Nursing Care Plan

Imbalanced Nutrition More than Body Requirements Nanda Nursing Diagnosis

noreply@blogger.com (Adhe Krisna) — Sun, 08 Jan 2012 19:12:36 PST

Imbalanced Nutrition More than Body Requirements Definition :

Imbalanced nutrition : more than body requirements refers to a caloric intake / excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue. As the amount of stored fat increases, the individual becomes overweight or obese. A person is said to be overweight when BMI is between 25 and 29.9 kg/m2 and obese when BMI is >30 kg/m2 . Factors that affect weight gain include genetics, sedentary lifestyle, and emotional factors associated with dysfunctional eating. Medical conditions associated with this problem are as follows: diabetes mellitus, severe hypertension, and Cushing’s syndrome. Cultural or ethnic background also influences eating habits. Overall nutritional requirements of geriatric patients are similar to those of younger patients, except that calories should be reduced because of their leaner body mass. The major goals for this problem is to maintain or restore optimal nutrition status, promote healthy nutritional practices, prevent complication associated with malnutrition and decrease weight.

Related Factors :

Cultural preferences
Excessive intake in relation to metabolic need
Lack of knowledge of nutritional needs, food intake, and/or appropriate food preparation
Metabolic disorders
Poor dietary habits

Psychosocial factors

Sedentary lifestyle

Socioeconomic status

Use of food as coping mechanism

Nursing Care Plan for Neonatal Hypoglycemia

noreply@blogger.com (Adhe Krisna) — Sun, 08 Jan 2012 19:10:02 PST

Neonatal hypoglycemia

Neonatal hypoglycemia is low blood sugar (glucose) in the first few days after birth.

Symptoms of Neonatal Hypoglycemia

Infants with hypoglycemia may not have symptoms. If they do occur, symptoms may include:

Bluish-colored skin (cyanosis)
Breathing problems
Decreased muscle tone (hypotonia)
Grunting
Irritability
Listlessness
Nausea, vomiting
Pale skin
Pauses in breathing (apnea)
Poor feeding
Rapid breathing
Problems with maintaining body heat
Shakiness
Sweating
Tremors
Seizures

Nursing Care Plan for Epistaxis

noreply@blogger.com (Adhe Krisna) — Sat, 14 Jan 2012 22:50:01 PST

Definition

Epistaxis is bleeding from the bottom of the nose can be primary or secondary, spontaneous or due to stimulation and is located next to the posterior or anterior.

Care Management

Blood flow will stop after the blood had frozen in the process of blood clotting. A medical opinion says that when the bleeding occurs, it is better if the head is tilted forward position (sitting position) to drain the blood and prevent entry into the esophagus and stomach.

First aid in case of epistaxis is to squeeze the front of your nose for three minutes. During the emphasis should breathe through the mouth. Mild bleeding will usually stop in this way. Do the same thing in case of recurrent bleeding, if it does not stop you should visit a doctor for help.

For chronic nose bleeds due to dryness of the nasal mucosa, is usually prevented by spraying saline in the nose up to three times a day.

If due to pressure, ice packs can be used to shrink blood vessels (vasoconstriction). If it still does not work, can be used nasal tampons. Tampons can stop a bleeding nose and the media is mounted 1-3 days.

Deaths from bleeding nose is something that is rare. However, if it caused damage to the maxillary artery can cause heavy bleeding through the nose and difficult to cure. Action of pressure, vasoconstrictor less effective. Possible healing maksillaris arterial structure (which can damage the facial nerve) is the only solution.

Related Articles :

Nursing Care Plan for Epistaxis

Ineffective Airway Clearance Nursing Care Plan for Epistaxis

Nursing Care Plan for Pain - Assessment, Diagnosis and Interventions

noreply@blogger.com (Adhe Krisna) — Fri, 16 Dec 2011 20:12:07 PST

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 Diagnosis and Nursing Intervention for Dengue Fever

noreply@blogger.com (Adhe Krisna) — Mon, 15 Aug 2011 17:46:31 PDT

Nursing Diagnosis and Nursing Intervention for Dengue Fever

Dengue fever also known as breakbone fever, is an infectious tropical disease caused by the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles. In a small proportion of cases the disease develops into the life-threatening dengue hemorrhagic fever, resulting in bleeding, low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs.

Nursing Diagnosis and Nursing Intervention for Dengue Fever

Nursing Diagnosis

Deficient Fluid volume : less than body requirements related to increased capillary permeability, bleeding, vomiting and fever.

Goal:

Body fluid volume adequat

Expected outcomes:

Body fluid volume returned to normal

Nursing Intervention for Dengue Fever

Assess the general state and condition of the patient
Observation of vital signs (temperature, pulse, respiratory rate)
Observation for signs of dehydration
Observation drip infusion and intravenous needle insertion site
Balance of fluid (the fluid input and out put)
Give the patient and family encourage patients to drink a lot
Instruct the patient's family to replace the patient's clothing is wet with sweat.

Nursing Diagnosis

Hyperthermia

Related to

dengue virus infection process

Goal :

Hypertermia can be resolved

Expected outcomes

Body temperature returned to normal

Nursing Intervention for Dengue Fever

Observation of vital signs, especially temperature
Give a cold compress (plain water) on the forehead and armpits
Change clothes soaked with sweat
Encourage the family to put on clothing that can absorb sweat like cotton.
Encourage the family to provide drinking lots of approximately 1500 to 2000 cc per day.
Collaboration with doctors in the provision Therapy, febrifuge.

Source : http://nursingdiagnosis-nursinginterventions.blogspot.com

Nursing Diagnosis and Nursing Intervention for Angina Pectoris

noreply@blogger.com (Adhe Krisna) — Mon, 15 Aug 2011 17:40:36 PDT

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand. Angina is a common presenting symptom (typically, chest pain) among patients with coronary artery disease. A comprehensive approach to diagnosis and to medical management of angina pectoris is an integral part of the daily responsibilities of health care professionals.

Nursing Diagnosis and Nursing Intervention for Angina Pectoris

Nursing Diagnosis

Decreased Cardiac Output

Related to

Inotropic changes, such as transient or prolonged myocardial ischemia and effects of medications;
alterations in rate, rhythm, and electrical conduction.

Criteria for outcome

Cardiac Pump Effectiveness
Demonstrate increased activity tolerance.
Report or display decreased episodes of dyspnea, angina, and dysrhythmias.
Participate in behaviors and activities that reduce the workload of the heart.

Nursing Intervention for Angina Pectoris

Monitor vital signs, eg heart rate, blood pressure.
Rationale: Tachycardia can occur because of pain, anxiety, hypoxemia, and decreased cardiac output. Changes also occur in blood pressure (hypertension or hypotension) due to cardiovascular response.

Record the color and the presence / quality of the pulse.
Rationale: decreased peripheral circulation when cardiac output falls, making skin color pale or gray (depending on the level of hypoxia) and decreased strength of peripheral pulses.

Maintain bed rest in a comfortable position during the acute episode.
Rationale: Lowering the oxygen consumption / demand, lowering employment and risk of myocardial decompensation.

Provide supplemental oxygen as needed
Rationale: Increase the supply of oxygen to the need to improve myocardial contractility, decrease ischemia, and lactic acid levels.

Source : http://nursingdiagnosis-nursinginterventions.blogspot.com

Nursing Diagnosis for Pulmonary Tuberculosis

noreply@blogger.com (Adhe Krisna) — Mon, 15 Aug 2011 17:35:32 PDT

Nursing Diagnosis for Pulmonary Tuberculosis

Nursing Diagnosis : Ineffective airway clearance related to :
- thick secretions
- weakness, bad cough efforts
- edema, tracheal / pharyngeal
Nursing Diagnosis : Impaired gas exchange related to :
- reduced effectiveness of lung surface
- atelectasis
- alveolar capillary membrane damage
- thick secretions
- bronchial edema
Nursing Diagnosis : Risk for infection related to :
- decreased immune system
- cilia function declines
- secretions that settle
- tissue damage due to the spread of infection
- malnutrition
- contaminated by the environment
- lack of knowledge about infectious germs
Nursing Diagnosis : Imbalanced Nutrition Less then Body Requirements related to :
- fatigue
- coughing frequently
- the production of sputum
- dyspnea
- anorexia
- impairment of financial capability
Nursing Diagnosis : Knowledge deficit about the condition, treatment, prevention relating to :
- nothing is explained
- wrong interpretation
- the information obtained is incomplete / inaccurate
- lack of knowledge / cognitive.

Source : http://nursing-care-plan.org

Nursing Diagnosis and Intervention for Pneumonia

noreply@blogger.com (Adhe Krisna) — Mon, 15 Aug 2011 17:30:35 PDT

Ineffective airway clearance related to inflammation, accumulation of secretionsGoal :
Effective way of breath, lung ventilation is adequate and there is no buildup of secretions.
Interventions :
- Monitor respiratory status every 2 hours, review the increase in respiratory status and abnormal breath sounds.
- Perform percussion, vibration and postural drainage every 4-6 hours.
- Give appropriate oxygen therapy program.
- Help cough up secretions / suction mucus.
- Give the comfortable position that allows the patient to breathe.
- Create a comfortable environment so that patients can sleep calmly.
- Monitor blood gas analysis to assess respiratory status.
- Give drink enough.
- Provide sputum for culture / sensitivity test.
- Manage provision of appropriate antibiotics and other drugs program.
Impaired gas exchange related to changes in alveolar capillary membrane.Goal :
Patients showed improvement ventilation, optimal gas exchange and tissue oxygenation is adequate.
Interventions :
- Observation of the level of consciousness, respiratory status, cyanosis signs every 2 hours.
- Give Fowler position semi-Fowler.
- Give oxygen by program.
- Monitor blood gas analysis.
- Create an environment of calm and comfort patients.
- Prevent the occurrence of fatigue in patients.
Deficient fluid volume related to inadequate oral intake, fever, tachypnoea.Goal :
Patients will maintain a normal body fluids.

Interventions :
- Record fluid intake and output.
- Monitor fluid balance: mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs.
- Maintain the accuracy of the drip infusion based on the program.
- Perform oral hygiene.
Activity intolerance related to decreased blood oxygen levels.Goal :
Patients can do activities based on conditions.
Interventions :
- Assess the patient’s physical tolerance.
- Assist patients in activities of daily activities.
- Provide age-appropriate games that patients with activities that do not spend a lot of energy, match the activity with the condition.
- Give oxygenation by program.
- Give the energy needs.

Source :

http://nursing-care-plan.org

Nursing Care Plan for Hyperemesis Gravidarum

noreply@blogger.com (Adhe Krisna) — Sat, 14 Jan 2012 22:30:47 PST

Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting duringpregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%

Nursing Assessment for Hyperemesis Gravidarum

Activity / rest
Systolic blood pressure decreases, pulse rate increased by more than 100 times per minute.

Ego Integrity
Interpersonal family conflicts, economic difficulties, changes in perception about the conditions, unplanned pregnancies.

Elimination
Changes in consistency; defecation, increased frequency of urination
Urinalysis: increased concentration of urine.

Food / fluid
Excessive nausea and vomiting (4-8 weeks), epigastric pain, weight loss (5-10 kg), oral mucous membrane irritation and red, low hemoglobin and hematocrit, breath smelled of acetone, reduced skin turgor, sunken eyes and dry tongue.

Breathing
Respiratory frequency increased.

Security
The temperature sometimes rises, weakness, icterus and may lapse into a coma.

Sexuality
Cessation of menstruation, when a state endangering the mother carried a therapeutic abortion.

Social Interaction
Changes in health status / stressors of pregnancy, changes in roles, the response of family members that can be varied to hospitalization and illness, the less support system.

Learning and education
- Everything is eaten and drunk vomited, especially if lasts long.
- Weight loss of more than 1 / 10 of normal body berast
- Skin turgor, dry tongue
- The presence of acetone in the urine.

Nursing Diagnosis and Intervention : Imbalanced Nutrition - Less Than Body Requirements for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Imbalanced Nutrition: Less Than Body Requirements related to the frequency of excessive nausea and vomiting.

Nursing Intervention for Hyperemesis Gravidarum

1. Restrict oral intake until the vomiting stops.
Rationale: Maintaining a fluid electrolyte balance and prevent further vomiting.

2. Give the anti-emetic drugs are prescribed.
Rationale: Preventing vomiting and maintain fluid and electrolyte balance.

3. Maintain fluid therapy can be saved.
Rationale: Correction of hypovolemia and electrolyte balance.

4. Record intake and output.
Rationale: Determining hydration fluids, and spending through vomiting.

5. Encourage to eat small meals but often
Rational: Can adequate intake of nutrients your body needs.

6. Advise to avoid fatty foods
Rational: fatty foods can stimulate nausea and vomiting.

7. Encourage to eat a snack such as crackers, bread and tea (hot) warm before waking up at noon and before bed.
Rational: snack can reduce or prevent nausea, vomiting, excessive excitatory.

8. Record intake, if oral intake can not be given within a certain period.
Rationale: To maintain a balance of nutrients.

9. Inspection of irritation or Iesi the mouth.
Rational: To know the integrity of the oral mucosa.

10. Review oral hygiene and personal hygiene and the use of oral cleaning fluid as often as possible.
Rationale: To maintain the integrity of the oral mucosa.

11. Monitor hemoglobin levels and Hemotokrit
Rationale: To identify the potential presence of anemia and decreased oxygen-carrying capacity. Clients with Hb levels less than 12 mg / dl or hematocrit levels are low, consider-trimester anemia I.

12. Urine Test against acetone, albumin and glucose ..
Rationale: Establish baseline data; done routinely to detect potential high-risk situations such as inadequate intake of carbohydrates.

13. Measure uterine enlargement
Rationale: Malnutrition mother affects fetal growth and aggravate the decrease in the complement of brain cells in the fetus, resulting in deterioration of fetal development and the possibilities further.

Nursing Diagnosis and Intervention : Imbalanced Nutrition - Less Than Body Requirements for Hyperemesis Gravidarum

Source : http://free-nursingcareplan.blogspot.com/2011/06/nursing-care-plan-for-hyperemesis.html

Nursing Care Plan for Peritonitis

noreply@blogger.com (Adhe Krisna) — Sat, 14 Jan 2012 23:12:22 PST

Peritonitis is an inflammation (irritation) of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs.

Symptoms

The belly (abdomen) is very painful or tender. The pain may become worse when the belly is touched or when you move.

Your belly may look or feel bloated. This is called abdominal distention.

Other symptoms may include:

Fever and chills
Fluid in the abdomen
Passing few or no stools or gas
Excessive fatigue
Passing less urine
Nausea and vomiting

ncbi.nlm.nih.gov

NCP - Nursing Care Plan for Peritonitis

Assessment of functional patterns

a. Activity / rest
Symptoms: weakness
Signs: ambulation difficulty

b. Circulation
Symptoms: tachycardia, sweating, pallor, hypotension (shock marks)
Signs: tissue edema

c. Elimination
Symptoms: inability to defecate and flaktus, diarrhea (sometimes).
Signs: hiccups, distension, abdominal silent.
Decreased urine output, dark colors
Decreased or absent bowel sounds (ileus), intermittent loud sounds, bowel sounds rough (obstruction), abdominal rigidity, tenderness.
Hiperresonan / tympani (ileus) lost sound dull on his liver.

Read More :
Nursing Assessment for Peritonitis

Nursing Diagnosis for Peritonitis

Acute pain related to an accumulation of fluid in the abdominal cavity

Hyperthermia related to the inflammatory process

Constipation related to decreased intestinal peristalsis

Read More :
Nursing Diagnosis for Peritonitis

Nursing Interventions for Peritonitis

Nursing Diagnosis Acute Pain

related to accumulation of fluid in the abdominal cavity

Objectives : Pain is lost / controlled

Expected outcomes: the patient expressed pain controlled / lost

Nursing Intervention and Rational for Peritonitis:

Read More :

Nursing Interventions for Peritonitis

Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

Risk for Infection Nursing Care Plan for Peritonitis

Nursing Assessment for Peritonitis

noreply@blogger.com (Adhe Krisna) — Sat, 14 Jan 2012 22:47:39 PST

Assessment of functional patterns

a. Activity / rest
Symptoms: weakness
Signs: ambulation difficulty

b. Circulation
Symptoms: tachycardia, sweating, pallor, hypotension (shock marks)
Signs: tissue edema

c. Elimination
Symptoms: inability to defecate and flaktus, diarrhea (sometimes).
Signs: hiccups, distension, abdominal silent.
Decreased urine output, dark colors
Decreased or absent bowel sounds (ileus), intermittent loud sounds, bowel sounds rough (obstruction), abdominal rigidity, tenderness.
Hiperresonan / tympani (ileus) lost sound dull on his liver.

d. Food / Fluids
Symptoms, anorexia, nausea / vomiting, thirst
Signs: projectile vomiting
Dry mucous membranes, tongue swelling, poor skin turgor.

e. Pain / security
Symptoms: abdominal pain, sudden severe, common, locally, spreads to the shoulders, constant movement.

f. Respiratory
Signs: shallow breathing, tachypnea

g. Security
Symptoms: a history of pelvic organ inflammation (salpingitis), postnatal infections.

h. Counseling and Learning
Symptoms: a history of penetrating abdominal gunshot wound sample / stab or blunt trauma to the abdomen, bladder perforation / rupture, GI tract diseases.

Related Articles :

Nursing Diagnosis for Peritonitis

Nursing Intervention for Peritonitis

Deficient Fluid Volume Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis

noreply@blogger.com (Adhe Krisna) — Sun, 24 Jul 2011 02:08:46 PDT

Peritonitis is an inflammation of the peritoneum, the serous membrane lines That part of the abdominal cavity and viscera. Peritonitis may be localised or generalized, and may result from infection (Often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process.

Nursing Diagnosis for Peritonitis

Acute pain related to an accumulation of fluid in the abdominal cavity

Hyperthermia related to the inflammatory process

Constipation related to decreased intestinal peristalsis

Deficient fluid volume related to the displacement of fluid from the extracellular, intracellular to the area of peritoneum

Imbalanced nutrition: less than body requirements related to decrease in peristaltic

Risk for infection related to inflammation.

Nursing Intervention for Peritonitis

Nursing Care Plan for Peritonitis

Nursing Interventions for Peritonitis

noreply@blogger.com (Adhe Krisna) — Sun, 24 Jul 2011 01:58:42 PDT

Nursing Interventions for Peritonitis

Nursing Diagnosis Acute Pain

related to accumulation of fluid in the abdominal cavity

Objectives : Pain is lost / controlled

Expected outcomes: the patient expressed pain controlled / lost

Nursing Intervention and Rational for Peritonitis:

a. Assess degree of pain
Rational: to compare the degree of pain on the previous condition.

b. Teach relaxation techniques and distractions
Rational: to control pain

c. Provide comfort measures
Rational: to provide emotional benefits, reduce pain

d. Collaboration of analgesic
Rational: to relieve pain

Nursing Diagnosis Hyperthermia

related to inflammatory process

Purpose: Hyperthermia patients can be resolved.

Expected outcomes:

Temperature within normal limits
Did not experience complications

Nursing Intervention and Rational Peritonitis :

a. Monitor the patient's body temperature
Rational: 38.90 C increase in temperature above indicate an acute infectious disease.

b. Give a warm compress
Rational: to help reduce fever

c. Monitor the temperature of the environment, limit / add the bed linen as indicated.
Rational: room temperature / number of blankets modified to maintain near-normal temperatures.

d. Collaboration of antipyretic
Rational: used to reduce fever

Nursing Care Plan for Peritonitis

Nursing Assessment for Peritonitis

Nursing Diagnosis for Peritonitis

Nursing Intervention for Peritonitis

The Role of Nurses in Rehabilitation Services to Schizophrenia Patients

noreply@blogger.com (Adhe Krisna) — Tue, 05 Jul 2011 23:29:42 PDT

The Role of Nurses in Rehabilitation Services to Schizophrenia Patients

Definition of rehabilitation

A complex process, encompassing many different disciplines and is a combination of efforts of medical, social, educational integrated to prepare, improve / maintain and nurture a person in order to regain the highest possible level of functional ability.

A process of recreation and development for people with disabilities to be able to implement the social function appropriately in society.

Schizophrenia

Schizophrenia is a mental illness. Symptoms include hallucinations (such as hearing voices), delusions (false ideas), disordered thoughts, and problems with feelings, behaviour and motivation. The cause is not clear. In many people symptoms recur or persist long-term, but some people have just one episode of symptoms that lasts a few weeks. Treatment includes medication, talking treatments and social support.

The role of nurses in mental patient schizophrenia

The role of nurses in mental patient rehabilitation services, especially patients with schizophrenia, it is very important, because in fact, schizophrenic patients are most chronic patients in mental hospitals.

Chronic patients is the first goal in rehabilitation so that they can be returned to the community and do not fill the bulk in mental Hospitals. Nurses are often the officer performing the service in mental hospitals, therefore, information, experiences and efforts taken by one nurse toward mental patients will be very instrumental in both the preparation, distribution / placement and supervision of rehabilitation. In addition, the role of nurses in rehabilitation is still needed especially in the family or the community involved in the implementation and facilitate rehabilitation efforts. At times like that nurses can provide guidance on how families can help the patient does not become a relapse is to keep providing activities that are useful to patients and do not even hidden. When the hospital's services are available day care services, the nurse should recommend that patients take part in day care.

Nursing Care Plan for Multiple Sclerosis

noreply@blogger.com (Adhe Krisna) — Sat, 25 Jun 2011 05:07:58 PDT

Nursing Care Plan for Multiple Sclerosis

Multiple sclerosis (abbreviated MS, also known as disseminated sclerosis or encephalomyelitis disseminata) is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms. Disease onset usually occurs in young adults, and it is more common in women. It has a prevalence that ranges between 2 and 150 per 100,000. MS was first described in 1868 by Jean-Martin Charcot. (wikipedia)

Nursing Care Plan for Multiple Sclerosis

Nursing Assessment for Multiple Sclerosis

Activity / rest
Symptoms: weakness, activity intolerance, numbness, paresthesia external
Signs: general weakness, decreased muscle tone / muscle mass, unsteady path / dragged, ataxia

Circulation
Symptoms: edema
Signs: extremity narrowed, not active, fragile capillaries

Ego integrity
Symptoms: anxiety, hopelessness, helplessness, decreased productivity

Elimination
Symptoms: nocturia, retention, incontinence, constipation, urinary tract infections
Signs: sphincter control is lost, kidney damage

Food / liquid
Symptoms: difficulty chewing / swallowing
Signs: hard to feed themselves

Hygiene
Symptoms: personal hygiene assistance
Signs: less self-care

Pain / discomfort
Symptoms: painful spasms, facial neuralgia

Security
Symptoms: a history of falls / trauma, use of assistive devices

Sexuality
Symptoms: impotent, impaired sexual function

Social Interaction
Symptoms: withdraw
Signs: speech disorders

Neuro Sensory
Symptoms: weakness, muscle paralysis, numbness, tingling, diplopia, blurred vision, memory loss, difficulty communicating, seizures
Signs: mental status (euphoria, depression, apathy, sensitive, disorientas)
Stammering, blindness in one eye, impaired sensation of touch / pain, nystagmus, diplopia
Lost motor skills, spastic paresis, ataxia, tremor, hiperfleksia, + Babinski, klonus on knee.

Nursing Diagnosis for Multiple Sclerosis

Impaired Physical Mobility related to weakness, muscle paresis, spasticity

Expected results :

Participate in a rehabilitation program
Demonstrate behaviors that maintain / increase activity

Nursing Intervention for Multiple Sclerosis

Determine the level of client activity
Assess the weaknesses
Provide regular change of position
Help fulfill the basic needs of clients according to needs
Collaboration: physical therapy / work by physiotherapists, medical treatment (steroids, baklofen, immunosuppressants)

Assessment in Hospitals - Home Health Care Planning

noreply@blogger.com (Adhe Krisna) — Wed, 22 Jun 2011 07:16:27 PDT

Assessment in Hospitals

Assessment in Hospital is an important step that brings the client throughout the process of care and the hospital to his home until the end of achieving optimal level of independence. The success of the planning process depends on the coordination between hospital and home health care providers. Once the client was referred to the agency-at-home care, planners-at-home care should assess medical needs, social needs, the needs of nursing, and rehabilitation needs of the client to determine whether the client is qualified or eligible to receive services.

Eligibility criteria determined by both the type of program or by insurance coverage. If the client was eligible for a referral program, planners-at-home care must begin the assessment and should incorporate the following things to achieve continuity of care and positive outcomes:

Hospital records review, allows the nurse to identify the primary and secondary diagnoses, medical history of clients, relevant laboratory values, treatment programs, counseling provided, required equipment, and therapeutic modalities.

Interviews with Clients / Family, Time to discuss the social and environmental aspects of client care at home. During the interview, nurses should be able to evaluate the adequacy of client support systems, family dynamics, their understanding of the disease, and their ability to learn and implement the necessary treatments or therapies.

Home Health Care Planning

The important part in the interview was to discuss the program goals. Clients should be given the opportunity to express expectations about the transition to home and the objectives of the program. Planners should also discuss the nature of the program and the importance of client participation in care planning. The client must agree that the program can meet their needs effectively.

Physical Assessment. Physical assessment is a key step in the assessment process. Physical Assessment establishes baseline data, relating to review hospital records and interview clients, to maintain continuity of care.

Case Conference. After completing the assessment, in-home care planners should collaborate with physicians, discharge planners, or social worker to develop a treatment plan. Continuity of care relies on communication among all staff involved.

Role of Nurses as Implementation of Home Health Care

noreply@blogger.com (Adhe Krisna) — Wed, 22 Jun 2011 06:43:43 PDT

The nurse is the part that can not be separated, and the birth of home health care organization and the success of the process. Nurses assess the needs of clients at home and integrate client and support system into the treatment plan. Communication of findings of increased home visits in-home care process and improve the abilities of all team members in a down effective plan to provide needed services. Services that can be administered as a whole include medical therapy, therapeutic nursing, physical therapy, speech therapy and occupational therapy, social work, nutrition, nursing assistant-at-home, laboratory, medical supplies and durable medical equipment. This collaborative approach ensures the handling of health care clients in a holistic / whole.

Documentation

Clear and comprehensive documentation on the initial assessment and nursing care plan, necessary to formulate goals and a realistic time frame. Repeat visits to the client will focus on issues identified since the beginning, counseling is needed, and some significant changes that occur during nursing visits. All documentation must inform nurses about the clinical actions of clients and client response to treatment planning and medical programs. These factors will determine the frequency of nursing visits according to the duration.

Role of Nurses as Implementation of Home Health Care

HOME CARE - Prevention of Disease Transmission

noreply@blogger.com (Adhe Krisna) — Wed, 22 Jun 2011 06:26:59 PDT

HOME CARE - Prevention of Disease Transmission

Because the prevalence of infectious diseases continue to rise, nurses must have knowledge, about how it takes to protect themselves and care-givers in-house.

Handwashing

Hand washing is set as the most effective method for preventing the spread of disease.

Instrument

Wherever possible, use client-owned equipment. Instruments, such as scissors and tweezers and nursing bag must be cleaned thoroughly after use.

Equipment for Protection.

When providing resuscitation mouth-to-mouth, if possible use a disposable face shield. Face shield can be provided by the health-care providers in-house. However, resuscitation bags are equipped with one-way valve is another type of emergency equipment that is used for the purpose of protection can be provided by nurses in her bag. Generally, valves and filters should be discarded after each use on the client.

Linen / Weaving Tools

Contaminated linen should be kept not in contact with clean linen and other clothing or surfaces of other objects. Linen must be changed every day and as often as possible or as needed.

Tools-Cutting tools

In some cases, clients purchase and provide their own at home, the tools sharp containers leak-proof which will be used as a disposal of needles, syringes and other sharp tools are disposable, like a lancet and a razor blade. These tools should be discarded immediately after use.

Spill Blood or Body Fluids

Spills of blood or other material that has the potential to be infected should be cleaned immediately using a bleach solution with a ratio of 1:10. Affected area should be cleaned thoroughly. Spills on the skin should be cleaned with liquid soap and running water.

Disposal of infectious waste

Disposable gloves should be worn when disposing of garbage. Hands should be washed immediately after handling garbage.

Other preventive measures.

Better to use liquid soap instead of using bar soap for bathing clients. Clients and family / caregiver should be instructed to replace the towels and clothes every day.

Nursing Care Plan for Social Isolation

noreply@blogger.com (Adhe Krisna) — Mon, 20 Jun 2011 22:44:56 PDT

Social Isolation

Isolation is a state where an individual or group experience or feel the need or desire to increase involvement with other people but are unable to make contact.

Social isolation is a state of loneliness experienced by a person because someone else expressed a negative attitude and threatening.

Behavior withdraw an attempt to avoid interaction with others, avoid contact with others.

Social isolation is a condition of loneliness expressed by the individual and perceived as being caused by others and as a negative situation that threatens. With characteristics: living alone in a room, the inability to communicate, withdrawal, lack of eye contact. Incompatibilities or immaturity of interests and activities with the development or for age. Pre ocupation with his own thoughts, repetition, action that is not meaningful. Expressing feelings of rejection or loneliness caused by others. Experiencing a different feeling with others, feel insecure amid the crowds.

Nursing Assessment for Social Isolation

Grouping the data on mental health assessment in the form of precipitation factor, stressor appraisal, coping resources owned by the client. Each doing instruction, write the place and date of clients admitted to treatment, nursing assessment includes :

Client Identity
Include client's name, age, sex, marital status, religion, dated to the hospital, informant, date of assessment, the client address.

Main complaint
Complaints are usually solitary (away from other people) is less or no communication, silent room, refuse interaction with others, do not perform daily activities, the dependent.

Predisposing factors
loss, separation, rejection of parents, parental expectations are unrealistic, the failure / frustration over and over, the pressure from peer groups; changes in social structure.

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Nursing Diagnosis, Interventions and Evaluation for Social Isolation

Nursing Diagnosis for Social Isolation
Disturbed Sensory Perception related to withdrawal

Goal
The client can:

Fostering a trusting relationship.
Mention the causes of withdrawal.
Mention the advantages relate to others.
Doing social relations gradually, the client - the nurse, the client - the group, the client - the family.
Expressing feelings after dealing with others.
Empowering support system.
Using medications appropriately and correctly.

Nursing Intervention for Social Isolation

Construct a trusting relationship: therapeutic greetings, introduce themselves, explain the purpose of interaction, create a peaceful environment, create a contract that clearly at every meeting (topic to be discussed, the place to talk, talk time).

Nursing Diagnosis, Interventions and Evaluation for Social Isolation

noreply@blogger.com (Adhe Krisna) — Mon, 20 Jun 2011 22:28:39 PDT

Nursing Diagnosis, Interventions and Evaluation for Social Isolation

Nursing Diagnosis for Social Isolation
Disturbed Sensory Perception related to withdrawal

Goal
The client can:

Fostering a trusting relationship.
Mention the causes of withdrawal.
Mention the advantages relate to others.
Doing social relations gradually, the client - the nurse, the client - the group, the client - the family.
Expressing feelings after dealing with others.
Empowering support system.
Using medications appropriately and correctly.

Nursing Intervention for Social Isolation

Construct a trusting relationship: therapeutic greetings, introduce themselves, explain the purpose of interaction, create a peaceful environment, create a contract that clearly at every meeting (topic to be discussed, the place to talk, talk time).

Pay attention and awards: do not accompany the client time to answer, saying "I'll sit beside you, if you want to say something I am ready to listen". If a client looked at the nurse's face said "there would you say?".

Listen to clients with empathy: give a chance to speak (not in a hurry), show the client the nurse to follow the conversation.

Talk with the client what the cause would not relate to others.

Discuss the perceived effect of the withdrawal.

Discuss the advantages make friends with others.

Assist clients to identify the capabilities of the client to hang.

Perform frequent and brief interaction with the client (if possible the same nurse).

Motivation / accompany the client to interact / meet with clients / other nurses, give examples of how to get acquainted.

Increase the gradual interaction client (one client, two clients, one nurse, two nurses, and so on).

Involve the client in a therapeutic group activity, socialization.

Assist clients perform activities of daily living with the interaction.

Facilities relationships with clients in therapeutic family.

Discuss with the client after each interaction / activity.

Give praise to the success of the client.

Nursing Evaluation for Social Isolation

Evaluation criteria:

Facial expressions are friends, show pleasure, no eye contact, like shaking hands, want to mention names, like answering the greeting, will sit side by side with nurses, want to express the problems encountered.

The client may be able to mention the cause withdraw from self, others and the environment.

Clients can mention the advantages and disadvantages in dealing with others.

The client is able to demonstrate a gradual social relationships: client - nurse, client - group, the client - the family.

The client can express his feelings after being in contact with others for themselves and others.

Families can participate in caring for the client to withdraw.

Nursing Diagnosis, Interventions and Evaluation for Social Isolation

Nursing Assessment for Social Isolation

noreply@blogger.com (Adhe Krisna) — Mon, 20 Jun 2011 21:51:37 PDT

Nursing Assessment for Social Isolation

Grouping the data on mental health assessment in the form of precipitation factor, stressor appraisal, coping resources owned by the client. Each doing instruction, write the place and date of clients admitted to treatment, nursing assessment includes :

Client Identity
Include client's name, age, sex, marital status, religion, dated to the hospital, informant, date of assessment, the client address.

Main complaint
Complaints are usually solitary (away from other people) is less or no communication, silent room, refuse interaction with others, do not perform daily activities, the dependent.

Predisposing factors
loss, separation, rejection of parents, parental expectations are unrealistic, the failure / frustration over and over, the pressure from peer groups; changes in social structure.

Physical Aspects
The results of measurements of vital signs (BP, pulse, temperature, breathing, height, weight) and physical complaints experienced by the client.

Psychosocial Aspects
Self-concept :
- Body Image :
  Refusing to see and touch the body parts that change or not to accept the bodily changes that have happened or will happen.
  Rejecting the explanation of changes in the body, negative perceptions about the body.
  Preoccupation with missing body parts, expressed despair, expressing fear.
- Identity
  Uncertainty see themselves, difficult to establish the desire and unable to make decisions.
- Role
  Changed or stopped functioning due to the role of disease, aging, school dropouts, layoffs.
- Self-Ideal
  Reveals despair due to his illness: expressed a desire that is too high.
- Self-esteem
  Clients have the interference / obstacles in conducting social relationships with others nearby in the life, the group that followed in the community.
  Client's belief in God and worship activities for (spiritual)
- Mental Status
  Less eye contact client / can not maintain eye contact, less able to initiate conversation, the client aloof and less able to relate to others, The feeling of hopelessness and less valuable in life.
Preparation needs to go home.
- The client is able to prepare and clean the cutlery
- The client is able bowel and bladder, using and cleaning toilets, cleaning the clothes and tidying up.
- On the observation bathing and dressing the client looks neat
- Clients can rest and sleep, can move inside and outside the home
- The client can run the program with the correct treatment.
Coping Mechanisms
Clients get into trouble if afraid or unwilling to tell him on the others (more frequent use of coping withdrew)

Nursing Assessment for Nursing Care Plan Social Isolation

Nursing Care Plan for Hypertension

noreply@blogger.com (Adhe Krisna) — Mon, 14 Nov 2011 08:07:29 PST

Nursing Assessment Nursing Care Plan for Hypertension

Assessment is the main basis 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.

The data collected can be divided into two (Kelliat, Budi Ana., 1995) :

Data base
Specific data relating to the current situation of the client which can be determined by the nurse, client or family.

The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).

Read More Nursing Assessment for Hypertension

Hypertension Nursing Diagnosis

Hypertension Nursing Interventions

Nursing Care Plan for COPD

noreply@blogger.com (Adhe Krisna) — Tue, 20 Dec 2011 21:58:19 PST

Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD)

Nursing Assessment for COPD (Chronic Obstructive Pulmonary Disease)

The Identity of the Client
Name, place and date of birth, age, sex, the responsible include: name, address, relationship with the client.

Perception of Health and Health Maintenance.
Review the status of a medical history of having experienced the client, what efforts and where clients get medical help, then what makes the client's health status declined.

Metabolic Nutrition
Ask the client about the type, frequency, and amount of food and drink clients in a day. Assess excessive or decreased appetite, nausea, vomiting or a review of the intravenous therapy, use of enteric tube, measuring weight, height measurement.

Elimination
Review of rekuensi, characteristics, difficulties / problems and also the use of assistive devices such as catheters, also measuring intake and output.
Elimination process, review the frequency, characteristics, difficulties / problems defecation and also the use of tools / interventions in defecation.

Activity and Exercise
Assess the ability of activities both before illness or condition now and also the use of assistive devices such as canes, wheel chairs and others. Ask the client about the use of leisure time. Are there any complaints on your breathing, such as the beating heart, chest pain, weak body.

Sleep and Rest
Ask the client's daily sleep habits. How to sleep atmosphere client whether light or dark. Often wake up during sleep caused by pain, itching, urination, difficulty and others.

Cognitive Perception
Ask the client whether to use vision aids, hearing. Is there any client trouble remembering things, how clients cope with discomfort: pain. Is there a perception of sensory disturbances such as blurred vision, hearing impaired. Assess the level of orientation to time place and person.

Perception and Self-Concept
Assess the behavior of the self, whether the client has experienced despair / frustration / stress, and how according to clients about themselves.

Role Relationships
What is the role of clients in the community and family, how client relationships in the community, family and coworkers. Assess whether there is disruption and disturbance of verbal communication in interactions with family members and others.

Sexual Production
Ask the client about the use of contraception and the problems that arise. How many children of clients and client's marital status.

Coping Mechanisms and Tolerance to Stress.
Assess the factors that make the client angry, where clients exchange opinions and coping mechanisms that are used for this. Assess client's current situation against conformity, expression, denial / rejection of self.

Belief System
Assess whether the client worship, clients follow a religion? Assess whether there are values on which clients embrace religion contrary to health.

Nursing Diagnosis Nursing Care Plan for COPD

Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.

Impaired Gas Exchange related to ventilation perfusion inequality.

Activity Intolerance related to imbalance between supply with oxygen demand.

Imbalanced Nutrition: Less than Body Requirements related to anorexia.

Disturbed Sleep Pattern related to discomfort, the setting position.

Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.

Anxiety related to threat to self-concept, the threat of death, unmet needs.

Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.

Knowledge Deficit related to lack of information, do not know the source of information.

Nursing Intervention Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD)

Nursing Diagnosis for COPD

Ineffective Airway Clearance related to bronchoconstriction, Increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

Goal:
Achieving client airway clearance

Nursing Intervention for COPD

Give the patient 6 to 8 glasses of fluid per day unless there is Cor pulmonale.
Teach and give the use of diaphragmatic breathing and coughing techniques.
Assist in the provision of a nebulizer action, measured dose inhalers.
Perform postural drainage with percussion and vibration in the morning and at night as required.
Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in color of sputum, sputum viscosity, increased shortness of breath, chest tightness, fatigue.
Give antibiotics as required.
Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.

Nursing Diagnosis for COPD

Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway Irritants.

Goal:
Improvement of breathing patterns

Nursing Intervention for COPD

Teach client diaphragmatic breathing exercises and breathing lips sealed.
Give encouragement to intersperse activity with periods of rest. Let the patient make decisions about treatment based on patient tolerance level.
Give encouragement to use the muscles of breathing exercises if required.

Nursing Assessment for Hypertension

noreply@blogger.com (Adhe Krisna) — Fri, 06 Jan 2012 19:43:16 PST

Nursing Assessment for Hypertension

Assessment is the main basis 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.

The data collected can be divided into two (Kelliat, Budi Ana., 1995) :

Data base
Specific data relating to the current situation of the client which can be determined by the nurse, client or family.

The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).

Basic Nursing Assessment data by Doenges (1999) :

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

Source :

Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions

Nursing Diagnosis for Hypertension

Nursing Intervention for Hypertension

Nursing Diagnosis for Hypertension

noreply@blogger.com (Adhe Krisna) — Sat, 14 May 2011 10:20:13 PDT

Nursing Diagnosis for Hypertension

Risk for Decreased Cardiac Output related to Increased afterload, vasoconstriction and myocardial ischemia.

Acute pain related to increased cerebral vascular pressure.

Activity Intolerance related to general weakness, imbalance Between supply and demand of oxygen.

Risk for Ineffective Tissue Perfusion : cerebral, renal, cardiac related to circulatory disorders.

Imbalanced Nutrition: More Than body requirements related to the input of excessive, monotonous lifestyle, cultural beliefs.

Inefektif Individual Coping related to situational crisis / maturasional, the support system is inadequate, ineffective coping methods.

Deficient Knowledge related to lack of information about the disease process and self-care.

Nursing Diagnosis for Hypertension

Nursing Intervention Nursing Care Plan for Hypertension