Nursing Care Plan for Nausea and Vomiting

Nursing Care Plan for Nausea and Vomiting

Vomiting  

Nausea

Nausea is the sensation (feeling) issued a strong food or want to vomit. Usually accompanied by autonomic signs such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, nausea closely related to anorexia. Nausea caused by distention or irritation in any part of the gastrointestinal tract, but can also be stimulated by higher brain centers.

Nausea is a common symptom of digestive disorders, but may also occur in fluid and electrolyte imbalance, infection, metabolic disorders, endocrine, and cardiac maze. Can also be as a result of drug therapy, surgery, and radiation.

Nausea is also common in the first trimester of pregnancy, nausea can arise from intense pain, anxiety, alcohol poisoning, excessive food or digest food or drinks that do not taste good.


Definition of "Vomit" is a discharge of most or all of the stomach contents food into the stomach occurs after a while, accompanied by contraction of the stomach and abdomen. (Vivian Nanny Lia Dewi, 2010)

In a simple sense of Vomiting is spending the stomach contents through the mouth. Another understanding of the vomiting is a discharge of most or all of the stomach contents food into the stomach occurs after a while, with stomach and abdominal contractions. In the first few hours after birth, the baby may experience vomiting mucus, sometimes with a little blood. Vomiting is not uncommon to settle after breast feeding or food, the situation is probably due to irritation of the gastric mucosa by a number of objects that are ingested during childbirth.

Many causes that can lead to vomiting, namely:

• Virus infection
• Stress
• Gestation
• Drug
• Myocardial infarction
• Uremia
• Other conditions

Therapeutic Intervention

Nausea and vomiting are very few require intervention. However, if left unchecked will lead to dehydration and electrolyte imbalance. Loss of hydrochloric acid from the stomach can cause metabolic alkalosis. Vomiting black, like coffee, showed vomit mixed with blood. Protection of the airway during vomiting are the most important measures to prevent aspiration. Increased risk of aspiration in patients with loss of consciousness, the elderly, and the failure of reflexes. Place the patient in a comfortable position so that vomit out. Beating back while vomiting can lead to aspiration.


Nursing Process in Patients with Nausea and Vomiting

Assessment / data collection

1. Episodes of nausea and vomiting
2. Medical condition
3. Drugs consumed
4. Treatment is being done

Early signs of fluid loss:

1. Weakness
2. Headache
3. Not be able to concentrate
4. Postural hypotension

Further signs of fluid loss:

1. Confused
2. Oliguria
3. Skin cool and moist
4. Chest and abdominal pain

Nursing Diagnosis, Planning, and Implementation

1 . Nausea related to various causes

The desired result :

• Patients expressed no nausea and vomiting .
• Odor-free environment , clean so it does not cause nausea .

Interventions :

1. Give anti- emetic .
2. Oral care , to reduce emesis and increased comfort .
3. Explained to the patient to avoid foods that cause or may cause vomiting .

2 . Risk for aspiration related to decreased reflexes or penuruanan awareness

The desired result :

• Airway and lung sounds clean patient

Iintervention :

1. Assess whether the patient is in the risk for aspiration .
2. Place the patient in a position to prevent aspiration .

3 . Deficient Fluid Volume

The desired result :

• Patient's vital signs within normal limits .

Interventions :

1. Monitor for signs of hypovolemia to prevent any complications that may occur .
2. Measure body weight each day .
3. Monitor intake output , and vital signs , and vital signs , blood pressure ortohstatik .
4. Give fluids by IV .
5. Discharge monitoring during treatment to prevent deficit and excess fluid .

Evaluation

Patients showed no nausea, lung sounds clean and normal vital signs .

Imbalanced Nutrition : less than body requirements related to nausea and vomiting

Risk for Fluid Volume Deficit related to Vomiting

Definition and Causes of Congenital Talipes Equinovarus

Definition and Causes of Congenital Talipes Equinovarus

Congenital Talipes Equinovarus  

Definition of CTEV (Congenital talipes Equinovarus)

Congenital talipes Equinovarus (CTEV) or so-called Clubfoot is a common term used to describe a common deformity in which the legs changed from its normal position which is common in children. CTEV is covering flexion deformity of the ankle, inversion of the legs, adduction of the forefoot, and media rotation of the tibia (Priciples of Surgery, Schwartz). Talipes derived from the talus (ankle) and pes (foot), suggesting an abnormality in the leg (foot) which causes the sufferer to walk on his ankle. Equinovarus being derived from the word equino and varus (bent towards the inside / medial).

Congenital talipes Equinovarus is a foot deformity in line twisted heel leg and foot plantar flexion experience. This situation is accompanied with a higher edge in the foot (supination) and the shift of the anterior part of the foot so that it rests on the medial axis of the vertical leg (adduction). With this type of foot arch higher (cavus) and foot in an equinus (plantar flexion). Equino congenital talipes varus is a condition in which the foot in plantar flexion position talocranialis, because musculus tibialis anterior is weak, Inversion ankle because musculus peroneus longus, brevis and Tertius weak, subtalar and midtarsal Adduction.


Causes of Congenital talipes Equinovarus

1. Causes of Congenital talipes Equinovarus until now not known for sure but allegedly are associated with : Persistence of fetal positioning, Genetic, amniotic fluid in the amniotic too little during pregnancy (oligohydramnios), Neuromuscular disorder (sometimes found along with other abnormalities such as Spina bifida or dysplasia of the pelvis). There are several theories that may be linked to CTEV :
2. Chromosomal theory , among others : germinativum defect of cells that are not fertilized and appear before fertilization .
3. Embryonic theory , among others : primary defect that occurs in cells that fertilized germinativum (quoted from Irani and Sherman) which implies a defect occurs between conception and 12 weeks of pregnancy.
4. Autogenic theory, the theory of development is hampered, among other temporary barriers of development that occurs on or around the week of the 7th to the 8th gestation. At this time there is a clear clubfoot deformity, but when these obstacles occur after 9 weeks, there was a clubfoot deformity is mild to moderate. The development of the theory of constraints associated with changes in genetic factors, known as the "Cronon". "Cronon" This is the right time to guide the progressive modification of any structure of the body during development. Therefore, clubfoot occurs due to disruptive elements (local and general) that cause changes in genetic factors (cronon).
5. Fetus theory, namely the development of a mechanical block due to intrauterine crowding.
6. Neurogenic theory, the primary defect in neurogenic tissue.
7. Amiogenic theory, that the primary defect occurs in the muscle.
8. Edward syndrome, which is a genetic disorder of chromosome number 18.
9. Outside influences such as the emphasis on when the baby is still in the womb because at least the amniotic fluid (oligohydramnios)
10. Can be found along with other congenital abnormalities such as spina bifida.
11. Ecstasy use by the mother during pregnancy.

Impaired Verbal Communication related to Acute Tonsillitis

Impaired Verbal Communication related to Acute Tonsillitis

Impaired Verbal Communication  

Acute Tonsillitis

Tonsillitis is defined simply as the swelling of the tonsils, which are located in the throat, towards the back of the mouth.

Acute tonsillitis comes on quickly and can be caused by a variety of organisms, including viruses, group A beta-hemolytic streptococci (Strep throat)and other types of bacteria.

Acute tonsillitis is caused by both bacteria and viruses and will be accompanied by symptoms of ear pain when swallowing, bad breath, and drooling along with sore throat and fever. In this case, the surface of the tonsil may be bright red or have a grayish-white coating, while the lymph nodes in the neck may be swollen.


Signs of Acute Tonsillitis :

1. There is hyperaemia of pillars, soft palate and uvula.
2. Often the breath is foetid and tongue is coasted.
3. Tonsils are red and swollen with yellowish spots of purulent material presenting at the opening of crypts (acute follicular tonsillitis) or there may be a whitish membrane on the medial surface of tonsil which can be easily wiped away with a swab (acute membranous tonsillitis). The tonsils may be enlarged and congested so much so that they almost meet in
4. the midline along with some oedema of the uvula and soft palate (acute parenchymatous tonsillitis).
5. The jugulodigastric lymph nodes are enlarged and tender.

Symptoms of Acute Tonsillitis:

1. Sore throat.
2. Fever. It may vary from 38 to 40°C and may be associated with chills and rigors. Sometimes, a child presents with an unexplained fever and it is only on examination that an acute tonsillitis is discovered.
3. Difficulty in swallowing. The child may refuse to eat anything due to local pain.
4. Earache. It is either referred pain from the tonsil or the result of acute otitis media which may occur as a complication.
5. Constitutional symptoms. They are usually more marked than seen in simple pharyngitis and may include headache, general body aches, malaise and constipation. There may be abdominal pain due to mesenteric lymphadenitis simulating a clinical picture of acute appendicitis.

Nursing Care Plan for Acute Tonsillitis

Nursing Diagnosis: Impaired verbal communication related to the effects of damage to the area to talk to the brain hemispheres.

Goal:

• Patients are able to communicate to meet their basic needs and show improvement in their communication skills.

Interventions :

1. Do a personal communication with the patient (often but short and easy to understand).
2. Create an atmosphere of acceptance of the changes experienced by the patient.
3. Teach the patient to improve communication techniques.
4. Use non-verbal communication techniques.
5. Collaboration in the implementation of speech therapy.
6. Observation of the patient's ability to communicate in both verbal and non-verbal.

Nursing Care Plan for Tonsillitis

Nursing Care Plan Tonsillectomy

Nursing Interventions for Acute Tonsillitis

6 Trigger Factors of Migraine Attacks

6 Trigger Factors of Migraine Attacks

Migraine  

Cause of migraine is not known clearly, but this can lead to a primary vascular disorder that usually occurs in women, and many have a strong tendency in the family. Migraines are also caused by the occurrence of a combination of vasodilation (widening of blood vessels) and the release of a chemical substance from nerve fibers that surrounds the blood vessels. When a migraine attack, the temporal artery (the artery that runs around the temple) will be widened. The widening will cause stretching of the nerve fibers around arteries thus stimulating these nerve fibers to release chemicals. This substance will cause inflammation, pain and migraine incredible.

Various factors that can trigger a migraine attack is determined by the presence of hereditary biological defects in the central nervous system. Among others:

1. Hormonal
Hormonal fluctuations are the trigger factor. the presence of glucose increased only 14% of women had an attack during menstruation. Reduced migraine attacks during pregnancy because estrogen levels are relatively high and constant, contrary porspartum first week, 14% of patients experienced severe attack due to lower levels of extradition. Use of the contraceptive pill also causes the frequency of migraine attacks.

2. Menopause
Migraine generally will increase the frequency and severity at the time of menopause. However, some cases improved after menopause. Hormonal therapy with low-dose estrogen can be given to treat migraine attacks after menopause.

3. Food
Variety of foods / substances can trigger a migraine attack. Common migraine triggers are alcohol based vasodilatory effect, where wine and beer are strong triggers. Foods containing tyramine, an amino acid derived from thyroxine.

4. Monosodium Glutamate
Is the most common migraine triggers, namely: headache accompanied by anxiety, dizziness, parastesia and hands, as well as abdominal pain and chest pain.

5. Environment
Environmental changes in the body which include hormonal fluctuations in the menstrual cycle and hormonal changes can lead to getting out of bed acute migraine attacks. Changes in the external environment include the weather, season, air pressure, altitude, and late meals.

6. Sensory stimuli
Flashing light, glare, bright sunlight, or the smell of perfumes, cleaning chemicals, cigarettes, sura noise and extreme temperatures.