and edema.</li>
<li>Intravenous fluids given to the client.</li>
<li>Urine output and record numbers per 24 hours.</li>
<li>Signs of dehydration such as decreased skin turgor, sunken eyes, the amount of urine. For clients with hemetemesis and melena often impaired renal function.</li>
</ul>
<br />
<br />
<b>3. Nutrition</b><br />
<br />
Assess:<br />
<ul>
<li>The client's ability to adapt to the diet: the first 3 days of liquid, then soft foods.</li>
<li>Client's diet.</li>
<li>Weight before bleeding.</li>
<li>Oral hygiene: because hemetemesis and melena, remnants of bleeding can be a source of infection that cause discomfort.</li>
</ul>
<br />
<br />
<b>4. Temperature</b><br />
<br />
Clients with hematemesis and melena generally increased temperatures around 38-39 degrees Celsius. In the state before the shock, skin temperature becomes cooler as a result of circulatory disorders. Stacking the rest of the bleeding is the source of infection in the digestive tract so that the client can increase the body temperature. In addition, long infusion can also be a source of infection that causes the body temperature to rise.<br />
<br />
<br />
<b>5. Elimination</b><br />
<br />
On the client hematemesis and melena generally impaired elimination.<br />
Assess:<br />
<ul>
<li>Amount and how expenses, due to impaired renal function. Reduced urine and usually do care bed rest.</li>
<li>Defecation, it is worth noting the number, color and consistency.</li>
</ul>
<br />
<br />
<b>6. Protection</b><br />
<br />
Socio-economic background of the client, because the haematemesis and melaena need to do some enforcement action as diagnosis and therapy for clients.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-87669673798562006272015-02-17T23:24:00.000+07:002015-02-17T23:24:22.990+07:00Dementia - 7 Nursing Diagnosis<b>Nursing Care Plan for Dementia</b><br />
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Dementia is a syndrome characterized by a variety of cognitive impairment without disturbance of consciousness. Impaired cognitive function among others in intelligence, learning and memory, language, problem solving, orientation, perception, attention and concentration, adjustment, and social skills. (Arif Mansjoer, 1999)<br />
<br />
<b>Dementia - 7 Nursing Diagnosis</b><br />
<br />
1. <a href="http://blog-nursingcareplan.blogspot.com/2015/02/nursing-care-plan-for-relocation-stress.html" target="_blank">Relocation Stress Syndrome</a> related to changes in the activities of daily life<br />
characterized by: confusion, concern, anxiety, seem anxious, irritable, defensive behavior, mental disorder, suspicious behavior, and aggressive behavior.<br />
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2. Altered thought processes related to physiological changes (degeneration of neurons is irreversible)<br />
characterized by: loss of memory, loss of concentration, not able to interpret the stimulation and assess reality accurately.<br />
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3. Disturbed sensory perception related to changes in perception, transmission, or sensory integration (neurological disease, is not able to communicate, sleep disorders, pain)<br />
characterized by: anxiety, apathy, anxiety, hallucinations.<br />
<br />
4. Disturbed Sleep Pattern related to changes in the environment<br />
characterized by: verbal complaints about difficulty sleeping, constantly awake, not able to determine the needs / bedtime.<br />
<br />
5. Self Care Deficit related to activity intolerance, decreased endurance and strength<br />
characterized by: a decrease in the ability to perform daily activities.<br />
<br />
6. Risk for injury related to the difficulty of balance, weakness, uncoordinated muscle, seizure activity.<br />
<br />
7. Risk for imbalanced Nutrition: more than body requirements related to easy to forget, setbacks hobby, sensory changes.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-36295663923208736842015-02-17T10:23:00.002+07:002015-02-17T10:23:42.444+07:00Nursing Care Plan for Relocation Stress Syndrome related to Dementia<b>Nursing Care Plan for Dementia</b><br />
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<b>Nursing Diagnosis : </b><b>Relocation Stress Syndrome</b><br />
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Relocation stress syndrome related to changes in the activities of daily life,<br />
<br />
characterized by: confusion, concern, anxiety, seem anxious, irritable, defensive behavior, mental disorder, suspicious behavior, and aggressive behavior.<br />
<br />
Goal: Having given nursing actions, the client is expected to be able to adapt to changes in their daily activities and the environment,<br />
<br />
with outcomes:<br />
<ul>
<li>Identify changes.</li>
<li>Able to adapt to environmental changes and activities of daily life.</li>
<li>Reduced anxiety and fear.</li>
<li>Make a positive statement about the new environment.</li>
</ul>
<br />
Interventions<br />
<ul>
<li>Do a mutually supportive relationship with the client.</li>
<li>Orient the environment and new routines.</li>
<li>Assess the level of stressors (adjustment, development, the role of the family, due to changes in health status).</li>
<li>Decide on a reasonable schedule of activities and enter into routine activities.</li>
<li>Provide explanations and fun information about the activities / events.</li>
</ul>
<br />
Rationale :<br />
<ul>
<li>To build trust and a sense of comfort.</li>
<li>Reduce anxiety and feeling disturbed.</li>
<li>To determine the client's perception about the incidence and severity of attacks.</li>
<li>Consistency reduce confusion and increase the sense of community.</li>
<li>Reduce tension, maintain mutual trust, and orientation.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-18642793726220450772015-02-17T10:11:00.001+07:002015-02-17T10:11:45.061+07:00Pathophysiology of Dementia<br />
The interesting thing of the symptoms of dementia patients (age greater than 65 years) is the change in personality and behavior that affect daily activities. Elderly people with dementia do not show symptoms are prominent in the early stages, they are as elderly in general are aging and degenerative. Initial awkwardness felt by patients themselves, they are difficult to remember and often forgotten when putting an object. They often cover up the matter and ensure that it is not unusual at their age. Similar confusion began to be felt by those closest living with them, they feel concerned about memory loss that is getting into, but once again the family feel that the fatigue and the elderly may need more rest. <br />
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They do not suspect a big problem behind the memory loss experienced by their parents.<br />
The next dementia symptoms appear usually in the form of depression in elderly, they keep a distance with the environment and more sensitive. Such conditions can be followed by the emergence of other diseases and usually will aggravate the Elderly. At this time may be elderly become very frightened even to hallucinate. This is where the family invites Elderly people with dementia to a hospital where dementia is not be the main focus of the examination. Often dementia escape scrutiny and are invaluable to the health care team. Not all health workers have the ability to be able to assess and recognize the symptoms of dementia.<br />
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The severity of dementia, can be influenced by psychosocial factors. The higher intelligence and education of patients before the illness, the higher is also the ability to compensate for intellectual deficit. Patients with rapid onset dementia (rapid onset) using self defense fewer than patients who experienced a gradual onset. Anxiety and depression can reinforce and exacerbate the symptoms. Pseudodementia can occur in individuals who are depressed and complained of memory impairment, but in fact he suffered from depression. When depression successfully addressed, then the cognitive defects will disappear.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-90092794499430526782015-02-17T10:01:00.000+07:002015-02-17T10:01:02.243+07:0020 Signs and Symptoms of Dementia<br />
According to Grayson (2004) states that dementia is not a common disease, but rather a collection of symptoms that caused some particular disease or condition resulting in changes in personality and behavior.<br />
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Dementia can be defined as cognitive and memory disorders that can affect daily activities. Dementia patients often show some disturbances and changes in daily behavior (behavior symptoms) that interfere (disruptive) or do not disturb (non-disruptive) (Voicer. L., Hurley, AC, Mahoney, E.1998).<br />
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<b>20 Signs and Symptoms of Dementia</b><br />
<ol>
<li>Damage to the whole range of cognitive functions.</li>
<li>Initially short-term memory loss.</li>
<li>Personality and behavioral disorders (mood swings).</li>
<li>Focal neurological deficits.</li>
<li>Irritability, hostility, agitation and seizures.</li>
<li>Psychotic disorders: hallucinations, illusions, delusions, and paranoia.</li>
<li>Limitations in ADL (Activities of Daily Living)</li>
<li>Difficulty managing finances.</li>
<li>Can not go home when traveling.</li>
<li>Forgot to put important stuff.</li>
<li>Difficult bathing, eating, dressing and toileting.</li>
<li>Easy drop and poor balance.</li>
<li>Unable to eat and swallow.</li>
<li>Urinary incontinence.</li>
<li>Can run away from home and can not go home.</li>
<li>Decline in memory that continues to happen. In patients with dementia, "forgot" to be part of daily life that can not be separated.</li>
<li>Impaired orientation time and place, for example: forget the day, week, month, year, where people with dementia.</li>
<li>Decline and inability to formulate the correct words into sentences, using words that are not appropriate for a condition, repeat the same words or stories.</li>
<li>Overexpression, such as excessive crying at the sight of a television drama, furious at small errors committed by others, fear and nervousness are unwarranted. People with dementia often do not understand why these feelings arise.</li>
<li>The change of behavior, such as: indifferent, withdrawn and anxious.</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-59964325602588328232015-02-16T23:57:00.000+07:002015-02-16T23:57:01.056+07:00Clinical Manifestations of Cephalalgia<br />
<b>Cephalalgia or headache </b>is one of the most important human physical complaints. Headache in fact is a symptom not a disease and can demonstrate an organic disease (neurological or other diseases), stress response, vasodilation (migraine), skeletal muscle tension (tension headaches) or a combination of these responses (Brunner & Suddart).<br />
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<b>Clinical Manifestations of Cephalalgia</b><br />
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<br />
<b>1. Migraines</b><br />
<br />
Migraine is a complex of symptoms that have characteristics at a certain time and severe head pain that occurs repeatedly. The cause of migraine is not clearly known, but it may be caused by primary vascular disorder that is usually more common in women and has a strong tendency in the family.<br />
<br />
Signs and symptoms of migraine in the cerebral, the result of varying degrees of cortical ischemia. The attack began with the scalp artery vasoconstriction and blood vessels of the retina and cerebral. Intra- and extracranial blood vessels dilate, causing pain and discomfort.<br />
<br />
Classic migraine can be divided into three phases, namely:<br />
<ul>
<li>Aura phase. Lasted approximately 30 minutes, and can provide an opportunity for patients to determine a drug used to prevent attacks inside. Symptoms of this period is the visual impairment (glare), tingling, itching feeling on the face and hands, a little weak in the extremities and dizziness. This aura period associated with vasoconstriction without pain that begins with the initial physiological changes. Cerebral blood flow is reduced, with a further loss of autoregulation and CO2 responsiveness damage.</li>
<li>Headache phases. Phase severe throbbing headache and made incapable of being associated with photophobia, nausea and vomiting. The duration of these circumstances vary, a few hours in a day or several days.</li>
<li>Recovery phase. Neck muscle contraction period and scalp are associated with local muscle pain and tension. Fatigue is usually the case, and the patient may sleep for a long time.</li>
</ul>
<br />
<br />
<b>2. Cluster Headache</b><br />
<br />
Cluster Headache is another form of vascular headache that often occurs in men. The attack comes in the form of piling or in groups, with excruciating pain and the eye area and temporal spread stricken face. Pain followed by watery eyes and nasal obstruction. The attack ended from 15 minutes to 2 hours are strengthened and decreased strength.<br />
<br />
<b>3. Tension Headache</b><br />
<br />
Physical and emotional stress can lead to contraction of the muscles of the neck and scalp, which causes tension headaches. Characteristics of headache is feeling pressure in the forehead, temples, or back of the neck. It is often depicted as a "heavy burden of covering the head". These headaches tend to be chronic rather than weight. Patients requiring sobriety, and usually these circumstances is an unspoken fear. Symptomatic relief may be given to the location of heat, massage, analgesics, antidepressants and muscle relaxants.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-18147615881292496782015-02-16T23:38:00.001+07:002015-02-16T23:38:24.673+07:005 Types of Personality in the ElderlyMental function. In general, a decline in cognitive and psychomotor function. Cognitive function includes prises learning, comprehension, understanding, action and others decreased, so that the behavior tends to be slower. Old age dementia, change and decline in cognitive function will be clear and progressive.<br />
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Psychomotor functions which include encouragement / act in general began to slow down so that the reaction and coordination also becomes slow. While a positive thing that is respected, elders, respected, wiser, more careful in action, where to seek advice. Broadly speaking there are 5 types of personality in elderly :<br />
<ol>
<li>Constructive Type: People from youth can accept the fact and life, become old accepted with ease. They have properties that are tolerant and flexible, so flexible in accepting the fact for example; retirement, loss of a spouse, and so on, they receive but not resigned.</li>
<li>Dependent types: passive nature is not ambitious, optimistic was implemented late marriage, dominated by his wife. In the elderly happy for retirement and relaxing, plenty to eat and enjoy the holiday. But if they lose their spouse feel lost depends who is a big problem, so it is not rare that they constantly sick and eventually followed his partner more quickly.</li>
<li>Independent type (self): At a young age who are active in social interaction, the reaction is quite good adjustment, and tend to reject the bid / help others. The situation is likely to be maintained until old age so anxious to face old age, for example, tends to delay retirement or remain active in the profession or job and did not seem to enjoy old age.</li>
<li>Hostile Type: People who tend to blame others for his mistakes, often complain, aggressive, suspicious, employment history is not fixed, can not see the positive side in the elderly, fear of death, jealous of the young people. Often behave as if they are looking for tranquility as the picture depicts him uneasy.</li>
<li>Type of self-hate: People who are critical of themselves, are not ambitious at work. Marriage less happy because a lot of self-pity, and children's lives, as if the past is supposed to be filled with all the desire has passed, finally resigned but not "nrimo". so much in crisis.</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-80113890110626462162015-02-16T23:09:00.001+07:002015-02-16T23:14:04.671+07:00Nursing Care Plan - Elderly Assessment of Mental State<b>Elderly Assessment of Mental State</b><br />
<br />
Mental status assessment is a systematic approach to collecting data on psychosocial functioning. This assessment includes: general appearance of the client, awareness, affective function, speech characteristics, orientation, attention and concentration, judgment, memory, perception, and the content and process of thought. This study aims to determine the thoughts and mental processes that influence the achievement of an optimal level of functioning elderly. This assessment is integrated in the interview and physical examination.<br />
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<b>Assessment of Mental Status</b><br />
<br />
<b>General Appearance</b><br />
<br />
The general appearance can provide a picture of psychological functions. The general appearance include: physical appearance, coordination of movements, facial expressions and posture. Physical appearance include: how to dress, personal care and personal hygiene.<br />
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<br />
<b>Awareness</b><br />
<br />
Awareness is the ability of individuals to make contact with their environment and with themselves (through the senses). When consciousness is good (not decreased), the orientation capabilities such as time, place and people will be better and be able to process incoming information effectively (through memory and judgment). In assessing the level of consciousness should be considered:<br />
<ul>
<li>The influence of medication.</li>
<li>Affective disorders.</li>
<li>Pathological conditions.</li>
</ul>
<br />
<b>Affective Functions</b><br />
<br />
Things that need to be considered in assessing the affective function in the elderly, namely:<br />
It is important to assess the significance of an event for the elderly to assess the depth and duration of affective that appear.<br />
Emotional expression is influenced by cultural and personal characteristics.<br />
In the elderly usually do not express their feelings directly / verbal. Therefore, it is important to observe the reaction of indirect / non-verbal of the elderly.<br />
It is important to use terms that can be accepted by the elderly at the time of the interview by focusing on the feelings experienced by the elderly. Can be initiated by using an open-ended question, such as: how are you today?<br />
<br />
Affective function impairment in the elderly is often the case is depression. The Geriatric Depression Scale (GDS) is a valid and reliable measurement is to determine the presence of depression. Use of GDS can facilitate clients express attitudes and feelings that are difficult expressed that actually associated with depression.<br />
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<br />
<b>Attention and Concentration</b><br />
<br />
Nurses must observe and record the response shown by the elderly at the time of assessment, namely when answering questions.<br />
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<br />
<b>Assessment</b><br />
<br />
Assessment is the ability to assess a situation correctly, to do according to the situation.<br />
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<br />
<b>Memory</b><br />
<br />
The memory includes a new memory, short-term memory and long term memory. Memory impairment can identify the presence of intellectual impairment / cognitive. The Short Portable Mental Status Quesionnaire (SPMQ) was used to detect the level of intellectual impairment.<br />
<br />
<br />
<b>Perception</b><br />
<br />
Perception is the power to know things, quality, relationships and differences through the process of observing, knowing and interpreting after getting his senses stimulated.<br />
In elderly perception disorder usually associated with dementia, depression and delirium.<br />
<br />
<br />
<br />
<b>Content and Thought Process </b><br />
<br />
The process of thought can be assessed at the time of the interview.<br />
<br />
<br />
<b>References</b><br />
<ol>
<li>Jeri B. Brown. Nancy K. Bedford, Sarah S. White. (1999). Gerontological Protocols for Nurse Practitioners. Lippincott, Philadelphia.</li>
<li>Miller, C.A. (1995). Nursing care of olders adults : Theory and practice. Philadelpia : JB Lippincott. Lippincott, Philadelphia</li>
<li>Staab,A.,S., & Hodges,l.,C.,(1996 ) Gerontological Nursing: Adaptation to the aging process</li>
<li>Matteson, M.A. and Mc. Connel, E.S. (1988). Gerontological Nursing : Concepts and practice. Philadelpia : WB Saunders Company.</li>
<li>Sheila L. Molony, Cristine M, Waszynski, Courtney H Leyder. (1999). Gerontological Nursing. Appleton & Lange. Conecticut.</li>
<li>Stuart, G.W and Sundeen, S.J, 1995. principles and practice of psychiatric nursing, St. Louis, Mosby Year Book.</li>
<li>Beck, CM, Rawlins and Williams, S.R, 1996, Mental health psychiatric nursing: A Holistic life-Cycle approach, St Louis, Mosby Co.</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-18435175906937615712015-02-11T00:53:00.001+07:002015-02-11T00:53:51.634+07:00Impaired Tissue Integrity - NCP for Diabetic Foot Ulcers<b>NCP for Diabetic Foot Ulcers</b><br />
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Diabetes mellitus is a metabolic disorder in which is found the inability to oxidize carbohydrates, due to interference with the normal mechanism of insulin, causing hyperglycemia, glycosuria, polyuria, thirst, hunger, body lean, and weakness.<br />
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People with diabetes may experience some complications together or there is a problem that dominates, which include vascular disorders, retinopathy, diabetic nephropathy, diabetic neuropathy and diabetic foot ulcers.<br />
<br />
Diabetic foot ulcers that are present in patients with diabetes mellitus due to diabetic angiopathy, diabetic neuropathy or trauma.<br />
<br />
Diabetic gangrene gangrene due to microangiopathy also called hot because although necrosis, acral areas it looks red and feels warm by inflammation, and usually palpable distal arterial pulsation. Usually there is a diabetic ulcer on the sole of the foot.<br />
<br />
Nursing Diagnosis : Impaired Tissue Integrity related to the presence of gangrene in the extremities.<br />
<br />
Goal: The achievement of the wound healing process.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Reduced edema around the wound.</li>
<li>Pus in the tissue is reduced.</li>
<li>The presence of granulation tissue.</li>
<li>Reduced wound stench.</li>
</ul>
Interventions:<br />
1. Assess spacious and state of the wound and the healing process.<br />
Rationale: proper assessment of the injury and the healing process will assist in determining the next action.<br />
<br />
2. Treat the wound properly: Clean the wound aseptically using a solution that is not irritating, lift the rest of the bandage that sticks to the wound and necrotomy dead tissue.<br />
Rational: Taking care of the wound with aseptic technique, can keep the wound contamination and irritating solution would damage arising tyang granulation tissue, necrotic tissue wrapping the rest can hinder the process of granulation.<br />
<br />
3. Collaboration with physicians to insulin administration, culture examination pussy blood sugar checks provision of anti-biotic.<br />
Rational: insulin will lower blood sugar levels, pus culture examination to determine the type of bacteria and antibiotics, are appropriate for treatment, examination of blood sugar levels to determine the progression of the disease.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-1441549891674472542015-01-31T00:18:00.000+07:002015-01-31T00:18:42.960+07:00Nursing Care Plan for Risk for Infection related to Cellulitis<br />
Cellulitis is an infection spread of bacteria into the skin and subcutaneous tissue. The infection can spread quickly and can get into the lymph vessels and blood flow. If this is the case, the infection can spread throughout the body.<br />
<br />
Cellulitis is an infection of the deeper layers of the skin. With the following characteristics :<br />
<ul>
<li>Suppurative inflammation reached the subcutaneous tissue.</li>
<li>Regarding the surface of lymphatic vessels.</li>
<li>Erythematous plaques, no clear boundaries and quickly expanded.</li>
</ul>
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<b>Nursing Care Plan for Cellulitis</b><br />
<br />
<b>Nursing Diagnosis : Risk for infection</b> related to the presence of skin lesions.<br />
<br />
Goal : The client shows no infection after nursing care.<br />
<br />
Expected outcomes :<br />
<ul>
<li>There are no signs of infection (calor, rubor, tumor, dolor).</li>
<li>Vital signs within normal limits : Blood pressure : 120/80 mmHg, pulse : 87 times / min, Temperature : 36-37'5 ° C, respiration : 18-20 x / minute.</li>
<li>Leukocytes within normal limits.</li>
</ul>
<br />
Intervention<br />
1. Observe for signs of infection.<br />
Rational : Seeing the development of therapies that have been given.<br />
<br />
2. Observation of vital signs.<br />
Rational : shows the circulation of the body.<br />
<br />
3. Treat the wound the client with the principles of aseptic.<br />
Rational : reducing the risk of cross contamination.<br />
<br />
4. Encourage the client to always maintain personal hygiene.<br />
Rational : reducing the risk of infection.<br />
<br />
5. Instruct the client to not suppress the injured area.<br />
Rational : depressed wound will cause reduced blood flow to the wound so that the wound gets worse.<br />
<br />
6. Teach the patient and family to know the signs and symptoms of infection.<br />
Rationale: to prevent things that could threaten the infection.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-79985393563970286342015-01-22T22:57:00.000+07:002015-01-22T22:57:14.082+07:003 Nursing Diagnosis for Mastoiditis<b>Mastoiditis</b><br />
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<br />
Definition<br />
<br />
Mastoiditis is an inflammation of the mastoid bone, usually derived from the tympanic cavity.<br />
<br />
According to Wilson mastoiditis is spreading germs to the mastoid of otitis media repeatedly.<br />
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Meanwhile, according to Nelson, Mastoiditis is an inflammation of the system air cells of the mastoid bone which accompanies acute and chronic otitis media with effusion accompanied. (Nelson, 1992: 592).<br />
<br />
<br />
Signs and symptoms<br />
<br />
Pain and tenderness in the back of the ear. Swelling of the mastoid. Complaints obtained a discharge from the ear for more than three weeks, it indicates that the infection of the middle ear mastoid already involved organs. Fever symptoms usually disappear and arise, this is due to the previous middle ear infections and antibiotics in the early course of the disease. If the fever is still felt after the administration of antibiotics, the suspicion on the mastoid infection becomes larger. The pain is usually felt on the back of the ear and felt worse at night, but it is difficult to obtain in patients who are still babies and have not been able to communicate. Hearing loss can occur or not depends on the size of the mastoid complex due to infection.<br />
<br />
<br />
Complication<br />
<br />
Facial paresis mentioned bone destruction which includes N. VII, so that continuity so disconnected. Can also be pressure N. VII by edema, transient paresis.<br />
Thrombophlebitis, located on the lateral sinus so that the infection can spread to the back.<br />
Intracranial complications such as meningitis, brain abscess, labyrinthitis.<br />
<br />
<br />
Management<br />
<br />
Common symptoms usually successfully treated with antibiotics, sometimes necessary myringotomy.<br />
If there is recurrence / persistent tenderness, fever, headache and discharge from the ear may need to be done mastoidectomy.<br />
<br />
<br />
Assessment<br />
<br />
1. Biodata<br />
Age: The average age of the affected mastoiditis between 6-13 months.<br />
Gender: men and women are equally affected by mastoiditis.<br />
<br />
2. The main complaint.<br />
Pain behind the ear.<br />
<br />
3. History of present illness<br />
Suffering from acute otitis media / chronic.<br />
<br />
4. Past medical history.<br />
History suffering from acute otitis media, and chronic.<br />
<br />
5. Patterns of health functions<br />
Rest and sleep patterns: pain suffered by clients can lead to disturbed sleep patterns and the rest.<br />
The pattern of activity: Pain experienced clients can restrict movement.<br />
<br />
6. Examination Support.<br />
<ul>
<li>Check blood</li>
<li>Photos mastoid</li>
<li>Ear bacterial culture</li>
</ul>
<br />
<b>Nursing Diagnosis for Mastoiditis</b><br />
<ol>
<li>Acute pain related to the mastoid surgery.</li>
<li>Risk for infection related to mastoidectomy, surgical trauma on the tissue and surrounding structures.</li>
<li>Knowledge deficit; of the mastoid disease, surgical procedures, and postoperative care and hope.</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-90959293790702920932015-01-22T01:42:00.000+07:002015-01-22T01:42:06.117+07:00Assessment - Nursing Care Plan for Low Birth Weight (LBW)<b>Nursing Care Plan for Low Birth Weight (LBW)</b><br />
<br />
<b>Assessment </b><br />
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<b>Subjective Data</b><br />
<br />
Subjective data is the client's perception and sensation of health problems. Subjective data consists of:<br />
<br />
1. Biography or the identity of the patient: includes name, date of birth, gender.<br />
<br />
2. Parents include: name (father and mother, age, religion, ethnicity or nationality, education, employment income, and address.<br />
<br />
3. Health history<br />
<br />
<blockquote class="tr_bq">
a. Antenatal history that needs to be studied or known of antenatal history in the LBW cases are:</blockquote>
<blockquote class="tr_bq">
<ul>
<li>State of the mother during pregnancy with anemia, hypertension, poor nutrition, smoking dependence on drugs or with diseases such as diabetes mellitus, cardiovascular and pulmonary.</li>
<li>Pregnancy at risk of preterm labor, for example; multiple births, congenital abnormalities, history of preterm labor.</li>
<li>Pregnancy tests are not continuous, or irregular examination and check the pregnancy is not the health workers.</li>
<li>The first day, the last day is not appropriate for gestational age (gestational Postdate or preterm).</li>
<li>History natal complications of childbirth also has a strong link with the problems in the newborn. </li>
</ul>
</blockquote>
<blockquote class="tr_bq">
b. Postnatal history </blockquote>
<blockquote class="tr_bq">
Which needs to be studied include:</blockquote>
<blockquote class="tr_bq">
<ul>
<li>Newborn Apgar scores of 1 minute first, second and 5 min Apgar scores (0-3); severe asphyxia, Apgar score (4-6); moderate asphyxia, Apgar scores (7-10); mild asphyxia.</li>
<li>Birth weight: preterm / low birth weight less than 2500 grams, 2500 grams at term, head circumference less or more than normal (34-36 cm).</li>
<li>Congenital abnormalities: Anencephal, hirocephalus, esophageal atresia.</li>
</ul>
</blockquote>
<br />
4. The pattern of nutrients<br />
Which needs to be studied in infants with low birth weight; gastrointentinal absorption disorders, vomiting aspiration, sucking weakness that needs to be given parenteral fluids or per-sonde according to the baby's condition to meet the needs of electrolytes, fluids, calories and also to correct dehydration, metabolic acidosis, hypoglycemia in addition to intravenous drug administration.<br />
<br />
5. The pattern of elimination<br />
Which needs to be studied in neonates is defecation: frequency, amount, consistency. Urination: frequency, amount.<br />
<br />
6. The socio-cultural background<br />
Cultural influence on LBW, maternal smoking habits, the dependence of certain drugs, especially the type of psychotropic drugs. The habit of consuming alcoholic beverages, mother habits on a strict diet or abstain from certain foods.<br />
<br />
7. The relationship of psychological<br />
Preferably as soon as the newborn be rooming with the mother if the baby's condition allows. This is useful where the baby will get the love and attention as well as to strengthen the psychological relationship between the mother and the baby. As with LBW because it requires intensive care.<br />
<br />
<br />
<b>Objective Data</b><br />
<br />
Objective data is data obtained through a measurement and inspection using recognized standards or applicable.<br />
<br />
1. General condition<br />
In neonates with low birth weight, became very weak and just moaning. The situation will be improved when the show active movement and crying loudly. Awareness of neonates can be seen from the response to stimuli. The existence of a stable body weight, body length according to age there is no enlargement of the head circumference can indicate a good condition of the neonate.<br />
<br />
2. Vital Signs<br />
Neonatal with post severe asphyxia, conditions will be good when handling asphyxia with true, accurate and fast. For preterm infants at risk of hypothermia when the body temperature less than 36 ° C and the risk of hyperthermia occurs when the body temperature less than 37 ° C. While the normal body temperature of 36.5 ° C - 37.5 ° C, the normal pulse between 120-140 times per minute normal respiration between 40-60 times per minute, often in neonatal with post severe asphyxia, breathing is not regular.<br />
3. Skin<br />
Body skin color; red, while the colored extremities; blue, in preterm infants are lanugo and vernix.<br />
<br />
4. Head<br />
Chances are found caput succedaneum or cephal hematoma, large fontanel concave or convex possibility of increased intracranial pressure.<br />
<br />
5. Eyes<br />
Color conjunctiva anemic or not anemic, no bleeding conjunctiva, sclera no yellow color, pupils show a reflection of the light.<br />
<br />
6. Nose<br />
There nostril breathing and there is a buildup of mucus.<br />
<br />
7. Mouth<br />
Pale or red lips, there is mucus or not.<br />
<br />
8. Ear<br />
Pay attention to cleanliness and abnormalities.<br />
<br />
9. Neck<br />
Pay attention to cleanliness because nenoatus neck short.<br />
<br />
10. Thorax<br />
Symmetrical shape, there is a pull intercostal, consider the sound of wheezing and Ronchi, frequency heart sounds more than 100 times per minute.<br />
<br />
11. Abdomen: The shape is cylindrical, hepatic baby is 1-2 cm below the arch costaae, on the lines of the mammary papilla, spleen not palpable, potbelly means the presence of ascites or tumor, sunken abdomen signs of diaphragmatic hernia, bowel sounds arise from 1 to 2 hours after the birth of a baby, often there is a retention due to GI Tract yet perfect.<br />
<br />
12. Umbilicus<br />
Withered umbilical cord, note there is bleeding or not, signs of infection in the umbilical cord.<br />
<br />
13. Genitalia<br />
In neonates at term testicular must come down, see the location of the urethral opening is there any abnormalities in male neonates, neonates of women see the labia majora and labia minora, the presence of whitish mucus secretion, sometimes bleeding.<br />
<br />
14. Anus<br />
Perhatiakan presence of blood in the stool, stool frequency, and color of the stool.<br />
<br />
15. Extremities<br />
The blue color, weak movement, acral cold, note the presence of a fracture or nerve paralysis or state their fingers as well as the amount.<br />
<br />
16. Reflex<br />
In preterm neonates post severe asphyxia and sucking reflex moro weak. Moro reflex can provide information on the state of the central nervous system or the presence of fractures.<br />
<br />
<br />
<b>Supporting Data</b><br />
<br />
Supporting Data; laboratory tests are important in diagnosis or causal right so that we can provide the right medicine anyway.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-10288264668475873662015-01-15T23:42:00.001+07:002015-01-15T23:42:26.242+07:00Fluid Volume Deficit and Imbalanced Nutrition - NCP for Bowel Obstruction<br />
<b>Nursing Care Plan for Bowel Obstruction</b><br />
<br />
<b>Nursing Diagnosis : Fluid Volume Deficit</b> related to inadequate intake and absorption ineffectiveness of the small intestine<br />
<br />
characterized by nausea, vomiting, fever and diaphoresis.<br />
<br />
Goal:<br />
<ul>
<li>Fluid and electrolyte needs are met,</li>
<li>Maintaining adequate hydration with evidence of mucous membranes moist, good skin turgor, and capillary refill good, stable vital signs, and individually passing urine properly.</li>
</ul>
<br />
Expected outcomes:<br />
<ul>
<li>Normal vital signs.</li>
<li>Fluid intake and output balance.</li>
<li>Elastic skin turgor.</li>
<li>Mucosa moist.</li>
<li>Electrolytes are within normal limits.</li>
</ul>
<br />
Interventions:<br />
<ul>
<li>Assess the patient's fluid needs.</li>
<li>Observation of vital signs: pulse, temperature, blood pressure, respiration.</li>
<li>Observation level of consciousness and signs of shock.</li>
<li>Observation bowel sounds every 1-2 hours.</li>
<li>Monitor intake and output closely.</li>
<li>Monitor the laboratory results of serum electrolytes, hematocrit.</li>
<li>Give an explanation to the patient and family about the actions taken: NGT, and fasting.</li>
<li>Collaboration with medical therapy for intravenous administration.</li>
</ul>
<br />
Rationale:<br />
<ul>
<li>Knowing the patient's fluid needs.</li>
<li>Drastic changes in vital signs is an indication of lack of fluids.</li>
<li>fluid and electrolyte deficiency can affect the level of consciousness and lead to shock.</li>
<li>Assess bowel function.</li>
<li>Assessing fluid balance.</li>
<li>Assessing fluid and electrolyte balance.</li>
<li>Increasing knowledge of the patient and family, and co-operation between the nurse-patient-family.</li>
<li>Meet the patient's fluid and electrolyte needs.</li>
</ul>
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<br />
<br />
<b>Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirements</b> related to impaired absorption of nutrients.<br />
<br />
Goal:<br />
Stable weight and nutrition resolved.<br />
<br />
Expected outcomes:<br />
<ul>
<li>No signs of mal nutrition.</li>
<li>Stable weight.</li>
<li>Patients do not experience nausea and vomiting.</li>
</ul>
<br />
Interventions :<br />
<ul>
<li>Review the individual factors that affect the ability to digest food, eg fasting status, nausea, paralytic ileus after the hose is removed.</li>
<li>Auscultation bowel sounds; palpation of the abdomen; record the passage of flatus.</li>
<li>Identification of the likes and dislikes of the patient's diet. Encourage selection of high protein foods and vitamin C.</li>
<li>Observations on the occurrence of diarrhea; foul odor and oily food.</li>
<li>Collaboration in the provision of drugs as indicated.</li>
</ul>
<br />
Rationale:<br />
<ul>
<li>Influence the choice of intervention.</li>
<li>Determining the return of peristalsis (usually within 2-4 days).</li>
<li>Improving patient cooperation with the dietary rules. Protein / vitamin C is a contributor utuma for tissue maintenance and repair. Malnutrition is a factor in the lowering of defense against infection.</li>
<li>Malabsorption syndrome may occur after surgery small intestine, require further evaluation and changes in diet, eg, low-fiber diet.</li>
<li>Prevent vomiting. Neutralize or reduce the formation of acid to prevent erosion and possible mucosal ulceration.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-75833217711557524732015-01-14T10:26:00.000+07:002015-01-14T10:26:45.979+07:00Nursing Care Plan for Osteosarcoma<br />
Sarcoma is a tumor derived from connective tissue. (Danielle. 1999: 244).<br />
<br />
Cancer is the uncontrolled neoplasm of anaplastic cells that invade tissue and tends to metastasize to the far side of the body. (Wong. 2003: 595).<br />
<br />
<br />
Etiology<br />
<ul>
<li>Radiation radioactive high doses.</li>
<li>Heredity.</li>
<li>Some pre-existing conditions such as bone Paget's disease (due to radiation exposure).</li>
<li>Oncogenic viruses (Smeltzer. 2001: 2347).</li>
</ul>
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Clinical manifestations<br />
<ul>
<li>Pain and swelling of the affected limb or (usually become more severe at night and increased in accordance with the progression of the disease).</li>
<li>Swelling, Swelling at or above the bones or joints and limited movement (Gale. 1999: 245).</li>
<li>Limitation of motion.</li>
<li>Pathologic fracture.</li>
<li>The reduced weight.</li>
<li>Palpable mass; and settled with soft skin temperature rises above the masses and distended veins and venous dilation.</li>
<li>The symptoms of metastatic disease include chest pain, cough, fever, weight loss and malaise (Smeltzer. 2001: 2347).</li>
</ul>
<br />
Assessment<br />
<br />
1. Identification of patients<br />
Name, age, gender, education, occupation, marital status, address, and others.<br />
<br />
2. Health history<br />
The patient complained of pain in the affected bone area.<br />
The client says hard to activity / limitation of motion.<br />
The client expressed anxiety will be the situation.<br />
<br />
3. Physical Assessment<br />
On palpation palpable mass on the affected area.<br />
Soft tissue swelling caused by a tumor.<br />
Neurovascular status assessments; tenderness.<br />
Limitations of range of motion.<br />
<br />
4. Results of laboratory / radiology<br />
There is a picture of the damage to bone and new bone formation.<br />
A picture of a sun ray spicules, or threads of bone from the bone cortex.<br />
Increased levels of alkaline phosphatase.<br />
<br />
<br />
<b>Nursing Diagnosisfor for Osteosarcoma</b><br />
<ol>
<li>Acute pain</li>
<li>Impaired Physical Mobility</li>
<li>Impaired Skin Integrity</li>
<li>Risk for infection</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-4717120080021575082015-01-13T00:39:00.001+07:002015-01-13T00:39:23.796+07:00Nursing Interventions for Hallucinations Hallucination is one of the problems that may be found from persepsual problems in schizophrenia., Which is defined as experience hallucinations or sensory impression that one of the sensory stimulus.<br />
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<br />
<br />
<b>Nursing Interventions for Hallucinations </b><br />
<ol>
<li>Nursing actions to help clients cope with the problem begins with the relationship of trust with clients.</li>
<li>Having built up a trusting relationship, the next nursing intervention is to help clients identify hallucinations.</li>
<li>Once the client knows hallucination, then clients are trained how commonly proven effective overcome or control hallucinations.</li>
<li>Observation signs of hallucinations on the client.</li>
<li>Avoid touching the client before signaling to the client that you receive the same treatment.</li>
<li>An acceptance will encourage clients to share the content of the hallucinations to you.</li>
<li>Do not reinforce hallucinations. Use the words "voice" rather than words like "they" who claimed validation indirectly.</li>
<li>Try to connect the times of occurrence of misperceptions with times of occurrence of anxiety.</li>
<li>Try to divert patients from misperceptions.</li>
</ol>
<br />
The effective way to decide hallucinations are:<br />
<ol>
<li>Rebuked hallucinations.</li>
<li>Interacting with others.</li>
<li>Activity regularly to prepare daily activities.</li>
<li>Utilizing the drug well.</li>
</ol>
Families need to be given an explanation of how the handling of clients who experienced hallucinations in accordance with the family's ability. This is important because the family is a system where the client comes and hallucinations as one of psychotic symptoms can last a long time (chronic) so that families need to also learn how to care clients with hallucinations at home.<br />
<br />
In control hallucinations psykofarmaka given by the medical team so that nurses should also facilitate the client to be able to use drugs appropriately. Principle five really should be the main focus in drug delivery.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-85520718746477330422015-01-13T00:11:00.001+07:002015-01-13T00:11:06.852+07:00Characteristics of Types of Hallucinations<br />
Hallucination is a maladaptive response of individuals who are in the range of responses neurobiology. It is the perception of most maladaptive response. If healthy client perception is accurate, able to identify and interpret the stimulus based on information received through the senses (hearing, sight, smell, taste, and tactile), with hallucinations client perceives a stimulus sensory stimulus even though it does not exist. Among the second response is the response of individuals who for some reason are abnormal perception that one perceives the stimulus it receives the so-called illusion. Clients experience the illusion if the interpretation of the stimulus does not accurately match sensory stimuli received.<br />
<br />
<br /><b>Characteristics of Types of Hallucinations</b><br />
<br />
1. Auditory Hallucinations 70% : Hear the sound or noise, most often voices. Voice-shaped noise less obvious to the words that clearly speaks about the client, even to the complete conversation between two people who experience hallucinations. Sound mind in which the client heard that the client was told to do something sometimes can be dangerous.<br />
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2. Visual Hallucinations 20% : Visual stimulus in the form of flashing lights, geometric drawings, cartoons, shadows complicated or complex. Shadows can be fun or scary like seeing monsters.<br />
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<br />
<br />
3. Olfactory Hallucinations : Smell certain odors such as the smell of blood, urine, and feces, usually smells unpleasant. Hallucinations of smell is often a result of a stroke, tumor, seizures, or dementia.<br />
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<br />
<br />
4. Gustatory Hallucination : Feel to taste like the taste of blood, urine or feces.<br />
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<br />
<br />
5. Tactile Hallucination : Experience pain or discomfort without apparent stimulus. Sense of electric shock that comes from the ground, inanimate objects or other people.<br />
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Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-90142072443732990892015-01-08T23:57:00.001+07:002015-01-08T23:57:50.427+07:00Nursing Care Plan for Amyotrophic Lateral Sclerosis (ALS)<b>Nursing Care Plan for Amyotrophic Lateral Sclerosis</b><br />
<br />
Amyotrophic lateral sclerosis is a degenerative diseases of upper and lower motor neurons, which is growing rapidly which causes the almost total paralysis. The loss of motor neurons does not include cranial nerves III, IV, and VI. Thus, some move faces including flashing maintained. Amyotrophic lateral sclerosis, also known as Lou Gehrig's disease and usually occurs in the decade-IV or V to life. The disease is usually fatal within 5 years increased, although some individuals may live much longer. Motor neuron degeneration occurs without apparent inflammation. Although myelin is not a primary place degeneration, loss of nerve axons, causing loss of myelin and scarring. The cause of amyotrophic lateral sclerosis is unknown although it is estimated viral infection, and metabolic disorders and trauma. In addition there is amyotrophic lateral sclerosis is a genetic influence the likelihood that a patient may suffer from amyotrophic lateral sclerosis by 10%. Recent evidence suggests that genetic relationships can occur in more cases. (Elizabeth, 2009).<br />
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Researchers studying the possible causes of amyotrophic lateral sclerosis include:<br />
<ul>
<li>Free radicals. In amyotrophic lateral sclerosis that is genetically inherited, gene mutation, which is in charge of producing the anti-oxidant enzyme, which protects nerve cells and free radicals.</li>
<li>Glutamate. Glutamate is a chemical in the brain, where people with amyotrophic lateral sclerosis higher levels. Allegedly high levels can damage nerve cells.</li>
<li>Autoimmune response. Sometimes, a person's immune system can attack normal cells in the body itself, this is what happens in amyotrophic lateral sclerosis.</li>
</ul>
Although the exact cause of amyotrophic lateral sclerosis is unknown, there are several risk factors that may increase the occurrence of amyotrophic lateral sclerosis:<br />
<ul>
<li>Heredity. 10% pasieen with amyotrophic lateral sclerosis passed down from parents.</li>
<li>Age. Usually the symptoms of the disease appear at the age of 40-60 years.</li>
</ul>
<br />
Clinical manifestations<br />
<br />
According to Lionel (2007), clinical symptoms seen in patients with amyotrophic lateral sclerosis, among others:<br />
<ul>
<li>Generally patients showed atrophy and weakness of the muscles of the upper limb is more often than the lower extremities.</li>
<li>Cramps and fasciculations may precede other motor symptoms. Motor signs are usually asymmetric.</li>
<li>There is no sensory symptoms and no involvement spingter that causes pelvic and abdominal muscle weakness and decreased fluid intake.</li>
<li>Some patients may experience a frontal-type dementia.</li>
<li>Most patients showed symptoms of dysarthria and dysphagia (progressive bulbar palsy variants).</li>
<li>There are signs of bulbar and pseudobulbar palsy mixture, such as atrophy and vesicles salida, but reflex jaw increased.</li>
<li>Patients at risk of infection due to aspiration and impaired muscle weakness mechanism.</li>
</ul>
<b><br /></b>
<b>Nursing Diagnosis for Amyotrophic Lateral Sclerosis</b><br />
<ol>
<li>Ineffective breathing pattern related to respiratory muscle weakness.</li>
<li>Risk for imbalanced Nutrition: less than body requirements to dysphagia / swallowing difficulties, secondary to cranial nerve disorders.</li>
<li>Impaired verbal communication related to dysarthria.</li>
<li>Impaired physical mobility related to weakness and muscular damage secondary to neuromuscular damage.</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-73919090853313982892014-12-17T18:59:00.000+07:002014-12-17T18:59:22.732+07:00Nursing Care Plan for Systemic Lupus Erythematosus <b>Nursing Diagnosis and Interventions for SLE</b><br />
<br />
Systemic lupus erythematosus (SLE) is an autoimmune disease. SLE is eight times more common in women than men. Up to 10% of people with lupus isolated to the skin will develop the systemic form of lupus (SLE). SLE is characterized by the production of unusual antibodies in the blood. The cause(s) of SLE is (are) unknown, however, heredity, viruses, ultraviolet light, and drugs all may play some role. <br />
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<b>Signs and Symptoms</b><br />
<br />
1. Musculoskeletal System<br />
Arthralgia, arthritis (synovitis), joint swelling, tenderness and pain when moving, stiffness in the morning.<br />
<br />
2. Integumentary System<br />
Acute lesions on the skin which comprises a butterfly-shaped rash that is transverse bridge of the nose and cheeks.<br />
Oral ulcers on the buccal mucosa or hard palate.<br />
<br />
3. Cardiac Systems<br />
Pericarditis is a cardiac manifestation.<br />
<br />
4. Respiratory System<br />
Pleurisy or pleural effusion.<br />
<br />
5. Vascular System<br />
Inflammation in the terminal arterioles that causes lesions papuler, erythematous and purpuric on tip toes, hands, elbows and forearm extensor surface or lateral side of the hand and continued necrosis.<br />
<br />
6. Urinary System<br />
Renal glomerulus are usually affected.<br />
<br />
7. Nervous System<br />
The spectrum of disorders of the central nervous system is very broad and covers all forms of neurological disease, frequent depression and psychosis.<br />
<br />
<br />
<b>Possibility of Nursing Diagnosis</b><br />
<ol>
<li>Pain (acute / chronic)</li>
<li>Fatigue</li>
<li>Impaired skin integrity</li>
<li>Impaired physical mobility</li>
<li>Impaired body image</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-57536857838472464702014-12-17T12:53:00.002+07:002014-12-17T12:53:46.949+07:00Orthostatic Hypotension - Causes, Signs and Symptoms<br />
<b>Orthostatic hypotension</b> is a drop in blood pressure that occurs suddenly when changing position from supine to sitting or upright position. Orthostatic hypotension is more frequent in patients taking antihypertensive medications. Symptoms such as sudden weak, dizzy, felt faint and fainting may occur. Orthostatic hypotension is often mild, lasting a few seconds to several minutes after standing. However, prolonged orthostatic hypotension may be a sign of a more serious problem, so it needs to consult with a doctor if they occur. Moreover, in case of loss of consciousness although momentarily. Mild orthostatic hypotension often do not require treatment. Many people sometimes feel dizzy or lightheaded after standing, and usually do not cause concern. Treatment for more severe cases of orthostatic hypotension depends on the cause. Orthostatic hypotension was defined as a decrease in systolic blood pressure of 20 mmHg or diastolic blood pressure 10 mmHg within three minutes of standing compared with blood pressure from sitting or supine position.<br />
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<b>Causes</b><br />
<br />
Orthostatic hypotension is caused primarily by gravity-induced blood-pooling in the lower extremities, which in turn compromises venous return, resulting in decreased cardiac output and subsequent lowering of arterial pressure. For example, changing from a lying position to standing loses about 700 ml of blood from the thorax, with a decrease in systolic and diastolic blood pressures. The overall effect is an insufficient blood perfusion in the upper part of the body.<br />
<br />
Still, the blood pressure does not normally fall very much, because it immediately triggers a vasoconstriction (baroreceptor reflex), pressing the blood up into the body again. (Often, this mechanism is exaggerated and is why diastolic blood pressure is a bit higher when a person is standing up, compared to a person in horizontal position.) Therefore, a secondary factor that causes a greater than normal fall in blood pressure is often required. Such factors include hypovolemia, diseases, and medications.<br />
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<b>Signs and symptoms</b><br />
<br />
When orthostatic hypotension is present, the following symptoms can occur after sudden standing or stretching (after standing):<br />
<ul>
<li>Dizziness</li>
<li>Euphoria or dysphoria</li>
<li>Bodily dissociation</li>
<li>Distortions in hearing</li>
<li>Lightheadedness</li>
<li>Nausea</li>
<li>Headaches</li>
<li>Temporary decrease in hearing</li>
<li>Blurred or dimmed vision (possibly to the point of momentary blindness)</li>
<li>Seizures</li>
<li>Generalized (or extremity) numbness/tingling and fainting</li>
<li>Coat hanger pain (pain centered in the neck and shoulders)</li>
<li>And in rare, extreme cases, vasovagal syncope (a specific type of fainting).</li>
</ul>
They are consequences of insufficient blood pressure and cerebral perfusion (blood supply). Occasionally, there may be a feeling of warmth in the head and shoulders for a few seconds after the dizziness subsides. The drop in blood pressure may cause a vasovagal episode to occur.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-52478623360473519042014-12-13T23:21:00.003+07:002014-12-13T23:21:38.349+07:0010 Causes and Risk Factors of OsteoarthritisThe cause of osteoarthritis is still yet to be revealed, but some risk factors for the onset of osteoarthritis include:<br />
<br />
1. Age<br />
Of all the risk factors for the onset of osteoarthritis, aging is the strongest factor. The prevalence and severity of orteoartritis increasing with increasing age. Osteoarthritis is almost never in children, rarely at the age under 40 years of age and often over 60 years.<br />
Physical and biochemical changes that occur with advancing age with a decrease in the amount of collagen and water content, and sediment shaped yellow pigment.<br />
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2. Genetic<br />
Hereditary factors also play a role in the onset of osteoarthritis example, the mother of a woman with osteoarthritis of the distal interphalangeal joints, there are two times more often osteoarthritis in the joints, and her daughters tend to have three times more often than women and daughters of women without osteoarthritis.<br />
Heberden's nodes is a form of osteoarthritis that is usually found in men whose parents osteoarthritis, whereas women, only one of the parents affected.<br />
<br />
3. Gender<br />
Women are more often affected by osteoarthritis of the knee and joints, and men more often osteoarthritis thigh, wrist and neck. In the complaint, under 45 years old, osteoarthritis approximately equal frequency in men and women. But over 50 years, the frequency osteoarthritis more in women than in men, it shows the hormonal role in the pathogenesis of osteoarthritis.<br />
<br />
4. Overweight (obesity)<br />
Real excessive weight associated with increased risk for the onset of osteoarthritis in women and in men. Obesity was not only associated with osteoarthritis in the joints that bear the burden, but also with other joint osteoarthritis (hand or sternoclavicular).<br />
<br />
5. Bone density and wear (wear and tear)<br />
Excessive use of joints could theoretically destroy cartilage through two mechanisms: erosion and degeneration process, because the material must contain.<br />
<br />
6. Injury joints, work and sport (trauma)<br />
Physical activity can lead to osteoarthritis is a trauma that causes damage to the integrity of the structure and biomechanics of the joint.<br />
<br />
7. Due to arthritis else<br />
Infection (rheumatoid arthritis; acute infection, chronic infection) cause an inflammatory reaction and spending destructive enzymes of cartilage matrix by the synovial membrane and inflammatory cells.<br />
<br />
8. Endocrine diseases<br />
In hyperthyroidism, the case of production of water and salts proteoglycan, which is excessive in whole tissue backers, thus damaging the physical properties of cartilage, ligaments, tendons, synovial, and skin. In diabetes mellitus, glucose will cause decreased proteoglycan production.<br />
<br />
9. Joint Mallignment<br />
In acromegaly due to the effect of growth hormone, then the cartilage will bounce and cause the joint to become unstable / balanced so as to accelerate the process of degeneration.<br />
<br />
10. Deposits in cartilage<br />
Hemochromatosis, Wilson disease, can precipitate calcium pyrophosphate hemosiderin, copper polymer, hemogentisis acid, monosodium urate crystals / pyrophosphate in cartilage.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-85493768877147086092014-12-09T21:26:00.001+07:002014-12-09T21:26:24.214+07:00Management of Dehydration in Elderly Patients<br />
Electrolyte abnormalities and dehydration in elderly patients is relatively easy to treat, but the diagnosis of dehydration considered difficult, due to the lack of supervision and constraints to accurately assess fluid balance. Clinical manifestations of dehydration may include dry skin, decreased skin turgor, and dry mucous membranes. However, reduced skin turgor can also occur due to aging and dry mouth, also can be caused by breathing through the mouth.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXSam8hRnvjKpldofngm-XAQX191JcE7cJHqHIUg55TuquSLVbzYbSyj7hSSEz4heakdPctKasAvwmGs-WpspKoKdR_yDKz08wPNsUl70t-7S90Ftit5ELqTiZyYOx9lwfQlEYOssa3Sg/s1600/Management+of+Dehydration+in+Elderly+Patients.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXSam8hRnvjKpldofngm-XAQX191JcE7cJHqHIUg55TuquSLVbzYbSyj7hSSEz4heakdPctKasAvwmGs-WpspKoKdR_yDKz08wPNsUl70t-7S90Ftit5ELqTiZyYOx9lwfQlEYOssa3Sg/s1600/Management+of+Dehydration+in+Elderly+Patients.jpg" height="200" width="320" alt="Nursing Care / Management of Dehydration in Elderly Patients" /></a></div>Clinical features :<br />
<ul><li>Dryness of mucous membranes.</li>
<li>Dry skin.</li>
<li>Decreased skin turgor.</li>
<li>Decreased sweating armpits.</li>
<li>Orthostatic hypotension.</li>
<li>Tachycardia and hypotension (show shock).</li>
<li>Cognitive impairment.</li>
<li>Reduced urine output.</li>
<li>Concentrated urine and high osmolality.</li>
</ul>In addition, patients with cognitive disorders such as dementia have a relatively high incidence of dehydration. Elderly patients with dementia often forget to drink, causing an increase in the incidence of dehydration in this patient population.<br />
<br />
Due to a change in the pathophysiology of fluid and electrolyte balance due to aging, elderly patients tend to suffer from dehydration and electrolyte imbalance perioperative. Morbidity that may occur due to salt retention among other cardiorespiratory complications, increased risk of infection, and impaired wound healing. While the disorder can affect fluid balance disturbances in the function of the gastrointestinal (GI).<br />
<br />
Fluid therapy to prevent dehydration, especially in elderly patients perioperative emphasis on strict monitoring of fluid balance and serum electrolyte levels, to prevent morbidity due to fluid retention and salt. A meta-analysis showed a decrease of 41% postoperative complications and length of stay in hospital shorter by providing near zero fluid balance method. Several other studies showed colloid bolus administration of small doses (200-250 mL) intraoperative can increase stroke volume and significantly improve clinical outcome.<br />
<br />
In conclusion, the treatment of dehydration in elderly patients, particularly perioperative needs monitoring of fluid and electrolyte balance very tight given that there are changes in the pathophysiology of fluid and electrolyte balance in this patient population, such as fluid and salt retention due to the decrease in renal function. Strictly maintain fluid balance can improve the clinical outcome of patients with advanced age, especially during the perioperative.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-59158567416494083882014-12-09T11:00:00.001+07:002014-12-09T11:00:59.121+07:00NCP for Pneumoconiosis - Etiology, Clinical Manifestations and Nursing Diagnosis<br />
<b>Nursing Care Plan for Pneumoconiosis</b><br />
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<b>Definition of Pneumoconiosis</b><br />
<br />
Pneumoconiosis is a chronic lung disease caused by inhalation of various forms of dust particles, especially in the industrial workplace, for long periods of time. Therefore, it is also said to be working lung disease, which is a specific part of the work -related illnesses, which related primarily to the exposed hazardous substances, whether they are gas or dust, in the workplace, and pulmonary disorders that may results from it. The severity and type of pneumoconiosis depends on what the dust particles consisting of, for example, small amounts of certain substances, such as asbestos and silica, can cause a serious reaction, while others may be harmless.<br />
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<b>Etiology of Pneumoconiosis</b><br />
<br />
Pneumoconiosis caused by inhaling dust can ferrous metals, silver / tin and barium. Siderosis occur as a result of inhalation of iron oxide, baritosis occur due to inhalation of barium and stannosis occur due to inhaling silver elements. Iron dust exposure occurs in the process of mining, milling and cutting metal.<br />
<br />
Inhalation of dust iron, silver and barium, lead to changes in lung structure which is very light so that only causes few symptoms. But this tissue reaction can be seen on chest x-ray as a large number of small areas that are not translucent. During the process of inspiration (breathing air), airborne dust particles having a diameter of more than 10 mm, filtered by hairs in the nose. Other dust particles, which enter through the mouth, is stored in the upper respiratory tract.<br />
<br />
Dust particles with a diameter of 5-10 mm, tend to live in the mucus that surrounds the bronchi and bronchioles, then swept toward the throat by a delicate hairs (cilia). From their throats will coughed or discarded, but some of them have swallowed. Particle diameter of less than 5 mm, more easily reach the lung tissue.<br />
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<br />
<a href="http://blog-nursingcareplan.blogspot.com/2014/12/pathophysiology-signs-and-symptoms-of.html" target="_blank"><b>Clinical Manifestations of Pneumoconiosis</b></a><br />
<ul>
<li>Dyspnea, in patients experiencing dyspnea became worse and progressive.</li>
<li>Pneumoconiosis generally nonproductive cough except in case of chronic bronchitis.</li>
<li>Severe restriction volume of inspiration and rapid pulse and continued.</li>
<li>Cyanosis may occur due to decreased ventilation accompanied by a decrease in the rate of diffusion.</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis for Pneumoconiosis</b><br />
<ol>
<li>Ineffective airway clearance</li>
<li>Impaired gas exchange</li>
<li>Risk for infection</li>
<li>Disturbed sleep patterns</li>
<li>Risk for fluid volume deficit</li>
<li>Imbalanced nutrition less than body requirements</li>
<li>Anxiety</li>
<li>Chronic pain</li>
<li>Knowledge deficit</li>
<li>Activity intolerance</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-90835598091265786362014-12-09T10:35:00.001+07:002014-12-09T10:35:04.579+07:00Pathophysiology, Signs and Symptoms of Pneumoconiosis due to Asbestosis<b>Pneumoconiosis due to Asbestosis</b><br />
<br />
The disease is caused by inhalation of asbestos dust, causing pneumoconiosis which is characterized by pulmonary fibrosis. Exposure can occurred in the industrial and mining areas or areas where the air asbestos dust polluted. Workers can be exposed to asbestosis is miners, milling, transportation, merchants, workers ship and the destroyer of asbestos workers.<br />
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In the early stages there may be no symptoms even though the X-ray of the thorax showed a picture of asbestosis / pleural thickening. The main symptom is shortness of breath initially occurs at the time of the activity. In the later stages a common symptom is shortness of breath at rest, cough, and weight loss. Shortness of breath continued to deteriorate despite the patient kept from exposure to asbestos, 15 years after the onset of the disease usually occurs cor pulmonale and death. Patients often have respiratory infections, malignancy of the bronchi, gastrointestinal and pleura are often the cause of death.<br />
<br />
In the early stages, the physical examination is not much showing abnormalities, due to diffuse fibrosis can be heard in the wet crackles under the posterior lobe. This sounds more clearly when there bronchiectasis (a disease characterized by the presence of pathological dilatation of the bronchi and ongoing chronic) due to distortion because of extensive pulmonary fibrosis. Clubbing (Clubbing finger) are often found in patients with asbestosis.<br />
<br />
Changes in the X-ray of the thorax is more obvious in the middle and bottom of the lungs, can be diffuse spots, or white spots, shadow heart often becomes blurred. The diaphragm can be elevated in advanced stage due to the shrinking lung. Usually occurs bilateral pleural thickening, seen in the middle and lower regions, especially in case of calcification. When the process further, visible picture of a wasp nest in the lower lobes. May be found bronchial malignancy or mesothelioma (pleural cancer). In contrast to coal pneumoconiosis and silicosis sufferers can have symptoms of shortness of breath without chest X-ray abnormalities. Examination of lung function showed abnormalities restriction even though there are no symptoms, in some patients there are abnormalities obstruction. Diffusion capacity and decreased lung compliance, at an advanced stage occurs hypoxemia.<br />
<br />
Lung biopsy may be necessary in certain cases to confirm the diagnosis. Transbronchial lung biopsy should be performed to obtain lung tissue. Bronchoscopic examination is also useful to get rid of or confirm the existence of bronchial carcinoma can occur simultaneously with the occurrence of asbestosis.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-66128215515846705982014-12-08T09:48:00.001+07:002014-12-08T09:48:33.777+07:00Hyperthermia - NCP for Hodgkin's Lymphoma<br />
<b>Nursing Care Plan for Hodgkin's Lymphoma</b><br />
<br />
Hodgkin lymphoma, also called Hodgkin disease, is a cancer of the lymphatic system. The lymphatic system forms part of the immune system. It contains specialised white blood cells called lymphocytes that help protect the body from infection and disease. Hodgkin lymphoma arises when developing lymphocytes undergo a malignant change, and multiply in an uncontrolled way. These abnormal lymphocytes, called lymphoma cells, form collections of cancer cells called tumours, in lymph nodes (sometimes known as ‘glands’) and other parts of the body.<br />
<br />
The most common symptom of Hodgkin lymphoma is a firm, usually painless swelling of a lymph node (swollen glands), usually in the neck, under the arms or in the groin. Other symptoms may include:<br />
<ul>
<li>recurrent fevers</li>
<li>excessive sweating at night</li>
<li>unintentional weight loss</li>
<li>persistent fatigue and lack of energy</li>
<li>generalised itching or a rash</li>
</ul>
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhv8W3FuVHQ8HazsixzlW4XXouYd0gy9MLk8sVlkzQZkpkHGUAuwZ22xZBc00rpmYQGNhhikFsInzKgGM43_DKWVUXgNP_U6Z_3N18Rto4Cc_yR3NEZo9vrgWlWkCDG-eAeUkrBg_MLL74/s1600/Nursing+Diagnosis+for+Hodgkin+Lymphoma.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="NCP for Hodgkin's Lymphoma" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhv8W3FuVHQ8HazsixzlW4XXouYd0gy9MLk8sVlkzQZkpkHGUAuwZ22xZBc00rpmYQGNhhikFsInzKgGM43_DKWVUXgNP_U6Z_3N18Rto4Cc_yR3NEZo9vrgWlWkCDG-eAeUkrBg_MLL74/s1600/Nursing+Diagnosis+for+Hodgkin+Lymphoma.jpeg" /></a></div>
<b>Nursing Diagnosis and Interventions for Hodgkin's Lymphoma</b><br />
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Hyperthermia related to the ineffectiveness of thermoregulation secondary to inflammation.<br />
<br />
Goal: body temperature back to normal,<br />
Characterized by:<br />
<ul>
<li>Temperature 36-37o C</li>
<li>Acral warm</li>
<li>Capilarry refill less than 3 seconds.</li>
</ul>
Nursing Intervention:<br />
1. Observation of the patient's body temperature.<br />
R /: By monitoring the temperature is expected to be known state so that it can take appropriate action.<br />
<br />
2. Encourage and provide plenty of drink (according to the needs of children under the age of fluid).<br />
R /: With a lot of drinking is expected to help maintain fluid balance in the body.<br />
<br />
3. Give a warm compress on the forehead, axilla, abdomen and groin.<br />
R /: Compress can help lower the patient's body temperature by conduction.<br />
<br />
4. Instruct the patient to put on thin clothes, loose and easy to absorb sweat.<br />
R /: The clothing is expected to prevent evaporation so that the body fluid balance.<br />
<br />
5. Collaboration in the provision of antipyretics.<br />
R /: Antipyretics will inhibit heat release by the hypothalamus.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-79614209660545449552014-12-05T23:25:00.002+07:002014-12-05T23:25:13.361+07:00The Concept of Growth and Development, Play, Nutrition and Impact of Hospitalization<b>Growth and Development, Play, Nutrition and the Impact of Hospitalization</b><br />
<br />
<b>1. Growth</b><br />
<br />
Growth is a natural process that occurs in every individual that is gradually, the child will be growing heavier and higher, growth is set as an increase in body size can be measured with a meter or centimeter of height and kilograms or grams for weight.<br />
<br />
<br />
<b>2. Developments</b><br />
<br />
Sigmund Freud was the development of a child under the age of 21 months.<br />
<br />
In the anal phase, the function of the body which give satisfaction around the anus, defecation / urination, happy to do their own, if not done properly will hold and do the trick. Gross motor sensory developments children are able to run, climb stairs alone with both feet each stage. Fine motor capable of opening the door, unlock, cutting, drinking using glass, use a spoon well. Psychosocial development, according to Erikson 1963 autonomy vs. shame and doubt, locomotor and flavors are ripe and there is confidence in the mother and the environment. Cognitive development, according to Jean Piaget sensory phase motors simulated efforts to satisfy the needs and pleasures, needs a lot of physical range of motion more coordinated, focused and purposeful.<br />
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<br />
<b>3. Nutrition</b><br />
<br />
Oral food sources:<br />
<ul>
<li>Breast milk is a complete food source most favored during the first 6 months, breast milk is the most nutritionally superior, safe from bacteria and cause fewer allergies, breast milk also contains anti-infective factors and immune cells.</li>
<li>Formula products, iron-fortified ready to eat is a choice but acceptable ation. Formula intake varies on each baby, but the average intake is 113 grams of six times per day.</li>
<li>Average water needs of 120-135 ml / kg / day.</li>
<li>Solid food can already be given to meet the nutritional needs.</li>
</ul>
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<b>4. Playing</b><br />
<ul>
<li>Play is a child task.</li>
<li>Play reflects the development and awareness of the environments.</li>
<li>Playing mainly independently.</li>
</ul>
<br />
The purpose of play is as follows:<br />
<ul>
<li>Stimulate psychological development.</li>
<li>Giving diversion from boredom, pain, and discomfort.</li>
<li>Provides tools for communication and expressing feelings.</li>
<li>Help develop sensory motor skills.</li>
</ul>
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<br />
<b>5. Impact of Hospitalization</b><br />
<br />
Hospitalization is a process that is due to a planned or emergency reasons, require the child to stay in the hospital, therapy and treatment until their return back home. During the process, the child and parents can experience a variety of events, according to some researchers aimed to experience a very traumatic and stressful, the main problem that occurs is due to the impact of separation from parents so that no interference formation of trust and affection. In children over 6 months of stranger anxiety or anxiety, when dealing with a stranger and anxious because of separation. Reactions that often appear at this age children are crying, angry, and a lot of movement as a gesture of stranger anxiety. When her mother abandoned the behavior shown is the loud cry of pain or their response to injury is usually a good cry, a lot of body movements, and facial expressions that are not fun.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-41583685724235858642014-12-05T01:05:00.002+07:002014-12-05T01:07:54.493+07:00Disturbed Sensory Perception : Auditory and Tactile Hallucinations<br />
<b>Nursing Care Plan for Auditory and Tactile Hallucinations</b><br />
<br />
Goal : The client is able to define and test the reality / and get rid of sensory perception errors.<br />
<br />
1. Short-term Goal : After the interaction, the client is able to build a trusting relationship.<br />
<br />
Expected outcomes :<br />
<ul>
<li>Shows understanding of verbal , written or response signal.</li>
<li>Indicates movement relaxed facial expression.</li>
<li>Eye contact shows, want to shake hands, to answer greetings, names, would sit side by side or opposite.</li>
</ul>
Action Plans<br />
<ul>
<li>Develop a relationship of trust with the use of the principles of therapeutic communication :</li>
<li>With friendly greet clients both verbal and non -verbal.</li>
<li>Introduce the name , nickname and nurses purpose acquainted.</li>
<li>Ask the full name of the client and the client's preferred nickname.</li>
<li>Create an apparent contract.</li>
<li>Show fairness, and occupies an appointment every time interaction.</li>
<li>Show empathy and accept what is.</li>
<li>Pay attention to clients and consider the needs of the client base.</li>
<li>Ask the client's feelings and problems faced by the client.</li>
<li>Listen attentively to the expression of the client's feelings.</li>
</ul>
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2. Short-term Goal : After the interaction, the client is able to recognize auditory and tactile hallucinations.<br />
<br />
Expected outcomes :<br />
<ul>
<li>The client is able to state the time, the content, the frequency of the appearance of hallucinations.</li>
<li>The client is able to mention the usual behavior when hallucinations appear.</li>
<li>The client is able to mention a result of the usual behavior when hallucinations occur.</li>
</ul>
<br />
Action Plans<br />
<ul>
<li>Perform frequent and brief contact gradually.</li>
<li>Observation of behavior associated with hallucinations.</li>
<li>Help clients recognize hallucination :</li>
</ul>
<blockquote class="tr_bq">
<ul>
<li>Ask if the client is experiencing hallucinations.</li>
<li>If the client answers yes , ask what is being experienced.</li>
<li>Say that nurses believe the client is experiencing this, but the nurses themselves do not experience it.</li>
<li>Say that there are other clients who experienced the same thing.</li>
<li>Say that the nurse will help.</li>
</ul>
</blockquote>
<ul>
<li>If the client is not hallucinating clarification about their experience hallucinations discussed with the client : the content, timing, frequency of occurrence of hallucinations (morning, noon, afternoon, evening, often or sometimes). The circumstances that cause or not cause hallucinations.</li>
</ul>
<br />
3. Short-term Goal : After the interaction, the client is able to control the auditory and tactile hallucinations.<br />
<br />
Expected outcomes :<br />
<ul>
<li>The client can mention a new way to control hallucinations.</li>
<li>The client can choose and implement new ways to control hallucinations.</li>
<li>The clients implement the preferred way to control hallucinations.</li>
</ul>
<br />
Action Plan :<br />
<ul>
<li>Discuss with the client how or action taken in case of hallucinations (sleep, angry, etc.)</li>
<li>Discuss ways in which the client :</li>
</ul>
<blockquote class="tr_bq">
<ul>
<li>If the method used adaptive give a compliment.</li>
<li>If the method used maladaptive losses discuss the way.</li>
</ul>
</blockquote>
<br />
<ul>
<li>Discuss new ways to cut / control the onset of hallucinations.</li>
<li>Help clients choose the method that has been encouraged and trained to give it a try.</li>
<li>Give a chance to do what is selected and trained.</li>
<li>Monitor the implementation of which has been selected and trained, if it managed to give a compliment.</li>
<li>Encourage clients to follow the group activity therapy, reality orientation, perception stimulation.</li>
</ul>
<br />
<br />
4. Short-term Goal : After the interaction, the client can support the family in control of auditory and tactile hallucinations.<br />
<br />
Expected outcomes :<br />
<ul>
<li>Families can build a trusting relationship with the nurse.</li>
<li>Families can mention understanding, signs, and actions to address the hallucinations.</li>
</ul>
<br />
Action Plan :<br />
<ul>
<li>Make a contract with the family for the meeting (time, place, and topic).</li>
<li>Discuss with family (at the time of meeting family / friendly visits)</li>
</ul>
<blockquote class="tr_bq">
<ul>
<li>Definition, signs symptoms, the occurrence, drugs, family members how to prevent hallucinations.</li>
<li>Provide information to control a hospital and how to seek help if hallucinations are not solved.</li>
</ul>
</blockquote>
<br />
5. Short-term Goal : After the interaction, the client can take advantage of the drug well.<br />
<br />
Expected outcomes :<br />
<ul>
<li>The client and family can mention the benefits of dose, drug side effects, and color name and dosage.</li>
<li>The client is able to demonstrate the use of drugs correctly.</li>
<li>The client and the family understand the effects stop taking the medication without recommendation.</li>
</ul>
<br />
Action Plan :<br />
<ul>
<li>Discuss with clients about the benefits and disadvantages of not taking medication, name, color, dosage, method, therapeutic effects and side effects of drug use.</li>
<li>Monitor client when use of the drug.</li>
<li>Give credit if the client is using the drug properly.</li>
<li>Discuss due to stop taking the medication without consulting a physician.</li>
<li>Encourage clients to consult to the doctor / nurse if things happen that are not desirable.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-1785363832590310342014-12-04T23:13:00.000+07:002014-12-04T23:13:18.865+07:00NCP for Knowledge Deficit related to Herniated Nucleus Pulposus<b>Nursing Diagnosis for HNP : Knowledge Deficit</b> : regarding condition, prognosis and actions related to misinformation, misinterpretation, given the lack of information, do not know the sources of information.<br />
<br />
Purpose :<br />
The client knows, understands, on the condition, prognosis and actions to be taken.<br />
<br />
Expected outcomes :<br />
<ul>
<li>The client can reveal an understanding of the condition, prognosis and action.</li>
<li>Doing back lifestyle changes.</li>
<li>Participate in the rule action.</li>
</ul>
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<br />
<br />
Nursing Intervention :<br />
<br />
<ul>
<li>Explain back disease process, and prognosis as well as restrictions to avoid activities such as driving a vehicle in a long period of time.</li>
<li>Provide information about a variety of things and instruct the patient to make changes "body dynamics" without the help and also do exercises including information about its own body mechanics to stand, lift and use shoe backers.</li>
<li>Discuss about treatment and some side effects.</li>
<li>Suggest to use the board / mat hard. Small pillows were a bit flat at the bottom of the neck, sloping bed with knees flexed avoid the prone position.</li>
<li>Discuss regarding dietary needs.</li>
<li>Avoid the use of heating preformance long time.</li>
<li>Refer back to the use of a soft neck collar.</li>
<li>Suggest to perform a medical evaluation on a regular basis.</li>
<li>Provide information about the signs that need to be reported in the next evaluation as puncture pain, loss of sensation / ability to walk.</li>
<li>Assess the likelihood to perform alternative treatments such as ; chemonucleolysis, surgical intervention.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-66887913159442231882014-12-04T16:52:00.002+07:002014-12-04T16:52:16.790+07:00Nursing Management for Herniated Nucleus Pulposus (Presurgery and Postsurgery) <br />
<b>Herniated Nucleus Pulposus (HNP)</b> is a condition in which the bones annulus and the nucleus is reduced elasticity to result in herniation of the nucleus to the annulus which presses the spinal nerves and cause pain (Long, 1996)<br />
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<br />
<b>Presurgery of Herniated Nucleus Pulposus</b><br />
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Most patients fear surgery on the spine. And thus requires a belief (that surgery does not weaken the back of the body) and explain the whole process. When data is collected in the form of medical history some pain, parastersia, and muscle spasm should be noted to provide a basis for comparison after surgery. Preoperative assessment should also include an evaluation of limb movement. Similarly, the function of the bladder and colon. To facilitate preoperative reverse procedure, the patient is taught turned by means of simultaneous unity (in roll) as part of preoperative preparation. Other forms of the ways in which post operation must be trained before surgery is deep breath, cough, and muscle exercises that will help maintain muscle tone.<br />
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<b>Postsurgery of Herniated Nucleus Pulposus </b><br />
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After excision of lumbar disc, it is necessary to check with frequent on vital signs, and injury to the vascular bleeding due to injury, is a complication of surgery discus should also be evaluated sensation and motor strength in the lower extremities and specific regular basis as well as the color and temperature foot and toes sensation. In addition it is also important to examine the possibility of urinary retention. Signs of neurological damage that may occur. Can be taught to clients on how to turn over in bed and described in order to exercise regularly . Avoid sitting except for defecation. Slightly flexed knee position which can provide muscle relaxation the back of the body. Clients are helped to move from one side to the other side which aims to reduce the pressure. But first be convinced that there is no injury caused by the displacement position. Reversing the client is done with the body as a whole unit ( rolled ) without grooves on the back.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-39543006278264418562014-12-03T16:00:00.001+07:002014-12-03T16:00:36.377+07:00Pathophysiology of Herniated Nucleus Pulposus (HNP)Herniated nucleus pulposus (HNP) can be caused by degenerative processes and trauma caused by (falls, accidents, and repeated minor stress such as lifting heavy objects) that lasts for a long time. Intervertebral discs is the tissue that lies between the two vertebrae, which is surrounded by the annulus fibrosus which consists of concentric tissue and fibrocartilage, which there are semi-liquid substance. This substance, called the nucleus pulposus containing files colagenoza fibers, connective tissue cells and cartilage cells. This material serves as shock absorbers between adjacent vertebral bodies, and also plays an important role in the exchange of fluids between the disc and the capillary. Intervertebral disc is formed around a quarter of the overall length of the vertebral column. Most thin disc located in the lumbar region. As we get older, the water content of the disc is reduced (from 90 % in infancy to 70 % in the elderly) and the disc becomes thinner so that the risk of HNP becomes larger. Polysaccharide protein loss in the discus lowering the water content of the nucleus pulposus.<br />
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Fractional developments are spread in the annulus weakens the defense in the nucleus herniation. In addition, the fibers become more coarse and experienced hyalinization, which have contributed to a change that causes the HNP through the annulus along the spinal nerve compression. In the intervertebral disc herniation, bulging into the nucleus of the disc annulus (a fibrous ring around the disc) with a result of nerve compression. Polysaccharide protein loss in the discus lowering the water content of the nucleus pulposus. Fractional developments are spread in the annulus weakens the defense in the nucleus herniation. After trauma (falls, accidents, and repeated minor stress such as lifting a heavy load for a long time) can be injured cartilage , capsule lead to spinal cord or may rupture and allow the nucleus pulposus when pushed against the spinal cord arise from the spinal column.<br />
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Most of disc herniation (a gradual process characterized attacks nerve root compression) occurs in the lumbar region of the lumbar area IV to V (L4 to L5), or fifth lumbar (L5 to S1), this happens because the area is the most received heavy weight pedestal us on exertion. Directions common herniation nucleus pulposus material is posterolateral. Because the lumbar nerve root area tilt down when it exits through the neural foramen, herniated disc between L5 and S1 nerve more influence than L5 S1. (Price, 2005), (Brunner & Suddarth, 2001), (Rasjad, 2003).<br />
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Herniated Nucleus Pulposus (HNP) who attacked the lumbar usually causes severe back pain, urgency, settled a few hours to a few weeks, the pain can be intensified when coughing, sneezing, or bending, and usually spread from the lower back to the buttocks to the lower limbs. Violent paresthesia symptoms may occur after decreasing pain, deformity such as loss of lumbar lordosis or scoliosis, spinal mobility decreased movement (in the acute stage movement at the lumbar very limited, then comes the pain at the time of the extension of the spine), tenderness in the area of herniation and buttocks (paravertebral), the client also usually stand with slightly leaning to one side.<br />
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If this continues condition can cause complications which include radiculitis (nerve root irritation), spinal cord injury, parestese, paralysis of the lower limbs.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-21104008355118956872014-12-03T15:35:00.004+07:002014-12-03T15:39:48.620+07:00Various Definitions of Herniated Nucleus Pulposus (HNP)<br />
Herniated nucleus pulposus (HNP) is a disease caused by trauma or degenerative changes in the nucleus mass strike vertebrae area ; L4 - L5, L5 - S1, or C5 - C6 causing severe lower back pain, chronic and recurrent or relapsed (Doenges, 1999).<br />
<br />
Herniated nucleus pulposus (HNP) is the prominence of the nucleus of the disc into the annulus (a fibrous ring around the disc) with a result of nerve compression (Smeltzer, 2001).<br />
<br />
Herniated nucleus pulposus (HNP) is herniation or protrusion out of the nucleus pulposus that occurs because of degeneration or trauma to the annulus fibrosus (Rasjad, 2003).<br />
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Herniation is a gradual process that is characterized by attacks of nerve root compression that cause a variety of symptoms and anatomical adjustment period. (Price, 2005).<br />
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Nucleus pulposus is like a ball bearing in the middle disc (cartilage plates that form a cushion between the vertebral body). (Smeltzer, 2001).<br />
<br />
Intervertebral discs are a piece of cartilage that forms a cushion between the vertebral bodies. Hard and fibrous material is combined in one capsule. Such as ball bearings in the middle disc called the nucleus pulposus. HNP is a rupture of the nucleus pulposus. (Brunner & Suddarth, 2002)<br />
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Herniated nucleus pulposus (HNP) can to the top or bottom of the vertebral body, can also directly into the vertebral canal. (Priguna Sidharta, 1990)<br />
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From some of the above, the authors conclude that the definition of herniated nucleus pulposus (HNP) is a disease caused by degenerative or traumatic process that is characterized by the prominence of the nucleus pulposus of the disc into the annulus which cause nerve compression, causing severe lower back pain, chronic and recurrent (relapse).Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-41501610497401863322014-12-03T15:16:00.001+07:002014-12-03T15:16:08.959+07:00Diagnostic Tests of Urinary Incontinence<br />
In assessing women with urinary incontinence is the history and physical examination are complete. Preliminary examination is not always diagnostic, but the information obtained will guide the clinician preformance choose the necessary diagnostic tests. In general, patient complaints, namely :<br />
<ul>
<li>Urine out when coughing, laughing, sneezing and exercise.</li>
<li>Urinary discharge can not be detained.</li>
<li>Urine dripping on the state of the bladder is full.</li>
</ul>
Complete physical examination includes examination of the abdomen, vaggginal, pelvic, rectal and neurological assessment. On abdominal examination can be obtained distended bladder, which shows an overflow incontinence, and confirmed by catheterization. Inspeculo can seem genital prolapse, cystocele and rectocele. The presence of urine in vagggina especially after a hysterectomy may be aware of a pelvic mass.<br />
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Simple test can be done after a physical examination to help determine the next action. Q-tip test ('the cotton swab test'), is a simple test to indicate the presence of genuine stress incontinence. Patients were told to empty the bladder, urine accommodated. Then the urine specimen taken by catheterization . The amount of urine from the urinary and bladder catheter is volume. Residual volume confirmed the diagnosis of overflow incontinence. Urine specimens sent to the laboratory.<br />
<br />
Further diagnostic tests are cystourethroscopy and diagnostic imaging. Cystourethroscopy done with general anesthesia and without anesthesia, can be seen in pathological states such as fistula, ectopic ureter or diverticulum. Test urodynamic include uroflowmetry and cystometry. Cystometry is a test that is most important, because it can show the state of hyperactive bladder, both normal and hypoactive. Diagnostic imaging includes ultrasound, CT scans and IVP are used to identify pathological abnormalities (such as fistula / tumor) and anatomical abnormalities (ectopic ureter).<br />
<br />
Additional tests are required for diagnostic evaluation that is 'pad pessary test'. People drink 500 ml of water for 15 minutes to fill the bladder. After half an hour, the patient exercises for 45 minutes by means of : standing from sitting (10 times), cough (10 times) , jogging in place (11 times), pick up objects from the floor (5 times), and hand washing of water for 1 minute. Test Pad positive when the weight equal to or greater than 1g. this test can indicate the presence of stress incontinence only if not obtained an unstable bladder.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-17321584463941344182014-12-02T16:57:00.000+07:002014-12-02T16:57:24.925+07:00Risk for Decreased cardiac output and Acute Pain - NCP for Acute Myocardial Infarction<br />
<b>Nursing Care Plan for Acute Myocardial Infarction</b><br />
<br />
<b>Nursing Diagnosis : Acute Pain</b> related to tissue ischemia secondary to arterial occlusion,<br />
characterized by:<br />
<ul>
<li>chest pain with / without deployment</li>
<li>facial grimacing</li>
<li>restless</li>
<li>delirium</li>
<li>changes in pulse, blood pressure.</li>
</ul>
Goal:<br />
<ul>
<li>Pain decreased after treatment measures.</li>
</ul>
Expected outcomes:<br />
<ul>
<li>Chest pain is reduced, for example, from a scale of 3 to 2, or from 2 to 1.</li>
<li>Facial expression relaxed / calm, not tense.</li>
<li>Not restless.</li>
<li>Pulse: 60-100 x / minute.</li>
<li>Blood pressure: 120/80 mm Hg.</li>
</ul>
Intervention:<br />
<ul>
<li>Observation characteristics, location, time, and travel is chest pain.</li>
<li>Instruct the client to stop activity and rest during an attack.</li>
<li>Help clients do relaxation techniques, such as deep breathing, behavioral distraction, visualization or guided imagery.</li>
<li>Maintain oxygenation with bi cannula, for example (2-4 L / min).</li>
<li>Monitor vital signs (pulse and blood pressure) every two hours.</li>
<li>Collaboration with the health care team in providing analgesic.</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis : Risk for Decreased cardiac output</b> related to changes in factors of electricity, decreased myocardial characteristics.<br />
<br />
Goal:<br />
<ul>
<li>Improved cardiac output / stable after the act of nursing.</li>
</ul>
Expected outcomes:<br />
<ul>
<li>No edema.</li>
<li>No dysrhythmias.</li>
<li>Normal urine output.</li>
<li>Vital signs within normal limits.</li>
</ul>
Iintervention:<br />
<ul>
<li>Maintain bed rest during the acute phase.</li>
<li>Assess and report any signs of decreased cardiac output, blood pressure.</li>
<li>Monitor urine output.</li>
<li>Assess and monitor vital signs every hour.</li>
<li>Assess and monitor EKG every day.</li>
<li>Give oxygen as needed.</li>
<li>Respiratory and cardiac auscultation every hour as indicated.</li>
<li>Maintain parenteral fluids and medications appropriate advice.</li>
<li>Provide appropriate food diet.</li>
<li>Avoid Valsalva maneuver, straining.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-15697957148387054472014-12-02T16:39:00.002+07:002014-12-02T16:39:27.097+07:00Hepatitis - Assessment, 3 Nursing Diagnosis and Interventions<br />
<b>Nursing Care Plan for Hepatitis</b><br />
<br />
<b>Assessment for Hepatitis</b><br />
<br />
1. Main Complaint: Usually the patient with hepatitis come with a complaint such as:<br />
<ul>
<li>Suddenly no appetite.</li>
<li>Fever (more often in HVA).</li>
<li>Rheumatic aches and headaches at HVB.</li>
<li>Malaise.</li>
</ul>
2. Health Assessment<br />
<ul>
<li>Activity, include: weakness, fatigue, malaise.</li>
<li>Circulation, include: bradycardia (severe hyperbilirubinemia), scleral jaundice of the skin, mucous membranes.</li>
<li>Elimination, including: dark urine, diarrhea, stool looks like the color of clay.</li>
<li>Food and fluid, include: anorexia, weight loss, nausea and vomiting, increased edema, ascites.</li>
<li>Neuro Sensory include: sensitive to stimuli, tend to sleep, lethargy, asterixis.</li>
<li>Pain / Leisure, include: abdominal cramps, right upper quadrant tenderness, headache, arthralgia, myalgia, itching (pruritus).</li>
<li>Sexuality, include: lifestyle / behavior increases the risk of exposure.</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis for Hepatitis :</b><br />
<ol>
<li>Imbalanced Nutrition Less than Body Requirements related to input failure to meet the metabolic needs: anorexia, nausea / vomiting and impaired absorption and digestion of food metabolism: decreased peristalsis (visceral reflex), bile restrained.</li>
<li>Pain (acute / chronic) related to swelling of the liver is inflamed liver and portal vein dam.</li>
<li>Ineffective breathing pattern related to intra-abdominal fluid collection, ascites decline in lung expansion and accumulation of secretions.</li>
</ol>
<br />
<br />
<b>Nursing Interventions for Hepatitis</b><br />
<br />
1. Imbalanced Nutrition Less than Body Requirements <br />
Expected outcomes:<br />
<ul>
<li>The patient will show behavioral changes in lifestyle to improve / maintain appropriate weight.</li>
<li>The patient will show weight gain goals with laboratory values and free signs of malnutrition.</li>
</ul>
<br />
Intervention:<br />
<ul>
<li>Assess dietary intake / calories. Give eat a little in frequency often and offer the greatest breakfast.</li>
<li>Provide oral care before meals.</li>
<li>Encourage eating in an upright sitting position.</li>
<li>Encourage inclusion of orange juice, beverage carbonate and heavy sweets all day.</li>
<li>Consult a dietitian, nutrition support team to provide appropriate dietary needs of patients, with the input of fat and protein as tolerated.</li>
<li>Assess the level of blood glucose.</li>
<li>Medical collaboration.</li>
</ul>
<br />
2. Pain (acute / chronic) <br />
Expected outcomes:<br />
<ul>
<li>Showed signs of physical pain and pain behavior in (not winced in pain, crying intensity and location)</li>
</ul>
<br />
Intervention:<br />
<ul>
<li>Collaboration with the individual to determine which method can be used for pain intensity.</li>
<li>Show on the client acceptance of the client's response to pain.</li>
<li>Acknowledge their pain.</li>
<li>Listen attentively to the client expression of pain.</li>
<li>Provide accurate information and explain the cause of the pain, how long the pain will end, if known.</li>
<li>Discuss with your doctor the use of analgesics that do not contain hepatotoxic effects.</li>
</ul>
<br />
3. Ineffective breathing pattern<br />
Expected outcomes:<br />
<ul>
<li>Adequate breathing pattern.</li>
</ul>
Intervention:<br />
<ul>
<li>Assess frequency, depth and respiratory effort.</li>
<li>Auscultation of breath sounds extra.</li>
<li>Give semi-Fowler's position.</li>
<li>Give a deep breath and coughing exercises effective.</li>
<li>Give oxygen as needed.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-60433306202905526792014-11-30T18:03:00.000+07:002014-11-30T18:03:13.510+07:00Nursing Management for Anaphylactic Shock<b>Anaphylactic Shock</b><br />
<br />
Anaphylactic reaction is a clinical syndrome due to an immunological reaction (allergic reaction) which are systemic, fast and furious that can cause respiratory, circulatory, digestive and skin. If the reaction is severe enough to cause shock known as anaphylactic shock which can be fatal. Skin test is one way to avoid this occurrence is not reliable, because it turns out with a negative skin test does not guarantee 100% for no anaphylactic reactions to the full dose. In addition, the skin test alone can cause anaphylactic shock in people with very sensitive. By him it was an attempt to avoid the onset of anaphylactic shock is almost closed for the medical profession who are always dealing with injections. The only way that can help us from this calamity not avoid injecting, because it is a powerful weapon for us, but how we give aid in lege-artist when the incident had happened to us. It required knowledge and skills in the management of anaphylactic shock. This paper will provide simple instructions on efforts to be done in managing anaphylactic shock.<br />
<br />
If complications occur anaphylactic shock after conceded allergens, either orally or parenterally, the first act of the most important is to identify and stop contact with allergens that are suspected to cause anaphylactic reactions. Immediately lay the patient on a hard base. Feet higher lift of the head to increase blood flow through the vein, in an effort to improve cardiac output and raise blood pressure.<br />
<br />
The next action is the assessment of airway, breathing, and circulation of cardiac pulmonary resuscitation phases to provide basic life support needs.<br />
Airway, airway assessment. Airway must be kept free so that there is no obstruction at all. For patients who are not aware, the position of the head and neck is set so that the tongue does not fall backwards over the airways, ie by doing the triple airway maneuver that is an extension of the head, pulling the mandible forward, and open mouth. Patients with total airway obstruction, should be helped by more active, through endotracheal intubation, cricothyrotomy, or tracheotomy. Breathing support, immediately give artificial breathing assistance if there are no signs of spontaneous breathing, either through mouth to mouth or mouth to nose. In anaphylactic shock with laryngeal edema, can result in airway obstruction total or partial. Patients who experienced a partial airway obstruction, in addition to being helped with medication, should also be given help breathing and oxygen 5-10 liters / min. Circulation support, ie when no palpable pulse in large arteries (a. Carotid or a. Femoral), apply external cardiac compression.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-31672323289993408322014-11-10T23:16:00.003+07:002014-11-10T23:16:37.056+07:00Diabetic Retinopathy Risk Factors, Symptoms and Treatment <br />
<b>Diabetic retinopathy is retinopathy</b> (damage to the retina) caused by complications of diabetes, which can eventually lead to blindness. <br />
<br />
Diabetic retinopathy is a condition occurring in persons with diabetes, which causes progressive damage to the retina, the light sensitive lining at the back of the eye. It is a serious sight-threatening complication of diabetes.<br />
<br />
<b>Risk factors for diabetic retinopathy</b>, include:<br />
<ul>
<li>Diabetes—people with Type 1 or Type 2 diabetes are at risk for the development of diabetic retinopathy. The longer a person has diabetes, the more likely they are to develop diabetic retinopathy, particularly if the diabetes is poorly controlled.</li>
<li>Race—Hispanic and African Americans are at greater risk for developing diabetic retinopathy.</li>
<li>Medical conditions—persons with other medical conditions such as high blood pressure and high cholesterol are at greater risk.</li>
<li>Pregnancy—pregnant women face a higher risk for developing diabetes and diabetic retinopathy. If gestational diabetes develops, the patient is at much higher risk of developing diabetes as they age.</li>
</ul>
<br />
<br />
<b>Symptoms of diabetic retinopathy</b><br />
<br />
During the initial stages, retinopathy does not cause any noticeable symptoms. You may not realise that your retina is damaged until the later stages, when your vision becomes affected.<br />
<br />
Possible symptoms of late-stage retinopathy include:<br />
<ul>
<li>shapes floating in your field of vision (floaters) </li>
<li>blurred vision </li>
<li>sudden blindness </li>
</ul>
<br />
<b>Treatment of diabetic retinopathy </b><br />
<br />
Treatment of diabetic retinopathy varies depending on the extent of the disease. It may require laser surgery to seal leaking blood vessels or to discourage new leaky blood vessels from forming. Injections of medications into the eye may be needed to decrease inflammation or stop the formation of new blood vessels. In more advanced cases, a surgical procedure to remove and replace the gel-like fluid in the back of the eye, called the vitreous, may be needed. A retinal detachment, defined as a separation of the light-receiving lining in the back of the eye, resulting from diabetic retinopathy, may also require surgical repair.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-24414300303501056052014-11-04T11:01:00.002+07:002014-11-04T11:01:44.767+07:00NCP - Nursing Assessment for Dengue Hemorrhagic Fever<br />
<b>Nursing Care Plan for Dengue Hemorrhagic Fever</b><br />
<br />
Assessment is the first step and the basis for a nurse to perform a systematic approach to collecting and analyzing the data, so as to know the needs of the client. Accurate data collection and systematic will help determine the health status and patterns of defense clients and facilitate the formulation of nursing diagnoses. (Doenges : 2000).<br />
<br />
Stage assessment is as follows :<br />
a. Data collection, which collects information about the strengths and weaknesses of the client by interview, observation, and physical examination by family, significant others, community, and medical records.<br />
<br />
b. The identity of the client and the family , consisting of :<br />
Client name, age, date of birth, gender, religion.<br />
Father's name, age, religion, occupation, education, address.<br />
Mother's name, age, religion, occupation, education, address.<br />
Date of children admitted to hospital, medical diagnosis, and all sources of information obtained.<br />
<br />
c. The main complaint, which is the reason most prominent in patients with DHF to come to the hospital.<br />
<br />
d. Medical history<br />
1) History of present illness<br />
This incidence of sudden heat complaints are accompanied by chills composmentis consciousness. The decrease of heat occurs between days 3 and 7 and the situation of children getting weaker. Sometimes accompanied by complaints of cough and cold, pain swallowing, nausea, diarrhea / constipation, headache, muscle pain, and the presence of bleeding manifestations in the skin.<br />
2) History of the disease ever suffered.<br />
What diseases ever suffered by the client, what ever suffered repeated attacks of DHF.<br />
3) Physical examination , consisting of :<br />
Inspection is a thorough observation of the client's health status (inspection of lesions on the skin). <br />
Percussion is a physical examination, to determine whether or not a normal organs. Palpation is a type of physical examination by palpating the client.<br />
Auscultation is by listening using a stethoscope (auscultation of the abdominal wall determines the bowel).<br />
<br />
e . Immunization history<br />
If the child has a good immunity, it is likely to be the onset of complications can be avoided.<br />
<br />
f. History of nutrition<br />
Nutritional status of children suffering from DHF can vary. All children with good and bad nutritional status may be at risk, if there is a predisposing factor. Children with DHF often experience nausea, vomiting, and decreased appetite. If this condition persists and is not accompanied by adequate nutrition, children can lose weight so their nutritional status becomes less.<br />
<br />
g . Patterns<br />
1) Nutrition and metabolism : frequency, type, abstinence, decreased appetite.<br />
2) Elimination (bowel movements). Sometimes children have diarrhea / constipation. While the DHF grade III -IV could happen melena.<br />
3) Elimination : urine is necessary to study whether frequent urination, a little / lot, pain / no. In DHF grade IV frequent hematuria.<br />
4) Sleep and rest. Children often experience lack of sleep due to pain / sore muscles and joints so that the quantity and quality of sleep and rest less.<br />
5) Cleanliness. Family efforts to maintain personal hygiene and the environment tend to be less, especially to clean mosquito breeding places.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-68461748347505969972014-11-03T10:36:00.001+07:002014-11-03T10:36:11.675+07:00NCP Pain (Acute / Chronic) related to Systemic Lupus ErythematosusSystemic lupus erythematosus is a systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage. It is both a type II and a type III hypersensitivity reaction in which bound antibody-antigen pairs (immune complexes) precipitate and cause a further immune response.<br />
<br />
SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidneys, and nervous system. The course of the disease is unpredictable, with periods of illness (called flares) alternating with remissions. The disease occurs nine times more often in women than in men, especially in women in child-bearing years ages 15 to 35, and is also more common in those of non-European descent.<br />
<br />
SLE is one of several diseases known as "the great imitators" because it often mimics or is mistaken for other illnesses. SLE is a classical item in differential diagnosis, because SLE symptoms vary widely and come and go unpredictably. Diagnosis can thus be elusive, with some people suffering unexplained symptoms of untreated SLE for years.<br />
<br />
Common initial and chronic complaints include fever, malaise, joint pains, myalgias, fatigue, and temporary loss of cognitive abilities. Because they are so often seen with other diseases, these signs and symptoms are not part of the diagnostic criteria for SLE. When occurring in conjunction with other signs and symptoms (see below), however, they are considered suggestive.<br />
<br />
<br />
Nursing Diagnosis : Pain (Acute / Chronic) related to inflammation and tissue damage.<br />
<br />
Goal:<br />
Improvement in comfort level<br />
<br />
Interventions :<br />
<ol>
<li>Implement actions to provide comfort (warm compresses, massage, change of position, rest, foam mattress, pillow support, splint, relaxation techniques, activities that divert attention).</li>
<li>Give anti-inflammatory preparations, analgesics as recommended.</li>
<li>Customize your treatment schedule to meet the needs of patients on pain management.</li>
<li>Encourage the patient to express his feelings about the nature of chronic pain and illness.</li>
<li>Describe the pathophysiology of pain and help patients to realize that pain is often brought to methods of therapy that has not been proven beneficial.</li>
<li>Assist in identifying the painful life of a person who brings the patient to use a method that has not proven beneficial therapies.</li>
<li>Perform an assessment of subjective changes in pain.</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-84282011843136447472014-10-31T22:45:00.002+07:002014-10-31T22:45:45.799+07:00Benign Prostatic Hyperplasia - Postoperative Care Plan<br />
<b>Nursing Diagnosis and Nursing Intervention for BPH</b><br />
<br />
1. Risk for infection related to invasive procedures: a tool for surgery, the catheter.<br />
<br />
Goal : not show signs of infection.<br />
<br />
Outcome :<br />
<ul>
<li>Clients do not have an infection.</li>
<li>Able to achieve healing time.</li>
<li>Vital signs within normal limits and no signs of shock.</li>
</ul>
<br />
Interventions :<br />
Maintain a sterile catheter system, provide treatment with a sterile catheter.<br />
R / Prevent the entry of bacteria and infection<br />
Encourage adequate fluid intake (2500 - 3000) so as to reduce the potential infection.<br />
R / Increase urine output so that the reduced risk of UTI and preserve renal function.<br />
Maintain a urinal bag under.<br />
R / Avoidance reflexes behind the urine which can enter the bacteria to the bladder.<br />
Observation of vital signs, report signs of shock and fever.<br />
R / Prevent before the shock.<br />
Observation of urine: color, amount, odor.<br />
R / Identify an infection.<br />
Collaboration with physicians to prescribe antibiotics.<br />
R / To prevent infection and help the healing process.<br />
<br />
<br />
2. Risk for bleeding related to surgery<br />
<br />
Goal : no bleeding.<br />
<br />
Outcome :<br />
<ul>
<li>Clients do not show signs of bleeding.</li>
<li>Vital signs within normal limits.</li>
<li>Urine smoothly through the catheter.</li>
</ul>
<br />
Interventions :<br />
Explain to the client about the cause of bleeding after surgery and signs of bleeding.<br />
R / Reduce client anxiety and find signs of bleeding<br />
Irrigation flow catheter if the catheter tract detected blob preformance<br />
R / Clots can block the catheter, causing stretching and bleeding bladder<br />
Provide a diet high in fiber and gave medicine to facilitate defecation.<br />
R / With increased pressure on prostatik fossa which will precipitate bleeding.<br />
Preventing the use of rectal thermometers, rectal examination, for at least one week.<br />
R / It can cause bleeding prostate.<br />
Monitor the catheter traction: traction time record in pairs and when traction is removed.<br />
R / Traction cause the development of balloon catheter into the fossa prostatik, reduce bleeding. Generally removed 3-6 hours after surgery.<br />
Observation: Vital signs every 4 hours, input and output and urine color<br />
R / early detection of complications, with appropriate intervention to prevent permanent tissue damage.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-71950743935564231962014-10-31T01:13:00.002+07:002014-10-31T01:13:45.059+07:00Decreased Cardiac Output - Angina Pectoris Care Plan<br />
<b>Nursing Care Plan for Angina Pectoris - Nursing Diagnosis : Decreased Cardiac Output</b><br />
<br />
Angina pectoris is chest pain often due to ischemia of the heart muscle, due in general to obstruction or spasm of the coronary arteries. The main cause of angina pectoris is improper contractivity of the heart muscle and coronary artery disease, due to atherosclerosis of the arteries feeding the heart. <br />
<br />
Angina pectoris can be quite painful, but many patients with angina complain of chest discomfort rather than actual pain: the discomfort is usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. Apart from chest discomfort, anginal pains may also be experienced in the epigastrium (upper central abdomen), back, neck area, jaw, or shoulders. This is explained by the concept of referred pain, and is due to the fact that the spinal level that receives visceral sensation from the heart simultaneously receives cutaneous sensation from parts of the skin specified by that spinal nerve's dermatome, without an ability to discriminate the two. Typical locations for referred pain are arms (often inner left arm), shoulders, and neck into the jaw. Angina is typically precipitated by exertion or emotional stress. It is exacerbated by having a full stomach and by cold temperatures. Pain may be accompanied by breathlessness, sweating, and nausea in some cases. In this case, the pulse rate and the blood pressure increases. Chest pain lasting only a few seconds is normally not angina (such as precordial catch syndrome).<br />
<br />
<b>Nursing Diagnosis</b><br />
<b><br />
</b> <a href="http://nandacareplan.blogspot.com/2013/12/decreased-cardiac-output-tetralogy-of.html" target="_blank"><b>Decreased Cardiac Output</b></a><br />
<br />
Related to :<br />
<ul>
<li>Inotropic changes, such as transient or prolonged myocardial ischemia and effects of medications;</li>
<li>alterations in rate, rhythm, and electrical conduction.</li>
</ul>
Outcomes<br />
<ul>
<li>Cardiac Pump Effectiveness</li>
<li>Demonstrate increased activity tolerance.</li>
<li>Report or display decreased episodes of dyspnea, angina, and dysrhythmias.</li>
<li>Participate in behaviors and activities that reduce the workload of the heart.</li>
</ul>
<br />
<b>Nursing Intervention for Angina Pectoris</b><br />
<br />
1. Monitor vital signs, eg heart rate, blood pressure.<br />
Rationale: Tachycardia can occur because of pain, anxiety, hypoxemia, and decreased cardiac output. Changes also occur in blood pressure (hypertension or hypotension) due to cardiovascular response.<br />
<br />
2. Record the color and the presence / quality of the pulse.<br />
Rationale: decreased peripheral circulation when cardiac output falls, making skin color pale or gray (depending on the level of hypoxia) and decreased strength of peripheral pulses.<br />
<br />
3. Maintain bed rest in a comfortable position during the acute episode.<br />
Rationale: Lowering the oxygen consumption / demand, lowering employment and risk of myocardial decompensation.<br />
<br />
4. Provide supplemental oxygen as needed<br />
Rationale: Increase the supply of oxygen to the need to improve myocardial contractility, decrease ischemia, and lactic acid levels.<br />
<br />
<br />
Source : <a href="http://nursingdiagnosis-nursinginterventions.blogspot.com/2011/07/nursing-diagnosis-and-nursing_8092.html" target="_blank">http://nursingdiagnosis-nursinginterventions.blogspot.com/2011/07/nursing-diagnosis-and-nursing_8092.html</a>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-82263171740284066392014-10-31T01:05:00.000+07:002014-10-31T01:06:51.765+07:00Risk for Injury and Disturbed Thought Processes - NCP for Alzheimer's Disease<br />
<b>Nursing Care Plan for Alzheimer's Disease</b><br />
<br />
Alzheimer's disease is the most common type of dementia. <br />
<br />
The exact cause of Alzheimer's disease is unknown, although a number of things are thought to increase your risk of developing the condition. These include:<br />
<ul>
<li>increasing age</li>
<li>a family history of the condition</li>
<li>previous severe head injuries</li>
<li>lifestyle factors and conditions associated with cardiovascular disease</li>
</ul>
The first sign of Alzheimer's disease is usually minor memory problems. For example, this could be forgetting about recent conversations or events, and forgetting the names of places and objects.<br />
<br />
As the condition develops, memory problems become more severe and further symptoms can develop, such as:<br />
<ul>
<li>confusion and disorientation</li>
<li>personality changes, such as becoming aggressive, demanding and suspicious of others</li>
<li>hallucinations (seeing things that are not there) and delusions (believing things that are untrue)</li>
<li>problems with language and speech</li>
<li>problems moving around without assistance</li>
</ul>
<br />
<b>Nursing Diagnosis and Interventions for Alzheimer's Disease</b><br />
<br />
<b>Nursing Diagnosis for Alzheimer's Disease : <a href="http://nandacareplan.blogspot.com/2014/02/risk-for-injury-related-to-dementia.html" target="_blank">Risk for Injury</a> </b><br />
<br />
related to:<br />
<ul>
<li>Unable to recognize / identify hazards in the environment.</li>
<li>Disorientation, confusion, impaired decision making.</li>
<li>Weakness, the muscles are not coordinated, the presence of seizure activity.</li>
</ul>
<br />
<br />
<b>Nursing Intervention for Alzheimer's Disease</b><br />
<ul>
<li>Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in visual perception.</li>
<li>Help the people closest to identify the risk of hazards that may arise.</li>
<li>Eliminate / minimize sources of hazards in the environment</li>
<li>Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.</li>
</ul>
<br />
Rational:<br />
<ul>
<li>Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.</li>
<li>An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.</li>
<li>Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.</li>
</ul>
<br />
<br />
<br />
<b>Nursing Diagnosis for Alzheimer's Disease : <a href="http://nandacareplan.blogspot.com/2014/02/altered-thought-processes-nursing-care.html" target="_blank">Disturbed Thought Processes</a></b><br />
related to :<br />
<ul>
<li>Irreversible neuro degeneration</li>
<li>Memory Loss</li>
<li>Psychological Conflict</li>
<li>Deprivation lie</li>
</ul>
<br />
<br />
<b>Nursing Intervention for Alzheimer's Disease</b><br />
<ul>
<li>Assess the level of cognitive disorders such as changes orientasiterhadap people, places and times, range, attention, thinking skills.</li>
<li>Talk with the people closest to the usual behavior change / length of the existing problems.</li>
<li>Maintain a nice quiet neighborhood.</li>
<li>Face-to-face when talking with patients.</li>
<li>Call patient by name.</li>
<li>Use a rather low voice and spoke slowly in patients.</li>
</ul>
Rational:<br />
<ul>
<li>Provide the basis for the evaluation / comparison that will come, and influencing the choice of intervention.</li>
<li>Noise, crowds, the crowds are usually the excessive sensory neurons and can increase interference.</li>
<li>Cause concern, especially in people with perceptual disorders.</li>
<li>The name is a form of self-identity and lead to recognition of reality and the individual.</li>
<li>Increasing the possibility of understanding.</li>
</ul>
<br />
Source : <br />
<a href="http://nursingdiagnosis-nursinginterventions.blogspot.com/2011/06/nursing-diagnosis-and-nursing_16.html" target="_blank">http://nursingdiagnosis-nursinginterventions.blogspot.com/2011/06/nursing-diagnosis-and-nursing_16.html</a>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-74285566468539875362014-10-30T23:25:00.000+07:002014-10-30T23:25:05.760+07:00Acute Pain and Ineffective Breathing Pattern - NCP for Scoliosis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0Rbtmf0bniwtHtM4Eo7n4fvPEyNZ4GERHPFrDEtkU5OjMFSvmxER23vX4TS8osQ81uAJGyk8hh0r7gursvwpAXbg1TMONNCm5NB6NChG5tsUAfnL6C8nVaB0uCecJu3ZAL7ik-EGIKxI/s1600/Nursing+Care+Plan+for+Scoliosis.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Care Plan for Scoliosis" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0Rbtmf0bniwtHtM4Eo7n4fvPEyNZ4GERHPFrDEtkU5OjMFSvmxER23vX4TS8osQ81uAJGyk8hh0r7gursvwpAXbg1TMONNCm5NB6NChG5tsUAfnL6C8nVaB0uCecJu3ZAL7ik-EGIKxI/s320/Nursing+Care+Plan+for+Scoliosis.png" /></a></div>
<b>Nursing Care Plan for Scoliosis</b><br />
<br />
Scoliosis is a medical condition in which a person's spine is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis can resemble an "S" or a "?", rather than a straight line.<br />
<br />
People having reached skeletal maturity are less likely to have a worsening case. Some severe cases of scoliosis can lead to diminishing lung capacity, putting pressure on the heart, and restricting physical activities.<br />
<br />
The signs of scoliosis can include:<br />
<ul>
<li>Uneven musculature on one side of the spine</li>
<li>A rib prominence or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis</li>
<li>Uneven hips, arms or leg lengths</li>
<li>Slow nerve action (in some cases)</li>
</ul>
<br />
Scoliosis is typically classified as either congenital (caused by vertebral anomalies present at birth), idiopathic (cause unknown, sub-classified as infantile, juvenile, adolescent, or adult, according to when onset occurred), or secondary to a primary condition.<br />
<br />
<br />
<b>Nursing Diagnosis and Interventions</b><br />
<br />
1. Acute Pain related to the position of lateral body tilt.<br />
<br />
Goal : Pain is reduced or lost<br />
<br />
Interventions :<br />
<ul>
<li>Assess the type, intensity and location of pain. Rational: Influencing choice / control the effectiveness of Interventions can influence the level of anxiety to pain.</li>
<li>Teach relaxation and distraction techniques. Rational: To divert attention, thereby reducing pain.</li>
<li>Teach and Encourage use of the brace. Rational: To Reduced pain during activity</li>
<li>Collaboration in the provision of analgesia. Rational: To relieve pain.</li>
</ul>
<br />
<br />
2. Ineffective Breathing Pattern related to the suppression of pain.<br />
<br />
Goal : The pattern of breathing Effectively.<br />
<br />
Interventions :<br />
<ul>
<li>Assess respiratory status every 4 hours.</li>
<li>Help and teach the patient to breath in any one hour. Rationale: Increasing the maximum ventilation and oxygenation.</li>
<li>Adjust bed semi-Fowler position to improv lung expansion. Rational: Sitting height allowing Easier breathing and lung expansion.</li>
<li>Monitor vital signs every 1 hour. Rational: general indicators, circulation status and adequacy of perfusion.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-10455239956230490842014-10-28T22:58:00.002+07:002014-10-28T22:59:13.740+07:00Nursing Care Plan for ITP Idiopathic Thrombocytopenic Purpura<b>Idiopathic Thrombocytopenic Purpura</b><br />
<br />
<b>Definition</b><br />
<ul>
<li>Thrombocytopenia is a deficiency of platelets, which are part of the blood clotting.</li>
<li>ITP is a bleeding state in the form of petechiae or ecchymosis in the skin / mucous membranes and other tissues with a decrease in platelet count due to an unknown cause. (ITP is most common in children at age 2-8 years), is more common in women.</li>
<li>ITP or idiopathic thrombocytopenic purpura. Idiopathic means the cause is unknown. Thrombocytopenic means the blood does not have enough blood platelets (thrombocytes). Purpura means someone has bruises that many (redundant).</li>
</ul>
<br />
Etiology<br />
<ul>
<li>Hypersplenism.</li>
<li>Virus infection.</li>
<li>intoxication ; food / medicine.</li>
<li>Chemicals.</li>
<li>Effects of fission (radiation, heat).</li>
<li>Lack of maturation factors (malnutrition).</li>
<li>Disseminated intra- vascular coagulation CKID.</li>
<li>Autoimmune.</li>
</ul>
<br />
Types of ITP :<br />
1. Acute.<br />
<ul>
<li>Originally found thrombocytopenia in children.</li>
<li>Platelet counts returned to normal within 6 months of diagnosis (spontaneous remission).</li>
<li>There were no subsequent recurrence.</li>
</ul>
<br />
2. Chronic<br />
<ul>
<li>Thrombocytopenia lasting more than 6 months after diagnosis.</li>
<li>Insidious onset.</li>
<li>Platelet counts remained below normal for the disease.</li>
<li>This form is mainly in adults.</li>
</ul>
<br />
3. Recurrent<br />
<ul>
<li>First thrombocytopenia.</li>
<li>Recurrent relapses.</li>
<li>Platelet counts returned to normal between the time of relapse.</li>
</ul>
<br />
<br />
Signs and Symptoms<br />
<ul>
<li>Prodormal period, fatigue, fever and abdominal pain.</li>
<li>Spontaneously arising petechiae and ecchymoses on the skin.</li>
<li>Epistaxis.</li>
<li>Oral mucosal bleeding.</li>
<li>Menorrhagia.</li>
<li>Bruising.</li>
</ul>
<br />
Examination Support<br />
<ul>
<li>In laboratory tests found Platelets less than 10,000 / ml . Sometimes it can happen mild anemia caused by bleeding.</li>
<li>Morphological examination of normal blood cells , except for a slightly enlarged platelets (megakaryocytes). Megakaryocytes are platelets produced in response to platelet destruction.</li>
<li>Examination of normal leukocytes.</li>
<li>In bone marrow examination were normal with normal or increased number of megakaryocytes</li>
<li>Bleeding elongated period.</li>
</ul>
<br />
<br />
Nursing Assessment<br />
<br />
1. Asymptomatic until the platelet count dropped below 20,000.<br />
2. Signs of bleeding.<br />
Petechiae occur spontaneously.<br />
Ecchymosis occurs in areas of minor trauma.<br />
Bleeding from the mucosa of the gums, nose, respiratory tract.<br />
Menoragie.<br />
Haematuria.<br />
Gastrointestinal Bleeding.<br />
4. Activity / rest.<br />
Symptoms :<br />
fatigue, weakness, general malaise.<br />
Low tolerance for exercise.<br />
Sign<br />
tachycardia / tachypnea, dyspnea on activity / rest.<br />
muscle weakness and decreased strength.<br />
5. Circulation.<br />
Symptoms :<br />
history of chronic blood loss, such as chronic GI bleeding, heavy menstruation.<br />
palpitations (tachycardia compensation).<br />
Signs :<br />
BP: systolic to diastolic steady improvement.<br />
6. Integrity ego.<br />
Symptoms : religious / cultural influence treatment options : refusal of blood transfusions.<br />
Signs : Depression.<br />
7. Elimination.<br />
Symptoms : Haematemesis, stool with fresh blood, melena, diarrhea, constipation.<br />
Signs : abdominal distension.<br />
8. Food / liquids.<br />
Symptoms :<br />
Reduction in dietary input.<br />
Nausea and vomiting.<br />
Signs : poor skin turgor, disheveled, lost elasticity.<br />
9. Neuro - sensory.<br />
Symptoms :<br />
Headache, dizziness.<br />
Weakness, decreased vision.<br />
Signs :<br />
Epistaxis.<br />
Mental : unable to respond (slow and shallow).<br />
10. Pain / comfort .<br />
Symptoms : Abdominal pain, headache.<br />
Signs : tachypnea, dyspnea.<br />
11. Breathing.<br />
Symptoms : shortness of breath at rest and activity.<br />
Signs : tachypnea, dyspnea.<br />
12. Security<br />
Symptoms : poor wound healing frequent infections, blood transfusions before.<br />
Signs : petechiae, ecchymosis.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-53742546485369580112014-10-25T22:46:00.000+07:002014-10-25T22:46:13.693+07:004 Nursing Diagnosis for MigraineMigraine is a chronic disorder characterized by the occurrence of mild to severe headaches that are often associated with symptoms of autonomic nervous system.<br />
<br />
The sign of headache unilateral (only on the upper half of the head), throbbing, and lasts for 2 to 72 hours. The symptoms are also accompanied, among others, nausea, vomiting, photophobia (more sensitive to light), phonophobia (increasingly sensitive to noise) and more intense pain when doing physical activity. Around-third of migraine sufferers experience: a kind of visual disturbance, sensory, speech, or motion / motor which is a sign that the headache will soon appear.<br />
<br />
Migraine is believed to occur as a result of a combination of various genetic and environmental factors. Approximately two-thirds of cases occur in people who are married. Hormone levels rise and fall can also affect: migraine slightly more common in young men than in young women before puberty, but in adults, approximately two to three times more common in women than men. The tendency of migraine is usually reduced during pregnancy. The exact mechanism of migraine is unknown. However, there is a belief that these diseases are caused by neurovascular disorders. The main theory underlying is an association with increased keterangsangan cerebral cortex and the control of abnormal cells in the nerve pain of trigeminal nucleus of the brainstem.<br />
<br />
Causes<br />
<br />
The main cause of migraine is unknown however, the disease is believed to be related to a combination of environmental and genetic factors. This disease occurs in people who have a family as much as two-thirds of all cases and is rarely caused by a single gene defect. A number of psychological conditions that have relevance include: depression, anxiety, and bipolar disorder as well as a variety of biological events or triggers. <br />
<br />
Signs and symptoms<br />
<br />
Migraines usually appear along with severe headaches and recurring to make a person can not perform normal activity, which is associated with autonomic symptoms. Approximately 15-30% of patients experiencing migraine with aura and migraine patients who experience migraine with aura also often experience migraine without aura. Levels of pain, duration of the headache, and frequency of attacks varies. Migraine that lasted for more than 72 hours are called migrainosus status. There are four phases that may occur before the appearance of migraine:<br />
<br />
Prodromal, occur several hours or days before the headache attack.<br />
Aura, which appeared just before the headache attacks.<br />
Phase pain, also called the headache phase.<br />
Postdromal, effects experienced after a migraine attack ends.<br />
<br />
<br />
<b>Nursing Diagnosis for Migraine</b><br />
<br />
1. Acute pain related to stress and tension, increased intracranial.<br />
characterized by: said pain, pale around the face, restless.<br />
<br />
2. Imbalance nutrition less than body requirements related to inability to input, digest, absorb, because the food factor biology, psychology.<br />
characterized by: nausea, vomiting, weight loss, anorexia.<br />
<br />
3. Disturbed Sleep Pattern related to headache.<br />
characterized by: insomnia, pale, limp.<br />
<br />
4. Knowledge Deficit related to lack of exposure information.<br />
characterized by: the improper behavior and excessive.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-11267734669564958042014-10-11T00:57:00.003+07:002014-10-11T00:57:14.375+07:00Sleep Disorders and Care PlanRest and sleep is a basic need that is needed by everyone. To be able to function normally, then everyone needs adequate rest and sleep. At rest and sleep, the body's recovery process to restore the stamina to be in optimal condition.<br />
<br />
Each individual has a need for rest and sleep are different. Patterns of rest and sleep well and regularly gives good effects on health. But in a state hospital, a person's sleep patterns are usually disrupted, so the nurse should seek to help meet client needs rest and sleep. The need for rest and sleep in a diseased individual is needed to accelerate the healing process. Therefore, the nurse must have good competencies related to needs rest and sleep.<br />
<br />
<br />
<b>1. Insomnia</b><br />
<br />
Insomnia is the inability to get enough sleep both in quality and quantity. Someone who wakes up from sleep, but have not had enough sleep can be called experience insomnia.<br />
<br />
There are three types of insomnia include :<br />
<ul>
<li>Initial insomnia : inability of a person to be able to start sleeping.</li>
<li>Intermittent Insomnia : inability to maintain the state of sleep or frequent waking sleep.</li>
<li>Terminal insomnia : waking up early and can not sleep anymore.</li>
</ul>
There are several factors that can cause a person to experience insomnia include pain, anxiety, fear, mental stress, and support the conditions for sleep.<br />
<br />
Nurses can help clients overcome insomnia through health education, creating a comfortable environment, the client relaxation training, and other measures. There are several actions or efforts that can be done to overcome insomnia are:<br />
<ul>
<li>Eating high protein foods before bed, such as cheese or milk.</li>
<li>Try to always go to bed at the same time.</li>
<li>Avoid sleeping in the afternoon or evening time.</li>
<li>Trying to sleep only when feel really sleepy and not at the time of full consciousness.</li>
<li>Avoid activities that generate interest before bed.</li>
<li>Do bodybuilding exercises every day, but not before bed.</li>
<li>Use release techniques and meditation muscles before trying to sleep.</li>
</ul>
<br />
<br />
<b>2. Somnambulism</b><br />
<br />
Somnambulism is a behavioral disorder that is very complex includes the existence of an automatic, and semi-purposeful motor action, such as opening the door, shut the door, sat on the bed, crashing into a chair, walking, and talking. Somnambulism is more common in children than adults . Someone who had somnabulism at risk of injury.<br />
Efforts should be made to anticipate somnabulisme namely by guiding the child. Other efforts that can be done to overcome somnabulism is to create a comfortable and safe environment, and may also include the use of drugs.<br />
<br />
<br />
<b>3. Enuresis</b><br />
<br />
Enuresis is involuntary urination (wetting). Occurs in children and adolescents, the most common among men. The cause is certainly not clear, but there are several factors that can cause such enuresis on bladder disorders, stress, and a rigid toilet training. Efforts should be made to prevent enuresis among other things : avoid stress, avoid drinking a lot before bed, and empty the bladder (urinary first) before bed.<br />
<br />
<b><br /></b>
<b>4. Narcolepsy</b><br />
<br />
Narcolepsy is a condition characterized by an uncontrollable desire to sleep. It can be said also of narcolepsy is sudden attack sleepy so he can fall asleep at any time where the attack sleep (drowsiness) is coming.<br />
The cause of narcolepsy is not exactly clear, but is thought to result from genetic damage to the central nervous system in which REM periods can not be controlled. Narcoleptic attacks can pose a hazard in the event at the time of driving the vehicle, the workers who worked on the tools swirling, or is on the brink.<br />
<br />
<br />
<b>5. Night terrors</b><br />
<br />
Night terrors are a nightmare. Generally occurs in children aged 6 years or more. After a few hours, the child instantly awake and screaming, pale and frightened.<br />
<br />
<br />
<b>6. Snoring</b><br />
<br />
Snoring is caused by a barrier to air flow in the nose and mouth. Swollen tonsils and adenoids may be a factor contributing to snoring. Base of the tongue that clog the airways in the elderly. The muscles in the back of the mouth slack and vibrate when air is passed breathing.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-18366840427725140742014-10-10T23:57:00.000+07:002014-10-10T23:57:07.953+07:00Some Causes of Nausea After Eating<br />
<b>Nausea after eating</b> can be a sign of a disorder (illness) is more serious. Nausea is a condition that refers to feelings of discomfort before the vomiting, but it does not always lead to vomiting. Nausea after eating can be caused due to various circumstances, such as eating certain foods, eating contaminated food and also eat too fast, etc. . This can occur both in children and adults.<br />
<br />
If nausea persists then you should get to the doctor to find the cause and treatment. Nausea is often associated with some other illnesses that either mild or serious.<br />
<br />
<br />
<b>Some Causes of Nausea After Eating</b><br />
<br />
1. Whole foods.<br />
Whole foods can also be the cause, some food is not suitable for some people and cause the digestion of food that is not running well.<br />
<br />
2. Diet.<br />
Consuming food quickly can cause nausea after eating. Heavy and fatty foods also tends to make people eat the bitter nausea. In some people, nausea can also occur due to eating too often.<br />
<br />
3. Food poisoning.<br />
<br />
Nausea can be caused by food poisoning, food allergies or, in such cases, patients may also experience headaches, body aches, fever, diarrhea, abdominal pain or cramping and vomiting. Parents and children are very vulnerable experience.<br />
<br />
4. GERD (gastroesophageal reflux disease).<br />
Gastroesophageal reflux disease (gerd) conditions that can lead to a condition in which excesses the level of stomach acid that causes nausea after eating. Some of these symptoms can be controlled by antacids.<br />
<br />
5. Blockage in the small intestine.<br />
A blockage in the small intestine is the most serious cause of feeling nauseous after eating and usually requires immediate medical attention. Because it can lead to a buildup of toxins in the bloodstream.<br />
<br />
6. Gall Bladder Pain<br />
<br />
People, who suffer from gallbladder disease, especially in the early stages , may experience nausea after eating. Typically, the initial symptoms appear when the person is eating greasy foods or high fat.<br />
<br />
7. Crohn's disease.<br />
In some individuals, Crohn's disease will be prone to nausea after eating, other more common symptoms of inflammatory conditions including chronic diarrhea and abdominal cramps.<br />
<br />
8. Symptoms pregnant.<br />
In the first half of pregnancy, nausea after eating is very common. You could say one of the signs of pregnancy is a feeling of nausea after eating.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-27862221658531785032014-10-10T23:37:00.000+07:002014-10-10T23:37:12.993+07:00Vomiting - Definition, Etiology, Signs and Symptoms<b>Nursing Care Plan for Vomiting</b><br />
<br />
<b>Definition</b><br />
<br />
Vomiting is spending exclusively stomach contents through the mouth with the help of contraction of the abdominal muscles. Need to distinguish between regurgitation, rumination, or gastroesophageal reflux.<br />
<br />
Regurgitation is the expulsion of material from the pharynx, or esophagus, usually characterized by the presence of undigested food or blood.<br />
<br />
Rumination is the compulsively focused attention on the symptoms of one's distress, and on its possible causes and consequences, as opposed to its solutions. Rumination is similar to worry except rumination focuses on bad feelings and experiences from the past, whereas worry is concerned with potential bad events in the future. Both rumination and worry are associated with anxiety and other negative emotional states.<br />
<br />
Gastroesophageal reflux disease (GERD) is a condition in which the stomach contents leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This can irritate the esophagus and cause heartburn and other symptoms.<br />
<br />
<br />
<b>Etiology</b><br />
<ul>
<li>Congenital abnormalities of the gastrointestinal tract, irritation of the stomach, esophageal atresia, atresia / stenosis, Hirschsprung, high intracranial pressure, how to feed or drink is wrong, and others.</li>
<li>In the newborn period more factors such as infections (urinary tract infections, hepatitis, peritonitis, etc.)</li>
<li>Psychological disorders, such as depression or anxiety state , especially in older children.</li>
</ul>
<br />
<br />
<b>Signs and Symptoms</b><br />
There are several disorders that can be identified as a result of vomiting, namely :<br />
<ul>
<li>Vomiting occurred a few hours after the release of mucus, which is sometimes accompanied by a little blood. This may have been due to irritation from a number of materials ingested during the birth process. Vomiting sometimes persist after first feeding.</li>
<li>Vomiting that occurs in the first days of birth, in large quantities, is not projective, not green , and tend to settle usually occurs as a result of small bowel obstruction.</li>
<li>Projectile vomiting occurring greenish and not a sign of stenosis of the pylorus.</li>
<li>Increased intracranial pressure and milk allergy.</li>
<li>Vomiting that occurs in children who appear healthy. Due to incorrect feeding techniques or psychosocial factors.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-53958712477427373352014-10-08T00:28:00.000+07:002014-10-08T00:28:03.725+07:00Oral Cancer, Symptoms, Causes and Risk Factors<br />
<b>Oral cancer</b> is a cancer that is found in all parts of the mouth . Oral cancer can occur on the lips, gums, tongue, mouth wall, and the palate or floor of the mouth.<br />
<br />
Oral cancer is one of several types of cancer group head and neck cancer category. Oral cancer, other cancers of the head and neck often have the same treatment procedure.<br />
<br />
To more clearly about oral cancer, please refer to the following explanation :<br />
<br />
<br />
<b>Symptoms of Oral Cancer</b><br />
<br />
Signs and symptoms of oral cancer include:<br />
<ul>
<li>Ulcers around the mouth that can not be cured.</li>
<li>Lumps or thickening of the skin of the mouth.</li>
<li>White or reddish stains in the mouth.</li>
<li>Tooth loss.</li>
<li>The composition of uneven teeth.</li>
<li>Pain in the tongue.</li>
<li>Pain or stiffness in the jaw.</li>
<li>Painful or difficult to chew.</li>
<li>Painful or difficult to swallow.</li>
<li>Sore throat.</li>
<li>Feeling like something is jammed in the throat.</li>
</ul>
<br />
<b>Causes of Oral Cancer</b><br />
<br />
Oral cancer occurs when cells in the lips or mouth DNA mutated. These mutations make the cells continued to grow and evolve, while others have normal cell cycles of life and death. Accumulation of oral cancer cells can form tumors. Can spread to other areas of the head and neck, and can also spread to other body parts.<br />
<br />
Oral cancer most originated from the thin cells that lines the inside of the lips and mouth (squamous cells). It is unclear what causes these cells to mutate. But doctors have identified factors that increase the risk of mouth cancer.<br />
<br />
<br />
<b>Risk factors of Oral Cancer </b><br />
<br />
Some factors that increase the risk of oral cancer include:<br />
<ul>
<li>Consuming tobacco either by smoking or chewing tobacco.</li>
<li>Consuming alcohol.</li>
<li>Too much sun exposure to the lips.</li>
<li>The sexually transmitted virus called HPV virus.</li>
<li>Cancer never experienced before.</li>
<li>Radiation treatment to the head and neck area.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-6635413754978360012014-10-08T00:08:00.001+07:002014-10-08T00:08:28.524+07:004 Types of Chronic Headache and Causes<br />
What is a chronic headache ? Chronic headache is a headache that is more than usual. The pain that never stops from the consequences caused by this chronic headaches often make sufferers can not stand.<br />
<br />
Chronic headache is a variation of the daily headaches. Defined that the daily headaches must occur 15 days or more than a month, at least three months. And is a major preoccupation of chronic daily headache, that the disease does not result in other conditions. So you need not worry, chronic headache is not an indication of a more severe illness or more dangerous, but only a daily cycle.<br />
<br />
Now, let us identify some of the causes and symptoms of chronic headaches through the following explanation :<br />
<br />
<b>Symptoms of Chronic Headaches</b><br />
<br />
Chronic daily headaches are classified by how long they felt the last time - more than four hours or fewer than four hours. The duration of the last headache you feel may indicate what type of headache you are experiencing.<br />
<ul>
<li>Chronic migraine</li>
<li>Chronic headaches due to blood pressure</li>
<li>New daily persistent headache</li>
<li>Hemicrania continua</li>
</ul>
<br />
<br />
<b>1. Chronic Migraine</b><br />
<br />
These headaches evolve from migraine that comes on suddenly. To be diagnosed, you must have a headache - migraine, headaches due to blood pressure or both - 15 days or more in a month, for three months. In addition, in eight days or more for the last three months, you must have experienced the following symptoms.<br />
<br />
Headache, you should have at least two of the following characteristics :<br />
<ul>
<li>Attacked only on one side of the head.</li>
<li>Cause throbbing pain.</li>
<li>Cause of the pain is to severe.</li>
<li>Being annoyed with regular physical activity.</li>
</ul>
<br />
And the symptoms that led to at least one of the following :<br />
<ul>
<li>Nausea, vomiting or both.</li>
<li>Sensitive to light and sound.</li>
</ul>
<br />
Otherwise, if your headaches respond to treatment triptans or ergot grab anticipation of these symptoms - in eight days or more in a month or more in a month in the last three months - it is also a chronic migraine.<br />
<br />
<br />
<b>2. Chronic headaches caused by tension (tension headaches)</b><br />
<br />
These headaches evolve from tension headaches that come on suddenly. These headaches may occur in the last hours or continuously.<br />
<br />
Chronic tension headaches caused by having at least two of the following characteristics :<br />
<ul>
<li>Pain on both sides of the head.</li>
<li>Cause mild to moderate pain.</li>
<li>Cause pain that feels pressured or tightened but not pulsating.</li>
<li>Not made to feel annoyed with routine physical activity.</li>
</ul>
In addition, it all led to at least one of the following :<br />
<ul>
<li>Sensitive to sound or light.</li>
<li>Mild nausea.</li>
</ul>
<br />
<br />
<b>3. New daily persistent headache</b><br />
<br />
These headaches became constant within a few days of the first time you have a headache.<br />
New daily persistent headache has at least two of the following characteristics :<br />
<ul>
<li>Pain on both sides of the head.</li>
<li>Cause pain that feels like pressure or tightening, but not pulsating.</li>
<li>Not made to feel annoyed with routine physical activity.</li>
</ul>
In addition, it all led to at least one of the following :<br />
<ul>
<li>Sensitive to sound or light.</li>
<li>Mild nausea.</li>
</ul>
<br />
<b>4. Hemicrania continua</b><br />
<br />
Hemicrania continua headache this causes pain on one side of the head that do not switch sides. They also :<br />
<ul>
<li>Daily and continues with the period without a sense of freedom from pain.</li>
<li>Causing pain but being stung when severe.</li>
<li>Responding to prescription pain reliever indomethacin (Indocin).</li>
<li>May sometimes be severe with symptoms such as migraine developed.</li>
</ul>
<br />
In addition, hemicrania continua headache causes most arrived one of the following :<br />
<ul>
<li>Tears or red eyes as a side effect.</li>
<li>Breath nasal or runny nose.</li>
<li>Wilt eyelid or pupillary constriction.</li>
</ul>
<br />
<br />
<b>Causes of Chronic Headaches</b><br />
<br />
The cause of most of the chronic daily headache is not so understandable . The primacy of chronic daily headache can not be identified on a case . Chronic daily headache occurs if :<br />
<ul>
<li>You have a heightened response to signs of pain .</li>
<li>The part of your brain that suppress pain do not work properly .</li>
</ul>
<br />
<br />
The frequency of headache may be caused by another disease or condition is different, including :<br />
<ul>
<li>Swelling or other problems on the blood vessels and the range of the brain, including stroke.</li>
<li>Infections, eg meningitis.</li>
<li>Both intracranial pressure that is too high or too low.</li>
<li>Brain tumors.</li>
<li>Traumatic injury to the brain.</li>
</ul>
Many people who have actually experienced headache frequency effects of too often take medical treatment of pain. If you take the medical treatment of pain - even without a prescription analgesics - more than three days a week, you have increased risk of headache.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-48133224121000936152014-10-02T00:30:00.001+07:002014-10-02T00:30:33.124+07:00Erythroderma - Common Causes, Symptoms and Treatment<b>Erythroderma </b>is an inflammatory skin disease with erythema and scaling that affects nearly the entire cutaneous surface.<br />
<br />
The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. The causes and their frequencies are as follows:<br />
<ul>
<li>Idiopathic - 30%</li>
<li>Drug allergy - 28%</li>
<li>Lymphoma and leukemia - 14%</li>
<li>Atopic dermatitis - 10%</li>
<li>Psoriasis - 8%</li>
<li>Contact dermatitis - 3%</li>
<li>Seborrheic dermatitis - 2%</li>
</ul>
<br />
<b>Symptoms of Erythroderma</b><br />
<ul>
<li>Red skin patches</li>
<li>Skin thickening</li>
<li>Skin peeling</li>
<li>Skin flaking </li>
</ul>
<br />
<b>Treatment</b><br />
<br />
The treatment is dependent on the cause. Topical steroids are the primary category of medications used to treat exfoliative dermatitis (ED). A sedative antihistamine may be a useful adjunct for pruritic patients, since it helps patients to sleep at night, thus limiting nocturnal scratching and excoriations. Antimicrobial agents often are used if an infection is suspected to be precipitating or complicating exfoliative dermatitis. Other drugs specifically indicated for management of underlying etiology of exfoliative dermatitis may be necessary.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-29591728117416413432014-10-02T00:04:00.001+07:002014-10-02T00:04:26.483+07:00Bronchiectasis - Prevention, Treatment, Signs and SymptomsBronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Extra mucus tends to form and pool in the parts of the airways that are widened. Widened airways with extra mucus are prone to infection. Bronchiectasis can develop at any age. It begins most often in childhood, but symptoms may not appear until much later. Bronchiectasis can occur as part of a birth defect or as a result of injury or other diseases, like tuberculosis, pneumonia and influenza. <br />
<br />
<b>Signs and Symptoms</b><br />
<ul>
<li>Dyspnea, pleuritic chest pain, wheezing, fever, weakness, fatigue, and weight loss.</li>
<li>Cough and daily mucopurulent sputum production, often lasting months to years (classic).</li>
<li>Blood-streaked sputum or hemoptysis from airway damage associated with acute infection. Rarely, episodic hemoptysis with little to no sputum production (ie, dry bronchiectasis).</li>
</ul>
<br />
<br />
<b>Prevention</b><br />
<br />
Preventing lung infections and lung damage can help prevent bronchiectasis. You can do this through:<br />
<ul>
<li>Vaccinations for measles and pertussis.</li>
<li>Avoiding toxic fumes, gases, smoke and other substances that can lungs harm.</li>
<li>Properly treating lung infections in children.</li>
<li>Avoiding inhaling small objects and seeking prompt medical care if this occurs.</li>
</ul>
<b><br /></b>
<b>Treatment</b><br />
<br />
Treatment modalities include the following:<br />
<ul>
<li>Antibiotics and chest physiotherapy are the mainstays.</li>
<li>Bronchodilators.</li>
<li>Corticosteroid therapy.</li>
<li>Dietary supplementation.</li>
<li>Oxygen (reserved for hypoxemic patients with severe disease).</li>
<li>Hospitalization for severe exacerbations.</li>
<li>Surgical therapies.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-15398996915268705332014-10-01T23:51:00.003+07:002014-10-01T23:51:52.592+07:00Empyema Treatment, Symptoms and Risk Factors<br />
An empyema is a collection of pus within a naturally existing anatomical cavity. Usually, this term refers to pus inside pleural cavity, or “pleural space.” Because empyema is pus, and pus is caused by an infection, empyema can lead to life-threatening problems such as sepsis (bacteria in the blood) and shock. <br />
<br />
Empyema is usually caused by an infection that spreads from the lung. It leads to a buildup of pus in the pleural space. Lung infections, such as pneumonia, and lung abscess are two of the most common ways that bacteria get into pleural space.<br />
<br />
<b>Risk factors</b> include: Bacterial pneumonia, Chest surgery, Lung abscess, Trauma or injury to the chest.<br />
<br />
<b>Symptoms</b><br />
<br />
<ul>
<li>Shortness of breath</li>
<li>Chest pain, which worsens when you breathe in deeply (pleurisy)</li>
<li>Excessive sweating, especially night sweats</li>
<li>Dry cough</li>
<li>General discomfort, uneasiness, or ill feeling (malaise)</li>
<li>Fever and chills </li>
<li>Weight loss (unintentional)</li>
</ul>
<b>Treatment</b><br />
<br />
The goal of treatment is to cure the infection. This involves removing the collection of pus from the space between the lung and the inner surface of the chest wall. Antibiotics are prescribed to control the infection.<br />
<br />
The health care provider will place a chest tube to completely drain the pus. A surgeon may need to perform a procedure to peel away the lining of the lung (decortication) if the lung does not expand properly. Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-59234274340449073892014-10-01T23:34:00.000+07:002014-10-01T23:52:34.400+07:00Juvenile Nasopharyngeal Angiofibroma (JNA) - Causes, Symptoms and Signs<br />
<b>Juvenile nasopharyngeal angiofibroma (JNA) </b>is a benign tumor of blood vessels in the nasopharynx are histologically benign but clinically malignant because of their destructive nature of bones and extends into the surrounding tissue, for example : to the paranasal sinuses, cheek, eye socket or skull (cranial vault), very easy to bleed and difficult to stop.<br />
<br />
Another term for angiofibroma in the literature include: juvenile angiofibroma, juvenile nasopharyngeal angiofibroma, JNA, nasal cavity tumors, nasal tumors, benign nasal tumors, nasal tumors (tumors of nose), nasopharyngeal tumors, nasopharyngeal angiofibroma.<br />
<br />
Causes <br />
<br />
The exact cause could not be determined.<br />
Theories about the causes of non paraganglionic chromaffin cells of the terminal branches of the maxillary artery also postulated.<br />
The results of comparative genomic hybridization analysis of these tumors revealed deletions also managed to chromosome 17, including the tumor suppressor gene p53 to the same as Her- 2 / neu oncogene.<br />
Various theories commonly cited. One of them is the theory of the tissue of origin, namely the idea that a specific attachment angiofibroma is on the roof of the posterolateral wall of the nasal cavity.<br />
<br />
Nasopharyngeal angiofibroma is a benign but locally invasive and damaging surrounding structures . Can be expanded into :<br />
a. Nasal cavity causing nasal obstruction, epistaxis and nasal discharge.<br />
b. Paranasalis sinuses. Maxillary sinus, sphenoidalis and ethmoidales all be attacked.<br />
c. Pterygomaxillary fossa, infratemporal fossa and cheek.<br />
d. Orbital give symptoms of proptosis and deformity "face - frog". Sign in with inferior orbital fissure and also damage the apex of the orbit. Can also enter the orbit through the superior orbital fissure.<br />
e. Cranial cavity. Cranial fossa media most frequently.<br />
<br />
<br />
Symptoms<br />
1. Nasal obstruction (80-90 %) and mucus (rhinorrhea). This is the most frequent symptom, especially at the beginning of the disease.<br />
2. Frequent nosebleeds (epistaxis) or discharge from the nose is the color of blood (blood - tinged nasal discharge). Nosebleeds, which ranges from 45-60 %, typically one-sided (unilateral) and recurrent.<br />
3. Headache (25 %), especially if the paranasal sinuses blocked.<br />
4. Swelling in the face, it happened about 10-18 %.<br />
5. Conductive hearing loss from eustachian tube obstruction.<br />
6. Diplopia that occur secondary to erosion into the cranial cavity and the pressure to the optic chiasm.<br />
7. Other symptoms may also occur such as : unilateral rhinorrhea, anosmia, decreased sensitivity to smell (hyposmia), recurrent otitis media, eye pain, deafness, ear pain, swelling of the palate, deformity of the cheek, and rhinolalia.<br />
<br />
Signs<br />
1. Appears grayish red mass visible in the posterior nasal pharynx ; nonencapsulated and often lobulated ; sessile or pedunculated. The incidence of nasal mass reaches 80 %.<br />
2. Proptosis, a bulging palate, buccal mucosa an intraoral mass, cheek mass, or swelling of the zygoma (generally accompanied by local extension). The incidence of orbital mass is about 15 %, whereas the incidence for bulging eyes (proptosis) about 10-15 %.<br />
3. Other signs include : serous otitis due to obstruction of the eustachian tube, zygomaticus swelling, and trismus (spasm of the jaw muscles) which is a sign that a tumor has spread to the infratemporal fossa. There is also a decrease in vision due to optic nerve tenting, but this rarely happens.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-27083641995326621242014-10-01T23:02:00.001+07:002014-10-01T23:02:24.134+07:0022 Type of Depression<ol>
<li>Agitated Depression is a major depressive disorder with psychomotor agitation .</li>
<li>Analytical Depressionis a developmental disorder physical, social, and intellectual development a baby that is the result of the absence of the mother.</li>
<li>Congennital Chondrosternal Depression is a deep basin, funnel-shaped anterior portion of the chest wall .</li>
<li>Doble Depressionis a major depresive episode that stands for a time on distractions distimik chronic, usually after the disturbance ends in the patient's back distimik normal conditions.</li>
<li>Endogenous Depression (Major Depression) is a type of depression caused by somatic or biological factors rather than environmental influences (in contrast to a reactive depression). Characterized by : psychomotor retardation, awake at dawn, weight loss drastic, severe guilt, and lack of reactivity environment .</li>
<li>Freezing Point Depressionis the depression of the freezing point of a liquid under the pure solvent, comparison to the concentration of the liquid solvent osmolality.</li>
<li>Leao 's Spreading Depression of Spreading Depression is depression of the normal electrical rhythm recorded from the cerebral cortex spread out from an area or keruskan cortical stimulation.</li>
<li>Major Depressionis a major depression disorder.</li>
<li>Neurotic Depression is the presence of depression is not a psychotic depression is sometimes used broadly to indicate the presence of depresssi without psychotic picture and sometimes more narrowly to indicate only a milder form of the Depression that would be diagnosed as a disorder according dismitik</li>
<li>DSM- IV criteria for depression or as active.</li>
<li>Otic Depression is hearing disorders in the hole.</li>
<li>Pacchionian d' s is a disorder of the foveola granularis.</li>
<li>Postactivation Depression is a reduction in M wave amplitude on the blood of an extra few minutes after stimulation a very hard contraction or after a fixed movement caused by repetitive nerve stimulation.</li>
<li>Precordial Depression is a disorder of the fossa epigastrica def. 1.</li>
<li>Psychotic Depression is a hard feeling, depresive disorders major with psychotic picture, such as hallucinations, delusions, mutism, or stupor . However, the term is generally used in a broader sense tomeliputiseluruh severe depression that cause social disorder or occupational functioning is striking, as a rough equivalent of disturbance depressivemayor or Endogenous Depression.</li>
<li>Pterygoid Depressionis a disruption in the fovea pterigoidalis.</li>
<li>Radial Depression is a disruption in the radial humeral fossa.</li>
<li>Reactive Depression is caused by external circumstances and some other environmental factors , as opposed to Endogenous. Depression with an absence of vegetative disorders are striking.</li>
<li>Retarded Depression is a Major Depression disorder with psychomotor retardation.</li>
<li>Situational Depression Reactive Depression</li>
<li>Supratrochlear Depression is a lightweight hollow on the anterior surface of the femur above the trochlea.Unipolar Depression is not followed by episodes of mania or hypomania as the disorder or major depresive distimik disorders.</li>
<li>Ventricular Depression is a disturbance in the measurement of venous pressure which lies between the ventricular wave and wave atriol .</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-29810793709799313482014-09-28T18:02:00.000+07:002014-09-28T18:02:01.764+07:00Nursing Care Plan for Nausea and Vomiting<b>Nursing Diagnosis and Inteventions for Nausea and Vomiting</b><br />
<br />
<b>Nausea:</b><br />
An uncomfortable feeling in the epigastric region, quite difficult to make a perfect definition. This event is usually accompanied by a decrease in muscle tone of the stomach, contraction, secretion, increased blood flow to the intestinal mucosa, hypersalivation, sweating, increased heart rate and changes in respiratory rithme. Duodenogastric reflux can occur during periods of nausea accompanied by retrograde peristalsis of the duodenum to the gastric antrum toward or antrum contraction occurs simultaneously, and duodenum.<br />
<br />
<b>Vomiting:</b><br />
Defined as the discharge of gastric contents with force like spray by mouth. This can occur as a protective reflex to remove toxic materials from the body or to reduce the pressure in the intestinal organs found underneath obstruction, these events are usually preceded by nausea and retching.<br />
<br />
<b>Nursing Diagnosis and Interventions for Nausea and Vomiting</b><br />
<br />
1. Fluid volume deficit related to excessive fluid output.<br />
Goal: fluid deficit is resolved.<br />
Outcomes: Signs of dehydration are not there, the oral mucosa and lips moist, fluid balance.<br />
<br />
Intervention:<br />
<ul>
<li>Observation of vital signs.</li>
<li>Observed signs of dehydration.</li>
<li>Measure the input and output of fluid (fluid balance).</li>
<li>Provide and encourage families to drink plenty of approximately 2000 - 2500 cc per day.</li>
<li>Collaboration with physicians in the delivery of fluid therapy, electrolyte laboratory examination.</li>
<li>Collaboration with a team of nutrition in low-sodium fluid administration.</li>
</ul>
<br />
2. Imbalanced Nutrition Less than Body Requiremen related to decreased intake.<br />
<br />
Characterized by:<br />
<ul>
<li>Decreased appetite.</li>
<li>Body weight decreased.</li>
<li>Not spent eating.</li>
<li>There nausea vomiting.</li>
</ul>
<br />
Purpose: the client is able to care for themselves.<br />
<br />
Intervention:<br />
1 Assess the extent to which the inadequate nutrition clients.<br />
Rational: analyzing the causes of implementing the intervention.<br />
<br />
2 Estimate / calculate caloric intake, keep the comments about the appetite to a minimum.<br />
Rationale: Identify deficiencies / needs nutrition focuses on the problem of making a negative mood and affect input.<br />
<br />
3 Measure the weight as indicated.<br />
Rational: Keep an eye on the effectiveness of the diet.<br />
<br />
4. Feed little but often.<br />
Rationale: Not giving a sense of boredom and nutrient intake can be increased.<br />
<br />
5. Encourage oral hygiene before meals.<br />
Rationale: The mouth is clean increase appetite.<br />
<br />
6 Offer a drink during meals when tolerant.<br />
Rational: It can reduce nausea and relieve gas.<br />
<br />
7 Assess about patient preferences / dislikes that cause distress.<br />
Rationale: Involving patients in planning, enabling the patient to have a sense of control and encouraged to eat.<br />
<br />
8 Provide a varied diet.<br />
Rationale: The food was varied client can increase appetite.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-30861526330792771152014-09-27T21:08:00.000+07:002014-09-27T21:08:07.046+07:00Nursing Care Plan for Pleural EffusionNursing Care Plan for Pleural Effusion<br />
<br />
Definition<br />
<br />
Pleural effusion is buildup of fluid in the pleural space, the primary disease process are rare but usually occurs secondary to other diseases. Effusion may be a clear fluid, which may be a transudate, exudate, or may be blood or pus (Diane C. Baughman, 2000)<br />
<br />
Pleural effusion is a collection of fluid in the pleural space that lies between the visceral and parietal surfaces, primary disease process is rare but the disease is usually secondary to other diseases. Normally, the pleural space contains a small amount of fluid (5 to 15ml) serves as a lubricant that allows the pleural surface to move without friction (Suzanne C. Smeltzer, 2002).<br />
<br />
<br />
Etiology<br />
<br />
Barriers resorption of fluid from the pleural cavity, because of the dam as in cardiac decompensation, renal disease, mediastinal tumors, Meigs syndrome (ovarian tumor) and superior vena cava syndrome.<br />
The formation of excess fluid, due to inflammation (tuberculosis, pneumonia, viral), bronchiectasis, abscess subphrenic amoeba that penetrate into the pleural cavity, because the tumor where incoming fluid and bleed due to trauma.<br />
<br />
Excess fluid pleural cavity, can be collected in the process neoplastic disease, thromboembolic, cardiovascular, and infection. It is caused by at least one of the four basic mechanisms:<br />
Increased subpleural or lymphatic capillary pressure.<br />
Decrease in colloid osmotic pressure of blood.<br />
The increase in negative intrapleural pressure.<br />
Inflammatory or neoplastic pleural.<br />
<br />
<br />
Signs and Symptoms<br />
The presence of liquid deposits due to friction resulting in feelings of pain, after quite a lot of liquid pain gone. If a lot of fluid, the patient will be short of breath.<br />
The existence of the cause of disease symptoms such as fever, chills, and pleuritic chest pain (pneumonia), high heat (cocci), subfebril (tuberculosis), a lot of sweat, cough, lots of ripples.<br />
Tracheal deviation away from the place of pain can occur if there is a significant accumulation of pleural fluid.<br />
Physical examination in the state of lying and sitting would be different, because the liquid will move. Affected part will be less engaged in breathing, fremitus weakened (touch and vocals), the region was found dull percussion, sits in a state of liquid surface forming a curved line (Ellis-Damoiseau-line).<br />
Found "Garland triangle", which is the area on the upper part of the tympanic percussion dim line-Damoiseau Ellis-line. Triangle Grocco-Rochfusz, namely the deaf because of fluid pushed to the other side of the mediastinum, the area was found to vesicular auscultation weakened with crackles.<br />
At the beginning and end of audible crackles pleural disease.<br />
<br />
<br />
Nursing Diagnosis<br />
<br />
1. Ineffective breathing pattern related to a decrease in lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, inflammatory process.<br />
<br />
2. Pain: Chest related to biological factors (tissue trauma) and physical factors (chest tube installation).<br />
<br />
3. Risk for injury related to the injury, chest drainage system, lack of security education / prevention.<br />
<br />
4. Knowledge Deficit: the conditions and rules of treatment.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-47886934538581111662014-09-26T11:00:00.000+07:002014-09-26T11:00:09.753+07:00Nursing Assessment Example for Dengue Fever<b>Dengue Fever</b><br />
<b>Assessment</b> phase of the nursing process is a dynamic process that is organized which includes three basic activities, namely: First, collect data systematically; second, sort and organize the data collected, the third document in a format that can be opened again. (Tarwoto wartonah, 2006)<br />
Assessment in children with Dengue Fever :<br />
a. The identity of the patient<br />
Name, age, gender, address, education, name of parents, parental education, and parental employment.<br />
b. The main complaint<br />
Reasons / a prominent complaint in patients with dengue hemorrhagic fever came to the hospital is a high body temperature and weak.<br />
c. History of present illness<br />
Obtained the existence of sudden heat complaints are accompanied by chills and fever when composmentis consciousness. The decrease of heat occurs between days 3 and 7 and the child is getting weaker. Sometimes accompanied with complaints of cough and cold, pain swallowing, nausea, vomiting, anorexia, diarrhea or constipation, headache, muscle and joint aches, pain uluh liver, and sore eye movement, as well as the manifestation of bleeding in the skin, gums (grade 3 and 4), melena, or hematemesis.<br />
d. Past medical history<br />
Any disease ever suffered. In Dengue Fever, children can experience a repeat attack of Dengue Fever with other types of viruses.<br />
e. Immunization history<br />
If the child has a good immunity, it is likely to be the onset of complications can be avoided.<br />
f. History of nutrition<br />
Nutritional status of children suffering from Dengue fever can vary. All children with good and poor nutritional status may be at risk, if there is a predisposing factor. Children who suffer from DHF often experience nausea, vomiting, and decreased appetite. If this condition persists, and is not accompanied by adequate nutrition, the child may experience weight loss nutritional status becomes less so.<br />
g. Environmental conditions<br />
Frequently occur in densely populated areas and a less clean environment (such as stagnant water and clothes hangers in the room).<br />
h. Patterns<br />
<ol>
<li>Nutrition and metabolism: frequency, type, abstinence, decreased appetite, decreased appetite.</li>
<li>Elimination or defecate. Sometimes the child has diarrhea or constipation. While Dengue Hemorrhagic Fever in the grade III-IV could happen melena.</li>
<li>Elimination of urine or urinating frequent urination needs to be assessed whether a little or a lot of pain or not. In grade IV Dengue Fever frequent hematuria.</li>
<li>Sleep and rest. Children often experience lack of sleep due to pain / aching muscles and joints so that the quantity and quality of sleep and rest less.</li>
<li>Cleanliness. Family efforts to maintain personal hygiene and the environment tend to be less, especially to clean mosquito breeding places of Aedes aegypti.</li>
<li>The behavior and responses when there is a family illness and efforts to maintain health.</li>
</ol>
i. The physical examination includes inspection, palpation, auscultation, and percussion from head to toe. Based on the level or (grade) Dengue Fever, the physical state of the child is is as follows:<br />
<ol>
<li>Grade I: composmentis awareness, weak general condition, vital signs and pulse weak.</li>
<li>Grade II: composmentis awareness, the general state of weakness, and spontaneous bleeding petechiae, bleeding gums and ear, and the pulse weak, small and irregular.</li>
<li>Grade III: awareness apathetic, somnolent, the general state of weakness, weak pulse, small and irregular, and the tension decreases.</li>
<li>Grade IV: coma consciousness, vital signs: pulse was not palpable, the tension is not measurable, irregular breathing, cold extremities, sweating, and skin looks blue.</li>
</ol>
j. Integumentary System<br />
1) The presence of petechiae on the skin, decreased skin turgor, and appears cold sweat, and moisture.<br />
2) Nail cyanosis / no<br />
3) Head and neck<br />
Head ache, face looks reddish because of fever (flusy), eye pallor, sometimes nose bleeding (epistaxis) in grade II, III, IV. In oral mucosa was found that dry mouth, bleeding gums and painful swallowing. While experiencing hyperemia pharing throat (at Grade II, III, IV).<br />
4) Chest<br />
Symmetrical shape and sometimes felt tight. In the thorax there is any liquid that accumulated in the lung to the right (pleural effusion), rales (+), Ronchi (+), which is usually found in grade III and IV.<br />
5) Abdomen<br />
Experiencing tenderness, liver enlargement (hepatomegaly), ascites.<br />
6) Extremities.<br />
Akral cold, and there was muscle pain, joints, and bones.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-22947273619558329972014-09-26T09:25:00.002+07:002014-09-26T09:25:33.581+07:00Nursing Implementation for Gastritis<b>Nursing Implementation for Gastritis.</b><br />
<br />
Implementation of nursing action is the initiative of a plan of action to achieve a specific goal. The implementation stage begins after the action plan drawn up and aimed at the nursing orders to help clients achieve the expected goals.<br />
<br />
Implementation is the initiative of a plan of action to achieve a specific goal. Implementation phase of care is the provision of nursing care actions that actually do to help clients achieve their objectives in the action plan have been made. (Nursalam, 2001; 63, quoted from Lyer, et.al, 1996)<br />
<br />
The things that must be considered when implementing the intervention is implemented as planned after validation, the mastery of interpersonal skills, intellectual and technical, intervention must be done carefully and efficiently in the right circumstances, the physical and psychological safety is protected and nursing documentation in the form of recording and reporting. (Gaffar, 1999; 65)<br />
<br />
The goal of the implementation is to assist clients in achieving its intended purpose, which includes an increase in health, disease prevention, health restoration and facilitate coping ". (Nursalam, 2001; 63).<br />
<br />
In the implementation of the action there are three stages that must be passed is the preparation, planning and documentation.<br />
<br />
1. Preparation, including:<br />
<ul>
<li>Review of nursing actions.</li>
<li>Analyze the knowledge and skills required.</li>
<li>Knowing the complications that may arise.</li>
<li>Determine and prepare the necessary equipment.</li>
<li>Preparation of a conducive environment.</li>
<li>Identify the legal and ethical aspects.</li>
</ul>
2. Interventions:<br />
<ul>
<li>Independent: Actions taken by a nurse without a doctor's orders or instructions or other health care team.</li>
<li>Interdependent: Action nurses to cooperate with a team of other health (nutrition, physicians, laboratories, etc.).</li>
<li>Dependent: Dealing with medical procedures or indicate where medical treatment carried out.</li>
</ul>
3. Documentation<br />
It is a complete and accurate records of the actions that have been implemented consisting of three types, namely:<br />
<ul>
<li>Sources Oriented Records (SOR).</li>
<li>Problem Oriented Records (POR).</li>
<li>Computer Assisted Records (CAR) (Nursalam, 2001; 53, quoted from Griffith, 1986)</li>
</ul>
<br />
The criteria are expected in the implementation of the gastritis is:<br />
<ul>
<li>Inform the patient to prepare for the first 6 hours of fasting.</li>
<li>Identifying and limiting foods that can cause discomfort.</li>
<li>Advise to eat little but often as indicated.</li>
<li>Health education to patients regarding therafi given and indications of drug administration.</li>
<li>Advised to rest before eating.</li>
<li>Advised bed rest and limited movement during the acute phase.</li>
<li>Shed some light on the importance of food so there is no doubt about which foods may exacerbate symptoms.</li>
<li>Monitor the physiological response to avoid any problems.</li>
<li>Make a note of behavior such as restlessness, irritability and irritability.</li>
<li>Creating a trusting relationship with frequent therapeutic communication.</li>
<li>Help patients perform deep breathing exercises.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-10125322010401246852014-09-26T09:05:00.001+07:002014-09-26T09:05:25.947+07:00Chronic and Acute Gastritis - 3 Nursing Interventions and Rationale<b>Nursing Interventions and Rationale for </b><b>Chronic and Acute Gastritis </b><br />
<br />
1. Acute Pain related to irritation of the gastric mucosa<br />
<br />
Short-term goal: Patients report reduced pain.<br />
Long-term goal: No irritation persists.<br />
<br />
Action Plan.<br />
Advise for the first 6 hours of fasting.<br />
Give soft foods little by little and give a warm drink.<br />
Identification and limit foods that cause discomfort.<br />
Observations pain, note the location, duration, intensity, (scale 0-10), as well as changes in the characteristics of pain.<br />
<br />
Rational.<br />
Reducing inflammation in the gastric mucosa.<br />
Gastric dilatation can occur when feeding too quickly after a period of fasting.<br />
Can cause distress to the various individuals / dyspepsia.<br />
Changes in pain characteristics may indicate the spread of diseases / complications.<br />
<br />
<br />
2. Imbalanced Nutrition: less than body requirements related to anorexia.<br />
<br />
Short-term goal: Entered adequate nutrition.<br />
Long-term goal: Maintain weight keep it balanced.<br />
<br />
Action Plan<br />
Create programs daily nutritional needs and the minimum weight standards.<br />
Give mouth care before and after meals.<br />
Physical activity monitor and record the activity level.<br />
Avoid foods that cause gas.<br />
Provide food with good ventilation, pleasant surroundings, with the situation in a hurry.<br />
<br />
Rational<br />
As a reference in the fulfillment of the patient's nutritional needs.<br />
Provide comfort to the mouth and can reduce nausea.<br />
Assist in maintaining muscle tone and weight as well as to control the rate of burning calories.<br />
Can affect appetite / digestion and nutrient input limit.<br />
Mennyenangkan environment can reduce stress and more conducive to eating.<br />
<br />
3. Anxiety related to change in health status<br />
<br />
Short-term goal: Patients can discuss the problems it faces.<br />
Long-term goal: Patients can solve the problem by using an effective source.<br />
<br />
Action Plan<br />
Observation of physiological responses, eg tachypnea, palpitations, dizziness.<br />
Note the behavior of instructions, eg: restlessness, irritability.<br />
Assess the fear and anxiety statements, provide feedback responses.<br />
Provide a quiet environment to rest.<br />
Give relaxation techniques, eg breathing exercises guidance dalamdan imagination.<br />
Help the patient to identify and positive coping.<br />
<br />
Rational<br />
May be an indication of the degree of anxiety experienced by the patient.<br />
Indicator of the degree of anxiety.<br />
Make therafiutik relationships, helping the patient to accept the feelings and decrease unnecessary anxiety about ignorance.<br />
Moving patients from outside stressors and increase relaxation, can also improve coping skills.<br />
Way of relaxation can help reduce fear and anxiety.<br />
Successful behavior can strengthen the patient in accepting anxiety, improve patients' sense of self-control and give confidence.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-34279222190928364472014-09-26T08:49:00.000+07:002014-09-26T08:49:26.526+07:00Clinical Manifestations of Chronic and Acute Gastritis <b>Acute Gastritis</b><br />
<br />
1. Acute simple exogenous gastritis<br />
<ul>
<li>Sudden epigastric pain.</li>
<li>Nausea with vomiting which in one after another.</li>
<li>When the attack, the patient sweating, restlessness, abdominal pain, and sometimes accompanied by heat and tachycardia.</li>
<li>Usually recover in 1-2 days.</li>
</ul>
2. Acute exogenous corrosive gastritis<br />
<ul>
<li>The patient collapsed with a cool skin.</li>
<li>Tachycardia and cyanosis.</li>
<li>Feelings such as burning, on the epigastrium.</li>
<li>Severe pain / colic.</li>
</ul>
<br />
3. Acute infectious gastritis<br />
<ul>
<li>Anorexia.</li>
<li>The epigastric distress.</li>
<li>Vomitus.</li>
<li>Hematemesis.</li>
</ul>
4. Acute gastritis hegmonos<br />
<ul>
<li>Sudden severe pain in the epigastrium.</li>
<li>Neusia.</li>
<li>Tension in the epigastrium.</li>
<li>Vomitus.</li>
<li>High heat and suffocation</li>
<li>Tachypnea.</li>
<li>Ekterik little dry tongue.</li>
<li>Tachycardia.</li>
<li>Cyanosis of the extremities.</li>
<li>Diarrhea.</li>
<li>Abdomen soft.</li>
<li>Leukocytosis.</li>
</ul>
<br />
<br />
<b>Chronic Gastritis</b><br />
1. Superficial gastritis<br />
<ul>
<li>Vague distress in the epigastrium.</li>
<li>Weight loss.</li>
<li>Bloating / full flavor at the epigastrium.</li>
<li>Nausea.</li>
<li>Sebelun the pain and after meals.</li>
<li>Feels dizzy.</li>
<li>Vomitus. </li>
</ul>
<br />
2. Atrophic gastritis<br />
<ul>
<li>The epigastric distress.</li>
<li>Anorexia.</li>
<li>Full sense of the abdomen.</li>
<li>Nausea.</li>
<li>Wind came out of the mouth.</li>
<li>Vomitus.</li>
<li>Easily offended.</li>
<li>Restless.</li>
<li>Mouth and throat feel dry. </li>
</ul>
<br />
3. Chronic hypertrophic gastritis<br />
<ul>
<li>Epigastric pain which is not always reduced after drinking milk.</li>
<li>Pain usually occurs at night.</li>
<li>Sometimes accompanied by melena.</li>
</ul>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-71446835555205959482014-09-10T17:35:00.002+07:002014-09-10T17:37:27.391+07:00Nursing Care Plan for Decubitus Ulcer / Pressure Sores<b>Assessment and Nursing Diagnosis for Decubitus Ulcer / Pressure Sores</b><br />
<br />
<br />
<b>Definition</b><br />
<br />
Decubitus is local tissue necrosis that tends to occur when the stress on the soft tissue between the bony external surface for a prolonged period (National Pressure Ulcer Advisory Panel [NPUAP], 1989a, 1989b).<br />
<br />
A new definition has been filed in the National Conference NPUAP 4th (1995a). Margolis (1995) mentions " the best definition of decubitus is damage to anatomical structure and function of normal skin as a result of external pressures associated with herniated discs and not cured by the order and the usual time. Furthermore, this disorder occurs in individuals who are in a chair or on a bed, often on incontinence and malnutrition or individuals who have difficulty eating alone, and impaired level of consciousness."<br />
<br />
Body parts are often experienced decubitus ulcers is the part where there is a protrusion of bone, namely the elbows, heels, hips, ankles, shoulders, back and back of the head.<br />
<br />
Although all parts of the body at risk for pressure sores, the lower part of the body are especially at high risk and need special attention.<br />
<br />
Common areas of decubitus is a bony ridge above and not covered by sub-cutaneous fat enough, for example; the sacrum, the greater trochanter and the anterior superior spine ischiadica, heel and elbow area.<br />
<br />
Decubitus is a serious matter, with morbidity and mortality in elderly clients.<br />
Pressure sores can occur at any stage of life , but this is a particular problem in the elderly. Particularly in clients with immobility. Old age has a great potential for pressure sores occur because the skin changes associated with aging include:<br />
<ul>
<li>Reduction of subcutaneous fat tissue.</li>
<li>Reduced collagen and elastin tissue.</li>
<li>Decreased efficiency of collateral capillaries on the skin so that the skin becomes thinner and fragile.</li>
</ul>
<br />
<br />
Etiology<br />
1. Extrinsic factors<br />
<ul>
<li>pressure</li>
<li>humidity</li>
<li>friction</li>
</ul>
2. Intrinsic factor<br />
<ul>
<li>age</li>
<li>temperature</li>
<li>nutrition</li>
</ul>
<br />
<br />
The other factors are :<br />
<ul>
<li>Decreased sensory perception.</li>
<li>Immobilization, and</li>
<li>Activity limitation.</li>
</ul>
The third factor is the impact of the duration and intensity of the pressure at the surface of the protruding bone.<br />
<br />
<br />
Clinical Manifestations and Complications<br />
<ul>
<li>The initial injury is a sign of redness that does not disappear when pressed thumb.</li>
<li>In more severe injuries encountered skin ulcers.</li>
<li>Can arise pain and signs of systemic inflammation, including fever and increased white blood cell count.</li>
<li>Infection can occur as a result of weakness and hospitalization is prolonged even in small ulcers.</li>
</ul>
<br />
<br />
<b>Assessment for Decubitus Ulcer / Pressure Sores</b><br />
<br />
1. Activity / rest<br />
Signs : decreased strength, endurance, range of motion limitations on the area of pain , eg disturbances ; muscle buds change.<br />
<br />
2. Circulation<br />
Signs : hypoxia, decreased peripheral pulse distal extremity injuries, general peripheral vasoconstriction with loss of pulse, white and cold, tissue edema formation.<br />
<br />
3. Elimination<br />
Signs : decreased urine output is the absence of the emergency phase, color ; maybe reddish black, in the event, identify muscle damage.<br />
<br />
4. Food / fluid<br />
Signs : general tissue edema, anorexia, nausea and vomiting.<br />
<br />
5. Neuro sensory<br />
Symptoms : area numb / tingling.<br />
<br />
6. Breathing<br />
Symptoms : decreased function of the spinal cord, cord edema, neurological damage, paralysis of abdominal and respiratory muscles.<br />
<br />
7. Ego integrity <br />
Symptoms : family problems, work, finances, disability.<br />
Signs : anxiety, crying, dependence, withdrawal, anger.<br />
<br />
8. Security<br />
Signs : a fracture due to the location (falls, accidents, tetanic muscle contraction, up to an electric shock).<br />
<br />
<br />
<b>Nursing Diagnosis for Decubitus Ulcer / Pressure Sores</b><br />
<ol>
<li>Impaired skin integrity</li>
<li>Impaired physical mobility</li>
<li>Imbalanced Nutrition : less than body requirements</li>
<li>Risk for infection</li>
<li>Pain ( acute / chronic )</li>
</ol>
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-17729840234819300132014-09-04T01:18:00.001+07:002014-09-04T01:18:27.585+07:00Nursing Care Plan for Atherosclerosis<b>Assessment for Atherosclerosis</b><br />
<br />
Assessment is the first step in the nursing process and basic overall, all of the data or client information, which is collected is needed to determine the nursing assessment of the client's problems with atherosclerosis.<br />
<br />
1. Activity and rest<br />
<ul>
<li>Weakness, <a href="http://nursing-diagnosis-intervention.blogspot.com/2012/05/fatigue-nursing-diagnosis-nic-noc.html" target="_blank">fatigue</a>, inability to sleep (possibly obtained tacycardia and dyspnea at rest or during activity).</li>
</ul>
2. Circulation<br />
<ul>
<li>History of <a href="http://blog-nursingcareplan.blogspot.com/2012/05/nursing-care-plan-for-myocardial.html" target="_blank">Acute Myocardial Infarction</a>, coronary heart disease, CHF, <a href="http://blog-nursingcareplan.blogspot.com/2011/05/nursing-care-plan-for-hypertension.html" target="_blank">Hypertension</a>, <a href="http://blog-nursingcareplan.blogspot.com/2010/07/nursing-care-plan-for-diabetes-mellitus.html" target="_blank">diabetes mellitus</a>.</li>
<li>Blood pressure may be normal or increased, the pulse may be normal or late Capilary refill time, dysrhythmia</li>
<li>The sound of the heart, extra heart sounds S3 or S4 may reflect the occurrence of heart failure / loss of ventricular contractility.</li>
<li>Heart rate may be increased or decreased.</li>
<li>Possible irregular heart rhythm, or also normaI.</li>
<li>Edema: jugular venous distension, edema anasarca, crackles may also arise with heart failure.</li>
<li>Skin color may pale, both lips and nails.</li>
</ul>
<br />
3. Elimination<br />
<ul>
<li>Bowel sounds may increase, or also normal.</li>
</ul>
4. Nutrition<br />
<ul>
<li>Nausea, loss of appetite, decreased skin turgor, sweat a lot, vomiting and weight changes.</li>
</ul>
5. Hygiene<br />
<ul>
<li>Dyspnea or chest pain or pounding in the chest while doing the activity.</li>
</ul>
6. Neoru sensory<br />
<ul>
<li>Violent headache, Changes mentation.</li>
</ul>
7. Comfort<br />
<ul>
<li>Onset of chest pain that does not suddenly disappear with rest or with the drugs.</li>
<li>Location of chest pain in the front of substernal, which may spread to the arms, jaw and face. </li>
<li>Characteristics of pain, may be said to be a pain ever experienced by the patient.</li>
<li>As a result of the pain as possible in getting the grinning face, changes in posture, crying, decreased eye contact, changes in heart rhythm, ECG, blood pressure, respiration and skin color as well as the level of consciousness.</li>
</ul>
<br />
8. Respiration<br />
<ul>
<li>Dyspnea with or without activity, productive cough, smokers with a history of chronic respiratory disease. On examination may get an increase in respiration, pale or cyanosis, crakcles breath sounds or wheezes or too vesukuler. Clear sputum or too pink / pink tinged.</li>
</ul>
9. Social Interaction<br />
<ul>
<li>Stress, difficulty in adapting to stressors, uncontrolled emotions.</li>
</ul>
10. Knowledge<br />
<ul>
<li>History in the family is suffering from heart disease, diabetes, stroke, hypertension, smokers.</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis for Atherosclerosis</b><br />
<br />
Nursing diagnoses that may arise in patients with atherosclerosis are:<br />
<br />
1. Risk for <a href="http://nursing-diagnosis-intervention.blogspot.com/2012/09/nursing-diagnosis-decreased-cardiac.html" target="_blank">decreased cardiac output</a> related to Strock volume.<br />
2. <a href="http://nandanursingdiagnoses.blogspot.com/2013/08/ineffective-tissue-perfusion-related-to.html" target="_blank">Ineffective Tissue perfusion</a> related to exchange disorder.<br />
3. <a href="http://nursing-diagnosis-intervention.blogspot.com/2012/07/knowledge-deficit-related-to.html">Knowledge Deficit</a> related to the lack of information regarding the sources of information.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-35511987385907416442014-08-21T00:15:00.000+07:002014-08-21T00:15:00.837+07:00Myocardial Infarction Books<b>The ECG in Acute Myocardial Infarction and Unstable Angina: Diagnosis and Risk Stratification (Developments in Cardiovascular Medicine)</b><br />
<br />
The ECG in Acute Myocardial Infarction and Unstable Angina, written by Drs. Hein Wellens, Anton Gorgels and Pieter Doevendans, is an excellent reference for any cardiac electrophysiologist, cardiologist, internist or emergency room physician. <br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/1402072147/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1402072147&linkCode=as2&tag=carplanur-20&linkId=564HQBXK2DAZHNCS">The ECG in Acute Myocardial Infarction and Unstable Angina: Diagnosis and Risk Stratification (Developments in Cardiovascular Medicine)</a><img src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=1402072147" width="1" height="1" border="0" alt="" style="border:none !important; margin:0px !important;" /><br />
<br />
<br />
<b>An Atlas of Myocardial Infarction and Related Cardiovascular Complications (Encyclopedia of Visual Medicine Series)</b><br />
<br />
This is a color atlas of myocardial infarction and related cardiovascular complications with 212 captioned illustrations and introductory review text. It is best described in the Foreword by Dr. Lawrence S. Cohen, Yale University School of Medicine, who says, Dr. Dymond has put together a well-illustrated atlas reflecting the current state of knowledge concerning myocardial infarction. The strength of this book rests with the illustrations. . . <br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/1850705054/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1850705054&linkCode=as2&tag=carplanur-20&linkId=F67CTNEG2MT5IYR3">An Atlas of Myocardial Infarction and Related Cardiovascular Complications (Encyclopedia of Visual Medicine Series)</a><img src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=1850705054" width="1" height="1" border="0" alt="" style="border:none !important; margin:0px !important;" /><br />
<br />
<br />
<b>Complications of Myocardial Infarction: Clinical Diagnostic Imaging Atlas with DVD, 1e (Cardiovascular Emergencies: Atlas and Multimedia)</b><br />
<br />
Review<br />
<br />
"This is a valuable addition to the literature on the treatment of the sequelae of myocardial infarction. The author has managed to effectively synthesize information from a number of divergent disciplines into a coherent and clinically relevant book... A broad array of potential complications which can result from myocardial infarction is explored. Evidence-based recommendations for managing these complications are provided in a concise and thorough fashion. All chapters are accompanied by an impressive array of illustrations, as well as photographs of relevant imaging findings and gross pathologic specimens. " - Doody's, 4 Stars ****<br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/1416052720/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1416052720&linkCode=as2&tag=carplanur-20&linkId=RWZ5FCU3Z53YL6MD">Complications of Myocardial Infarction: Clinical Diagnostic Imaging Atlas with DVD, 1e (Cardiovascular Emergencies: Atlas and Multimedia)</a><img src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=1416052720" width="1" height="1" border="0" alt="" style="border:none !important; margin:0px !important;" /><br />
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-36584609728990345422014-08-21T00:02:00.002+07:002014-08-21T00:02:57.552+07:00The Best Anxiety Books<b>Not To Worry: 92 Affirmations That Apply How To Stop Worrying Techniques For Curing The Symptoms Of Anxiety</b><br />
<br />
About the Author<br />
Gary Vurnum is one of the most popular self-improvement authors on the Internet. Discover how Gary can help you truly achieve the life of your dreams at www.Vurnum.com <br />
<br />
Not To Worry: 92 Affirmations That Apply How To Stop Worrying Techniques For Curing The Symptoms Of Anxiety is a simple and easy-to-apply book in which you will discover ninety-two affirmations you can immediately use to apply how to stop worrying techniques for curing the symptoms of anxiety in the shortest time possible. <br />
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Read More : <a href="http://www.amazon.com/gp/product/1450540732/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1450540732&linkCode=as2&tag=carplanur-20&linkId=SHQB64SOZZSQAZCO">Not To Worry: 92 Affirmations That Apply How To Stop Worrying Techniques For Curing The Symptoms Of Anxiety</a><img alt="" border="0" src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=1450540732" height="1" style="border: none !important; margin: 0px !important;" width="1" /><br />
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<br />
<b>The 10 Best-Ever Anxiety Management Techniques: Understanding How Your Brain Makes You Anxious and What You Can Do to Change It </b><br />
<br />
About the Author<br />
Margaret Wehrenberg, Psy.D., is a licensed psychologist in private practice and a popular public speaker. She is the author of The Anxious Brain, The 10 Best-Ever Anxiety Management Techniques, and The 10 Best-Ever Depression Management Techniques. She lives in St. Charles, Missouri. <br />
<br />
A strategy-filled handbook to understand, manage, and conquer your own stress.<br />
Anxiety disorders-grouped into three main categories: panic, generalized anxiety, and social anxiety-are among the most common and pervasive mental health complaints. From the subtlest effect of sweaty palms during a work presentation to the more severe symptom of reclusion, anxiety casts a wide net.<br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/0393705560/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0393705560&linkCode=as2&tag=carplanur-20&linkId=UN77MQAGEOTTS6MM">The 10 Best-Ever Anxiety Management Techniques: Understanding How Your Brain Makes You Anxious and What You Can Do to Change It</a><img alt="" border="0" src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=0393705560" height="1" style="border: none !important; margin: 0px !important;" width="1" /><br />
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<br />
<b>The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy</b><br />
<br />
Review<br />
<br />
The Mindfulness and Acceptance Workbook for Anxiety combines the accumulated wisdom of the ages with up-to-date, cutting-edge developments in scientific psychology. In an easy-to-read and fun format, those suffering from anxiety in all of its guises will find the keys to breaking loose from its shackles. By emphasizing acceptance of toxic emotions (and illustrating ways to accomplish this), rather than struggling to overcome them, the person inside you may finally emerge to set your life on a new, productive, and valued course. Highly recommended for all those struggling with worry, anxiety, and fear.<br />
—David H. Barlow, PhD, professor of psychology and psychiatry at Boston University and author of Anxiety and Its Disorders<br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/1572244992/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1572244992&linkCode=as2&tag=carplanur-20&linkId=POUY36BSADIQXLKG">The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy</a><img alt="" border="0" src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=1572244992" height="1" style="border: none !important; margin: 0px !important;" width="1" />Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-54181009151268454592014-08-20T23:48:00.000+07:002014-08-20T23:48:18.331+07:00Alzheimer's Disease Books<b>Alzheimer's Disease: What if There was a Cure? </b><br />
<br />
About the Author Mary T. Newport, M.D., has provided care to newborns in Florida since 1983 and is currently the founding director of the newborn intensive care unit at Spring Hill Regional Hospital. In July 2008 Dr. Newport wrote an article, "What If There Was a Cure for Alzheimer's Disease and No One Knew?" which was circulated around the world and became the subject of a lecture she presented at the 2010 Alzheimer's Disease International Conference in Thessaloniki, Greece. <br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/B00CP7ZCLS/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00CP7ZCLS&linkCode=as2&tag=carplanur-20&linkId=RMFZY2I6MPJZODT3">Alzheimer's Disease: What if There was a Cure? </a><br />
<br />
<br />
<b>A Caregiver's Guide to Alzheimer's Disease (300 Tips for Making Life Easier)</b><br />
<br />
About the Author<br />
Patricia R. Callone is the Vice President of Institutional Relations for Creighton University. For six years she served on the Board of Directors of the Alzheimer's Association Midlands Chapter. She has experience with Alzheimer's as both an educator and as a caregiver.<br />
<br />
Connie Kudlacek, BS is the Executive Director of the Alzheimer's Association Midlands Chapter.<br />
<br />
Barbara C. Vasiloff is the co-founder and President of Discipline With Purpose, Inc.<br />
<br />
Janaan Manternach is a well respected author and educator.<br />
<br />
Dr. Roger A. Brumback is a Professor of Pathology and Psychiatry and the Chairman of the Department of Pathology at the Creighton University School of Medicine. <br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/B0049ENHQC/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B0049ENHQC&linkCode=as2&tag=carplanur-20&linkId=WQKUACOOLLPYQC5M">A Caregiver's Guide to Alzheimer's Disease (300 Tips for Making Life Easier)</a><img alt="" border="0" src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=B0049ENHQC" height="1" style="border: none !important; margin: 0px !important;" width="1" /><br />
<br />
<b><br />
Alzheimer's Disease and Other Dementias: A Practical Guide</b><br />
<br />
About the Author<br />
<br />
Marc E. Agronin, MD, is a board-certified adult and geriatric psychiatrist; he serves as the medical director for mental health and clinical research at the Miami Jewish Health Systems and as an affiliate associate professor of psychiatry and neurology at the University of Miami Miller School of Medicine. He is the author of numerous articles and books in the field of psychiatry and a nationally known speaker and expert on Alzheimer’s disease and other late-life psychiatric disorders. In 2008, Dr. Agronin was named "clinician of the year" by the American Association for Geriatric Psychiatry. He is the author of How We Age: A Doctor’s Journey into the Heart of Growing Old and Therapy with Older Clients: Key Strategies for Success, as well as coeditor of Principles and Practice of Geriatric Psychiatry, second edition.<br />
<br />
Read More : <a href="http://www.amazon.com/gp/product/0415857007/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0415857007&linkCode=as2&tag=carplanur-20&linkId=CD73E6MVBUKX2ZK5">Alzheimer's Disease and Other Dementias: A Practical Guide</a><img src="http://ir-na.amazon-adsystem.com/e/ir?t=carplanur-20&l=as2&o=1&a=0415857007" width="1" height="1" border="0" alt="" style="border:none !important; margin:0px !important;" /><br />
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-4832363706488066732014-08-20T15:25:00.000+07:002014-08-20T15:25:27.219+07:00Causes and Management of Splenomegaly<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUyfZUtkbT3KJ6vclFBwPgApXPUjEWyZ24hCmPU7bcaLkaq1GfCRZyBdfeCZNi1Pn2UKxvu5nzVQfPyJNsrV6pL__fJxwOqv4E5-RL-2_bTFeTI39dLr3_NH_97oEE9jqlXpjnClDro-M/s1600/Nursing+Care+Plan+for+Splenomegaly.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Care Plan Management of Splenomegaly" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUyfZUtkbT3KJ6vclFBwPgApXPUjEWyZ24hCmPU7bcaLkaq1GfCRZyBdfeCZNi1Pn2UKxvu5nzVQfPyJNsrV6pL__fJxwOqv4E5-RL-2_bTFeTI39dLr3_NH_97oEE9jqlXpjnClDro-M/s320/Nursing+Care+Plan+for+Splenomegaly.jpg" /></a></div>
Splenomegaly is enlargement of the spleen, these events usually occur as a result of lymphocyte proliferation in the spleen due to an infection elsewhere in the body. How to measure or unit using Schuffner I up to Shuffner VIII by dividing the distance between the three points made in the abdominal wall in 8 parts.<br />
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<br />
<b>Causes of Splenomegaly</b><br />
<br />
Splenomegaly due to macrophage proliferation occurs if there are dead cells (primarily red blood cells) in the amount of excessive and needs to be cleared from the circulation. Splenomegaly may occur due to accumulation of blood in the spleen, usually a complication of portal hypertension. Splenomegaly in response to infection, both accompanied by lymphadenopathy or not accompanied by lymphadenopathy.<br />
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Some of the diseases that lead to splenomegaly, such as infectious diseases such as malaria, typhoid abdomen, bruselois, bacterial endocarditis, splenic abscess, and others. In addition, blood diseases such as hemolytic anemia and leukemia. Also neoplastic diseases such as Hodgkin's disease, lymphosarcoma, malignant tumors, or cysts of the spleen.<br />
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<br />
<b>Management of Splenomegaly</b><br />
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Actions that can be performed when there is splenomegaly certainly related to the main causes of splenomegaly. However, if the spleen has not resistant to swelling, the removal of the spleen is called a splenectomy, which when it occurs excessively destruction of peripheral blood (hypersplenism), because it would be very dangerous.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-62446954227198359272014-08-20T15:13:00.001+07:002014-08-20T15:13:47.376+07:00Management, Signs and Symptoms of Anemia<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_rVASzvQOyBMb-_UScQyo1AF3HY5K_M_h0Wjf7yeJaXwnDEVna8yp22PKMv2HnnTUhyphenhyphenHXy5yymLEBPrKuWJY7q8g-iiXENFoF__TZf3X_KawYwpxuFvIWuQV7hVwSo-NOPZCE043eR08/s1600/Management,+Signs+and+Symptoms+of+Anemia.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_rVASzvQOyBMb-_UScQyo1AF3HY5K_M_h0Wjf7yeJaXwnDEVna8yp22PKMv2HnnTUhyphenhyphenHXy5yymLEBPrKuWJY7q8g-iiXENFoF__TZf3X_KawYwpxuFvIWuQV7hVwSo-NOPZCE043eR08/s320/Management,+Signs+and+Symptoms+of+Anemia.jpeg" alt="Management, Signs and Symptoms of Anemia" /></a></div>Symptoms of Anemia:<br />
<br />
When anemia occurs in a long time, the concentration of hemoglobin present in very low numbers before symptoms appear. The symptoms include:<br />
<ul><li>Asymptomatic: especially when anemia occurs in a long time</li>
</ul><blockquote class="tr_bq"><blockquote class="tr_bq">Lethargy.<br />
Shortness of breath or tightness, especially when beraktfitas.<br />
Head feels light.<br />
Palpitations.</blockquote></blockquote><blockquote class="tr_bq">Meanwhile, signs of anemia that must be considered during the examination are:</blockquote><ul><li>Pale mucous membranes, namely; mouth, conjunctiva, nails.</li>
</ul><blockquote class="tr_bq"><blockquote class="tr_bq">Hyperdynamic circulation, such as tachycardia, the pulse disappears, the flow systolic murmur.<br />
Heart failure.<br />
Retinal bleeding.</blockquote></blockquote><br />
Specific signs in patients with anemia include:<br />
<blockquote class="tr_bq"><ul><li>Glossitis: occurs in patients with megaloblastic anemia, iron deficiency anemia.</li>
<li>Angular Stomatitis: occurs in patients with iron deficiency anemia.</li>
<li>Jaundice (yellowish): caused by hemolysis, mild megaloblastic anemia.</li>
<li>Splenomegaly: due to hemolysis and megaloblastic anemia.</li>
<li>In foot ulceration: occurs in sickle-cell anemia</li>
<li>Bone deformity: occurs in thalassemia</li>
<li>Peripheral neuropathy, optic atrophy, spinal degeneration, the effects of vitamin B12 deficiency.</li>
<li>Crisp blue gums (Burton's line), encephalopathy, and peripheral motor neuropathy often seen in patients with metal poisoning.</li>
</ul></blockquote><br />
<br />
<b>Management</b><br />
<br />
Therapy directed at the cause of the anemia, can be:<br />
<ol><li>Blood transfusion.</li>
<li>Corticosteroids or other drugs that can suppress the immune system.</li>
<li>Administration of erythropoietin, a hormone that plays a role in the process of hematopoiesis, serves to form the bone marrow in the process of hematopoiesis.</li>
<li>Supplementation of iron, vitamin B12, vitamins, and other minerals needed.</li>
</ol>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-27820188500176053462013-01-21T08:54:00.000+07:002013-01-21T08:54:16.684+07:00Activity Intolerance - Nursing Diagnosis Interventions for Hepatitis B<b>Nursing Care Plan for Hepatitis B</b><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUdzPWsYtNFMCq_u0G8fpvSK_W_42yft2tDl4IoludWtUGa7n53HOk3DHhEUi9D1sTGrBrLTA_JfOQV5WNbcuYXUBV6ycONsAGWcbcm7pU4P1-u__yAfYWLosDKubppXGw5OPupUPUUBE/s1600/Nursing+Diagnosis+for+Hepatitis+B.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="219" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUdzPWsYtNFMCq_u0G8fpvSK_W_42yft2tDl4IoludWtUGa7n53HOk3DHhEUi9D1sTGrBrLTA_JfOQV5WNbcuYXUBV6ycONsAGWcbcm7pU4P1-u__yAfYWLosDKubppXGw5OPupUPUUBE/s320/Nursing+Diagnosis+for+Hepatitis+B.jpg" width="320" /></a></div>
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<br />
<br />
Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus. It is a major global health problem and the most serious type of viral hepatitis. It can cause chronic liver disease and puts people at high risk of death from cirrhosis of the liver and liver cancer. <br />
<br />
The hepatitis B virus reproduces in liver cells, but the virus itself is not the direct cause of damage to the liver. Rather, the presence of the virus triggers an immune response from the body as the body tries to eliminate the virus and recover from the infection. This immune response causes inflammation and may seriously injure liver calls. Therefore, there is a balance between the protective and destructive effects of the immune response to the hepatitis B virus. <br />
<br />
<b>Symptoms</b><br />
<br />
Most people do not experience any symptoms during the acute infection phase. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.<br />
<br />
In some people, the hepatitis B virus can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer. <br />
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<b><a href="http://nanda-nurse-diary.blogspot.com/2013/01/nursing-diagnosis-for-hepatitis-b.html" target="_blank">Nursing Diagnosis for Hepatitis B</a> </b><br />
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<a href="http://nanda-nurse-diary.blogspot.com/2012/12/activity-intolerance-related-to-pain-of.html" target="_blank"><b>Activity intolerance</b></a> related to general weakness, decreased strength / endurance; pain, have limited activity; depression<br />
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<br />
characterized by: a report weakness, decreased muscle strength, refused to move.<br />
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Goal: Clients showed improvement on activity.<br />
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Expected outcomes: expressed understanding of the situation / risk factors and individual treatment programs.<br />
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<br />
<b>Intervention and Rational:</b><br />
<b></b><br />
<b><br /></b>
1. Increase bed rest, create a tranquil environment.<br />
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Rationale: Increasing rest, and provides the energy used for healing.<br />
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<br />
2. Change position often, give a good skin care.<br />
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Rational: improving respiratory function and minimizes pressure on certain areas to reduce the risk of tissue damage.<br />
<br />
<br />
3. Increase activity as tolerated premises.<br />
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Rational: prolonged bed rest can reduce the ability.<br />
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<br />
4. Encourage stress management techniques, examples of progressive <br />
relaxation, visualization, imagination guidance, provide appropriate <br />
entertainment activities.<br />
<br />
Rationale: increased relaxation and increased energy.<br />
<br />
<br />
5. Monitor recurrence of anorexia and enlarged liver tenderness.<br />
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Rational: shows a lack of resolution of the disease, requiring a break-up.<br />
<br />
<br />
6. Assist in the procedure as indicated<br />
<br />
Rational: removing the causative agent of toxic hepatitis can limit the degree of tissue damage.<br />
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<br />
7. Give medications as indicated: sedative, anti-anxiety agents.<br />
<br />
Rational: to assist in the management of sleep needs.<br />
<br />
<br />
8. Monitor liver enzyme levels.<br />
<br />
Rational: to help determine the appropriate level of activity as a potential increase in the risk of recurrent preterm.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-68947330003098931682012-09-20T09:37:00.001+07:002012-09-20T09:37:15.771+07:00DHF - 3 Nursing Diagnosis and Interventions<div class="separator" style="clear: both; text-align: center;">
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<b>Nursing Care Plan for DHF - 3 Nursing Diagnosis and Interventions</b><br />
<br />
Formulation of nursing care plan for patients with DHF should refer to the problem of nursing diagnoses are made. Note that the action can be given according to the actions that are independent and collaboration. The author will present the principles of nursing action plan in accordance with the nursing diagnoses:<br />
<br />
1. <b>Fluid Volume Deficit</b> related to increased capillary permeability, bleeding, vomiting and fever.<br />
<br />
Purpose:<br />
Disorders of body fluid volume can be resolved<br />
<br />
Expected outcomes:<br />
Body fluid volume returns to normal<br />
<br />
Intervention:<br />
1) Assess the general condition and the condition of the patient.<br />
2) Observation vital signs (temperature, pulse, respiration).<br />
3) Observation for signs of dehydration.<br />
4) Observation drip infusion, and the infusion needle insertion site.<br />
5) Balance fluid (fluid input and output).<br />
6) Give the patient and family encourage patients to give the drink a lot less than from 1500 to 2000 cc per day.<br />
7) Instruct patient's family to replace the patient's clothes were soaked with sweat.<br />
<br />
2. <b>Hyperthermia</b> related to dengue virus infection process.<br />
<br />
Purpose:<br />
Hyperthermia can be resolved<br />
<br />
Expected outcomes:<br />
Body temperature returned to normal<br />
<br />
Intervention:<br />
1) Observation vital signs, especially temperature.<br />
2) Give a compress on the forehead and armpits.<br />
3) Change clothes that have been soaked with sweat.<br />
4) Encourage the family to put on clothing that can absorb sweat like cotton.<br />
5) Encourage your family to drink lots of approximately 1500 to 2000 cc per day.<br />
6) Collaboration with doctors in therapy, febrifuge.<br />
<br />
c. <b>Imbalanced Nutrition, Less Than Body Requirements</b> related to the nausea, vomiting, no appetite.<br />
<br />
Purpose:<br />
Disorders of nutrition is resolved<br />
<br />
Expected outcomes:<br />
Nutrient intake increased client<br />
<br />
Intervention:<br />
1) Assess the client's nutritional intake and changes.<br />
2) Measure weight loss clients every day.<br />
3) Give the client in warm and eat small portions but often.<br />
4) Give the patient warm water when it complained of nausea.<br />
5) Perform a physical examination Abdomen (auscultation, percussion, and palpation).<br />
6) Collaboration with doctors in anti-emetic therapy.<br />
7) Collaboration with the team in determining nutritional diet.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-48914696350255653412012-07-25T23:41:00.000+07:002012-07-25T23:41:40.897+07:00Nursing Care Plan for Hyperthermia<center><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLpc__98rCaauDW92EAey13Y8zKorVWgyOeNkbx1zFhxlEA1HJmxvD8ifxDX6IvAjYs2KvL1TooW89CpKs9SuucSfuwfxft-BU2AJakzxQmu8HtayeRNMud9TQuEKGwmRXKjplQdSOgjhv/s1600/mengatasi+demam.jpg" target="_blank"><img alt="Nursing Care Plan for Hyperthermia" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgLpc__98rCaauDW92EAey13Y8zKorVWgyOeNkbx1zFhxlEA1HJmxvD8ifxDX6IvAjYs2KvL1TooW89CpKs9SuucSfuwfxft-BU2AJakzxQmu8HtayeRNMud9TQuEKGwmRXKjplQdSOgjhv/s1600/mengatasi+demam.jpg" /></a></center><br />
<br />
<b>Hyperthermia</b><br />
<br />
Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death.<br />
<br />
The most common causes are heat stroke and adverse reactions to drugs. Heat stroke is an acute condition of hyperthermia that is caused by prolonged exposure to excessive heat or heat and humidity. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body temperature to climb uncontrollably. Hyperthermia is a relatively rare side effect of many drugs, particularly those that affect the central nervous system. Malignant hyperthermia is a rare complication of some types of general anesthesia.<br />
<br />
Hyperthermia can be created artificially by drugs or medical devices. Hyperthermia therapy may be used to treat some kinds of cancer and other conditions, most commonly in conjunction with radiotherapy.<br />
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Hyperthermia differs from fever in the mechanism that causes the elevated body temperatures: a fever is caused by a change in the body's temperature set-point.<br />
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The opposite of hyperthermia is hypothermia, which occurs when an organism's temperature drops below that required for normal metabolism. Hypothermia is caused by prolonged exposure to low temperatures and is also a medical emergency requiring immediate treatment.<br />
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<b>Signs and symptoms</b><br />
<br />
Hot, dry skin is a typical sign of hyperthermia. The skin may become red and hot as blood vessels dilate in an attempt to increase heat dissipation, sometimes leading to swollen lips. An inability to cool the body through perspiration causes the skin to feel dry.<br />
<br />
Other signs and symptoms vary depending on the cause. The dehydration associated with heat stroke can produce nausea, vomiting, headaches, and low blood pressure. This can lead to fainting or dizziness, especially if the person stands suddenly.<br />
<br />
In the case of severe heat stroke, the person may become confused or hostile, and may seem intoxicated. Heart rate and respiration rate will increase (tachycardia and tachypnea) as blood pressure drops and the heart attempts to supply enough oxygen to the body. The decrease in blood pressure can then cause blood vessels to contract, resulting in a pale or bluish skin color in advanced cases of heat stroke. Some victims, especially young children, may have seizures. Eventually, as body organs begin to fail, unconsciousness and coma will result.<br />
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<br />
<b>Hyperthermia</b><br />
<br />
<b>Related To :</b><br />
<ul><li>Infection</li>
<li>Inflammation</li>
<li>Dehydration</li>
<li>CNS Pathology</li>
<li>Exposure to heat/sun</li>
<li>Impaired physical environment</li>
<li>Vigorous activity</li>
</ul><br />
<b>Evidenced by :</b><br />
<ul><li>Temperature over 37.8 C (100 F) orally, or 38.8 C (101 F) rectally.</li>
<li>Malaise/weakness</li>
<li>Loss of appetite</li>
<li>Tachycardia</li>
<li>Shivering/goose pimples</li>
<li>Dehydration</li>
<li>Flushed skin/li></li>
<li>Warm to touch</li>
<li>Increased respiratory rate</li>
</ul><b>Goal :</b> The patient will : Maintian normal body temperature.<br />
<br />
<br />
<b>Nursing Interventions</b> :<br />
<ul><li>Administer antipyretics per physician's order.</li>
<li>Remove excess clothing or blankets.</li>
<li>Assess possible etiology of increased temperature.</li>
<li>Encourage fluids when indicated.</li>
<li>Assess temperature q ___ hours.</li>
<li>Provide air condition/fan if appropriate.</li>
</ul>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.com0tag:blogger.com,1999:blog-8964861545481954600.post-60506914034727914562012-07-25T23:33:00.000+07:002012-07-25T23:33:44.596+07:00Nursing Care Plan for Acute Otitis Media<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhptrr_lk5wwkzj3KsrjhHu6URhzy-pGaejX810saSgAONuqfEkSVQlSQcPworCxQI8TJev_EphI11bDnxramuh50kwlrn-UXQ5qdCqYZdmyCm8m9a4so-o7ALGXokSN-pLr9Ix5aIH3xNI/s1600/Nursing-Care-Plan-for-Acute-Otitis-Media-NCP-AOM.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Care Plan for Acute Otitis Media" border="0" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhptrr_lk5wwkzj3KsrjhHu6URhzy-pGaejX810saSgAONuqfEkSVQlSQcPworCxQI8TJev_EphI11bDnxramuh50kwlrn-UXQ5qdCqYZdmyCm8m9a4so-o7ALGXokSN-pLr9Ix5aIH3xNI/s320/Nursing-Care-Plan-for-Acute-Otitis-Media-NCP-AOM.jpg" width="320" /></a></div><br />
<b>Nursing Diagnosis for Acute Otitis Media and Nursing Interventions for Acute Otitis Media</b><br />
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<b>Nursing Assessment for Acute Otitis Media</b><br />
<ul><li>Assess the presence of pain behaviors: verbal and non-verbal.</li>
<li>Assess the increase in temperature (an indication of the infection process).</li>
<li>Assess the presence of enlarged lymph nodes in the neck area.</li>
<li>Assess nutritional status and adequacy of fluid intake of calories.</li>
<li>Assess the possibility of deafness.</li>
</ul><br />
<b>Nursing Diagnosis for <a href="http://nursing-diagnosis-intervention.blogspot.com/2012/07/pathophysiology-of-acute-otitis-media.html" target="_blank">Acute Otitis Media</a></b><br />
<ol><li><a href="http://nursing-diagnosis-intervention.blogspot.com/2012/05/acute-pain-chronic-pain-nursing.html" target="_blank">Acute Pain</a> related to inflammation of the middle ear tissue.</li>
<li>Disturbed Sensory Perception: auditory conductive disorder related to the sound of the organ.</li>
</ol><br />
<b>Nursing Interventions for Acute Otitis Media</b><br />
<br />
1. Acute Pain related to inflammation of the middle ear tissue.<br />
<br />
Purpose: The reduction in pain.<br />
<br />
Intervention:<br />
<ul><li>Assess the level of intensity of the client and client's coping mechanisms.</li>
<li>Give analgesics as indicated.</li>
<li>Distract the patient by using relaxation techniques: distraction, guided imagination, touching, etc..</li>
</ul><br />
2. Disturbed Sensory Perception: auditory conductive disorder related to the sound of the organ.<br />
<br />
Purpose: to improve communication<br />
<br />
Intervention:<br />
<ul><li>Reduce noise in the client environment.</li>
<li>Looking at the client when speaking.</li>
<li>Speaking clearly and firmly on the client without the need to shout.</li>
<li>Provide good lighting when the client relies on the lips.</li>
<li>Using the signs of non-verbal (eg facial expressions, pointing, or body movement) and other communications.</li>
<li>Instruct family or the people closest to the client on how techniques of effective communication so that they can interact with clients.</li>
<li>If the client wants, the client can use hearing aids.</li>
</ul>Source : <a href="http://nursing-diagnosis-intervention.blogspot.com/2012/07/nursing-care-plan-for-acute-otitis-media.html" target="_blank">http://nursing-diagnosis-intervention.blogspot.com/2012/07/nursing-care-plan-for-acute-otitis-media.html</a>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.com1tag:blogger.com,1999:blog-8964861545481954600.post-53525178061070169902012-06-04T08:20:00.000+07:002014-08-19T00:54:28.372+07:00Nursing Care Plan for Cystitis<span class="date-header"></span> <br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUOWifaMvycwjbNxLnf5K5JUAbkmR02XK6PpxvouEq3sJk4itOOEQ0LAK-_KWX63BvQm6GM2qE2tQ_BRwE4rMDfgkHqZeWAzUqGE7JwwKEOcFJ3H6bprNZ1-noLGTBSoczl_G6xuBEqjzV/s1600/123_124_1.jpg" target="_blank"><img alt="Nursing Assessment for Cystitis" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUOWifaMvycwjbNxLnf5K5JUAbkmR02XK6PpxvouEq3sJk4itOOEQ0LAK-_KWX63BvQm6GM2qE2tQ_BRwE4rMDfgkHqZeWAzUqGE7JwwKEOcFJ3H6bprNZ1-noLGTBSoczl_G6xuBEqjzV/s320/123_124_1.jpg" id="BLOGGER_PHOTO_ID_5632769077606964402" style="cursor: hand; cursor: pointer; display: block; height: 256px; margin: 0px auto 10px; text-align: center; width: 320px;" /></a><br />
<br />
<b>Cystitis</b> is an infection of the bladder that almost always follows bacterial infection in the urine. It is the most common type of urinary tract infection (UTI), particularly in women. Symptoms include painful or burning urination, a frequent urge to urinate, strong smelling urine, cloudy or bloody urine and lower abdominal pain.<br />
<br />
<br />
<b>Nursing Assessment for Cystitis</b><br />
<br />
<b>Identity </b><br />
<ul><li>Age: occurs at all ages. </li>
<li>Sex: more common in women and increased incidence according to age and sexual activity. </li>
<li>Place of residence: whether or not a predisposing factor. </li>
</ul><br />
<b>Main Complaints: </b><br />
<ul><li>Pain or burning in the urethra when urinating </li>
<li>Urine slightly </li>
<li>Discomfort in the supra pubic region </li>
</ul><br />
<b>Disease History </b><br />
<ul><li>History of Urinary Tract Infection </li>
<li>Obstruction of the urinary tract </li>
<li>Other health problems, such as diabetes mellitus, sexual history. </li>
</ul><br />
<b>Physical examination </b><br />
<ul><li>Abdominal infection, and palpation of the lower urinary bledder: no maximum discharge </li>
<li>Inflammation and lesions in the urethral meatus and vaginal introitus</li>
<li>Assess urination: the urge, frequency, dysuria, the stinging smell of urine, pain in the supra pubic</li>
</ul><br />
<b>Psychosocial Examination </b><br />
<ul><li>Often occurs in adolescence and young adulthood, sexual activitas arise feelings of shame and guilt. </li>
<li>Feelings of fear of recurrence, which led to the rejection of sexual activity. </li>
<li>Pain and fatigue are related to the infection can affect job performance and activities of daily living. </li>
</ul><br />
<b>Laboratory examination </b><br />
<br />
<b>Urinalis </b><br />
When infection occurs, showing bacteriuria, WBC (White Blood Cell), RBC (Red Blood Cell) and deposits of white blood cells with renal involvement.<br />
<br />
Sensitivity tests: a lot of microorganisms sensitive to antibiotics and antiseptic associated with recurrent infections<br />
<br />
<b><br />
</b><br />
<div><b>Radiographic assessment </b><br />
<br />
<ul><li>Cystitis Diagnosis based on history, medical examination and laboratory, if there is urinary retention and urinary flow obstruction performed IPV (Identivikasi changes and structural abnormalities) </li>
<li>Culture: Identifying the bacteria that causes </li>
<li>X-ray kidney, ureter and bladder to identify the real structure of the anomaly.</li>
</ul></div><b>Nursing Diagnosis for Cystitis</b><br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjctMm0GDQMV5n5fADGeynSvGi1eOBOi-8LG1VhYCZb5vLM-mJqnz0v3PHTcxQb9yK49NATeaQ20whlSq8dMx_BfTiEfzfQ77Pk8PsvzX3RvsfMSLDFZ1RQTd4hsdxlWJ519Fq3EWfWWE/s1600/cystitis.jpg" target="_blank"><img alt="Cystitis Nursing Diagnosis" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjctMm0GDQMV5n5fADGeynSvGi1eOBOi-8LG1VhYCZb5vLM-mJqnz0v3PHTcxQb9yK49NATeaQ20whlSq8dMx_BfTiEfzfQ77Pk8PsvzX3RvsfMSLDFZ1RQTd4hsdxlWJ519Fq3EWfWWE/s320/cystitis.jpg" id="BLOGGER_PHOTO_ID_5632750504130234146" style="cursor: hand; cursor: pointer; display: block; height: 225px; margin: 0px auto 10px; text-align: center; width: 220px;" /></a><br />
<b>Cystitis</b><br />
<div><b><br />
Cystitis</b> is a term that refers to bladder inflammation that results from any one of a number of distinct syndromes. It is most commonly caused by a bacterial infection in which case it is referred to as a urinary tract infection.<br />
<br />
<b>Signs and symptoms</b><br />
<ul><li>Pressure in the lower pelvis</li>
<li>Painful urination (dysuria)</li>
<li>Frequent urination (polyuria) or urgent need to urinate (urinary urgency)</li>
<li>Need to urinate at night (nocturia)</li>
</ul><br />
<b>Nursing Diagnosis for Cystitis</b></div><ol><li><b><i>Acute Pain</i></b></li>
<b><i> </i></b>
<li><b><i>Risk for Infection</i></b></li>
<b><i> </i></b>
<li><b><i>Alteration in Patterns of Urinary Elimination</i></b></li>
<b><i> </i></b>
<li><b><i>Deficient Knowledge</i></b></li>
</ol>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-45621936539725907942012-06-04T08:13:00.000+07:002014-08-19T00:53:42.576+07:00Nursing Care Plan for Tetanus<br />
<b>General</b><br />
<b><br />
</b><br />
History of present illness: the existence of serious injuries and burns and inadequate immunization.<br />
<br />
<b>Specific</b><br />
<ul>
<li>Respiratory System: dyspnea, and cyanosis asphyxia due to contraction of the respiratory bibs.</li>
<li>Cardiovascular System: dysrhythmias, tachycardia, hypertension and bleeding, the body temperature initially 38-40 ° C or febrile up to the terminal 43-44 ° C.</li>
<li>Neurologic System: irritability (early), weakness, convulsions (late), paralysis of one or several nerves of the brain.</li>
<li>Urinary System : urine retention (bladder distention and no urine output / oliguria)</li>
<li>Digestive System: constipation due to no bowel movements.</li>
<li>Integument and muskuloskletal System: tingling at the site of wound pain, sweating (hyper-hydration), was originally preceded trismus, spasm of the facial muscle contractions to increase the eyebrows, risus sardonicus, stiff muscles and difficulty swallowing.</li>
<li>If this continues there will be a status of general convulsions and seizures.</li>
</ul>
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhta0ItJ0seSBwF-T0ohjbnM7l8BA5GfkqIb2K-Pza2USeJJvHXOmcoAqF6fuCPW2Mh6x47zcf2CCBxdny3x5oT3j1Wig402QAsnL1sOqubsHkvMD3Td7RHSpxgjaRPuMP9MIf-KzdCL8s/s1600/Nursing_Diagnosis_for_Tetanus.jpg" target="_blank"><img alt="Nursing Diagnosis for Tetanus" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhta0ItJ0seSBwF-T0ohjbnM7l8BA5GfkqIb2K-Pza2USeJJvHXOmcoAqF6fuCPW2Mh6x47zcf2CCBxdny3x5oT3j1Wig402QAsnL1sOqubsHkvMD3Td7RHSpxgjaRPuMP9MIf-KzdCL8s/s320/Nursing_Diagnosis_for_Tetanus.jpg" id="BLOGGER_PHOTO_ID_5745895073167605986" style="cursor: hand; cursor: pointer; display: block; height: 213px; margin: 0px auto 10px; text-align: center; width: 320px;" /></a><br />
<br />
<span style="font-weight: bold;">Nursing Diagnosis for Tetanus</span><br />
<br />
1. Ineffective airway clearance<br />
<br />
2. Ineffective Breathing Pattern<br />
<br />
3. Hyperthermia<br />
<br />
4. Altered Nutrition: Less than body requirements<br />
<br />
5. Risk of fluid and electrolyte imbalance<br />
<br />
6. Risk for injury<br />
<br />
7. Knowledge deficient<br />
<br />
8. Disturbed sleep pattern<br />
<br />
<a href="http://careplannursing.blogspot.com/2012/02/hyperthermia-nursing-care-plan-for.html" target="_blank">Hyperthermia Nursing Care Plan for Tetanus</a> Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-7280176882757036422012-05-24T10:00:00.000+07:002014-08-19T00:59:31.590+07:00Nursing Care Plan for Alzheimer's Disease<b>Nursing Assessment for Alzheimer's Disease</b><br />
<br />
<span style="font-size: small;"><b>Alzheimer's disease (AD)</b> is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects a person's ability to carry out daily activities.<br />
<br />
AD begins slowly. It first involves the parts of the brain that control thought, memory and language. People with AD may have trouble remembering things that happened recently or names of people they know. A related problem, mild cognitive impairment(MCI), causes more memory problems than normal for people of the same age. Many, but not all, people with MCI will develop AD.<br />
<br />
In AD, over time, symptoms get worse. People may not recognize family members or have trouble speaking, reading or writing. They may forget how to brush their teeth or comb their hair. Later on, they may become anxious or aggressive, or wander away from home. Eventually, they need total care. This can cause great stress for family members who must care for them.<br />
<br />
AD usually begins after age 60. The risk goes up as you get older. Your risk is also higher if a family member has had the disease.<br />
<br />
No treatment can stop the disease. However, some drugs may help keep symptoms from getting worse for a limited time.<br />
<br />
<span style="font-style: italic;">NIH: National Institute on Aging</span><br />
<a href="http://www.nlm.nih.gov/medlineplus/alzheimersdisease.html" target="_blank">nlm.nih.gov</a> </span><br />
<h3 class="post-title" style="font-weight: normal;">
<br />
</h3>
<div style="text-align: center;">
<a href="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001767/bin/23214.jpg" target="_blank"><img alt="Nursing Assessment for Alzheimer's Disease" src="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001767/bin/23214.jpg" /></a></div>
<br />
<br />
<span style="font-weight: bold;">Nursing Assessment for Alzheimer's Disease</span><br />
<ol>
<li>Activity / rest<br />
Signs: anxiety, helplessness, sleep pattern disturbance, lethargy and impaired motor skills.<br />
Symptoms: feeling melting</li>
<li>Circulation<br />
Symptoms: History of cerebral vascular disease / systemic, hypertension, embolic episodes</li>
<li>Ego integrity<br />
Signs: hide incompetence, sit down and<br />
watch the other, the first activity might accumulate<br />
objects are not moving and emotional stability<br />
Symptoms: suspicious or afraid of the situation / person fantasies, misperceptions of the environment, loss of multiple.</li>
<li>Elimination<br />
Signs: Incontinence of urine / feaces<br />
Symptoms: The urge to urinate</li>
<li>Food / fluid<br />
Signs: loss of ability to chew, avoiding / refusing to eat and looked increasingly thin.<br />
Symptoms: Historical episodes of hypoglycemia, changes<br />
in taste, appetite, weight loss.</li>
<li>Hygiene<br />
Signs: a lack of personal habits, forget to go to the bathroom and less interested in eating time<br />
Symptoms: Need help, depending on other people</li>
<li>Neuro Sensory<br />
Symptoms: Improvement of symptoms that exist primarily<br />
cognitive changes, loss of sensation and existence propriosepsi<br />
history of cerebral vascular disease / systemic as well as seizure activity.</li>
<li>Comfort<br />
Signs: ekimosis laceration and a sense of hostile / attack others<br />
Symptoms: A history of serious head trauma,<br />
accident trauma</li>
<li>Social Integrity<br />
Signs: Loss of social control, inappropriate behavior<br />
Symptoms: Feeling lost power</li>
</ol>
<br />
<br />
<b>Nursing Diagnosis for Alzheimer's Disease</b><br />
<ol>
<li>Change the thought process related to :<ul>
<li>Irreversible neuronal degeneration</li>
<li>Memory Loss</li>
<li>Psychological Conflict</li>
<li>Sleep deprivation</li>
</ul>
</li>
<li>Changes in sensory perception related to :<ul>
<li>Changes in perception, transmission and / or sensory integration</li>
<li>Limitations related to the social environment</li>
</ul>
</li>
<li>Changes in sleep patterns related to :<ul>
<li>Changes in sensory</li>
<li>Psychological pressure</li>
<li>Changes in activity patterns</li>
</ul>
</li>
<li>The risk of trauma related to :<ul>
<li>The inability to recognize / identify hazards in the environment</li>
<li>Disorientation, confusion, impaired decision making</li>
<li>Weakness, the muscles are not coordinated, the presence of seizure activity.</li>
</ul>
</li>
</ol>
<br />
<br />
<b>Nursing Intervention for Alzheimer's Disease</b><br />
<br />
Nursing Diagnosis for Alzheimer's Disease<br />
<br />
<span style="font-weight: bold;">Risk for Injury</span> related to:<br />
<ul>
<li><span class="long_text" id="result_box"><span style="background-color: white;" title="tidak mampu mengenali / mengidentifikasi bahaya">Unable to</span></span> recognize / identify hazards in <span class="IL_AD" id="IL_AD8">the environment</span>.</li>
<li>Disorientation, confusion, impaired decision making.</li>
<li>Weakness, the muscles are not coordinated, the presence of seizure activity.</li>
</ul>
<br />
<span style="font-weight: bold;">Nursing Intervention for Alzheimer's Disease</span><br />
<ul>
<li>Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in <span class="IL_AD" id="IL_AD3">visual perception</span>.</li>
<li>Help the people closest to identify the risk of hazards that may arise.</li>
<li>Eliminate / minimize sources of hazards in the environment</li>
<li>Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.</li>
</ul>
<br />
<span style="font-weight: bold;">Rational:</span><br />
<ul>
<li>Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.</li>
<li>An impaired cognitive and perceptual <span class="IL_AD" id="IL_AD10">disorders</span> are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.</li>
<li>Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.</li>
</ul>
<br />
<br />
<span style="font-weight: bold;">Nursing Diagnosis for Alzheimer's Disease</span><br />
<br />
<span style="font-weight: bold;">Disturbed Thought Processes</span> related to :<br />
<ul>
<li>Irreversible neuro degeneration</li>
<li>Memory Loss</li>
<li>Psychological Conflict</li>
<li>Deprivation lie</li>
</ul>
<br />
<span style="font-weight: bold;">Nursing Intervention for Alzheimer's Disease</span><br />
<ul>
<li>Assess the level of cognitive disorders such as changes orientasiterhadap people, places and times, range, attention, thinking skills.</li>
<li>Talk with the people closest to the usual behavior change / length of the existing problems.</li>
<li>Maintain a nice quiet neighborhood.</li>
<li>Face-to-face when talking with patients.</li>
<li>Call patient by name.</li>
<li>Use a rather low voice and spoke slowly in patients.</li>
</ul>
<br />
<span style="font-weight: bold;">Rational:</span><br />
<ul>
<li>Provide the basis for the evaluation / comparison that will come, and influencing the choice of intervention.</li>
<li>Noise, crowds, the crowds are usually the excessive sensory <span class="IL_AD" id="IL_AD2">neurons</span> and can increase interference.</li>
<li>Cause concern, especially in people with perceptual disorders.</li>
<li>The name is a form of self-identity and lead to recognition of reality and the individual.</li>
<li>Increasing the possibility of understanding.</li>
</ul>
<i></i>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-21955928824647928192012-05-15T13:24:00.000+07:002014-08-19T01:02:41.098+07:00Nursing Care Plan for Myocardial Infarction<span style="font-weight: bold;">Nursing Assessment for Acute Myocardial Infarction (AMI)</span><br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnatLWnCGNtrla-xcq-N4jLN8XMB35K_uDhBbna63p9OhTE66Od0r9cvls2HCbh-HYYvjW7bxFZ3eh97lJF5eZt-fc8akE_T5ezliFwDZabcNd8B_NXTnTNod1df9QLGjtu_03nWpgNng/s1600/heart.jpg" target="_blank"><img alt="Nursing Assessment for Acute Myocardial Infarction (AMI)" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnatLWnCGNtrla-xcq-N4jLN8XMB35K_uDhBbna63p9OhTE66Od0r9cvls2HCbh-HYYvjW7bxFZ3eh97lJF5eZt-fc8akE_T5ezliFwDZabcNd8B_NXTnTNod1df9QLGjtu_03nWpgNng/s320/heart.jpg" id="BLOGGER_PHOTO_ID_5608644864210842210" style="cursor: pointer; display: block; height: 320px; margin: 0px auto 10px; text-align: center; width: 310px;" /></a><br />
<span style="font-weight: bold;">Myocardial infarction (MI)</span> or <span style="font-weight: bold;">acute myocardial infarction (AMI)</span>, commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).<br />
<a href="http://en.wikipedia.org/wiki/Myocardial_infarction" target="_blank">wikipedia</a><br />
<br />
<br />
<span style="font-weight: bold;">Primary Assessment</span> needs to be done on the <span style="font-weight: bold;">Nursing Care Plan for Acute Myocardial Infarction (AMI)</span>, among others:<br />
<br />
<span style="font-weight: bold;">Airways</span><br />
<span style="font-weight: bold;"> </span><br />
<ol>
<li>Blockage or accumulation of secretions</li>
<li> Wheezing or crackles</li>
</ol>
<span style="font-weight: bold;">Breathing</span><br />
<ol>
<li> Shortness of breath with mild activity or rest</li>
<li> Respiration more than 24 x / min, irregular rhythm shallow</li>
<li> Ronchi, crackles</li>
<li> The expansion of the chest is not full</li>
<li> Use of auxiliary respiratory muscles</li>
</ol>
<span style="font-weight: bold;">Circulation</span><br />
<ol>
<li> Weak pulse, irregular</li>
<li> Tachycardia</li>
<li> Blood pressure increase / decrease</li>
<li> Edema</li>
<li> Nervous</li>
<li> Acral cold</li>
<li> Pale skin, cyanosis</li>
<li> Decreased urine output</li>
</ol>
<br />
<span class="date-header"></span><span style="font-weight: bold;">Secondary Assessment</span> needs to be done on the <span style="font-weight: bold;">Nursing Care Plan for Acute Myocardial Infarction (AMI)</span> :<br />
<ol>
<li>Activities<ul>
<li>Symptoms:<br />
<ul>
<li> Weakness</li>
<li> Fatigue</li>
<li> Can not sleep</li>
<li> Settled lifestyle</li>
<li> No regular exercise schedule</li>
</ul>
</li>
<li>Signs:<ul>
<li>Tachycardia</li>
<li>Dyspnea at rest or activity</li>
</ul>
</li>
</ul>
</li>
<li>Circulation<ul>
<li>Symptoms:<br />
<ul>
<li> History of Acute Myocardial Infarction (AMI)</li>
<li> Coronary artery disease</li>
<li> Blood pressure problems</li>
<li> Diabetes mellitus.</li>
</ul>
</li>
<li>Signs:<br />
<ul>
<li> Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or stand</li>
<li> Pulse: normal, full or not strong or weak / strong quality with slow capillary filling, irregular (dysrhythmias)</li>
<li> Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased contractility / complaints ventricle</li>
<li> Murmur: If there are shows valve failure or dysfunction of heart muscle</li>
<li> Friction: suspected pericarditis</li>
<li> Heart rhythm can be regular or irregular</li>
<li> Edema: juguler venous distention, edema dependent, peripheral, general edema, cracles may exist with heart failure or ventricular</li>
<li> Color: Pale or cyanotic, flat nail, on mucous membranes or lips</li>
</ul>
</li>
</ul>
</li>
<li>Ego integrity<ul>
<li>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</li>
<li>Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain</li>
</ul>
</li>
<li>Elimination<ul>
<li>Signs: normal, decreased bowel sounds.</li>
</ul>
</li>
<li>Food or fluid<ul>
<li>Symptoms: nausea, anorexia, belching, heartburn, or burning</li>
<li>Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes</li>
</ul>
</li>
<li>Hygiene<ul>
<li>Symptoms or signs: difficulty perform maintenance tasks</li>
</ul>
</li>
<li>Neuro Sensory<ul>
<li>Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)</li>
<li>Signs: mental changes, weakness</li>
</ul>
</li>
<li>Pain or discomfort<ul>
<li>Symptoms:<br />
<ul>
<li> Sudden onset of chest pain (may or may not relate to activities), not relieved by rest or nitroglycerin (although most deep and visceral pain)</li>
<li> 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.</li>
<li> Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.</li>
<li> Intensity: Usually 10 (on a scale of 1-10), may experience the worst pain ever experienced.</li>
<li> Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly</li>
</ul>
</li>
</ul>
</li>
<li>Respiratory:<ul>
<li>Symptoms:<br />
<ul>
<li> Dyspnea with or without job</li>
<li> Nocturnal dyspnea</li>
<li> Cough with or without sputum production</li>
<li> History of smoking, chronic respiratory disease.</li>
</ul>
</li>
<li>Signs:<br />
<ul>
<li> Increased respiratory rate</li>
<li> Shortness of breath / strong</li>
<li> Pallor, cyanosis</li>
<li> Breath sounds (clean, cracles, wheezing), sputum</li>
</ul>
</li>
</ul>
</li>
<li>Social interactions<ul>
<li>Symptoms:<ul>
<li>Stress</li>
<li>Difficulty coping with the stressors that exist eg illness, treatment in hospital</li>
</ul>
</li>
<li>Signs:<ul>
<li>Difficulty rest - sleep</li>
<li>Response too emotional (angry constantly, fear)</li>
<li>Withdraw</li>
</ul>
</li>
</ul>
</li>
</ol>
<br />
<br />
<span style="font-weight: bold;">Nursing Diagnosis for Myocardial Infarction</span><i> </i><br />
<br />
<span style="font-weight: bold;">Nursing Intervention for Myocardial Infarction</span><i> </i>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-14398175824988599732012-04-19T17:47:00.000+07:002014-08-19T01:11:49.026+07:00Nursing Care Plan for Gastritis<b>Gastritis</b><br />
<br />
Gastritis is an inflammation of the stomach lining. Many things can cause gastritis. Most often the cause is infection with the same bacteria -- <i>Helicobacter pylori</i> -- that causes stomach ulcers. An autoimmune disorder, a backup of bile into the stomach, or long term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can also cause gastritis. In some cases, the stomach lining may be "eaten away," leading to sores (peptic ulcers) in the stomach or first part of the small intestine. Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). In most cases, gastritis does not permanently damage the stomach lining.<br />
<br />
Causes:<br />
<br />
Gastritis can be caused by infection, irritation, autoimmune disorders (where the body' s immune system mistakenly attacks the stomach), or backflow of bile into the stomach (bile reflux). Gastritis can also be caused by a blood disorder called pernicious anemia.<br />
<br />
Infections can be caused by:<br />
<ul class="CausesUL adamUL"><li class="CausesLi adamLi">Bacteria (usually <i class="CausesEmpha adamEmpha">Helicobacter pylori</i>)</li>
<li class="CausesLi adamLi">Virus (including herpes simplex virus)</li>
<li class="CausesLi adamLi">Parasite</li>
<li class="CausesLi adamLi">Fungus</li>
</ul><br />
A number of things can cause irritation, including:<br />
<ul class="CausesUL adamUL"><li class="CausesLi adamLi">Long term use of NSAIDs, such as ibuprofen (Advil, Motrin) or naproxen (Aleve)</li>
<li class="CausesLi adamLi">Alcohol use</li>
<li class="CausesLi adamLi">Cigarette smoking</li>
<li class="CausesLi adamLi">Chronic vomiting</li>
<li class="CausesLi adamLi">Coffee and acidic beverages</li>
<li class="CausesLi adamLi">Too much stomach acid (such as from stress)</li>
<li class="CausesLi adamLi">Eating or drinking caustic or corrosive substances (such as poisons)</li>
<li class="CausesLi adamLi">Trauma (for example, radiation treatments or having swallowed a foreign object)</li>
</ul><br />
Other causes for gastritis are very rare. These include:<br />
<ul class="CausesUL adamUL"><li class="CausesLi adamLi">Systemic disease (for example, Crohn's disease)</li>
<li class="CausesLi adamLi">Sarcoidosis</li>
</ul><br />
Signs and Symptoms:<br />
<br />
The most common symptoms of gastritis are stomach upset and pain. Other possible symptoms include:<br />
<ul class="Signs anUL adamUL"><li class="Signs anLi adamLi">Indigestion (dyspepsia)</li>
<li class="Signs anLi adamLi">Heartburn</li>
<li class="Signs anLi adamLi">Abdominal pain</li>
<li class="Signs anLi adamLi">Hiccups</li>
<li class="Signs anLi adamLi">Loss of appetite</li>
<li class="Signs anLi adamLi">Nausea</li>
<li class="Signs anLi adamLi">Vomiting, possibly of blood or material that looks like coffee grounds</li>
<li class="Signs anLi adamLi">Dark stools</li>
</ul><br />
<br />
Source : <a href="http://www.umm.edu/altmed/articles/gastritis-000067.htm#ixzz1sTwWy9Lg" style="color: #003399;" target="_blank">http://www.umm.edu</a><br />
<br />
<br />
<b><br />
</b><br />
<b>5 Nursing Diagnosis for Gastritis</b><br />
<br />
1. Risk for Deficient Fluid Volume related to inadequate intake, vomiting.<br />
<br />
2. Imbalanced Nutrition : Less Than Body Requirements related to inadequate intake, anorexia.<br />
<br />
3. Acute Pain related to inflammation of gastric mucosa.<br />
<br />
4. Activity intolerance related to physical weakness.<br />
<br />
5. Knowledge Deficit : about diseases related to lack of information.<br />
Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-26306897171237779672012-04-19T17:34:00.001+07:002014-08-19T01:13:12.433+07:00Nursing Care Plan for COPD<b>Chronic obstructive pulmonary disease (COPD)</b>, also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), is the occurrence of chronic bronchitis or emphysema, a pair of commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath (dyspnea). In clinical practice, COPD is defined by its characteristically low airflow on lung function tests. In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time. In England, an estimated 842,100 of 50 million people have a diagnosis of COPD.<br />
<br />
COPD is caused by noxious particles or gas, most commonly from tobacco smoking, which triggers an abnormal inflammatory response in the lung.<br />
<br />
The diagnosis of COPD requires lung function tests. Important management strategies are smoking cessation, vaccinations, rehabilitation, and drug therapy (often using inhalers). Some patients go on to require long-term oxygen therapy or lung transplantation.<br />
<a href="http://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease" rel="nofollow" target="_blank">wikipedia</a><br />
<br />
<h3 class="post-title entry-title">10 Nursing Diagnosis for Chronic Obstructive Pulmonary Disease (COPD) </h3><div class="post-header"></div><br />
<br />
<b>1. Ineffective airway clearance</b><br />
<br />
related to:<br />
<ul><li>bronchoconstriction,</li>
<li>increased sputum production,</li>
<li>ineffective cough,</li>
<li>fatigue / lack of energy,</li>
<li>bronchopulmonary infection.</li>
</ul><b>2. Ineffective breathing pattern</b><br />
<br />
related to:<br />
<ul><li>shortness of breath,</li>
<li>mucus,</li>
<li>bronchoconstriction</li>
<li>airway irritants.</li>
</ul><b>3. Impaired gas exchange</b><br />
<br />
related to:<br />
<ul><li>ventilation perfusion inequality</li>
</ul><b>4. Activity intolerance</b><br />
<br />
related to:<br />
<ul><li>imbalance between oxygen supply with demand.</li>
</ul><b>5. Imbalanced Nutrition: less than body requirements</b><br />
<br />
related to:<br />
<ul><li>anorexia.</li>
</ul><b>6. Disturbed sleep pattern</b><br />
<br />
related to:<br />
<ul><li>discomfort,</li>
<li>sleeping position.</li>
</ul><b>7. Bathing / Hygiene Self-care deficit</b><br />
<br />
related to:<br />
<ul><li>fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency.</li>
</ul><b>8. Anxiety</b><br />
<br />
related to:<br />
<ul><li>threat to self-concept,</li>
<li>threat of death,</li>
<li>purposes that are not being met.</li>
</ul><b>9. Ineffective individual coping</b><br />
<br />
related to:<br />
<ul><li>lack of socialization,</li>
<li>anxiety,</li>
<li>depression,'</li>
<li>low activity levels and an inability to work.</li>
</ul><b>10. Deficient Knowledge</b><br />
<br />
related to:<br />
<ul><li>lack of information,</li>
<li>do not know the source of information.</li>
</ul>Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.comtag:blogger.com,1999:blog-8964861545481954600.post-82281594649521696832012-02-13T10:04:00.000+07:002012-02-13T10:04:57.452+07:00Nursing Care Plan for Hemorrhoids<b>Nursing Care Plan for Hemorrhoids (Before Surgery and After Surgery)</b><br />
<br />
Hemorrhoid is the inflammation of the veins in the rectum which causes bleeding and heavy pains during bowel movement. They can be very disturbing. Hemorrhoids mostly occur in pregnant ladies and also in older people. <br />
<br />
There are two types of hemorrhoids, internal hemorrhoids and external hemorrhoids.<br />
<br />
The more common of the two types is the external type. Hemorrhoids occur when the blood vessels in the tissue of the rectum or anus become inflamed. This can happen for a large number of reasons, but the most common reason would be irregular defecation - whether it is constipation or diarrhea.<br />
<br />
The external type of hemorrhoids is more commonly noted perhaps because of the pain one feels. Internal hemorrhoids are not usually painful, even if they do rupture and release blood. However, the pain of an external hemorrhoid is easily perceived as a sign of something wrong, which causes one to examine the bowl before flushing - whereas a painless internal hemorrhoid may go unnoticed as one flushes automatically.<br />
<br />
External hemorrhoids are subject to numerous irritations as a result of their protruding nature. The most common displays that may be suffering from external hemorrhoids are:<br />
<ul><li>Presence of bleeding. It is not uncommon for external hemorrhoids to itch and bleed.</li>
<li>Itching is a common symptom and as mentioned above, this can result in bleeding. It is important to keep the area clean and dry to expedite healing.</li>
<li>Pain in the area is also a problem. People often make jokes at the expense of the hemorrhoid sufferer, but the sufferer is likely not laughing. The pain is very intense if they become thrombosed hemorrhoids. Lumps are often noticed by the hemorrhoid sufferer. They are often accompanied by an intense itching sensation.</li>
</ul>One of the symptoms oh hemorrhoids is itching sensation in the affected area. Don not scratch the affected area since they may cause bleeding and swelling and as a result the condition worsens. It is always good to keep the anal region clean and unaffected because the affected region has all chances of spreading to the remaining area.<br />
<br />
To prevent hemorrhoids it is advisable to keep the body hydrated. Drink lots of water, this eases the bowel movement and thus reduces the chances of hemorrhoids. Applying Aloe Vera externally minimizes the swelling and pain. Sitting in the same place for long time also causes hemorrhoids, therefore prevent sitting for a long time in the same place and take frequent breaks.<br />
<br />
<div style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBbk02nE-6evADjt_GZBv8UsrrmTkt4iRTH63CdM6rt8mc_KURCJ2cGVuaAZYSh58yJFFoZ88VK3OYDF5nGu6Oo_G-r-rCfjnyfjV7ZFYPFrg7_gbrSe6kTbyCMTobkmuxSz-xdqPoIxpn/s1600/19.jpg" target="_blank"><img alt="Nursing Care Plan for Hemorrhoids" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBbk02nE-6evADjt_GZBv8UsrrmTkt4iRTH63CdM6rt8mc_KURCJ2cGVuaAZYSh58yJFFoZ88VK3OYDF5nGu6Oo_G-r-rCfjnyfjV7ZFYPFrg7_gbrSe6kTbyCMTobkmuxSz-xdqPoIxpn/s1600/19.jpg" /></a></div><br />
<b>Nursing Diagnosis for Hemorrhoids (Before Surgery and After Surgery)</b><br />
<br />
1. <a href="http://nursing-care-plan.blogspot.com/2011/12/constipation-nursing-care-plan.html" target="_blank">Constipation</a> related to ignore the urge to defecate due to pain during defecation<br />
<br />
2. <a href="http://nanda-list.blogspot.com/2011/11/nanda-anxiety.html" target="_blank">Anxiety</a> related to plan surgery<br />
<br />
3. <a href="http://blog-nursingcareplan.blogspot.com/2012/02/acute-pain-related-to-hemorrhoids.html" target="_blank">Acute pain </a>related to irritation, pressure and rectal sensitivity in the area / anal and anorectal disease secondary to postoperative spasm of the sphincter.<br />
<br />
4. Impaired Urinary Elimination related to the fear of postoperative pain.<br />
<br />
5. <a href="http://careplannursing.blogspot.com/2011/12/risk-for-infection-nursing-care-plan.html" target="_blank">Risk for infection</a> related to inadequate primary defenses.<br />
<br />
6. <a href="http://careplannursing.blogspot.com/2012/02/deficient-knowledge-nursing-care-plan.html" target="_blank">Deficient knowledge</a> related to the lack of information about home care.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.com1tag:blogger.com,1999:blog-8964861545481954600.post-15245532829661377402012-02-13T09:20:00.000+07:002012-02-13T09:20:10.488+07:00Acute Pain related to Hemorrhoids<b>Acute Pain related to Hemorrhoids</b><br />
<b><br />
</b><br />
<b>Hemorrhoids </b>are essentially formed when the nerves around the rectal area, which are typical there to control the passing of the stool, encounters heavy or continuous pressure. This results in the nerves being pressed causing them to swell and are painful to the touch.<br />
<br />
<b>Hemorrhoid surgery</b> is recommended to people who have a severe case of hemorrhoids. It's the removal of swollen veins around the anus. For most people, this in not an inpatient procedure where you need to be admitting to the hospital. Unless you have prolapsed or problematic hemorrhoids.<br />
<br />
Surgery is a painful-and sometimes traumatic-experience in a person's life. Nobody can escape the after effects of excruciating pain and soreness after having spent hours in the operating room.<br />
<br />
Patients with hemorrhoids are often confronted with the possibility of a surgery and what to do after hemorrhoid surgery. The amount of time needed to recover from a surgery depends on the type of surgical procedure done to the patient. A major surgery may require a longer recovery period compared to a minor one. A hemorrhoid surgery, however, is classified under minor surgery and doesn't require the patient to spend a night at the hospital.<br />
<br />
<div style="text-align: center;"><img alt="Acute Pain related to Hemorrhoids" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEcHUEjTaNd6RfeLQzMseNAqOxxN9AnMNxMD3CvIegqdBFqrmPYGIbkSPCwstWwVNGr3sklEGcc0U-YEDycuHiNRaAhZOZ2joPign02POsUYfZKkpbGB5NzNmDOFb0iO9WGhPsbtZdzrH9/s1600/ambeien%252B2.jpg" /></div><b><br />
</b><br />
<b>Nursing Care Plan for Hemorrhoids</b><br />
<br />
<b>Nursing Diagnosis: Acute Pain</b> related to a postoperative wound<br />
<br />
PURPOSE:<br />
1) the patient's face was calm<br />
2) normal vital signs<br />
3) The patient said the pain is reduced or lost<br />
4) The patient can rest, sleep<br />
<br />
NURSING INTERVENTION:<br />
<br />
1. Give the patient a pleasant sleeping position.<br />
Rational: to lower the voltage abdomen<br />
<br />
2. Change the bandage every morning according to aseptic techniques.<br />
Rationale: to protect patients from cross contamination during the dressing change. Acted as a wet dressing of external contamination and cause discomfort.<br />
<br />
3. Exercise road as early as possible.<br />
Rational: to reduce the problems that occur due to immobilization.<br />
<br />
4. Observations of the rectal area if there is bleeding<br />
Rational: bleeding on the network, local inflammation or infection can increase the pain.<br />
<br />
5. Provide an explanation of the purpose of installation of flue-anus (anus to funnel to drain the remnants of the bleeding that occurs in order to get out).<br />
Rational: knowledge about the benefits of the chimney to make the patient understand the anus to funnel anus to cure the wound.Si Krisnahttp://www.blogger.com/profile/04680712385648790411noreply@blogger.com1