Nursing Care Plan for Cushing's Syndrome

Nursing Care Plan for Cushing's Syndrome

Nursing Care Plan for Cushing's Syndrome  

Definition of Cushing's syndrome

Cushing's syndrome is a condition caused by hyperadrenocorticism, is more often found in women, due to neoplasms in the adrenal cortex / anterior pituitary, or a result of long-term intake of glucocorticoids for therapeutic interest (Dorland).

Etiology of Cushing's syndrome

• Excessive activity of the adrenal cortex
• Corticosteroids / ACTH excess
• Adrenal cortex hyperplasia.

Symptoms of Cushing's syndrome

Most people with Cushing syndrome will have:

• Upper body obesity (above the waist) and thin arms and legs
• Round, red, full face (moon face)
• Slow growth rate in children

Skin changes that are often seen:

• Acne or skin infections
• Purple marks (1/2 inch or more wide) called striae on the skin of the abdomen, thighs, and breasts
• Thin skin with easy bruising

Muscle and bone changes include:

• Backache, which occurs with routine activities
• Bone pain or tenderness
• Collection of fat between the shoulders (buffalo hump)
• Rib and spine fractures (caused by thinning of the bones)
• Weak muscles

Women with Cushing syndrome often have:

• Excess hair growth on the face, neck, chest, abdomen, and thighs
• Menstrual cycle that becomes irregular or stops

Men may have:

• Decreased or no desire for sex
• Impotence

Other symptoms that may occur with this disease:

• Mental changes, such as depression, anxiety, or changes in behavior
• Fatigue
• Headache
• Increased thirst and urination

Management of Cushing's Syndrome

As more Cushing's Syndrome is caused by a pituitary tumor than adrenal tumor, the treatment is often directed at the pituitary gland.

1. Transsphenoidal hypophysectomy, surgical removal of the tumor.
2. Radiation pituitary gland, takes several months to control the symptoms.
3. Adrenalectomy, the treatment of choice for patients with primary adrenal hypertrophy.
4. Baffle adrenal enzyme preparations (ie, metyrapon, aminoglutethimide, mitotane, ketoconazole) to reduce hiperadrenalisme if due to ectopic ACTH secretion.

Nursing Care Plan for Cushing's Syndrome

Nursing Diagnosis for Cushing's Syndrome

1. Risk for injury and Risk for infection related to weakness and changes in protein metabolism and inflammatory response.
2. Self-care Deficit: weakness, feeling of tiredness, muscle atrophy and changes in sleep patterns.
3. Impaired skin integrity related to edema, impaired healing and the skin is thin and fragile.
4. Disturbed Body Image related to changes in physical appearance, sexual dysfunction and decreased activity levels.
5. Disturbed Thought Processes related to fluctuations in emotions, irritability and depression.

Tips to Lowering Blood Sugar in Diabetes

Tips to Lowering Blood Sugar in Diabetes

Hypertension  

Lowering Blood Sugar in Diabetes Mellitus is very difficult to do, the key appropriate diet is often overlooked so that blood sugar levels continue to rise. In normal people, blood sugar levels can be reabsorbed by the cells to be processed into energy as a source of human motion. Whereas in diabetic patients, a simple sugar remains in the blood stream and cause blood sugar levels to rise. Therefore, for patients with diabetes need to add fibrous foods in the daily diet.

Reduce Excess Fat

Excess fat will affect the sensitivity of cells to insulin substances in the body, which then disrupt the function of insulin to absorb blood sugar. This will result in a rise in blood sugar levels drastically. Reduce excess fat to lower blood sugar is best, of course with regular exercise. Burn fat also aims to maintain a healthy weight and reduce the risk of cardiovascular disease. In this regard, please note.

Herbs for Diabetes Patients

Herbs are believed to reduce blood sugar levels naturally very much. The type of these plants include; bitter melon, turmeric, ceremai, bitter, mango leaves, gotu kola, ginseng, red betel leaf. That need to be considered in the use of herbs to lower blood sugar levels, is about the possibility of hypoglycemia. The use of herbal plants is certainly for a while, and not good if consumed continuously. To keep the best blood sugar levels naturally by adjusting the diet.

How to cultivate food for people with diabetes

Processing of food consumed will affect how patients with diabetes keep blood sugar levels. For example, to cook the rice to be consumed by people with diabetes is to use a regular pan is heated on the stove, not the engine or electric rice cooker appliance. It aims to keep the unraveling of complex carbohydrates into simple carbohydrates, and trigger a rise in blood sugar levels.

Cooking vegetables for diabetics, should not be too long. It is intended that the content of complex carbohydrates and nutrients in vegetables are not damaged. Diabetes sufferers, should also reduce fried foods. As a substitute, you can stir frying, grilling or using a vacuum frying techniques with particular cookware.

7 Ways to Take Care of Elderly Affected Hypertension

7 Ways to Take Care of Elderly Affected Hypertension

Hypertension  

Hypertension is a condition where a person experiences an increase in blood pressure above normal indicated by the systolic number (top) and the bottom number (diastolic) blood pressure on examination using a blood pressure measuring device either in the form of mercury cuff (sphygmomanometer) or other digital devices .

The normal value of a person's blood pressure with height, weight, activity level and general health normal is 120/80 mmHg. In daily activities, normal blood pressure is stable with a numeric value range. But in general, the numbers decreased blood pressure during sleep and increased time when activity or exercise.

Here are some important things to consider in caring for elderly people who have hypertension:

1. Elderly affected by hypertension, decreased organ function, including the sense of taste. Usually the elderly will likely feel less salt or food was bland, although according to the usual size, salinity was fitting. Because of this, you need to do is to add sugar or spices cooking on food, but it is recommended not to use because of the flavor flavoring has a high salt content. In addition, if you want to buy food such as snacks and fast food, consider the salt content listed on the packaging.

2. Reduce foods containing sodium to less than 100 mmol / day (less than 6 g of sodium chloride, or less than 2.4 g of sodium per day).

3. Help the elderly to reduce weight up to a healthy weight and eat a diet rich in fruits and vegetables.

4. Help the elderly to limit consumption of caffeine and alcohol.

5. Accompany the elderly to light exercise such as walking, tai-chi, gymnastics heart that can be done 3-5 times / week for 30-45 minutes. However, avoid the habit of standing in a long time and perform strenuous activities, such as going up - and down the stairs.

6. Remind elderly, to change positions slowly. For example, when Elderly want to stand up from a lying position, preferably in advance Elderly sitting for about 5 minutes. If it does not feel dizzy, then stand slowly.

7. Help the elderly to measure blood pressure to elderly health worker, clinic or other health facility.

Home Health Care for The Elderly

Home Health Care for The Elderly

Home Health Care for The Elderly  

Metabolic diseases such as hypertension, diabetes mellitus, osteoporosis, and stroke often complained about by parents in the elderly stage.

Older people with age above 50 years old are very susceptible to diseases, which include: diabetes mellitus, hypertension, and Osteoporosis. Therefore, for early prevention, you should always remind parents to avoid foods that are hard, dense, and too salty, sour or sweet.

Diet for the Elderly

Then you also have to adjust their diet. Reducing the share of food in the elderly needs to be done, because the energy needs of the parents dropped so drastically. In order not to affect the stamina and health of the elderly, you can make gradual reduction in size of the meal. You should also begin to provide food that is rather soft, easily digested by the stomach.

Right Food for the Elderly

In addition to adjusting the diet, other things that are needed to maintain the health of the elderly is that calcium can be obtained from drinking milk. Calcium is a substance used to strengthen bones, prevent body bent and reduce osteoporosis. so drinking milk on a regular basis, is highly recommended for the elderly.

Other substances are also very important for the elderly is Omega 3. Substances that are very useful for the body, can be obtained from fish, vegetables, fruit and fish oil, with the aim to prevent the occurrence of symptoms of stroke in elderly parents.

Right Sport for the Elderly

In addition to providing nutritious food intake for the elderly and maintaining the proper diet, you also have to set a routine exercise for the elderly. Indeed sporting activities undertaken not as heavy as you are still young. However, for the elderly walking is the simplest activity and relatively safe. Walking activity can train the heart muscle strength, leg and maintain smooth breathing for the elderly.

Conclusion:

• Metabolic diseases such as diabetes mellitus, hypertension, stroke and osteoporosis often complained of by the elderly,
• To keep Health Care, can be done with lifestyle and healthy eating, as well as light exercise on a regular basis.

The Scope of Nursing Research

The Scope of Nursing Research

The Scope of Nursing Research  

The scope of nursing research problem is divided into six (6) scope of the research problem, namely:

A. Basic Nursing and Nursing Management

1. Development of concepts and theories of nursing
   Focuses on the study of theory that has been there to convince the public, that the science of nursing is different with other health professions, as well as the spesific knowledge in the nursing field, consisting of:
   
   1. Adaptation theory. (Calista Roy)
   2. Self-care deficits. (Orem)
   3. Environmental health. (Florence Nightingale)
   4. The concept of nursing practice models. (Betty Neuman)
2. Issue of basic human needs
   Study of the causes and efforts to meet basic needs, include:
   
   1. Oxygenation problems
   2. Nutritional problems
   3. Fluid and electrolyte problems
   4. Elimination problem
3. Nursing Education
   
   1. Curriculum development and implementation
   2. Students and faculty
   3. Learning methods
   4. Evaluation system
4. Nursing Management
   
   1. The role and performance of nurses
   2. Nursing management system
   3. The role and performance of nursing committee
5. The role and function of professional organizations
   
   1. Organizational roles within nursing practice system (Registration, license, legalization).
   2. Role of standard-setting organizations within nursing practice.
   3. Organization's role in the development of the higher education system of nursing.

B. Pediatric Nursing
Scope of pediatric nursing research, based on a philosophy of nursing children (Biopsychosocial) children due to hospitalization and nursing roles in children and families, including:

1. Impact of hospitalization.
2. Developmental problems of children.
3. Child immunization issues.
4. Nursing care problems of children with disorders body system.

C. Maternity Nursing
The scope of this study focused on women of childbearing age couples, prenatal, natal and post natal and reproductive disorders, include:

1. Problems of pregnant women
2. Maternal intrapartum problems (I - IV) and nursing care of low birth weight babies, assessment - evaluation)
3. Postpartum maternal problems (vulvar hygiene, breast care, postnatal exercises, how to breastfeed)
4. Maternal problems with reproductive disorders (early detection of reproductive disorders, anxiety Ca cervix)

D. Medical-surgical Nursing and Emergency
In the scope of medical-surgical nursing, research focusing on askep clients with impaired adult body systems approach to the nursing process.

1. Scope of Medical Surgical Nursing Science
   
   • Immune system
     
     1. Effect of regular exercise to increase endurance.
     2. The effect of vitamin A on the production of leukocytes.
     3. Relationship anxiety with immune function.
   • Respiration and oxygenation system
     1. Differences in the effectiveness of the use of masks and hoses oxygenation (catheter)
     2. The most effective nursing interventions for the treatment of clients with hoarding thick secretions in the airways.
   • Cardiovascular system
     1. Effect of physical exercise on health improvement coronary heart patients.
     2. O2 delivery methods are most effective to improve / maintain PaCO2.
     3. Terapy influence relaxation to decrease pain angina pectoris clients.
   • Neural system
     
     1. Effectiveness of the method in dealing with acute pain distraction postoperative patients.
     2. Effectiveness with warm water immersion in overcoming the pain of dislocation.
     3. The most effective method for detecting early impairment of consciousness.
   • Urinary system
     
     1. Educational relationship with dietary adherence clients with kidney stones.
     2. Influence the frequency of sexual intercourse on the incidence of BPH.
     3. BPH influence on the formation of urinary tract stones.
   • Gastrointestinal tract
     
     1. Dietary adherence relationship to the incidence of peptic ulcers in clients with gastritis.
     2. The most effective method in reducing pain in NGT installation.
     3. Effect of frequency / number of smoking on the incidence of gastritis.
   • Endocrine system
     
     1. Client compliance with diabetes mellitus, the diet
     2. The most effective method in dealing with hypoglycemia
     3. Client adherence diabetes mellitus, the blood sugar control
2. Scope of Emergency Nursing
   
   • Respiratory gravity
     
     1. Early detection of severe breathing method on the client
        
     2. The role of nurses in addressing severe breathing
        
     3. Technical development chest physio therapy
   • Cardiovascular gravity
     
     1. The role of the nurse within the gravity handlers cardio-vaskuer (use of DC sock)
   • Psychiatric emergency
     
     1. Effective methods of binding (restrain) client rampage 
     2. The role of the nurse within the handling of client rage, depression and suicide attempts.

E. Psychiatric Nursing Science

1. Scope of application of the nursing process
   
   • Influence on the development of therapeutic modalities klein depression.
   • Development of therapeutic communication techniques
   • Development of therapeutic modalities
2. Therapeutic group activities
   
   • Effective methods of activity therapy for depression client
3. Therapeutic environment / environmental manipulation
   
   • Effectiveness of preventive home visits to clients relapse of mental disorder
   • Recurrence relation with the client receiving the surrounding environment.

F. Nursing Community, Family and Gerontic

1. Scope of Community
   
   • Ommunity participation in efforts to improve public health.
   • Maternal perception of the implementation of ante-natal
   • TB patient compliance in the implementation of therapy (DOTS)
2. Scope of family
   
   • Terapiutik communication effectiveness in a family approach
   • Family roles to the treatment of pulmonary Tb
   • Perceptions of family heads towards family planning program
3. Scope Gerontic
   
   • Method approach is effective in elderly
   • The role of nurses within nutritional needs of the elderly
   • Effect of occupational therapy on stress reduction elderly.
     

Purpose and Implications of Nursing Research

Purpose and Implications of Nursing Research

Purpose and Implications of Nursing Research  

Nursing research is a systematic study, assessing problems or phenomena paktik nursing and nursing care through kreatiif study, initiating and evaluating change, take action to generate new knowledge that is useful for nursing.

Research activities in a systematic and regular moves, ranging from;

1. discovery issues;
2. collect data based on appropriate research design;
3. data analysis and;
4. formulate the conclusion of the study.

Control is a key element of the scientific approach. Involves inserting control conditions in order to study the situation the problem can be minimized and the validity and reliability (precision) can be achieved. Empirical is the process by which an event rooted in objective and collected directly or indirectly through sensing and is used for the formulation of the problem. Empirical investigation result of research objectivity because the idea / ideas tested in real situations. Generalization is a hallmark slah scientific method, meaning the study did not use the scientific method to a specific event, but should be able to use the research results to a broad scope. Generalization fosters science, provide explanations and predictions for pristiwa that will happen.

Purpose of research is to define, develop and test the truth, especially the science of knowledge. It also aims to find discordant thoughts in solving the problem. This is consistent with the objectives of research is to find answers to questions on an issue faced through basic and applied research activities.

The results of a study in the form of findings will provide the implications for parties:

1. Science (enhance existing knowledge);
2. Repair services or programs;
3. Follow-up studies in comprehension.

That is why research must be clear, open, honest and can be repeated or developed by others. Even more than that, the results of the study should be widely disesiminasikan either through print media and large group discussions such as seminars or panel discussions.

Nursing research conducted to address nursing issues and solving specific problems. This was done to develop a complete knowledge for nursing. Studying the field of nursing research integrity and knowledge of human behavior and influence one another is an attempt to learn the health issues related to human behavior and how that behavior relationships to health and illness.

The purpose of nursing research to improve the practice of the nursing profession in particular for improving the quality of nursing care.

Nursing Care of The Elderly with Immobility and Functional Mobility

Nursing Care of The Elderly with Immobility and Functional Mobility

Nursing Care Plan  

Various changes occur in the musculoskeletal system, including bone loss (osteoporosis), enlarged joints, tendon stiffness, limited motion, thinning of the intervertebral disc, and muscle weakness, occurs in the aging process.

In the elderly, the collagen structure is less able to absorb the energy. Joint cartilage degeneration and areas that support the body longer to heal. This resulted in the occurrence of osteoarthritis. So also in muscle mass and strength is also reduced.

Definition

Mobility is the movement that gave freedom and independence for someone. Although this type of activity changed throughout human life, mobility is central to participate in and enjoy life. Maintaining optimal moblitas very important for the mental and physical health of all elderly.

Mobility is not an absolute and static in determining the ability to walk; optimal but mobility is something individualistic, relative, and depends on the dynamic interaction between environmental factors and social, afetif and physical function. For one, optimal mobility may be running about 8 kilometers per day; for others, mobility may involve limited movement with the help.

Immobility is broadly defined as the level of activity that is less than optimal mobility. Barriers to physical mobility nursing diagnosis, potential disuse syndrome, and activity intolerance providing a more limited definition of immobility and immobility included in a broader definition.

Immobility, activity intolerance and disuse syndrome often occurs in the elderly. Studies on the incidence of nursing diagnoses used for the elderly who are in care institutions revealed that barriers to physical mobility is the first or the second diagnosis most often appear. The prevalence of this problem extends beyond the institutions to involve the entire elderly.


Impaired Physical Mobility

Definition

A state of the limited ability of independent physical movement experienced by a person.

Defining characteristics :

• Inability to move with purpose in the environment, including bed mobility, move, and ambulation.
• Reluctance to perform the movement.
• Limitation of range of motion.
• Decrease the power, control, or muscle mass.
• Experienced restrictions on movement, including protocols and medical mechanical.
• Impaired coordination.

Related factors :

• Activity intolerance.
• Decreased strength and endurance.
• Pain and discomfort.
• Perceptual or cognitive disorders.
• Neuromuscular disorders.
• Depression.
• Severe anxiety.

Potential Disuse Syndrome

Definition

A state of someone who is at risk to suffer damage as a result of the body's systems of musculoskeletal inactivity recommended by the physician or unavoidable.

Risk factors :

• Paralysis
• Mechanical immobilization
• Immobilization recommended by the doctor
• severe pain
• Changes in level of consciousness

Activity Intolerance

Definition

A state of energy insufficiency in physiological or psychological on a person to survive or complete activities of daily living is needed or desired.

Defining characteristics :

• Verbal report of fatigue or weakness.
• Heart rate or blood pressure is not normal to the activity.
• Discomfort or dyspnea after the move.
• Electrocardiographic changes indicating the presence of dysrhythmias or ischemia.

Related factors :
Bed rest and immobility
General weakness
Sedentary lifestyle
Imbalance between oxygen supply and requirement


Internal Factors

Various internal factors resulted in the immobilization of the body or body parts. Detailed discussion of internal factors which contribute to immobility can be found in the related chapters in this text.

Internal factors that cause or contribute to the immobilization

• Musculoskeletal function decline
• Muscles (atrophy, dystrophy, or injury)
• Bones (fractures infection, tumor, osteoporosis, or osteomalacia)
• Joints (arthritis and tumors)
• Combination structure (and cancer drugs)

Changes in neurological function

• Infection (eg, ensevalitis)
• Tumor
• Trauma
• Drugs
• Vascular disease (eg, stroke)
• Demyelinating disease (eg, multiple sclerosis)
• Degenerative diseases (eg, Parkinson's disease)
• Exposure to toxic products (eg, carbon monoxide)
• Metabolic disorders (eg, hypoglycemia)
• Nutrition disorders

Pain

• Multiple and varied causes such as chronic illness and trauma

Perceptual deficits

• Excess or shortage of input sensory perception

Reduced ability cognitive
Koqnitif process disturbances, such as severe dementia

Fall

• Physical effects: injury or fracture
• Psychological effects: syndrome after fall

Changes in social relations

• Actual factors (eg, loss of a spouse, moving away from family, or friends)
• Perceptual factors (eg, change of mindset as depression)

Psychological aspects

• Helplessness in learning.
• Depression

External Factors

Many external factors that alter the mobility of the elderly. These include therapeutic program, the characteristics of residence and staff, nursing care delivery systems, barriers, and institutional policies.

1.) Therapeutic program
Medical treatment program has a strong influence on the quality and quantity of patient movement. Examples of programs include restrictions on mechanical factors and pharmacological, bed rest, and restrein.
2.) Occupant characteristics Institutions
Mobility levels and patterns of behavior of a group of peers may affect client mobility patterns and behavior.
3.) characteristics of staff
Three characteristics of the nursing staff is affecting the mobility patterns of knowledge, commitment, and the amount.
4.) Nursing care delivery systems
Type of nursing care delivery system in use at the institution can affect the mobility status of its inhabitants.
5.) Barriers
Physical and architectural barriers can interfere with mobility. Physical barriers include the lack of available tools for mobility, knowledge in the use of mobility aids inadequate for foot rest.
6.) Institutional policies
Another important environmental factor for Lasia are the policies and procedures of the institution.

Theories of Aging Process (Biology, Sociology and Psychology)

Theories of Aging Process (Biology, Sociology and Psychology)

Geriatric Nursing  

Theories of Aging Process : Biology

1. Theory "Genetic Clock"

This theory states that occur as a result of the aging process at the genetic program inside nuclei. This clock will spin in a certain period of time and if the clock has run out of rotation then, would impede the process of mitosis. This is demonstrated by the results of the study Haiflick, (1980) cited Darmojo and Martono (1999) on the theory that stated the relationship between the ability of cells to divide in culture with somatic mutation of species age (error catastrophe theory) Another important thing to consider in analyzing factors actor is the cause of the aging process of the environmental factors that cause the occurrence of somatic mutations. It is now known that radiation and chemicals can shorten the life. According to this theory that progressive mutations in somatic cell DNA, will cause a decline in the ability of these cells functionally.

2. Theory "Error"

One hypothesis is that associated with somatic cell mutations are hypothesized "Error castastrophe" (Darmojo and Martono, 1999). According to the theory of aging caused by accumulated an assortment of errors throughout the human life. As a result of these errors will result in errors of metabolism that can cause cell damage and cell function slowly.

3. The theory of "autoimmune"

Aging process may occur due to changes in post-translational protein which can result in reduced ability of the body's immune system to recognize - self recognition. If the somatic mutation causes abnormalities in the cell surface, then this will result in the body's immune system considers cells undergoing changes as foreign cells and destroy Goldstein (1989) quoted by Aziz (1994). This is evidenced by the rising prevalence of auto-antibodies in the elderly (Brocklehurst, 1987 quoted from Darmojo and Martono, 1999). On the other hand the body's own immune system defenses decreased in the aging process, the antigen being attacked to decrease, resulting in pathological cells increases with age menigkatnya (Suhana, 1994 dikutif of Nuryati, 1994)

4. Theory "Free Radical"

Aging can occur due to the interaction of the components of free radicals in the human body. Free radicals can be: superoxide (O2), Hydroxyl radicals (OH) and hydrogen peroxide (H2O2). Free radicals are very damaging because it is highly reactive, so it can react with DNA, proteins, and unsaturated fatty acids. According Oen (1993) dikutif of Darmojo and Martono (1999) states that the older the age of the more free radicals are formed, so that poses destruction continues, the more damage cell organelles cells eventually die.

5. Wear & Tear Theory

Excess effort and stress cause the damaged body cells.

6. Collagen Theory 

Increase the amount of collagen in the tissue causing tissue damage and slowing the speed of repair tissue cells.


Theories of Aging Process : Sociology

1. Activity theory
Aging will cause a decrease in the number of activities directly.

2. Continuity theory
Continued existence of a personality that led to the existence of a pattern of behavior that increase stress.

3. Disengagement Theory
Lose touch with the outside world such as community relations, relationships with other individuals.

4. Age stratification theory
Because the people who fall in old age will accelerate the aging process.


Theories of Aging Process : Psychology

1. Maslow's theory of human needs
People who can reach 5% actualization according to research and not everyone can achieve that requirement perfectly.

2. Jung's theory
There are levels of living which has the task in the development of life.

3. Course of Human Life Theory
A person in relation to the environment is no maximum level.

4. Development Task Theory
Each stage of life has age-appropriate developmental tasks.

Imbalanced Nutrition related to Hyperemesis Gravidarum

Imbalanced Nutrition related to Hyperemesis Gravidarum

Obstetrical Nursing  

Nursing Care Plan for Hyperemesis Gravidarum - Nursing Diagnosis : Imbalanced Nutrition: less than body requirements

Hyperemesis Gravidarum

Nausea and vomiting (emesis gravidarum) is a natural phenomenon and is often caught in the first trimester of pregnancy. Nausea usually occurs in the morning, but can arise at any time and at night. These symptoms occur approximately 6 weeks after the first day of the last menstrual period and lasts for approximately 10 weeks. Nausea and vomiting occur in 60-80% primi gravida and 40-60% multi gravida. One in every thousand pregnancies, these symptoms become more severe.

Nausea is largely attributable because of increased levels of estrogen and HCG (Human Chorionic Gonadrotropin) in serum. Physiological effect of the hormone increase is not clear, probably because the central nervous system or the gastric emptying of the stomach is reduced. In general, women can adapt to this situation, though symptoms of severe nausea and vomiting that can last up to 4 months. Daily work was interrupted, and the general condition became worse. This condition is called hyperemesis gravidarum. Complaints of symptoms and physiological changes determine the severity of the disease. (Prawirohardjo, 2002)

Hyperemesis gravidarum is defined as excessive vomiting or uncontrolled during pregnancy, which causes dehydration, electrolyte imbalance, or nutritional deficiencies, and weight loss. The incidence of this condition is approximately 3.5 per 1000 births. Although most cases of missing and disappeared over time, one out of every 1,000 pregnant women will undergo hospitalization. Hyperemesis gravidarum usually disappear on their own (self-limiting), but healing is slow and frequent relapses are common. The condition often occurs among primigravida women and tends to recur in subsequent pregnancies. (Lowdermilk, 2004).


Nursing Diagnosis for Hyperemesis Gravidarum : Imbalanced Nutrition: less than body requirements related to excessive frequency of nausea and vomiting.

Nursing Intervention for Hyperemesis Gravidarum

1. Limit oral intake until the vomiting stops.
R /: Maintain electrolyte fluid balance and prevent further vomiting.

2. Give anti-emetic drugs are prescribed at low doses.
R /: Preventing vomiting and maintain fluid and electrolyte balance.

3. Maintain fluid therapy is programmed.
R /: Correct the hypovolemia and electrolyte balance.

4. Record intake and output.
R /: Determining hydration fluids through vomiting and spending.

5. Anjurjan eat small meals but often.
R /: Can adequate intake of nutrients your body needs.

6. Instruct to avoid fatty foods.
R /: to stimulate nausea and vomiting.

7. Instruct the patient to eat a snack such as biscuit, bread and hot tea before getting out of bed during the day and before bed.
R /: Food distraction can reduce or avoid excessive excitatory nausea vomiting.

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

9. Inspection of an irritation or lesions in the mouth.
R /: To determine the integrity of the oral mucosa.

10. Assess oral hygiene and personal hygiene as well as the use of oral cleaning fluids as often as possible.
R /: To maintain the integrity of the oral mucosa.

11. Monitor hemoglobin and hematocrit.
R /: Identify the potential anemia and decreased oxygen-carrying capacity of the mother.

12. Test urine for acetone, albumin and glucose.
R /: Establish baseline data; performed routinely to detect potential high-risk situations such as the inadequate intake of carbohydrate, diabetic and hypertension due to pregnancy ketoasedosis.

13. Measure uterine enlargement.
R /: Malnutrition affects maternal fetal growth and aggravate komplemensel decrease in fetal brain, resulting in deterioration of fetal development and the possibilities further.

Ineffective Tissue perfusion : peripheral related to Atherosclerosis

Ineffective Tissue perfusion : peripheral related to Atherosclerosis

Nursing Diagnosis and Interventions  

Atheroscleros is when the inside of the arteries are thickened, hardened and stiffened, causing the space for blood flow to be narrowed or closed. This will decrease the oxygen supply to local or distant tissues.

Atherosclerosis is a disease of the arterial blood vessels (arteries), in which the walls of the blood vessels become thickened and hardened by "plaques." The plaques are composed of cholesterol and other lipids, inflammatory cells, and calcium deposits.

Cause:

• Coronary Artery Disease -loss of blood to areas of the heart
• Stroke -loss of blood to areas of the brain
• Peripheral Vascular Disease -characterized by leg pain with walking

Symptoms depend on which arteries are affected. For example:

• Coronary (heart) arteries-may cause symptoms of heart disease, such as chest pain
• Arteries in the brain-may cause symptoms of a stroke such as weakness or dizziness
• Arteries in the lower extremities-may cause pain in the legs or feet and trouble walking

Ineffective Tissue perfusion : peripheral

Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Defining Characteristics:

• Edema;
• positive Hoeman's sign;
• altered skin characteristics (hair, nails, moisture);
• weak or absent pulses;
• skin discolorations;
• skin temperature changes;
• altered sensations;
• diminished arterial pulsations;
• skin color pale on elevation, color does not return on lowering the leg;
• slow healing of lesions; cold extremities;
• dependent, blue, or purple skin color

Nursing Diagnosis for Atherosclerosis : Ineffective Tissue perfusion : peripheral related to circulation disorders.

Goal: demonstrate improved perfusion

Outcomes: a peripheral pulse, skin color and temperature is normal, the increase behaviors that increase tissue perfusion.

Nursing Interventions and Rational:

1. Observation of the affected part of skin color.
R /: Skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; skin changes (colorless, shiny / tense).
R /: These changes indicate progress or chronic process.

3. View and examine the skin for ulceration, lesions, areas of gangrene.
R /: Lesions can occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue.

4. Push the right nutrients and vitamins.
R /: The balance of a good diet includes protein and adequate hydration, necessary for healing.

5. Monitior signs of tissue perfusion adequacy.
R /: To know the early signs of impaired perfusion.

6. Encourage the patient performs the exercises, or exercises gradually extremities.
R /: For circulation.

Risk for Infection related to Premature Rupture of Membranes

Risk for Infection related to Premature Rupture of Membranes

Risk for Infection  

Nursing Care  Plan for Premature Rupture of Membranes

Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins. If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of membranes (PPROM).

PROM occurs in about 8 to 10 percent of all pregnancies. PPROM (before 37 weeks) accounts for one fourth to one third of all preterm births.

The management of PPROM is among the most controversial issues in perinatal medicine. Points of contention include:

• Expectant management versus intervention
• Use of tocolytics
• Duration of administration of antibiotic prophylaxis
• Timing of administration of antenatal corticosteroids
• Methods of testing for maternal/fetal infection
• Timing of delivery.

Risk Factors and Causes:

Certain types of infections appear to be able to cause preterm PROM, and in rare cases procedures such as amniocentesis can cause PROM, but researchers do not believe there is a single cause of the condition. The following are some known risk factors:

• Lower socioeconomic status
• history of PPROM
• bleeding during pregnancy
• Smoking
• Prior preterm birth
• Sexually transmitted diseases
• Multiple pregnancy
• Polyhydramnios

The following are the most common symptoms of PROM. However, each woman may experience symptoms differently. Symptoms may include:

• Leaking or a gush of watery fluid from the vagina
• Constant wetness in underwear

If you notice any symptoms of PROM, be sure to call your doctor as soon as possible. The symptoms of PROM may resemble other medical conditions. Consult your doctor for a diagnosis.


Nursing Diagnosis for Premature Rupture of Membranes : Risk for Infection related to invasive procedures, recurrent vaginal examination, and amniotic membrane rupture.

Goal: maternal infection does not occur

Expected outcomes: Mother states / shows are free of any signs of infection.

Nursing Interventions for Premature Rupture of Membranes:

1. Perform initial vaginal examination, when the contraction pattern repeat, or maternal behavior indicates progress.
R /: Repeated vaginal examinations play a role in the incidence of ascending tract infections.

2. Monitor temperature, pulse, respiration, and white blood cells as indicated.
R /: Within 4 hours after membrane rupture, chorioamnionitis incidence increased progressively in accordance with the time indicated by vital signs.

3. Give prophylactic antibiotics when indicated.
R /: Antibiotic may protect against the development of chorioamnionitis in women at risk.

Disturbed Sleep Pattern related to Alzheimer's Disease

Disturbed Sleep Pattern related to Alzheimer's Disease

Nursing Diagnosis and Interventions  

Nursing Care Plan for Alzheimer's Disease - Nursing Diagnosis : Disturbed Sleep Pattern

Alzheimer's disease is the most common form of dementia. Dementia is a group of symptoms associated with a decline in the way the brain functions, affecting the memory and the way behave. There is no cure for the disease, which worsens as it progresses, and eventually leads to death. Early symptoms are often mistakenly thought to be 'age-related' concerns, or manifestations of stress. In the early stages, the most common symptom is difficulty in remembering recent events.

As the disease advances, symptoms can include confusion, irritability, aggression, mood swings, trouble with language, and long-term memory loss. As the sufferer declines they often withdraw from family and society. Gradually, bodily functions are lost, ultimately leading to death. Since the disease is different for each individual, predicting how it will affect the person is difficult. AD develops for an unknown and variable amount of time before becoming fully apparent, and it can progress undiagnosed for years.

The cause and progression of Alzheimer's disease are not well understood. Research indicates that the disease is associated with plaques and tangles in the brain. There are no available treatments that stop or reverse the progression of the disease.

Because AD cannot be cured and is degenerative, the sufferer relies on others for assistance. The role of the main caregiver is often taken by the spouse or a close relative. Alzheimer's disease is known for placing a great burden on caregivers; the pressures can be wide-ranging, involving social, psychological, physical, and economic elements of the caregiver's life. In developed countries, AD is one of the most costly diseases to society.

Disturbed Sleep Pattern

Time-limited disruption of sleep (natural periodic suspension of consciousness)

Defining Characteristics:

• Prolonged awakenings;
• sleep maintenance insomnia;
• self-induced impairment of normal pattern;
• sleep onset >30 minutes;
• early morning insomnia;
• awakening earlier or later than desired;
• verbal complaints of difficulty falling asleep;
• verbal complaints of not feeling well-rested;
• increased proportion of Stage 1 sleep;
• dissatisfaction with sleep;
• less than age-normed total sleep time;
• three or more nighttime awakenings;
• decreased proportion of Stages 3 and 4 sleep (e.g., hyporesponsiveness, excess sleepiness, decreased motivation);
• decreased proportion of REM sleep (e.g., REM rebound, hyperactivity, emotional lability, agitation and impulsivity, atypical polysomnographic features);
• decreased ability to function

Nursing Diagnosis for Alzheimer's Disease : Disturbed Sleep Pattern related to changes in sensory

Goal: changes in sleep patterns can be resolved client

Outcomes:

• No changes in behavior and appearance (restless).
• Able to create adequate sleep patterns with a decrease of the mind hovering (daydreaming).
• Able to determine the cause of inadequate sleep.

Nursing Interventions:

1. Provide a comfortable environment for improving sleep (turn off the lights, ventilation adequate space, suitable temperature, avoid noise).
R /: Constraints on cortical reticular information will be reduced during sleep, improving the automatic response, thus increasing cardiovascular response to noise during sleep.

2. Encourage exercise during the day and lower mental activity / physical in the afternoon.
R /: Physical activity and mental fatigue that lead to long can increase confusion, which is programmed activities without excessive stimulation increased sleep time.

3. Give afternoon snacks, warm milk, bath, and massage the patient's back.
R /: Improve relaxation with drowsiness.

4. Lower the number of drinks the afternoon. Voiding before bed.
R /: Reduce the need for up to urinate during the night.

5. Encourage clients to listen to soft music.
R /: Lowering the sensory stimulation by blocking other sounds from the surrounding environment that would inhibit sleep.

Acute Pain related to Atherosclerosis

Acute Pain related to Atherosclerosis

Nursing Diagnosis and Interventions  

Nursing Care Plan for Atherosclerosis - Nursing Diagnosis : Acute Pain

Atherosclerosis is an inflammation in human blood vessels, which caused accumulation of atheromatous plaque.

Atherosclerosis (also known as arteriosclerotic vascular disease or ASVD) is a specific form of arteriosclerosis in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol and triglyceride.

Atherosclerosis is a chronic disease that remains asymptomatic for decades. Atherosclerotic lesions, or atherosclerotic plaques are separated into two broad categories: Stable and unstable (also called vulnerable).

Clinically, atherosclerosis is typically associated with men over the age of 45. Sub-clinically, the disease begins to appear at early childhood, and perhaps even at birth. Noticeable signs can begin developing at puberty. Though symptoms are rarely exhibited in children, early screening of children for cardiovascular diseases could be beneficial to both the child and his/her relatives.


Acute Pain

Definition : Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months (NANDA)

Defining Characteristics:

Subjective

Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).

Objective

Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.


Nursing Diagnosis for Atherosclerosis : Acute Pain related to impaired ability of blood vessels to supply oxygen to the tissues.

Having given nursing care, is expected to decrease pain, with outcomes: patient states; chest pain disappear or be in control, the patient does not seem grimace, demonstrate relaxation techniques.

Nursing Intervention

1. Monitor the characteristics of pain through verbal response, and hemodynamics (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
R /: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

2. Assess the picture of pain experienced by patients include: place, intensity, duration, quality, and distribution.
R /: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other diseases, so we get accurate data.

3. Provide a comfortable environment, reduce the activity, limit visitors.
R /: Helps reduce external stimuli that can add to the tranquility so that the patient can rest and the heart does not work too hard.

4. Teach relaxation techniques with a deep breath
R /: Helps relieve pain experienced by the patient psychologically which can distract the patient that is not focused on the pain experienced.

5. Observation of vital signs before and after drug administration.
R /: They can cause respiratory depression and hypotension.

Ineffective Breathing Pattern related to Pleural Effusion

Ineffective Breathing Pattern related to Pleural Effusion

Pulmonary Nursing  

Nursing Care Plan for Pleural Effusion - Nursing Diagnosis : Ineffective Breathing Pattern

Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is present in the pleura.

Some of the more common causes are:

• Congestive heart failure
• Pneumonia
• Liver disease (cirrhosis)
• End-stage renal disease
• Nephrotic syndrome
• Cancer
• Pulmonary embolism
• Lupus and other autoimmune conditions

Other less common causes of pleural effusion include:

• Tuberculosis
• Autoimmune disease
• Bleeding (due to chest trauma)
• Chylothorax (due to trauma)
• Rare chest and abdominal infections
• Asbestos pleural effusion (due to exposure to asbestos)
• Meig’s syndrome (due to a benign ovarian tumor)
• Ovarian hyperstimulation syndrome

Symptoms of pleural effusion include:

• Chest pain
• Dry, nonproductive cough
• Dyspnea (shortness of breath, or difficult, labored breathing)
• Orthopnea (the inability to breathe easily unless the person is sitting up straight or standing erect)

Ineffective Breathing Pattern

Definition : Inspiration and/or expiration that does not provide adequate ventilation

Defining Characteristics :

• Accessory muscle use
• Abnormal heart rate response to activity
• Altered respiratory rate or depth or both
• Assumption of 3-point position
• Decreased minute ventilation
• Decreased vital capacity
• Decreased tidal volume
• Dyspnea
• Nasal flaring
• Prolonged expiratory phase
• Pursed lip breathing

Nursing Diagnosis for Pleural Effusion : Ineffective Breathing Pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, inflammatory process.

Possibility evidenced by:

• dyspnoea, 
• tachypnea, 
• respiratory depth changes, 
• use of accessory muscles, 
• impaired development of the chest, 
• cyanosis, 
• abnormal blood gas analysis.

Goal: Effective breathing pattern

Outcomes:

• Showed normal breathing pattern / effective with normal blood gas analysis.
• Free cyanosis and signs of hypoxia symptoms.

Nursing Intervention:

1. Identify the etiology or trigger factor.
2. Evaluation of respiratory function (rapid breathing, cyanosis, changes in vital signs).
3. Auscultation of breath sounds.
4. Note the position of the trachea and chest development, review fremitus.
5. Maintain a comfortable position is usually the head of the bed elevated.
6. Give oxygen via cannula / mask
7. When the chest tube is installed:
   • check the vacuum controller, liquid limit.
   • Observation of air bubbles bottle container.
   • Hose clamp on the bottom of the drainage in the event of a leak.
   • Keep an eye on the ebb and flow of water reservoir.
   • Note the character / number of chest tube drainage.

Deficient Knowledge related to Herniated Nucleus Pulposus

Deficient Knowledge related to Herniated Nucleus Pulposus

Nursing Diagnosis and Interventions  

Nursing Care Plan for Herniated Nucleus Pulposus - Nursing Diagnosis : Deficient Knowledge

Definition
A herniated disc is a fragment of the disc nucleus which is pushed out of the outer disc margin, into the spinal canal through a tear or "rupture." In the herniated disc's new position, it presses on spinal nerves, producing pain down the accompanying leg. This produces a sharp, severe pain down the entire leg and into the foot. The spinal canal has limited space which is inadequate for the spinal nerve and the displaced herniated disc fragment.

The compression and subsequent inflammation is directly responsible for the pain one feels down the leg, termed "sciatica." The direct compression of the nerve may produce weakness in the leg or foot in a specific patter, depending upon which spinal nerve is compressed.

A herniated disc is a definite displaced fragment of nucleus pushed out through a tear in the outer layer of the disc (annulus). For a disc to become herniated, it typically is in an early stage of degeneration.


Deficient Knowledge

Absence or deficiency of cognitive information related to a specific topic

Defining Characteristics:

• Verbalization of the problem;
• inaccurate follow-through of instruction;
• inaccurate performance of test;
• inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Nursing Diagnosis for Herniated Nucleus Pulposus : Deficient Knowledge : about the condition, prognosis and actions related to misinformation, misinterpretation, given the lack of information, not to know the sources of information.

Goal: The Client acknowledges, understands, about the condition, prognosis and actions to be taken.

Outcomes:

• Clients can express understanding of the condition, prognosis and action.
• Doing back lifestyle changes.
• Participate in the rule action.

Nursing Interventions:

1). Describe the process of disease and prognosis as well as restrictions on activities such as driving a vehicle in avoiding long periods of time.

2). Provide information about a variety of things as well as instruct patients to make changes "body dynamics" without the help and also do exercises including information about its own body mechanics to stand, lift and use of ancillary shoes.

3). Discuss the treatment and some side effects.

4). Suggest to use the board / mat hard. Small pillows were a little flat in the bottom of the neck, side sleeping position with knees flexed avoid prone.

5). Discuss dietary needs.

6). Avoid the use of heating preformance long time.

7). Refer back to the use of a soft neck collar.

8). Suggest to conduct regular medical evaluation.

9). Provide information about signs that need to be reported at the next evaluation as puncture pain, loss of sensation / ability to walk.

10). Assess the likelihood to alternative treatments such as chemonucleolysis, surgical intervention.

Disturbed Sensory Perception (visual) related to Glaucoma

Disturbed Sensory Perception (visual) related to Glaucoma

Nursing Diagnosis and Interventions  

Nursing Care Plan for Glaucoma - Nursing Diagnosis : Disturbed Sensory Perception (visual)

Glaucoma is a group of eye disorders leading to progressive damage to the optic nerve, and is characterized by loss of nerve tissue resulting in loss of vision. The optic nerve is a bundle of about one million individual nerve fibers and transmits the visual signals from the eye to the brain. The most common form of glaucoma, primary open-angle glaucoma, is associated with an increase in the fluid pressure inside the eye. This increase in pressure may cause progressive damage to the optic nerve and loss of nerve fibers. Vision loss may result. Advanced glaucoma may even cause blindness. Not everyone with high eye pressure will develop glaucoma, and many people with normal eye pressure will develop glaucoma. When the pressure inside an eye is too high for that particular optic nerve, whatever that pressure measurement may be, glaucoma will develop.

Glaucoma is the leading cause of blindness among Hispanics.

There are many types of glaucoma and many theories about the causes of glaucoma. The exact cause is unknown. Although the disease is usually associated with an increase in the fluid pressure inside the eye, other theories include lack of adequate blood supply to the nerve.

Disturbed Sensory Perception

Disturbed Sensory Perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)

Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Defining Characteristics:

• Poor concentration;
• auditory distortions;
• change in usual response to stimuli;
• restlessness;
• reported or measured change in sensory acuity;
• irritability;
• disoriented in time, in place, or with people;
• change in problem-solving abilities;
• change in behavior pattern;
• altered communication patterns;
• hallucinations;
• visual distortions

Nursing Diagnosis for Glaucoma : Disturbed Sensory Perception (visual) related to impaired sensory reception: impaired organ status.

Goal: The use of optimum vision.

Outcomes:

• Maintain visual acuity field without further loss.

Nursing Interventions :


1. Make sure the degree or type of vision loss.
R /: Affect and the patient's expectations of future intervention options.

2. Encourage the patient to express feelings of loss / likely loss of vision.
R /: While early intervention to prevent blindness, patients face the possibility of experience or experience partial or total vision loss. Although vision loss has occurred can not be repaired (although with treatment), deprived of further preventable.

3. Show giving eye drops, droplets counting example, follow a schedule, not one dose.
R /: Controlling IOP, prevent further vision loss.

Deficient Fluid Volume related to Diabetic Ketoacidosis

Deficient Fluid Volume related to Diabetic Ketoacidosis

Nursing Diagnosis and Interventions  

Nursing Care Plan for Diabetic Ketoacidosis - Nursing Diagnosis : Deficient Fluid Volume

Diabetic ketoacidosis is a state of emergency or acute Type I diabetes, is caused by the increased acidity of the body of ketone bodies due to deficiency or insulin deficiency, characterized by hyperglycemia, acidosis, and ketones due to a lack of insulin (Stillwell, 1992).

Diabetic ketoacidosis is often the first sign of type 1 diabetes in people who do not yet have other symptoms. It can also occur in someone who has already been diagnosed with type 1 diabetes. Infection, injury, a serious illness, missing doses of insulin, or surgery can lead to diabetic ketoacidosis in people with type 1 diabetes.

Most cases of diabetic ketoacidosis occur in people with type 1 diabetes, although it can also be a complication of type 2 diabetes.

Symptoms of diabetic ketoacidosis include:

• Deep, rapid breathing
• Dry skin and mouth
• Flushed face
• Fruity smelling breath
• Nausea and vomiting
• Stomach pain

Deficient Fluid Volume

Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level)

Defining Characteristics:

• Decreased urine output;
• increased urine concentration;
• weakness;
• sudden weight loss (except in third-spacing);
• decreased venous filling;
• increased body temperature;
• decreased pulse volume/pressure;
• change in mental state;
• elevated hematocrit;
• decreased skin/tongue turgor;
• dry skin/mucous membranes;
• thirst;
• increased pulse rate;
• decreased blood pressure

Nursing Diagnosis for Diabetic Ketoacidosis : Deficient Fluid Volume related to excessive secretion of fluid (osmotic diuresis) due to hyperglycemia

Outcomes:

• Vital signs within normal limits
• Peripheral pulse can be palpated
• Skin turgor and capillary refill good
• Balance urine output
• Normal electrolyte levels

Nursing Intervention:

• Observation of input and output of fluids every hour.
• Observation drip infusion.
• Monitor vital signs and level of consciousness every 15 minutes, if stable continue for every hour.
• Observation of skin turgor, mucous membranes, acral, capillary refill
• Monitor results of laboratory tests: hematocrit, BUN / creatinine, blood osmolarity, sodium, potassium.
• EKG monitor.
• CVP monitoring (when used).
• Collaboration with other health team:
• Parenteral fluid administration : Giving insulin therapy, Catheter urine, CVP installation if possible

Impaired Physical Mobility related to Herniated Nucleus Pulposus

Impaired Physical Mobility related to Herniated Nucleus Pulposus

Nursing Diagnosis and Interventions  

Nursing Care Plan for Herniated Nucleus Pulposus - Nursing Diagnosis : Impaired Physical Mobility

HNP, or a herniated nucleus pulposus, is the more medically oriented term for what most people refer to as a “herniated disc.” The nucleus pulposus is the gel-like inner material found within the thick, outer wall of each intervertebral disc, which are soft, sponge-like bodies responsible for providing support and flexibility along the entire length of the spine. Due to the gradual deterioration of these discs over time as part of the natural aging process, these discs develop a tear and the nucleus pulposus can push through the disc wall and extrude into the spinal canal – a condition known as a herniated nucleus pulposus.


Impaired Physical Mobility

A limitation in independent, purposeful physical movement of the body or of one or more extremities

Defining Characteristics:

• Postural instability during performance of routine activities of daily living (ADLs);
• limited ability to perform gross motor skills;
• limited ability to perform fine motor skills;
• uncoordinated or jerky movements;
• limited range of motion;
• difficulty turning;
• decreased reaction time;
• movement-induced shortness of breath;
• gait changes (e.g., decreased walking speed, difficulty initiating gait, small steps, shuffles feet, exaggerated lateral postural sway);
• engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on preillness/predisability);
• slowed movement;
• movement-induced tremor

Nursing Diagnosis for Herniated Nucleus Pulposus : Impaired Physical Mobility

related to pain and discomfort, muscle spasm restrictive therapy. For example: bed rest, neurovascular damage.
Goal: No impairment of physical mobility.

Outcomes:

• Clients expressed understanding of the situation / risk factors and individualized treatment rules.
• Demonstrate behavioral techniques.
• Maintain or improve the strength and function of body parts affected and or compensation.

Nursing Intervention:

1. Provide protective measures as indicated by the specific situation.
2. Note the emotional response / behavior on immobilization. Provide appropriate activities with patients.
3. Follow the activities / procedures with rest methods. Instruct the patient to participate in regular daily activities within individual limitations.
4. Help the patient to perform range of motion exercises active or passive.
5. Instruct the patient to train the lower leg / knee. Value of the edema, erytema the lower extremities.
6. Assist patients in performing activities of progressive ambulation.
7. Demonstrate the use of auxiliary equipment such as a walker, cane.
8. Provide good skin care, massage pressure points after each change of position. Check the state of the skin under the brace, with a specific time period.

Urinary Retention related to Benign Prostatic Hyperplasia (BPH)

Urinary Retention related to Benign Prostatic Hyperplasia (BPH)

Urinary Retention  

Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate. Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria, and bladder calculi.

BPH involves hyperplasia (an increase in the number of cells) rather than hypertrophy (a growth in the size of individual cells), but the two terms are often used interchangeably, even amongst urologists.

Urinary retention

Incomplete emptying of the bladder

Defining Characteristics:

Measured urinary residual >150 to 200 ml or 25% of total bladder capacity;
obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying);
irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia);
overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)


Nursing Care Plan for Benign Prostatic Hyperplasia (BPH)

Nursing Diagnosis : Urinary Retention related to mechanical obstruction, enlarged prostate, decompensated detrusor muscle.

Goal:

• Urination by a considerable amount, with no palpable bladder.
• Shows post-voiding residual of less than 50 ml in the absence of droplets / excess flow.

BPH Nursing Intervention and Rational:

1. Encourage clients to urinate every 2 to 4 hours.
R /: Minimizing excessive retention of urine in the bladder.

2. Observation of the flow of urine. Note the size of the force.
R /: Useful for evaluating obstruction and intervention options.

3. Supervise and record time, the number of each micturition. Note the decrease in spending and changes in urine specific gravity.
R /: Urinary retention increases the pressure in the upper urinary tract that can affect the kidneys.

4. Encourage drinking water to 3000 ml / day.
R /: Increased flow of fluid to maintain renal perfusion and kidney cleanse, bladder from bacterial growth.

5. Perform catheterization and perianal care.
R /: Reduce the risk of ascending infection.

Acute Pain related to Gastritis

Acute Pain related to Gastritis

Nursing Diagnosis and Interventions  

Nursing Care Plan for gastritis - Nursing Diagnosis : Acute Pain

Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter pylori, chronic bile reflux, and stress; certain autoimmune disorders can cause gastritis as well. The most common symptom is abdominal upset or pain. (wikipedia)

Acute Pain

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than less than 6 months.

Defining Characteristics:

Subjective

Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).

Objective

Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.


Nursing Diagnosis for Gastritis : Acute Pain related to inflammation of the mucosal lining of the stomach (gastric)

Goal: Pain is reduced with no inflammation or irritation of the gastric mucosa

Outcomes:

• Pain scale is reduced
• Do not feel pain in the epigastric.
• Not grimace (no abdominal tenderness)

Gastritis Nursing Interventions and Rational:

1. Record complaints of pain, including the location, duration, intensity (scale of 0-10)
R /: Pain is not always there, but if there is to be compared with the previous patient's symptoms of pain, which can help diagnose the etiology and occurrence of bleeding complications.

2. Review the factors that increase or decrease pain.
R /: Assist in making diagnoses and treatment needs.

3. Give food a little but often as an indication for patients.
R /: Food has the effect of neutralizing acid, also destroy the gastric contents. Eating little to prevent distension.

4. Assistive range of motion exercises active / passive.
R /: Reduce joint stiffness, pain minimize discomfort.

5. Provide frequent oral care and comfort measures (back massage, change of positions).
R /: Bad breath due to retained secretions, causing no appetite and can increase nausea. Gingivitis and dental problems can be improved.

6. Give medications as indicated.
R /: Lowering the acidity of gastric absorption or by neutralizing chemical.

Gastritis - Definition, Classification, Pathophysiology and Prevention

Risk for Impaired Skin integrity related to Diarrhea

Risk for Impaired Skin integrity related to Diarrhea

Risk for Impaired Skin integrity  

Diarrhea is a condition that is classified as the appearance of loose, watery stools and/or a frequent need to go to the bathroom.

Diarrhea may be related to a viral or bacterial infection and is sometimes the result of food poisoning. The condition commonly known as traveler’s diarrhea occurs when you’ve been exposed to bacteria or parasites while on vacation to developing countries. (healthline.com)


Impaired Skin integrity

Altered epidermis and/or dermis

Defining Characteristics:

• Invasion of body structures;
• destruction of skin layers (dermis);
• disruption of skin surface (epidermis)

Nursing Care Plan for Diarrhea - Nursing Diagnosis : Risk for Impaired Skin integrity :perianal related to increased frequency of bowel movements (diarrhea)

Goal: Impaired skin integrity is resolved

Outcomes:

• Integrity of the skin returns to normal
• No irritation

Interventions and Rational :

1. Assess skin damage / irritation every bowel movement.
R /: Knowing how much damage.

2. Discuss and explain the importance of keeping the beds.
R /: Environmental cleanliness and beds, can reduce the irritation and infection.

3. Demonstrate and involve families in caring for perianal (when wet, and dressed down as well as the base).
R /: Humid temperatures accelerate the irritation.

4. Adjust the position or sitting with 2-3 hour intervals.
R /: Position adjustment can help improve comfort.

Deficient Fluid Volume related to Diarrhea

Deficient Fluid Volume related to Diarrhea

Pediatric Nursing  

Nursing Care Plan for Diarrhea - Nursing Diagnosis : Deficient Fluid Volume


Diarrhea is the condition of having three or more loose or liquid bowel movements per day. The most common cause is gastroenteritis.

Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having more stools than is normal for that person.

Deficient Fluid Volume

Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level)

Defining Characteristics:

• Decreased urine output;
• increased urine concentration;
• weakness;
• sudden weight loss (except in third-spacing);
• decreased venous filling;
• increased body temperature;
• decreased pulse volume/pressure;
• change in mental state;
• elevated hematocrit;
• decreased skin/tongue turgor;
• dry skin/mucous membranes;
• thirst;
• increased pulse rate;
• decreased blood pressure

Nursing Diagnosis for Diarrhea : Deficient Fluid Volume related to frequent bowel movements

Goal:

• Fluid balance can be maintained within normal limits.
• Maintain adequate fluid volume.
• Fluid and electrolyte deficits can be resolved.

Outcomes:

• Mucous membranes moist
• Good skin turgor
• Input and output balanced

Diarrhea Nursing Interventions and Rational :

1. Observation of vital signs
R /: hypotension, tachycardia, fever may indicate a response to and / or the effects of fluid loss.

2. Observation for signs of dehydration.
Rapid population feces through the intestine reducing the absorption of low circulating volume of water causes mucous membrane dryness and thirst. Concentrated urine specific gravity has increased.

3. Appropriate laboratory examination program; electrolytes, hematocrit, pH, serum albumin.
R /: Determine the need and effectiveness of replacement therapy.
Give medications as indicated: Anti-diarrhea

4. Provision of appropriate fluid and electrolyte therapy program.
R /: Maintaining bowel rest will require replacement to correct fluid loss / anemia.

5. Administration of drugs as indicated.

Decreased Cardiac output related to Hypertension

Decreased Cardiac output related to Hypertension

Nursing Diagnosis and Interventions  

Nursing Care Plan for Hypertension - Nursing Diagnosis : Decreased Cardiac output



Hypertension is the term used to describe high blood pressure.

Blood pressure is a measurement of the force against the walls of your arteries as your heart pumps blood through your body.

Blood pressure readings are usually given as two numbers -- for example, 120 over 80 (written as 120/80 mmHg). One or both of these numbers can be too high.

The top number is called the systolic blood pressure, and the bottom number is called the diastolic blood pressure.

• Normal blood pressure is when your blood pressure is lower than 120/80 mmHg most of the time.
• High blood pressure (hypertension) is when your blood pressure is 140/90 mmHg or above most of the time.
• If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called pre-hypertension.(nlm.nih.gov)

Decreased Cardiac output

Inadequate blood pumped by the heart to meet metabolic demands of the body

Defining Characteristics:

• Altered heart rate/rhythm: arrhythmias (tachycardia, bradycardia);
• palpitations;
• EKG changes;
• altered preload:
• jugular vein distention;
• fatigue;
• edema;
• murmurs;
• increased/decreased central venous pressure (CVP);
• increased/decreased pulmonary artery wedge pressure (PAWP);
• weight gain;
• altered afterload: cold/clammy skin;
• shortness of breath/dyspnea;
• oliguria;
• prolonged capillary refill;
• decreased peripheral pulses;
• variations in blood pressure readings;
• increased/decreased systemic vascular resistance (SVR);
• increased/decreased pulmonary vascular resistance (PVR);
• skin color changes;
• altered contractility: crackles;
• cough;
• orthopnea/paroxysmal nocturnal dyspnea;
• S3 or S4 sounds;
• behavioral/emotional: anxiety;
• restlessness

Nursing Diagnosis for Hypertension : Decreased Cardiac output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy

Goal: Clients want to participate in activities that lower blood pressure / cardiac workload

Outcomes:

• Blood pressure within an acceptable range of individuals.
• Rhythm and heart rate stabilized in the normal range.

Hypertension Nursing Interventions and Rational :

1. Monitor your blood pressure . Measure in both arms / thighs for initial evaluation . Use the proper cuff size and accurate technique .
R / : Comparison of pressure gives a more complete picture of the involvement / field of vascular problems.

2 . Note the presence , quality of central and peripheral pulses .
R / : pulse on the carotid , jugular , radial and femoral probably observed / palpable . Pulse in the legs may be decreased , reflecting the effect of vasoconstriction ( increased SVR ) and venous congestion .

3 . Auscultation of the heart tone , and breath sounds .
R / : S4 commonly heard in patients with severe hypertension due to atrial hypertrophy ( increase in volume / pressure atrium ) . Development S3 , showed ventricular hypertrophy and malfunction . Cracles existence , wheezing may indicate pulmonary congestion secondary to the occurrence or chronic heart failure .

4 . Observe skin color , moisture , temperature , and capillary refill time .
R / : The pale , cool , moist skin and slow capillary refill time may be related to vasoconstriction or reflect decompensation / decrease in cardiac output .

5. Note the general edema / specific.
R /: May indicate heart failure, kidney or vascular damage.

6. Provide a quiet, comfortable, reduce, activity / environment commotion, limit the number of visitors and length of stay.
R /: Helps to reduce sympathetic stimulation; increase relaxation.

7. Maintain restrictions on activities, such as, resting in bed / chair; schedule rest periods without interruption; aids patients perform self-care activities as needed.
R /: Reduce stress and tension that affect blood pressure and hypertensive disease course.

8. Perform actions that comfortable, such as., Back and neck massage, elevating the head of the bed.
R /: Reduce discomfort and can reduce sympathetic stimulation.

9. Encourage relaxation techniques, manual imagination, vision activities.
R /: to reduce stress design, create a calming effect, so it will decrease blood pressure.

10. Monitor response to medication to control blood pressure.
R /: response to drug therapy "stepped" (which consisted of diuretics, sympathetic inhibitors, and vasodilators) depends on the individual and synergistic effects of the drug. Because of these side effects, it is important to use the drug in the least amount and lowest doses.

Deficient Knowledge related to Laparotomy

Deficient Knowledge related to Laparotomy

Surgical Nursing  

Nursing Care Plan for Laparotomy - Nursing Diagnosis : Deficient Knowledge


A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as celiotomy. (wikipedia)

Deficient Knowledge

Absence or deficiency of cognitive information related to a specific topic

Defining Characteristics:

• Verbalization of the problem;
• inaccurate follow-through of instruction;
• inaccurate performance of test;
• inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Nursing Diagnosis for Laparotomy : Deficient Knowledgerelated to lack of information, do not know the source of information.

Outcomes:

• Reveals an understanding of the disease process and treatment.

Interventions and Rational :

1. Review the procedure and postoperative expectations.
R /: To provide basic knowledge of where the patient can make an informed choice.

2. Discuss the importance of adequate fluid intake, dietary needs.
R /: Increases healing and normalization of bowel.

3. Demonstrate belutan wound care or appropriate.
R /: Increases healing, reduce the risk of infection, providing an opportunity to observe the wound.

4. Revisit gastrotomi hose care when the patient is discharged with this tool.
R /: Increase the independence, improve self-care skills.

5. Identify signs that require medical evaluation, fever settled, swelling, erythema, artau opening the wound edges, change drainage characteristics.
R /: Early recognition of complications and immediate intervention can prevent progression of the situation serious, life-threatening.

6. Encourage gradual increase in activity in accordance tolernsi and balance with adequate rest periods.
R /: Prevent fatigue, stimulate circulation and normalizing organ function, improve healing.

Anxiety related to Laparotomy

Anxiety related to Laparotomy

Surgical Nursing  

Nursing Care Plan for Laparotomy - Nursing Diagnosis : Anxiety


A laparotomy is a surgical incision (cut) into the abdominal cavity. This operation is performed to examine the abdominal organs and aid diagnosis of any problems, including abdominal pain. In many cases, the problem – once identified – can be fixed during the laparotomy. In other cases, a second operation is required. Another name for laparotomy is abdominal exploration.

Anxiety

A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat.

Defining Characteristics:

Behavioral

• Diminished productivity;
• scanning and vigilance;
• poor eye contact;
• restlessness;
• glancing about;
• extraneous movement (e.g., foot shuffling, hand/arm movements);
• expressed concerns resulting from change in life events;
• insomnia;
• fidgeting

Affective

• Regretful;
• irritability;
• anguish;
• scared;
• jittery;
• overexcited;
• painful and persistent increased helplessness;
• rattled;
• uncertainty;
• increased wariness;
• focus on self;
• feelings of inadequacy;
• fearful;
• distressed;
• apprehension;
• anxious

Physiological

• Voice quivering

Objective

• Trembling/hand tremors; insomnia

Subjective

• Shakiness; worried; regretful

Nursing Diagnosis for Laparotomy : Anxiety related to surgical procedure, preoperative procedures.

Outcomes:

• Patients will demonstrate the ability focus on new knowledge and skills.
• Identification of symptoms as an indicator of anxiety itself.
• Showed no aggressive behavior.
• Communicating and handling negative feelings appropriately.
• Relaxed and comfortable in the move.

Interventions and Rational :
1. Monitor patient's signs and symptoms of anxiety while nursing assessment.
R /: Assessment of patients with anxiety conditions carefully allows nurses to make nursing priorities.

2. Focus discussion on stressors that affect the condition of the patient.
R /: Focus discussion facilitates the ability of the patient to express fears and feelings are felt and build a therapeutic relationship.

3. Discuss the patient's perception will be a surgical procedure, the fear associated with the operation.
R /: Discussion will make the patient's perception and fear to express themselves and explore self-knowledge.

4. Provide information procedure before surgery, the patient's illness and surgery preparation
R /: Measures to increase knowledge and anxiety reduction.