NCP for Pressure Sores / Decubitus Ulcer - Physical Examination, Assessment and 6 Nursing Diagnosis

Basic Concepts of Nursing Care

ASSESSMENT

1. Identity
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).

2. Main Complaint
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).

3. Disease History Now
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, fever, edema, and neuropathy (Carpenito, LJ, 1998)

4. Personal and Family History
Family history of disease needs to be asked because the wound healing can be affected by inherited diseases, such as diabetes, allergies, hypertension (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.

5. History of Medicine
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.

6. History Diet
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.

7. Socio-Economic Status
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.

8. Health History, such as: Long bed rest, immobilization, incontinence, nutrition or hydration inadequate.

9. Psychosocial Assessment
The possibility that psychosocial examination results appear on the client, namely: Feelings of depression, frustration, anxiety, desperation.

10. Activities of daily
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.


PHYSICAL EXAMINATION

General state
Generally, people come in sick and agitated or anxious as a result of the damage suffered skin integrity.

Vital Signs
Normal blood pressure, rapid pulse, increased temperature and increased respiration rate.

Examination Head And Neck

• 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.
• Eyes: Covers symmetry, conjunctiva, pupillary reflexes to light and impaired vision.
• Nose: Includes examination of the nasal mucosa, hygiene, do not arise nostril breathing, no secretions.
• Mouth: Record the state of cyanosis or dry lips.
• 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.
• Neck: Knowing the position of the trachea, carotid pulse, whether there is enlargement of the jugular veins and glands linfe.

Examination Chest and Thorax
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.

Abdomen
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.

Urogenital
Inspection abnormalities in perinium. Usually clients with ulcers and paraplegia catheterized to urinate.

Musculoskeletal
The existence of fractures would cause the client bet rest for a long time, resulting in decreased muscle strength.

Neurological examination
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.


Physical Assessment: Skin

Inspection of the skin
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:

• Color, influenced by blood flow, oxygenation, temperature and pigment production.
• Edema, during the inspection of the skin, the nurse noted the location, distribution and color of local edema.
• 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.
• Integrity, which must be considered that the location, shape, color, distribution, if there is drainage or infection.
• Skin hygiene.
• Vascularization, bleeding from blood vessels produce petechie and echimosis.
• Palpation of the skin, Noteworthy are lesions on the skin, moisture, temperature, texture or elasticity, skin turgor.

NURSING DIAGNOSES

1. Impaired Skin Integrity related to mechanical damage of tissue, secondary to pressure, shearing and friction.
2. Chronic pain related to skin trauma, infection of skin and wound care.
3. Risk for infection related to the display of decubitus ulcers to feces / urine drainage.
4. Imbalanced Nutrition: Less than Body Requirements related to anorexia secondary to insufficient oral input.
5. Impaired physical mobility related to restriction of movement required, the status of which is not conditioned, loss of motor control or change in mental status.
6. Ineffective family coping related to chronic wounds, changes in body image.

Nursing Care Plan for Decubitus Ulcer / Pressure Sores

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Sample of Assessment - Nursing Care Plan Gastritis

Sample of Nursing Care Plan for Gastritis

Nursing Assessment

1. Anamnese include:
   • Name :
     
   • Age :
     
   • Gender :
     
   • Type of work :
     
   • Address :
     
   • Tribe / Nation :
     
   • Religion :
     
   • The level of education: for those with low education level / low gain knowledge of gastritis, it will underestimate the disease, even just think of gastritis as upset stomach and will eat regular foods that can cause and exacerbate the disease.
   • History of illness and health
     • The main complaint: Pain in the pit of the stomach and lower right abdomen.
     • History of the disease at this time: Covers the journey of illness, initial symptoms are felt from the client, complaints arise suddenly or gradually felt, trigger factors, efforts to resolve the issue.
     • Past history of disease: Includes diseases associated with the disease now, history of the hospital, and a history of drug use.
   
   
   
2. Physical examination, the Review of systems (ROS)
   
   General condition: there was pain on physical examination there is tenderness in the epigastric quadrants.
   
   • B1 (breath): tachypnea
   • B2 (blood): tachycardia, hypotension, dysrhythmias, weak peripheral pulses, peripheral charging slow, pale skin color.
   • B3 (brain): headache, weakness, level of consciousness can be disturbed, disorientation, pain epigastrum.
   • B4 (bladder): oliguria, fluid balance disorders.
   • B5 (bowel): anemia, anorexia, nausea, vomiting, heartburn, intolerance to spicy foods.
   • B6 (bone): fatigue, weakness



3. Assessment Focus
   1. Activity / Rest
      Symptoms: weakness, fatigue
      Signs: tachycardia, tachypnea / hyperventilation (in response to activity)
   
   
   2. Circulation
      Symptoms: weakness, sweating
      Signs:
      
      • Hypotension (including postural)
      • Tachycardia, dysrhythmias (hypovolemia / hypoxemia)
      • Weak peripheral pulse
      • Slow capillary refill (vasoconstriction)
      • Skin color pale, sianosis (depending on the number of blood loss)
      • Weakness of skin / mucous membranes, sweating (shows status of shock, acute pain, psychological responses)
      
      
   3. Ego integrity
      Symptoms: acute or chronic stress factors (financial, labor relations), feelings of helplessness.
      Sign: a sign of anxiety, such as anxiety, pallor, sweating, narrowing of attention, shaking, trembling voice.
   
   
   4. Elimination
      Symptoms: a history of previous hospitalization due to bleeding gastroenteritis (GE) or problems associated with GE, such as injury or gastric ulcer, gastritis, gastric surgery, gastric irradiation area. Changes in bowel habit / characteristic stool.
      Signs:
      
      • Abdominal tenderness, distention
      • Bowel sounds: often hyperactive during hemorrhage, hypo-active after the bleeding.
      • The characteristics feses: diarrhea, blood color of dark, brownish or sometimes red bright, foamed, odor rotten (steatorrhoea), constipation can occur (a change diet, the use of antacids).
      • Urinary output: decreased, concentrated.
      
      
   5. Food / fluid
      Symptoms:
      
      • Anorexia, nausea, vomiting (throwing up that extends beyond the pyloric obstruction suspected in connection with a duodenal injury),
      • Swallowing problems: hiccups
      • Heartburn, sour belching, nausea or vomiting
      Symptoms: vomiting with a dark coffee color or bright red, with or without blood clots, dry mucous membranes, decreased mucus production, poor skin turgor (chronic bleeding).
   
   
   6. Neurosensory
      Symptoms: flavor pulsed, dizziness / sick heads because of rays, weakness.
      Sign: the level of consciousness can be impaired, the range of slightly inclined to sleep, disorientation / confusion, fainting and coma (depending on the volume of circulation / oxygenation).
   
   
   7. Pain / Comfort
      Symptoms:
      
      • Pain, described as a sharp, shallow, burning, stinging, sudden severe pain may be accompanied by perforation. Sense of discomfort / distress faint after eating a lot and lost with a meal (acute gastritis).
      • Pain epigastrum left until the middle / back or spread to occur 1-2 hours after eating and relieved by antacids (gastric ulcers).
      • Pain left to epigastrum / or spread to his back occurred approximately 4 hours after eating when the stomach is empty and relieved by food or antacids (duodenal ulcer).
      • No pain (esofegeal varices or gastritis).
      • Trigger factors: food, cigarettes, alcohol, the use of certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors.
      Signs: wrinkled face, be careful in the area of ​​pain, pallor, sweating, narrowing attention.
   
   
   8. Security
      Symptoms: allergy to the drug / sensitive
      Sign: an increase in temperature, spider angioma, palmar erythema (showing cirrhosis / portal hypertension)
   
   
   9. Guidance / Learning
      Symptoms: the use of prescription drugs

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Assessment of Mental Status in Elderly

How To Assess Mental Status in Elderly

Elderly group can experience a variety of mental disorders such as in the younger age groups. To identify mental problems that arise in the elderly need to do the assessment. Nursing assessment is an early stage that determines the next step to determine nursing diagnoses and planning.

Nursing assessment in psycho-geriatric clients is a complex process. Influence aspects of biological, psychological, and sociocultural due to the aging process leading to difficulties in identifying the problems that arise. Mental status assessment is a systematic approach to collect data on psychosocial functioning.

This assessment includes: General appearance of clients, awareness, affective functions, characteristic speech, orientation, attention and concentration, judgment, memory, perception, as well as content and process of thought. This study aims to determine the thoughts and mental processes that affect the achievement of optimal levels of functioning elderly. This assessment is integrated in the interview and physical examination.

Assessment of Mental Status in Elderly

General appearance

General appearance, can provide a picture of psychological functioning. General appearance, including: physical appearance, coordination of movement, facial expression and posture. Physical appearance include: how to dress, care and personal hygiene.

Observations can be done to assess the general appearance:

• Is the client's physical appearance indicates a psychological dysfunction?
• Does gait, posture and facial expressions indicate a psychological disorder?
• Are there signs of tardive dyskineksia or unfavorable effects caused by medication?

Awareness

Awareness is the ability of individuals to make contact with their environment and with oneself (through the five senses). When the consciousness of both (not decrease) the orientation capabilities such as time, place and people will be fine and able to process incoming information effectively (through memory and judgment). In assessing the level of awareness needs to be considered:

• effect of medication
• affective disorder
• pathologic conditions

Observations can be done to assess the level of consciousness:

• Is the level of awareness of current clients?
• Are there fluctuations in the level of awareness of the client. If there is any particular pattern?
• Are there physical factors that affect the level of consciousness, ie the influence of medication, pathologic conditions, and affective disorders?
• Are there psychosocial factors that influence the level of awareness such as: anxiety, depression, or sleep disorders?

Affective Functions

Things that need to be considered in assessing an affective function in the elderly are:

• Important to assess the significance of an event for the elderly to assess the depth and duration affect the displayed
• Emotional expression is influenced by cultural and personal characteristics
• In the elderly usually do not express their feelings directly / verbally. Therefore it is important to observe iti the reaction of indirect / non-verbal of the elderly.
• Important to use terms that are acceptable to the elderly at the time of the interview by focusing on the feelings felt by the elderly. Can be initiated by using the open ended question such as: how is he today?

Observations can be done to assess the affective functions:

• How do you feel current clients?
• Are the indicators that describe the mood / anxiety / depression on the client?
• Are there any factors that cause anxiety following on the client such as pathological conditions, treatments or interventions that affect the central nervous system?
• How that is done by the client to cope with feelings that are not as usual?
• Are there things you want to discuss about the client's feelings?

Characteristics of speech

Characteristics of speech include: understanding, articulation, pauses, quality, quantity and coherent. Cultural factors may affect the characteristics of speech.

Observation to study the characteristics of the speech:

• Is the client able to answer according to questions asked?
• Does normal speech pause, slow or fast?
• Is the tone of voice to show certain feelings such as anger, resentment, sadness, despair, etc.?
• Does the voice sound soft or hard?
• Is adal articulation difficulties?
• Are the sentences pronounced coherent elderly?
• Is there the following factors that may affect the characteristics of speech such as: dry mouth, toothless, the effects of medication or alcohol?
• Are there signs of agnosia, aphasia, or word repetition?

Orientation

The orientation includes orientation to place, person and time.

Interviews to assess client orientation:

• People: Who are your name, What was the name of your child? What was the name my husband / wife?, Etc.
• Time: What time is it? , When should you eat breakfast? What day is it? , Boast what now? , etc.
• Place: Where may you now? , Where is your address? What is the name of this town? , What is the name of this place? etc.

Attention and Concentration

Nurses must observe and record the response shown by the elderly at the time of assessment, when answering questions.

Observations to assess attention and concentration:

• What about client behavior during the interview?
• Whether clients eager to answer questions?
• If it does not answer the question or the answer given is incorrect because it is not capable, cultural factors or lack of motivation?
• Is there a signs of anger, resentment, sadness, despair, etc.?

Memory

The memory includes a new memory, short-term memory and long-term memory. Memory impairment can identify any impairment of intellectual / cognitive. The Short Portable Mental Status Quesionnaire (SPMQ) is used to detect the level of intellectual impairment.


Pereption

Perception is the power to know things, qualities, relations and differences through a process to observe, learn and interpret the following senses get stimulated.

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Nursing Assessment of Pleural Effusion - Patterns of Health Functions

Nursing Assessment of Pleural Effusion

Provision of Nursing Care is a therapeutic process that involves cooperation relations with clients, families or communities to achieve optimal health levels (Canpernito, 2000.2).

Nurses need the scientific method in the therapeutic process of the nursing process. The nursing process is used to assist nurses in nursing practice in a systematic in addressing nursing problems that exist, where the four components influence each other, namely: assessment, planning, implementation and evaluation form a chain.

Patterns of Health Functions

1) Health Perception and Health Management

The existence of medical and hospital care affect the change in perceptions about health, but it sometimes raises an incorrect perception towards health maintenance. The possibility of a history of smoking, drinking alcohol and drug use can be a predisposing factor of disease onset.

2) Nutritional Metabolic Pattern

In the assessment of nutritional and metabolic patterns, we need to take measurements of height and weight to determine the patient's nutritional status, but also need to be asked eating and drinking habits before and during the hospital, patients with pleural effusion will experience a decrease in appetite as a result of shortness of breath and an emphasis on abdominal structures. Increased metabolism will occur due to the disease process. patients with pleural effusion are generally weak state.

3) Elimination Pattern

In the assessment of the pattern of elimination need to be asked about bowel habits before and after in hospital. Because the patient's general condition is weak, the patient will be more bed rest so that it will cause constipation, but due to digestion on the structure of the abdomen causes a decrease in the peristaltic muscles of the digestive tract.

4) Activity and Exercise Pattern

Due to shortness of breath, tissue oxygen demand will be less satisfied and examination will quickly experience fatigue on minimal activity. Besides, patients will also reduce its activity due to chest pain. And to meet the needs of its most ADL needs of patients assisted by a nurse and family.

5) Sleep Rest Pattern

The presence of chest pain, shortness of breath and increased body temperature will affect the fulfillment of needs sleep and rest, in addition to changes in environmental conditions of a quiet home environment into the hospital environment, where many people are walking around, noisy, and so forth.

6) Role-Relationship Pattern

As a result of illness, patients will experience a change in role, eg a housewife patient, the patient can not perform its function as a mother who must care for their children, taking care of her husband. In addition, the role of patients in the community is also changing and all that affects the patient's interpersonal relationships.

7) Self-Perception-Self-Concept Pattern

Patient's perception of themselves will change. Patients who had been healthy, suddenly experienced pain, shortness of breath, chest pain. As a layman, the patient may be assumed that the disease is dangerous and deadly disease. In this case the patient might lose a positive image of himself.

8) Cognitive-Perceptual Pattern

Sensory function of patients had no change, so does the thinking process.

9) Sexuality and Reproduction

For patients who do not know the process will experience stress and illness may be a lot of patients ask nurses and doctors who cared for him or anyone who may be more to know about his illness.

10) Coping-Stress Tolerance Pattern

Sexual needs of patients in this case sexual intercourse would be disturbed for a while because the patient was in hospital and his physical condition was weak.

11) Value-Belief Pattern

As a religious patient will be closer himself and always pray to God.

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DHF Nursing Assessment

DHF Nursing Assessment

Assessment is the initial stage of the nurse to obtain the required data before performing nursing care. Assessment in patients with "DHF" can be done with the interview technique, measurement, and physical examination.

As for its phases include:
a. Assessing the data base, the need of bio-psycho-social-spiritual patients from various sources (patient, family, medical records and other health team members).

b. Identify potential sources and are available to meet patient needs.

c. Review the history of nursing.

d. Assess the presence of increased body temperature, signs of bleeding, nausea, vomiting, no appetite, heartburn, muscle and joint pain, signs of shock (rapid and weak pulse, hypotension, cold and moist skin, especially on the extremities, cyanosis , restlessness, loss of consciousness).

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Nursing Assessment Nursing Care Plan for Pneumonia

Pneumonia

Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States.

Nursing Care Plan for Pneumonia

Nursing Assessment for Pneumonia

1. Health History :
   • A history of previous respiratory tract infection / cough, runny nose, takhipnea, fever.
   • Anorexia, difficulty swallowing, vomiting.
   • History of disease associated with immunity, such as; morbili, pertussis, malnutrition, immunosuppression.
   • Other family members who suffered respiratory illness.
   • Productive cough, breathing nostrils, rapid and shallow breathing, restlessness, cyanosis.
   
   
2. Physical Examination :
   • Fever, takhipnea, cyanosis, nostrils.
   • Auscultation of lung: wet ronchi, stridor.
   • Laboratory: leukocytosis, AGD abnormal, the LED increases.
   • Chest X-rays: abnormal (scattered patches of consolidation in both lungs).
   
   
3. Psychosocial Factors :
   • Age, growth.
   • Tolerance / ability to understand the action.
   • Coping.
   • The experience of parting with the family / parents.
   • The experience of previous respiratory tract infections.
   
   
4. Family Knowledge, Psychosocial :
   • The level family knowledge about the disease bronchopneumonia.
   • Experience in dealing with the family of respiratory disease.
   • Readiness / willingness of families to learn to care for her child.
   • Family Coping
   • The level of anxiety.

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

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