Care Plan Nursing

Irritant and Allergic Contact Dermatitis - Definition and Causes

2016-02-09T17:55:00.000+07:00

Contact Dermatitis

Contact dermatitis is dermatitis caused by contact with a substance / certain materials attached to the skin and cause allergic or irritant reaction. The rash is limited to specific areas and often have strict limits. There are two types of contact dermatitis, namely:

1. Irritant Contact Dermatitis

Definition

Irritant contact dermatitis is a contact dermatitis caused by materials that are irritants that can cause tissue damage. Irritant contact dermatitis is divided into two, namely acute irritant contact dermatitis and chronic irritant contact dermatitis (cumulative).
1. Acute Irritant contact dermatitis is an irritant dermatitis that occurs immediately after contact with substances that are toxic irritant strong, for example, concentrated sulfuric acid.
2. Chronic irritant contact dermatitis (Cumulative) is an irritant dermatitis that occurs due to frequent contact with materials that are not so strong irritants, such as soap detergents, antiseptic solution.

Causes

The cause of this type of dermatitis are materials that are irritants, such as solvents, detergents, lubricating oils, acid alkali, sawdust, abrasive, a solution of concentrated salts, low molecular weight plastic or hygroscopic chemicals or toxins and animal enzymes.

2. Allergic Contact Dermatitis

Definition

Allergic contact dermatitis is a dermatitis or inflammation of the skin that occurs after contact with an allergen through the process of sensitization. Allergic contact dermatitis is an allergic contact dermatitis due to sensitization to the substance of a diverse causing an inflammatory reaction in the skin for those who experience hypersensitivity to allergens as a result of previous exposure.

Causes

The cause of allergic contact dermatitis are allergens, most commonly in the form of chemicals with less weight of 500-1000 Dalton, which is also called a simple chemical. Dermatitis arising influenced by the potential allergen sensitization, the degree of exposure, and the extent of penetration of the skin.
Dermatitis is usually present as acute vesicular dermatitis in a few hours to 72 hours after contact. Course of the disease peaked at 7 to 10 days, and recovered within 2 days in the absence of repeated exposure. The most common reaction is rhus dermatitis, which is an allergic reaction to poison ivy and poison smack. Predisposing factors that cause allergic contact is any circumstance causing skin integrity is compromised, for example static dermatitis.

Seven Things You Can Do To Prevent Alzheimer's Disease

2016-02-06T09:38:00.002+07:00

How To Prevent Alzheimer's Disease - Alzheimer's Disease is one of the most feared diseases of everyone. This disease can make a person lose mind and thoughts. Alzheimer's also a lot of attacking young children. Actually Alzheimer's is strongly influenced by genetic factors, but health experts observed that there are other factors that can make someone stricken with Alzheimer's. These factors, among others, nutrition, education, diabetes, and mental as well as physical activity.

By knowing how much the effects of the disease, of course, prevention must be done as early as possible. Alzheimer's disease is difficult to treat, but Alzheimer's can still be prevented. How can I prevent Alzheimer's? Here are seven things you can do to prevent Alzheimer's.

1. Consumption of foods containing antioxidants

Foods with antioxidants can prevent dementia and preventing certainly prevent Alzheimer's. Lots of vegetables and fruits that are rich in antioxidants. In addition, tea also contains many antioxidants.

2. Reduce fatty foods

Not only obesity, fat may also trigger changes in brain function for the better or worse. Alzheimer's can also be triggered from fatty foods. Should reduce the consumption of saturated fats because it can make the brain cells which become inefficient. Besides reducing the consumption of fried foods such as fried foods, fried rice, etc.

3. Exercise

Diligent exercise turned out to stimulate the production of good cholesterol. The researchers claim the good cholesterol can serve as an anti-inflammatory for preventing damage to the brain system.

4. Stimulation of brain growth

The brain begins to shrink at the age of 30-40 years. But investigators believe a person can increase the size of the brain by studying diligently. Try to learn new things, expand friendship as stimulation, reading books, browsing the Internet or buying games that stimulate the brain.

5. Reduce Sweet foods

Sweet foods not only cause weight problems. Many sweet meal can also initiate brain damage. Suzanne de La Monte, MD, MPH, a neuropathologist from Brown University with a team doing research. Shows that eating too much sugar can cause insulin resistance that worsen the condition of the brain.

6. Cook your own meals at home

By cooking your own meals, we can ensure itself the materials used are the best and healthier than buying food outside.

7. Keep Your Teeth

Teeth and gums are not clean can be toxic to the brain and tends to make the memory is getting low. Therefore diligent brushing and flossing can help keep your teeth and sharpen memory.

Nursing Care Plan for Hyphema : Acute Pain

2015-10-16T10:36:00.002+07:00

Hyphema or blood in the anterior chamber can occur due to blunt trauma (Sidarta, 1998). When the patient is sitting, hyphema will be seen to collect in the bottom of the anterior chamber and hyphema can occupy the entire space anterior chamber. Blood in the aqueous humor fluid can form a layer that is visible. This type of injury does not have to lead to perforation of the eyeball.

Acute pain related to exposure of pain receptors secondary to blunt trauma.

Goal: The pain is reduced

Expected outcomes:

The patient demonstrated knowledge of pain control.
The patient experience and demonstrate a period of sleep is not disturbed.
The patient expresses pain decreased with mild pain scale (1-3).

Interventions:

Assess the type, intensity and location of pain.
Use pain scale levels to determine the dose of analgesics.
Maintain bed rest in an upright position or the position of head of 60º.
Perform eye bandage on the affected part.
Give a cold compress to reduce pain and swelling.
Give sedation to minimize activity.
Collaboration: Giving therapy to reduce pain.
Give a back rub, a change of position for
increase comfort.
Help teach relaxation techniques.

Pain and Anxiety - NCP for Uterine Myoma (Fibroid)

2015-10-10T08:50:00.001+07:00

Uterine Myoma (Fibroid)

Uterine fibroids are benign smooth muscle tumors of the uterus. The exact cause is unclear. However, fibroids run in families and appear to be partly determined by hormone levels. Symptoms depend on the location and size of the fibroid. Important symptoms include abnormal uterine bleeding, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary frequency or retention, and in some cases, infertility.

Pain (acute / chronic) related to intrauterine tissue damage.

Goal: Pain is reduced.

Expected outcomes:

0-1 pain scale,
The client said the pain was reduced until it disappears,
Do not feel pain during mobilization,
Vital signs within normal limits.

Intervention:
1) Review the pain scale.
R /: Identify needs and appropriate interventions.

2) Encourage clients to use relaxation techniques and pain distraction.
R /: To divert the attention of the mother and the pain that is felt.

3) Motivation: for mobilization as indicated.
R /: Accelerating involution and reduce the pain gradually.

4) Encourage clients to rest.
R /: Reduce pain.

5) Collaboration: providing analgesic.
R /: Loosening the peripheral nervous system to decrease pain.

Anxiety related to lack of knowledge.

Goal: The client is not worried.

Expected outcomes:

No anxiety,
Knowledge of the client and family to disease increases.

Intervention:
1) Assess the level of knowledge / perceptions of the client and family to the disease.
R /: Ignorance can be the basis of the onset of anxiety.

2) Help clients to identify the causes of anxiety.
R /: Involving the client actively in nursing action is the support that may be useful for clients and increase client self-awareness.

3) Encourage the client to express feelings.
R /: Helps to increase the comfort of the client.

4) Give the physical comfort and security environment on the client.
R /: Giving comfort of the client.

5) Explain the things around curettage to be known by the client and family.
R / Counselling for clients is needed to increase knowledge and build support sisterm families to reduce the anxiety of clients and families.

Deficient Knowledge - Rheumatoid Arthritis Nursing Care Plan

2015-10-09T15:31:00.001+07:00

Nursing Care Plan for Rheumatoid Arthritis

Deficient Knowledge (about the disease, prognosis, and treatment needs) related to the lack of exposure / recall, misinterpretation of information.

Evidenced by:

Questions / requests for information, statements misconceptions.
Not exactly follow the instruction / complications can be prevented.

Expected outcomes: The patient will be:

Demonstrate an understanding of the condition / prognosis, treatment.
Develop a plan for self-care, including lifestyle modifications consistent with mobility or activity restrictions.

Intervention and Rationale

1. Review the process of the disease, prognosis, and future expectations.
R /: Provide knowledge of where patients can make informed choices.

2. Discuss the habits of the patients in the management of the hospital, through; diet, medication, and a balanced diet, exercise and rest.
R /: The purpose of disease control is to suppress the inflammatory own / other tissue to maintain joint function and prevent deformity.

3. Assist in planning integrated realistic schedule of activities, rest, personal care, administering medications, physical therapy, and stress management.
R /: Provide structure and reduce anxiety during the handling of complex chronic disease processes.

4. Emphasize the importance of continuing management pharmacotherapeutics.
R /: Advantages of drug therapy depends on the accuracy of the dose.

5. Encourage digest medication with food, milk, or an antacid at bedtime.
R /: Limiting irrigation gastric, pain reduction will improve sleep and reduce stiffness in the morning.

6. Identification of the side effects of drugs that harm, eg tinnitus, gastrointestinal bleeding, and purpuric rash.

7. Emphasize the importance of reading product labels and reduce drug use-the-counter medicines without a doctor's approval.
R /: Many products contain salicylic hidden that can increase the risk of servings worth of drugs / dangerous side effects.

8. Review the importance of a balanced diet with foods rich in vitamins, protein and iron.
R /: Increase the general healthy feeling and tissue repair.

9. Encourage obese patients to lose weight and provide information about weight loss as needed.
R /: Weight reduction will reduce the pressure on the joints, especially the hips, knees, ankles, feet.

10. Provide information about the tools.
R /: Reduce compulsion to use the joints and allows individuals to participate more comfortably in activities that are necessary.

Nursing Diagnosis and Interventions for Pediatric GERD

2015-10-09T10:21:00.001+07:00

Gastroesophageal reflux disease (GERD) is a chronic digestive disease. GERD (gastroesophageal reflux disease) is a condition in which the acidified liquid content of the stomach backs up into the esophagus.

The cause of GERD is complex and may involve multiple causes.

Like in adults with the condition, gastroesophageal reflux is the upward movement of stomach contents into the esophagus and sometimes into or out of the mouth.

According to the National Digestive Disease Information Clearinghouse, a child's immature digestive system is usually to blame. They add that most infants grow out of GERD by the time they are 1 year old.

Symptoms of Acid Reflux in Infants and Children

Frequent or persistent cough
Crying with feeding or after feeding
Heartburn, gas, or abdominal pain
Frequent or recurrent vomiting
Refusing to eat or difficulty eating (choking or gagging with feeding)

Nursing Diagnosis for Gastroesophageal Reflux Disease (GERD)

Deficient Fluid Volume related to input, nausea and vomiting / excessive spending.
Acute pain related to inflammation of the esophagus lining.
Imbalanced Nutrition: less than body requirements related to anorexia, nausea, vomiting.
Risk for Impaired Gas Exchange
Risk for Impaired Home Maintenance
Risk for Aspiration related to barriers to swallow, decreased reflux larynx and glottis to liquid reflux.
Ineffective airway clearance related to fluid reflux into the larynx and throat.
Impaired swallowing related to narrowing / stricture of the esophagus due to gastroesophageal reflux disease.
Anxiety related to the disease process.

Nursing Interventions for Gastroesophageal Reflux Disease (GERD)

1. Increase fluid intake and adequate nutrition.

Keep head of bed at a position 60 degrees for 30 minutes to 40 minutes.
Give food a little but often 2 to 3 hours.
Thicken the milk with cereal.
Give dinner.
Measure weight each morning.
Monitor intake and output.

2. Observe and report any signs of respiratory distress, assess for changes in respiratory status.

3. Before the surgery is done to prepare the client and family for surgery.

4. Monitor the operating side to wholeness.

5. Prevent abdominal distension.

Maintain patency of a nasogastric tube (NG) or gastrostomy, if installed.
Check hose NG position.
Auscultation bowel sounds.

6. Monitor for signs and symptoms of postoperative hemorrhage.

Decreased blood pressure and increased pulse apex.
Blood in NG drainage.
Drainage like coffee grounds would exist in the first 24 hours.

7. Help the parents to express feelings or frustration because they feel responsible or not enough help.

8. Give the stimulation activity.

Discharge planning and home care.
Encourage parents about drug administration.
Encourage parents about feeding.
Encourage parents to report any vomiting or presence of fresh blood.

Difficulty Swallowing (Dysphagia) related to Throat Disorders

2015-10-05T18:44:00.002+07:00

Dysphagia is difficulty swallowing.

A person may have difficulty moving the food from the upper part of the throat into the esophagus because of abnormalities in the throat.

This problem most often occurs in people who have abnormalities in voluntary muscle (skeletal muscle) or nerves, that sufferers:

Dermatomyositis: Dermatomyositis (DM) is a connective-tissue disease related to polymyositis (PM) that is Characterized by inflammation of the muscles and the skin.
Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal (voluntary) muscles of the body.
Muscular dystrophy is a group of diseases that cause progressive weakness and loss of muscle mass.
Poliomyelitis (polio) is a highly infectious viral disease, which mainly affects young children.
Pseudobulbar palsy is a medical condition characterised by the inability to control facial movements (such as chewing and speaking) and caused by a variety of neurological disorders.
Disorders of the brain and spinal cord such as Parkinson's disease and amyotrophic lateral sclerosis (Lou Gehrig's disease).
People who drank phenothiazines (antipsychotic drugs) could also have trouble swallowing because the drug affects the throat muscles.

When one of these abnormalities cause difficulty swallowing, patients often regurgitating food through the nose, or breathe it into the trachea (windpipe) and will coughed.

At cricopharyngeal incoordination, valve upper esophagus (cricopharyngeal muscle) remain closed or opened by means uncoordinated.

Abnormal functioning valve that allows food repeatedly into the trachea and lungs, which causes chronic lung disease.

When untreated, this condition can lead to the formation of diverticula, a sac formed when layers of the esophagus pushed out and backwards through cricopharyngeal muscle.

Dysphagia is generally a symptom of a disorder or disease in the oropharynx and esophagus.

Clinical manifestations are often found is the sensation of food stuck in the throat or chest when swallowing. Locations sense of heaviness in the chest area, it can show abnormalities in the thoracic esophagus. But if the blockage is in the neck, disorder located in the pharynx or cervical esophagus.

Symptoms can be of two types, namely; oropharyngeal dysphagia and esophageal dysphagia. Oropharyngeal dysphagia symptom is difficulty trying to swallow, choking or inhaling saliva into the lungs during swallowing, coughing during swallowing, vomiting fluids through the nose, breathe while swallowing food, weak voice, and weight decreased. While the symptoms of esophageal dysphagia is the sensation of pressure in the middle of the chest, sensation of food stuck in the throat or chest, chest pain, painful swallowing, heartburn include chronic, belching, and sore throat.

Dysphagia can also be accompanied by other complaints, such as nausea, vomiting, regurgitation, hematemesis, melena, anorexia, hypersalivation, cough, and rapid weight loss is reduced.

Difficulty swallowing can occur in all age groups, resulting from congenital abnormalities, structural damage, and / or certain medical conditions. Problems in swallowing is a common complaint obtained among the elderly. Therefore, the incidence of dysphagia is higher in the elderly and in patients with stroke. Approximately 51-73% of stroke patients suffering from dysphagia.

Nursing Care Plan for Dysphagia

8 Benefits of Distance Learning

2015-10-05T17:36:00.001+07:00

Distance Learning is a solution-based learning model of teaching and learning activities are constrained by time, space, and human resources. Need to be agreed beforehand that the model of distance learning can be divided into several parts. The first part is a distance learning within the scope of e-learning, which is an online media that have the resources to support the process of teaching and learning activities based on information technology over the internet. This system may contain material of books, teaching modules, practice questions, and discussion forums.

According Soekartawi (2005), there are several benefits of distance learning, which are:

Learning can be done with the nature of open, flexible and not limited by time. Long learning time also depends on the ability of each learner. Learners can determine at any time to learn, according to the availability of time each. If the learner has achieved the learning objectives, he can stop it. Conversely, if the learner still needs time to repeat the subject of learning, he can immediately repeat it without depending on other learners or teachers. Remembering, learning materials stored in the computer, it means the material is easily updated in accordance with the development of science and technology. The learners can ask the things that are poorly understood directly to the teacher, so that the accuracy of the answers can be guaranteed.
Help the interaction between the students who are in remote areas and lecturer / instructor with the holding of regular meetings;
Reach learners in a wide scope for improving educational equity. Possible occurrence of education distribution to all corners of the country with a capacity of unlimited capacity, because it does not require a classroom. Teachers and students do not need to be face to face directly in the classroom, because that is used is a computer facility connected to the Internet or intranet. Thus, with this kind of learning will reduce the operational costs of education, such as the cost of construction and building maintenance, transportation, lodging, paper, stationery and so on.
Reducing the school dropout rate, or dropped out of college.
Improving learning achievement, especially for students who experience barriers geographically as far from the site of learning.
Increase confidence for learners.
Increase the depth of knowledge that no longer limited by distance, time, or age. Learners can choose a topic or instructional materials in accordance with the wishes and needs of each. This is very good because it can support the achievement of learning goals. Such is believed to be the educator, that learners will be very effective when in accordance with the wishes and needs of learners.
Overcome the shortage of education.

Levels of Health Education Services

2015-10-05T17:17:00.003+07:00

Health education can be based on five levels of prevention, namely:

1) Health Promotion
At this level of health education is needed, for example in personal hygiene, environmental sanitation, regular health checks, nutrition and healthy living habits.

2) Specific Protection
At this level of health education is needed to increase public awareness. for example; about the importance of immunization as a means of protection against disease in both children and adults. The immunization program is a special protection service.

3) Early Diagnosis and Prompt Treatment
At this level of health education is needed because of the low level of knowledge and awareness about health and disease that occurs in people. This situation makes it difficult to detect a disease that occurs in the community, people do not want to check and treat the disease. Prevention level activities include finding case, cure and prevention of the disease process continues, preventing the spread of infectious diseases, and prevention of complications.

4) Disability Limititaton
At this level of education necessary because public health is often obtained not want to continue treatment to completion or unwilling to perform the examination and treatment of the disease completely or do not want to do the examination and treatment of the disease completely. This happens due to lack of understanding and awareness of health and illness. At this level of activities include treatments to stop the disease, prevention of further complications, overcome disability and prevent death.

5) Rehabilitation
At the level of health education is needed because after recovering from a particular disease, one might be defective. To remedy the flaws that needed training. To perform an exercise properly determined in accordance program, there needs to be an understanding and awareness of the people concerned. In addition, there is a sense of shame and fear are not acceptable for return to the community after recovering from an illness or perhaps people do not want to receive other community members who are recovering from an illness.

Clinical signs of Urinary Retention

2015-10-05T16:34:00.001+07:00

Urinary retention is a buildup of urine in the bladder due to the inability of the bladder to empty the bladder.

The main symptoms of acute urinary retention is no urine output for several hours and there is a distended bladder. Clients who are under the influence of anesthetics or analgesics may only feel pressure, but clients are aware of the great pain due to bladder distension beyond its normal capacity. In severe urinary retention, bladder can hold 2000 to 3000 ml of urine. Retention caused by urethral obstruction, trauma surgery, changes sensory and motor nerve stimulation of the bladder, side effects of medication and anxiety.

Clinical Signs of Urinary Retention:

Inconvenience for the pubic area.
Distended bladder.
Inability to urinate.
Frequent urination when the bladder contains little urine (25-50ml).
The imbalance in the amount of urine output and intake.
Increasing concerns and the desire to urinate.
The presence of urine in the bladder 3000-4000ml.

Urinary retention can cause an infection that can result from excessive bladder distension, impaired blood supply to the bladder wall and the proliferation of bacteria. Impaired renal function may also occur, especially when there is obstruction of the urinary tract.

Anemia - Assessment and 4 Nursing Diagnosis

2015-08-13T22:58:00.002+07:00

Nursing Care Plan for Anemia

Assessment

1. Activity / Rest

Fatigue, weakness, general malaise.
Loss of productivity, reduction in the passion for work.
Low tolerance for exercise.
The need for rest and sleep more.

2. Circulation

A history of chronic blood loss.
A history of chronic infective endocarditis.
Palpitations.

3. Integrity ego

Religious or cultural beliefs influence the selection of treatment, for example: rejection of blood transfusions.

4. Elimination

A history of pyelonephritis, kidney failure.
Flatulence, malabsobsi syndrome.
Hematemesis, Melana.
Diarrhea or constipation

5. Food / liquids

Decreased appetite.
Nausea / vomit.
Body weight decreased.

6. Pain / comfort

The location of pain, especially in the abdomen and head.

7. Breathing

Shortness of breath at rest or activity

8. Seyuality

Menstrual changes, for example; menorrhagia, amenorrhea
Decreased sexual function.
Impotence.

Nursing Diagnosis

1. Impaired tissue perfusion related to a decrease in the supply of oxygen / nutrients to the cells.

Characterized by:

Palpitations,
Pale skin, mucous membranes dry, brittle nails and hair,
Cold extremities,
Changes in blood pressure, slow capillary refill,
Inability to concentrate, disorientation.

2. Activity intolerance related to imbalance of oxygen supply

Characterized by:

Weakness and fatigue,
Complained decrease in activity / exercise,
More need of rest / sleep,
Palpitations, tachycardia, increased blood pressure.

3. Imbalanced Nutrition: less than body requirements related to failure to digest, absorption of food

Characterized by:

Weight loss is normal,
Decrease skin turgor, oral mucosal changes,
Decreased appetite, nausea,
Loss of muscle tone.

4. Constipation or diarrhea related to a decrease in the amount of food, change the digestive process, adverse effects of drug use

Characterized by:

Any changes in the frequency, characteristics, and the amount of feces,
Nausea, vomiting, decreased appetite,
Abdominal pain,
Peristaltic disorders.

Nursing Diagnosis for Diabetic Foot Ulcers

2015-02-12T13:35:00.000+07:00

Diabetic foot ulcers are one of the complications that are often found in people with diabetes mellitus (DM). It is estimated that 5-10% of people with diabetes found any ulceration of the legs, and about 1% of them will undergo amputation. Four of the five non-traumatic amputation in adults caused by diabetic foot. Besides being a problem for people, also be costs for patients or the government.

The cause of diabetic foot ulcers multifactorial, however there are three things that are most important as the pathogenesis of diabetic foot are:

neuropathy (sensory, motor and autonomic).
impaired circulation (microcirculation and makrosirkulasi), and
infection.

Socio-economic factors and the level of knowledge is an important factor to poor people with diabetic foot ulcers circumstances. Lack of understanding of the patient regarding the prevention of diabetic foot and leg hygiene factors heighten the incidence of diabetic foot ulcers. In addition, both of these factors are often a cause of diabetic foot infections with broad.

Factors that influence the occurrence of diabetic ulcers are divided into endogenous factors and ekstrogen.
1) Endogenous factors

Genetic, metabolic.
Diabetic angiopathy.
Diabetic neuropathy.

2) Exogenous factors

Trauma.
Infection.
Drug.

Nursing Diagnosis for Diabetic Foot Ulcer

Impaired tissue perfusion related to the weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels.
Impaired tissue integrity related to the presence of gangrene in the extremities.
Impaired sense of comfort (pain) related to ischemic tissue.
Impaired physical mobility related to pain in the wound.
Risk for Infection (sepsis) related to high blood sugar levels.
Disturbed Sleep Pattern related to pain in the wound in the leg.

Nursing Care Plan for Cellulitis

2015-01-30T23:38:00.001+07:00

Cellulitis is a skin disorder that is characterized by redness, swelling, tenderness and pain in the skin due to inflammation of the connective tissue of the skin caused by a bacterial infection. Infected people generally feel unwell with fever, chills and shaking. It occurs when bacteria like streptococcus and staphylococcus attack injured or damaged skin, such as body piercing, eczema or open wounds. Although the infection can spread to the adjacent skin, this disorder is not contagious because it occurs in the deepest skin layers. This condition can occur any body part, but more often in the arms, lower legs, neck and head area. Can be cured with antibiotics, but it needs to do a skin biopsy to detect bacteria. If left untreated, can cause blood poisoning (sepsis), endocarditis (an infection of the heart valves form) or necrotizing fasciitis (a serious infection of the tissue), where all of this is a medical emergency.

Nursing Care Plan for Cellulitis

Assessment

1. Identity
Name, gender, age, marital status, religion, ethnicity, education, language spoken, occupation, address.

2. History of the disease.

3. The main complaint
Patients usually complain of pain in the wound, sometimes accompanied by fever, chills and malaise.

4. Past medical history.
Asked cause injury to the patient and the disease before it ever like this, is there any allergy owned and history of drug use.

5. History of present illness
There are injuries to specific body parts with characteristic red color, soft, swollen, warm, painful, tense and shiny skin.

6. The family medical history
Usually there is a history in the family of patients suffering from diseases of cellulitis or other skin diseases.

7. The state of emotion psychology
The patient was calm, and emotionally stable.

8. The state of socio-economic
Usually attack on socioeconomic simple.

Physical Examination
1. General condition : Weak
Blood Pressure : decreased (less than 120/80 mmHg).
Pulse : decreased (less than 90 times / min).
Temperature : Increased (more than 37.5 degrees Celsius).
Respiration : Normal.
2. Head : Seen cleanliness, shape, is there any edema or not.
3. Eyes : Not anemic, no jaundice, light reflex (+).
4. Nose : No respiratory lobe.
5. Mouth : Health, not pale.
6. Ear : No wax.
7. Neck : No enlargement of the gland.
8. Heart : Heart rate increased.
9. Extremities : Are there any injuries to the extremities.
10. Integumentary : Early symptoms include redness and tenderness felt in a small area on the skin. Infected skin becomes hot and swollen, and looks like an orange peel peeling (peau d'orange). On the infected skin can be found a small fluid-filled blisters (vesicles) or a large fluid-filled blisters (bullae), which can rupture.

Nursing Diagnosis for Cellulitis

Acute pain related to local inflammatory response of subcutaneous tissue.
Hyperthermia related to the process of infection / inflammation systemic.
Risk for infection related to the presence of skin lesions.
Impaired tissue integrity related to the presence of red lesions.
Impaired physical mobility related to neuromuscular disorders, pain / discomfort, decreased strength and resistance.

Nursing Care Plan for Low Birth Weight - Risk for Infection

2015-01-21T23:01:00.000+07:00

Low birth weight babies are babies born with birth weight less than 2500 grams regardless of pregnancy. Birth weight is the weight of a baby who weighed within 1 hour after birth.

The cause of LBW is very complex. LBW can be caused by pregnancy preterm, small for gestational age baby or a combination of both.

Preterm babies are babies born before 37 weeks' gestation. Most preterm infants are not ready to live outside the womb and find it difficult to start breathing, sucking, fight infection and keep the body in order to keep warm.

Low birth weight (LBW) is newborn birth weight less than 2500 grams (up to 2499 grams). Associated with the handling and life expectancy, low birth weight babies are distinguished in:

Low birth weight 1500-2500 g birth weight.
Very low birth weight, birth weight less than 1500 grams.
Extreme low birth weight, birth weight less than 1000 grams.

(Prawirohardjo, 2002)

Immediate complications that can occur in infants of low birth weight among others:

Hypothermia.
Hypoglycemia.
Fluid and electrolyte disturbances.
Hyperbilirubinemia.
Respiratory distress syndrome.
Infection.
Intravascular hemorrhage.
Apnea of prematurity.
Anemia.

Long-term problems that may arise in LBW among others:

Developmental disorders.
Impaired growth.
Visual impairment.
Hearing disorders.
Chronic lung disease.
The increase in the frequency of congenital abnormalities.

Nursing Diagnosis : Risk for infection related to immunological defense ineffective.

Goal: There are no signs of infection.

Expected outcomes:

Normal temperature.
No signs of infection.
Leukocytes 5000-10000.

Nursing Interventions :

Assess for signs of infection.
Perform insulation another baby suffering from an infection at the discretion of institutions.
Before and after handling the baby, do handwashing.
Make sure all equipment is in contact with the baby clean and sterile.
Prevent personal transmitted infections for no direct contact with the baby.

Rationale:

To find early signs of infection.
Actions taken to minimize the occurrence of infection wider.
To prevent infection.
To prevent infection persists in infants.

Nursing Care Plan for Osteosarcoma - Impaired Physical Mobility

2015-01-14T10:17:00.002+07:00

Osteosarcoma is a primary malignant bone tumors are the most common and often fatal and can occur as a secondary metastases from extremity limb in 50% of cases. Usually found on the former site of radiation or more often as a broadcaster in Paget's disease. Osteosarcoma often occurs in men in the age group 10-25 years and the parents who have Paget's disease.

Nursing Diagnosis for Osteosarcoma : Impaired physical mobility related to muskuluskletal damage, pain, and amputation.

Goal: mobillitas physical damage is resolved entirely.

Subjective data: The client said it was difficult to move.
Objective data: The client looks impaired coordination; decreased muscle strength, control and mass.

Expected outcomes:

The patient stated understanding of individual situations, treatment programs, and security measures,
The patient seemed to participate in training programs / shows willingness to participate in activities,
The patient showed technique / behaviors enabling the move action, and
The patient seemed to maintain coordination and mobility corresponding optimal level.

Intervention:

1. Assess the level of immobilization caused by edema and the patient's perception of immobilization.
R /: The patient will restrict the movement as one of perception (perception are not proportional).

b. Encourage participation in recreational activities (watching TV, reading newspapers, etc.).
R /: Provides the opportunity to expend energy, focus, improve the patient's sense of self control and help in reducing social isolation.

3. Instruct the patient to perform active and passive exercises on the injury or not.
R /: Increases blood flow to the muscles and bones to improve muscle tone, maintain joint mobility, prevent contractures / atrophy and reapsorbsi Ca unused.

4. Assist patients in self-care.
R /: Increases strength and muscle circulation, improve the patient in control of the situation, increasing the willingness of the patient to recover.

5. Provide High-protein diet and High calories, vitamins, and minerals.
R /: Speed up the process of healing, prevent weight loss, because the immobilization usually weight loss.

6. Collaboration with the physiotherapy department.
R /: To determine the exercise program.

Nursing Care Plan - Diarrhea : Assessment and Diagnosis

2014-08-20T21:46:00.000+07:00

Nursing Care Plan for Diarrhea

Diarrhea is a disease characterized by increased frequency of defecation more than usual (more than 3 times / day) accompanied by a change in stool consistency (a liquid), with / without blood and / or mucus (Suraatmaja, 2007).

Around the world there are approximately 500 million children suffer from diarrhea each year, and 20% of all deaths in children living in developing countries associated with diarrhea and dehydration. Diarrheal disorders can involve the stomach and intestines (gastroenteritis), small intestine (enteritis), colon (colitis) or colon and intestines (enterocolitis). Diarrhea is usually classified as acute and chronic diarrhea (Wong, 2009).

Diarrhea is a condition of increased fecal weight (more than 200 mg / day) which can be attributed to increased fluid, the frequency of bowel movement, not feeling the perianal, and a sense of urgency for bowel movements with or without fecal incontinence. Diarrhea is divided into Acute and Chronic diarrhea. Acute diarrhea lasts 2 weeks or less, while chronic diarrhea duration of more than 2 weeks. Further discussion regarding devoted chronic diarrhea (Hooward, 1995 cit Sutadi 2003).

Classification

According to WHO (2005) diarrhea can be classified to:

Acute diarrhea, ie diarrhea lasting less than 14 days.
Dysentery, the diarrhea is accompanied by blood.
Persistent diarrhea, the diarrhea that lasts more than 14 days.
Diarrhea accompanied by severe malnutrition.

According to Ahlquist and Camilleri (2005), diarrhea divided into:

Acute, if less than 2 weeks, persistent if it lasts for 2-4 weeks. More than 90% of the causes of acute diarrhea are the causative agents of infectious and will be accompanied by vomiting, fever and abdominal pain. 10% were caused by the treatment, intoxication, ischemia and other conditions.
Chronic, if it lasts more than 4 weeks. In contrast to acute diarrhea, a common cause of chronic diarrhea caused by non-infectious causes such as allergic and others.

According Kliegman, Marcdante and Jenson (2006), states that based on the amount of loss of fluid and electrolytes from the body, diarrhea can be divided into:

Diarrhea without dehydration: At this rate of diarrhea sufferers do not become dehydrated because of diarrhea frequency is still within tolerable limits and there are no signs of dehydration.
Diarrhea with mild dehydration (3% -5%): At this level patients with diarrhea 3 times or more, sometimes vomiting, thirsty, have decreased urination, decreased appetite, activity has begun to decline, the pressure pulse is normal or tachycardia minimum and a physical examination within normal limits.
Diarrhea with moderate dehydration (5% -10%): In this situation, the patient will experience tachycardia, urinating less or no, irritability or lethargy, eye and large fontanel becomes concave, reduced skin turgor, mucous membranes of the lips and mouth and the skin appears dry, reduced tear and the elongated capillary refill (greater or equal to 2 seconds) with skin cold and pale.
Diarrhea with severe dehydration (10% -15%): In this situation, the patient has lost a lot of fluid from the body and is usually in a state of patients experienced tachycardia with weak pulse, hypotension and pulse pressure spreads, no urine output, eyes and large fontanel becomes very concave, no tear production, not being able to drink and the situation began to apathy, decreased consciousness and also the very elongated capillary refill (greater or equal to 3 seconds) with a cold and pale skin.

Nursing Care Plan for Diarrhea

Assessment

1. Identity
Noteworthy is the age. Episodes of diarrhea occurred in the first 2 years of life. Highest incidence is 6-11 months age group. Most bacteria stimulate gut immunity against infection, it helps explain the decline insidence disease in older children. At the age of 2 years or more of active immunity begins to form. Most cases are due to intestinal infection and asymptomatic enteric bacteria spread mainly clients are not aware of the infection. Economic status also influential, especially from the diet and treatment.

2 The main complaint
Defecate more than 3 times, vomiting, diarrhea, bloating, fever.

3. History of present illness
Defecating yellow-green color, mixed with mucus and blood or mucus only. Watery consistency, frequency is more than 3 times, spending time: 3-5 days (acute diarrhea), more than 7 days (prolonged diarrhea), more than 14 days (chronic diarrhea).

4. Past medical history
Never before have diarrhea, use of antibiotics or corticosteroids long term (candida albicans changes from saprophyte become parasites), food allergies, respiratory infections, UTI, OMA measles.

5. History of nutrition
At toddler age children are given food as in adults, the portion given 3 times per day with additional fruit and milk. Malnutrition in children toddler age are particularly vulnerable. The way good food management, food hygiene and sanitation, hand washing habits.

6. Family health history
There is one family that is experiencing diarrhea.

7 History of environmental health
Food storage at room temperature, less hygiene, neighborhood.

Nursing Diagnosis for Diarrhea

Diarrhea
Hyperthermia
Deficient Fluid Volume
Anxiety: parents
Deficient Knowledge : on diarrheal disease
Decreased cardiac output
Ineffective breathing pattern
Activity intolerance

Nursing Care Plan for Endocarditis

2014-08-12T14:04:00.001+07:00

Nursing Diagnosis for Endocarditis

Endocarditis is an inflammation of the endocardium (the membrane that lies in the heart).

Causes

Endocarditis more often caused by bacteria, fungi, or other microorganisms, can be caused by the operation; resulting from intravenous injection using dirty needles or through wounds found on the skin and mucous. Organisms can run in the blood flow towards the heart. As a result, the heart valves become inflamed, valves become damaged, and the formation of blood clots in the infected area. A person who has suffered injury or illness in the endocardium the easier it is for people suffering from endocarditis. This caused a blood clot from the surface of a wound can adsorb microorganisms, which can reproduce more and more on the injured area. Intravenous drug could cure endocarditis.

Symptoms

Endocarditis can be found in the acute or subacute form. In the subacute form, general and non-specific symptoms, including stiffness, fever, and pain. On physical examination, the evidence is just an abnormality of heart murmurs. Acute endocarditis is less happening can occur suddenly and cause a short breathing, fever, high fever, rapid heartbeat and irregular. Infection can be easily expanded and can destroy the valves of the heart, causing heart failure.

Test and Diagnosis

Various test and diagnosis done is:

Blood test.
Echocardiogram.
Electrocardiogram.
X-ray of the chest.
CT and MRI scans.

Nursing Diagnosis for Endocarditis

Acute pain related to systemic effects of the infection.
Risk for decreased cardiac output related to disturbances in heart valve and the endothelium.
Risk for Imbalanced Body Temperature.
Risk for Ineffective Tissue perfusion related to embolization

Cephalalgia

2014-08-12T13:51:00.001+07:00

Cephalalgia is a condition of pain in the head: sometimes a pain in the back of the neck or back top, also known as headache. These diseases include the grievances of the disease is often raised.

Headache is a universal problem, with a prevalence of nearly 99%, and is the most common reason for neurological referral. Headaches can have little clinical significance, but also may be a sign of the presence of life-threatening diseases. Pain in the head caused by traction / withdrawal, migration, inflammation, spasme of blood vessels, or distention of the head or neck structures that are sensitive to pain.

One type of headache that is often the Complaint is headache or migraine. Migraine attack feels tormented and sometimes sudden. Migraine sufferer will feel pain and throbbing like beaten and pulled and is usually accompanied with GI tract disorders such as nausea and vomiting. Patients tend to be more sensitive to light, sound and scent. It was certainly very disturbing and can inhibit the activity of the patients.

Migraine attacks can occur several times a year to a few times a week, with attacks usually 1-2 hours long. Migraine or headache the actual cause is not yet known with certainty. However, the predicted type of headache is caused due to a brain hiperaktifitas electric impulses that increase blood flow in the brain which results in dilation of the blood vessels of the brain and the process of inflammation (inflammatory lesions). There is also a tension-type headaches (tension type headache, or TTH) characteristics are both sides of the head as diremas with strong, but not accompanied by other symptoms (no nausea, vomiting, light sensitivity, etc.).

Most headaches are primary that is, without any underlying diseases such as migraine, cluster, and tension type headaches. However there is also a headache caused by an underlying disease process or condition or commonly called secondary headaches, which this case should be the focus early in the diagnostic evaluation of headache. Manifestation of an underlying systemic disease can help in the diagnosis of the etiology of headache and should always be sought. Because if up late can be fatal.

Constipation Care Plan - Nursing

2014-08-12T10:47:00.001+07:00

Constipation

Constipation is a disorder of the digestive system where a person experiencing excessive hardening of feces making it difficult to remove and can cause great pain in patients. Constipation is pretty great also called obstipation. And severe obstipation can cause fatal intestinal cancer for patients.

Causes

Constipation or constipation is a complaint on the digestive system of the most common and is found in the wider community including around us. Even estimated that around 80% of people have experienced constipation or constipation. Common causes of constipation or constipation that is around us, among others:

Lack of body fluids or dehydration.
Hot suffer.
Stress or depression and compact enough activity.
Influence of hormones in the body (eg in menstruation or pregnancy).
Bowel less elastic (usually because it is in the pregnancy or old age).
Anatomic abnormalities in the digestive system.
Lifestyle and irregular eating patterns (such as poor diet).
Side effects from drinking something that contains a lot of calcium or aluminum (eg antidiare drugs, analgesics, and antacids).
Lack of vitamin C intake and lack of fiber.
Is a symptom of disease (eg, typhus and hernia).
Often withhold stimulus to defecate in a long time.
Emotion, because the emotion or anxiety intestines spasm, sehigga pertaltik intestine and large intestine absorbs stopped returning fluid feces. Consequently stool becomes hard.
Rarely or less work.
Advantages of fiber consumption.
The advantages of eating meat. Especially red meat because it was difficult to digest and has a lot of iron. Iron is the substance that makes the hardening of feces, making it dark and black.
Of drug abuse, such as drug laxatives. For example, the application of mineral oil is useful for launching peristaltic motion. Eventually the intestines become accustomed to and dependent on the drug, resulting in a slow intestinal reactions, and inhibits intestinal peristalsis self.
Frozen foods save time and energy, but cause many health problems. Frozen foods have very low fiber and a lot of preservatives that can disrupt the bowel movement. Like ice cream barely contain fiber so it can help regulate bowel movements combined with sugar and milk in it can harden the stool.
Eating certain fruits or vegetables that can compress excess dirt naturally like bananas.

Signs and symptoms

Symptoms and signs will vary from person to person, because of diet, hormones, lifestyle and shape of the large intestine of each person is different, but usually the symptoms and signs commonly found on most or sometimes some patients are as follows :

Stomach feels full, and even feels numb manure pile (if manure has accumulated about 1 week or more, patients with stomach looks like being pregnant).
Feces become harder, warm, darker, a little more than usual amount (less than 30 grams), and can even form a small bow when it is severe.
At the time of bowel removed or discarded hard stools, sometimes must mengejan or pressing his stomach in advance so as to remove the feces (even to suffer hemorrhoid and cold sweat).
Heard noises in the stomach.
The anus feels full, and as something hampered accompanied with pain as a result of frictional heat and hard stools.
Frequency throw up wind accompanied a more disagreeable odor than usual (even sometimes patients may have trouble or can not totally get rid of the wind).
A decline in the frequency of bowel movements, and increased bowel transit time (usually defecate be 3 days or more).
Sometimes experiencing nausea and even vomiting if it is severe.
Back pain when feces accumulated quite a lot.
Bad breath.

As for the psychological symptoms that can occur in the patients with constipation, among others:

Lack of confidence
Prefers to be alone or away from the vicinity.
Still feel hungry but when eating faster satiety (especially when pregnant stomach will feel heartburn) because the space in the stomach is reduced.
Emotion is increasing rapidly.
Often pounding so fast that lead to emotional stress so vulnerable headaches or even fever.
The body does not fit, uncomfortable, tired, tired quickly, and droop so lazy to do things sometimes even sleepy.
Less zealous in carrying out the activity.
Daily activities have been disrupted as a body feels overburdened resulting quality and decreased work productivity.
Can decrease appetite.

Prevention

Do not junk at an arbitrary point.
Avoid foods that are high in fat and sugar.
Drink at least 1.5 to 2 white liters of water (about 8 glasses) of fluid a day and others every day.
Sports, such as walking (jogging) can be done. At least 10-15 minutes for light exercise, and at least 2 hours for a heavier workout.
Familiarize defecate regularly and do not like to hold a bowel movement. No need to force a bowel movement every day when there is no stimulus for the digestive cycle every person differently.
Consumption of foods that contain enough fiber, such as fruits and vegetables.
Sleep at least 4 hours a day.
Add herbal flavor in food, except chili.
Diet is not excessive.
Consuming anti-inflammatory foods, such as avocado, apples, and coconut.

Nursing Care Plan for Deficient Fluid Volume (Hypovolemia)

2014-05-21T09:01:00.000+07:00

Definition

Extracellular Fluid Volume Deficient or hypovolemia (FVD) is isotonic body fluid loss, which is accompanied by loss of sodium and water in the same relative amount. Volume deficits often termed isotonic dehydration that should be used for conditions of relatively pure water loss resulting in hypernatremia.

Etiology

Factors that affect the body's fluid and electrolyte balance, among others:

Age:

Fluid intake needs vary depending on age, because age affects the surface area of the body, metabolism, and weight. Infant and children are more susceptible to interference than the fluid balance adulthood. In old age often occurs due to fluid balance disorders with impaired renal function or heart.

Climate:

People who live in areas that are hot (high temperature) and low air humidity has an increased loss of body fluids and electrolytes through sweat. While someone who indulge in a hot environment can lose up to 5 L of fluid per day.

Stress:

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 can increase blood volume.

Diet:

Diet affects the intake of fluids and electrolytes. When inadequate nutritional intake, the body will burn protein and fat so it will spare protein and serum albumin will be decreased even though both are indispensable in the process fluid balance so that this will lead to edema.

Clinical manifestations

Clinical signs and symptoms which may be obtained on the client with hypovolemia include: dizziness, weakness, fatigue, syncope, anorexia, nausea, vomiting, thirst, mental confusion, constipation, oliguria. Depending on the type of fluid loss. Hypovolemia may be accompanied by acid-base imbalance, or osmolar electrolyte. Depletion (CES) severe, can lead to hypovolemic shock.

Compensatory mechanisms of the body on the condition of hypovolemia, is to be an increase in the sympathetic nervous system stimulation (increased frequency of heart, inotropic [contraction of the heart] and vascular resistance), thirst, release of antidiuretic hormone [ADH], and the release of aldosterone. The condition can lead to hypovolemia long acute renal failure.

Complication

Loss of abnormal GI: vomiting, NG suction, diarrhea, intestinal drainage.
Abnormal skin loss: excessive diaphoresis secondary to fever or exercise, burns, cystic fibrosis.
Abnormal kidney loss: diuretic therapy, diabetes insipidus, osmotic diuresis (polyuria form), adrenal insufficiency, osmotic diuresis (uncontrolled diabetes, post-use of contrast agents.
Spasium third or plasma to interstitial fluid displacement: peritonitis, intestinal obstruction, burns, acites.
Hemorragia.
Changes in input: coma, lack of fluids.

Nursing Care Plan for Deficient Fluid Volume (Hypovolemia)

Assessment

Intake-output.
Weight.
Breath sounds.
Edema.
Check skin turgor.

Nursing Diagnosis

Deficient Fluid Volume: less than body requirements related to diarrhea, gastric fluid loss, diaphoresis, polyuria.
Impaired skin integrity related to dehydration and or edema.

Outcomes:

Individuals will:

Increasing fluid intake of at least 2000 ml / day (unless contraindicated).
Telling the need to increase fluid intake during stress or heat.
Maintain urine specific gravity within normal limits.
Showed no signs and symptoms of dehydration.

Interventions:

Assess the preferred and non-preferred; give a favorite drink in the diet limits.
Plan objectives fluid intake (eg, 1000 ml during the morning, afternoon 800 ml, and 200 ml of the evening).
Assess individual understanding of the reasons to maintain adequate hydration and methods to achieve goals fluid intake.

NCP Cholera - 6 Nursing Diagnosis and Interventions

2014-05-20T09:34:00.001+07:00

Nursing Care Plan for Cholera

Cholera, a severe diarrheal disease caused by the bacterium Vibrio cholerae, has plagued human populations for centuries. This waterborne illness poses significant public health challenges, particularly in regions with inadequate sanitation and limited access to clean water. This article explores the causes, symptoms, transmission, and global efforts in the prevention and management of cholera.

Causes and Transmission:

Vibrio cholerae, the bacterium responsible for cholera, typically thrives in contaminated water and food sources. The primary mode of transmission is through the ingestion of contaminated water or food, often via the consumption of raw or undercooked seafood, or contaminated fruits and vegetables.
Once ingested, the bacterium releases a toxin that affects the small intestine, leading to rapid and profuse watery diarrhea—a hallmark symptom of cholera. The severity of the disease can range from mild to severe, with severe cases potentially progressing to life-threatening dehydration without prompt intervention.

Symptoms:

Watery Diarrhea: Cholera is characterized by the sudden onset of profuse, painless, and watery diarrhea, often described as "rice-water stool."
Vomiting: Individuals with cholera may experience vomiting, contributing to fluid loss and dehydration.
Dehydration: Rapid fluid loss can lead to severe dehydration, accompanied by symptoms such as sunken eyes, dry mucous membranes, lethargy, and a rapid heart rate.
Muscle Cramps: Dehydration can cause muscle cramps and weakness.

Nursing Assessment for Cholera

Assess the status of dehydration (skin color, temperature, acral, skin turgor, mucous membranes, eyes, crown, body temperature, pulse, respiration, behavior, weight loss).
Observe for manifestations of acute diarrhea
- A sudden attack of diarrhea
- Fever
- Anorexia, nausea, vomiting
- Weight loss
- Pain and abdominal cramps, abdominal distension
- Increased bowel sounds / hyper-peristaltic
- Malaise
- Bowel movements more than 3 times a day, liquid stool consistency, with / or without mucus and blood
Assess the psychosocial status of families
Assess the level of knowledge of family
- Knowledge of diarrhea at home
- Knowledge of dietary
- Knowledge about the prevention of recurrent diarrhea

Nursing Diagnosis for Cholera

Deficient fluid volume related to excessive fluid loss through the stool or emesis
Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake
Risk for infection related to microorganisms that penetrate the gastrointestinal tract.
Impaired Skin Integrity: perianal, related to irritation from diarrhea
Anxiety related to separation from parents, unfamiliar environment, a stressful procedure.
Interrupted Family Processes related to crisis situations, lack of knowledge about diseases, treatment of clients.

Nursing Interventions for Cholera

Deficient fluid volume related to excessive fluid loss through the stool or emesis

Goal :

Maintain adequate hydration

Expected outcomes:

No signs of dehydration: elastic skin turgor, sunken fontanel not, the patient is not agitated, mucous membranes moist, no weight loss.

Nursing Interventions and Rational:
1) Record Intake Output every 24 hours.
R / Knowing the status of dehydration and evaluate the effectiveness of interventions.

2) Measure the child's weight every day.
R / observe dehydration.

3) Measure vital signs and evaluation of skin turgor, mucous membranes, mental status.
R / observe dehydration.
4) Tell the family to give the child a drink gradually.
R / improve hydration.

collaboration:
5) Give oral rehydration solution (ORS).
R / rehydration and replacement of fluid loss through the stool.

6) Provide and monitor IV fluids as indicated (collaboration).
R / replacement fluid loss.

7) Observe the results of the electrolyte.
R / know the level of hydration and the effectiveness of interventions.

Imbalanced Nutrition: Less Than Body Requirements related to loss of fluids through diarrhea, inadequate intake

Goal :

consume adequate nutrition intake.

Expected outcomes:

No weight loss (weight stable)
Eating out 1 serving.
No nausea, vomiting.

Nursing Interventions and Rational:

1) Evaluation of nutritional status and weight loss
R / Identifying the need for further intervention.

2) Notify and motivation of mothers / families to continue breast-feeding.
R / breast milk reduces the severity and duration of disease and provide additional nutrients.

3) Tell the mother to give the child to eat small meals but often
R / increase food intake.

4) Observe and record the response to feeding.
R / know the tolerance of feeding.

Bibliography:

Ali, M., Nelson, A. R., Lopez, A. L., & Sack, D. A. (2015). Updated global burden of cholera in endemic countries. PLoS Neglected Tropical Diseases, 9(6), e0003832. doi: 10.1371/journal.pntd.0003832
Clemens, J. D., Nair, G. B., Ahmed, T., Qadri, F., Holmgren, J., & Cholera Symposium Participants. (2017). Cholera. The Lancet, 390(10101), 1539-1549. doi: 10.1016/S0140-6736(17)30559-7

Bladder Cancer - Nursing Diagnosis : Imbalanced Nutrition and Deficient Knowledge

2014-01-23T10:20:00.001+07:00

Nursing Care Plan for Bladder Cancer

1. Imbalanced Nutrition: Less Than Body Requirements
related to:

hyper-metabolic-related cancer, the consequences of chemotherapy, radiation, surgery (anorexia, gastric irritation, lack of sense of taste, nausea), emotional distress, fatigue, inability to control pain

characterized by:

inadequate intake,
loss of sense of taste,
loss of appetite,
weight down to 20% or more below the ideal,
decreased muscle mass and subcutaneous fat,
constipation,
abdominal cramping.

Goal:

Showed a stable weight, normal laboratory results and no sign of malnutrition.
Stated understanding of the need for adequate intake.
Participate in the management of diet-related illness.

Interventions :

Monitor food intake every day, whether eating in accordance with the needs of the client.
Measure weight, triceps size and observed weight loss.
Assess pale, slow wound healing and parotid gland enlargement.
Encourage clients to consume high-calorie foods with adequate fluid intake. Instruct too little food to clients.
Control of environmental factors such as foul odors or noise. Avoid foods that are too sweet, fatty and spicy.
Create a pleasant dining atmosphere for example, a meal with friends or family.
Encourage relaxation techniques, visualization, moderate exercise before eating.
Encourage open communication about anorexia problems experienced by clients.

Collaboration:

Observe laboratory studies such as total lymphocytes, serum transferrin and albumin.
Give treatment as indicated.
Attach a nasogastric tube for enteral feeding, balanced with infusion.

Rational:

Provide information about nutritional status.
Provides information about the addition and weight loss.
Showed very poor nutritional state.
Calories are energy sources.
Prevent nausea and vomiting, excessive distension, dyspepsia which causes a decrease in appetite and reduce harmful stimulus which can increase anxiety.
In order for the client to feel like being at home alone.
To induce a feeling of wanting to eat / arouse appetite.
In order to overcome together (with a dietitian, nurse and client).
To determine / establish the occurrence of nutritional deficiencies as a result of the course of disease, treatment and care of the client.
Facilitate the intake of food and beverages with maximum results and right as needed.

2. Deficient Knowledge about the disease, prognosis and treatment
related to:

lack of information,
misinterpretation,
cognitive limitations.

characterized by:

often asked,
stating the problem,
statement misconceptions, is not accurate in mengikiuti instruction / prevention of complications.

Goal:

Can accurately say about diagnosis and treatment at the level of proximity ready.
Following the procedure well and explain the reasons to follow those procedures.
Having the initiative of changing lifestyles and participate in treatment.
In cooperation with the furnisher.

Interventions:

Review understanding of the client and family about the diagnosis, treatment and consequences.
Determine the client's perception about cancer and its treatment, tell the client about the experience of other clients who have cancer.
Give accurate and factual information. Answer the questions specifically, avoid unnecessary information.
Provide guidance to client / family before following the treatment procedure, the old therapy, complications. Be honest with the client.
Encourage clients to provide verbal feedback and correct misconceptions about the disease.
Review client / family about the importance of optimal nutrition status.
Encourage clients to assess the oral mucous membranes regularly, note the presence of erythema, ulceration.
Encourage clients to maintain the cleanliness of the skin and hair.

Rational:

Avoid duplication and repetition of the client's knowledge.
Lets do justification to errors as well as errors of perception and conception of understanding.
Assist the client in understanding the disease process.
Assist clients and families in making treatment decisions.
Knowing the extent of understanding the client and client's family about the disease.
Increasing knowledge of the client and family regarding adequate nutrition.
Reviewing the development of the processes of healing and signs of infection and problems with oral health can affect the intake of food and beverages.
Improving the integrity of the skin and head.

Source : http://nursing-care-plan.blogspot.com/2014/01/imbalanced-nutrition-and-knowledge.html

Imbalanced Nutrition Less Than Body Requirements - NCP for Typhoid Fever

Nursing Care Plan for Dysphagia

2013-09-03T13:27:00.001+07:00

Dysphagia is the medical term for difficulty swallowing symptoms.
Swallowing disorders can occur in all age groups resulting from congenital abnormalities, structural damage, and / or medical condition. in patients who have had a stroke, and in patients who are admitted hospital acute or chronic care facilities.

Dysphagia is classified into two major groups, namely oropharyngeal dysphagia (or transfer dysphagia) and esophageal dysphagia.

1. Oropharyngeal dysphagia

Oropharyngeal dysphagia arises from abnormalities in the oral cavity, pharynx, and esophagus, can be caused by stroke, Parkinson's disease, neurological disorders, muscular dystrophy Oculopharyngeal, decreased flow of saliva, xerostomia, dental problems, oral mucosal abnormalities, mechanical obstruction (malignancy, osteofi, increasing the upper esophageal sphincter tone, radiotherapy, infection, and drugs (sedatives, anticonvulsants, antihistamines). oropharyngeal dysphagia symptoms are difficulty swallowing, including the inability to recognize food, difficulty putting food in the mouth, inability to control food and saliva in the mouth, difficulty to start swallowing, coughing and choking during swallowing, weight loss is not clear why, changes in eating habits, recurrent pneumonia, voice alteration (wet voice), nasal regurgitation. Upon examination, treatment can be done with techniques postural, swallowing maneuvers, dietary modification, environmental modification, oral sensory awareness technique, vitalstim therapy, and surgery. Bilatidak untreated, dysphagia can lead to aspiration pneumonia, malnutrition, or dehydration.

2 . Esophageal dysphagia

Esophageal dysphagia arises from abnormalities in the corpus of the esophagus , the lower esophageal sphincter , or gastric cardia . Usually caused by esophageal stricture , esophageal malignancy , esophageal rings and webs , achalasia , scleroderma , spastic motility disorders including diffuse esophageal spasm and non-specific esophageal motility disorders . Food is usually held some time after ingestion , and it will be as high as suprasternal notch or behind the sternum as the site of obstruction , oral or pharyngeal regurgitation , changes in eating habits , and recurrent pneumonia . If there is a solid and liquid food dysphagia , most likely a motility problem . When the patient initially experienced solid food dysphagia , but subsequently with liquid food dysphagia , it is most likely a mechanical obstruction . After being able to distinguish between problems motility and mechanical obstruction , it is important to pay attention to whether temporary or progressive dysphagia . Dysphagia can be caused motility while diffuse esophageal spasm or nonspecific esophageal motility disorder . Progressive motility dysphagia can be caused by scleroderma or achalasia with a burning sensation in the area of chronic heartburn , regurgitation , respiratory problems , or weight loss . Dysphagia can be caused by temporary mechanical esophageal ring . And progressive mechanical dysphagia can be caused by esophageal stricture or esophageal malignancy . When it can be concluded that the disorder is esophageal dysphagia , then the next step is a barium examination or upper endoscopy . Barium examination should be performed before endoscopy to avoid perforation . When the suspected presence of achalasia on barium examination , then performed manometry for diagnosis of achalasia . When suspected esophageal strictures , then endoscopy . If no abnormalities are suspected as above , the endoscope can be done prior to barium examination . Normal endoscopy , should be continued denganmanometri , and if manometry is also normal , then the diagnosis is functional dysphagia . Thorax is simple to pneumonia.CT examination and MRI scans provide a good overview of structural abnormalities , especially when used to evaluate patients with dysphagia who is suspected due to central nervous system disorders . Having known the diagnosis , the patient is usually sent to the ENT , gastrointestinal , pulmonary , or oncology , depending on the cause . Consultation with a dietician is also necessary , as most patients will need your dietary modification .

Nursing Assessment for Dysphagia

Nursing Assessment is necessary in patients with impaired swallowing or disphagya include:

History of previous illness
History of stroke
History of use of medical devices: tracheostomy, NGT, mayo tube, ETT, post endoscopy examination
History surgery laryx blood, pharynx, esophagus, thyroid
Postoperative oral region
Physical examination
Mouth shape is not symmetrical
Seemed an inflammation of the pharynx
Presence of candida in oral / mouth
Pharyngeal edema

Nursing Diagnosis for Dysphagia

1. Impaired Swallowing
2. Risk for Imbalanced Nutrition: less than body requirements
3. Risk for aspiration

Nursing Management for Dysphagia

NCP Dermatitis - Gordon's 11 Functional Health Patterns

2013-08-27T16:19:00.000+07:00

Gordon's 11 Functional Health Patterns - Nursing Care Plan for Dermatitis

1. Health Perception-Health Function

A history of previous infection.
Previous treatment failed.
History of taking certain drugs, eg., Vitamins; herbs.
Are there regular consultation to the doctor.
Personal hygiene is lacking.
Unhealthy environment, living overcrowding.

2. Nutritional Metabolic Pattern

Daily diet: the number of meals, meal times, how many times a day to eat.
Habit of eating certain foods: oily, spicy.
Preferred food types.
Decreased appetite.
Vomiting.
Weight loss.
Poor skin turgor, dry, scaly, cracked, bump.
Changes in skin color, there are patches, itching, burning or stinging.

3. Elimination Pattern

Frequent sweating.
Ask urination and bowel patterns.

4. Exercise Activity Pattern

Fulfillment disrupted everyday.
General weakness, malaise.
Tolerance to low activity.
Easy to sweat when doing light activity
Changes in breathing patterns while doing the activity.

5. Sleep-Rest Pattern

Trouble sleeping at night because of stress.
Nightmare.

6. Cognitive-Perceptual Pattern

Changes in concentration and memory.
Knowledge of the disease.

7. Self-Perception Pattern

Feeling insecure or inferior.
Feelings of isolation.

8. Role-Relationship Pattern

Living alone or married.
Frequency of interaction is reduced.
Changes in physical capacity to carry out the role.

9. Sexuality-Reproductive Pattern

Interference with the biological needs a partner.
The use of drugs that affect hormones.

10. Coping-Areas Management Pattern

Emotionally unstable.
Anxiety, fear of illness.
Disorientation, restlessness.

11. Value belief system

Changes in the client's self in worship.
Religion.

Want to Have Ideal Body

2013-06-22T11:15:00.001+07:00

There is no one thing that will be difficult to say if indeed we still do not give a trial. If it has never tried anything we just stay quiet, like a diet program. Many have also complained to feel very hard and difficult to be able to succeed in the program. One that can be very difficult to say soon is making a radical change. This is better done with a small stage, but later changes could also be a part of your own lifestyle.

Some of that must know if there is a small change that can make a life style in daily, but will get a very good hasill and ideal future.

Here is a thing that should be done in order to get the ideal body :

For those of you who despise often eat in front of the news channel. If you eat in front of the news channel was doing or playing in front of the screen whether it's a laptop or gadget. Therefore you have to eat at the table, in order to concentrate on the value of calories are eaten. Then fill with the food menu calorie menu right.

Buy a small plate. Most of them ate the portion corresponding to their plate, that is the purpose for a small plate. We will be a little more food than usual with a large plate.
Eat slowly. Chew slowly way, the sooner you are still not satisfied to chew. Chew till soft, put a spoon in while you're still chewing earlier. Try'll definitely get used to.
The most important activity is increased further yan sweat outside. Such as sports and gymnastics. To burn calories you are not required to exercise on weight alone, you can replace with your daily activities. Like choosing to take the stairs rather than the elevator. If traveling in near the goal, we can walk with our feet.