tag:blogger.com,1999:blog-39975630853130918692024-03-05T23:02:20.015+07:00Nurses Nandanandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comBlogger141125tag:blogger.com,1999:blog-3997563085313091869.post-58039030803054925362015-10-16T15:09:00.001+07:002019-02-12T23:20:37.062+07:00Nursing Diagnosis and Interventions for Morbid Obesity<br />
Morbid obesity is a multifactorial disease, which occurs due to excessive accumulation of fat tissue, so as to disturb the health. Obesity occurs when a large and growing number of fat cells in a person's body. When a person to gain weight, the fat cell size will increase and then the numbers increased. Research to study a variety of hormones and the neuroendocrine system, which regulates energy balance and body fat is a long standing challenges in the field of biology, with obesity as an important public health focus. Today we live in an era when more weight (body mass index (BMI) 23-24.9 kg / m2) and obese (BMI 25-30 kg / m2) has become an epidemic, with allegations that the increased prevalence of obesity will reach 50% in 2025 for developed countries.<br />
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Actual current health worker must appear together more and more to know about the regulation of body weight, the mechanism of the development of overweight and obese, and the number of comorbidities associated with almost all subspecialty. Because only by studying it we can conduct a comprehensive approach to effective treatment for obesity.<br />
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<b>Nursing Diagnosis and Interventions for Morbid Obesity</b><br />
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1. Imbalanced Nutrition: more than body requirements related to the increase in the intake of nutrients.<br />
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Interventions:<br />
<br />
<ul>
<li>Create a meal plan with the patient.</li>
<li>Measure body weight per day.</li>
<li>Emphasize the importance of realizing full and stop inputs.</li>
<li>Give liquid diet, softer, high in protein and fiber and low in fat with the addition of liquid as needed.</li>
<li>Refer to a dietitian</li>
<li>Encourage clients to do a lot of activities.</li>
</ul>
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Rationale:<br />
<ul>
<li>After the act of division, decreased gastric capacity of approximately 50 ml, so the need to eat a little.</li>
<li>Supervision loss and nutritional needs.</li>
<li>Overeating may cause nausea / vomiting.</li>
<li>Provide nutrients without adding calories.</li>
<li>Need help planning a diet that meets the nutritional needs.</li>
<li>Do a lot of activities can burn more calories.</li>
</ul>
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<br />
2. Ineffective breathing pattern related to a decrease in lung expansion.<br />
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Goal: breathing pattern becomes effective.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Maintain adequate ventilation.</li>
<li>Not experiencing cyanosis or other signs of hypoxia.</li>
</ul>
Interventions:<br />
<ul>
<li>Monitor the speed / depth of breath. auscultation of breath sounds.</li>
<li>Investigate cyanosis, increased restlessness.</li>
<li>Elevate the head of the bed 30 degrees.</li>
<li>Encourage deep breathing exercises.</li>
<li>Change position periodically and ambulation as early as possible.</li>
<li>Give supplemental oxygen.</li>
<li>help the patient use breathing apparatus.</li>
<li>Monitor pulse oximetry when indicated.</li>
</ul>
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Rationale:<br />
<ul>
<li>Respiratory snore decrease ventilation, can cause hypoxia.</li>
<li>Encourage the development of the diaphragm or lung expansion and minimize the maximum pressure in the abdominal contents.</li>
<li>Increase the maximum lung expansion and airway clearance.</li>
<li>Increase air filling the entire segment of the lung, mobilize and remove secretions.</li>
<li>Maximizing preparations for the exchange of oxygen and decreased breath work. Increase lung expansion, lowering atelectasis.</li>
<li>Show ventilation / oxygenation and acid-base status, used as a basis for evaluating the need for respiratory therapy.</li>
</ul>
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3. Activity intolerance related to being overweight.<br />
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Goals: The need to move fulfilled.<br />
Expected outcomes: <br />
<ul>
<li>Physical activity increases. </li>
<li>Normal ROM. </li>
<li>The client can perform the activity.</li>
</ul>
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Interventions:<br />
<ul>
<li>Create a schedule of activities to do and ask the client to do it with discipline.</li>
<li>Help the client to engage in activities that hard to do.</li>
<li>Make sure the client motivation to sustain the movement.</li>
<li>Encourage the client perform normal daily activities, according to ability.</li>
<li>Collaboration with physiotherapy.</li>
</ul>
Rationale:<br />
<ul>
<li>Reduce stiffness and familiarize the client activity.</li>
<li>Help clients to more easily perform the activity.</li>
</ul>
nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-23294623721852642682015-10-07T10:19:00.002+07:002019-02-12T23:21:59.105+07:00Nursing Management for Necrotizing Enterocolitis<b>Necrotizing Enterocolitis (NEC)</b> is a serious disease of the newborn gastrointestinal tract, characterized by extensive tissue death occurs in the intestinal wall. The disease is becoming one of the problems in neonates with very low birth weight (VLBW infants). In general, NEC is more common in premature neonates than full-term neonates. Risk factors causes of NEC are premature birth, early enteral feeding, the intestinal mucosal injury, and the presence of bacteria in the intestine.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzi3UxtnkmdyFOJqO0yBTENV5kALi5JZhvFV49dQAj-qIaoJabZtJo77nLPm34F8fETqXUbCzKiMZYgbbQA1ui7NshyphenhyphencRV7k-pgaAA86GmLmNT5jnjuxaA5Ky0FuryYN8ab3I4ON7b7Ag/s1600/nursing-management-for-necrotizing-enterocolitis.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Management for Necrotizing Enterocolitis" border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzi3UxtnkmdyFOJqO0yBTENV5kALi5JZhvFV49dQAj-qIaoJabZtJo77nLPm34F8fETqXUbCzKiMZYgbbQA1ui7NshyphenhyphencRV7k-pgaAA86GmLmNT5jnjuxaA5Ky0FuryYN8ab3I4ON7b7Ag/s320/nursing-management-for-necrotizing-enterocolitis.jpeg" width="320" /></a></div><b>Causes</b> <br />
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This disease most often appears in sick neonates, and is a surgical emergency that occurs most frequently among neonates. Necrotizing enterocolitis is a disease that predominantly occurs in preterm neonates. In the premature neonate, there is a lowering immunocompetence, immaturity of the gastrointestinal tract, and abnormalities of peristalsis. This can lead to maldigestion and malabsorption of nutrients that stimulate the growth of bacteria, colonization and intestinal ischemia in premature neonates. Moreover, cardiorespiratory instability, homeostatic, and poor blood flow autoregulation, causing premature neonates more susceptible to ischemic events, or hypoxia and put them at risk for NEC.<br />
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<b>Predisposing Factors</b><br />
<ul><li>Low birth weight and preterm.</li>
<li>Neonates with asphyxia.</li>
<li>Neonates with respiratory distress syndrome / recurrent apnea.</li>
<li>Neonates born PRM or other perinatal infections.</li>
<li>Neonates with umbilical vein catheterization.</li>
<li>Cyanotic congenital heart disease.</li>
<li><a href="https://nursesnanda.blogspot.com/2015/09/hypothermia-in-newborn-definition-types.html">Hypothermia</a>, hypotension and other general state of disorder.</li>
</ul><b><br />
</b> <b>Clinical Manifestation</b><br />
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Symptoms that appear on the NEC may occur suddenly but onset usually occurs in 1-2 weeks after birth and can occur up to several weeks. NEC onset inversely related to gestational age, where neonates born at 28 weeks tend to suffer from the disease is greater than in more mature age neonates.<br />
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Here are some of the clinical picture shown by the neonate:<br />
<ul><li>Aspirate / bilious vomiting.</li>
<li>Food intolerance.</li>
<li>Bloody stools.</li>
<li>Distension and <a href="https://nursesnanda.blogspot.com/2015/09/acute-pain-related-to-abdominal.html">abdominal pain</a> may progress to the stage of perforation with an overview: Abdominal pain increases. Abdominal wall hard and looked pale. Edema of the abdominal wall. Bowel sounds disappear. There are abdominal mass.</li>
<li><a href="https://nursesnanda.blogspot.com/2012/01/septic-shock-emergency-nursing.html">Sepsis</a> with clinical features: temperature instability. Jaundice. Apnea and bradycardia. Lethargy. À hypoperfusion shock (Lissaueur Tom and Avroy Fanaroff: 86).</li>
</ul><br />
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<b><a href="https://nursesnanda.blogspot.com/2015/07/nursing-process-management.html">Nursing Management</a> for Necrotizing Enterocolitis</b><br />
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Basic principles of nursing management of NEC is planning nursing care in acute abdomen with the threat of septic peritonitis. The aim is to prevent worsening of the disease, intestinal perforation, and shock. If NEC occurs in epidemic group, the patients should be considered for isolation.<br />
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1. <span class="short_text" id="result_box" lang="en"><span class="hps">General Care</span></span><br />
Neonates treated in an incubator in a private room with a notice of action aseptic / antiseptic. Monitoring of vital signs carried out continuously, fluid and electrolyte balance properly recorded and performed abdominal x-ray.<br />
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2. Rest Intestine<br />
Oral feeding was stopped, decompression of the stomach by placing orogastric tube (evidence level III, level B recommendation). Lavement given when the neonate has not defecation.<br />
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3. <a href="https://nursesnanda.blogspot.com/2011/12/nutritional-metabolic-pattern.html">Nutrition</a>: Parenteral and Enteral.<br />
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4. Antibiotics.<br />
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5. Acidosis.<br />
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6. Disseminated intravascular coagulation<br />
This situation can be suspected when: Low hematocrit. Low platelets. Prothrombin time elongated. Thromboplastin time elongated. Decreased fibrinogen.<br />
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7. Surgery.nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-45020502938958457762015-09-15T21:05:00.000+07:002019-02-12T23:24:14.009+07:00Sample Nursing Care Plan for Uterine Prolapse (Post Operative)<div class="separator" style="clear: both; text-align: center;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHj0mcBZ7SbLenVJC3BBYdPQkooRl-PZb3u1y3D9cvtHysQvaW0yEkFtJb12fGmyrjxt0LBFnWgQX4ZRK4ylsi30YPZvbQaPqcXGPeRhMZJ3aBpNcC2dTYm3JBSbBRvYgXzUOzVDX0rMk/s1600/nursing-care-plan-for-uterine-prolapse.jpeg" /></div><b>Uterine Prolapse (Post Operative)</b><br />
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<b>Assessment</b><br />
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Subjective Data:<br />
<ul><li>Pain in the area of operation.</li>
<li>Tired.</li>
<li>Dizzy.</li>
<li>Nausea, bloating.</li>
</ul>Objective Data :<br />
<ul><li>There is a wound in the groin.</li>
<li>Fasting.</li>
<li>Mucous membranes dry mouth.</li>
</ul><br />
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<b>Possible Nursing Diagnosis for Uterine Prolapse (Post Operative)</b><br />
<ol><li><a href="https://nursesnanda.blogspot.com/2012/01/acute-pain.html">Acute pain </a>related to the surgical wound.</li>
<li>Risk for fluid volume deficit related to vomiting after surgery.</li>
<li>Impaired skin integrity related to the surgical wound.</li>
<li>Risk for hypertermia related to surgical wound infection.</li>
<li>Knowledge deficit: surgical wound care related to lack of information.</li>
</ol><br />
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<b>Nursing Interventions for Uterine Prolapse (Post Operative)</b><br />
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1. Acute pain related to the surgical wound.<br />
<br />
Goal: Pain disappeared after the act of nursing.<br />
Expected outcomes:<br />
<ul><li>Pain is reduced gradually.</li>
</ul>Interventions:<br />
<ul><li>Assess the patient's pain intensity.</li>
<li>Observation of vital signs and patient complaints.</li>
<li>Place the patient on a bed with a technique that is appropriate to the surgery performed.</li>
<li>Give the sleeping position that is fun and safe.</li>
<li>Instruct the patient to immediately move gradually.</li>
<li>Give appropriate analgesic therapy medical program.</li>
<li>Take action with the child nursing care.</li>
<li>Teach relaxation techniques.</li>
</ul><br />
2. Risk for fluid volume deficit related to vomiting after surgery.<br />
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Goal: There is no shortage of fluid volume.<br />
Expected outcomes:<br />
<ul><li>Elastic skin turgor, not dry,</li>
<li>No nausea and vomiting.</li>
</ul>Interventions:<br />
<ul><li>Observation of vital signs every 4 hours.</li>
<li>Monitor the infusion.</li>
<li>Give drink and eat gradually.</li>
<li>Monitor for signs of dehydration.</li>
<li>Monitor and record the fluid in and out.</li>
<li>Measure body weight per day.</li>
<li>Record and inform the doctor about vomiting.</li>
</ul><br />
3. Impaired skin integrity related to the surgical wound.<br />
<br />
Goal: Damage to skin integrity is resolved.<br />
Expected outcomes:<br />
<ul><li>The surgical wound is clean, dry, no swelling. no bleeding.</li>
</ul><br />
Interventions:<br />
<ul><li>Observation of the state of the surgical wound of signs of inflammation: fever, redness, swelling and discharge.</li>
<li>Treat the wound with sterile technique.</li>
<li>Keep around the surgical wound.</li>
<li>Give nutritious foods and encourage patients to eat.</li>
<li>Involve the family to keep the clan surgical wound environment.</li>
<li>Teach family in the care of the surgical wound.</li>
</ul><br />
4. Risk for hypertermia related to surgical wound infection.<br />
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Goal: Hyperthermia is resolved.<br />
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Expected outcomes:<br />
<ul><li>The surgical wound is clean, dry, not swollen. no bleeding.</li>
<li>The temperature in the normal range (36-37 ° C).</li>
</ul>Interventions:<br />
<ul><li>Observation of vital signs every 4 hours.</li>
<li>Give appropriate antibiotic therapy medical program.</li>
<li>Give a warm compress.</li>
<li>Monitor the infusion.</li>
<li>Ambulatory surgical wound with sterile technique.</li>
<li>Keep the surgical wound.</li>
<li>Monitor and record the fluid in and out.</li>
</ul><br />
5. Knowledge deficit: surgical wound care related to lack of information.<br />
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Goal: The client knows how to take care of the surgical wound.<br />
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Expected outcomes:<br />
<ul><li>Parents understand the operation wound care.</li>
<li>Parents can maintain cleanliness and surgical wound treatment.</li>
</ul>Interventions:<br />
<ul><li>Teach parents how to care for the surgical wound and keep it clean.</li>
<li>Discuss about the wishes of the family wanted to know.</li>
<li>Allow the patient's family to ask.</li>
<li>Explain about the care of patients at home, do not wet and dirty bandage.</li>
<li>Suggest to continue treatment / take medication regularly at home, and control back to the doctor.</li>
</ul><br />
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<b>Evaluation</b><br />
<ol><li>Obtain pain relief.</li>
<li>Patients receive adequate fluid intake volume.</li>
<li>Improved patient skin integrity.</li>
<li>Good skin turgor.</li>
<li>The client's body temperature within normal limits.</li>
<li>Gain knowledge about uterine prolapse and treatment program.</li>
<li>Mentions how the surgical wound care is good and right.</li>
</ol>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-30089932015013755682015-09-13T22:42:00.000+07:002015-09-13T22:42:06.154+07:00Nursing Diagnosis and Interventions for Mental RetardationNursing Diagnosis and Interventions for Mental Retardation<br />
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1. Delayed Growth and Development r / t abnormalities in cognitive function.<br />
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Goal: Growth and development goes according to stages.<br />
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Interventions :<br />
<ul>
<li>Assess the factors causing developmental disorders of children.</li>
<li>Identification and use of educational resources to facilitate optimal child development.</li>
<li>Provide stimulation activities, according to age.</li>
<li>Monitor the patterns of growth (height, weight, head circumference and refer to a dietitian to obtain nutritional intervention)</li>
</ul>
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2. Impaired Verbal Communication r / t delayed language skills of expression and reception.<br />
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Goal: Communication fulfilled in accordance stages of child development.<br />
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Interventions:<br />
<ul>
<li>Improve communication verbal and tactile stimulation.</li>
<li>Give repetitive and simple instructions.</li>
<li>Give enough time to communicate.</li>
<li>Encourage continuous communication with the outside world, for example: newspapers, television, radio, calendar, clock.</li>
</ul>
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3. Risk for Injury r / t aggressive behavior / uncontrolled motor coordination.<br />
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Goal: Indicates changes in behavior, lifestyle to reduce risk factors and to protect themselves from injury.<br />
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Intervention:<br />
<ul>
<li>Provide a safe and comfortable position.</li>
<li>Difficult child behavior management.</li>
<li>Limit excessive activity.</li>
<li>Ambulate with assistance; give special bathroom.</li>
</ul>
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4. Impaired social interaction r / t trouble speaking / social adaptation difficulties<br />
<br />
Goal: Minimize disruption of social interaction.<br />
<br />
Intervention:<br />
<ul>
<li>Help children identify personal strengths.</li>
<li>Give knowledge to people nearby, about mental retardation.</li>
<li>Encourage children to participate in activities with friends and other family.</li>
<li>Encourage the children to maintain contact with friends.</li>
<li>Give positive reinforcement on the results achieved by children.</li>
</ul>
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5. Family processes, Interrupted r / t have children mental retardation.<br />
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Goal: Family show an understanding of the child's illness and its treatment<br />
<br />
Intervention:<br />
<ul>
<li>Assess understanding family about the child's illness and treatment plan.</li>
<li>Emphasize and explain other health team, about the child's condition, procedures and therapies are recommended.</li>
<li>Use every opportunity to improve understanding of the disease and its treatment family</li>
<li>Repeat as often as possible information.</li>
</ul>
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6. Self-care deficit r / t the physical and mental incompetence / lack of maturity development.<br />
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Goal: Perform self-care, appropriate age and developmental level of the child.<br />
<br />
Intervention:<br />
<ul>
<li>Identification of the need for personal hygiene and provide assistance as needed.</li>
<li>Identification of difficulties in self-care, such as lack of physical movement, cognitive decline.</li>
<li>Encourage children to do their own maintenance.</li>
</ul>
<br />
Education for parents:<br />
<ul>
<li>For each stage of child development ages.</li>
<li>Support the involvement of parents in child care.</li>
<li>Anticipatory guidance and management face a difficult child behavior.</li>
<li>Inform the existing educational facilities and groups, etc.</li>
</ul>
nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-24376988868768249032015-09-13T22:18:00.002+07:002019-02-13T06:58:06.172+07:00Chronic Pain, Impaired Physical Mobility and Disturbed Body Image r/t Scoliosis<b>Nursing Diagnosis and Interventions for Scoliosis</b><br />
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<div class="separator" style="clear: both; text-align: center;"><img alt="Nursing Care Plan for Scoliosis" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGEHIbV6A1t2g44KQTXyTxDKUYkkunzWaigXc5-bL7iJQ9Gw1TltkHYJEH6zhBgN_117pDYGsIEQwKn6BkrDESqof4Kh_HUlm2NfzqG_FsqwVrQJK1CFa7xGf931n1InqbtY8VXfzhbOo/s1600/Chronic-Pain-Impaired-Physical-Mobility-Disturbed-Body-Image-Scoliosis.jpeg" /></div>Scoliosis is a medical condition in which a person's spinal axis has a three-dimensional deviation. Although it is a complex three-dimensional condition, on an X-ray, viewed from the rear, the spine of an individual with scoliosis can resemble an "S" or a "C", rather than a straight line. Scoliosis is typically classified as either congenital (caused by vertebral anomalies present at birth), idiopathic (cause unknown, sub-classified as infantile, juvenile, adolescent, or adult, according to when onset occurred), or secondary to a primary condition.<br />
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<b>Chronic Pain</b> : back related to body position tilted laterally.<br />
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Goal: Pain is reduced or lost.<br />
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Interventions:<br />
<br />
1. Assess the type, intensity and location of pain.<br />
R /: Helpful in evaluating the pain, define the intervention options, specify the effectiveness of the therapy.<br />
<br />
2. Adjust the position that increases the sense of comfort.<br />
R /: Reduce muscle tension and coping adequately.<br />
<br />
3. Maintain a quiet environment.<br />
R /: Increase sense of comfort.<br />
<br />
4. Teach relaxation and distraction techniques.<br />
R /: To divert attention, thus reducing pain.<br />
<br />
5. Encourage postural exercises regularly.<br />
R /: With posturan exercise regularly speed up the process to fix the position of the body.<br />
<br />
6. Collaboration: providing analgesic.<br />
R /: To meredahkan pain.<br />
<br />
<br />
<a href="https://nursesnanda.blogspot.com/2012/05/impaired-physical-mobility-related-to.html"><b>Impaired Physical Mobility</b></a> related to unbalanced posture.<br />
<br />
Goal: Improve the physical mobility.<br />
<br />
Interventions:<br />
<br />
1. Assess the level of physical mobility.<br />
R /: Influencing choice / monitoring the effectiveness of the intervention.<br />
<br />
2. Increase activity if the pain is reduced.<br />
R /: Provide an opportunity to expend energy.<br />
<br />
3. Help and teach active joint range of motion exercises.<br />
R /: Increase muscle strength and circulation.<br />
<br />
4. Involve the family in performing self-care.<br />
R /: Family cooperative can provide comfort to the patient.<br />
<br />
<br />
<b>Disturbed Body Image</b> related to posture tilted laterally.<br />
<br />
Goal: body image disturbance is resolved.<br />
<br />
Interventions:<br />
<br />
1. Encourage to express feelings and problems.<br />
R /: Assist in ensuring trouble to start the troubleshooting process.<br />
<br />
2. Give an open environment or supporting the patient.<br />
R /: Increase the statement of beliefs / values about positive subjects and identify misconceptions / myths that can affect the assessment of the situation.<br />
<br />
3. Discuss the patient's perception about themselves and their relationship to change and how the patient sees himself in the pattern / role functioning normally.<br />
R /: to help define the problem in relation to the previous pattern of life and assist in problem solving.<br />
<br />
4. Encourage / provide visits by people who suffer from scoliosis, especially those that have succeeded in rehabilitation.<br />
R /: Friends who have gone through the same experience, acting as role models and can provide validity statement and also hope for recovery and a normal.nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-53733594013923747192015-09-07T01:35:00.000+07:002019-02-13T06:42:16.924+07:00Newborn Priority Nursing Diagnosis and Intervention<br />
<b>Nursing Priority</b><br />
<ul><li>Facilitate adaptation to life outside the uterus.</li>
<li>Maintain thermo-neutrality.</li>
<li>Prevent complications.</li>
<li>Increase parent-child closeness.</li>
<li>Provide information and anticipatory guidance to parents.</li>
</ul><b>Home Goals:</b><br />
<ul><li>Newborns effectively adapt to life outside the uterus.</li>
<li>Free of complications.</li>
<li>Parent-child closeness done.</li>
<li>Parents express confidence in infant care.</li>
</ul><br />
<div class="separator" style="clear: both; text-align: center;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhN2zFeo7JTbRe8vyycw0YnrBjnZZdjzQKtEvYxBBndhOvc82tHg0fafKG22A0QbvALOqH4_rZKXaBw0ksyyg_FViAlwPSn63Fp2kHeKmuWq3KI9bc3xYr39wC9acSCQ4T5yvf1w9udaPc/s1600/Newborn+Priority+Nursing+Diagnosis+and+Intervention.jpeg" /></div><b>Nursing Diagnosis for Newborn</b><br />
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<b>First Hours of Life</b> (Marilynn E. Doenges and Mary Frances Moorhouse, 2001 in the Maternal Infant Care Plan, p. 558-566)<br />
<br />
1. Risk for <a href="https://nursesnanda.blogspot.com/2015/07/impaired-gas-exchange-related-to-lung.html">Impaired gas exchange</a><br />
related to antepartum stress, excessive mucus production, and stress due to cold.<br />
<br />
Goal:<br />
Free from signs of respiratory distress.<br />
<br />
Interventions :<br />
<ul><li>Measure the Apgar score in the first minute and five minutes after birth.</li>
<li>Note the prenatal complications that affect the status of the placenta and / or fetal (ie., Heart or kidney disorders, hypertension due to pregnancy, or diabetes).</li>
<li>Clear the airway; nasopharyngeal suction slowly, as needed. Monitor the apical pulse during suctioning.</li>
<li>Dry the baby with a warm blanket, place stockings head cover, and place it in the arms of parents.</li>
<li>Put the baby in a modified Trendelenburg position at an angle of 10 degrees.</li>
</ul><br />
Rationale :<br />
<ul><li>Help determine the need for immediate intervention (ie., Suction, oxygen). Total score from 0 to 3 showed severe asphyxia or possibility to control neurological dysfunction and / or chemically with breathing. Scores 4 to 6 aggravate the difficulty adapting to extrauterine life. Score 7 to 10 indicates no trouble adapting to extrauterine life.</li>
<li>This complication can lead to chronic hypoxia and acidosis, increasing the risk of damage to the central nervous system and require repair after birth.</li>
<li>Helps eliminate accumulation of fluid, facilitates breathing efforts, and help prevent aspiration. Inhalation of oropharynx cause vagal stimulation that lead to bradycardia.</li>
<li>Lowering effects of cold stress (ie., An increase in oxygen demand) and is associated with hypoxia, which can further depress respiration effort and lead to acidosis when the baby force with the end product of anaerobic metabolism of lactic acid.</li>
<li>Facilitate the drainage of mucus from the nasopharynx and trachea with gravity.</li>
</ul><br />
2. Risk for Altered body temperature<br />
related to inability to chills, body surface area in relation to the mass, the amount of subcutaneous fat finite, non-renewable sources of fat brown and some white fat deposits, thin epidermis with pooling of blood vessels close to the skin.<br />
<br />
Goal:<br />
Free signs of respiratory distress and cold stress.<br />
<br />
Interventions :<br />
<ul><li>Note the presence of fetal distress or hypoxia.</li>
<li>Dry the head and the body of a newborn baby, put the stockings headgear; and wrap in a warm blanket.</li>
<li>Place the newborn in warm environments or at arm's parents. Warm objects that contact the baby (ie., Scales, stethoscopes, examination table and hands).</li>
<li>Note the ambient temperature. Eliminate air flow and minimize the use of air conditioning; warm up when given oxygen through a mask.</li>
<li>Assess the neonate's core temperature, skin temperature secar continuous monitoring with skin testing tool appropriately.</li>
</ul><br />
Rationale :<br />
<ul><li>Reduce heat loss due to evaporation and conduction, humidity protects the baby from the air flow or air conditioner, and limit the stress of displacement of the uterus warm environment to a cold environment (possibly 5 F [19 ° C] lower than the temperature of intrauterine) , (Note: Due to the relatively large area of a newborn baby's head in relation to the body, the baby can experience dramatic heat loss of moisture, the head is not closed).</li>
<li>Prevent heat loss through conduction, in which heat is removed from the newborn to the object or surface that is cooler than the baby. Being held tightly near the body of parents of newborns and skin contact with the skin reduce heat loss in newborns.</li>
<li>A decrease in ambient temperature 2 ° C (3.6 F) sufficient to indicate neonatal oxygen consumption. Heat loss through convection occurs when the baby loses heat to the cooler air flow. Lost via radiation occurs when heat is removed from the newborn to the object or surface that is not directly related to the newborn (ie., The walls of the incubator).</li>
<li>Body temperature should be maintained closer to 36,5˚C (97,6˚F). Core temperature (rectal) usually 0,5˚C (0,9˚F) higher than skin temperature, but the continuous displacement of the core to the skin occurs so that the difference between the core and skin temperature is greater, the faster removal is becoming increasingly rapid temperature cool.</li>
</ul><br />
<br />
3. Altered family processes<br />
related to transition the development and / or additional family members.<br />
<br />
Goal:<br />
Precisely identify the baby to ensure the correct family relationships.<br />
<br />
Interventions :<br />
<ul><li>Inform parents about the needs of the newborn soon and care given.</li>
<li>Place the baby in arm mother / father, as soon as conditions allow the newborn.</li>
<li>Encourage parents to caress and talk to the newborn; encourage mothers to breastfeed if desired.</li>
</ul><br />
Rationale :<br />
<ul><li>Eliminate the anxiety of parents with regard to their baby's condition. Help parents understand the rationale for intervention in the period from the beginning of the newborn.</li>
<li>The first hour of the baby's life is the most special meaning for family interaction which can increase the initial closeness between parent and baby and the acceptance of newborns as a new family member.</li>
<li>Provide an opportunity for parents and newborns start the process of recognition and proximity.</li>
</ul>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-15038847100864058662015-09-03T23:47:00.003+07:002015-09-03T23:47:35.049+07:00Nursing Care Plan for Hyperbilirubinemia in Infants<br />
Hyperbilirubinemia is a condition where excessive concentration of bilirubin in the blood, causing joundice in neonates (Dorothy R. Marlon, 1998)<br />
<br />
<br />
<br />
1. Impaired Skin Integrity related to jaundice or radiation.<br />
<br />
Goal: good skin integrity / normal.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Good skin integrity could be maintained.</li>
<li>No injuries / lesions on the skin.</li>
<li>Good tissue perfusion.</li>
<li>Protect the skin and retain moisture and natural treatments.</li>
</ul>
Intervention:<br />
<ul>
<li>Avoid wrinkles in the bed.</li>
<li>Keep your skin to stay clean and dry.</li>
<li>Mobilization of the patient every 2 hours.</li>
<li>Monitor the existence of skin redness.</li>
<li>Wash with soap and warm water.</li>
</ul>
<br />
2. Hyperthermia related to exposure to a hot environment.<br />
<br />
Goal: temperature in the normal range.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Body temperature within normal range.</li>
<li>Pulse and respiration within normal limits.</li>
<li>There is no change in skin color.</li>
</ul>
Intervention:<br />
<ul>
<li>Monitor the temperature as much as possible.</li>
<li>Monitor skin color.</li>
<li>Monitor blood pressure, pulse, and respiration.</li>
<li>Monitor intake and output.</li>
</ul>
<br />
3. Fluid volume deficit related to inadequate fluid intake, phototherapy, and diarrhea.<br />
<br />
Goal: adequate body fluids.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Adequate fluid.</li>
</ul>
<br />
Intervention:<br />
<ul>
<li>Record the number and quality of feces.</li>
<li>Monitor the skin turgor.</li>
<li>Monitor intake output.</li>
<li>Give water between breastfeeding or giving a bottle.</li>
</ul>
<br />
4. Knowledge Deficit related to the limitations of exposure.<br />
<br />
Goal: family got knowledge about the disease that affects children.<br />
<br />
Expected outcomes:<br />
<ul>
<li>The family said the understanding of the disease, condition, prognosis and treatment programs.</li>
<li>Families are able to carry out the procedure described correctly.</li>
<li>The family was able to explain again what is described nurse / other health team.</li>
</ul>
Iintervention:<br />
<ul>
<li>Describe the pathophysiology of the disease.</li>
<li>Describe the signs and symptoms of the disease that usually appears in the right way.</li>
<li>Describe the disease process in a proper way.</li>
<li>Provide information on the patient's family about the conditions in an appropriate manner.</li>
</ul>
nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-83904087264443166042015-09-03T23:29:00.000+07:002015-09-03T23:29:12.274+07:00Hypothermia in Newborn - Definition, Types and Symptoms<b>Definition of Hypothermia</b><br />
<br />
Definition of hypothermia in newborns According to the Practical Handbook for Maternal and Neonatal Health Care (2002: M-122) "Hypothermia in newborns is a body temperature below 36.5 ° C measurement is made in the armpit for 3-5 minutes ".<br />
<br />
Hypothermia baby is a baby's body temperature below normal (less than 36.5 0C). Hypothermia is one of the most common cause of death of the newborn, especially weighing less than 2.5 Kg.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBFTCtnKgBdqtiyRKnzu1RB6-FnPrKaugGVFCsUyF3faOQeDFt6ZC7pCRqhVH6oTP4FDeXGhkUz8iv0htBCxxYKXL1rKWie7Tal_L3ZhhCc4mEwnnTsVhX-7GcR-tcSrDQilMLUQC5y_E/s1600/Hypothermia+in+Newborn+-+Definition%252C+Types+and+Symptoms.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Hypothermia in Newborn - Definition, Types and Symptoms" border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBFTCtnKgBdqtiyRKnzu1RB6-FnPrKaugGVFCsUyF3faOQeDFt6ZC7pCRqhVH6oTP4FDeXGhkUz8iv0htBCxxYKXL1rKWie7Tal_L3ZhhCc4mEwnnTsVhX-7GcR-tcSrDQilMLUQC5y_E/s320/Hypothermia+in+Newborn+-+Definition%252C+Types+and+Symptoms.jpg" width="320" /></a></div>
Hypothermia can cause hypoglycemia (low blood sugar levels), metabolic acidosis (high blood acidity) and death. Because the body quickly uses energy to keep warm, so that when the baby cold requires more oxygen. Therefore, hypothermia can lead to reduced flow of oxygen to the tissues.<br />
<br />
<br />
<b>Types of Hypothermia</b><br />
<br />
Several types of hypothermia, namely:<br />
<ol>
<li>Accidental hypothermia occurs when core body temperature dropped to less than 35 ° C.</li>
<li>Primary accidental hypothermia is a result of direct exposure to cold air, and previously healthy.</li>
<li>Secondary accidental hypothermia is a complication of systemic disorders (whole body) are serious. Most occurrence in winter (snow) and cold climate.</li>
</ol>
<br />
<br />
<b>Symptoms of Hypothermia</b><br />
<ol>
<li>Baby's feet and hands felt colder than the chest.</li>
<li>Reduced activity.</li>
<li>Weak sucking ability.</li>
<li>Weak cries.</li>
<li>Fingers and feet bluish.</li>
</ol>
nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-54523305903474170712015-09-03T09:23:00.002+07:002019-02-13T06:55:00.627+07:00Acute Pain related to Abdominal Distension<br />
Abdominal distension is the process of increasing abdominal pressure resulting in increased pressure in the stomach and the abdominal wall. Distention can occur mild or severe depending on the pressure generated. Abdominal distention can occur locally or complete and can be gradual or sudden. Acute abdominal distension may be a sign of peritonitis or signs of acute obstruction of the stomach.<br />
Abdominal distension may result from fat, flatus, fetus (pregnant or intra-abdominal mass, ectopic pregnancy) or a liquid. Liquids and gases are normal in the GIT, but not in the peritoneal space. If liquid or gas can not exit freely, abdominal distension can occur. In the peritoneal space, distention can cause acute hemorrhage, accumulation of ascites fluid or air from the perforations of the organs in the abdomen.<br />
<br />
Acute abdomen terminology has been widely known but difficult to define precisely. But as a reference, acute abdomen is a nontraumatic sudden onset disorder with primary symptoms of abdominal area and require immediate surgery.<br />
<br />
The term acute abdomen or abdominal distress described the clinic as a result of gravity in the abdomen that usually occurs suddenly with pain as the main complaint. This situation requires immediate countermeasures are often in the form of surgery, for example on the obstruction, perforation, or bleeding.<br />
<br />
Many conditions can cause acute abdomen. Broadly speaking, the situation can be grouped into five areas:<br />
<ul><li>Bacterial inflammation processes - chemical;</li>
<li>Mechanical obstruction: such as volvulus, hernia, or adhesions;</li>
<li>Neoplasms / tumors: carcinomas, polipus, or ectopic pregnancy;</li>
<li>Vascular disorders: embolism, thromboembolism, perforation, and fibrosis;</li>
<li>Congenital abnormalities.</li>
</ul>The most common causes of acute abdomen are:<br />
<ul><li>Gastrointestinal tract abnormalities: non-specific pain, appendicitis, infection of the small intestine and colon, strangulated hernias, peptic ulcer perforation, perforation of the bowel, Meckel diverticulitis,</li>
<li>Boerhaeve syndrome, inflammatory bowel disorder, Mallory Weiss syndrome, gastroenteritis, acute gastritis, mesenteric adenitis.</li>
<li>Pancreatic abnormalities: acute pancreatitis.</li>
<li>Urinary tract abnormalities: renal or ureteral colic, acute pyelonephritis, cystitis, acute renal infarction.</li>
<li>Liver, spleen, and biliary tract abnormalities: acute cholecystitis, acute cholangitis, liver abscess, ruptured liver tumor, spontaneous rupture of the spleen, splenic infarction, biliary colic, acute hepatitis.</li>
<li>Gynecological abnormalities: ruptured ectopic pregnancy, twisted ovarian tumors, ovarian follicular cysts rupture, acute salpingitis, dysmenorrhea, endometriosis.</li>
<li>Vascular abnormalities: aortic aneurysm rupture and visceral, acute ischemic colitis, mesenteric thrombosis.</li>
<li>Peritoneal abnormalities: intra-abdominal abscesses, peritonitis primary, tuberculosis peritonitis.</li>
<li>Retroperitoneal abnormalities: retroperitoneal bleeding.</li>
</ul><br />
<a href="https://nursesnanda.blogspot.com/2012/01/acute-pain.html"><b>Acute pain</b></a> related to distention, rigidity.<br />
<br />
Goal: pain is resolved or controlled.<br />
<br />
Expected outcomes: patients revealed a decrease in discomfort; expressed pain at a tolerable level, indicating relaxation.<br />
<br />
Intervention:<br />
<ul><li>Maintain bed rest in a comfortable position; do not support the knee.</li>
<li>Assess location, weight and type of pain.</li>
<li>Assess effectiveness and monitor for side effects anlgesik.</li>
<li>Give a planned rest period.</li>
<li>Assess and advise doing for the practice of active or passive range of motion every 4 hours.</li>
<li>Change positions frequently and give a back rub and skin care.</li>
<li>Auscultation bowel sounds; note the increase in rigidity or pain; give enema slowly when been booked.</li>
<li>Provide and encourage alternative measures of pain relief.</li>
</ul>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-43442129542022578642015-09-03T08:47:00.001+07:002019-02-13T06:43:40.615+07:00Paraplegia - 5 Nursing Diagnosis and Interventions<b>Nursing Care Plan for Paraplegia</b><br />
<br />
<b>Paraplegia</b> is the loss of movement and sensation in the lower extremities and all or part of the body as a result of injury to the thoracic or medulla. Lumbar or sacral spinal nerve roots. (Smeilzer, Suzanne C., et al. 2001: 2230).<br />
<br />
<br />
<b>Nursing Diagnosis and Interventions for Paraplegia</b><br />
<br />
<br />
<b>Nursing Diagnosis 1. : <a href="https://nursesnanda.blogspot.com/2012/05/impaired-physical-mobility-related-to.html">Impaired physical mobility</a></b> related to neurons damage, sensory and motor function.<br />
<br />
Goal: Improving mobility.<br />
<br />
Expected outcomes: Maintaining the position of the function evidenced by the absence of contractures, foot drop, increasing the strength of the sick body / compensation, demonstrate techniques / behaviors enabling reenact activities.<br />
<br />
Interventions:<br />
<ul><li>Assess the functions of sensory and motor patients every 4 hours.</li>
<li>Change the patient's position every two hours by taking into account the stability and comfort of the patient's body.</li>
<li>Give retaining board on the patient's foot.</li>
<li>Use muscle orthopedic, circulation, hand splints.</li>
<li>Perform passive ROM after 48-72 after injury 4-5 times / day.</li>
<li>Monitor pain and fatigue in patients.</li>
<li>Consult physiotherapy to exercise and muscle use as splints.</li>
</ul>Rationale:<br />
<ul><li>Assigning capabilities and limitations of the patient every 4 hours.</li>
<li>Preventing pressure sores.</li>
<li>For prevent drop.</li>
<li>Prevent contractures.</li>
<li>Increase stimulation and prevent contractures.</li>
<li>Showed the presence of excessive activity.</li>
<li>Provide appropriate inducement.</li>
</ul><br />
<b>Nursing Diagnosis 2. Risk for Impaired skin integrity</b> related to decrease in immobility, decreased sensory function.<br />
<br />
Goal: Maintaining the integrity of the skin.<br />
<br />
Expected outcomes: The state of the patient's skin intact, free of redness, free from infection on the location of the distressed.<br />
<br />
Interventions:<br />
<ul><li>Assess risk factor for impaired skin integrity.</li>
<li>Assess the patient's condition every 8 hours.</li>
<li>Use a special bed.</li>
<li>Change positions every two hours with anatomical position.</li>
<li>Maintain the cleanliness and dryness bed and the patient's body.</li>
<li>Perform special massage / soft over a bony area every two hours with a circular motion.</li>
<li>Assess the patient's nutritional status and give food with high protein.</li>
<li>Perform maintenance on the area of skin abrasions / broken every day.</li>
</ul>Rationale:<br />
<ul><li>One of them is immobilization, loss of sensation, incontinence bladder / bowel.</li>
<li>Earlier prevent the occurrence of pressure sores.</li>
<li>Reducing the pressure, thereby reducing the risk of <a href="https://nursesnanda.blogspot.com/2015/09/nursing-care-plan-for-decubitus-ulcer.html">pressure sores</a>.</li>
<li>Depressed area will lead to hypoxia, a change of position improves blood circulation.</li>
<li>Humid and dirty facilitate the occurrence of skin damage.</li>
<li>Improve blood circulation.</li>
<li>Maintain the integrity of the skin and the healing process.</li>
<li>Accelerate the healing process.</li>
</ul><br />
<br />
<b>Nursing Diagnosis 3. : <a href="http://nanda-nic-noc.blogspot.com/2013/04/urinary-retention-nursing-diagnosis.html" target="_blank">Urinary retention</a></b> related to an inability to urinate spontaneously, interruption spinothalamicus pathways.<br />
<br />
Goal: Increased urinary elimination.<br />
Expected outcomes: The patient can maintain bladder emptying without residues and distension, clear urine, urine culture is negative, fluid intake and output balance.<br />
<br />
Interventions:<br />
<ul><li>Assess for signs of urinary tract infection.</li>
<li>Assess fluid intake and output.</li>
<li>Do the catheter according to the program.</li>
<li>Instruct the patient to drink 2-3 liters every day.</li>
<li>Check the patient's bladder every 2 hours.</li>
<li>Check urinalysis, culture and sensibility.</li>
<li>Monitor body temperature every 8 hours.</li>
</ul>Rationale:<br />
<ul><li>The effects of the ineffectiveness of the bladder is a urinary tract infection.</li>
<li>Knowing inadequate kidney function and effective bladder.</li>
<li>The effects of spinal cord injury is the reflex micturition disorders that need assistance in urine output.</li>
<li>Prevent urine more concentrated which resulted in the onset of infection.</li>
<li>Knowing the residue as a result of autonomic hyperreflexia.</li>
<li>Knowing infection.</li>
<li>Increased temperature indication of the presence of infection.</li>
</ul><br />
<br />
<b>Nursing Diagnosis 4. : <a href="https://nursesnanda.blogspot.com/2011/10/physical-examination-for-constipation.html">Constipation</a> </b>related to the atony intestine as a result of autonomic disturbances, interruption spinothalamicus pathways.<br />
<br />
Goal: Improving bowel function.<br />
<br />
Expected outcomes: The patient is free of constipation, stool softening circumstances, shaped.<br />
<br />
Interventions:<br />
<ul><li>Assess the pattern of bowel elimination.</li>
<li>Give drink 1800 - 2000 ml / day if there are no contraindications.</li>
<li>Auscultation bowel sounds, assess for abdominal distension.</li>
<li>Avoid using oral laxatives.</li>
<li>Mobilize if possible.</li>
<li>Evaluation and record bleeding at the time of elimination.</li>
<li>Give suppository according to the program.</li>
<li>Provide high-fiber diet.</li>
</ul><br />
Rationale:<br />
<ul><li>Determining a change of elimination.</li>
<li>Prevent constipation.</li>
<li>Determine the peristaltic movement of the bowel.</li>
<li>Habitual use of laxatives will occurs dependence.</li>
<li>Increase the peristaltic movement.</li>
<li>The possibility of bleeding due to irritation.</li>
<li>Stool softeners making it easier elimination.</li>
<li>Fiber increases stool consistency.</li>
</ul><br />
<b>Nursing Diagnosis 5. <a href="http://nanda-nic-noc.blogspot.com/2013/03/chronic-pain-nursing-diagnosis.html">Chronic pain</a></b> related to treatment, long immobility, psychic injury.<br />
<br />
Goal: To provide a sense of comfort: pain.<br />
<br />
Expected outcomes: Reported decrease pain / discomfort, identify ways to cope with pain, demonstrate the use of the skills of relaxation and entertainment activities, according to individual needs.<br />
<br />
Interventions:<br />
<ul><li>Assess for the presence of pain, help the patient identify and quantify pain, such as the location, the type of pain intensity on a scale of 0-1.</li>
<li>Give comfort measures, for example, a change in position, massage, warm compresses / cold as indicated.</li>
<li>Encourage the use of relaxation techniques, for example, guidance imagination visualization, deep breathing exercises.</li>
<li>Collaboration administration of drugs according to indications, muscle relaxants, analgesics; anti-anxiety.</li>
</ul>Rationale:<br />
<ul><li>Patients usually report pain above the level of injury, for example; chest / back or the possibility of a headache than a tool stabilizer.</li>
<li>Alternative actions to control pain.</li>
<li>Refocused attention, increase the sense of control, and can improve coping skills.</li>
<li>Needed to relieve spasms / muscle pain or to eliminate-anxiety and increase the rest.</li>
</ul>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-26911693145280222402015-09-01T22:37:00.001+07:002019-02-13T06:51:45.885+07:00NCP for Pressure Sores / Decubitus Ulcer - Physical Examination, Assessment and 6 Nursing Diagnosis<br />
<b>Basic Concepts of Nursing Care</b><br />
<br />
<b>ASSESSMENT</b><br />
<br />
1. Identity<br />
Age need to be asked because of an association with wound healing or regeneration of cells. While race and ethnicity need to be assessed for skin that looks normal on certain nationalities and races, sometimes appear abnormal on the client with other nationalities and races (Smeltzer & Brenda, 2001). Jobs and hobbies are also asked to determine whether the client sedentary or less active, causing suppression of blood vessels that causes reduced oxygen supply, the cells do not get enough nutrients and metabolic waste accumulated garbage results. Eventually the cells die, the skin ruptured and there was a shallow pit and decubitus sores on the surface (Carpenito, LJ, 1998).<br />
<br />
2. Main Complaint<br />
Most complaints are perceived by clients that are looking for help. Complaints are disclosed clients in general, ie the pain. Location injuries usually found in prominent areas, for example in the area behind the head, buttocks area, heel, shoulder and groin area that suffered ischemia causing decubitus ulcers (Bouwhuizen, 1986).<br />
<br />
3. Disease History Now<br />
Things that need to be assessed is started when a complaint is felt, the location of the complaint, intensity, duration or frequency, of the factors that aggravate or mitigate the attack, as well as other complaints that accompany and efforts that have been made nurses here have to connect with the skin problems symptoms such as itching, burning, numbness, immobilization, pain, <a href="https://nursesnanda.blogspot.com/2012/08/typoid-fever-hyperthermia-related-to.html">fever</a>, edema, and neuropathy (Carpenito, LJ, 1998)<br />
<br />
4. Personal and Family History<br />
Family history of disease needs to be asked because the wound healing can be affected by inherited diseases, such as <a href="https://nursesnanda.blogspot.com/2012/01/nanda-diabetes.html">diabetes</a>, allergies, <a href="https://nursesnanda.blogspot.com/2012/01/hypertension-high-blood-pressure-causes.html">hypertension</a> (CVA). A history of skin diseases and medical procedures ever experienced by the client. This is to provide information on whether the change in the skin is a manifestation of systemic diseases such as chronic infections, cancer, diabetes.<br />
<br />
5. History of Medicine<br />
Do clients ever used drugs. Which need to be assessed by a nurse ie: When treatment starts, dose and frequency, end time of taking the medication.<br />
<br />
6. History Diet<br />
Assessed namely; weight, height, body growth and food consumed daily. Inadequate nutrition which causes the skin susceptible to lesions and a long process of wound healing.<br />
<br />
7. Socio-Economic Status<br />
To identify environmental factors and the level of the economy that may affect the pattern of daily life, as this allows can cause skin diseases.<br />
<br />
8. Health History, such as: Long bed rest, immobilization, incontinence, nutrition or hydration inadequate.<br />
<br />
9. Psychosocial Assessment<br />
The possibility that psychosocial examination results appear on the client, namely: Feelings of depression, frustration, <a href="https://nursesnanda.blogspot.com/2012/04/anxiety-related-to-urinary-tract.html">anxiety</a>, desperation.<br />
<br />
10. Activities of daily<br />
Patients were immobilized in a long time there will be an ulcer in the area that stands out because of the weight rests on a small area that is not much tissue under the skin to hold the skin damage. So it is necessary to increase range of motion exercises and weight lifting. But in case of paraplegia, there will be no muscle power (in the lower limbs), decreased intestinal peristalsis (Constipation), decreased appetite and sensory deficits in the area of paraplegia.<br />
<br />
<br />
<b>PHYSICAL EXAMINATION</b><br />
<br />
General state<br />
Generally, people come in sick and agitated or anxious as a result of the damage suffered skin integrity.<br />
<br />
Vital Signs<br />
Normal blood pressure, rapid pulse, increased temperature and increased respiration rate.<br />
<br />
Examination Head And Neck<br />
<ul><li>Head And Hair: Examination covering the head shape, deployment and change of hair color as well as the examination of the wound. If there is a wound in the area, causing pain and skin damage.</li>
<li>Eyes: Covers symmetry, conjunctiva, pupillary reflexes to light and impaired vision.</li>
<li>Nose: Includes examination of the nasal mucosa, hygiene, do not arise nostril breathing, no secretions.</li>
<li>Mouth: Record the state of cyanosis or dry lips.</li>
<li>Ears: Record forms of hearing loss due to foreign objects, bleeding and wax. In patients who are bed rest at an angle left / right, then, is likely to occur ulcer area earlobe.</li>
<li>Neck: Knowing the position of the trachea, carotid pulse, whether there is enlargement of the jugular veins and glands linfe.</li>
</ul><br />
Examination Chest and Thorax<br />
Inspection forms of thorax and lung expansion, auscultation of the respiratory rhythm, vocals premitus, the additional sounds, heart sounds, and an extra heart sounds, percussion thorax to look for abnormalities in the thorax area.<br />
<br />
Abdomen<br />
Form a flat stomach, bowel sounds decreased due to immobilization, there was a time because of constipation, and abdominal percussion hypersonor if abdominal distention or tense.<br />
<br />
Urogenital<br />
Inspection abnormalities in perinium. Usually clients with ulcers and paraplegia catheterized to urinate.<br />
<br />
Musculoskeletal<br />
The existence of fractures would cause the client bet rest for a long time, resulting in decreased muscle strength.<br />
<br />
Neurological examination<br />
Level of consciousness be assessed with GCS system. The value could be decreased if there is severe pain (neurogenic shock) and heat or high fever, nausea, vomiting, and stiff neck.<br />
<br />
<br />
<b>Physical Assessment: Skin</b><br />
<br />
Inspection of the skin<br />
Assessment involves the skin around the area of the skin including mucous membranes, scalp, hair and nails. The appearance of skin that needs to be examined is the color, temperature, humidity, dryness, skin texture (rough or smooth), lesions, vascularity. Which must be observed by nurses, namely:<br />
<ul><li>Color, influenced by blood flow, oxygenation, temperature and pigment production.</li>
<li>Edema, during the inspection of the skin, the nurse noted the location, distribution and color of local edema.</li>
<li>Humidity, Normally, humidity increases due to increased activity or high ambient temperature, dry skin can be caused by several factors, such as dry or moist environments unsuitable, inadequate fluid intake, the aging process.</li>
<li>Integrity, which must be considered that the location, shape, color, distribution, if there is drainage or infection.</li>
<li>Skin hygiene.</li>
<li>Vascularization, bleeding from blood vessels produce petechie and echimosis.</li>
<li>Palpation of the skin, Noteworthy are lesions on the skin, moisture, temperature, texture or elasticity, skin turgor.</li>
</ul><br />
<b><br />
</b> <b>NURSING DIAGNOSES</b><br />
<ol><li>Impaired Skin Integrity related to mechanical damage of tissue, secondary to pressure, shearing and friction.</li>
<li>Chronic pain related to skin trauma, infection of skin and wound care.</li>
<li>Risk for infection related to the display of decubitus ulcers to feces / urine drainage.</li>
<li><a href="https://nursesnanda.blogspot.com/2012/04/nursing-interventions-for-testicular.html">Imbalanced Nutrition</a>: Less than Body Requirements related to anorexia secondary to insufficient oral input.</li>
<li><a href="https://nursesnanda.blogspot.com/2012/05/impaired-physical-mobility-related-to.html">Impaired physical mobility</a> related to restriction of movement required, the status of which is not conditioned, loss of motor control or change in mental status.</li>
<li><a href="https://nursesnanda.blogspot.com/2012/01/ineffective-coping.html">Ineffective family coping</a> related to chronic wounds, changes in body image.</li>
</ol><br />
<h3 class="post-title entry-title" itemprop="name"><a href="https://nursesnanda.blogspot.com/2015/09/nursing-care-plan-for-decubitus-ulcer.html">Nursing Care Plan for Decubitus Ulcer / Pressure Sores</a></h3>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-61288867666887024882015-09-01T21:46:00.001+07:002019-02-13T06:49:41.542+07:00Nursing Care Plan for Decubitus Ulcer / Pressure Sores<b>Decubitus Ulcer / Pressure Sores</b><br />
<br />
<b>Definition</b><br />
<br />
Decubitus ulcer is a local tissue necrosis that tends to happen when the soft tissues between the bony prominences depressed, with the external surface in the long term. (National Pressure Ulcer Advisory Panel [NPUAP], 1989a, 1989b).<br />
<br />
Decubitus ulcer is an area of dead tissue caused by lack of blood flow area concerned. Decubitus comes from the Latin that means lying. Lying does not always lead to bedsores. Therefore, some people prefer the term pressure sores because of pressures that is the main cause of decubitus ulcers (Wolf, Weitzel & Fuerst (1989: 354) in Fundamentals of Nursing)<br />
<br />
<br />
<b>Etiology</b><br />
<br />
Decubitus sores are caused by a combination of extrinsic and intrinsic factors in patients.<br />
<br />
<b>Extrinsic Factors</b><br />
<ul><li>Pressure: stressed skin and underlying tissue between the bones with another hard surface, such as beds and operating tables. Light pressure for a long time as dangerous as great pressure in a short time. Local microcirculation disorders occur later lead to hypoxia and necrosis. (interface pressure). Interfacial pressure is force per unit area of the body with the mattress surface. If the interfacial tension is greater than the average capillary pressure, the capillaries will easily collapse, the area becomes easier to ischemia and necrotic. Average capillary pressure is about 32 mmHg.</li>
<li>Friction and shifts: repeated friction will cause abrasion, so that the damaged tissue integrity. The strained skin, the skin layer shifts, local microcirculation disturbances.</li>
<li>Humidity: will cause maceration, usually due to incontinence, drain and perspiration. Macerated tissue will be easily eroded. In addition, the moisture also lead to skin prone to friction and tearing of tissue (shear). Alvi incontinence is more significant in the development of pressure sores than urinary incontinence because of bacteria and enzymes in the stool can damage the surface of the skin.</li>
<li>Cleanliness of the beds, appliances weaving a tangled and dirty, or medical equipment that causes the client fixed on a certain attitude also facilitate the occurrence of pressure sores.</li>
</ul><br />
<br />
<b>Intrinsic Factor</b><br />
<ul><li>Age: the elderly will decrease the elasticity and vascularity. Older patients have a high risk of developing pressure sores because of skin and tissue will change with aging. Aging results in muscle loss, decreased levels of serum albumin, a decrease in inflammatory response, decreased skin elasticity, as well as a decrease in cohesion between the epidermis and dermis. These changes, combined with other aging factors will make your skin decreases tolerance to pressure, friction, and energy tearing. In addition, as a result of aging is the reduction of subcutaneous fat tissue, reduced collagen and elastin tissue. decreasing the efficiency of collateral capillaries in the skin so the skin becomes thinner and fragile.</li>
<li>Decrease in sensory perception: Patients with decreased sensory perception will be decreased to feel the sensation of pain due to pressure on the bone protruding. When this happens in a long duration, the patient will be susceptible to pressure sores. because pain is a sign that normally encourages a person to move. Nerve damage (eg due to injury, stroke, diabetes) and coma can cause a reduced ability to feel pain.</li>
<li>Loss of consciousness: a neurological disorder, trauma, narcotic analgesics.</li>
<li>Malnutrition: People who are malnourished (malnutrition) does not have a protective layer of fat, and skin does not undergo complete recovery due to shortage of nutrients that are important. Therefore, the client with malnutrition are also at high risk of suffering from decubitus ulcers. In addition, malnutrition can be impaired wound healing. Usually associated with hypo-albumin. Hypoalbuminemia, weight loss, and malnutrition is generally identified as a predisposing factor for the occurrence of pressure sores. According to research Guenter (2000) stages three and four of pressure sores in elderly people associated with weight loss, low levels of albumin, and inadequate food intake.</li>
<li>Mobility and activities: Mobility is the ability to change and control the position of the body, while the activity is the ability to move. Patients who lie constantly in bed without being able to change the position at high risk for developing pressure sores. People who can not move (eg paralyzed, very weak, deprived). Immobility is the most significant factor in the incidence of pressure sores.</li>
<li>Smoking: Nicotine found in cigarettes can reduce blood flow and have toxic effects on the endothelium of blood vessels. According to the research Suriadi (2002) there was a significant association between smoking and the development of the pressure sores.</li>
<li>Skin temperature: According to the research Sugama (1992) rise in temperature is a significant factor in the risk of pressure sores.</li>
<li>The ability of the cardiovascular system decreases, so that the skin perfusion decreased.</li>
<li>Anemia.</li>
<li>Hypoalbuminemia, high risk of pressure sores and slow down healing.</li>
<li>Diseases that damage blood vessels also facilitate exposed to pressure sores and pressure sores worsen.</li>
</ul><br />
<br />
<b>Clinical Manifestations</b><br />
<br />
Occur in patients with paraplegia, quadriplegia, spina bifida, multiple<br />
sclerosis and prolonged immobilization in the hospital. In addition, other factors need to be known of the history of the patient, including; onset, duration, history of previous treatment, wound care, previous surgical history, nutritional status and changes in body weight, a history of allergies, alcohol consumption, smoking and socio-economic circumstances of the patient. Anamnesis systems including include fever, night sweats, spasm (rigid), paralysis, odor, pain (Arwaniku, 2007). According NPUAP (National Pressure Ulcer Advisory Panel).<br />
<br />
<b>Pressure sores is divided into four stages, namely:</b><br />
<br />
<b>Stage 1:</b> ulceration limited to the epidermis and dermis with erythema on the skin. Patients with good sensibility will complain of pain, this stage is usually reversible and can be cured in 5-10 days.<br />
<i>Signs and Symptoms:</i><br />
A change of the skin that can be observed. When compared with normal skin, it will appear as a sign of the following: changes in skin temperature (colder or warmer), changes the consistency of tissue (more hard or soft), changes in sensation (itching or pain), In people who have white skin, sores may appear as redness persist. Whereas in people with dark skin, the wound will appear as a persistent red, blue or purple.<br />
<br />
<b>Stage 2: </b>ulceration of the dermis, epidermis and into broad to the adipose tissue visible erythema and induration, and partial damage to the skin (epidermis and dermis partially) characterized by blisters. This stage can be cured in 10-15 days.<br />
<i>Signs and Symptoms: </i><br />
Loss of partial layers of the epidermis or dermis of the skin, or both. Character is a superficial wound, abrasion, blister, or forming a shallow pit.<br />
<br />
<b>Stage 3: </b>ulceration extending into the layer of fat and muscle subshell has begun to interfere with the edema and inflammation, infection will disappear fibril structure. Damage to all layers of the skin to the subcutaneous, do not pass through the fascia. Usually heal in 3-8 weeks.<br />
<i>Signs and Symptoms: </i><br />
Loss of skin layers are complete, including damage or necrosis of subcutaneous tissue or deeper, but not to the fascia. The wound looks like a deep hole.<br />
<br />
<b>Stage 4: </b>ulceration and necrosis extends the fascia, muscles and joints. Can be cured in 3-6 months.<br />
<i>Signs and symptoms :</i><br />
The loss of skin layers complete with extensive damage, tissue necrosis, damage to the muscles, bones or tendons. The presence of a deep hole and sinus passages are also included in stage IV of pressure sores.<br />
<br />
<h3 class="post-title entry-title" itemprop="name"><a href="https://nursesnanda.blogspot.com/2015/09/ncp-for-pressure-sores-decubitus-ulcer.html">NCP for Pressure Sores / Decubitus Ulcer - Physical Examination, Assessment and 6 Nursing Diagnosis</a></h3>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-6636912363728714392015-08-27T09:52:00.001+07:002015-08-27T09:52:04.506+07:00Altered Fluid and Electrolyte Balance related to Dysentery<br />
<b>Nursing Care Plan for Dysentery</b><br />
<br />
Dysentery is an inflammation of the large intestine characterized by abdominal pain and bowel. Defecate repeatedly that causes the patient to lose a lot of fluid and blood. Dysentery is derived from the Greek, ie dys (interference) and enteron (intestine), which means inflammation of the intestine that cause widespread symptoms with symptoms of bowel movements with bloody stools, watery diarrhea with volume slightly, defecation with feces mixed with mucus and pain when defecation (tenesmus).<br />
<br />
Symptoms of dysentery :<br />
<ul>
<li>Defecate with bloody stools.</li>
<li>Watery diarrhea with little volume.</li>
<li>Defecation with feces mixed with mucus (mucus).</li>
<li>Pain during defecation (tenesmus).</li>
</ul>
Characteristics of the time if exposed to dysentery are as follows:<br />
<ul>
<li>High fever (39.50 ° C - 40.0 ° C), Appear toxic.</li>
<li>Vomiting.</li>
<li>Cramping pain in the abdomen and pain in the anus during defecation.</li>
<li>Sometimes accompanied by similar symptoms of encephalitis and sepsis.</li>
<li>Diarrhea with blood and mucus in the stool.</li>
<li>Aire stool frequency are generally less.</li>
<li>Severe abdominal pain (colic).</li>
</ul>
Complication<br />
<ul>
<li>Dehydration</li>
<li>Electrolyte disorders, especially hyponatremia</li>
<li>Convulsions</li>
<li>Protein loosing enteropathy</li>
<li>Sepsis and DIC</li>
<li>Hemolytic uremic syndrome</li>
<li>Malnutrition / malabsorption</li>
<li>Hypoglycemia</li>
<li>Rectal prolapse</li>
<li>Reactive arthritis</li>
<li>Guillain-Barre syndrome</li>
<li>Ameboma</li>
<li>Toxic megacolon</li>
<li>Local perforation</li>
<li>Peritonitis</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis for Dysentery : Altered Fluid and Electrolyte Balance</b> related to fluid loss secondary to diarrhea.<br />
<br />
Goal: Fluid and electrolyte balance is maintained to the fullest.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Vital signs within normal limits.</li>
<li>Elastic turgor, mucous membranes moist lips, the fontanel is not sunken.</li>
<li>Mushy consistency of bowel movements, frequency of 1 time per day.</li>
</ul>
<br />
Intervention:<br />
1) Monitor for signs and symptoms of lack of fluids and electrolytes.<br />
R /: Decreased blood flow causes dryness of mucous fluid volume and urine concentration. Early detection allows immediate fluid replacement therapy to correct the deficit.<br />
<br />
2) Monitor intake and output.<br />
R /: Dehydration can increase glomerular filtration rate makes the output inadequate to clear metabolic waste.<br />
<br />
3) Measure body weight every day.<br />
R /: Detects fluid loss, a decrease of 1 kg of body weight equals 1 liter of fluid loss.<br />
<br />
4) Encourage the family to give the drink a lot on the client, 2-3 liters / day.<br />
R /: Replacing lost fluids and electrolytes orally.<br />
<br />
Collaboration:<br />
<br />
5) Laboratory tests of serum electrolytes (Na, K, Ca, BUN).<br />
R /: Correction is balanced fluid and electrolytes, BUN to determine kidney function (compensation).<br />
<br />
6) The liquid parenteral (IV line) according to age.<br />
R /: Replacing fluids and electrolytes adequately and quickly.<br />
<br />
7) <span class="short_text" id="result_box" lang="en"><span class="hps">Provision of medicines.</span></span>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-48525804023896437452015-07-07T14:41:00.000+07:002015-07-07T14:41:19.736+07:00Acute Pain related to Lung Cancer<b>Nursing Care Plan for Lung Cancer</b><br />
<br />
Acute pain related to cancer cell invasion<br />
<br />
Goal: after the nursing intervention, the expected decrease pain scale clients.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Reported pain gone / controlled.</li>
<li>Looked relaxed and sleep / rest.</li>
<li>Participate in activities desired / required.</li>
</ul>
<br />
Intervention and rational:<br />
<br />
1). Ask the patient about pain. Determine the characteristics of pain. Create ranges intensity on a scale of 0-10.<br />
Rational: Assist in the evaluation of the painful symptoms of cancer. The use of scale ranges help patients assess the level of pain and provide a tool for the evaluation of the effectiveness of analgesic, improving pain control.<br />
<br />
2) Assess statement of verbal and non-verbal patient's pain.<br />
Rationale: The discrepancy between verbal / non-verbal can provide clues degree of pain, the need / keefeketifan intervention.<br />
<br />
3) Write down the possible causes of pain patofisologi and psychology.<br />
Rational: posterolateral incision is uncomfortable for the patient from the anterolateral incision. Besides the fear, distress, anxiety and loss of appropriate diagnosis of cancer can interfere with the ability to cope.<br />
<br />
4) Instruct to express feelings of pain.<br />
Rational: Fear / problems can increase muscle tension and lower the threshold of pain perception.<br />
<br />
5) Provide comfort measures. Encourage and teach the use of relaxation techniques.<br />
Rationale: Increase relaxation and distraction.nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-11870772612535939722015-07-07T14:25:00.001+07:002015-07-07T14:25:29.277+07:00Impaired Gas Exchange related to Lung Cancer<b>Nursing Care Plan for Lung Cancer</b><br />
<br />
<br />
Nursing Diagnosis : Impaired gas exchange related to hypoventilation<br />
<br />
Goal: after nursing interventions, clients showed improvement in gas exchange.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Clients will show the results of blood gas analysis within the range of normal limits.</li>
<li>The skin will be free of symptoms of respiratory distress.</li>
<li>Clients will notice improvement in mental status.</li>
</ul>
<br />
Intervention and rasioanal:<br />
<br />
1). Note the depth of breathing frequency, difficulty breathing. Observations use a respirator muscles, breath lips, skin changes / mucous membranes, such as pale, cyanosis.<br />
Rational: Respiratory increased as a result of pain or as an initial compensation mechanism for damage lung tissue.<br />
<br />
2). Lung auscultation.<br />
Rational: consolidation and reduced air flow in the lungs indicates the area involved.<br />
<br />
3). Investigate changes in mental status / level of consciousness.<br />
Rational: can show increased hypoxia or complications such as mediastinal shift when accompanied by tachypnea, tachycardia, deviation of the trachea.<br />
<br />
4). Maintain patency of the airway by positioning, exploitation, and use of a ventilator.<br />
Rational: airway obstruction affecting ventilation and impairs gas exchange.<br />
<br />
5). Change positions frequently, place the patient in a sitting position, or lying down.<br />
Rational: maximize lung expansion and drainage secret.<br />
<br />
6). Instruct / aids in deep breathing exercises.<br />
Rational: increase the maximum ventilation and oxygenation and prevent atelectasis.<br />
<br />
7). Assess client's response to the activity, the period of rest or restricted activity as tolerated.<br />
Rationale: increased consumption of oxygen demand and stress lead to increased dyspnea and changes in vital signs.<br />
<br />
8). Give supplemental oxygen with humidification as indicated.<br />
Rational: maximizing the dosage of oxygen.<br />
<br />
9). Monitor blood gas analysis, pulse oximetry. Record levels of Hb.<br />
Rational: PO2 decrease, or increase in PCO2 may indicate the need for ventilatory support. Significant blood loss can lead to a decrease in oxygen-carrying capacity.nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-64879959117966941082015-07-06T10:03:00.001+07:002015-07-06T10:03:59.125+07:00Nursing Process Management<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOmnR9EtIx2H-_q5FKV4b85GlLk6MvvfrVkFT7MLpB3Z8aJCIfr5jbfw6dr5KxKCX2eIc8eJSSWTJOWYmDY3Dl5OypsD-ii5AkzMEaWk6rRFHbRtDcju9YsUAHy31bDrRWSRxk0_U2mKI/s1600/Nursing+Process+Management.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhOmnR9EtIx2H-_q5FKV4b85GlLk6MvvfrVkFT7MLpB3Z8aJCIfr5jbfw6dr5KxKCX2eIc8eJSSWTJOWYmDY3Dl5OypsD-ii5AkzMEaWk6rRFHbRtDcju9YsUAHy31bDrRWSRxk0_U2mKI/s1600/Nursing+Process+Management.jpeg" /></a></div>
<b>Definition of Management</b><br />
<br />
According to Gillies (1986) Management is defined as a process in completing the work through others. While the nursing management is a process of working through a member of the nursing staff to provide nursing care in a professional manner. The nursing manager is required to plan, organize, lead, and evaluate the facilities and infrastructure available to provide nursing care as effectively and efficiently as possible for individuals, families, and communities.<br />
<br />
Nursing management process in accordance with the nursing process as a method of execution in a professional nursing care, so expect the two can be mutually supportive. As the process of nursing, nursing management consists of the above: data collection, diagnosis / problem identification, planning, implementation, and evaluation of results. Because the nursing management have specificity against the majority of power rather than a clerk, then each stage in the management process more complicated when compared with the nursing process.<br />
<br />
<br />
<b>Management for Nurses</b><br />
<br />
Why a nurse must learn the science of leadership and management? At least three reasons why the answer as a nurse had to learn it. The reason is because the nurses have a role are as follows:<br />
<br />
1. The role of the nurse as coordinator.<br />
<br />
That the task of providing nursing care, a nurse should be able to manage the patient which it is responsible. For the treatment of patients is not carried out by nurses themselves but must cooperate with doctors, nutritionists, physiotherapists and other health team. To manage other health team. To manage other health team to be more orderly, organized, planned well coordinated, then the nurse needs to master the science of leadership and management.<br />
<br />
2. Nurses act as leaders and managers.<br />
<br />
The number and qualifications of nurses who work in the treatment room are many and varied. In the implementation of nursing care, nurses are organized and led by the head of the infirmary. The head of the infirmary will perform the role as a manager at the same time play the role as a leader, organize and direct the nurse in charge. In reality though is set up and directed, either frequent conflicts among nurses and between nurses and head room as a leader. Therefore, in order to anticipate and address the problems that will arise nurses need to learn and master the science of management and leadership.<br />
<br />
3. Nurses act as leaders and managers themselves.<br />
<br />
As a professional nurse, each nurse must be able to lead and to govern themselves. Without a good self-management skills hard to nurse will be able to provide professional nursing care services to patients.nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-82495159199285511492015-07-06T09:25:00.003+07:002019-02-13T06:45:20.729+07:00Nursing Diagnosis and Interventions for Endocarditis<br />
<b>Nursing Diagnosis for Endocarditis</b><br />
<ol><li><a href="https://nursesnanda.blogspot.com/2011/11/nanda-activity-intolerance.html"><b>Activity intolerance</b></a> r / t decreased cardiac output due to endocarditis.</li>
<li><a href="https://nursesnanda.blogspot.com/2012/04/anxiety-related-to-urinary-tract.html"><b>Anxiety</b></a> r / t threat to sudden death, lack of knowledge about the condition.</li>
<li><b>Disturbed sleep pattern</b> r/t chills (fever), sweats as a result of the infection.</li>
</ol><br />
<br />
Nursing Interventions for Endocarditis<br />
<br />
1. Activity intolerance r / t decreased cardiac output due to endocarditis.<br />
<br />
Goal: the patient is able to demonstrate the durability of the activity.<br />
<br />
Plan of action:<br />
<ul><li>Monitor tolerance for activity.</li>
<li>Check the pulse before and after the activity.</li>
<li>Plan activities that allow for a period of rest.</li>
<li>Reduce the patient's activity.</li>
<li>Help with daily activities as needed.</li>
<li>Instruct the patient to bedrest.</li>
</ul>Rationalization:<br />
<ul><li>Physical endurance can be improved when the activity is done growing.</li>
<li>This intervention as an indication that the patient has a limit of maximum activity.</li>
<li>Bedrest reduce the workload of the heart by reducing .The energy needed by the body.</li>
</ul><br />
2. Anxiety r / t threat to sudden death, lack of knowledge about the condition.<br />
<br />
Goal: Anxiety is reduced by criteria relaxed facial expression, understanding of the condition.<br />
<br />
Plan of action:<br />
<ul><li>Explain to the patient about the situation.</li>
<li>Give a chance to the patient to express feelings.</li>
<li>Divert the attention of the patient.</li>
<li>Involve the family in nursing.</li>
<li>Create a quiet environment.</li>
<li>Consult your doctor if the patient remains anxious.</li>
</ul>Rationalization:<br />
<ul><li>Anxiety cause an additional stress to the heart condition.</li>
<li>The family is the closest of the patients who know about the state of the patient so that families are able to provide mental support to the patients.</li>
</ul><br />
<br />
3. Disturbed sleep pattern r/t chills (fever), sweats as a result of the infection.<br />
<br />
Goal: The need for restful sleep enough, with the criteria; the patient is not shivering and sweating is reduced, the temperature 36 - 37º C.<br />
<br />
Action Plan:<br />
<ul><li>Observation of body temperature.</li>
<li>Create a comfortable environment (bedding, clothing).</li>
<li>Instruct the patient to use a thin blanket.</li>
<li>Implement treatment from a doctor.</li>
</ul>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-28463506576990757242012-09-15T00:10:00.002+07:002012-09-15T00:13:53.024+07:005 Diet Tips for High Cholesterol<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8uSi6SjGl3UmcMzy6ELwyhihhJMDRp2pvCDAFPxc2hnz_Cekg6uGn5qXp9UF1u0StIi7UEpYKLhh72YAm2EZWkmxnSW6ZmrtFqB7O51ISt_oehaQ7mni7DC2iuUYjO6TSGVz9TY58yh0/s1600/High+Cholesterol+Diet.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 244px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8uSi6SjGl3UmcMzy6ELwyhihhJMDRp2pvCDAFPxc2hnz_Cekg6uGn5qXp9UF1u0StIi7UEpYKLhh72YAm2EZWkmxnSW6ZmrtFqB7O51ISt_oehaQ7mni7DC2iuUYjO6TSGVz9TY58yh0/s320/High+Cholesterol+Diet.jpg" alt="" id="BLOGGER_PHOTO_ID_5788081671904104562" border="0" /></a>Cholesterol in the field of public health in the know with bad cholesterol, the good cholesterol, and triglycerides. Good cholesterol or medical term is HDL (High Density Cholesterol) has the function to remove excess cholesterol from cells and artery walls and carry cholesterol back to the liver for disposal. Meanwhile, the bad cholesterol, is the LDL (Low Density Cholesterol) carry cholesterol from the liver and released into the blood vessel wall, may cause the accumulation / plaque on the walls of blood vessels that can cause constriction of blood vessels. Triglycerides are another type of fat contained in the food.<br /><br />Surely that will be discussed high cholesterol are more specific to the bad cholesterol. Here are 5 Diet Tips for High Cholesterol, such as:<br /><br /><span style="font-style: italic;">1. Eat foods that are low in cholesterol.</span> Cholesterol is the result of a typical animal products, then this type of diet is recommended to reduce consumption of animal products, which are rich in cholesterol, such as for example is the brain, organ meats, egg yolks, fatty red meat and animal fats. Reduce saturated fats also will use. Food of animal origin, such as milk, cheese, meat, margarine, or cheese, usually contain saturated fat.<br /><br /><span style="font-style: italic;">2. Increase your fiber intake.</span> Especially water-soluble fiber, because it inhibits the absorption of cholesterol in the intestinal wall. Examples of vegetables and fruits are high soluble fiber such as squash, eggplant, radish, melon, watermelon, star fruit and guava. Use foods high in soluble fiber such as gelatin, seaweed, and fro, grass jelly, snack on replacing high-carb snacks. The study showed that consumption of nuts every day for six weeks can reduce cholesterol by 10 percent. So the food can fall into the category of cholesterol-lowering foods. And in turn, there are some foods that raise cholesterol levels in our blood. Probably about the foods that increase cholesterol levels will be discussed in another post.<br /><br /><span style="font-style: italic;">3. Increase consumption of fish than meat.</span> For most people we'd rather eat meat than fish meal. Though the content of Omega 3 fatty acids, found in fish play a role in shaping the prostacyclin which will prevent coronary heart disease, and increase the dilation of blood vessels. Prompts are good for health in terms of fish consumption was 2-3 times per week, and hopefully we can start liking different types of fish food for the future.<br /><br /><span style="font-style: italic;">4. The food processing and correct.</span> Equally important in keeping cholesterol levels remained normal is food processing. Although the selected foods low in cholesterol, when cooked with oils containing saturated oil, it still contains a high cholesterol diet. Suggested food processing is to be steamed, roasted, or boiled. When you are accustomed to fried foods, reduce the portions or choose how to cook with frying oil taking in small amounts. So if the food we are included in a cholesterol-lowering diet.<br /><br /><span style="font-style: italic;">5. Consumption of Soy Milk.</span> This type of milk can be used as an alternative source of calcium and phosphorus as a substitute for cow's milk. Included in this are soy foods. The U.S. Food and Drug Administration recommends the consumption of soy protein, at least 25 grams per day to reduce cholesterol. There are a lot of soy-based food options available around us, ranging from tofu, tempeh and soy milk.<br /><br />So a little about tips for people with high cholesterol and may be useful and can provide benefits. To the person who was having heart disease and acquired risk factors one of which is cholesterol will require a special diet with high cholesterol heart anyway. And it also needs to be discussed with the cardiologist and a nutritionist as well to help the heart-healthy diet.nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-67606633507336471272012-09-04T23:59:00.004+07:002012-09-05T00:08:11.918+07:00Hypoparathyroidism Definition, Etiology, Clinical Manifestations and Pathophysiology<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxVEV9MQRytxgrwu_oI7u9MIzCe87BIHVnA3h8xd_bsHsRrBnwbYE18t5E5Rn12vKc9W-CuYSl7OiS4_UIe2Nj_TSXSkPXHIveZ-AZjTkcp5P7LPQOThxXclc5VWDnZXDDUOnVXPDDhaI/s1600/nursing_care_plan_for_hypoparathyroidism.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 179px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxVEV9MQRytxgrwu_oI7u9MIzCe87BIHVnA3h8xd_bsHsRrBnwbYE18t5E5Rn12vKc9W-CuYSl7OiS4_UIe2Nj_TSXSkPXHIveZ-AZjTkcp5P7LPQOThxXclc5VWDnZXDDUOnVXPDDhaI/s320/nursing_care_plan_for_hypoparathyroidism.jpg" alt="" id="BLOGGER_PHOTO_ID_5784368548876659922" border="0" /></a><span style="font-weight: bold;">Definition of Hypoparathyroidism</span><br /><br />Hypoparathyroidism is a combination of symptoms of parathyroid hormone production is inadequate. This situation rarely found and are generally often caused by damage to or removal of the parathyroid glands during parathyroid or thyroid surgery, and rarer still is the absence of the parathyroid glands (in congenital). Sometimes a specific cause is not known.<br /><br /><span style="font-weight: bold;">Etiology of Hypoparathyroidism</span><br /><br />Rare primary hypoparathyroidism, and if there is usually found in children under the age of 16 years. There are three categories of hypoparathyroidism:<ol><li>Deficiency of parathyroid hormone secretion, there are two main causes:<ul><li>Post surgical removal of the gland partiroid and total <a href="http://nursesnanda.blogspot.com/2012/09/nursing-care-plan-for-thyroidectomy.html">thyroidectomy</a>.</li><li>Idiopathic, the disease is rare and can be congenital or acquired.</li></ul></li><li>Hipomagnesemia</li><li>Secretion of parathyroid hormone is not activated.</li><li>Resistance to parathyroid hormone (pseudohypoparathyroidism).</li></ol><span style="font-weight: bold;">Clinical Manifestations of Hypoparathyroidism</span><br /><br />Hypocalcaemia causes irritability neuromuskeler system and helped cause the main symptoms of hypoparathyroidism in the form of tetanus.<br /><br />Tetanus is a comprehensive muscle hipertonia with tremors and spasmodic or uncoordinated contractions that occur with or without an attempt to commit voluntary movement. In a state of latent tetanus symptoms are tingling and cramps in the extremities with complaints of feeling stiffness in both hands and feet. In a real situation tetanus, signs include bronchospasm, laryngeal spasm, carpopedal spasm (flexion of the elbow and wrist joints and extension sensi carpophalangeal), dysphagia, photophobia, cardiac arrhythmias and seizures. Other symptoms include <a href="http://nursesnanda.blogspot.com/2012/04/anxiety-related-to-urinary-tract.html">anxiety</a>, irritability, <a href="http://nursesnanda.blogspot.com/2012/02/nanda-depression.html">depression</a> and even <a href="http://nursesnanda.blogspot.com/2011/11/nursing-care-plan-for-delirium.html">delirium</a>. Changes in the ECG and hypotension may occur. (Brunner & Suddath, 2001)<br /><br /><span style="font-weight: bold;">Pathophysiology of Hypoparathyroidism</span><br /><br />In hypoparathyroidism are disorders of the metabolism of calcium and phosphate, which decreased serum calcium (up to 5 mgr%) and elevated serum phosphate (up 9.5 to 12.5 mgr%).<br />In the post-surgery due to inadequate production of parathyroid hormone due to removal of the parathyroid glands during surgery. The first operation was to deal with the situation by lifting hyperparathyroidism the parathyroid glands. The aim is to overcome the excessive secretion of parathyroid hormone, but usually too much tissue is removed.<br /><br />Second operation associated with the operation of total thyroidectomy. This is because the location of the thyroid and parathyroid gland anatomy nearby (get blood from a vein of the same) so that the parathyroid glands can be affected by incision or lifted. It is very rare and is usually less than 1% in thyroid surgery. In many patients an inadequate production of parathyroid hormone secretion transient postoperative thyroid or parathyroid glands, so the diagnosis can not be made immediately after the operation.<br /><br />In Pseudohypoparathyroidism symptoms and signs of hypoparathyroidism but normal levels of PTH in the blood or increased. Since the network does not respond to the hormone, the disease is a disease of the receptor. There are two forms:<br /><ul><li>in the form of more frequent, occurring congenital reduction in Gs activity by 50%, and PTH normally can not increase the concentration of cyclic AMP,</li><li>the form of the rarer, but the normal cyclic AMP response fosfaturik disturbed hormone effects.</li></ul>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-92031793014327008672012-09-04T09:52:00.002+07:002012-09-04T10:00:00.172+07:00Nursing Care Plan for Thyroidectomy (Preoperative and Postoperative)<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbEUb_kGRdpaESK4B4CePhp5L3fFYZLGBdGFkbp_zNg0Z4KU03rqUDlmX8KtFefeZXFgeCzZbSmm5Sx36-Sc39U3MBUYmx4FwnxW5_nFBujcC-VNRr2F8TqcqZPaDMg43e4AoTlEXLgFU/s1600/Thyroidectomy+Preoperative+and+Postoperative.JPG"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 246px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbEUb_kGRdpaESK4B4CePhp5L3fFYZLGBdGFkbp_zNg0Z4KU03rqUDlmX8KtFefeZXFgeCzZbSmm5Sx36-Sc39U3MBUYmx4FwnxW5_nFBujcC-VNRr2F8TqcqZPaDMg43e4AoTlEXLgFU/s320/Thyroidectomy+Preoperative+and+Postoperative.JPG" alt="" id="BLOGGER_PHOTO_ID_5784150772925998690" border="0" /></a><span style="font-weight: bold;">Nursing Assessment</span><br /><br /><span style="font-weight: bold;">Preoperative</span><br /><br />1. Activity / exercise<br />Insomnia, increased sensitivity, muscle weakness, impaired coordination, severe fatigue, muscle atrophy, increased respiratory frequency, tachypnea, dyspnea<br /><br />2. Elimination<br />Urine in large amounts, diarrhea.<br /><br />3. Coping / self defense<br />Experiencing severe anxiety and stress, both emotional and physical, emotional instability, depression.<br /><br />4. Nutrition and metabolic<br />Nausea and vomiting, the temperature rises above 37.4 º C. Enlargement of the thyroid, non-pitting edema, especially in the pretibial, diarrhea or constipation.<br /><br />5. Cognitive and sensory<br />Talk fast and raucous, confusion, restlessness, coma, tremors of the hands, hyperactive deep tendon reflexes, orbital pain, photophobia, palpitations, chest pain (angina).<br /><br />6. Reproductive / sexual<br />Decreased libido, hypomenorrhea, menorea and impotent.<br /><br /><span style="font-weight: bold;">Postoperative</span><br /><br />1. Basic assessment data<br /><ul><li>The pattern of activity / rest: insomnia, severe weakness, impaired coordination</li><li>Neuro-sensory patterns: impaired mental status and behavior, such as confusion, disorientation, anxiety, sensitive to stimuli, hyperactive deep tendon reflexes.</li></ul>2. Priority of Nursing<br /><ul><li>Returns the status of hyperthyroidism with preoperative</li><li>Preventing complications</li><li>Eliminating pain</li><li>Provide information on procedures</li></ul>3. Purpose of repatriation<br /><ul><li>Complications can be prevented or reduced</li><li>Pain disappeared</li><li>Surgical procedure / prognosis and treatment can be understood</li><li>May need assistance in treatment techniques partially or completely,</li><li>Daily activities, maintaining the house chores.</li></ul><br /><span style="font-weight: bold;">Nursing Diagnosis and Interventions for Thyroidectomy - Preoperative</span><br /><br />1. <a href="http://nursesnanda.blogspot.com/2012/04/nursing-interventions-for-testicular.html">Imbalanced Nutrition, Less Than Body Requirements</a> related to the inability of clients to enter or swallow food.<br /><br /><span style="font-style: italic;">Goal:</span><br />Expected levels of available nutrients to meet metabolic demands.<br /><br /><span style="font-style: italic;">Expected outcomes:</span><br /><ul><li>Fulfilled food intake, fluid and nutrients</li><li>Tolerance to the recommended diet</li><li>Maintain body mass and body weight within normal limits</li><li>Reported adequacy energy level</li></ul><span style="font-weight: bold;">Nursing Intervention:</span><br />1. Auscultation of bowel sounds<br />Rational: hyperactive bowel sounds reflecting an increase in the lower stomach motalitas or alter the function of absorption.<br /><br />2. Monitor food intake every day. And weights every day and report a decrease.<br />Rational: weight loss continuously in a state of sufficient caloric intake is an indication of the failure of antithyroid therapy.<br /><br />3. Avoid feeding can increase the peristaltic bowel.<br />Rationale: increased motalitas gut can cause diarrhea and absorption of necessary nutrients.<br /><br />4. Collaborate with doctors medicinal drugs or vitamins that are needed to meet the nutritional needs of clients.<br /><br />Evaluation:<br />The level of nutrients available to the client able to meet the metabolic needs.<br /><br /><br /><span style="font-weight: bold;">Nursing Diagnosis </span><span style="font-weight: bold;">and Interventions </span><span style="font-weight: bold;">for Thyroidectomy - Postoperative</span><br /><br />1. <span style="font-weight: bold;">Ineffective airway clearance</span> related to airway obstruction (airway spasm).<br /><br /><span style="font-style: italic;">Goal:</span><br />Kepatenan maintain airway.<br /><br /><span style="font-style: italic;">Expected outcomes:</span><br /><ul><li>Demonstrate effective airway clearance evidenced by gas exchange and ventilation harmless.</li><li>Easy to breathe.</li><li>No: restlessness, cyanosis, and dyspnea.</li><li>Oxygen saturation in the normal range.</li></ul><span style="font-weight: bold;">Nursing Intervention:</span><br />1. Monitor respiratory rate, depth, and the work of breathing.<br />Rational: normal breathing sometimes quickly, but development of respiratory distress is indicative of tracheal compression due to edema or hemorrhage.<br /><br />2. Auscultation breath sounds, record a voice crackles.<br />Rational: rhonchi is indicative of obstruction / laryngeal spasm which require rapid evaluation and intervention.<br /><br />3. Check the neck bandage every hour on the initial postoperative period, and then every 4 hours.<br />Rationale: Surgical neck region can cause airway obstruction due to postoperative edema.<br /><br /><br />2. <a href="http://nursesnanda.blogspot.com/2012/01/acute-pain.html">Acute pain</a> related to postoperative edema<br /><br /><span style="font-style: italic;">Goal:</span><br />Expected to control pain and can be reduced.<br /><br /><span style="font-style: italic;">Expected outcomes:</span><br /><ul><li>No moans</li><li>Relaxed facial expression</li><li>Reported pain may be reduced or lost, from the scale of 7 is reduced to 2.</li></ul><span style="font-weight: bold;">Nursing Intervention:</span><br />1. Assess for signs of pain in both verbal and nonverbal, note the location, intensity (scale of 0-10), and duration.<br />Rationale: useful in evaluating pain, choice determine the effectiveness of therapeutic interventions.<br /><br />2. Provides patient in semi-Fowler position, and chock the head / neck with a small pillow.<br />Rational: to prevent hyperextension neck and protect the integrity of the suture line<br /><br />3. Instruct the patient to use relaxation techniques, such as imagination, soft music, progressive relaxation.<br />Rational: help untyuk refocus attention and help patients to cope with pain / discomfort more effectively.<br /><br />4. Give analgesics prescribed and evaluation of effectiveness.<br />Rational: analgesics in severe pain may need to block pain.<br /> <br />Evaluation:<br />Pain on the client can be reducednandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-38682429860118104842012-08-26T22:43:00.002+07:002013-05-13T22:08:17.508+07:00Hallucinations<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2wVVIYcQU1RvtP6ApVrIkkcdatBF4o08zcJPXhqKZqRUP7bRL7Q4hSw5dXMUCK_vBAuGk1-hTgqQRleqyQT58QE4YYb-DsNYGooxBbfHeaX79SSiR4XGs6RKRduWIVIsT-4h3c9y37Dk/s1600/nursing_care_plan_for_hallucinations.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5781009322292019826" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2wVVIYcQU1RvtP6ApVrIkkcdatBF4o08zcJPXhqKZqRUP7bRL7Q4hSw5dXMUCK_vBAuGk1-hTgqQRleqyQT58QE4YYb-DsNYGooxBbfHeaX79SSiR4XGs6RKRduWIVIsT-4h3c9y37Dk/s320/nursing_care_plan_for_hallucinations.jpg" style="cursor: hand; cursor: pointer; float: left; height: 275px; margin: 0 10px 10px 0; width: 183px;" /></a><span style="font-weight: bold;">Nursing Diagnosis for Hallucinations</span><br />
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<span style="font-weight: bold;">Definition of Hallucinations</span><br />
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Hallucination is a false perception by the senses in the absence of external stimuli (Cook & Fontain, Essentials of Mental Health Nursing, 1987).<br />
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<span style="font-weight: bold;">Classification of Hallucinations</span><br />
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In clients with mental disorders there are several types of hallucinations with certain characteristics, including:<br />
<ol>
<li><span style="font-style: italic;">Auditory Hallucinations</span>: characterized by hearing the sound, especially the sound of voices, the client usually hear people talking about what he was thinking and ordered to do something.</li>
<li><span style="font-style: italic;">Visual Hallucinations</span>: characterized by visual stimuli in the form of radiant light, geometric picture, cartoons and / or extensive and complex panorama. Vision can be fun or scary.</li>
<li><span style="font-style: italic;">Olfactory Hallucination</span>: characterized by a foul odor, fishy and disgusting odors such as blood, urine or feces. Sometimes fragrant smell. Usually associated with stroke, tumors, seizures and dementia.</li>
<li><span style="font-style: italic;">Tactile Hallucinations</span>: characterized by pain or uncomfortable without a visible stimulus. Example: the sensation of electricity coming from the ground, inanimate objects or others.</li>
<li><span style="font-style: italic;">Gustatory Hallucinations</span>: characterized by feeling something rotten, putrid and disgusting.</li>
<li><span style="font-style: italic;">General somatic sensations</span>: characterized by feeling the body functions such as blood flow through the vein or artery, or the formation of urine ingested food.</li>
</ol>
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<span style="font-weight: bold;">The Process of Hallucinations</span><br />
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Auditory hallucinations are the most common forms of perceptual disorders in clients with mental disorders (schizophrenia). The form of hallucinations may be noises or buzzing. But the most frequent form of words arranged in sentences that influence the behavior of the client, so the client produces specific responses such as self-talk, fight or other harmful response. Can also be listening to the voice hallucinations client with attentive listening to others who do not speak or on inanimate objects.<br />
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Auditory hallucinations are a major sign of the disorder of schizophrenia and a minor diagnostic requirement for involutional melancholia, mania depressive psychosis and organic brain syndroma.<br />
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<span style="font-weight: bold;">Nursing Diagnosis for Hallucination</span><br />
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1. Risk for Violence: Self-Directed or Other-Directed<br />
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2. Disturbed Sensory Perception: hallucination<br />
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3. Impaired Social Interaction<br />
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4. Impaired Verbal Communication<br />
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5. Altered thought processes<br />
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6. Self-care deficitnandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-92064597452796019092012-08-25T09:27:00.002+07:002012-08-25T09:30:54.496+07:00Typoid Fever - Hyperthermia related to the infection process<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbFOoC2hOTK_vJ_bTqG6dUEMm_GAbsBFRjJrUmjNG8FiartkJn-NL1sMQsjTSdwn1GhWk0L1tMgYcuvkc8er0YXmQVm1ok7HNWlWuTTcwOoDe_rJguAhFUNssN3Y0V-_thd_ykoa60Bjk/s1600/hyperthermia_related_to_typoid_fever.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 320px; height: 198px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbFOoC2hOTK_vJ_bTqG6dUEMm_GAbsBFRjJrUmjNG8FiartkJn-NL1sMQsjTSdwn1GhWk0L1tMgYcuvkc8er0YXmQVm1ok7HNWlWuTTcwOoDe_rJguAhFUNssN3Y0V-_thd_ykoa60Bjk/s320/hyperthermia_related_to_typoid_fever.jpg" alt="" id="BLOGGER_PHOTO_ID_5780432424337787170" border="0" /></a>Here are examples of nursing diagnosis and interventions Hyperthermia, in patients with Typoid Fever:<br /><br /><span style="font-weight: bold;">Nursing Diagnosis for Typoid Fever: Hyperthermia</span> related to the infection process<br /><br /><span style="font-weight: bold;">Nursing Intervention</span>:<br />1) Monitor the body temperature at least every 2 hours.<br />Rationale: Knowing the temperature changes, the temperature of 38.9 to 41.1 C showed the inflammatory process.<br /><br />2) Describe efforts to address hyperthermia and assist clients / families in carrying out these efforts, such as giving a cold compress on the frontal region, groin and axilla, blanket the patient to prevent the loss of body warmth, increase your fluid intake by drinking more.<br />Rationale: Helps reduce fever.<br /><br />3) Observation vital signs (blood pressure, temperature, pulse and respiration) every 2-3 hours.<br />Rationale: Vital signs can give you a general state of the client.<br /><br />4) Monitor decreased level of consciousness.<br />Rationale: Determine interventions to prevent further complications.<br /><br />6) Encourage families to limit the activities of the client.<br />Rationale: In order to speed up the healing process.<br /><br />5) Collaboration with other medical teams to antipyretic medication and antibiotics.<br />Rationale: Drug antiperitik to reduce the heat and antibiotics treat infections salmonella typhi bacilli.nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-62856084012918873802012-08-25T09:06:00.002+07:002013-05-13T22:09:24.168+07:00Typoid Fever<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1S2i4j-eUgA4eZ4AHEW3qono0gtcHwBwIV02TgcD_P8kry4-Dph0JcZx05wDii3ky39kEMwM7f9iJLPUwnNCrVwBQvwgfEzOw77smltFwvnaMrDeB4u_TOE2Vqw9Y1Q7qTyMj7lWHLcc/s1600/nanda_nursing_diagnosis_for_typoid_fever.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5780426581768782994" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1S2i4j-eUgA4eZ4AHEW3qono0gtcHwBwIV02TgcD_P8kry4-Dph0JcZx05wDii3ky39kEMwM7f9iJLPUwnNCrVwBQvwgfEzOw77smltFwvnaMrDeB4u_TOE2Vqw9Y1Q7qTyMj7lWHLcc/s320/nanda_nursing_diagnosis_for_typoid_fever.jpg" style="cursor: hand; cursor: pointer; float: left; height: 213px; margin: 0 10px 10px 0; width: 320px;" /></a><span style="font-weight: bold;">Typoid fever</span> is an acute infectious disease that usually affects the gastrointestinal tract with symptoms of more than seven days of fever, gastrointestinal disorders and disturbances of consciousness.<br />
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According to Lewis, et al (2000: 192) "Typoid fever disease caused by infection with the bacteria Salmonella typhi".<br />
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According to Ruth F Craven and Constance J, Hirnie (2002: 1011) typoid fever signs and symptoms include <a href="http://nursesnanda.blogspot.com/2012/03/headaches-nursing-care-plan.html">headache</a>, heat, abdominal pain, diarrhea and vomiting.<br />
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According to Ngastiyah (2005: 237), Typoid fever in children are usually milder than adults. Future shoots 10-20 days, the shortest 4 days if the infection occurs through food, whereas if through drink longest 30 days. During the incubation period may be found prodromal symptoms, feeling unwell, lethargy, pain, headache, dizziness and not excited, then the following clinical symptoms that are commonly found, namely:<br />
<br />
a. Fever<br />
In the typical case, the fever lasts 3 weeks remitten is febrile, and the temperature was not very high. The first week, the body temperature gradually increased every day, down in the morning and rose again on the afternoon and evening. In the third week the temperature gradually dropped and normal again.<br />
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b. Disorders of the gastrointestinal tract<br />
In the mouth there is a breath smells, lips dry and chapped. Tongue covered with dirty white membrane (coated tongue), the tip and edges red. Abdominal bloating can be found. Enlarged liver and spleen accompanied by pain and inflammation.<br />
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c. Disorders of consciousness<br />
Generally patients decreased consciousness, namely apathy until samnolen. Rarely sopor, coma or anxiety (except for serious illness and delayed treatment). Other symptoms can also be found, in the back and limbs can be found reseol, the red spots due to emboli result in skin capillaries, which are found in the first week of fever, sometimes found also tachycardia and epistaxis.<br />
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d. Relapses<br />
Relapse is the recurrence typoid fever symptoms, but mild and lasts shorter. Occurred in the second week after the normal body temperature, the occurrence of difficult to explain. According to the theory of relapses occur because of the presence of bacilli in organs that can not be destroyed by drugs or substances.<br />
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<span style="font-weight: bold;">Nursing Diagnosis for Typoid Fever</span><br />
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1. Hyperthermia<br />
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2. <a href="http://nursesnanda.blogspot.com/2011/11/nanda-activity-intolerance.html">Activity intolerance</a><br />
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3. Risk for fluid volume deficit<br />
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4. Imbalanced Nutrition, Less Than Body Requirements<br />
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5. Diarrhea<br />
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6. <a href="http://nursesnanda.blogspot.com/2012/01/acute-pain.html">Acute Pain</a><br />
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7. Knowledge Deficitnandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-59623236444699032842012-08-24T10:33:00.003+07:002014-09-07T17:21:00.611+07:00Asthma - 7 Nursing Diagnosis and Interventions<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCODPmo9klpVcUD3oR-e3cLAFJ9IKNP1ifzZ2ZoGKQm_zPkJlj_n1CcE1wjzKQvv_UdZ9Th4c4dx0OdkNC1vktbgDzKWlALEtSWGVcKJq7_-7pKDyABVRbAZFLiIkBV4KDHFVCxIaIcxo/s1600/nanda_nursing_diagnosis_for_asthma.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 213px; height: 320px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCODPmo9klpVcUD3oR-e3cLAFJ9IKNP1ifzZ2ZoGKQm_zPkJlj_n1CcE1wjzKQvv_UdZ9Th4c4dx0OdkNC1vktbgDzKWlALEtSWGVcKJq7_-7pKDyABVRbAZFLiIkBV4KDHFVCxIaIcxo/s320/nanda_nursing_diagnosis_for_asthma.jpg" alt="" id="BLOGGER_PHOTO_ID_5780080892157289330" border="0" /></a><span style="font-weight: bold;">Nursing Care Plan for Asthma : Nanda Nursing Diagnosis and Interventions</span><br /><br />1. <a href="http://nursesnanda.blogspot.com/2012/04/ineffective-airway-clearance-related-to.html"><span style="font-weight: bold;">Ineffective airway clearance</span></a> related to airway spasm, secretion retention, amount of mucus.<br /><br />Goal: The patient showed the ability to maintain the cleanliness of the airway, with the expected outcomes:<br /><ul><li>There is no secret</li><li>Lungs clear sound</li></ul>Intervention:<br />1. Airway menagement:<br /><ul><li>Free the airway (suction)</li><li>Monitor the chest wall retraction</li><li>Monitor respiration rate</li><li>Give a semi-Fowler position</li></ul>2. Clear the airway:<br /><ul><li>Listen to lung sounds</li><li>Encourage the patient to drink warm</li><li>Do suction</li><li>Monitor oxygen delivery</li><li>Evaluation of lung sounds after suction</li></ul><br />2. <span style="font-weight: bold;">Ineffective breathing pattern </span>related to spasm of the airway, respiratory muscle fatigue.<br /><br />Goal: Adequate patient's respiratory status, with the result criteria:<br /><ul><li>Respiration rate is within normal limits</li><li>Not seen the use of additional respiratory muscles</li><li>No complaints of pain in breathing</li></ul>Intervention:<br />1. Airway management:<br /><ul><li>Monitor respiratory patients</li><li>Monitor the use of additional respiratory muscles (chest wall retraction)</li><li>Monitor Vitas signs; respiration, pulse, blood pressure, temperature</li><li>Position the patient in semi-Fowler position</li></ul>2. Oxygen Therapy:<br /><ul><li>Provide oxygen according to program</li><li>Give oxygen through a nasal or face mask canul<ul><li>The flow of 1-6 liters / minute oxygen concentration produces 24-44%</li><li>The flow of 5-8 liters / minute oxygen concentration produces 40-60%</li><li>The flow of 8-12 liters / min oxygen concentration produces 60-80%</li><li>The flow of 8-12 liters / min oxygen concentration producing 90%</li></ul></li></ul>3. Collaboration for bronchodilator therapy.<br /><br /><br />3.<a style="font-weight: bold;" href="http://nursesnanda.blogspot.com/2011/09/nursing-diagnosis-of-empyema-impaired.html">Impaired gas exchange</a> related to bronchospasme, damage to the alveoli.<br /><br />Goal: effective gas exchange, with expected outcomes:<br /><ul><li>Free from symptoms of respiratory failure, cianosis, nostril breath</li><li>Blood gas analysis results within normal limits.</li></ul>Intervention:<br />1. Airway management:<br /><ul><li>Position the patient in a position semifowler</li><li>Auscultation of breath sounds of patients</li><li>Patient's fluid balance</li><li>Monitor respiration rate</li><li>Clear the airway of secretions (Suction)</li><li>Teach the client to use an inhaler<br /></li></ul>2. Acid-base management:<br /><ul><li>Monitor blood gas analysis</li><li>Monitor electrolyte levels</li><li>Monitor oxygen saturation</li><li>Collaboration of medication to maintain the acid-base balance (sodium bicarbonate)</li><li>Monitor hemodynamic status</li></ul><br />4. Activity intolerance related to imbalance of oxygen supplied to the needs<br /><br />Goal: The patient showed tolerant state of activity, with the expected outcomes:<br /><ul><li>No shortness of breath on exertion</li><li>Able to move up</li></ul>Intervention:<br />1. Energy management:<br /><ul><li>Determine the causes of fatigue</li><li>Monitor respiratory (respiration, dyspnoea, pallor)</li><li>Help clients choose the activities that can be done</li><li>Recommended to increase the intake of nutrients</li></ul>2. Monitor response of breathing during activity, assess abnormal response in respiration, blood pressure, pulse.<br /><br /><br />5. <span style="font-weight: bold;">Knowledge deficit</span>: about asthma, related to lack of information sources.<br /><br />Goal: increase patient knowledge about asthma, the expected outcomes:<br /><ul><li>Knowing trigger asthma</li><li>Knowing about the things that need to be avoided</li><li>Knowing the handling of the attack.</li></ul>Intervention:<br />1. Assess the things that have been known to patients<br /><br />2. Assess the patient's condition before health education, do not provide health education, while patients in the state of attack.<br /><br />3. Education:<br /><ul><li>Explain the meaning of asthma</li><li>Explain the trigger factor</li><li>Describe the things that need to be avoided: elergan factors, stress, excessive cold weather activity</li><li>Explain how the handler during an asthma attack at home</li><li>Evaluate what has been delivered.</li></ul><br />6. <a style="font-weight: bold;" href="http://nursesnanda.blogspot.com/2012/04/anxiety-related-to-urinary-tract.html">Anxiety</a> related to crisis situations: changes in health status<br /><br />Goal: The patient can control anxiety and increase coping, with expected outcomes:<br /><ul><li>Patient's expression relaxed</li><li>Vital signs are within normal limits</li></ul>Intervention:<br />1. Lower levels of anxiety:<br /><ul><li>Listen to their patients</li><li>Explain each will perform maintenance procedures</li><li>Instruct the patient to accompany the family as a support system during an asthma attack</li></ul>2. Teach termination worried if stress can not be avoided:<br /><ul><li>Turning his attention upward</li><li>Respiratory control by drawing a deep breath (relaxation)</li><li>Position your body relax</li><li>Make a relaxed mood, relaxed facial expression.</li></ul><br />7. Imbalanced Nutrition, Less Than Body Requirements related to an increase in shortness of breath, intolerance to activity<br /><br />Goal: Nutrition clients adequate, with expected outcomes:<br /><ul><li>Increased oral input</li></ul>Intervention:<br />1. Environmental Management:<br /><ul><li>Provide a relaxed dining atmosphere</li><li>Limit visitors during mealtimes<br /></li></ul>2. Manage your nutrition:<br /><ul><li>Assess the client's food preferences and diet recommended</li><li>Monitor oral intake, if not enough add parenteral nutrition</li><li>Anjurrkan eat small meals but often</li><li>Anjurrkan for clients favorite meals</li><li>Collaboration with the nutrition.</li></ul>nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.comtag:blogger.com,1999:blog-3997563085313091869.post-36228978940577412492012-08-24T08:50:00.002+07:002012-08-24T08:53:08.672+07:00Pathophysiology of Acute Gastritis and Chronic Gastritis<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjR0xXUIhx_BeluxovUlOH18oDxvKoN3IQI_jjRFBL0meYxyiifeXPXHGFZvACA0O6rJi-zWdXl2XT8k7-XSnb-NSOzkptFvnuNp1IpSzXPpwhNLTVFEcmaIJ93CnL8FxPYGA0QEM9mhSs/s1600/Pathophysiology+of+Acute+Gastritis+and+Chronic+Gastritis.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 220px; height: 200px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjR0xXUIhx_BeluxovUlOH18oDxvKoN3IQI_jjRFBL0meYxyiifeXPXHGFZvACA0O6rJi-zWdXl2XT8k7-XSnb-NSOzkptFvnuNp1IpSzXPpwhNLTVFEcmaIJ93CnL8FxPYGA0QEM9mhSs/s320/Pathophysiology+of+Acute+Gastritis+and+Chronic+Gastritis.jpg" alt="" id="BLOGGER_PHOTO_ID_5780051742970405250" border="0" /></a><span style="font-weight: bold;">Pathophysiology of Acute Gastritis</span><br /><br />Acute gastritis can be caused by stress, chemical substances such as drugs and alcohol, spicy foods, hot and sour. In experiencing the stress will occur sympathetic nerve stimulation NV (vagus nerve), which will increase the production of hydrochloric acid (HCl) in the stomach. The presence of HCl that is in the stomach will cause nausea, vomiting and anorexia.<br /><br />Chemicals or stimulating foods will cause columnar epithelial cells, whose function is to produce mucus, reducing production. While it is the function of mucus to protect gastric mucosa that did not participate undigested. The response of the gastric mucosa due to decreased vasodilation, mucous secretion varies among gastric mucosal cells. There gastric mucosal lining cells produce HCl (especially the fundus) and blood vessels. Vasodilatation gastric mucosa will cause increased production of HCl. Anorexia can also cause pain. The pain inflicted by HCl contact with the gastric mucosa. Response due to decreased gastric mucosal mucus secretion may be eksfeliasi (exfoliation). Gastric mucosal cell exfoliation will lead to erosion of the mucosal cells. Mucosal cell loss due to erosion lead to bleeding. Bleeding happens to people with life-threatening, but it can also stop yourself because the process of regeneration, so that erosion disappear within 24-48 hours after hemorrhage.<br /><br /><span style="font-weight: bold;">Pathophysiology of Chronic Gastritis</span><br /><br />Helicobacter pylori is a gram-negative bacteria. These organisms invade the gastric surface cells, aggravate the onset of cell desquamation and chronic inflammatory responses appeared on gastric ie: destruction of the gland and metaplasia. Metaplasia is one of the body's defense mechanism against irritation, namely by replacing the gastric mucosal cells, such as cells desquamosa stronger. Because cell desquamation stronger then the elasticity is also reduced. At the time of digesting food, the stomach peristaltic movement but as a replacement cells will give rise to inelastic stiffness, which in turn cause pain. Metaplasia also cause loss of mucous cells in the lining of the stomach, so it will cause damage to the mucosal lining of the blood vessels. Damage to blood vessels will cause bleeding (Price, Sylvia and Wilson, Lorraine, 1999: 162).nandahttp://www.blogger.com/profile/16423891532718712063noreply@blogger.com