Care Plan

Nursing Care Plan for Cesarean Section (C-section)

2012-05-24T15:16:00.002+07:00

A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems happen during delivery. These include

Health problems in the mother
The position of the baby
Not enough room for the baby to go through the vagina
Signs of distress in the baby

C-sections are also more common among women carrying more than one baby.

The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. However, more than half of women who have a C-section can give vaginal birth later.

Nursing Assessment for Cesarean Section

Assessment is the systematic process of gathering, verification, and communication of client data (Potter & Perry, 2005).

The assessment results are found on the client by cesarean section on nursing care plan maternal / infant (Doenges & Moorhouse, 2001) namely:

Assessment of client data base
Review the record of prenatal and intraoperative and indications for cesarean birth.

Circulation
Blood loss during surgical procedures of approximately 600-800 ml.

Ego integrity
Can show emotional labilitas of excitement to fear, anger or withdrawn. Client / partner may have questions or wrongly accept a role in the birth experience. Perhaps expressing inability to deal with new situations.

Elimination
Urinary catheter may be inserted, clear urine and pale bowel sounds absent, vague or unclear.

Food / fluid
Abdomen soft with no distension at baseline.

Neoro sensory
Damage to the movement and sensation below the level of spinal epidural anesthesia.

Pain
Discomfort may complain of a variety of sources such as surgical trauma, incision and accompanying pain, distended bladder-abdominal, the effects of anesthesia. The mouth may be dry.

Respiratory
The sound is clear and vesicular lung.

Security
Abdominal bandage may seem a little stain or dry and intact. Line parenteral, when used patent-free and hand erythema, swelling and tenderness.

Se.uality
Fundus contractions stronger and located at the umbilicus. Lochea is free flow and excessive clot / lot.

Diagnostic tests
Complete blood count, hemoglobin / hematocrit (Hb / Ht): assessing the change from preoperative levels and evaluate the effects of blood loss in surgery. Urinalysis: urine culture, blood, vaginal, and lochea.

Nursing Diagnosis for Cesarean section (C-section)

1. Acute pain related to postoperative wound

2. Risk for infection related to invasive procedures, skin damage, decrease in Hb

3. Risk for injury (mother) related to tissue trauma

4. Risk for impaired gas exchange (the fetus)

5. Deficient Knowledge : up to surgery

6. Anxiety

Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative

Nursing Diagnosis

Risk for infection

Related to :

bleeding,
postoperative wound

Goal :
There were no infections, bleeding and wounds, after surgery.

Nursing Intervention for Cesarean Section Postoperative

Assess the condition of output / dischart out; number, color, and odor from the operation wound.
R / recording the changes in output. The existence of a darker color with a bad smell may be a sign of infection.

Tell the client the importance of wound care during the postoperative period.
R / Infection can arise from lack of cleanliness of the wound.

Have a general culture in the output.
R / Various bacteria can be identified through the output.

Perform wound care.
R / Incubation germs in the wound area can cause infection.

Tell the client how to identify signs of infection.
R / Various clinical manifestations can be nonspecific sign of infection, fever and increased pain may be symptoms of infection.

Nursing Diagnosis

Acute Pain

Related to

postoperative wound

Goal :
Pain is reduced / no pain

Nursing Intervention for Cesarean Section Postoperative

Assess the condition of pain experienced by the client.
R / Measurement of the level of pain can be performed with pain scales.

Tell the client suffered pain and its causes.
R / Improving coping clients, in dealing with pain.

Teach relaxation techniques.
R / Reduced perception of pain.

Collaboration of analgesics.
R / Reduced pain can be done by giving oral or systemic analgesics, in a broad spectrum / specific.

List of Pulmonary Tuberculosis Nursing Diagnosis NANDA

2012-05-16T10:05:00.002+07:00

Pulmonary tuberculosis (TB) is a highly contagious disease caused by a bacteria known as Mycobacterium tuberculosis. TB generally affects the lungs, but it also can invade other organs of the body, like the brain, kidneys and lymphatic system.

TB is spread through coughing, sneezing, and spitting. Only a small amount of inhaled germs are needed to become infected, however prolonged exposure to someone else who has TB is the easiest way to get the disease. Those who have a weakened immune system are even more at risk.

Many people who are infected with TB have few or no symptoms at all, at least in the beginning. Some people develop symptoms slowly, over time, and pay little attention to them until the disease has reached the advanced stages. When symptoms do appear, they generally include:

fatigue
loss of appetite and weight loss
cough with purulent and/or bloody sputum
night sweats
low-grade fever that occurs mostly in the afternoon
lethargy

Pulmonary Tuberculosis Nursing Diagnosis - NANDA

a. Ineffective airway clearance

related to viscous secretions or blood secretions, weakness, poor cough effort, edema, tracheal / pharyngeal.

b. Impaired Gas Exchange

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

c. Imbalanced Nutrition: Less Than Body Requirements

related to fatigue, frequent coughing, the sputum production, dyspnea, anorexia, decreased financial capabilities.

d. Acute pain

related to lung inflammation, persistent cough.

e. Hyperthermia

related to active inflammatory process.

f. Intolerance Activity

related to the imbalance between supply and oxygen demand.

g. Knowledge Deficit: about conditions, treatments, prevention

associated with no one to explain, the interpretation is wrong, the information obtained is incomplete / inaccurate, lack of knowledge / cognitive

h. Risk for the spread of infection / re-infection activity related to inadequate primary defenses, decreased ciliary function / static secretions, tissue damage caused by the spread of infection, malnutrition, environmental contamination, lack of information about the bacterial infection.

Nursing Home / Home Care Mattresses

2012-04-13T23:18:00.002+07:00

Nursing Home / Home Care Mattresses Size: 75" x 35"

Product Description

GF1500-175-1633 Size: 75" x 35" Features: -Economical, innerspring mattress. -Designed specifically for nursing homes and home care use. -Vented and reversible. -Mattress dimensions: 35'' width, 7'' height. -Easy to maintain, comfortable. -One year limited manufacturer warranty. Specifications: -Meets 16 CFR 1633 requirements. -Weight capacity: 350 lbs. -Overall dimensions: 7'' H x 35'' W x 75''-84'' D.

3M Littmann Cardiology III Stethoscope

2012-04-13T22:56:00.002+07:00

3M Littmann Cardiology III Stethoscope

Product Description

Littmann Cardiology III Stethoscope, Adult Ideal use for Cardiology or other High Performance adult and pediatric applications.

Features two tunable diaphragms (adult and pediatric) for listening to both low and high frequency sounds. Two-tubes-in-one design helps eliminate tube rubbing noise. The pediatric side of the chestpiece easily converts to a traditional bell by simply replacing the diaphragm with the nonchill bell sleeve included with each stethoscope.

Offers a solid stainless steel chestpiece, nonchill rims, and an adjustable doubleleaf binaural spring. 3M Littmann Snap Tight Soft-Sealing eartips provide an excellent acoustic seal and comfortable fit.

Nursing Diagnosis for Tuberculosis

2012-03-19T01:53:00.001+07:00

Tuberculosis, a bacterial infection, most commonly affects the lungs. Tuberculosis can also affect the central nervous system, lymphatic system, circulatory system, genitourinary system, bones and joints. Often Called TB for short, tuberculosis is the most common major infectious disease today. With that title the virus is infecting two billion people which is approximately one-third of the world's population. Nine million new cases of active disease annually, resulting in two million deaths. Most of these cases and deaths are in developing countries.

The disease tuberculosis is caused by the bacteria Mycobacterium tuberculosis. Tuberculosis can affect any part of the body but usually infects the lungs. Tuberculosis is spread through airborne droplets occurring when an infected individual sneezes, talks, or coughs. However, prolonged exposure to the infected individual must occur before you may become infected. The body may harbor the bacteria while the immune system prevents sickness. For this reason, there are two forms of TB: latent tuberculosis and active tuberculosis.

In many patients the infection of Tuberculosis waxes and wanes. Treatment with appropriate antibiotics kills bacteria and allows healing to take place. Areas where Tuberculosis has affected will eventually be replaced by scar tissue. A complete medical evaluation for Tuberculosis includes a medical history, a physical examination, a tuberculin skin test, a serological test, a chest X-ray, and microbiologic smears and cultures. This is quite an extensive procedure as you can see, but if you look at the numbers above it is a necessary process.

Active tuberculosis simply means that the tuberculosis bacteria are growing within the body causing an active infection. Signs and symptoms of active tuberculosis include fatigue, slight fever, chills, night sweats, loss of appetite, unintended weight loss, a cough that lasts three or more weeks producing discolored or bloody sputum, and pain with coughing or breathing. Active tuberculosis is highly contagious.

Read More :

Nursing Diagnosis for Tuberculosis

Key Terms of Nursing Diagnosis

2012-03-13T23:05:00.001+07:00

Key Terms of Nursing Diagnosis

Key Terms of Nursing Diagnosis

NANDA, North American Nursing Diagnosis Association—Formed in 1973, this group is responsible for developing a classification system of nursing diagnoses.Expected outcome—A measurable individual, family, or community state, behavior, or perception that is measured along a continuum and is responsive to nursing interventions.

Medical diagnosis—A medical determination of disease or syndrome performed by a physician. The focus is on the disease process and the physical, genetic, or environmental cause of that process.

NIC, Nursing Interventions Classification— Developed by the Iowa Intervention Project, this is a collection of nursing interventions linked to the NANDA diagnoses. The 2000 publication includes approximately 500 interventions.

NOC, Nursing Outcomes Classification— Developed by the Iowa Outcome Project, this is a comprehensive, standardized classification of patient outcomes developed to evaluate the effects of nursing interventions. The outcomes may be linked to the NANDA diagnoses and other diagnoses systems. The 2000 publication includes 260 outcomes.

Nursing assessment—The way in which a nurse gathers and evaluates data about a client (individual, family, or community). The assessment includes a physical examination, interviewing, and observations. Assessment is also the first step in the nursing process.

Nursing diagnostic statement—The formal, written documentation of a nursing diagnosis. It includes the label or diagnosis, the etiology, and the indicators. In the statement, the etiology is preceeded by the phrase "related to." The indicators are the assessment data that led to the diagnosis. They are preceeded by the phrase, "as evidenced by."

Nursing intervention—Any treatment that a nurse performs on a patient in response to a nursing diagnosis to reach a projected outcome.

Risk diagnosis—A nursing diagnosis that recognizes a potential problem not an existing problem. The indicators for risk diagnoses are risk factors that are identified through assessment.

Source : http://nandadiagnosis.blogspot.com/2011/05/key-terms-of-nursing-diagnosis.html

Family Nursing Care Plan for Tuberculosis

2012-03-12T20:15:00.000+07:00

Family Nursing Diagnosis - Nursing Care Plan for Tuberculosis

Nursing Diagnosis that may arise in families with tuberculosis disease are:

a. Nutrition less than body requirements related to anorexia
b. Risk for Infection related to the secret is out
c. Ineffective airway clearance related to the accumulation of excessive secretions.
d. Disruption of gas exchange related to the decreased oxygen supply

In formulating nursing diagnoses in the family need to be a priority issue and a matter of priority criteria.

Priority issues

Things that need to be considered in the priority issues are as follows:
a. Not possible, the problems of health and nursing are found in the family can be addressed simultaneously.
b. Need to consider the problems that can threaten the lives of families like the problem of disease.
c. Need to consider the response and attention to family nursing care to be provided.
d. Family involvement in solving problems they face.
e. Family resources that can support problem solving health / family nursing.
f. Family and cultural knowledge.

Criteria for priority problems

Some of the criteria in priority setting problems:
1. Nature of the problem, are grouped into: health threats, is ill or unwell and crisis situations.

2. Possible problems can be changed, is the likelihood of success to reduce the problem or prevent a problem when it's done nursing and medical interventions.
Factors that may affect the problem of TB can be changed are:
a. Knowledge and action for the problem of tuberculosis.
b. Family resources, such as finance, personnel, facilities and infrastructure.
c. Care resources, including the knowledge and skills in handling the problem of tuberculosis.
d. Community resources, can be in the form of facilities, organization.

3. Potential problems of tuberculosis, to prevent, is the nature and severity of problems that will arise and TB can be reduced or prevented through nursing and health measures.
Things that need to be considered in view of the potential problem of prevention of tuberculosis are:
a. Severity / difficulty of the problem, this is related to severity of disease or tuberculosis that showed the prognosis and severity of tuberculosis suffered by family members.
b. Action has been and is being run, is an act to prevent and treat tuberculosis in order to improve the health status of the family.
c. The duration of the problem, severity of problems associated with tuberculosis in the family and the potential problems to be prevented.
d. The existence of high-risk groups within the family or a group of highly sensitive adds to the potential to prevent problems.

4. Prominence of the tuberculosis problem, is how families see and assess the tuberculosis problem in terms of severity and urgency to be addressed through nursing and medical interventions.

Nursing Care Plan for Tuberculosis

Tuberculosis Nursing Care Plan includes general and specific objectives based on problems that come with the criteria and standards that refer to the cause. Furthermore formulate action-oriented nursing criteria and standards.

There are several levels of objectives in the planning of nursing according to Friedman (1998: 64). Short-term goals that are measurable, immediate and specific. And long-term goal which is the final level of the broad purposes stated expected by nurses and families to be reached.

The purpose of nursing care in a family with tuberculosis:

A. Short term goals include:
Once the information is given to the families of tuberculosis, the family is able to recognize the problem of tuberculosis, is able to take decisions and be able to care for family members suffering from tuberculosis.

Evaluation criteria:
a. Verbal response, the family is able to mention the understanding, the signs and symptoms, causes, treatment and prevention of transmission of tuberculosis.
b. Effective response, the family able to care for family members suffering from tuberculosis.
c. Psychomotor response, the family is able to modify the environment for people with tuberculosis.

Evaluation standards:
Definition, signs and symptoms, causes, prevention of tuberculosis, prevention of transmission and ways of treatment of tuberculosis.

2. Long-term goals
Problem of TB in the family can be resolved / reduced after nursing actions.

Intervention phase begins with the completion of treatment planning. Like the opinion of Friedman (1998: 67). During the implementation of nursing interventions, new data is continuously flowing into. Because this information (the response from the client, the situation changes, etc.) were collected, nurses need to be quite flexible and can adapt to review the family situation by making modifications to the plan without a plan. In choosing nursing actions depending on the nature of the problem and the resources available for solving.

Read More : http://nanda-nursing-care-plan.blogspot.com/2012/03/family-nursing-diagnosis-nursing-care.html

Nursing Diagnosis for Pain (Acute / Chronic)

2012-03-12T20:12:00.000+07:00

There are many things that can cause a person pain and different people have different tolerances for types of pain. Someone with a low tolerance may find many things very painful. Someone with a higher tolerance may be able to withstand these things.

There is the pain of a headache and there are many kinds of headaches that produce vaious degrees and quality of pain. There is organ pain when something is wrong inside and muscle pain when they are pushed beyond the norm either by exercise or emergency. Pain can be mild and a mere annoyance, or brutal and debilitating.

Acute pain is a pain that is recent, a sudden onset of pain, something that has been caused by an accident, a fall, an injury, or something of that nature. Acute pain is usually quite strong and ranges from a sharp nerve pain or shooting pain, to a very strong ache. It can be made worse by certain movements and may restrict you from doing things.

These are some of the obvious things that cause instant pain but sometimes acute pain seems to appear out of nowhere. For example, the sudden onset of lower back pain or neck spasms.
Generally the majority of acute pain conditions are caused by muscle spasms. Sure they may feel like they are incredibly painful because when muscles spasm they can also entrap and irritate nerves. Acute pain conditions are generally easy to treat and do not leave any residual problems. Massage therapy is the treatment used to alleviate muscular problems. Remedial massage acts by stimulating the muscles that are in spasm so they release. By stimulating the right muscles the body will then correct itself, releasing the muscle spasms and bringing your body back to normal.

Nursing Diagnosis for Pain – Acute

Acute Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

Nursing Diagnosis for Pain – Chronic

Chronic Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.

Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult.

Nursing Diagnosisi Nursing Care Plan for Pain

Nursing Diagnosis and Nursing Interventions for Hallucinations

2012-02-12T11:25:00.004+07:00

Hallucinations are sensory experiences in the absence of stimulation (stimulus) such as patients hear voices, whispering in his ear when there is no source of the voice that whisper (Hawari, 2001).

Hallucinations - The person can touch, feel, hear, smell and see imaginary things, which do not exist in reality. Such symptoms are because of the deterioration in the brain's reception, as a result brain responds to fake sensory input.

Hallucinations can be further classified as:

Tactile Hallucination: A person experiencing this can feel imaginary hands touching him or can feel insects moving all over his body.

Auditory Hallucination: The person who suffer from such hallucination can hear and communicate with a person that is non-existent in real life. Sometimes, he can also hear someone constantly talking to him. He might even hear an inner voice to tell him about impending danger.

Olfactory Hallucination: The person can smell things that no one can.

Visual Hallucination: The person who experiences this type of hallucination can see objects and people that do not exist in real life. He is able to share thoughts with his imaginary friends and spend time with them.

Read More :

Nursing Interventions for Hallucinations

Health - Beta Glucan Lowers Blood Lipids

2012-01-31T18:16:00.002+07:00

Beta glucan Lowers Blood Lipids

BERLIN—Barley beta-glucan reduces serum lipid levels, according to research presented in April at the First International Congress on Pre-Diabetes and Metabolic Syndrome.

In the six-week study, 76 men and 79 women with hypercholesterolemia, aged

25 to 73, completed a four-week lowfat diet prior to baseline. At the beginning of the trial, test subjects were randomly allocated to one of four treatment groups or a control group and assayed for blood lipids and other cardiovascular disease (CVD) biomarkers. During the course of the study, test groups were administered 3 g and 5 g doses of low molecular weight (LMW) or high molecular weight (HMW) barley beta-glucan (from Cargill) twice daily, in cereal and juice.

Posttreatment assessment of blood lipids and other CVD biomarkers revealed improvements in low-density lipoprotein (LDL) cholesterol, triglycerides, markers of glycemic control

(glycosylated hemoglobin, HOMA model) and a key marker of inflammation

(hs-CRP).

The researchers concluded both doses of LMW and HMW barley beta-glucan improved blood lipids over a six-week treatment period. More Visit : http://mhlnk.com/15D98314

Breast Enlargement Implant Dangers

2012-01-31T17:58:00.003+07:00

Breast Enlargement Implant Dangers

3% suffer leakage within three years causing a deflated implant

Occasionally, breast implants may break or leak. The saline fill is salt water and will be absorbed by the body without ill effects. Older implants with silicone gel can leak also. If this occurs, one of two things may occur. If breakage of the implant shell that has a contracture scar around it, then it may not feel like anything has happed. If the shell breaks and there is not a contracture scar, then leakage into the surrounding tissue results in a sensation that the implant is deflating. The leaking gel may collect in the breast and a new scar may form around it. In other cases gel can migrate through the lymphatic system to another area of the body. Breaks may require a second operation and replacement of the leaking implant. If the gel has migrated it may not be possible to remove all of the silicone gel. This silicone gel is the what some say is related to the initiation of connective tissue disorders.

One study they reviewed showed that 63.6% of breast implants which had been in place for between one and 25 years had ruptured or were leaking. (http://news.bbc.co.uk/1/hi/sci/tech/33450.stm)

For silicone gel and saline-filled implants, some causes of rupture or deflation include : damage by surgical instruments during surgery, overfilling or underfilling of the implant with saline solution (specific only to saline-filled breast implants), capsular contracture ,closed capsulotomy , stresses such as trauma or intense physical manipulation ,excessive compression during mammographic imaging, placement through umbilical incision ,site injury to the breast, normal aging of the implant ,unknown/unexplained reasons.

For more information visit: http://mhlnk.com/94494ED0

Nursing Diagnosis for Dementia

2012-01-18T09:24:00.001+07:00

Dementia is a medical condition that affects the brain. It is more common in older people, starting at about the age of sixty years and over.

Ageing is one cause of this condition, but there are other causes such as a stroke, Alzheimer's disease, or an injury to the brain from head trauma. Someone with Dementia may forget simple things that should be familiar to them.

People generally go through Dementia in three stages. During the first stage, a person will have trouble remembering things that they would typically know otherwise. Things such as phone numbers, how to get home, where they parked their car, and other common daily tasks are some of the things that will not be remembered by a person affected by Dementia. The next stage of Dementia is more serious and noticeable by people that know the person. In this stage the individual often does not know how to complete tasks around their own home such as cooking, getting dressed properly and washing themselves. Sometimes in this stage, the person affected also has trouble with their speech. The last stage begins to affect the body as well as the mind. The person may have weakness in certain parts of their body. It may cause them to not be able to move their arms and legs. Their ability to speak may worsen to the point of not making any sense when they talk.

Nursing Diagnosis for Dementia NANDA

Read More : Nursing Interventions for Dementia

http://nursing-care-plan.blogspot.com/2012/01/nursing-diagnosis-for-dementia-nanda.html

8 Nursing Diagnosis for Pneumonia

2012-01-11T11:58:00.002+07:00

DEFINITION OF PNEUMONIA

Pneumonia is an acute inflammation of the lung parenchyma are usually derived from an infection. (Price, 1995)
Pneumonia is an inflammation of the lung parenchyma, distal to the terminal bronchioles including respiratory bronchioles, alveoli, and cause consolidation of lung tissue and cause local disruption of gas exchange. (Zul, 2001)
Bronchopneumonia is used to describe pneumonia that has spread pattern mottled, irregular in one or more localized areas within the bronchi and extends into the adjacent lung parenchyma in the vicinity. In bronchopneumonia occurred consolidation stained area. (Smeltzer, 2001).

ETIOLOGY OF PNEUMONIA
bacterium
Bacterial pneumonia is usually found in old age. Organisms such as gram posifif: Steptococcus pneumonia, S. aerous, and streptococcus pyogenesis. Gram-negative bacteria such as Haemophilus influenza, Klebsiella pneumonia and P. Aeruginosa.
virus
Caused by influenza viruses that spread through droplet transmission. Cytomegalovirus in this case known as the leading cause of viral pneumonia.
mushrooms
Infections caused by fungi such as histoplasmosis spread through inhalation of air containing spores and are commonly found in bird feces, soil and compost.
protozoa
Cause the occurrence of Pneumocystis carinii pneumonia (CPC). Usually affects patients who have immunosupresi. (Reeves, 2001)

CLINICAL MANIFESTATION OF PNEUMONIA
Clinical manifestations of bronchopneumonia are among others:
1. Difficulty and pain when breathing

pleuritic pain
Shallow breathing and snoring
Tachypnea

2. Breath sounds over the area that had a late consolidation

Decreases, then disappears
Cracels, rhonchi, egofoni

3. Chest movement is not symmetrical
4. Chills and fever 38.8 ° C to 41.1 ° C, delirium
5. Diaphoresis
6. Anorexia
7. Malaise
8. Thick cough, productive

Greenish yellow sputum then turns into a reddish or rusty

9. Restless
10. Cyanosis

Area sirkumoral
Bluish nail beds

11. Psychosocial problems: disorientation, anxiety, fear of dying
Read More :

8 Nursing Diagnosis for Pneumonia

Ineffective Airway Clearance
Impaired Gas Exchange
Ineffective Breathing Pattern
Increased Body Temperature
Risk for Infection
Activity Intolerance
Pain
Imbalanced Nutrition Less Than Body Requirements

Nursing Care Plan for Mental Retardation

2012-01-09T10:05:00.000+07:00

Pediatric Nursing Care Plan - Mental Retardation Nursing Assessment

Assessment can be done through:

Neuroradiology can find abnormalities in the structure of the cranium, such as classification or increased intracranial pressure.
Echoencephalography can show the tumor and hematoma.
A brain biopsy is only useful on a small number of children retardasii mentally. Not easy for parents to accept the role in brain tissue making even small amounts because they add to the brain damage is inadequate.
Bio-chemical research to determine the metabolic rates of various materials which are known to affect brain tissue if not found in large quantities or small, such as hyperglycemia in preterm neonates, accumulation of glycogen in muscles and neurons, fat deposits in the brain and high levels of phenylalanine.

Or can perform the following assessments:

Assessment of physical
Assessment for growing up
Family history assessment, especially regarding mental retardation and hereditary disorders in which mental retardation is one of the main species.
Medical history to obtain evidence of trauma to prenatal, perinatal, postnatal, or physical injury.
Prenatal maternal infection (eg, rubella), alcoholism, drug consumption.
Inadequate nutrition.
Environmental deviations.
Psychiatric disorders (eg, Autism).
Infections, particularly those involving the brain (eg, meningitis, encephalitis, measles) or high body temperature.
Chromosome abnormalities.
Assist with diagnostic tests such as: analysts chromosomes, metabolic dysfunction, radiography, tomography, electro ensephalography.
Perform or assist with intelligence tests. Stanford Binet, Wechsler intellence, Scale, American Assiciation of Mental Retardation Adaptive Behavior Scale.
Observation of an early manifestation of mental retardation:
- Not responsive to contact.
- Poor eye contact during breastfeeding.
- Decrease in spontaneous activity.
- Decreased awareness of sound vibrations.
- Sensitive stimuli.
- Breast-feeding is slow.

Read More :

Nursing Care Plan Mental Retardation Nursing Diagnosis and Interventions

Physical Examination for Congestive Heart Failure (CHF)

2012-01-09T10:03:00.001+07:00

Congestive heart failureor Heart failure is inability of the heart to pump an adequate amount of blood to the systemic circulation to meet the body's metabolic demands.

In most cases, heart failure is a process that occurs over time, when an underlying condition damages the heart or makes it work too hard, weakening the organ. Heart failure is characterized by shortness of breath (dyspnea) and abnormal fluid retention, which usually results in swelling (edema) in the feet and legs.

Common symptoms of congestive heart failure include:

Shortness of breath with exertion or when lying down
Cough
Swelling in legs, feet and ankles (pooling of blood)
Swelling of the abdomen
Weight gain
Loss of appetite, indigestion
Irregular or rapid pulse
Low blood pressure
Weakness and fatigue
Heart palpitations (feeling the heart beat)
Difficulty sleeping
Other symptoms may include:
Decreased in alertness or ability to concentrate
Decreased urine production
Nighttime urination (the need to get out of bed to go to the bathroom)
Nausea and vomiting

Physical Examination for Congestive Heart Failure (CHF)

Nursing Diagnosis for Congestive Heart Failure (CHF) - Activity Intolerance

2011-12-24T23:37:00.000+07:00

Nursing Diagnosis for Congestive Heart Failure (CHF)

Activity Intolerance

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

Characterized by:

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

Goals / evaluation criteria:

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

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

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

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

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

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

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

Nursing Care Plan for Pain

2011-12-23T22:29:00.001+07:00

Pain

Pain is the most common reason a person seeking medical assistance. Pain occurs with the disease process, diagnostic examination and treatment process. Pain is very annoying and difficult for many people. The nurse could not see and feel the pain experienced by the client, because pain is subjective (between one individual with another individual is different in addressing the pain). Nurses provide nursing care to clients in various situations and circumstances, which provide interventions to improve comfort. According to some theories of nursing, comfort is the basic requirement that the client is the purpose of nursing care. The statement was supported by Kolcaba who said that comfort is a state has met basic human needs.

Definition of Pain

Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation, or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives information on the pain's location, intensity, and something about its nature. The various conscious and unconscious responses to both sensation and perception, including the emotional response, add further definition to the overall concept of pain.

What do you know about Pain ?

Pain is tiring and requires a lot of energy
Pain is subjective and individualized
Pain can not be objectively assessed as X-rays or blood lab
Nurses can assess patients' pain just by looking at physiological changes and behavior of client statements
Only the client knows when pain and pain arising
Pain is a physiological defense mechanism
Pain is a warning sign of tissue damage
Pain started the inability
The false perception that causes pain so pain management is not optimal

In summary, Mahon, argued pain following attributes:

Pain is an individual
Pain is not fun
Is a strength that dominate
Are endless

Nursing Care Plan for Urethral Stricture

2011-12-23T22:20:00.001+07:00

Definition of Urethral Stricture

A urethral stricture is a narrowing of a section of the urethra. It causes a blocked or reduced flow of urine which can lead to complications.

Symptoms and signs

Symptoms of urethral stricture is a typical small stream of urine and branched irritation and other symptoms of infection such as frequency, urgency, dysuria, sometimes with infiltrates, abces and fistula. Symptoms are retained urine.

Physical Examination

Anamnese

To find the absence of symptoms and signs of urethral stricture also to look for causes of urethral stricture.

General and local examination

To check on the patient also to change in urethral fibrosis, infiltrates, abscesses or fistulas.

Examination Support

Laboratory: urea, creatinine, to see the renal physiology. Radiological Diagnosis must be made with urethrography. Retrograde urethrography to see the anterior urethra. Antegrade urethrography to see the posterior urethra. Bipoler urethrography is a combination of antegrade and retrograde urethrography examinations. With this examination can be expected in addition to the diagnosis of urethral strictures can be also determined the length of urethral stricture are important for therapy planning / operations.

Basic Concepts of Nursing Care

In nursing care is carried out by using the nursing process. The nursing process is a form of dynamic problem-solving process in an effort to improve and maintain optimal patient through a systematic approach to help patients. Nursing theories and concepts are implemented in an integrated manner in which organized phases which include:

Assessment, Nursing Diagnosis, Interventions, Implementation, Evaluation.

1. Assessment

Assessment of clients with urological disorders including data collection and data analysis. In data collection, sources of client data obtained from the client's own self, family, nurse, physician or from medical records.

Data collection include:
Biodata client and the client responsible. Biodata clients consist of the name, age, gender, education, occupation, status, religion, address, date of hospital admission, register number, and medical diagnostics.

Past medical history will provide information about health or disease of the past who have suffered in the past.

Physical Examination
Done by inspection, palpation, percussion, auscultation of the body's system, it will be found to any of the following: general state of the client postoperative urethral stricture should be viewed in terms of: a state generally include appearance, awareness, style of speech. On postoperative urethral stricture impaired bladder elimination patterns that do permanent catheter.

Respiratory system
Needs to be studied starting from the nose shape, presence or absence of pain in the nostrils, the movement of the nostrils during breathing, symmetry chest movement during breathing, auscultation of breath sounds and respiratory problems that arise. Is it clean or there Ronchi, as well as the frequency of breath. This is important because it affects the development of immobilization and mobilization of pulmonary secretions in the airway.

Cardiovascular system
Began to be studied conjunctival color, lip color, presence or absence of elevation of the jugular vein can be assessed by auscultation of heart sounds in the chest and the measurement of blood pressure by palpation of the pulse frequency can be calculated.

Digestive System
That were examined include the state of teeth, lips, tongue, appetite, intestinal peristalsis, and bowel movements. The purpose of this assessment to find out early deviations in this system.

Genitourinary system
Can be assessed from the presence or absence of swelling and pain in the waist area, observation and palpation of the lower abdominal area to determine the presence of urinary retention and review of the state of genitourinary tools shape the outside of the presence or absence of tenderness and lumps and how spending urine, smooth or there painful micturition time, and how the color of urine.

Musculoskeletal system
What needs to be studied on this system Range of Motion is the degree of movement joints from head to lower limbs, discomfort or pain were reported when the client moves, the tolerance time clients move and observation of injuries to the muscles must be studied as well, because the client usually immobility tonus and decreased muscle strength.

Integumentary System
What needs to be studied is the state of skin, hair and nails, skin examination include: texture, moisture, turgor, color and function of touch.

Neurosensori System
Studied is consistent Neurosensori cerebral function, cranial nerve function, sensory function and reflex function.

The pattern of daily activities
The pattern of daily activities on clients who experience post op urethral strictures include the frequency of meals, food types, portion sizes, types and quantity of drinking and elimination that includes defecation (frequency, color, consistency) and urination (frequency, number of urine that come out every day and the color of urine). Personal hygiene (frequency of bathing, washing hair, brushing teeth, changing clothes, combing hair and nails). Sports (frequency and type) and recreation (frequency and recreation).

Urethral Stricture Nursing Diagnosis, Interventions, Implementation and Evaluation

Source : http://nursing-care-plan.blogspot.com/2011/12/nursing-care-plan-for-urethral.html

Nursing Care Plan for Thyroid Cancer

2011-12-17T11:15:00.000+07:00

DEFINITION OF THYROID CANCER

Thyroid cancer is a malignancy of the thyroid, which has 4 types, namely: papillary, follicular, anaplastic and medullary. Thyroid cancer rarely causes enlargement of the gland, more often causes a small growth (nodules) in the gland. Most thyroid nodules are benign, thyroid cancer is usually curable.

Thyroid cancer often limits the ability to absorb iodine, and limit the ability to produce thyroid hormone, but sometimes produce enough thyroid hormone, causing hyperthyroidism.

ETIOLOGY THYROID CANCER

The etiology of this disease is uncertain, which acts specifically to occur well differentiated (papillary and follicular) are the radiation and endemic goitre, and for medullary type is genetic factors. Not known a carcinoma, which for anaplastic and medullary cancer.

Radiation is one of the etiological factors of thyroid cancer. Many cases of cancer in children previously received radiation to the head and neck because of other diseases. Usually the effects of radiation occur after 5-25 years, but an average of 9-10 years. TSH stimulation of the old is also one of etiological factors of thyroid cancer. Other risk factors are family history of thyroid cancer and chronic goiter.

Read More :

Nursing Care Plan for Thyroid Cancer - Assessment, Diagnosis and Interventions

Nursing Care Plan for Mesothelioma

2011-08-22T08:47:00.004+07:00

Mesothelioma

Mesothelioma is a form of cancer that is almost always caused by exposure to asbestos. In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the organs. The most common site is the pleura (the outer layer of the lungs and internal chest wall), but may also occur in the peritoneum (the lining of the abdominal cavity), heart, pericardium (the sac that surrounds the heart) or tunica vaginalis.

Mesothelioma Signs and Symptoms

These symptoms may be Caused by mesothelioma or by other, less serious conditions.

That Mesothelioma affects the pleura can cause these signs and symptoms:

Chest wall pain
Pleural effusion, or fluid Surrounding the lung
Shortness of breath
Fatigue or anemia
Wheezing, hoarseness, or cough
Blood in the sputum (fluid) coughed up (hemoptysis)

In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung. The disease may metastasize, or spread, to other parts of the body.

That tumors affect the abdominal cavity Often do not cause symptoms until They are at a late stage. Symptoms include:

Abdominal pain
Ascites, or an abnormal buildup of fluid in the abdomen
A mass in the abdomen
Problems with bowel function
Weight loss

In severe cases of the disease, the following signs and symptoms may be present:

Blood clots in the veins, the which may cause thrombophlebitis
Disseminated intravascular coagulation, a disorder Causing severe bleeding in many body organs
Jaundice, or yellowing of the eyes and skin
Low blood sugar levels
Pleural effusion
Pulmonary emboli, or blood clots in the arteries of the lungs
Severe ascites

A mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs.
Source : wikipedia.org

Mesothelioma Diagnostic Test

Pleural biopsy
Then histologic study of the specimen ..
Chest x-rays
Computed tomography scans of the chest

Nursing Care Plan for Mesothelioma

Nursing Assessment Nursing Care Plan for Mesothelioma

Assessment is the main base of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment - a careful collection of data about clients, Their families, the data obtained through interviews, observation and examination.

Patient Identity
The identity of the client: name, age, marital status, religion, tribe / nation, education, occupation, income, address and registration number.

Main complaint: chest pain and dyspnea, hoarseness cough, anorexia, weight loss, weakness and fatigue.

Previous medical history: exposure to asbestos

Physical examination:
- Inspection: shortness of breath and, finger clubbing.
- Auscultation: diminished chest sounds
- Percussion: dullness over lung fields

Nursing Care Plan for Mesothelioma

Nursing Diagnosis and Nursing Interventions for Mesothelioma

Source : http://nanda-nursing.blogspot.com/2011/08/nursing-care-plan-for-mesothelioma.html

Nursing Diagnosis and Nursing Interventions for Mesothelioma

2011-08-22T08:40:00.002+07:00

Nursing Diagnosis for Mesothelioma

Ineffective airway clearance
Ineffective breathing pattern
Pain
Impaired gas exchange
Impaired physical mobility
Anxiety
Excess fluid volume
Fatigue
Hopelessness
Impaired skin integrity
Risk for infection

Nursing Interventions for Mesothelioma

Monitor respiratory status, Provide oxygen as ordered.
Assist the patient to a comfortable position (Fowler's position, for example)
Provide action for patient comfort: Such as repositioning and relaxation techniques.
Provide treatment to reduce pain, according to therapy programs. Monitor and document the medication's effectiveness.
If mobility decreases, turn the patient frequently. Provide skin care, particularly over bony prominences. Encourage him to be as active as possible.
Monitor I.V. fluid intake to avoid circulatory overload and pulmonary congestion.
Monitor vital signs: blood pressure, respiration, pulse, body temperature.
Teach relaxation techniques.
Teach breathing and positioning variations to ease the dyspnea associated with progressive disease

Nursing Diagnosis, Nursing Interventions NCP for Mesothelioma

Nursing Care Plan for Hepatocellular Carcinoma - Hepatoma

2011-08-19T11:09:00.002+07:00

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC, also called malignant hepatoma) is the most common type of liver cancer. Most cases of HCC are secondary to either a viral hepatitide infection (hepatitis B or C) or cirrhosis (alcoholism being the most common cause of hepatic cirrhosis).

Signs and symptoms

HCC may present with jaundice, bloating from ascites, easy bruising from blood clotting abnormalities or as loss of appetite, unintentional weight loss, abdominal pain,especially in the upper -right part, nausea, emesis, or fatigue.
wikipedia

Nursing Assessment Nursing Care Plan for Hepatocellular Carcinoma - Hepatoma

Biodata

The assessment is important to know the background, socioeconomic status, customs / culture, and spiritual beliefs, so easy in the communications and determine appropriate nursing actions.

Nursing History

The main complaint: The enlargement of the liver is felt more and more annoying so that it can lead to complaints of shortness of breath is felt more heavily in addition accompanied by abdominal pain.

History of present illness
Disease history can now be obtained through other people or by the client itself.

Disease history of the past
Disease history of the past studied to obtain data on disease ever suffered by the client.

Family Disease History
Family history of disease studied to find out data about the disease that had experienced ol er family members.

Physical Examination

Clinical symptoms

Early Phase: Asymptomatic.
Further Phase: No known symptoms are pathognomonic.

Complaints of abdominal pain, weakness and weight loss, anorexia, feeling of fullness after a meal is sometimes accompanied by vomiting and nausea. If there is metastasis to bone sufferers complain of bone pain.

On physical examination can be obtained:

Ascites
Jaundice
Splenomegaly, spider nevi, palmar erythema, edema.

In general, nursing assessment on the client with a case of hepatoma, include:

Metabolic disorders
Bleeding
Ascites
Edema
Hypoalbuminemia
Jaundice / icterus
Endocrine Complications
Activities were disrupted by treatment

Nursing Diagnosis for Hepatocellular Carcinoma

Nursing Interventions for Hepatoma - Hepatocellular Carcinoma

Nursing Diagnosis for Hepatocellular Carcinoma

2011-08-18T10:33:00.002+07:00

Nursing Diagnosis for Hepatocellular Carcinoma

Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea, impaired absorption, metabolism of vitamins.

Ineffective Breathing Pattern related to the presence of ascites and emphasis diapragma.

Acute pain related to tension in the abdominal wall.

Activity intolerance related to imbalance between supply oxygenation to the needs.

Risk for deficient fluid volume related to excessive ascites, bleeding, and edema.

Risk for infection related to deficiency of white blood cells.

Impaired Skin Integrity related to pruritus, edema, and ascites.

Altered Se.uality and Se.ual Dysfunction related to hormonal dysfunction and decreased libido.

Anxiety related to hospitalization.

Knowledge deficient: the disease process and its causes.

Social isolation related to the risk of spreading infection.

Nursing Diagnosis for Hepatocellular Carcinoma

Nursing Intervention for Hepatoma - Hepatocellular Carcinoma

Source : http://nandanursingdiagnosis.blogspot.com

Nursing Interventions for Hepatoma - Hepatocellular Carcinoma

2011-08-18T09:58:00.002+07:00

Nursing Intervention for Hepatoma - Hepatocellular Carcinoma

Nursing Diagnosis for Hepatoma - Hepatocellular Carcinoma

Acute pain related to tension in the wall of the abdomen (ascites)

Goal :
Demonstrate the use of relaxation skills and entertainment activities as indicated pain.
Reported the maximum pain relief.

Nursing Intervention :

Determine the history of pain such as location, frequency, duration and intensity (0-10) and measures of pain relievers for example provide a comfortable position.
Provide basic comfort measures such as repositioning, rubbing his back.
Assess pain level / control value

Rational :

Provide basic data to evaluate the need / effectiveness of interventions such as: pain is the individual who combined both physical and emotional responses.
Increase relaxation and help refocus attention.
Maximum pain control.

Nursing Diagnosis for Hepatoma - Hepatocellular Carcinoma

Activity intolerance related to imbalance between supply oxygenation to the needs

Goal :
Can perform activities according to the ability of the body.

Nursing Intervention :

Encourage the patient to do anything if possible, such as bathing, getting up from a chair / bed, walk.
Increase activity according to ability.
Monitor the physiological response to such activities; changes in blood pressure, heart rate and breathing.
Give oxygen as indicated

Rational :

Increasing the strength / stamina and enables patients to become more active without significant fatigue.
Tolerance depends on the stage of the disease process, nutritional status, fluid balance and reactions to therapeutic rules.
The presence of hypoxia, lowering oxygen availability for cellular uptake and aggravate fatigue.

Nursing Diagnosis for Hepatoma - Hepatocellular Carcinoma

Imbalanced Nutrition : Less Than Body Requirements related to anorexia, nausea, impaired absorption

Goal :

Demonstrated stable weight, weight gain progressively towards the goal, with normalization of laboratory values and limit signs of malnutrition.
Countermeasures understanding of individual influences on adequate input.

Nursing Intervention :

Monitor the input of food every day, give pasein diary about the food as indicated.
Encourage patients to eat a diet high in calories and rich in protein with adequate fluid intake.
Encourage the use of supplements and foods often / less that divided during the day.
Give antiemetics on a regular schedule before / during and after the administration of antineoplastic agents as appropriate.

Rational :

The effectiveness of individual dietary assessment in the disappearance of nausea, post-therapy.
Patients should try to find a solution / the best combination.
Increased metabolic needs as well as the fluid (to remove residual production).
Supplements can play an important role within to maintain adequate caloric intake and protein.
Nausea / vomiting at least reduce the ability and psychological side effects of chemotherapy that causes stess.

Nursing Interventions Nursing Care Plan for Hepatocellular Carcinoma - Hepatoma

Sepsis and Septic Shock Emergency Nursing Care Plan

2011-08-07T23:29:00.002+07:00

Definition of Sepsis

Sepsis is a systemic response to bacteremia. At the time of bacteremia caused changes in the circulation, leading to decreased tissue perfusion and Septic Shock occurs. Approximately 40% of patients with sepsis caused by gram-positive microorganisms and 60% due to gram-negative microorganisms. The most common organisms causing sepsis are Staphylococcus aureus and Pseudomonas sp.

Signs and Symptoms of Sepsis

Patients with sepsis and septic shock is an acute illness. Assessment and treatment is needed. Patients can die from sepsis. Common symptoms are:

fever
sweat
headache
muscle aches

Find out the source of primary infection. Consider the source of infection the following:

urinary infection
respiratory tract infections
dermatitis
meningitis
endocarditis
intra-abdominal infections
osteomyelitis
pelvic inflammatory disease
se.ually transmitted diseases

Nursing Assessment - Sepsis and Septic Shock Emergency Nursing Care Plan

Always use the ABCDE approach.

Airway

Make sure the airway clearance
Give the tool a respirator if necessary (nasopharyngeal)
If a decline in respiratory function immediately contact the anesthesiologist and the patient may be brought immediately to the ICU

Breathing

Assess the amount of breathing, more than 24 times / minute is a significant symptom
Assess oxygen saturation
Check arterial blood gases to assess the oxygenation status and the possibility of acidosis
Give 100% oxygen via non re-breath mask
Chest auscultation, to determine the presence of chest infection
Photo thoracic radiograph

Circulation

Assess heart rate, more than 100 times / minute is a significant sign
Monitoring blood pressure
Check the capillary refill time
Attach infusion using a large canul
Replace catheter
Perform a complete blood
Record the temperature
Prepare the urine and sputum examination

Disability

Confused is one of the first signs of sepsis patients, whereas previously there were no problems (healthy and good).
Assess level of consciousness

Exposure

If the source of infection is unknown, look for the existence of injuries, cuts and the injection site and the source of other infections.

Sign of the threat to life

Severe sepsis defined as sepsis that caused the failure of organ functions. If it is causing a threat to the life of the patient should be taken to the ICU, while the indications are as follows:

decline in kidney function
decline in cardiac function
hypoksia
acidosis
clotting disorders
acute respiratory distress syndrome (ARDS)

Sepsis and Septic Shock Emergency Nursing Care Plan