tag:blogger.com,1999:blog-45164897369549583012024-02-19T13:16:08.966+07:00Nursing NotesNurse Bloghttp://www.blogger.com/profile/13726903998974600056noreply@blogger.comBlogger136125tag:blogger.com,1999:blog-4516489736954958301.post-25652757119503883602015-01-29T22:04:00.001+07:002015-01-29T22:04:18.689+07:00Hyperthermia related to Cellulitis<b>Nursing Diagnosis and Interventions for Cellulitis</b> <br />
<br />
Cellulitis is an infection of the skin caused by bacteria. Cellulitis can be caused by bacteria and organisms that are normally present in the skin. Cellulitis usually happens when there is a disturbance that causes the previously exposed skin, such as cuts, burns, insect bites or surgical wound. Cellulitis can occur anywhere in the body, but the most common parts affected by cellulitis is a skin on the face and legs. Cellulitis can only attack the upper skin, but if not treated and the more severe infections, can spread to the blood vessels and lymph nodes.<br />
<br />
Early symptoms include redness and tenderness felt in a small area on the skin.<br />
Infected skin becomes hot and swollen, and looks like an orange peel peeling (peau d'orange).<br />
<br />
In the infected skin can be found a small fluid-filled blisters (vesicles) or a large fluid-filled blisters (bullae), which can rupture.<br />
<br />
Because of the infection spreading to a wider area, the nearby lymph nodes to swell and soft palpable. Lymph nodes in the groin enlarged due to infection in the leg, underarm lymph nodes enlarged due to infection in the arm. <br />
<br />
Patients may experience fever, chills, increased heart rate, headache and low blood pressure. Sometimes these symptoms occur several hours before other symptoms appear on the skin. But in some cases these symptoms did not exist. Sometimes it can arise abscess, as a result of cellulitis.<br />
<br />
<br />
<b>Nursing Diagnosis and Interventions for Cellulitis</b> <br />
<br />
<b>Hyperthermia</b> related to the process of infection / inflammation systemic.<br />
<br />
Goal : The client indicates a decrease in body temperature after nursing care.<br />
<br />
Expected outcomes :<br />
<ul>
<li>Vital signs within normal limits.</li>
<li>No fever.</li>
<li>Intake - output balance.</li>
</ul>
<br />
Intervention :<br />
<br />
1. Observation blood pressure body temperature, respiratory rate and pulse.<br />
Rational : indicates the status of the body circulation.<br />
<br />
2. Monitor intake and output every 8 hours.<br />
Rational : shows the hydration status.<br />
<br />
3. Encourage a lot of drinking in the absence of contraindications.<br />
Rational : replace body fluids lost due to an increase in the rate of metabolism.<br />
<br />
4. Maintain adequate ventilation in the room.<br />
<br />
5. Give a warm compress.<br />
Rationale: helps lower body temperature.<br />
<br />
6. Use a thin clothes and absorb sweat.<br />
Rational : provide comfort and speed up the process of decline in body temperature.<br />
<br />
7. Instruct the client to the total bedrest.<br />
Rational : excessive activity can increase the body's metabolism so that the temperature is increasing.<br />
<br />
Collaboration<br />
<br />
8. Maintain IV fluids according to the program.<br />
Rational : to support and expand the volume of circulation, especially if inadequate oral input.<br />
<br />
9. Give antipyretic therapy as recommended by your doctor.<br />
Rationale: helps reduce fever and response hypermetabolism, lowering fluid loss invisible.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-88648266251219577902015-01-22T10:42:00.000+07:002015-01-22T10:42:05.369+07:00Imbalanced Nutrition: Less Than Body Requirements related to Low Birth Weight<br />
<b>Nursing Care Plan for <a href="http://nandanursingdiagnoses.blogspot.com/2015/01/risk-for-ineffective-thermoregulation.html">Low Birth Weight</a></b><br />
<br />
Nursing Diagnosis : <a href="http://nandanursingdiagnoses.blogspot.com/2013/06/malaria-imbalanced-nutrition-less-than.html">Imbalanced Nutrition: Less Than Body Requirements </a>related to<br />
<ul>
<li>decrease nutrient deposits,</li>
<li>immaturity of enzyme production,</li>
<li>weak abdominal muscles,</li>
<li>weak reflexes.</li>
</ul>
Goal: nutrients are met as needed.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Babies get the calories and essential nutrients are adequate.</li>
<li>Maintain growth and weight gain in a normal curve with weight gain remains, at least 20-30 grams / day.</li>
</ul>
<br />
<br />
<b>Interventions :</b><br />
<br />
Independent:<br />
<ul>
<li>Assess maturity reflex, with regard to feeding (eg, sucking, swallowing, and cough).</li>
<li>Auscultation presence of bowel sounds, assess physical status and respiratory status.</li>
<li>Assess the weight by measuring body weight every day, then documented in infant growth charts.</li>
<li>Monitor the input and output. Calculate the consumption of calories and electrolytes every day.</li>
<li>Assess the level of hydration, note fontanelle, skin turgor, urine specific gravity, the condition of the mucous membranes, weight fluctuations.</li>
<li>Assess for signs of hypoglycemia; tachypnea and irregular breathing, apnea, lethargy, temperature fluctuations, and diaphoresis. Poor feeding, nervous, crying, high tone, trembling, eyes upside down, and seizure activity.</li>
</ul>
Collaboration:<br />
<ul>
<li>Monitor laboratory tests as indicated: serum glucose, blood urea nitrogen, creatinine, osmolality, serum / urine, urine electrolyte.</li>
<li>Give electrolyte supplements as indicated for example calcium gluconate 10%.</li>
</ul>
<br />
<b>Rationale :</b><br />
<br />
Independent:<br />
<br />
<ul>
<li>Determine the appropriate method of feeding for infants.</li>
<li>The first infant feeding stable has peristaltic can begin 6-12 hours after birth. If there is respiratory distress, parenteral fluids indicated, and oral fluid had to be postponed.</li>
<li>Identifying the risk and the degree of risk to growth patterns. SGA infants with excess extracellular fluid possibility of losing 15% of birth weight. SGA infants may have lost weight in the uterus or decrease fat deposits / glycogen.</li>
<li>Provide information about the actual input in conjunction with an approximate adjustment needs to be used in the diet.</li>
<li>Increased metabolic needs of SGA infants may increase fluid requirements. Infant state of hyperglycemia can lead to diuresis in infants. Intravenous fluids may be needed to meet increased demand, but must be carefully handled to avoid fluid overload.</li>
<li>Because glucose is the main source of fuel for the brain, deficiency can cause permanent damage to the CNS. Hypoglycemia significantly improve the mobility of mortality and severe effects of time dependent on the duration of each episode.</li>
</ul>
<br />
Collaboration:<br />
<ul>
<li>Hypoglycemia can occur in the early 3 hours of birth infants SGA when glycogen stores quickly reduced and gluconeogenesis inadequate because of a decrease in deposits of protein drugs and fat.</li>
<li>Detecting changes in renal function associated with a decrease in deposits of nutrients and fluid levels due to malnutrition.</li>
<li>Metabolic instability in SGA infants / LGA may require supplements to maintain homeostasis.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-11016257574593494022015-01-21T10:27:00.001+07:002015-01-21T10:30:22.959+07:00Risk for Ineffective Thermoregulation related to Low Birth Weight<br />
<b>Nursing Care Plan for Low Birth Weight</b><br />
<br />
<b>Nursing Diagnosis : Risk for Ineffective Thermoregulation</b><br />
<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEip-s14Skc701o0Svox6MNjfL16eWDBUsrT48fmkxhiQsNwIc37GxzjgMwp7hG_Gv_bTIDepfEGCemJCNmLq8IapK9kkbytcu239s1BgkM4ZLPpon80jkmIxjv7NBfL5CGkNzP2LUs0uKz0/s1600/Risk+for+Ineffective+Thermoregulation+related+to+Low+Birth+Weight.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Risk for Ineffective Thermoregulation related to Low Birth Weight" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEip-s14Skc701o0Svox6MNjfL16eWDBUsrT48fmkxhiQsNwIc37GxzjgMwp7hG_Gv_bTIDepfEGCemJCNmLq8IapK9kkbytcu239s1BgkM4ZLPpon80jkmIxjv7NBfL5CGkNzP2LUs0uKz0/s1600/Risk+for+Ineffective+Thermoregulation+related+to+Low+Birth+Weight.jpg" /></a></div>
Low birth weight (LBW) is newborn birth weight less than 2500 g (up to 2499 g). Relating to the treatment and life expectancy, low birth weight babies can be divided into:<br />
<ul>
<li>Low birth weight, birth weight 1500 - 2500 g.</li>
<li>Very low birth weight, birth weight less than 1500 g.</li>
<li>Extreme low birth weight, birth weight less than 1000 g.</li>
</ul>
<br />
<b>Clinical Manifestations</b><br />
<br />
1. Signs and symptoms of preterm infants according Surasmi (2003: 32), among others:<br />
<ul>
<li>Gestational age equal to or less than 37 weeks.</li>
<li>Weight loss is equal to or shellfish than 2500 grams.</li>
<li>Body length is equal to or less than 46 cm.</li>
<li>Nails are not yet past the fingertip length.</li>
<li>Limit the forehead and scalp hair ends are unclear.</li>
<li>Head circumference is equal to or less than 33 cm.</li>
<li>Chest circumference is equal to or less than 30 cm.</li>
<li>Lanugo hair is still a lot.</li>
<li>Thin subcutaneous fat tissue or less.</li>
<li>The ear cartilage growth is not perfect, so it seems not palpable cartilage earlobe.</li>
<li>Heel shiny, smooth soles.</li>
<li>Genitals: the baby boy pigmentation and scrotal rugae; less, the testes do not descend into the scrotum, to baby girl protruding clitoris, labia minora covered by the labia majora.</li>
<li>Weak muscle tone so that the baby is less active and weak movement.</li>
<li>Nerve function yet or less mature, resulting in reflex suction, swallowing and cough is still weak or ineffective and weak cries.</li>
<li>Mammary gland tissue is still lacking due to the growth of fat tissue is still lacking.</li>
<li>Vernix no or less.</li>
</ul>
<br />
2. Signs and symptoms of infants according Surasmi dysmature (2003: 34), among others:<br />
<ul>
<li>Dysmature preterm infants: visible physical symptoms of preterm coupled with growth retardation symptoms.</li>
<li>Dysmature term and postterm infants</li>
<li>Symptoms of placental insufficiency and duration depending on the time of the baby suffering from a deficit, growth retardation would happen if the deficit lasting (chronic).</li>
<li>Stadium baby dismature:</li>
</ul>
<blockquote class="tr_bq">
1. First<br />
<ul>
<li>The baby looked thin and relatively longer.</li>
<li>Loose skin, dry as a permanent stain is not yet meconium.</li>
</ul>
2. Second<br />
<ul>
<li>There are signs of the first stage.</li>
<li>The green color of the skin of the placenta and umbilical (as meconium mixed), amniotic settles on the skin, umbilicus and placenta due to intrauterine anorexia.</li>
</ul>
3) Third<br />
<ul>
<li>There is a sign of the third stage.</li>
<li>The skin, nails, yellow cord.</li>
<li>Found signs of anorexia intrauterine long.</li>
</ul>
</blockquote>
<br />
<b>Nursing Diagnosis for : Risk for Ineffective Thermoregulation</b> related to immature CNS (central regulation of residues, reduced lean body mass to surface area, subcutaneous fat loss, inability to feel cold and clammy, poor metabolic reserves).<br />
<br />
Goal: Thermoregulation becomes effective in accordance with the development.<br />
<br />
Expected outcomes:<br />
Maintaining the skin or axillary temperature (35 - 37,50C).<br />
<br />
<b>Nursing Interventions :</b><br />
<br />
Independent:<br />
<ul>
<li>Assess the temperature with a rectal temperature check at first, then check the temperature of the axilla or use a thermostat with an open base and spreader warm.</li>
<li>Place the baby in an incubator or in a warm state.</li>
<li>Monitor the temperature control system, spreader warm (keep the upper limit of 98.6 ° F, depending on the size and age of the baby)</li>
<li>Assess output and urine specific gravity.</li>
<li>Monitor weight gain in a row. If weight gain is inadequate, increase the ambient temperature as indicated.</li>
<li>Note the development of tachycardia, redness, diaphoresis, lethargy, apnea or seizure activity.</li>
</ul>
<br />
Collaboration:<br />
<ul>
<li>Monitor laboratory tests as indicated (serum glucose, electrolytes and bilirubin levels).</li>
<li>Give medications in accordance with the indication.</li>
</ul>
<br />
Rationale :<br />
<ul>
<li>Hypothermia make babies tend to feel stressed because of the cold, the use of fatty deposits can not be updated if there is and decreased sensitivity to increasing CO2 levels or decreased levels of O2.</li>
<li>Maintaining a thermoneutral environment, helps prevent stress due to the cold.</li>
<li>Hyperthermia with an increased rate of oxygen and glucose metabolism as well as the need for water loss can occur when the ambient temperature is too high.</li>
<li>The decline in output and an increase in specific gravity of urine associated with a reduction in renal perfusion during periods of stress because of the cold.</li>
<li>The inadequate weight gain despite adequate caloric intake may indicate that the calories are used to maintain the ambient temperature of the body, thus requiring an increase in ambient temperature.</li>
<li>Signs of hyperthermia can be continued in brain damage if not resolved.</li>
<li>Cold stress increases the need for glucose and oxygen and can lead to problems when a baby has acid base anaerobic metabolism when oxygen levels are not enough available. Increased levels of indirect bilirubin may occur due to the release of fatty acids from brown fat metabolism by fatty acids compete with bilirubin in the bond part in albumin.</li>
<li>Helps prevent seizures relating to changes in CNS function induced hyperthermia.</li>
<li>Fixing acidosis can occur in hypothermia and hyperthermia.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-58684218978285029012015-01-14T09:45:00.001+07:002015-01-14T09:45:44.705+07:00Nursing Diagnosis and Interventions for Osteosarcoma (osteogenic sarcoma)<br />
Osteosarcoma (osteogenic sarcoma) is a tumor that arises from bone-forming mesenchyme. (Wong. 2003: 616).<br />
<br />
The places most often affected are the distal femur, proximal tibia and proximal humerus. The most rare is the pelvis, column, vertebrae, mandible, clavicle, scapula, or bones of the hands and feet. More than 50% of cases occur in the knee area. (Otto.2003: 72).<br />
<br />
Clinical manifestations<br />
<br />
a. Bone pain.<br />
Bone pain is the most common symptom found in the process of metastasis to bone and is usually the initial symptoms are recognized by the patient. Pain arising from stretching the periosteum and the endosteum nerve stimulation by tumor. The pain can be intermittent and more pronounced at night or while resting.<br />
<br />
b. Fractures<br />
The presence of bone metastases can cause bone structure becomes more fragile and at risk for fracture. Sometimes fractures arise before other symptoms. Areas are often fractured long bones in the upper and lower extremities and spine.<br />
<br />
c. Emphasis spinal cord<br />
When a process of metastasis to the spine, the spinal cord becomes desperate. Displacement of the spinal cord is not only painful but also parese or numbness in the extremities, micturition disorders, or numbness around the abdomen.<br />
<br />
d. Elevation of calcium levels in the blood<br />
This is due to the high release of calcium from bone reserves. Elevation of calcium can cause loss of appetite, nausea, thirst, constipation, fatigue, and even impaired consciousness.<br />
<br />
e. other symptoms<br />
When metastasis to the bone marrow, symptoms according to the type of blood cell that is affected. Anemia can occur when on red blood cells. If the white blood cells are affected, the patient DAPT easily infected infeksi.Sedangkan on platelet disorders, can cause bleeding.<br />
<br />
<br />
<b>Nursing Diagnosis and Interventions for Osteosarcoma (osteogenic sarcoma)</b><br />
<br />
<br />
1. Chronic pain related to pathological processes and surgery.<br />
Goal : Pain is reduced / no pain.<br />
Intervention:<br />
<ul>
<li>Give an explanation to the client on how to cope with pain and cause pain.</li>
<li>Teach relaxation and distraction techniques.</li>
<li>Monitor vital signs</li>
<li>Collaboration in providing analgesic.</li>
</ul>
2. Risk for injury related to pathologic fractures associated with tumors.<br />
Goal: Not the case of injury (injury).<br />
Intervention:<br />
<ul>
<li>Explain to the client on how to cope with and the occurrence of injury.</li>
<li>Limit activity.</li>
</ul>
3. Low Self-Esteem related to the loss of body parts or change roles.<br />
Goal: Improved self-esteem and no complications.<br />
Intervention:<br />
<ul>
<li>Provide motivation to the client.</li>
<li>Involves the role of the family.</li>
</ul>
4. Knowledge deficit related to lack of knowledge about the disease process and treatment programs.<br />
Goal: The client can understand the disease process and treatment programs.<br />
Intervention:<br />
<ul>
<li>Explain to the client about the disease process and treatment programs.</li>
<li>Encourage clients to comply with the treatment program.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-29534037814184443982014-12-09T12:48:00.000+07:002014-12-09T12:48:41.944+07:0010 Nursing Diagnosis related to Pneumoconiosis<b>Nursing Care Plan for Pneumoconiosis</b><br />
<br />
Pneumoconiosis is a respiratory disease caused by particles (dust) that enter or settle in the lungs. Pneumoconiosis diseases of many kinds, depending on the type of particles (dust) entering or inhaled into the lungs. Some types of pneumoconiosis diseases that are often found in areas that have many industrial and technological activities, ie silicosis, asbestosis, Byssinosis, anthracosis and beriliosis.<br />
<br />
Most pneumonia, can be through aspiration infectious particles. Infectious particles filtered in the nose, or caught and cleaned by mucus and ciliated epithelium in the airways. When a particle (virus / bacteria) can reach the lungs, the particles will be dealing with alveolar macrophages, and also with systemic immune mechanisms, and humoral.<br />
<br />
By the time the body undergoes changes anatomical and physiological defense, then the infectious particles can reach the lungs, then spread and cause pneumonia. More than 40 minerals inhaled causes lung lesions and abnormalities of X-rays. Most, such as lead, barium and iron, are relatively harmless and accumulate in the lungs in the same way as coal, but do not produce a functional or morphological abnormalities. Asbestos dust into the body through a variety of ways. Among others, by vacuuming when breathing, swallowing saliva and phlegm together or consume food and drinks that contain a small number of fibers. Most fibers are ingested allegedly penetrate the intestinal wall, but subsequent migration in the body is unknown. After a long latency period, between 20-40 years, these fibers can cause cancer.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUV9nELwnlFRBg3f3Vm9JoZiwiuvu8HHDBpO7yp0VTfvdWNDwqlbwAcVbQTOOq8vYnMBfWUFkK_kkukcDm-i8KNXKw34eZuuvuaLKS8zL4VHiHLxmkhIAcuajnPw5_wV3oDnsZkUuFjCZW/s1600/10+Nursing+Diagnosis+related+to+Pneumoconiosis.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUV9nELwnlFRBg3f3Vm9JoZiwiuvu8HHDBpO7yp0VTfvdWNDwqlbwAcVbQTOOq8vYnMBfWUFkK_kkukcDm-i8KNXKw34eZuuvuaLKS8zL4VHiHLxmkhIAcuajnPw5_wV3oDnsZkUuFjCZW/s1600/10+Nursing+Diagnosis+related+to+Pneumoconiosis.jpeg" /></a></div>
<br />
<br />
<br />
<br />
<b>Nursing Diagnosis that may occur in patients Pneumoconiosis :</b><br />
<br />
<ol>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2012/09/pneumonia-ineffective-airway-clearance.html">Ineffective airway clearance</a> related to the increased production of secretions or thick secretions.</li>
<li>Anxiety related to difficulty breathing and fear Suffocation.</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2014/08/disturbed-sleep-pattern-ncp-for-pleural.html">Disturbed Sleep Pattern</a> related to cough, inability to perform the supine position, the environmental stimuli.</li>
<li>Imbalanced nutrition less than body requirements related to loss of appetite and nausea and vomiting.</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2014/08/nursing-interventions-and-rationales.html">Impaired gas exchange</a> related to airway obstruction.</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2013/08/copd-risk-for-infection-and-impaired.html">Risk for infection</a> related to chronic disease processes.</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2014/02/chronic-pain-related-to-osteoporosis.html">Chronic pain</a> related to inflammation of the lung parenchyma.</li>
<li>Knowledge deficit : the condition and the need for action related to misinterpretation.</li>
<li>Activity intolerance related to imbalance between supply and oxygen demand.</li>
<li>Risk for <a href="http://nandanursingdiagnoses.blogspot.com/2011/11/nanda-nursing-diagnoses-fluid-volume.html">fluid volume deficit</a> related to fever, sweating, vomiting.</li>
</ol>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-50362581581409408012014-08-26T11:11:00.001+07:002014-08-26T11:11:43.867+07:00Importance Check Blood Sugar in Diabetes<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIl2H8S82UjU0KXWlHB8hEJFiNEb6R-KwxmxkZ3wXlme6wbdSEuQIgtbssJDS3BceJFK_bGUDZZ3emBf5agOUydjGSAYfo2DlI9k2iXfh0yzQbnCfnFFhsPAN1-KJS52PtmaG-F0RhlnKp/s1600/Importance+Check+Blood+Sugar+in+Diabetes.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Importance Check Blood Sugar in Diabetes" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIl2H8S82UjU0KXWlHB8hEJFiNEb6R-KwxmxkZ3wXlme6wbdSEuQIgtbssJDS3BceJFK_bGUDZZ3emBf5agOUydjGSAYfo2DlI9k2iXfh0yzQbnCfnFFhsPAN1-KJS52PtmaG-F0RhlnKp/s320/Importance+Check+Blood+Sugar+in+Diabetes.jpeg" /></a></div>
Blood sugar levels is a major concern for people with diabetes. This disease is swirling blood sugar problems, very dangerous if too high, too low, too, if it can be dangerous too. Although the blood sugar levels are usually manifested in the clinical condition of patients with diabetes, but often do not realize until its effects are already happening complications.<br />
<br />
Effects of high blood sugar levels that are too high are complications in organ damage in the body. Usually the damage is so permanent, so it is difficult to cure and life-threatening. This consideration which makes checking blood sugar levels should be done regularly. At least at the beginning of developing diabetes may be more frequent, but when it is stable, can be rarer. It is not recommended to check blood sugar levels when no clinical complaints, this is usually referred to as the complications and do not get used.<br />
<br />
But sugar checks can also be used to monitor health, eg for diabetes prevention. This is of course for those who love to eat great food and sugary and high fat. This character is in accordance with the prospective people with diabetes. In most cases of diabetes is not detected its presence, know-know have no complaints, only discovered when exposed to diabetes. Though this could have been avoided if routine checks blood sugar levels.<br />
<br />
Indeed, blood sugar levels are not absolute, it still must be compromised by a person's clinical condition. However, check your blood sugar could be a sort of alarm, of course, nothing wrong in diet and lifestyle and even this must be corrected. Similarly, in diabetics, by knowing the position of blood sugar levels, can regulate the diet, improve your diet and enhance your lifestyle.<br />
<br />
<br />
Check fasting blood sugar levels<br />
<br />
It is standard to check fasting blood sugar levels for diabetes patients. Although it could also have your own tools if a random glucose level can be known. However, fasting blood sugar levels is sufficient, usually easy to do in health services such as health centers. It can determine the condition of the blood sugar levels, so knowing what to do on a diet and daily activities.<br />
<br />
Blood sugar levels that are known to be a picture of food intake and activity settings that should be changed or improved. In people with diabetes do have a balanced diet in a set pattern, so do not get too tight or too loose. Although the blood sugar levels could be compromised, but always have to be adjusted to the patient's clinical condition. Each person will be special, although it could have the same sugar content.<br />
<br />
<br />
Check blood sugar levels in healthy current<br />
<br />
There is often overlooked for people with diabetes, the blood sugar checks when there are complaints. And if there are complaints clearly there is something wrong in blood sugar levels. There are healthier ways of doing checks blood sugar levels, which is doing while being healthy, so they can do a control diet or activity effectively.<br />
<br />
When a habit to check the blood sugar levels only when there is a complaint, it will create new problems in the future. At the moment there are complaints diabetics usually does have blood sugar levels that are not normal, could be too low or too high. It would be dangerous when it is a complication too far. Healing mechanisms will become more difficult. More difficult to control blood sugar levels in the body when the organs have been damaged.<br />
<br />
In some cases people with diabetes, so easy to give in to the disease, and mostly because it has complications. When this condition is difficult to cure, even damage becomes more serious especially with emotional state becomes unstable. The feeling of pain or discomfort will worsen control of blood sugar levels, so here the importance of checking blood sugar levels regularly.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-67378768867682410682014-08-26T11:00:00.002+07:002014-08-26T11:00:36.387+07:00Nursing Care Plan for Hyperglycemia - Assessment and Diagnosis<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCYHcR38ESvIuEmS2t445kwnJJoh07OErovxlo1NZ4bfsgI9rxMarCxTqJewwei_84rDjsFpyI4vrcUTVptLGtefPldUM30hV34qsN5RIwqWtvmiaeNHMFkdUuD7Y0nFrXtjO66aSacPuD/s1600/Nursing+Care+Plan+for+Hyperglycemia+-+Assessment+and+Diagnosis.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Nursing Care Plan for Hyperglycemia" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCYHcR38ESvIuEmS2t445kwnJJoh07OErovxlo1NZ4bfsgI9rxMarCxTqJewwei_84rDjsFpyI4vrcUTVptLGtefPldUM30hV34qsN5RIwqWtvmiaeNHMFkdUuD7Y0nFrXtjO66aSacPuD/s320/Nursing+Care+Plan+for+Hyperglycemia+-+Assessment+and+Diagnosis.jpeg" /></a></div>
Hyperglycemia is a condition where there is an increase in plasma glucose levels in the blood. A condition called hyperglycemia is when blood glucose levels exceeded 180 mg / dL, but sometimes symptoms of hyperglycemia did not appear and was not detected even though the levels are already very high (270-360 mg / dL).<br />
<br />
The following symptoms may be found in hyperglycaemia, where 3 of the first symptoms is a classic triad of symptoms of hyperglycemia:<br />
<ul>
<li>Polyphagia (frequent hunger)</li>
<li>Polydipsia (frequently thirsty)</li>
<li>Polyuria (frequent urination)</li>
<li>Vision shaded</li>
<li>Weakness and feeling sleepy</li>
<li>Weight loss</li>
<li>Wounds difficult to heal</li>
<li>Dry mouth</li>
<li>Recurrent infections</li>
<li>Cardiac arrhythmias</li>
<li>Stupor</li>
<li>Commas</li>
</ul>
<br />
<br />
<b>Nursing Assessment for Hyperglycemia</b><br />
<br />
1 Activity / Rest<br />
<ul>
<li>Symptoms: Weakness, fatigue, difficult to move / run. Muscle cramps, decreased muscle tone. Impaired sleep / rest.</li>
<li>Signs: tachycardia and tachypnea in the state of rest or with activity.</li>
</ul>
<br />
2 Circulation<br />
<ul>
<li>Symptoms: A history of hypertension; Acute MI. Claudication, numbness, and tingling in the extremities.</li>
<li>Foot ulcers, healing old. </li>
<li>Signs: Tachycardia. Postural changes in blood pressure; hypertension. Decreased pulse / no</li>
<li>Dysrhythmias. Crackles; DVJ (CHF). Skin hot, dry, and redness; sunken eyeballs.</li>
</ul>
<br />
3 Ego Integrity<br />
<ul>
<li>Symptoms: Stress; dependent on others. Financial problems associated with the condition.</li>
<li>Signs: Anxiety, sensitive excitatory.</li>
</ul>
4 Elimination<br />
<ul>
<li>Symptoms: Changes in the pattern of urination (polyuria), nocturia. Pain / burning, difficulty urinating (infection), the new UTI / repetitive. Abdominal tenderness. Diarrhea.</li>
<li>Signs: dilute urine, pale, yellow; polyuria (may progress to oliguria / anuria in case of severe hypovolemia).</li>
<li>Misty urine, foul smell (infection). Abdomen hard, the presence of ascites. Weak and decreased bowel sounds; hyperactive (diarrhea).</li>
</ul>
5. Food / Fluid<br />
<ul>
<li>Symptoms: Loss of appetite. Nausea / vomiting. Do not follow the diet; increase in input glucose / carbohydrate. Weight loss over a period of several days / weeks. Thirsty. The use of diuretics (thiazides).</li>
<li>Signs: Dry skin / scaly, ugly tugor. Stiffness / abdominal distension, vomiting. Enlargement of the thyroid (increased metabolic demand with increased blood sugar). Odor halotosis / sweet, fruit odor (acetone breath).</li>
</ul>
6 Neurosensory<br />
<ul>
<li>Symptoms: Dizziness / reel. Headaches. Tingling, numbness weakness in the muscles. Paresthesias.</li>
<li>Visual impairment. </li>
<li>Signs: Disorientation; drowsiness, lethargy, stupor / coma (advanced stage). Memory impairment (new, past); mentally screwed. Deep tendon reflexes, decreased (coma). Seizure activity.</li>
</ul>
<br />
7 Pain / Leisure<br />
<ul>
<li>Symptoms: Abdominal tension / pain (moderate / severe).</li>
<li>Signs: face grimacing with palpitations; looks to be very careful.</li>
</ul>
8 Respiratory<br />
<ul>
<li>Symptoms: Feeling a lack of oxygen, cough with / without sputum purulent (depending on the presence of infection / no).</li>
<li>Signs: Hungry air. Cough, with / without purulent sputum (infection). Respiratory frequency.</li>
</ul>
9. Security<br />
<ul>
<li>Symptoms: Dry skin, itching; skin ulcers.</li>
<li>Signs: fever, diaphoresis. Damaged skin, lesion / ulceration. Decreased general strength / range of motion.</li>
<li>Paresthesia / paralysis of muscles, including respiratory muscles (if potassium levels decreased with quite sharp).</li>
</ul>
10 Sexuality<br />
<ul>
<li>Symptoms: vaginal discharge (likely an infection). Impotence problem in men; orgasm difficulties in women.</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis for for Hyperglycemia</b><br />
<ol>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2011/12/deficient-fluid-volume-nursing-care.html">Deficient Fluid Volume</a></li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2013/06/malaria-imbalanced-nutrition-less-than.html">Imbalanced Nutrition: Less Than Body requiremen</a>.</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2013/06/risk-for-infection-related-to-malaria.html">Risk for Infection</a>.</li>
<li>Risk for <a href="http://nandanursingdiagnoses.blogspot.com/2014/02/disturbed-sensory-perception-and.html">Disturbed Sensory Perception</a></li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2013/06/nursing-diagnosis-for-diabetes-mellitus.html">Fatigue</a></li>
<li>Powerlessness</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2012/08/nursing-diagnosis-knowledge-deficit-for.html">Knowledge Deficit</a> (learn) about the disease, prognosis, and treatment needs.</li>
</ol>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-13578242999330914882014-08-25T09:18:00.000+07:002014-08-25T09:21:41.837+07:00Gordon's Functional Health Patterns for Pleural Effusion<b>11 Gordon's Functional Health Patterns</b><br />
<br />
1) Health Perception – Health Management Pattern <br />
The presence of medical treatment and hospitalization affect change perceptions about health, but sometimes also led to wrong perception of health care. The possibility of a history of smoking, drinking alcohol and using drugs could be a factor predisposing disease.<br />
<br />
2) Nutritional - Metabolic Pattern<br />
In the assessment of nutritional and metabolic pattern, we need to take measurements of height and weight to determine the nutritional status of the patient, as well as the need to be asked eating and drinking habits before and during hospital admission, patients with pleural effusion will experience a decrease in appetite due to shortness of breath and an emphasis on abdominal structures. Increased metabolism will occur as a result of the disease process. patients with pleural effusion generally weak state.<br />
<br />
3) Elimination Pattern<br />
In the assessment of the pattern of elimination need to be asked about the illusion and defecation habits before and after hospital admission. Because the patient's general condition is weak, the patient will be much bed rest that will cause constipation, in addition to the structure of the abdomen due to gastrointestinal causes a decrease in the peristaltic muscles degestivus tract.<br />
<br />
4) Activity - Exercise Pattern<br />
Due to shortness of breath, tissue oxygenation needs to be less fulfilled and the patient will quickly experience fatigue on minimal exertion. Besides, patients will also reduce activity due to chest pain. And to meet the needs of patients ADL partly assisted by nurses and their families.<br />
<br />
5) Sleep – Rest Pattern <br />
The presence of chest pain, shortness of breath and an increase in body temperature will affect the fulfillment of the need for sleep and rest, other than that due to changes in the environmental conditions of a quiet home environment to the hospital setting, where many people are paced, noisy and others.<br />
<br />
6) Role - Relationship Pattern<br />
As a result of illness, the patient directly will change roles, eg a housewife patient, the patient can not perform the function as a mother who must care for their children, taking care of her husband. In addition, the patient's role in society is also changing and all that affects the patient's interpersonal relationships.<br />
<br />
7) Self-perception - Self-concept Pattern<br />
Patient's perception of the self will change. Patients who are otherwise healthy, a sudden onset of pain, shortness of breath, chest pain. Patients may be assumed that the disease is dangerous and deadly disease. In this case the patient may lose the positive image of the self.<br />
<br />
8) Cognitive - Perceptual Pattern<br />
Sensory function of patients did not change, as well as thought processes.<br />
<br />
9) Sexuality - Reproductive Pattern<br />
Sexual needs of the patient in this case sexual intercourse will be disturbed for a while because the patient is in the hospital and his physical condition is still weak.<br />
<br />
10) Coping - Stress Tolerance Pattern<br />
For patients who do not know the disease process may be experiencing stress and many patients will ask nurses and doctors who cared for him or those who might be considered more to know about the disease.<br />
<br />
11) Value - Belief Pattern<br />
As a religious patient will get closer to God.<br />
<br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2014/08/gordons-functional-health-patterns-for.html">Gordon's Functional Health Patterns for Pleural Effusion</a><br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2014/08/disturbed-sleep-pattern-ncp-for-pleural.html">Disturbed Sleep Pattern NCP for Pleural Effusion</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-29249232280039513302014-08-25T08:37:00.000+07:002014-08-25T08:37:03.820+07:00Disturbed Sleep Pattern NCP for Pleural Effusion<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi61IOfci0Ea6wJiez9Ya9xsadC6tNjQaIjahXS-w_QnbXZkAdJE0n9hdbzKRwcNR2BXmOonuac4rHjID8WMA3-CRXWF0aZTwiSqbHKrApeXxsM_b3Y2E1WZ8_IEX7qnCbHs5PMC_HJYWFM/s1600/Disturbed+Sleep+Pattern+NCP+for+Pleural+Effusion.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="Disturbed Sleep Pattern NCP for Pleural Effusion" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi61IOfci0Ea6wJiez9Ya9xsadC6tNjQaIjahXS-w_QnbXZkAdJE0n9hdbzKRwcNR2BXmOonuac4rHjID8WMA3-CRXWF0aZTwiSqbHKrApeXxsM_b3Y2E1WZ8_IEX7qnCbHs5PMC_HJYWFM/s320/Disturbed+Sleep+Pattern+NCP+for+Pleural+Effusion.jpg" /></a></div>
<b>Nursing Care Plan for Pleural Effusion</b><br />
<br />
Pleural effusion is a health condition where the amount of excess fluid accumulates in the pleural cavity. This limits the ability of the lungs to grow and therefore the patient for breathing difficulties.<br />
<br />
There is a thin layer of fluid between the lung and the chest wall, in the human body. This liquid is very important because it acts as a lubricant between the chest wall and the lungs when we breathe. Cavity or space between the chest wall and the lung, where it accumulates fluid, called the pleura, and the liquid is called pleural fluid. Abnormal increase in the amount of pleural fluid causes the chest wall separated from the lungs.<br />
<br />
Possible signs of pleural effusion:<br />
<ul>
<li>Emphasis on the lungs.</li>
<li>Chest pain (does not occur in all patients).</li>
<li>Difficulty in breathing.</li>
<li>Cough and fever with empyema (when pneumonia has caused effusion).</li>
<li>Hiccups.</li>
<li>Dyspnea (shortness of breath).</li>
</ul>
<br />
<b>Nursing Diagnosis for <a href="http://nandanursingdiagnoses.blogspot.com/2014/04/nursing-assessment-of-pleural-effusion.html">Pleural Effusion</a> : Disturbed Sleep Pattern</b> related to persistent cough and pleuritic pain.<br />
<br />
Goal: There was no disruption of sleep patterns and needs are met rest-sleep.<br />
<br />
<b>O</b>utcomes:<br />
<ul>
<li>Patients no shortness of breath,</li>
<li>patients can sleep comfortably without experiencing interference,</li>
<li>patients can sleep easily within 30-40 minutes and the patient rest or sleep within 3-8 hours per day.</li>
</ul>
<br />
Interventions:<br />
1 Give the position as comfortable as possible for patients.<br />
Rasonal: semi-Fowler's position or a pleasant position will facilitate the circulation of O2 and CO2.<br />
<br />
2 Determine the motivation habits before bedtime in accordance with the habits of patients before treatment.<br />
Rationale: Changing pattern that has become a habit before sleeping, will disrupt the sleep process.<br />
<br />
3 Instruct the patient to relaxation exercises before bed.<br />
Rationale: Relaxation can help overcome sleep disorders.<br />
<br />
4 Observe the patient's general condition.<br />
Rationale: Observations to determine changes in the patient's condition.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-48913475630798487692014-08-21T22:46:00.000+07:002014-08-21T22:46:07.655+07:00Ineffective Breathing Pattern - Nursing Diagnosis and Interventions<b>Ineffective breathing pattern related to paralysis of the diaphragm muscle.</b><br />
<br />
Intervention:<br />
1 Maintain airway; head position without movement.<br />
Rationale: Patients with cervical injury will require help to prevent aspiration / maintain the airway.<br />
<br />
2 Perform suction mucus, if necessary, record the number, type and characteristics of the secretions.<br />
Rationale: If the cough is not effective, the suction needed to remove secretions, and reduce the risk of respiratory infections.<br />
<br />
3 Assess respiratory function.<br />
Rational: Trauma C5-6 cause partial loss of respiratory function, due to respiratory muscle paralysis.<br />
<br />
4. Auscultation of breath sounds.<br />
Rational: Hypoventilation usually occur or lead to the accumulation of secretions that result in pneumonia.<br />
<br />
Observation 5. skin color.<br />
Rationale: Describes the presence of respiratory failure that requires immediate action.<br />
<br />
6 Assess abdominal distension and muscle spasm.<br />
Rational: Full abnormalities in the stomach caused by paralysis of the diaphragm.<br />
<br />
7 Instruct the patient to drink a minimum of 2000 cc / day.<br />
Rational: help thin secretions, increasing the mobilization of secretions as an expectorant.<br />
<br />
8 Perform measurement of vital capacity, tidal volume and respiratory strength.<br />
Rationale: Determining the function of the respiratory muscles. Continuous assessment to detect the presence of respiratory failure.<br />
<br />
9 Monitor blood gas analysis.<br />
Rationale: To determine the function of gas exchange abnormalities as an example: hyperventilation low PaO2, and PaCO2 increased.<br />
<br />
10 Give oxygen in the proper way: the method chosen in accordance with the state isufisiensi breathing.<br />
<br />
· Perform physiotherapy breath.<br />
Rational: to prevent retained secretionsUnknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-68793361989319126312014-08-21T10:23:00.000+07:002014-08-21T10:23:16.341+07:008 Pain Nursing Diagnosis and Interventions<b>Nursing Diagnosis and Interventions for Pain </b><br />
<br />
<br />
1. Pain related to abdominal distension.<br />
<br />
Intervention:<br />
Observation of vital signs.<br />
Assess the level of pain.<br />
Set a comfortable position for the client.<br />
Give a warm compress on the area of the abdomen.<br />
Collaboration with physicians in the delivery of analgesic therapy as indicated.<br />
<br />
<br />
2. Pain related to muscle spasms, shifting bone fragments.<br />
<br />
Intervention:<br />
Review the location, intensity and type of pain.<br />
Maintain immobilization of the affected part with bed rest.<br />
Provide a quiet environment and give impetus to conduct entertainment activities.<br />
Change position to help if tolerated.<br />
Explain the procedure before starting.<br />
Keep an eye in doing range of motion exercises (passive / active).<br />
<br />
<br />
3. Pain related to ischemic tissues.<br />
<br />
Intervention:<br />
Assess the level, frequency, and pain experienced by the patient's reaction.<br />
Rational: to find out how severe the pain experienced by the patient.<br />
<br />
Explain to patients about the causes of the onset of pain<br />
Rationale: The patient's understanding of the causes of pain that occurs will reduce the strain of patients and allows patients to be invited to cooperate in taking action.<br />
<br />
Create a quiet environment<br />
Rationale: Excessive Rangasanga of environment will aggravate pain.<br />
<br />
Teach distraction and relaxation techniques.<br />
Rational: distraction and relaxation techniques can reduce the pain felt by the patient.<br />
<br />
Adjust the position of the patient as comfortable as possible as you wish of the patient.<br />
Rationale: a comfortable position will help provide opportunities for relaxation in the muscles optimally.<br />
<br />
Perform massage and compress the wound with the current BWC wound care.<br />
Rational: massage can increase spending vaskulerisasi and pussy while BWC as a disinfectant that can provide a sense of comfort<br />
<br />
Collaboration with physicians for analgesia.<br />
Rational: analgesic medications can help reduce the patient's pain.<br />
<br />
<br />
4. Pain related to tissue trauma<br />
<br />
Intervention:<br />
Independent:<br />
Observation and record the location of the severity of complaints (scale 0-10) and the effects of pain.<br />
Rationale: Helps to distinguish the cause of pain and provide information about the progress or improvement of disease, complications, and effectiveness of interventions.<br />
<br />
Monitor vital signs.<br />
Rationale: Increased pain will improve vital signs.<br />
<br />
Teach to use relaxation techniques and deep breathing or distraction techniques such as listening to music or reading a book.<br />
Rationale: Helps divert or control the pain, refocus and improve coping<br />
<br />
Collaboration: Giving analgesics as indicated.<br />
Rationale: Reduces pain.<br />
<br />
<br />
5. Acute pain related to irritation of the gastric mucosa (gastric).<br />
<br />
Intervention:<br />
Note the presence of epigastric pain (heartburn sensations such as burning / heat), sore<br />
<br />
Motivation clients not to eat late. Eating snacks in between meals when the stomach was sore.<br />
<br />
Observations no other accompanying complaints such as nausea / vomiting, abdominal bloating.<br />
<br />
Observations of vital signs<br />
<br />
Give appropriate medications medical program.<br />
<br />
<br />
6. Pain related to injury.<br />
<br />
Intervention:<br />
Assess the pain scale 0-5.<br />
Rational: patient reported pain usually above the injury level.<br />
<br />
Aids patients in the identification of trigger factors.<br />
Rational: pain is influenced by; anxiety, tension, temperature, bladder distension and lay down long.<br />
<br />
Provide comfort measures.<br />
Rationale: provide a sense nayaman a way to help control pain.<br />
<br />
Encourage the patient to use relaxation techniques.<br />
Rational: to refocus attention, increase the sense of control.<br />
<br />
Give anti-pain medication order.<br />
Rational: to relieve muscle pain or to relieve anxiety and improve the rest.<br />
<br />
<br />
<br />
7. Pain related to postoperative conditions<br />
<br />
Intervention:<br />
Anticipate the need for pain medication and or additional methods of pain relief.<br />
<br />
Note the document, and the identification of complaints of pain in the side of the incision; abdominal, facial grimacing to pain, decreased mobility, behavioral distraction / relief.<br />
<br />
8. Pain related to surgical incision secondary to amputation<br />
<br />
Intervention:<br />
Evaluation of pain: derived from Panthom sensation of limb or incision.<br />
In the event of limb pain Panthom Give analgesics (collaborative).<br />
Teach clients provide gentle pressure to put butts in the towel and pulled the towel with berlahan.<br />
<br />
Give pain medication as order and evaluate its effectiveness.<br />
<br />
Give other comfort measures that can help, such as a change in position with a pillow or bolster.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-80387343455463774982014-08-20T22:09:00.002+07:002014-08-20T22:09:54.926+07:003 Epidemiology of Diarrhea<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhErVJuL2vKbMpBQv2F-znmYBw-3USQo7IaYHSn-Z5kmIsaNe9fiCMn6TtyILC6HYl3FHDi32Qor840ffxNa2kNVEiNU7CykfQRh0vc9DNKE-KUlyPmQQFcfC6UgBVp0YLCZsMDk0iYHTxT/s1600/Nursing+Care+Plan+for+Diarrhea.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" care="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhErVJuL2vKbMpBQv2F-znmYBw-3USQo7IaYHSn-Z5kmIsaNe9fiCMn6TtyILC6HYl3FHDi32Qor840ffxNa2kNVEiNU7CykfQRh0vc9DNKE-KUlyPmQQFcfC6UgBVp0YLCZsMDk0iYHTxT/s320/Nursing+Care+Plan+for+Diarrhea.jpeg" iarrhea="" plan="" /></a></div>
<b>Epidemiology of Diarrhea</b><br />
<br />
<b>The spread of germs that cause diarrhea</b><br />
<br />
Germs that cause diarrhea are usually spread through fecal-oral, among others through food / drink contaminated feces or direct contact with the feces of patients. Some behaviors can lead to the spread of enteric bacteria and increase the risk of diarrhea behavior include:<br />
<ol>
<li>Not provide full breast milk in the first 4-6 months of life in infants who are not breastfed risk to suffer from diarrhea greater than in infants fed breast milk is full and the possibility of suffering from severe dehydration is also greater.</li>
<li>Using milk bottles, use the bottle facilitates digestion by germs, because the bottle is difficult to clean.</li>
<li>Storing cooked foods at room temperature. When food is stored several hours at room temperature the food will be contaminated and the bacteria will multiply.</li>
<li>Using contaminated drinking water. The water may have been contaminated from the source or at the time kept in the home, home contamination can occur if the storage area is not closed or when contaminated hands touch the water at the time of taking water from the storage place.</li>
<li>Not washing hands after defecation and after throwing feces child or before eating and feeding a child.</li>
<li>Not throwing feces (stool including infants) with completely. Often assume that the baby's stools are not dangerous when in fact it contains a virus or bacteria in the large amount of animal feces while it can cause infections in humans.</li>
</ol>
<br />
<br />
<b>Host factors that increase susceptibility to diarrhea</b><br />
<br />
Several factors in the host may increase the incidence of some diseases and duration of diarrhea. These factors are:<br />
<ul>
<li>Not breastfeeding up to 2 years. Breast milk contains antibodies that can protect us against various germs that cause diarrhea such as Shigella and V cholerae.</li>
<li>Malnutrition. Severity of illness, duration and increased risk of death due to diarrhea in children who suffer from nutritional disorders, especially in patients with malnutrition.</li>
<li>Measles, diarrhea and dysentery are common and result in severe in children who are suffering from measles within the last 4 weeks of this as a result of a decrease in immune patients.</li>
<li>Immunodeficiency / immunosuppression. This situation may only be temporary, such as after a viral infection (such as measles) or maybe that last as long as in patients with AIDS (Automune Deficiensy Syndrome) in children severe immunosuppression, diarrhea can occur because germs are not parogen and may also last long.</li>
<li>Soon Proportional, diarrhea is more common in children under five years old group (55%).</li>
</ul>
<br />
<b>Environmental factors and behavior</b><br />
<br />
Diarrheal disease is one disease-based environment, the two dominant factors, namely water supply and excreta disposal, these two factors will interact with environmental factors If human behavior is not healthy because of diarrhea and accumulate germs contaminated with human behavior that is not healthy too . Namely through food and drink, it can cause diarrhea cases.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-18383407708344524382014-08-12T10:21:00.002+07:002014-08-12T10:21:59.268+07:00Urinary Tract Infection - Symptoms and Signs in Children and the Elderly<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsb-Px7uHSB8adyrKu4JOKrUy4lNNSUTZJcmF8hXAQw8kOnfkFYQFd8ZhGV13FWuQAAvhOiEASFoXvbPbdnAu1zoOIE9i00uh_a-cU1uCRdp0r89Y-DwdgIxZ9LtIysBGpTWw5bwJygzNZ/s1600/Urinary+Tract+Infection+-+Symptoms+and+Signs+in+Children+and+the+Elderly.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjsb-Px7uHSB8adyrKu4JOKrUy4lNNSUTZJcmF8hXAQw8kOnfkFYQFd8ZhGV13FWuQAAvhOiEASFoXvbPbdnAu1zoOIE9i00uh_a-cU1uCRdp0r89Y-DwdgIxZ9LtIysBGpTWw5bwJygzNZ/s320/Urinary+Tract+Infection+-+Symptoms+and+Signs+in+Children+and+the+Elderly.jpg" /></a></div>
<b>Symptoms and Signs in Children and the Elderly </b><br />
<br />
Lower <a href="http://nandanursingdiagnoses.blogspot.com/2014/08/nanda-urinary-tract-infection.html">urinary tract infection</a> is also known as bladder infections. Symptoms most often found is a burning sensation when urinating and frequent urination need (or urge to urinate) without body duh vagina and severe pain. These symptoms may vary from mild to severe and in healthy women lasted an average of six days. Pain above the pubic bone or the lower back may also appear. People who suffer from urinary tract infection on, or pyelonephritis, may experience pelvic <a href="http://nandanursingdiagnoses.blogspot.com/2014/03/acute-pain-ncp-for-urinary-tract.html">pain</a>, fever, or nausea and vomiting in addition to the classic symptoms of lower urinary tract infection. Sometimes the urine may appear bloody or contain piuria (pus in urine) can be seen.<br />
<br />
<b>In children</b><br />
<br />
In children, symptoms of <a href="http://nandanursingdiagnoses.blogspot.com/2013/04/urinary-tract-infection-7-nursing.html">urinary tract infection</a> may be just a <a href="http://nandanursingdiagnoses.blogspot.com/2012/09/5-types-of-fever.html">fever</a>. Because the symptoms are less obvious, when she was less than two years, or men in less than one year are not circumcised fever, most medical organizations recommend that a urine culture done. Babies can be difficult to eat, vomiting, more sleep, or looks yellow. In older children, can arise new symptoms of urinary incontinence (loss of bladder control).<br />
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<b>In the elderly</b><br />
<br />
Urinary tract symptoms often do not appear on the elderly. The symptoms may be vague and only appear as incontinence, changes in mental state, or fatigue. Meanwhile, some people came to the providers of health services with early symptoms of sepsis, which is an infection in the blood. Diagnosis can be difficult because obviously a lot of older people who already have a previous incontinence or dementia.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-81863427567467725242014-08-12T10:06:00.001+07:002014-08-12T10:09:24.623+07:00Nanda for Urinary Tract Infection<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPSbL9zzF-ce5mSGgvC_ktTsfL5qdCKRFSks9A0A0197IpBYIkdXMOWuusjaUHIGPTqlMLLZ-q_Xpg4l8SF6blWGd6jmsixRH9ZYj8VX-D6PrBJ7ivdc4DDSicCnij7NavV5zGooIRzDX4/s1600/Nanda+Urinary+Tract+Infection.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPSbL9zzF-ce5mSGgvC_ktTsfL5qdCKRFSks9A0A0197IpBYIkdXMOWuusjaUHIGPTqlMLLZ-q_Xpg4l8SF6blWGd6jmsixRH9ZYj8VX-D6PrBJ7ivdc4DDSicCnij7NavV5zGooIRzDX4/s320/Nanda+Urinary+Tract+Infection.jpg" /></a></div>
<b>Nanda Nursing Diagnosis for Urinary Tract Infection</b><br />
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Urinary tract infection is a bacterial infection on top of the urinary tract. While on the urinary tract is called cystitis (bladder infection) moderate, and when on the urinary tract is called pyelonephritis (kidney infection). Symptoms of urinary tract under cover painful urination and frequent urination or the urge to urinate (or both), while the symptoms of pyelonephritis include fever and pelvic pain as well as symptoms of urinary tract infection bottom. In the elderly and small children, the symptoms can be vague or non-specific. Bacteria linked to the cause of the second type is adalahEscherichia coli, but other bacteria, viruses, or fungi can cause rare cases.<br />
<br />
Urinary tract infections are more common in women than in men, with half of the women had at least one infection during their lives. Relapse is common. Risk factors among female anatomy, sexual relationships, and family history. Pyelonephritis, when something, usually found after a bladder infection but can also be caused by an infection that is transmitted through the blood. Diagnosis in young healthy women can be based on symptoms alone. In people with vague symptoms, diagnosis may be difficult because the bacteria may be found without causing infection. In complex cases or when treatment fails, urine culture may be beneficial. In people who often suffer from infections, low dose antibiotics can be consumed as a preventative measure.<br />
<br />
In case that is not complex, urinary tract infections can be easily treated with antibiotics short term, although resistance to many antibiotics used to treat this condition tends to increase. In complex cases, antibiotics over a long period of time or intravenous may be needed, and if the symptoms have not improved within two or three days, required further diagnostic examination. In women, urinary tract infection is a bacterial infection most commonly found, that 10% suffer from urinary tract infections each year.<br />
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A number of preventive measures have not been confirmed can affect the frequency of urinary tract infections include: the use of the contraceptive pill or condoms, urinate immediately after intercourse, the kind used in apparel, personal hygiene method used after urination or bowel movements, or whether someone usually with bath or shower (shower). That is still less evidence about the effect of resist urination, use of tampons, and rinsing with a hose directly.<br />
<br />
In people who often suffer from urinary tract infections and use spermicides or diaphragm as a method of contraception, it is recommended to use other means. Cranberry (juice or capsules) can reduce the incidence in people who often suffer from infections, but there is a problem in the long-term tolerance for GI tract disorders that occur in more than 30% of people. Use twice a day is better than the use of one time per day. Until 2011, probiotics intravagina still require further research to determine whether it is beneficial. The use of condoms without spermicides or contraceptive pill use does not increase the risk of urinary tract infection medium.<br />
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<b>Nanda Nursing Diagnosis for <a href="http://nandanursingdiagnoses.blogspot.com/2013/04/urinary-tract-infection-7-nursing.html">Urinary Tract Infection</a></b><br />
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1. <a href="http://nandanursingdiagnoses.blogspot.com/2014/08/acute-pain-related-to-abdominal.html">Acute pain</a><br />
<br />
2. Hyperthermia<br />
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3. Impaired Urinary Elimination<br />
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4. <a href="http://nandanursingdiagnoses.blogspot.com/2013/06/risk-for-fluid-volume-deficit-related.html">Risk for Fluid Volume Deficit</a><br />
<br />
5. Disturbed Sleep Pattern<br />
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6. <a href="http://nandanursingdiagnoses.blogspot.com/2013/06/malaria-imbalanced-nutrition-less-than.html">Imbalanced Nutrition, Less Than Body Requirements</a><br />
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7. Anxiety<br />
<br />
8. <a href="http://nandanursingdiagnoses.blogspot.com/2012/08/nursing-diagnosis-knowledge-deficit-for.html">Knowledge Deficit</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-7693984545814596932014-08-11T07:59:00.000+07:002014-08-11T07:59:03.374+07:00Polyhydramnios - Important Note about Amniotic Fluid<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjPEdYPjLX9jRMOkcAyQyqVUVTFxVFIOx5RYRnzp3jWbhlzLJ8msI_v97L_AnFsxKOBCPALFVPElVU3dCBp4Nm51iAdFfYRDnLCNSX0uO3GCcfLcmX0OWzMnpLKkC4UHswd703Wr6tQNUD/s1600/Polyhydramnios+-+Important+Note+about+Amniotic+Fluid.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjPEdYPjLX9jRMOkcAyQyqVUVTFxVFIOx5RYRnzp3jWbhlzLJ8msI_v97L_AnFsxKOBCPALFVPElVU3dCBp4Nm51iAdFfYRDnLCNSX0uO3GCcfLcmX0OWzMnpLKkC4UHswd703Wr6tQNUD/s320/Polyhydramnios+-+Important+Note+about+Amniotic+Fluid.jpg" /></a></div>
Amniotic fluid [AF] can be detected from the very beginning of formation of the gestational sac (extra-embryonic coelom or chorionic cavity). This firstly water-like fluid originates from the maternal plasma, and passes through the fetal membranes by osmotic and hydrostatic forces. As the placental and fetal vessels develop, the fluid passes through the fetal tissue, as the exsudatum of the skin. After the 20th-25th week of pregnancy when the keratinization of skin occurs, the quantity of amniotic fluid begins to depend on the factors that comprise the circulation of AF.<br />
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The volume of amniotic fluid is positively correlated with the growth of fetus.<br />
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Amniotic fluid is inhaled and exhaled by the foetus. It is essential that fluid be breathed into the lungs in order for them to develop normally. Swallowed amniotic fluid also creates urine and contributes to the formation of meconium. Amniotic fluid protects the developing baby by cushioning against blows to the mother's abdomen, allowing for easier fetal movement and promoting muscular/skeletal development. Amniotic fluid swallowed by fetus help in the formation of gastrointestinal tract.<br />
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Polyhydramnios is a medical condition describing an excess of amniotic fluid in the amniotic sac. It is seen in about 1% of pregnancies. It is typically diagnosed when the amniotic fluid index (AFI) is greater than 24 cm. There are two clinical varieties of polyhydramnios:<br />
<ul>
<li>Chronic polyhydramnios where excess amniotic fluid accumulates gradually</li>
<li>Acute polyhydramnios where excess amniotic fluid collects rapidly</li>
</ul>
In most cases, the exact cause cannot be identified. A single case may have one or more causes, including intrauterine infection (TORCH), rh-isoimmunisation, or chorioangioma of the placenta. In a multiple gestation pregnancy, the cause of polyhydramnios usually is twin-to-twin transfusion syndrome. Maternal causes include cardiac problems, kidney problems, and maternal diabetes mellitus, which causes fetal hyperglycemia and resulting polyuria (fetal urine is a major source of amniotic fluid).<br />
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There are several pathologic conditions that can predispose a pregnancy to polyhydramnios. These include a maternal history of diabetes mellitus, Rh incompatibility between the fetus and mother, intrauterine infection, and multiple pregnancies.<br />
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During the pregnancy, certain clinical signs may suggest polyhydramnios. In the mother, the physician may observe increased abdominal size out of proportion for her weight gain and gestation age, uterine size that outpaces gestational age, shiny skin with stria (seen mostly in severe polyhydramnios), dyspnea, and chest heaviness. When examining the fetus, faint fetal heart sounds are also an important clinical sign of this condition.<br />
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<b>Treatment of Polyhydramnios</b><br />
<ul>
<li>Mild asymptomatic polyhydramnios is managed expectantly. For a woman with symptomatic polyhydramnios may need hospital admission. Antacids may be prescribed to relieve heartburn and nausea.</li>
<li>No data support dietary restriction of salt and fluid.</li>
<li>In some cases, amnioreduction, also known as therapeutic amniocentesis, has been used in response to polyhydramnios.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-42389598189495226132014-08-11T07:29:00.000+07:002019-02-13T23:35:03.028+07:00Nanda for Congestive Heart Failure (CHF)<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAKZUaukTGxGkiDECgEcNQr8N7m_PKKp3RM9TbH7Gy6OqlugfOs7wD7IGatkOqjTl1jceDNZFdg2OBc9Luu7FIPoTcsumtMtzCMLkXF_2i_poSqbKdF82WjPwtOSt2pYXFgy1dkjWkQtCg/s1600/Nanda+for+Congestive+Heart+Failure+(CHF).jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAKZUaukTGxGkiDECgEcNQr8N7m_PKKp3RM9TbH7Gy6OqlugfOs7wD7IGatkOqjTl1jceDNZFdg2OBc9Luu7FIPoTcsumtMtzCMLkXF_2i_poSqbKdF82WjPwtOSt2pYXFgy1dkjWkQtCg/s320/Nanda+for+Congestive+Heart+Failure+(CHF).jpeg" /></a></div><b>Nanda Nursing Diagnosis for Congestive Heart Failure (CHF)</b><br />
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<br />
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused by:<br />
<ul><li>diseases that weaken the heart muscle,</li>
<li>diseases that cause stiffening of the heart muscles, or</li>
<li>diseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood.</li>
</ul><br />
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Symptoms may notice first:<br />
<ul><li>fatigue</li>
<li>swelling in your ankles, feet, and legs</li>
<li>weight gain</li>
<li>increased need to urinate, especially at night</li>
</ul>Symptoms that indicate condition has worsened:<br />
<ul><li>irregular heartbeat</li>
<li>a cough that develops from congested lungs</li>
<li>wheezing</li>
</ul><br />
Symptoms that indicate a severe heart condition that requires immediate medical attention:<br />
<ul><li>chest pain that radiates through the upper body (this can also be a sign of a heart attack)</li>
<li>rapid breathing</li>
<li>skin that appears blue (from lack of oxygen in your lungs)</li>
<li>fainting</li>
</ul><br />
<br />
<b>Nanda for <a href="http://nandanursingdiagnoses.blogspot.com/2012/09/diagnosis-examination-of-chf.html">Congestive Heart Failure (CHF)</a></b><br />
<ol><li><a href="http://nandanursingdiagnoses.blogspot.com/2014/08/activity-intolerance-home-care.html">Activity Intolerance</a> </li>
<li>Decrease Cardiac Output </li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2012/08/excess-fluid-volume-nanda-nursing.html">Excess Fluid Volume</a> </li>
<li>Risk for Impaired Skin Integrity</li>
</ol><br />
Nanda Anemia<br />
Nanda Angina Pectoris<br />
Nanda Appendicitis<br />
Nanda Asthma<br />
Nanda Congestive Heart Failure<br />
Nanda Conjunctivitis<br />
Nanda COPD<br />
Nanda Depression<br />
Nanda Diabetes<br />
Nanda HemorrhoidsUnknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-51416693492114992222014-08-11T00:13:00.001+07:002014-08-11T00:13:29.532+07:00Nursing Interventions for Ineffective Coping<br />
<b>Nursing Interventions and Rationales</b><br />
<ul>
<li>Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation. <i>Situational factors must be identified to gain an understanding of the client's current situation and to aid client with coping effectively (Norris, 1992).</i></li>
<li>Observe for strengths such as the ability to relate the facts and to recognize the source of stressors. <i>Family members who are coping with critical injuries often feel defeated, hopeless, and like a failure; therefore it is imperative to verbally commend them for their strengths and use those strengths to aid functioning (Leske, 1998).</i></li>
<li>Monitor risk of harming self or others and intervene appropriately. See care plan for Risk for Suicide. <i>Situational factors can lead to depression or risk for suicide. Identification of such factors leads to appropriate referral or help (Norris, 1992). A client with hopelessness and an inability to problem solve often runs the risk of suicide (Buchanan, 1991). In these cases immediate referral for mental health care is essential (Norris, 1992).</i></li>
<li>Help client set realistic goals and identify personal skills and knowledge. <i>Involving clients in decision making helps them move toward independence (Connelly et al, 1993).</i></li>
<li>Use empathetic communication, and encourage client/family to verbalize fears, express emotions, and set goals. <i>Acknowledging and empathizing creates a supportive environment that enhances coping (Feeley, Gottlieb, 1998). Clients report increased satisfaction and empowerment, greater compliance with mutually agreed-upon goals, and less anxiety and depression when communication is empathic (Wells-Federman et al, 1995). Acknowledgment of feelings communicates support and conveys that clients are understood (Leske, 1998).</i></li>
<li>Encourage client to make choices and participate in planning of care and scheduled activities. <i>Participation gives a feeling of control and increases self-esteem.</i></li>
<li>Provide mental and physical activities within the client's ability (e.g., reading, television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports, games). <i>Interventions that enhance body awareness such as exercise, proper nutrition, and muscular relaxation may be effective for treating anxiety and depression (Wells- Federman et al, 1995).</i></li>
<li>If the client is physically able, encourage moderate aerobic exercise. <i>Aerobic exercise increases one’s ability to cope with acute stress (Anshel, 1996).</i></li>
<li>Use touch with permission. Give client a back massage using slow, rhythmic stroking with hands. Use a rate of 60 strokes a minute for 3 minutes on 2-inch wide areas on both sides of the spinous process from the crown to the sacral area. <i>A gentle touch can display acceptance and empathy (Hopkins, 1994). Slow stroke back massage decreased heart rate, decreased systolic and diastolic blood pressure, and increased skin temperature at significant levels. The conclusion is that relaxation is induced by slow stroke back massage (Meek, 1993).</i></li>
<li>Provide information regarding care before care is given. <i>In traumatic situations, families have a need for information and explanations (Hopkins, 1994). Providing information prepares the family for understanding the situation and possible outcomes (Leske, 1998). Adequate information and training before and after treatment reduces anxiety and fear (Herranz, Gavilan, 1999).</i></li>
<li>Discuss changes with client before making them. <i>Communication with the medical staff provides patients and families with understanding of the medical condition (Grootenhuis, Last, 1997).</i></li>
<li>Discuss client’s/family’s power to change a situation or the need to accept a situation. <i>Such a discussion helps the client maintain self-esteem and look at the situation realistically with the aid of a trusted individual (Norris, 1992). In threatening situations, people search for reasons for the event(s). This search is an effort to make sense of the event, gain control, and cope (Grootenhuis, Last, 1997).</i></li>
<li>Use active listening and acceptance to help client express emotions such as crying, guilt, and anger (within appropriate limits). <i>Active listening provides the client and/or family a nonjudgmental person to listen to them and relieve their guilt feelings (Hopkins, 1994). Acknowledgment of feelings communicates support and conveys that they are understood (Leske, 1998).</i></li>
<li>Avoid false reassurance; give honest answers and provide only the information requested. <i>Identification of previously used effective coping mechanisms allow the nurse to focus attention on necessary education and referral (Norris, 1992).</i></li>
<li>Encourage client to describe previous stressors and the coping mechanisms used. <i>Describing previous experiences strengthens effective coping and helps eliminate ineffective coping mechanisms.</i></li>
<li>Be supportive of coping behaviors; allow client time to relax. <i>A supportive presence creates a supportive environment to enhance coping (Feeley, Gottlieb, 1998).</i></li>
<li>Help clients to define what meaning their symptoms might have for them. <i>In one study, the importance of helping clients find meaning in their suffering experiences was identified as a strategy perceived as helpful with a group of patients who had the diagnosis of multiple sclerosis (Pollock, Sands, 1997).</i></li>
<li>Encourage use of cognitive behavioral relaxation (e.g., music therapy, guided imagery). Relaxation techniques, desensitization, and guided imagery can help clients cope, increase their sense of control, and allay anxiety (Narsavage, 1997). <i>Relaxation with guided imagery is a technique used with increasing frequency to help individuals improve their performance and control their responses to stressful situations (Rees, 1993). Music is not a cure, but it can lift the human spirit, comfort the heart, and inspire the soul. Imagery is useful for relaxation and distraction (Fontaine, 1994). The provision of information and general mastery may play a role in decreasing helplessness and dysfunctional coping (Nicassio et al, 1997).</i></li>
<li>Use distraction techniques during procedures that cause client to be fearful. <i>Distraction is used to direct attention toward a pleasurable experience and block the attention of the feared procedure (DuHamel, Redd, Johnson-Vickberg, 1999).</i></li>
<li>Use systematic desensitization when introducing new people, places, or procedures that may cause fear and altered coping. <i>Fear of new things diminishes with repeated exposure (DuHamel, Redd, Johnson- Vickberg, 1999).</i></li>
<li>Provide the client/family with a video of any feared procedure to view before the procedure. Ensure that the video shows a patient of similar age and background. <i>Videos provide the client/family with the information necessary to eliminate fear of the unknown (DuHamel, Redd, Johnson-Vickberg, 1999).</i></li>
<li>Refer for counseling as needed. <i>Arranging for referral assists the client in working with the system, and resource use helps to develop problem-solving and coping skills (Feeley, Gottlieb, 1998).</i></li>
</ul>
<br />
<b>Geriatric</b><br />
<br />
<ul>
<li>Engage client in reminiscence. <i>Reminiscence can activate past sources of self-esteem and aid in coping (Nugent, 1995).</i></li>
<li>Be aware of client's fear of illness. Identify and reinforce patterns the elderly client has previously used to respond to stress. Allow client time to reminisce about past successes. The elderly client has had a lifetime of experience dealing with stressful events. <i>A standard reminiscence interview and one that focused on successfully met challenges reduced state anxiety and enhanced coping self-efficacy when measured against both attention-placebo and no-intervention control groups (Rybarczyk, Auerbach, 1990).</i></li>
<li>Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects). <i>Such alterations may be contributing to confusion and must be corrected (Matthiesen et al, 1994). Medications are considered the most common cause of delirium in the ICU (Harvey, 1996).</i></li>
<li>Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping. An older individual's responses to age-related stress will depend on the balance of personality strengths and weaknesses. <i>Severe or multiple stresses in late life may overwhelm an individual's coping skills and lead to personality change (Agronin, 1998).</i></li>
<li>Increase and mobilize support available to the elderly client. Encourage interaction with family and friends. <i>Friends and relatives have shared many of the older person's life experiences. Such mutual interests and overlapping memories can serve to stimulate and focus conversation and contribute effectively to the client's self-esteem (Erber, 1994). Support from family, friends, and the medical community aids coping ability (Grootenhuis, Last, 1997).</i></li>
<li>Maintain continuity of care by keeping the number of caregivers to a minimum. <i>Consistency in caregivers helps decrease anxiety and fosters trust by providing the client and family with familiar faces (Hopkins, 1994).</i></li>
</ul>
<br />
<b>Multicultural</b><br />
<ul>
<li>Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of effective coping. <i>The client’s coping behavior may be based on cultural perceptions of normal and abnormal coping behavior (Leininger, 1996).</i></li>
<li>Assess for intergenerational family problems that can overwhelm coping abilities. <i>Intergenerational family problems put families at risk of dysfunction (Seiderman et al, 1996).</i></li>
<li>Encourage spirituality as a source of support for coping. <i>Many African-Americans and Latinos identify spirituality, religiousness, prayer, and church-based approaches as coping resources (Samuel-Hodge et al, 2000; Bourjolly, 1998; Mapp, Hudson, 1997).</i></li>
<li>Negotiate with the client with regard to the aspects of coping behavior that will need to be modified. <i>Give and take with the client will lead to culturally congruent care (Leininger, 1996).</i></li>
<li>Identify which family members the client can rely on for support. <i>Many Latinos, Native Americans, and African-Americans rely on family members to cope with stress (Abraido-Lanza, Guier, Revenson, 1996; Seiderman et al, 1996).</i></li>
<li>Assess the influence of fatalism on the client’s coping behavior. <i>Fatalistic perspectives involve the belief in some African-American and Latino populations that you cannot control your own fate and influence health behaviors (Phillips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996). </i></li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-77637157450698735682014-08-10T23:47:00.000+07:002014-08-10T23:54:48.700+07:00Acute Pain related to Abdominal Distention<br />
<b>Nursing Care Plan for Abdominal Distention</b><br />
<br />
<b>Nursing Diagnosis : <a href="http://nandanursingdiagnoses.blogspot.com/2014/02/acute-pain-ncp-angina-pectoris.html">Acute Pain</a> related to Abdominal Distention</b><br />
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Abdominal distension occurs when substances, such as air (gas) or fluid, accumulate in the abdomen causing its outward expansion beyond the normal girth of the stomach and waist. It is typically a symptom of an underlying disease or dysfunction in the body, rather than an illness in its own right. People suffering from this condition often describe it as "feeling bloated." Sufferers often experience a sensation of fullness, abdominal pressure and possibly nausea, pain or cramping. In the most extreme cases, upward pressure on the diaphram and lungs can also cause shortness of breath. Through a variety of causes (see below), bloating is most commonly due to buildup of gas in the stomach, small intestine or colon. The pressure sensation is often relieved, or at least lessened, by burping (belching) or passing gas (flatulence). Medications that settle gas in the stomach and intestines are also commonly used to treat the discomfort and lessen the abdominal distension.<br />
<br />
Abdominal distension (or "distended abdomen") can be a sign of many other conditions, including:<br />
<ul>
<li>Celiac disease</li>
<li>Tropical sprue</li>
<li>Small bowel bacterial overgrowth syndrome</li>
<li>Kwashiorkor</li>
<li>Eosinophilic gastroenteritis</li>
<li>Giardiasis</li>
<li>Strongyloidiasis</li>
<li>Coccidiosis</li>
<li>Capillaria philippinensis</li>
<li>Hookworm Disease</li>
<li>Whipple's disease</li>
<li>Ascites</li>
<li>Diverticulitis</li>
<li>Fasciolosis</li>
<li>Kidney stones</li>
<li>Lactose intolerance</li>
<li>Obstructed bowel</li>
<li>Polycystic liver disease</li>
<li>Pregnancy</li>
<li>Premenstrual syndrome</li>
<li>Weight gain</li>
<li>Ovarian cancer</li>
<li>Inflammatory Bowel Disease (Crohn's disease and ulcerative colitis)</li>
</ul>
<br />
<br />
Nursing Interventions : <br />
<ul>
<li>Observation of vital signs.</li>
<li>Assess the level of pain.</li>
<li>Set a comfortable position.</li>
<li>Give a warm compress on the area of the abdomen.</li>
<li>Collaboration with doctors in therafi analgesics as indicated.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-80978061840859828882014-08-10T23:31:00.000+07:002014-08-10T23:31:57.352+07:00Nanda for Insomnia<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiatz6aBH1miVT3KjAiq2WNli35csJaw3v-B86y541Bhgms5aASL7PKc7k_NLVUlmUUPUDFLFzFbcOrefn7VU0gi7p1BYF_7Ql6aQCyf1yPraGjf6v1ztS8AL1TxKb9omSiTXk3TBXCtC6H/s1600/Nanda+for+Insomnia.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiatz6aBH1miVT3KjAiq2WNli35csJaw3v-B86y541Bhgms5aASL7PKc7k_NLVUlmUUPUDFLFzFbcOrefn7VU0gi7p1BYF_7Ql6aQCyf1yPraGjf6v1ztS8AL1TxKb9omSiTXk3TBXCtC6H/s320/Nanda+for+Insomnia.jpg" /></a></div>
<b>Nanda Nursing Diagnosis for Insomnia</b><br />
<br />
Insomnia is a symptom of a sleep disorder in recurrent difficulty to sleep or maintaining sleep, although there is a chance for it. The symptoms are typically followed by functional impairment while awake.<br />
<br />
Insomnia is often caused by the presence of a disease or as a result of psychological problems. In this case, medical or psychological assistance will be required. One of the psychological therapies that effectively deal with insomnia is cognitive therapy. In the therapy, a patient is taught to improve sleep habits and eliminate counter-productive assumptions about sleep.<br />
<br />
Many people with insomnia depending on sleeping pills and other sedative substances to be rested. All sedative drugs have the potential to cause psychological dependence such as the notion that they can not sleep without the drug.<br />
<br />
<br />
<b>Causes of Insomnia</b><br />
<br />
Insomnia is not a disease, but a symptom that has a variety of causes, such as emotional disorders, physical disorders and drug use.<br />
<br />
Difficulty sleeping often occurs, both the young and the elderly; and often occur in conjunction with emotional disorders, such as anxiety, restlessness, depression or fear.<br />
<br />
Sometimes a person have trouble sleeping simply because the body and brain are not tired.<br />
<br />
With increasing age, sleep tends to decrease. Stage of sleep also changes, where stage 4 becomes shorter and eventually disappear, and at all stages more awake. These changes, although normal, often make parents think that they are not getting enough sleep.<br />
<br />
The pattern of waking at dawn more often found in the elderly. Some people fall asleep normally but wake up several hours later and it's hard to fall asleep again.<br />
<br />
Sometimes they sleep in a state of restless sleep and feeling unsatisfied. Woke up at dawn, at any age, is a sign of depression.<br />
<br />
People who are able to experience disrupted sleep patterns are reversed sleep rhythm, they are not asleep at the time to sleep and wake up in time to sleep.<br />
<br />
This often occurs as a result of:<br />
<ul>
<li>Jet lag (especially if traveling from east to west).</li>
<li>Working at night.</li>
<li>Frequently changing work hours.</li>
<li>Excessive alcohol use.</li>
<li>Drug side effects (sometimes).</li>
<li>Damage to the brain (as encephalitis, stroke, Alzheimer's disease).</li>
</ul>
<br />
<br />
<b>Symptoms of <a href="http://nandanursingdiagnoses.blogspot.com/2014/04/10-ways-to-overcome-insomnia-difficulty.html">Insomnia</a></b><br />
<br />
Patients find it difficult to fall asleep or stay awake at night and feel tired all day. Beginning the process of sleep in patients with insomnia refers to a prolonged latency from bedtime to sleep. In the psycho-physiological insomnia, patients may complain of feeling anxious, tense, worried, or considering the continuous problems in the past or in the future as they lay in bed too long without sleep. In acute insomnia, it is possible there is a triggering event, such as death or disease affecting a loved one. This can be attributed to the onset of insomnia. This pattern may be fixed from time to time, and the patient may experience insomnia, repeated constantly. The greater the effort expended in trying to sleep, sleep becomes more difficult to obtain. Watching the clock when every minute and hour passed only increase feelings of urgency and effort to fall asleep. The bed can eventually be viewed as a battlefield, and sleep more easily achieved in a foreign environment.<br />
<br />
<br />
<b>Treatment of Insomnia</b><br />
<br />
Treatment of insomnia depends on the cause and severity of insomnia.<br />
<br />
Parents who experience sleep changes as we age, usually do not require treatment, because these changes are normal.<br />
<br />
Insomniacs should remain calm and relaxing couple of hours before bedtime and create a comfortable atmosphere in the bedroom; dim light and not noisy.<br />
<br />
If the cause is emotional stress, given drugs to reduce stress. If the cause is depression, given anti-depressants.<br />
<br />
If the sleep disturbance associated with normal activities the patient and the patient felt well, sleeping pills can be given for the time being. Another alternative to treat insomnia without drugs by therapeutic hypnosis is or hypnotherapy.<br />
<br />
<br />
<b>Nanda for Insomnia</b><br />
<ol>
<li>Disturbed Sleep Pattern</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2014/02/disturbed-sensory-perception-and.html">Anxiety</a></li>
<li>Ineffective individual coping</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2014/08/nursing-interventions-and-rationales.html">Impaired gas exchange</a></li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2012/09/risk-for-injury-related-to-infectious.html">Risk for Injury</a></li>
<li>Self-concept disturbance</li>
</ol>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-26035950017561616602014-08-09T23:13:00.002+07:002014-08-09T23:21:36.593+07:00Activity Intolerance - Home Care Interventions and Client / Family Teaching<br />
<b>Home Care Interventions </b><br />
<br />
1. Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services.<br />
<br />
2. Assess the home environment for factors that precipitate decreased activity tolerance: presence of allergens such as dust, smoke, and those associated with pets; temperature; energy-intensive activity patterns; and furniture placement. Refer to occupational therapy if needed to assist the client in restructuring the home and activity of daily living patterns. R/ : Clients and families often estimate energy requirements inaccurately during hospitalization because of the availability of support.<br />
<br />
3. Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events).<br />
<br />
4. Provide client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity. <br />
R/ : Social isolation can contribute to activity intolerance.<br />
<br />
5. Discuss the importance of sexual activity as part of daily living. Instruct the client in adaptive techniques to conserve energy during sexual interactions. <br />
R/ : Families may make unsafe choices for sexual activity or place added stress on themselves trying to cope with this issue without proper support or teaching.<br />
<br />
6. Instruct the client and family in the importance of maintaining proper nutrition and rest for energy conservation and rehabilitation.<br />
<br />
7. Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living.<br />
<br />
8. Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g., assistive devices, oxygen, medication, catheters, massage), especially for hospice patients. Evaluate intermittently. <br />
R/ : Assessments ensure the safety and appropriate use of these supports.<br />
<br />
9. Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated. R/ : Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).<br />
<br />
10. Be aware of increased risk of bone fracture even after muscle strength is normalized, especially in osteopenic-prone individuals such as estrogen-deficient women and the elderly. <br />
R/ : Reduction in weight bearing muscle activity during bed rest invariably produces significant changes in calcium balance and, in weeks, changes in bone mass (Bloomfield, 1997)<br />
<br />
11. Allow terminally ill clients and their families to guide care. <br />
R/ : Control by the client or family promotes effective coping.<br />
<br />
12. Provide increased attention to comfort and dignity of the terminally ill client in care planning. For example, oxygen may be more valuable as a support to the client's psychological comfort than as a booster of oxygen saturation. <br />
<br />
<br />
<br />
<b>Client/Family Teaching</b><br />
<br />
1. Instruct client on rationale and techniques for avoiding activity intolerance.<br />
<br />
2. Teach client to use controlled breathing techniques with activity.<br />
<br />
3. Teach client the importance and method of coughing, clearing secretions.<br />
<br />
4. Instruct client in the use of relaxation techniques during activity.<br />
<br />
5. Help client with energy conservation and work simplification techniques in ADLs.<br />
<br />
6. Teach client the importance of proper nutrition.<br />
<br />
7. Describe to client the symptoms of activity intolerance, including which symptoms to report to the physician.<br />
<br />
8. Explain to client how to use assistive devices or medications before or during activity.<br />
<br />
9. Help client set up an activity log to record exercise and exercise tolerance.<br />
<br />
Related :<br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2013/04/nanda-activity-intolerance.html" title="Permalink to NANDA Activity Intolerance">NANDA Activity Intolerance</a> <br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2014/08/activity-intolerance-home-care.html" title="Permalink to Activity Intolerance - Home Care Interventions and Client / Family Teaching">Activity Intolerance - Home Care Interventions and Client / Family Teaching</a><br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2014/08/nursing-interventions-and-rationales_9.html" title="Permalink to Nursing Interventions and Rationales for Activity Intolerance">Nursing Interventions and Rationales for Activity Intolerance</a><br />
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-26300086760859903162014-08-09T23:05:00.005+07:002014-08-09T23:21:23.303+07:00Nursing Interventions and Rationales for Activity Intolerance<b>Nursing Interventions for Activity Intolerance</b><br />
<br />
<br />
1. Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. R/: Determining the cause of a disease can help direct appropriate interventions.<br />
<br />
2. Assess client daily for appropriateness of activity and bed rest orders. R/ : Inappropriate prolonged bed rest orders may contribute to activity intolerance. A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999).<br />
<br />
3. Minimize cardiovascular deconditioning by positioning clients as close to the upright position as possible several times daily. <br />
R/ : The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998).<br />
<br />
4. If appropriate, gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to chair sitting, to standing, to ambulation. R/ : Increasing activity helps to maintain muscle strength, tone, and endurance. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous, 1998).<br />
<br />
5. Ensure that clients change position slowly. Consider using a chair-bed (stretcher-chair) for clients who cannot get out of bed. Monitor for symptoms of activity intolerance. <br />
R/ : Bed rest in the supine position results in loss of plasma volume, which contributes to postural hypotension and syncope (Creditor, 1993).<br />
<br />
6. When getting clients up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs. <br />
R/ : Heart rate and blood pressure responses to orthostasis vary widely. Vital sign changes by themselves should not define orthostatic intolerance (Winslow, Lane, Woods, 1995).<br />
<br />
7. Perform range-of-motion exercises if client is unable to tolerate activity. <br />
R/ : Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Creditor, 1994).<br />
<br />
8. Refer client to physical therapy to help increase activity levels and strength.<br />
<br />
9. Monitor and record client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (ACSM, 1995):<br />
o Excessive fatigue<br />
o Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency<br />
o Onset of angina with exercise<br />
o Palpitations<br />
o Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced left bundle block, second- or third-degree atrioventricular block, frequent premature ventricular contractions)<br />
o Exercise hypotension (drop in systolic blood pressure of more than 10 mm Hg from baseline blood pressure despite an increase in workload, when accompanied by other evidence of ischemia)<br />
o Excessive rise in blood pressure (systolic greater than 220 mm Hg or diastolic greater than 110 mm Hg); NOTE: these are upper limits; activity may be stopped before reaching these values<br />
o Inappropriate bradycardia (drop in heart rate greater than 10 beats/min) with no change or increase in workload<br />
o Increased heart rate above the prescribed limit<br />
<br />
10. Instruct client to stop activity immediately and report to physician if experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort, tightness, or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. <br />
R/ : These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician (McGoon, 1993). The client should be evaluated before resuming activity (Thompson, 1988).<br />
<br />
11. Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. <br />
R/ : Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).<br />
<br />
12. Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers. <br />
R/ : Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998).<br />
<br />
13. Assess urinary incontinence related to functional ability. Assess independent ability to get to the toilet and remove and adjust clothing. R/ : The loss of functional ability that accompanies disease often leads to continence problems. The cause may not be the person's bladder instability but his or her ability to get to the toilet quickly (Nazarko, 1997).<br />
<br />
14. Assess for constipation. <br />
R/ : Impaired mobility is associated with increased risk of bowel dysfunction, including constipation. Constipation increases the risk of urinary tract infection and urge incontinence (Nazarko, 1997).<br />
<br />
15. Consider dietitian referral to assess nutritional needs related to activity intolerance. <br />
R/ : Severe malnutrition can lead to activity intolerance. Dietitians can recommend dietary changes that can improve the client's health status (Peckenpaugh, Poleman, 1999).<br />
<br />
16. Refer the cardiac client to cardiac rehabilitation for assistance in developing safe exercise guidelines based on testing and medications. R/ : Cardiac rehabilitation exercise training improves objective measures of exercise tolerance in both men and women, including elderly patients with coronary heart disease and heart failure. This functional improvement occurs without significant cardiovascular complications or other adverse outcomes (Wenger et al, 1995).<br />
<br />
17. Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity. <br />
R/ : Supplemental oxygen increases circulatory oxygen levels and improves activity tolerance (Petty, Finigan, 1968; Casaburi, Petty, 1993).<br />
<br />
18. Monitor a chronic obstructive pulmonary disease (COPD) client's response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, and skin tone changes such as pallor and cyanosis.<br />
<br />
19. Instruct and assist COPD clients in using conscious controlled breathing techniques such as pursing their lips and diaphragmatic breathing. <br />
R/ : Training clients with COPD to slow their respiratory rate with a prolonged exhalation (with or without pursed lips) helps control dyspnea and results in improved ventilation, increased tidal volume, decreased respiratory rate, and a reduced alveolar-arterial oxygen difference. This breathing pattern not only helps relieve dyspnea but can improve the ability to exercise and carry out ADLs (Mueller, Petty, Filley, 1970; Casaburi, Petty, 1993).<br />
<br />
20. Provide emotional support and encouragement to client to gradually increase activity. <br />
R/ : Fear of breathlessness, pain, or falling may decrease willingness to increase activity.<br />
<br />
21. Refer the COPD client to a pulmonary rehabilitation program. <br />
R/ : Pulmonary rehabilitation has been shown to improve exercise capacity, walking ability, and sense of well-being (Fishman, 1994).<br />
<br />
22. Observe for pain before activity. If possible, treat pain before activity, and ensure that client is not heavily sedated. <br />
R/ : Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.<br />
<br />
23. Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen). R/ : Assistive devices can increase mobility by helping the client overcome limitations.<br />
<br />
24. Use a walking belt when ambulating a client who is unsteady. <br />
R/ : With a walking belt the client can walk independently, but the nurse can provide support if the client's knees buckle.<br />
<br />
25. Work with client to set mutual goals that increase activity levels.<br />
<br />
<br />
<br />
Geriatric<br />
<br />
26. Slow the pace of care. Allow client extra time to carry out activities.<br />
<br />
27. Encourage families to help/allow elder to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary. <br />
R/ : Encouraging activity not only enhances good functioning of the body's systems but also promotes a sense of worth by providing an opportunity for productivity (Eliopoulous, 1997).<br />
<br />
28. When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting. <br />
R/ : Orthostatic hypotension is common in the elderly as a result of cardiovascular changes, chronic diseases, and medication effects (Mobily, Kelley, 1991). <br />
<br />
Related :<br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2013/04/nanda-activity-intolerance.html" title="Permalink to NANDA Activity Intolerance">NANDA Activity Intolerance</a> <br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2014/08/activity-intolerance-home-care.html" title="Permalink to Activity Intolerance - Home Care Interventions and Client / Family Teaching">Activity Intolerance - Home Care Interventions and Client / Family Teaching</a><br />
<br />
<a href="http://nandanursingdiagnoses.blogspot.com/2014/08/nursing-interventions-and-rationales_9.html" title="Permalink to Nursing Interventions and Rationales for Activity Intolerance">Nursing Interventions and Rationales for Activity Intolerance</a>Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-69406304122772724582014-08-05T15:04:00.000+07:002014-08-05T15:08:52.108+07:00Nursing Notes : Hepatitis A Symptoms, Incubation Period and Prevention<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEii8MYelqW8TQ36-J82SkPftEwbpD-gFIrrdkUcJrj5YWxLm3UOgsmF_kguIgQSbL4b1Wmg63MujMK2hl__vLZYB5AV78K9BS-KLUPfBMGyMYpO6aAyHgSgTrplTCbRtEFizIWIw5zH4ow2/s1600/Nursing+Notes+-+Hepatitis+A+Symptoms,+Incubation+Period+and+Prevention.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEii8MYelqW8TQ36-J82SkPftEwbpD-gFIrrdkUcJrj5YWxLm3UOgsmF_kguIgQSbL4b1Wmg63MujMK2hl__vLZYB5AV78K9BS-KLUPfBMGyMYpO6aAyHgSgTrplTCbRtEFizIWIw5zH4ow2/s320/Nursing+Notes+-+Hepatitis+A+Symptoms,+Incubation+Period+and+Prevention.jpg" /></a></div>
Hepatitis A<br />
<br />
Hepatitis A is a disease caused by a virus that is spread by dirt / feces of patients; usually through food (fecal - oral), not through sexual activity or through blood. Hepatitis A is lighter than other types of hepatitis (B and C). While hepatitis B and C is spread through blood and sexual activity media and more dangerous than Hepatitis A.<br />
<br />
<br />
<b>Symptoms</b><br />
<br />
Often there is nothing for young children;<br />
<br />
Hepatitis A can be divided into 3 stages:<br />
<ol>
<li>Introduction (prodromal) with symptoms of fatigue, lethargy, fever, loss of appetite and nausea;</li>
<li>Stadium with symptoms of yellow (jaundice stage); and</li>
<li>Recovery stage (konvalesensi). Symptoms of yellow is not always found. Performed to confirm the diagnosis of liver enzyme tests, SGPT, SGOT. Because the hepatitis A can also occur inflammation of the bile ducts, the examination gamma-GT and alkaline phosphatase can be done in addition to the levels of bilirubin.</li>
</ol>
<br />
Signs and symptoms of Hepatitis A are:<br />
<ul>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2012/09/fatigue-related-to-hyperthyroidism.html">Fatigue</a></li>
<li>Nausea and vomiting</li>
<li>Abdominal pain or discomfort, especially in the area of the liver (on the right side below the ribs)</li>
<li>Loss of appetite</li>
<li><a href="http://nandanursingdiagnoses.blogspot.com/2012/09/5-types-of-fever.html">Fever</a></li>
<li>Dark-colored urine</li>
<li>Muscle pain</li>
<li>Yellowing of the skin and eyes (jaundice).</li>
</ul>
<br />
<b><br />
</b> <b>Incubation Period</b><br />
<br />
Transmission of hepatitis A virus or hepatitis virus type A (HVA) through the fecal-oral, the virus is found in the stool. The virus is also easily transmitted through food or beverages that have been contaminated, also sometimes through sex with an infected person.<br />
<br />
Symptoms of hepatitis A usually do not appear until you have the virus for several weeks. <a href="http://nandanursingdiagnoses.blogspot.com/2014/08/nursing-notes-hepatitis-symptoms.html">Hepatitis A</a> is associated with a clean lifestyle. In many cases, hepatitis A infection never develop to severe hepatitis B or C so it will not cause liver cancer. However, Hepatitis A continues to be treated well because of reduced productivity for those who need to be hospitalized.<br />
<br />
Time from exposure to illness from approximately 2 to 6 weeks. Patients will experience symptoms such as fever, weakness, fatigue, and lethargy, in some cases, vomiting often occurs continuously, causing the whole body felt weak. Fever that occurs is a continuous fever, unlike other fever is dengue fever, tuberculosis, thypus, etc..<br />
<br />
<br />
<b>Suggested Exile</b><br />
<br />
During the 2 weeks after the first symptoms or 1 week after the onset of <a href="http://nandanursingdiagnoses.blogspot.com/2014/02/obstructive-jaundice-related-to-common.html">jaundice</a>. Patients are also expected to maintain cleanliness. And better to be hospitalized in order to receive adequate medical assistance.<br />
<br />
<br />
<b>Prevention</b><br />
<br />
Mild cases of hepatitis A usually does not require treatment, and most people who are infected recover completely with no permanent liver damage.<br />
<br />
Good hygiene practices, such as washing hands with soap before eating and after toilet is one of the best ways to protect themselves against viral hepatitis A. People close to the patient may require immunoglobulin therapy. Hepatitis A immunization can be done in the form of its own (Havrix) or a combination with hepatitis B vaccine (Twinrix). Hepatitis A immunization is done two times, namely primary and booster vaccinations were performed 6-12 months later, while hepatitis B immunization is done three times, namely basic, one-month and 6 months later. Hepatitis A immunization is recommended for people who are potentially infected as a boarder and they are often snacks outside the home.<br />
<br />
There is no specific treatment for hepatitis A, since the infection itself will usually heal in 1-2 months. However, to reduce the impact of damage to the liver and speed the healing process, the following steps will be given treatment while hospitalized.<br />
<br />
1 Rest. The goal is to provide enough energy for the body's immune system to fight infections.<br />
<br />
2 Anti nausea. One of the effects of infeksiHhepatitis A is nausea, which reduces appetite. This impact must be addressed because nutrition is very important in the healing process.<br />
<br />
3 Rest liver. The function of the liver is to metabolize drugs that have been used in the body. Because liver inflammation is experiencing pain, then drugs and alcohol are not necessary and the like should be avoided during illness.<br />
<br />
Prevention for Hepatitis A is doing vaccinations are also available for people who are at high risk.Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-28616777398178166942014-08-05T08:03:00.001+07:002014-08-05T08:03:36.398+07:00Diarrhea - Home Care Interventions and Client / Family Teaching<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihz4w7QeIdg34Ux8ghnXXZnig4Tb0dbiBwo2QDAeOFYl2p0ILVBKP_zIFgKVS8iTDLT_aKn8eOe3Tv6-1OXEqfHiEGFsyLcoXCmpXF7oIZnKBYfOJumE7zK_8lKmDgYjA4p77jLFkNCNtd/s1600/Diarrhea+-+Home+Care+Interventions+and+Client++Family+Teaching.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEihz4w7QeIdg34Ux8ghnXXZnig4Tb0dbiBwo2QDAeOFYl2p0ILVBKP_zIFgKVS8iTDLT_aKn8eOe3Tv6-1OXEqfHiEGFsyLcoXCmpXF7oIZnKBYfOJumE7zK_8lKmDgYjA4p77jLFkNCNtd/s320/Diarrhea+-+Home+Care+Interventions+and+Client++Family+Teaching.jpg" /></a></div>
<b>NANDA Definition: </b>Passage of loose, unformed stools<br />
<br />
<b>Home Care Interventions</b><br />
<br />
1. Assess the home for general sanitation and methods of food preparation. Reinforce principles of sanitation for food handling.<br />
<br />
2.Assess for methods of handling soiled laundry if client is bedbound or has been incontinent. Instruct or reinforce Standard Precautions with family and bloodborne pathogen precautions with agency caregivers. The Bloodborne Pathogen Regulations of the Occupational Safety and Health Administration (OSHA) identify legal guidelines for caregivers.<br />
<br />
3. When assessing medication history, include over-the-counter drugs, both general and those currently being used to treat the diarrhea. Instruct clients not to mix over-the-counter medications when self-treating. Mixing over-the-counter medications can further irritate the gastrointestinal system, intensifying the diarrhea or causing nausea and vomiting.<br />
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<b>Client/Family Teaching</b><br />
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1. Encourage avoidance of coffee, spices, milk products, and foods that irritate or stimulate the gastrointestinal tract.<br />
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2. Teach appropriate method of taking ordered antidiarrheal medications; explain side effects.<br />
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3. Explain how to prevent the spread of infectious diarrhea (e.g., careful handwashing, appropriate handling and storage of food).<br />
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4. Help client to determine stressors and set up an appropriate stress reduction plan.<br />
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5. Teach signs and symptoms of dehydration and electrolyte imbalance. Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-3846551388325669632014-08-05T07:55:00.000+07:002014-08-05T07:55:41.374+07:00Nursing Notes : Diarrhea Causes, Symptoms, Treatment and Prevention<div class="separator" style="clear: both; text-align: center;">
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<b>Diarrhea</b><br />
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Diarrhea is a disease in which the stool or feces turns into soft or liquid which usually happens at least three times in 24 hours. In developing countries, diarrhea is the most common cause of infant mortality, and also kills more than 2.6 million people annually.<br />
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<b>Causes</b><br />
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This condition can be a symptom of injury, disease, allergies (fructose, lactose), excess vitamin C, and eating certain fruits. Usually accompanied by abdominal pain and often nausea and vomiting. There are several other conditions involving, but not all symptoms of diarrhea, and the formal medical definition of diarrhea is defecation in excess of 200 grams per day.<br />
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Eating food that is acidic, spicy all at once to excess can cause diarrhea as well as making the intestine shock.<br />
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This occurs when insufficient fluid is absorbed by the colon. As part of the digestion process, or due to fluid intake, food is mixed with large amounts of water. Therefore digested food consisting of fluid before it reaches the large intestine. The large intestine absorbs water, leaving the remaining material as a semisolid stool. When the large intestine is damaged / inflammation, absorption does not occur and the result is watery stools.<br />
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Diarrhea is most commonly caused by a viral infection but also often the result of bacterial toxins. In sanitary living conditions and with ample food and water available, otherwise healthy patient usually recovers from viral infection common in a few days and a maximum of one week. But for individuals who are sick or malnourished, diarrhea can cause severe dehydration and can become life-threatening without treatment.<br />
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Diarrhea can be a symptom of more serious diseases, such as dysentery, cholera or botulism, and can also be indicative of a chronic syndrome such as Crohn's disease. Though appendicitis patients do not generally have diarrhea, diarrhea are common symptoms of appendicitis.<br />
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Diarrhea can also be caused by excessive alcohol consumption, especially in someone who does not eat enough. so if want to consume alcohol better eating beforehand.<br />
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Unstable weather conditions, poor sanitation shelter and housing conditions were still stained with a pool of water, also the difficulty of accessing clean water easily cause diarrhea outbreak after flooding. Diarrhoeal diseases are visible light can actually be life threatening, because when the body is dehydrated, then all organs will be impaired. Diarrhea will be more dangerous if it occurs in children.<br />
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<b>Symptoms</b><br />
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Symptoms are usually found is defecate constantly accompanied by prolonged heartburn, dehydration, nausea and vomiting. But other symptoms that can arise include stiffness in the back, and belly rings often.<br />
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<b>Treatment</b><br />
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Treatment for diarrhea involves the patient consuming adequate amounts of water to replace lost, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. ORS and zinc tablets are the treatment of choice and has an estimated primary has saved 50 million children in the last 25 years. For many people, further treatment and formal medical advice is needed.<br />
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If not available ORS powder, ORS can be made with the following ingredients:<br />
<ul>
<li>200 ml of water or a glass the size of a ripe starfruit.</li>
<li>2 teaspoons of sugar.</li>
<li>1/2 teaspoon fine salt.</li>
</ul>
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Diarrhea is usually required under medical supervision:<br />
<ul>
<li>Diarrhea in toddlers</li>
<li>Moderate or severe diarrhea in children</li>
<li>Diarrhea associated with blood.</li>
<li>Diarrhea that continues for more than 2 weeks.</li>
<li>Diarrhea is accompanied by other common diseases such as abdominal pain, fever, weight loss, and others.</li>
<li>Diarrhea in people traveling (possibly exotic infections such as parasites)</li>
<li>Diarrhea in institutions such as hospitals, child care, mental health institutes.</li>
</ul>
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<b>Prevention</b><br />
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Prevention of diarrhea several ways, among others:<br />
<ul>
<li>Keep hydrated with balanced electrolyte. This is the most appropriate way in most cases of diarrhea, dysentery and even. Consuming large amounts of water are not diseimbangi with edible electrolyte can lead to electrolyte imbalance which is dangerous and in some rare cases can be fatal (water intoxication).</li>
<li>Trying to eat more frequently but with smaller portions, regular frequency, and do not eat or drink too fast.</li>
<li>Intravenous fluid: sometimes, especially in children, can be life-threatening dehydration and intravenous fluids may be required.</li>
<li>Oral rehydration therapy: Drinking a solution of sugar / salt, which can be absorbed by the body.</li>
<li>Maintain hygiene and isolation: body hygiene is a major factor in limiting the spread of disease.</li>
</ul>
Unknownnoreply@blogger.comtag:blogger.com,1999:blog-4516489736954958301.post-32718875270545178332014-08-05T00:46:00.001+07:002014-08-05T00:56:03.949+07:00Nursing Interventions and Rationales for Impaired Gas Exchange<br />
<b>Nursing Interventions and Rationales</b><br />
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1. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns. Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia.<br />
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2. Auscultate breath sounds q __ h(rs). Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia.<br />
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3. Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi, Keyes, 1994). In late stages the client becomes lethargic, somnolent, and then comatose (Pierson, 2000).<br />
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4. Monitor oxygen saturation continuously, using pulse oximeter. Note blood gas results as available. An oxygen saturation of less than 90 <span lang="EN-GB" style="color: black; font-family: "Verdana","sans-serif"; font-size: 9.0pt;"><i><span style="font-family: "Verdana","sans-serif";">(normal: 95% to 100%) </span></i></span><br />
<span lang="EN-GB" style="color: black; font-family: "Verdana","sans-serif"; font-size: 9.0pt;"><i><span style="font-family: "Verdana","sans-serif";">or a partial pressure of oxygen of less than 80 </span></i></span><span lang="EN-GB" style="color: black; font-family: "Verdana","sans-serif"; font-size: 9.0pt;"><em><span style="font-family: "Verdana","sans-serif";"> (normal: 80 to 100) indicates significant oxygenation problems.</span></em></span><br />
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5. Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes. Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious (Carpenter, 1993).<br />
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6. If client is acutely dyspneic, coach the client to slow respiratory rate using touch on the shoulder, demonstrating slower respirations while making eye contact with the client, and communicating in a calm, supportive fashion. Anxiety can exacerbate dyspnea, causing the client to enter into a dyspneic panic state (Gift, Moore, Soeken, 1992; Bruera et al, 2000). The nurse's presence, reassurance, and help in controlling the client's breathing can be very beneficial (Truesdell, 2000).<br />
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7. Demonstrate and encourage the client to use pursed-lip breathing. Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels (Breslin, 1992). Pursed-lip breathing can result in increased exercise performance (Casciarai et al, 1981), and it empowers the client to self-manage dyspnic incidences (Truesdell, 2000).<br />
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8. Position client with head of bed elevated, in a semi-Fowler's position as tolerated. Semi-Fowler's position allows increased lung expansion because the abdominal contents are not crowding the lungs.<br />
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9. If client has unilateral lung disease, alternate semi-Fowler's position with lateral position (with a 10- to 15-degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with a pulmonary abscess or hemorrhage or interstitial emphysema. Gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation (Lasater-Erhard, 1995; Yeaw, 1992).<br />
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10. If client has a bilateral lung disease, position in either a semi-Fowler's or side-lying position, which increases oxygenation as indicated by pulse oximetry (or if client has pulmonary catheter, venous oxygen saturation). Turn client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into a supine position and evaluate oxygen status. Turning is important to prevent complications of immobility, but in critically ill clients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation (Winslow, 1992). Critically ill clients should be turned carefully and watched closely (Gawlinksi, Dracup, 1998).<br />
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11. If client is obese or has ascites, consider positioning client in reverse Trendelenburg position at 45 degrees for periods as tolerated. A study demonstrated that use of the reverse Trendelenburg position at 45 degrees resulted in increased tidal volumes and decreased respiratory rates in a group of intubated clients with obesity, abdominal distention, and ascites (Burns et al, 1994; Winslow, 1996).<br />
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12. Consider positioning the client prone with upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation, and turn back if desaturation occurs. Do not put in prone position if client has multisystem trauma. Partial pressure of arterial oxygen has been shown to increase in the prone position, possibly because of greater contraction of the diaphragm and increased function of ventral lung regions (Douglas et al, 1977; Lasater-Erhard, 1995; Curley, 1999). Prone positioining improves hypoxemia significantly (Dupont et al, 2000). In one study clients with multisystem trauma had serious iatrogenic injuries with prone positioning, including wound dehiscence, chest wall pressure necrosis, and a cardiac arrest (Offner et al, 2000).<br />
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13. If client is acutely dyspnic, consider having client lean forward over a bedside table, if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Celli, 1998). The tripid position can be helpful during times of dypnea (Dunn, 2001).<br />
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14. Help client deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles as tolerated. This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective<br />
NOTE: If client has excessive fluid in respiratory system, see interventions for Ineffective Airway clearance.<br />
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15. Monitor the effects of sedation and analgesics on client's respiratory pattern; use judiciously. Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia.<br />
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16. Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia.<br />
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17. Administer humidified oxygen through appropriate device (e.g., nasal cannula or face mask per physician's order); watch for onset of hypoventilation as evidenced by increased somnolence after initiating or increasing oxygen therapy. A client with chronic lung disease client may need a hypoxic drive to breathe and may hypoventilate during oxygen therapy.<br />
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18. Provide adequate fluids to liquefy secretions within the client's cardiac and renal reserve. If client is severely debilitated from chronic respiratory disease, consider use of a wheeled walker to help in ambulation.<br />
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19. Use of a wheeled walker has been shown to result in significant decrease in disability, hypoxemia, and breathlessness during a 6-minute walk test (Honeyman, Barr, Stubbing, 1996).<br />
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20. Monitor nutritional status. Refer client for a dietary consult if needed. Many clients with emphysema are malnourished. Improved nutrition can help improve inspiratory muscle function (Meeks et al, 1999).<br />
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21. If chronic pulmonary disease is interfering with quality of life, refer client for pulmonary rehabilitation. Pulmonary rehabilitation programs that include desensitization to dyspnea and guided mastery with monitored exercise are preferable. Pulmonary rehabilitation has been shown to improve exercise capacity, ability to walk, and sense of well-being (Fishman, 1994; American Thoracic Society, 1999; Janssens, 2000). The processes of desensitization and guided mastery for control of dyspnea have helped clients learn to be in control of their condition and have increased the amount of activity they can tolerate (Carrieri-Kohlman et al, 1993).<br />
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22. Refer client to pulmonary rehabilitation team if client has chronic respiratory disease. This team is multidisciplinary, and working together can help increase exercise capacity, decrease dyspnea, improve quality of life, and decrease admissions to the hospital (Celli, 1998).<br />
NOTE: If client becomes ventilator-dependent, see care plan for Impaired spontaneous Ventilation.<br />
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Geriatric<br />
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23. Use central nervous system depressants carefully to avoid decreasing respiration rate. An elderly client is prone to respiratory depression.<br />
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24. Maintain low-flow oxygen therapy. An elderly client is susceptible to oxygen-induced respiratory depression.<br />
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25. Encourage client to stop smoking. There are substantial health benefits for elderly clients who stop smoking (Foyt, 1992). <!--90--><!--90-->Unknownnoreply@blogger.com