Nursing Diagnosis and Interventions for Morbid Obesity

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.

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.




Nursing Diagnosis and Interventions for Morbid Obesity

1. Imbalanced Nutrition: more than body requirements related to the increase in the intake of nutrients.

Interventions:

• Create a meal plan with the patient.
• Measure body weight per day.
• Emphasize the importance of realizing full and stop inputs.
• Give liquid diet, softer, high in protein and fiber and low in fat with the addition of liquid as needed.
• Refer to a dietitian
• Encourage clients to do a lot of activities.

Rationale:

• After the act of division, decreased gastric capacity of approximately 50 ml, so the need to eat a little.
• Supervision loss and nutritional needs.
• Overeating may cause nausea / vomiting.
• Provide nutrients without adding calories.
• Need help planning a diet that meets the nutritional needs.
• Do a lot of activities can burn more calories.

2. Ineffective breathing pattern related to a decrease in lung expansion.

Goal: breathing pattern becomes effective.

Expected outcomes:

• Maintain adequate ventilation.
• Not experiencing cyanosis or other signs of hypoxia.

Interventions:

• Monitor the speed / depth of breath. auscultation of breath sounds.
• Investigate cyanosis, increased restlessness.
• Elevate the head of the bed 30 degrees.
• Encourage deep breathing exercises.
• Change position periodically and ambulation as early as possible.
• Give supplemental oxygen.
• help the patient use breathing apparatus.
• Monitor pulse oximetry when indicated.

Rationale:

• Respiratory snore decrease ventilation, can cause hypoxia.
• Encourage the development of the diaphragm or lung expansion and minimize the maximum pressure in the abdominal contents.
• Increase the maximum lung expansion and airway clearance.
• Increase air filling the entire segment of the lung, mobilize and remove secretions.
• Maximizing preparations for the exchange of oxygen and decreased breath work. Increase lung expansion, lowering atelectasis.
• Show ventilation / oxygenation and acid-base status, used as a basis for evaluating the need for respiratory therapy.

3. Activity intolerance related to being overweight.

Goals: The need to move fulfilled.
Expected outcomes:

• Physical activity increases.
• Normal ROM.
• The client can perform the activity.

Interventions:

• Create a schedule of activities to do and ask the client to do it with discipline.
• Help the client to engage in activities that hard to do.
• Make sure the client motivation to sustain the movement.
• Encourage the client perform normal daily activities, according to ability.
• Collaboration with physiotherapy.

Rationale:

• Reduce stiffness and familiarize the client activity.
• Help clients to more easily perform the activity.

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Newborn Priority Nursing Diagnosis and Intervention

Nursing Priority

• Facilitate adaptation to life outside the uterus.
• Maintain thermo-neutrality.
• Prevent complications.
• Increase parent-child closeness.
• Provide information and anticipatory guidance to parents.

Home Goals:

• Newborns effectively adapt to life outside the uterus.
• Free of complications.
• Parent-child closeness done.
• Parents express confidence in infant care.

Nursing Diagnosis for Newborn

First Hours of Life (Marilynn E. Doenges and Mary Frances Moorhouse, 2001 in the Maternal Infant Care Plan, p. 558-566)

1. Risk for Impaired gas exchange
related to antepartum stress, excessive mucus production, and stress due to cold.

Goal:
Free from signs of respiratory distress.

Interventions :

• Measure the Apgar score in the first minute and five minutes after birth.
• 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).
• Clear the airway; nasopharyngeal suction slowly, as needed. Monitor the apical pulse during suctioning.
• Dry the baby with a warm blanket, place stockings head cover, and place it in the arms of parents.
• Put the baby in a modified Trendelenburg position at an angle of 10 degrees.

Rationale :

• 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.
• This complication can lead to chronic hypoxia and acidosis, increasing the risk of damage to the central nervous system and require repair after birth.
• Helps eliminate accumulation of fluid, facilitates breathing efforts, and help prevent aspiration. Inhalation of oropharynx cause vagal stimulation that lead to bradycardia.
• 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.
• Facilitate the drainage of mucus from the nasopharynx and trachea with gravity.

2. Risk for Altered body temperature
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.

Goal:
Free signs of respiratory distress and cold stress.

Interventions :

• Note the presence of fetal distress or hypoxia.
• Dry the head and the body of a newborn baby, put the stockings headgear; and wrap in a warm blanket.
• Place the newborn in warm environments or at arm's parents. Warm objects that contact the baby (ie., Scales, stethoscopes, examination table and hands).
• Note the ambient temperature. Eliminate air flow and minimize the use of air conditioning; warm up when given oxygen through a mask.
• Assess the neonate's core temperature, skin temperature secar continuous monitoring with skin testing tool appropriately.

Rationale :

• 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).
• 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.
• 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).
• 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.

3. Altered family processes
related to transition the development and / or additional family members.

Goal:
Precisely identify the baby to ensure the correct family relationships.

Interventions :

• Inform parents about the needs of the newborn soon and care given.
• Place the baby in arm mother / father, as soon as conditions allow the newborn.
• Encourage parents to caress and talk to the newborn; encourage mothers to breastfeed if desired.

Rationale :

• 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.
• 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.
• Provide an opportunity for parents and newborns start the process of recognition and proximity.

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Paraplegia - 5 Nursing Diagnosis and Interventions

Nursing Care Plan for Paraplegia

Paraplegia 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).


Nursing Diagnosis and Interventions for Paraplegia


Nursing Diagnosis 1. : Impaired physical mobility related to neurons damage, sensory and motor function.

Goal: Improving mobility.

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.

Interventions:

• Assess the functions of sensory and motor patients every 4 hours.
• Change the patient's position every two hours by taking into account the stability and comfort of the patient's body.
• Give retaining board on the patient's foot.
• Use muscle orthopedic, circulation, hand splints.
• Perform passive ROM after 48-72 after injury 4-5 times / day.
• Monitor pain and fatigue in patients.
• Consult physiotherapy to exercise and muscle use as splints.

Rationale:

• Assigning capabilities and limitations of the patient every 4 hours.
• Preventing pressure sores.
• For prevent drop.
• Prevent contractures.
• Increase stimulation and prevent contractures.
• Showed the presence of excessive activity.
• Provide appropriate inducement.

Nursing Diagnosis 2. Risk for Impaired skin integrity related to decrease in immobility, decreased sensory function.

Goal: Maintaining the integrity of the skin.

Expected outcomes: The state of the patient's skin intact, free of redness, free from infection on the location of the distressed.

Interventions:

• Assess risk factor for impaired skin integrity.
• Assess the patient's condition every 8 hours.
• Use a special bed.
• Change positions every two hours with anatomical position.
• Maintain the cleanliness and dryness bed and the patient's body.
• Perform special massage / soft over a bony area every two hours with a circular motion.
• Assess the patient's nutritional status and give food with high protein.
• Perform maintenance on the area of ​​skin abrasions / broken every day.

Rationale:

• One of them is immobilization, loss of sensation, incontinence bladder / bowel.
• Earlier prevent the occurrence of pressure sores.
• Reducing the pressure, thereby reducing the risk of pressure sores.
• Depressed area will lead to hypoxia, a change of position improves blood circulation.
• Humid and dirty facilitate the occurrence of skin damage.
• Improve blood circulation.
• Maintain the integrity of the skin and the healing process.
• Accelerate the healing process.

Nursing Diagnosis 3. : Urinary retention related to an inability to urinate spontaneously, interruption spinothalamicus pathways.

Goal: Increased urinary elimination.
Expected outcomes: The patient can maintain bladder emptying without residues and distension, clear urine, urine culture is negative, fluid intake and output balance.

Interventions:

• Assess for signs of urinary tract infection.
• Assess fluid intake and output.
• Do the catheter according to the program.
• Instruct the patient to drink 2-3 liters every day.
• Check the patient's bladder every 2 hours.
• Check urinalysis, culture and sensibility.
• Monitor body temperature every 8 hours.

Rationale:

• The effects of the ineffectiveness of the bladder is a urinary tract infection.
• Knowing inadequate kidney function and effective bladder.
• The effects of spinal cord injury is the reflex micturition disorders that need assistance in urine output.
• Prevent urine more concentrated which resulted in the onset of infection.
• Knowing the residue as a result of autonomic hyperreflexia.
• Knowing infection.
• Increased temperature indication of the presence of infection.

Nursing Diagnosis 4. : Constipation related to the atony intestine as a result of autonomic disturbances, interruption spinothalamicus pathways.

Goal: Improving bowel function.

Expected outcomes: The patient is free of constipation, stool softening circumstances, shaped.

Interventions:

• Assess the pattern of bowel elimination.
• Give drink 1800 - 2000 ml / day if there are no contraindications.
• Auscultation bowel sounds, assess for abdominal distension.
• Avoid using oral laxatives.
• Mobilize if possible.
• Evaluation and record bleeding at the time of elimination.
• Give suppository according to the program.
• Provide high-fiber diet.

Rationale:

• Determining a change of elimination.
• Prevent constipation.
• Determine the peristaltic movement of the bowel.
• Habitual use of laxatives will occurs dependence.
• Increase the peristaltic movement.
• The possibility of bleeding due to irritation.
• Stool softeners making it easier elimination.
• Fiber increases stool consistency.

Nursing Diagnosis 5. Chronic pain related to treatment, long immobility, psychic injury.

Goal: To provide a sense of comfort: pain.

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.

Interventions:

• 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.
• Give comfort measures, for example, a change in position, massage, warm compresses / cold as indicated.
• Encourage the use of relaxation techniques, for example, guidance imagination visualization, deep breathing exercises.
• Collaboration administration of drugs according to indications, muscle relaxants, analgesics; anti-anxiety.

Rationale:

• Patients usually report pain above the level of injury, for example; chest / back or the possibility of a headache than a tool stabilizer.
• Alternative actions to control pain.
• Refocused attention, increase the sense of control, and can improve coping skills.
• Needed to relieve spasms / muscle pain or to eliminate-anxiety and increase the rest.

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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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Acute Pain related to Lung Cancer

Nursing Care Plan for Lung Cancer

Acute pain related to cancer cell invasion

Goal: after the nursing intervention, the expected decrease pain scale clients.

Expected outcomes:

• Reported pain gone / controlled.
• Looked relaxed and sleep / rest.
• Participate in activities desired / required.

Intervention and rational:

1). Ask the patient about pain. Determine the characteristics of pain. Create ranges intensity on a scale of 0-10.
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.

2) Assess statement of verbal and non-verbal patient's pain.
Rationale: The discrepancy between verbal / non-verbal can provide clues degree of pain, the need / keefeketifan intervention.

3) Write down the possible causes of pain patofisologi and psychology.
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.

4) Instruct to express feelings of pain.
Rational: Fear / problems can increase muscle tension and lower the threshold of pain perception.

5) Provide comfort measures. Encourage and teach the use of relaxation techniques.
Rationale: Increase relaxation and distraction.

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Impaired Gas Exchange related to Lung Cancer

Nursing Care Plan for Lung Cancer


Nursing Diagnosis : Impaired gas exchange related to hypoventilation

Goal: after nursing interventions, clients showed improvement in gas exchange.

Expected outcomes:

• Clients will show the results of blood gas analysis within the range of normal limits.
• The skin will be free of symptoms of respiratory distress.
• Clients will notice improvement in mental status.

Intervention and rasioanal:

1). Note the depth of breathing frequency, difficulty breathing. Observations use a respirator muscles, breath lips, skin changes / mucous membranes, such as pale, cyanosis.
Rational: Respiratory increased as a result of pain or as an initial compensation mechanism for damage lung tissue.

2). Lung auscultation.
Rational: consolidation and reduced air flow in the lungs indicates the area involved.

3). Investigate changes in mental status / level of consciousness.
Rational: can show increased hypoxia or complications such as mediastinal shift when accompanied by tachypnea, tachycardia, deviation of the trachea.

4). Maintain patency of the airway by positioning, exploitation, and use of a ventilator.
Rational: airway obstruction affecting ventilation and impairs gas exchange.

5). Change positions frequently, place the patient in a sitting position, or lying down.
Rational: maximize lung expansion and drainage secret.

6). Instruct / aids in deep breathing exercises.
Rational: increase the maximum ventilation and oxygenation and prevent atelectasis.

7). Assess client's response to the activity, the period of rest or restricted activity as tolerated.
Rationale: increased consumption of oxygen demand and stress lead to increased dyspnea and changes in vital signs.

8). Give supplemental oxygen with humidification as indicated.
Rational: maximizing the dosage of oxygen.

9). Monitor blood gas analysis, pulse oximetry. Record levels of Hb.
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.

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Nursing Diagnosis and Interventions for Endocarditis

Nursing Diagnosis for Endocarditis

1. Activity intolerance r / t decreased cardiac output due to endocarditis.
2. Anxiety r / t threat to sudden death, lack of knowledge about the condition.
3. Disturbed sleep pattern r/t chills (fever), sweats as a result of the infection.

Nursing Interventions for Endocarditis

1. Activity intolerance r / t decreased cardiac output due to endocarditis.

Goal: the patient is able to demonstrate the durability of the activity.

Plan of action:

• Monitor tolerance for activity.
• Check the pulse before and after the activity.
• Plan activities that allow for a period of rest.
• Reduce the patient's activity.
• Help with daily activities as needed.
• Instruct the patient to bedrest.

Rationalization:

• Physical endurance can be improved when the activity is done growing.
• This intervention as an indication that the patient has a limit of maximum activity.
• Bedrest reduce the workload of the heart by reducing .The energy needed by the body.

2. Anxiety r / t threat to sudden death, lack of knowledge about the condition.

Goal: Anxiety is reduced by criteria relaxed facial expression, understanding of the condition.

Plan of action:

• Explain to the patient about the situation.
• Give a chance to the patient to express feelings.
• Divert the attention of the patient.
• Involve the family in nursing.
• Create a quiet environment.
• Consult your doctor if the patient remains anxious.

Rationalization:

• Anxiety cause an additional stress to the heart condition.
• 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.

3. Disturbed sleep pattern r/t chills (fever), sweats as a result of the infection.

Goal: The need for restful sleep enough, with the criteria; the patient is not shivering and sweating is reduced, the temperature 36 - 37º C.

Action Plan:

• Observation of body temperature.
• Create a comfortable environment (bedding, clothing).
• Instruct the patient to use a thin blanket.
• Implement treatment from a doctor.

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Asthma - 7 Nursing Diagnosis and Interventions

Nursing Care Plan for Asthma : Nanda Nursing Diagnosis and Interventions

1. Ineffective airway clearance related to airway spasm, secretion retention, amount of mucus.

Goal: The patient showed the ability to maintain the cleanliness of the airway, with the expected outcomes:

• There is no secret
• Lungs clear sound

Intervention:
1. Airway menagement:

• Free the airway (suction)
• Monitor the chest wall retraction
• Monitor respiration rate
• Give a semi-Fowler position

2. Clear the airway:

• Listen to lung sounds
• Encourage the patient to drink warm
• Do suction
• Monitor oxygen delivery
• Evaluation of lung sounds after suction

2. Ineffective breathing pattern related to spasm of the airway, respiratory muscle fatigue.

Goal: Adequate patient's respiratory status, with the result criteria:

• Respiration rate is within normal limits
• Not seen the use of additional respiratory muscles
• No complaints of pain in breathing

Intervention:
1. Airway management:

• Monitor respiratory patients
• Monitor the use of additional respiratory muscles (chest wall retraction)
• Monitor Vitas signs; respiration, pulse, blood pressure, temperature
• Position the patient in semi-Fowler position

2. Oxygen Therapy:

• Provide oxygen according to program
• Give oxygen through a nasal or face mask canul
  • The flow of 1-6 liters / minute oxygen concentration produces 24-44%
  • The flow of 5-8 liters / minute oxygen concentration produces 40-60%
  • The flow of 8-12 liters / min oxygen concentration produces 60-80%
  • The flow of 8-12 liters / min oxygen concentration producing 90%

3. Collaboration for bronchodilator therapy.


3.Impaired gas exchange related to bronchospasme, damage to the alveoli.

Goal: effective gas exchange, with expected outcomes:

• Free from symptoms of respiratory failure, cianosis, nostril breath
• Blood gas analysis results within normal limits.

Intervention:
1. Airway management:

• Position the patient in a position semifowler
• Auscultation of breath sounds of patients
• Patient's fluid balance
• Monitor respiration rate
• Clear the airway of secretions (Suction)
• Teach the client to use an inhaler
  

2. Acid-base management:

• Monitor blood gas analysis
• Monitor electrolyte levels
• Monitor oxygen saturation
• Collaboration of medication to maintain the acid-base balance (sodium bicarbonate)
• Monitor hemodynamic status

4. Activity intolerance related to imbalance of oxygen supplied to the needs

Goal: The patient showed tolerant state of activity, with the expected outcomes:

• No shortness of breath on exertion
• Able to move up

Intervention:
1. Energy management:

• Determine the causes of fatigue
• Monitor respiratory (respiration, dyspnoea, pallor)
• Help clients choose the activities that can be done
• Recommended to increase the intake of nutrients

2. Monitor response of breathing during activity, assess abnormal response in respiration, blood pressure, pulse.


5. Knowledge deficit: about asthma, related to lack of information sources.

Goal: increase patient knowledge about asthma, the expected outcomes:

• Knowing trigger asthma
• Knowing about the things that need to be avoided
• Knowing the handling of the attack.

Intervention:
1. Assess the things that have been known to patients

2. Assess the patient's condition before health education, do not provide health education, while patients in the state of attack.

3. Education:

• Explain the meaning of asthma
• Explain the trigger factor
• Describe the things that need to be avoided: elergan factors, stress, excessive cold weather activity
• Explain how the handler during an asthma attack at home
• Evaluate what has been delivered.

6. Anxiety related to crisis situations: changes in health status

Goal: The patient can control anxiety and increase coping, with expected outcomes:

• Patient's expression relaxed
• Vital signs are within normal limits

Intervention:
1. Lower levels of anxiety:

• Listen to their patients
• Explain each will perform maintenance procedures
• Instruct the patient to accompany the family as a support system during an asthma attack

2. Teach termination worried if stress can not be avoided:

• Turning his attention upward
• Respiratory control by drawing a deep breath (relaxation)
• Position your body relax
• Make a relaxed mood, relaxed facial expression.

7. Imbalanced Nutrition, Less Than Body Requirements related to an increase in shortness of breath, intolerance to activity

Goal: Nutrition clients adequate, with expected outcomes:

• Increased oral input

Intervention:
1. Environmental Management:

• Provide a relaxed dining atmosphere
• Limit visitors during mealtimes
  

2. Manage your nutrition:

• Assess the client's food preferences and diet recommended
• Monitor oral intake, if not enough add parenteral nutrition
• Anjurrkan eat small meals but often
• Anjurrkan for clients favorite meals
• Collaboration with the nutrition.

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Sample of Nursing Diagnosis - Interventions for Gastritis

Nursing Care Plan for Gastritis : Sample of Nursing Diagnosis and Nursing Interventions


1. Nursing Diagnosis: Risk for Fluid Volume Deficit related to inadequate intake and excessive fluid output (nausea and vomiting)

Goal:
After nursing actions, adequate fluid intake.

Expected outcomes are:

• The mucosa of the lips moist
• Good skin turgor
• Good capillary refill
• Input and output balanced

Nursing Interventions:

• Fill your individual needs. Encourage clients to drink.
• Provide additional IV fluids as indicated.
• Monitor vital signs, evaluation of skin turgor, capillary refill and mucous membranes.
• Collaboration: the provision of drugs.

Rational:

• Adequate fluid intake will reduce the risk of patient dehydration.
• Replacing lost fluids and improve fluid balance in the immediate phase.
• Indicate the status of dehydration or the possibility of the need to increase fluid replacement.
• Provision of drugs serves to inhibit gastric acid secretion.

2. Nursing Diagnosis: Acute pain related to irritation of the gastric mucosa secondary to psychological stress.

Goal:
After the act of nursing, pain can be reduced, patients can rest and generally good condition.

Expected outcomes are:

• Clients express the pain diminished or disappeared.
• The client does not grimace in pain.
• Vital signs are within normal limits.
• The pain intensity was reduced (reduced pain scale 1-10).
• Demonstrate relax, rest, sleep, increased activity quickly.

Nursing Interventions:

• Investigate complaints of pain, note the location, intensity of pain, and pain scale.
• Instruct patient to report pain as soon as it began.
• Monitor vital signs.
• Explain the causes and effects of pain on the client and his family.
• Encourage rest during the acute phase.
• Encourage relaxation techniques.
• Provide an environment conducive situation.
• Collaboration with the medical team in the delivery of the action.

Rationale:

• To find out where the pain and facilitate interventions to be performed.
• Early intervention to facilitate recovery of muscle control pain by decreasing muscle tension.
• Autonomic responses include, changes in blood pressure, pulse, respiration, associated with pain relief.
• With the causes and consequences of pain the client is expected to participate in treatment to reduce pain.
• Reduce pain that was exacerbated by movement.
• Decrease muscle tension, increase relaxation, and increased sense of control and coping abilities.
• Provide support (physical, emotional, increased sense of control, and coping skills).
• Eliminate or reduce the client's complaints of pain.

3. Nursing Diagnosis : Imbalanced Nutrition: Less Than Body Requirements related to the lack of food intake.

Goal:
After the patient's nutritional needs of nursing actions are met.

Expected outcomes are:

• General condition is quite
• Good skin turgor
• Increased weight
• Difficulty swallowing is reduced

Nursing Interventions :

• Instruct patient to eat small meals but frequently.
• Give soft foods.
• Perform oral hygiene.
• Measure weight basis.
• Texture observation, the patient's skin turgor.
• Observations of nutritional intake and output.

Rationale:

• Keeping the patient remained stable nutritional prevent nausea and vomiting.
• To facilitate the patient to swallow.
• Oral hygiene can stimulate the appetite of the patient.
• Knowing the development of nutritional status of patients.
• Knowing a patient's nutritional status.
• Knowing a patient's nutritional balance.

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Example of Nursing Diagnosis - Benign Prostatic Hyperplasia (BPH)

Nursing Care Plan for Benign Prostatic Hyperplasia

BPH - Example of Nursing Diagnosis


Nursing Assessment of benign prostatic hyperplasia (BPH)

1. Before Operation

a. Subjective Data :

• The client told pain while urinating.
• Difficult urination.
• Increased frequency of urination.
• Frequent waking at night for micturition.
• The desire to urinate can not be postponed.
• Pain or feel hot at the time of micturition.
• Jets of urine fell.
• Not satisfied after micturition, the bladder does not empty properly.
• If you want to have to wait long micturition.
• The amount of urine decreased and should straining during urination.
• The flow of urine is not smooth / disjointed.
• Urine continue dripping after urination.
• Feeling tired, no appetite, nausea and vomiting.
• The client was concerned with the treatment to be performed.

b. Objective Data

• Facial expressions seem to hold the pain.
• Posted catheter.

2. After Surgery

a. Subjective Data

• The client told pain in postoperative wound
• The client says do not know about diet and medication after operation

b. Objective Data

• Expression of pain appears to hold
• There is a closed postoperative wound dressing
• Looks Weak
• Installed irrigation hoses, catheters, infusion

Medical History

Past medical history, history of present illness, family history of disease, BPH impact on patient's lifestyle, whether the patient experienced urinary problems.


Physical Assessment

1) Disturbances in urination, such as:

• Frequent urination
• Waking at night to urinate
• Feeling like a very urgent micturition
• Pain during micturition, weak urinary jet
• Not satisfied after micturition
• The amount of urine decreased and should straining during urination
• The flow of urine is not smooth / broken, urine continues to drip after urination.
• Pain when urinating
• There was blood in the urine
• The bladder feels full
• Pain in the waist, back, stomach discomfort.
• Urine is retained in the bladder, bladder distention occurs

2) Common symptoms such as fatigue, no appetite, nausea, vomiting, and epigastric discomfort
3) Assess the status of emotions: anxiety, fear
4) Examine the urine: the number, color, clarity, odor
5) Assess vital signs

Diagnostic examination

• Radiographic Examination
• Urinalysis
• Lab such as blood chemistry, complete blood, urine

Assess the level of understanding and knowledge of the client and family about the situation and the disease process, treatment and care on the way home.

Nursing Diagnosis for Benign Prostatic Hyperplasia

a. BPH - Pre Surgery :

1. Acute Pain
2. Anxiety
3. Imbalanced Nutrition Less Than Body Requirements
4. Impaired Urinary Elimination

b. BPH - Post Surgery :

1. Acute pain
2. Risk for Infection
3. Knowledge Deficit: about the disease, diit, and treatment
4. Self care deficit

Source : http://nursesnanda.blogspot.com/2012/07/example-of-nursing-diagnosis-benign.html

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Nursing Diagnosis for Conjunctivitis

Conjunctivitis is a common eye disease that may be caused by excessive eye strain or infections due virus or bacteria. Conjunctivitis or pink eye is one of those conditions that effect children, adults and animals. It can be highly contagious and some people, particularly children, seem to suffer repeat bouts of it.

Conjunctivitis is a highly contagious disease and it is treatable. The human body itself takes measures to cure the pink eyes. Since the soreness causes pain, many home treatments are suggested and they also found to be very effective.

Types of Conjunctivitis

Allergic conjunctivitis

Allergic conjunctivitis is often caused by dust mites, pollen and cosmetics and is common in people who have hay fever, asthma and eczema. It can cause mild to severe itching and often makes the eyes red and sore. If it's seasonal conjunctivitis it may just last a few weeks, however, allergic conjunctivitis may be consistent if you live around animals or are allergic to house dust. Speak to your doctor or pharmacist if you're worried about this condition and take antihistamines as prescribed.

Viral conjunctivitis

Viral conjunctivitis usually occurs after a cold or a sore throat and it is highly contagious.

It causes a watery discharge to leak from the eye and can spread easily from one eye to the other. It can turn the eye pink and might can also cause itching if it becomes particularly nasty. Viral conjunctivitis usually clears up by itself; however, ocular lubricants and painkillers can ease the symptoms. If you've got this disease it's essential that you always wash your hands thoroughly and to remove discharge using a clean cotton bud.

Bacterial conjunctivitis

Bacterial conjunctivitis is caused by bacteria such as staphylococci, streptococci or haemophilus and is a particularly nasty form of the condition. It causes the eyes to feel gritty, inflamed and sore and a yellow, sticky discharge may form sticking the eyes together overnight. Bacterial conjunctivitis usually lasts a week, but antibiotic drugs can help. Like viral conjunctivitis, it's highly contagious, so always maintain a high level of hygiene if you're infected and visit your optometrist if you have any concerns.

Symptoms of Conjunctivitis

The pink eye effect is one of the first signs of conjunctivitis. The sufferer may complain of dry or itchy eyes and, particularly children, will tend to rub them a lot. There can also be a discharge from the eye - this can range from a clear watery look to yellow or green. The color is often an indication of what type of conjunctivitis the person is suffering from. In severe cases, the eyes may be glued shut on waking. This is caused by the discharge weeping out from between the eyelids during sleep, then drying on the eyelashes, effectively gluing them together.


Nursing Diagnosis for Conjunctivitis

1. Acute Pain

related to inflammation of the conjunctiva

characterized by:
Clients say the discomfort (pain) is felt
The face looks the pain (pain expression).

2. Anxiety

related to lack of knowledge about the disease process

characterized by:
Clients say about anxiety.
Clients look anxious and nervous.

3. Self-concept disturbance

related to a change in the eyelid (swelling / edema).

4. Risk for injury

related to the limits of vision.

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Nursing Care Plan for Angina pectoris - 4 Diagnosis and Interventions

1. Acute Pain related to myocardial ischemia

Nursing interventions:

• Review the description and the factors that aggravate the pain.
• Observation of vital signs every 5 minutes on each attack of angina pectoris.
• Create a quiet environment, limit the visitor when necessary.
• Put the client on total bedrest during episodes of angina (the first 24-30 hours) with a semi-Fowler position.
• Give soft foods and let the client rest 1 hour after meals.
• Teach distraction and relaxation techniques.
• Medical collaboration in terms of drug delivery.

2. Activity intolerance related to decreased cardiac output.

Nursing interventions:

• Maintain bed rest in a comfortable position.
• Provide adequate rest periods, aids in the fulfillment of self-care activities in accordance with the indication.
• Record the color and quality of the pulse.
• Increase client activity on a regular basis.
• ECG Monitor with frequent, and record ECG if there are complaints of angina pectoris.

3. Anxiety related to fear of the threat of sudden death.

Nursing interventions:

• Explain all procedures act.
• Increase expression of feelings and fear.
• Encourage family and friends to consider the client as before.
• Tell the client that the medical program has been made to reduce / limit the attack to come and increase the stability of the heart.
• Collaboration.

4. Knowledge Deficit: (need to learn) about the disease, treatment needs related to the lack of information.

Nursing interventions:

• Emphasize the need to prevent angina attacks.
• Push to avoid the factors / situations as the originator of angina episodes.
• Assess the importance of weight control, smoking cessation, dietary changes and exercise.
• Show / encourage clients to monitor their own pulse rate during the activity, avoid stress.
• Discuss the steps taken in the event of an attack of angina.
• Encourage clients to follow a predetermined program.

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4 Nursing Diagnosis for Cholelithiasis

Nanda Nursing Diagnosis for Cholelithiasis

1. Acute Pain related to:

• biological trauma obstruction / spasm tract inflammatory processes, iskhemia / tissue necrosis

characterized by:

• Complaints of pain, colik billiary (pain frequency).
• Facial expressions as pain, a cautious attitude.
• Autonomic responses (changes in blood pressure, pulse).
• Focus on self-limited.

2. Risk for Deficient Fluid Volume related to:

• Increase in gastric fluid loss: vomiting, gastric distention and hipermolity.
• Treatment has the effect of reducing the fluid.
• The freezing process

characterized by:

• Signs and symptoms of unstable can not be applied to the actual diagnosis.

3. Imbalanced Nutrition Less Than Body Requirements related to:
Risk factors that affect:

• Imposed on themselves and given limited food, nausea, vomiting, dyspepsia, pain.
• Loss of nutrients, affect digestion due to disturbance / narrowing of the bile duct.

4. Deficient Knowledge: about prognosis and treatment needs related to:

• Re asking about information.
• Imformasi misinterpretation.
• Have not / do not know the source of information.

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8 Nursing Diagnosis - Nursing Care Plan for Bladder Cancer

Nursing Care Plan for Bladder Cancer

Symptoms of Bladder Cancer are blood while passing urine, heavy hurt at times of urinating, sensation of urinating but no passage of urine.

During the early stages of the bowel cancer, there may not be any obvious symptoms, however as the Cancer Grows, one can notice blood in stools or rectal bleeding is common. When one notices a change in their normal bowel habits Such as diarrhea, Constipation or frequent visits to the toilet, It could be an indication of something not right.

Also Unexplained loss of weight or appetite and stomach pain can also occur. As the cancer Grows the bleeding in the bowel can lead to anemia Causing breathless and fatigue, as there is not enough oxygen in the body.

Bladder cancer has the which Various types of symptoms are determined by where the cancerous cells have started. The symptoms of bladder cancer can originate from bladder infection / UTI (urinary tract infection) and therefore require tests to find the true cause of the problem.

8 Nursing Diagnosis for Bladder Cancer

1. Anxiety
2. Acute Pain
3. Imbalanced Nutrition Less Than Body Requirements
4. Knowledge deficient
5. Fluid Volume Deficit
6. Risk for infection
7. Risk for Sexual Dysfunction
8. Risk for Impaired Skin Integrity

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Nursing Diagnosis HNP - Nursing Interventions Herniated Nucleus Pulposus

1. Nursing Diagnosis for Herniated nucleus pulposus : Acute pain related to nerve compression, muscle spasm

Nursing Interventions for HNP:

• Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10
• Maintain bed rest, semi-Fowler position with spinal, hip and knee in flexion, supine position
• Use logroll (board) during a change of position
• Assist patients in the installation of brace / corset
• Limit your activity during the acute phase according to the needs
• Teach relaxation techniques
• Collaboration: analgesics, traction, physiotherapy

2. Nursing Diagnosis: Impaired physical mobility related to pain, muscle spasm, restrictive therapy, and neuromuscular damage

Nursing Interventions:

• Give / aids patients to perform passive range of motion exercises and active
• Assist patients in ambulation activities progressive
• Provide good skin care, massage point pressure after rehap change in position. Check the state of the skin under the brace with the periods of time.
• Note the emotional responses / behaviors in immobilizing
• Demonstrate the use of auxiliary equipment such as a cane.
• Collaboration: analgesic

3. Nursing Diagnosis for HNP: Anxiety related to the ineffectiveness of individual coping

Nursing Interventions:

• Assess the patient's anxiety level
• Provide accurate information
• Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities.
• Review of the secondary problems that may hinder the desire to heal and may impede the healing process.
• Involve the family.

4. Nursing Diagnosis for Herniated nucleus pulposus: Deficient knowledge related to the lack of information about the condition, prognosis

Nursing Interventions:

• Explain the process of disease and prognosis, and restrictions on activities
• Provide information about your own body mechanics to stand, lift and use ancillary shoes
• Discuss the treatment and its side effects.
• Recommend to use the board / mat is strong, a small pillow under the neck a bit flat, sloping bed with knees flexed, avoiding the tummy.
• Avoid the use of heaters in a long time
• Provide information about signs that need attention such as stab of pain, loss of sensation / ability to walk.

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6 Nursing Diagnosis for Tonsillitis

Nanda Nursing Diagnosis for Tonsillitis

Tonsillitis is inflammation of the tonsils. Become inflamed tonsils when then enlarge, Produce pain on swallowing, Produce fever, bad breath and can make-the neck lymph glands to Become tender. Patients complain of feeling unwell Often, reduced appetite and painful mouth opening.

Signs and Symptoms of tonsillitis. Patients are usually fever, sore skull, may be seriously ill and was very painful, especially when swallowing and opening the mouth accompanied by trismus (difficulty opening the mouth). When the larynx is affected, the voice will be hoarse. On examination of the pharynx appears hiperemis, swollen tonsils, hiperemis: there is detritus (tonsillitis folibularis), sometimes detritus adjacent to sati (laturasis tonsillitis) or a pseudo membrane. Palatinus anterior arch looks pushed out and pushed past the midline uvula. Sub-mandibular gland swelling and tenderness, especially in children.

Enlarged adenoids can cause mouth breathing, ear discharge, the head is often hot, bronchitis, noisy breathing breathing's baud.

Do a thorough physical examination, and a careful medical history collection to rule out systemic conditions or related conditions. Tonsillar swabs were cultured to determine the presence of bacterial infection. If the adenoid tonsils are infected, it can take lead suppurative otitis media resulting in hearing loss, patients should be given a thorough examination audiometik sensitivity / resistance can be made if necessary.

 

6 Nursing Diagnosis for Tonsillitis
1. Ineffective Airway Clearance related to obstruction of breath due to foreign bodies; excess production secret.

2. Acute Pain related to swelling of tissues; surgical incision.

3. Imbalanced Nutrition Less Than Body Requirements related to the anorexia; difficulty swallowing.
 
5. Knowledge deficit related to lack of understanding, pemajaran / recall.

6. Risk for Fluid Volume Deficit related to the risk of bleeding due tondilektomi operative action.

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Nursing Diagnosis for Myasthenia Gravis

Myasthenia Gravis Definition

Myasthenia Gravis is a neuromuscular transmission disorder affecting the muscles of the body that works under a person's consciousness. Characteristics that appear in the form of excessive weakness and fatigue commonly occur in the muscles of voluntary and it is influenced by cranial nerve function (Brunner and Suddarth 2002).

Myasthenia Gravis is a neuromuscular disorder that affects the transmission of impulses to the voluntary muscles of the body (Sandra M. Neffina 2002).

Myasthenia Gravis Etiology

The cause of this disorder is unknown, but the possibility due to a disruption or destruction of acetylcholine receptors at the neuromuscular junction due to an autoimmune reaction. Damaged muscle contractions cause muscle weakness.

Myasthenia Gravis Clinic Manifestations

• Extreme muscle weakness and prone to fatigue
• Diplopia (double vision)
• Ptosis (eyelid fall)
• Dysphonia (voice disorders)
• Weakness of the diaphragm and intercostal muscles causing progressive respiratory distress.

Pathophysiology

Basic abnormality in myasthenia gravis is the damage to the transmission of nerve impulses to the muscle cells due to loss of the ability or the loss of post-synaptic membrane of normal receptors at the neuromuscular junction. Research shows a 70-90% decrease in acetylcholine receptors at the neuromuscular junction of each individual. Myasthenia gravis is an autoimmune disease to be considered as being directed against the acetylcholine receptor (ACHR) that damages the neuromuscular transmission.

Nursing Diagnosis for Myasthenia Gravis

1. Ineffective breathing pattern related to respiratory muscle weakness.

2. Impaired physical mobility related to weakness of voluntary muscles.

3. Risk for aspiration related to the weakness of bulbar muscles.

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Ineffective Tissue Perfusion related to Anemia

Nursing Diagnosis for Anemia: Impaired Tissue Perfusion

Definition: Decrease in oxygen resulting in damage to tissue maintenance.

Defining characteristics:
1. Cardiopulmonary

• Changes in respiratory frequency
• The use of additional respiratory muscles
• Abnormal blood gas analysis
• Dyspnea
• Arrhythmias
• Chest pain
• Chest retraction
• Capilary refill more than 3 seconds
• Bronchospasm

2. Peripheral

• Edema
• Changes in skin characteristics
• Changes in skin temperature
• Bluish
• Impaired sensation
• Cold extremities
  
• Wound healing is a long

3. Gastrointestinal

• Voice intestinal hipoaktif
• Nausea
• Abdominal distention
• Abdominal pain

4. Renal

• Changes in blood pressure
• Hematuria
• Oliguria
• Increased BUN and creatinine

5. Cerebral

• Abnormal speech
• Weakness of the extremities
• Changes in mental status
• Changes in pupil reaction
• Difficulty swallowing
• Changes in motor response

Related factors:

• Decrease in hemoglobin in the blood

Diagnosis, Goals, Outcomes, Nursing Interventions:

Ineffective tissue perfusion related to decrease in hemoglobin in the blood

NOC 1:
Status of peripheral and cerebral tissue perfusion
Criteria:

• Filling capilary refil
• The power of peripheral pulse distal
• The power of the proximal peripheral pulsation
• Symmetry proximal peripheral pulsation
• The level of normal sensation
• The color of normal skin
• The power of muscle function
• Integrity of the skin
• Warm skin temperature
• There was no peripheral edema
• There is no pain in the extremities

NOC 2:
Circulation status
Criteria:

• Blood pressure was within normal limits
• The power of the pulse within normal limits
• The average blood pressure within normal limits
• Central venous pressure within normal limits
• There was no orthostatic hypotension
• There is no additional heart sounds
• There is no angina
• There was no orthostatic hypotension
• Analysis of blood within normal limits as
• Difference in arterial and venous oxygen levels are normal
• No additional breath sounds
• The power of peripheral pulse
• No widening of the veins
• There was no peripheral edema

NIC:

1. Circulation treatment
activities:

• Check the peripheral pulses
• Record the color and temperature
• Check the refill capilery
• Record prosntase edema, especially in the extremities
• Do not exceed the elevation of the hands of the heart
• Keep the client warm
• Monitor fluid status, input and output sesuaiMonitor lab Hb and HMT
• Monitor bleeding
• Monitor hemodynamic status, neurological and vital signs

2. Monitor vital signs
activities:

• Monitor blood pressure, pulse, temperature and respiration
• Note the fluctuations in blood pressure
• Monitor blood pressure at the time the client lying down, sitting and standing
• Measure blood pressure in both arms and compare
• Monitor blood pressure, pulse, respiration, before, during and after activity
• Monitor heart rate and rhythm
• Monitor heart sound
• Monitor respiratory rate and rhythm
• Monitor lung sounds
• Monitor abnormal rhythm of the breath
• Monitor temperature, color and moisture
• Monitor peripheral cyanosis

3. Monitor neurological status
activities:

• Monitor the size, shape, kesmetrisan and pupillary reaction
• Monitor level of consciousness
• Monitor the level of orientation
• Monitor GCS
• Monitor vital signs
• Monitor patient response to treatment

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Risk for Infection Anemia Nursing Diagnosis and Interventions

Nursing Diagnosis for Anemia: Risk for Infection related to Inadequate secondary defenses.

Objectives: Infection does not occur.

Expected outcomes are:

• Identify the behaviors to prevent / reduce the risk of infection.
• Improve wound healing, free of purulent drainage or erythema, and fever.

Nursing Interventions for Anemia Risk for Infection

Independent

1. Increase good hand washing; by care givers and patients.
Rationale: to prevent cross contamination / bacterial colonization. Note: patients with severe anemia / aplastic can be risky due to the normal flora of the skin.

2. Maintain strict aseptic techniques in the procedure / treatment of wounds.
Rational: reduce the risk of colonization / infection of bacteria.

3. Give skin care, peri-anal and oral carefully.
Rational: reduce the risk of damage to the skin / tissue and infection.

4. Motivation changes in position / ambulation that often, coughing and deep breathing exercises.
Rational: improving the ventilation of all lung segments and help mobilize secretions to prevent pneumonia.

5. Increase enter adequate fluids.
Rational: to assist in breathing secret dilution to facilitate spending and prevent stasis of body fluids such as respiratory and renal

6. Monitor / limit visitors. Provide isolation if possible.
Rational: limiting exposure to bacteria / infections. Protection of insulation required in aplastic anemia, when the immune response is impaired.

7. Monitor body temperature. Note the presence of chills and tachycardia with or without fever.
Rational: the process of inflammation / infection requires evaluation / treatment.

8. Observe erythema / wound fluid.
Rational: indicators of local infection. Note: the formation of pus may not exist when granulocytes depressed.

Collaboration

1. Take a specimen for culture / sensitivity as indicated.
Rational: to distinguish the presence of infection, identifying the specific pathogen and affects treatment options.

2. Give topical antiseptic; systemic antibiotics.
Rational: may be used for prophylactic treatment to reduce colonization or local infection process.

Related Articles :

Nanda Anemia

Anemia - Ineffective Tissue Perfusion Nursing Diagnosis and Interventions

10 Nanda Nursing Diagnosis for Anemia

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Nursing Diagnosis Dengue Haemorrhagic Fever (DHF)

Nursing Diagnosis Dengue haemorrhagic fever (DHF)

Preparation of nursing diagnoses made ​​after the data obtained, and then grouped and focused according to the problems that arise as an example of nursing diagnoses that may arise in cases of DHF include:

a. Deficient fluid volume related to increased capillary permeability, bleeding, vomiting and fever.

b. Hyperthermia related to dengue virus infection process.

c. Imbalanced Nutrition Less than Body Requirements associated with nausea, vomiting, no appetite.

d. Lack of knowledge about the family disease process related to the lack of information

e. Risk for Bleeding related to thrombocytopenia.

f. Hypovolemic shock related to bleeding

Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect children under 10 years of age. It causes abdominal pain, hemorrhage (bleeding), and circulatory collapse (shock). DHF is also called Philippine, Thai, or Southeast Asian hemorrhagic fever and dengue shock syndrome.

DHF starts abruptly with high continuous fever and headache. There are respiratory and intestinal symptoms with sore throat, cough, nausea, vomiting, and abdominal pain. Shock occurs two to six days after the start of symptoms with sudden collapse, cool, clammy extremities (the trunk is often warm), weak pulse, and blueness around the mouth (circumoral cyanosis).

In DHF, there is bleeding with easy bruising, blood spots in the skin (petechiae), spitting up blood (hematemesis), blood in the stool (melena), bleeding gums, and nosebleeds (epistaxis). Pneumonia is common, and inflammation of the heart (myocarditis) may be present.

Patients with DHF must be monitored closely for the first few days since shock may occur or recur precipitously (dengue shock syndrome). Cyanotic (bluish) patients are given oxygen. Vascular collapse (shock) requires immediate fluid replacement. Blood transfusions may be needed to control bleeding.

The mortality (death) rate with DHF is significant. With proper treatment, the World Health Organization estimates a 2.5% mortality rate. However, without proper treatment, the mortality rate rises to 20%. Most deaths occur in children. Infants under a year of age are especially at risk of dying from DHF.

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