tag:blogger.com,1999:blog-48425580509477367422024-03-06T05:21:52.918+07:00NANDA - Nursing DiagnosisWibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comBlogger96125tag:blogger.com,1999:blog-4842558050947736742.post-82423943244747192192015-06-03T16:44:00.001+07:002015-06-03T16:44:18.096+07:00Ineffective airway clearance - NCP for Bronchitis<b>Nursing Care Plan for Bronchitis - <a href="http://nanda-diagnosis.blogspot.com/2014/07/ineffective-airway-clearance-and.html">Ineffective airway clearance</a></b><br />
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Respiration is gas exchange, namely oxygen (O²) needed by the body for the metabolism of cells and carbon dioxide (CO²) generated from the metabolism excreted from the body through the lungs. Respiration is breathing air from outside events containing oxygen and exhale air that contains a lot of carbon dioxide out of the body.<br />
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The respiratory system is an organ system that serves to take O2 from the atmosphere into the body's cells for transporting CO2 produced by the cells of the body back into the atmosphere. Respiratory organs also serve to talk and play a role in the production of acid-base balance, the body's defense against foreign substances, and hormonal regulation of blood pressure. Respiration is gas exchange between the individual and the environment or the entire process of gas exchange between the atmospheric air and blood and the blood to the body's cells (Syaifuddin, 2002).<br />
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The respiratory system is basically formed by the respiratory tract and lungs along with the wrapping (pleura) and chest cavity are protected. In the chest cavity there is also the heart. Chest cavity separated by the abdominal cavity, by the diaphragm. Airway through which the air is the nose, pharynx, larynx, trachea, bronchi, bronchioles and alveoli.<br />
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Bronchitis is an inflammation of the bronchi. Bronchitis can be acute or chronic (Irma Somantri, 2009).<br />
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Bronchitis is an inflammation of the bronchioles, bronchi, and trachea by various causes. Bronchitis usually more often caused by viruses such as rhinovirus, respiratory syncitial virus (RSV), influenza virus, parainfluenza virus, and coxsackie virus (Arif Muttaqin, 2008).<br />
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Bronchitis is an inflammation of the bronchi in the lower respiratory tract. This disease can be caused by bacteria, viruses, or exposure to inhaled irritants (Brunner & Suddarth, 2002).<br />
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Chronic bronchitis can be experienced by everyone without any distinction. Frequency morbidity of chronic bronchitis is more frequent in men than women. It's just that until now no definite comparative figures. Age sufferers of chronic bronchitis is more common in the over 50 years (Suparyanto, 2010).<br />
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According to Robert L. Wilkins and James B. Dexter in the book Respiratory Diseases: Principles of Patient Care, Chronic bronchitis is one of lung disease in which the patient has a chronic productive cough associated with bronchial inflammation. Before known to suffer from chronic bronchitis, initially patients who experienced a long and productive cough is usually diagnosed by a physician experienced tuberculosis, lung cancer, and congestive heart failure (Puspitasari, 2009).<br />
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Chronic bronchitis is often equated with emphysema, even though they are different. Both of these diseases are often found in patients with Chronic Obstructive Pulmonary Disease (COPD). COPD twice in men, more than women, because men are expected heavier smokers than women, but the incidence in women has increased and stabilized in men (Price, 1992).<br />
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<b>Nursing Diagnosis for Bronchitis : <a href="http://nanda-diagnosis.blogspot.com/2014/07/ineffective-airway-clearance-related-to.html">Ineffective airway clearance</a></b> related to the increased production of secretions<br />
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Goal: The client does not feel shortness of breath and no sputum.<br />
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Outcomes:<br />
<ul>
<li>Maintain a patent airway with breath sounds clean or clear.</li>
<li>Shows behavior to improve airway clearance, for example: an effective cough.</li>
</ul>
Interventions :<br />
<ul>
<li>Assess the respiratory function, breath sounds, rhythm speed.</li>
<li>Assess comfortable position for a client.</li>
<li>Festive and encourage clients to cough effectively.</li>
<li>Giving mucolytics.</li>
<li>Collaboration: Give the drug as indicated.</li>
</ul>
Rationale :<br />
<ul>
<li>Assist their breathing pattern changes.</li>
<li>Can facilitate the circulation of breathing in the body.</li>
<li>Cough teach effectively so patients independently.</li>
<li>To lower airway spasm.</li>
<li>Lowering the mucosal edema and smooth muscle spasm.</li>
</ul>
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<b><a href="http://nanda-diagnosis.blogspot.com/2012/12/impaired-gas-exchange-related-to.html">Impaired Gas Exchange related to Bronchitis</a></b>Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-52707980249651449012015-06-01T10:21:00.000+07:002015-06-01T10:21:37.361+07:00Physical Examination of Urinary Incontinence in the Elderly<br />
Urinary incontinence is the inability to hold urine. Urinary incontinence is one of the manifestations of the disease are often found in geriatric patients. It is estimated that the prevalence of urinary incontinence ranges between 15-30% of elderly people and 20-30% in geriatric patients who were hospitalized suffered incontinence of urine, and urine incontinence likely to rise 25-30% at the age of 65-74 years.<br />
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Urinary incontinence problem is the number of events increased two times higher in women than men. This disorder is more common in women who have given birth than had never given birth (nulliparous).<br />
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Changes due to the aging process affects the lower urinary tract. Such changes predispose the elderly to experience incontinence, but does not cause incontinence. So incontinence is not a normal part of the aging process.<br />
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The purpose of the initial evaluation is to ensure the existence of urinary incontinence and identify the causes temporary, patients need to be evaluated further, and patients can start treatment without the need for sophisticated tests.<br />
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History of the disease should be emphasis on symptoms in detail in order to be determined the type of incontinence, pathophysiology and trigger factors.<br />
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1. The length of time and the characteristics of urinary incontinence.<br />
<ul>
<li>The timing and amount of urine when experiencing urinary incontinence and when dry (continental).</li>
<li>Fluid intake, type (coffee, cola, tea) and a number.</li>
<li>Other symptoms such as nocturia, dysuria, frequency, hematuria and pain.</li>
<li>Accompanying events such as coughing, surgery, diabetes, drugs.</li>
<li>Changes in the function of the colon or bladder.</li>
</ul>
2. Treatment of urinary incontinence before and the results<br />
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The medical history should pay attention to issues such as diabetes, heart failure, venous insufficiency, cancer, neurological problems, stroke and Parkinson's disease. This includes a history of the urogenital system such as abdominal and pelvic surgery, childbirth, or urinary tract infection. Evaluation of both medicines purchased by prescription or bought over the counter are also important. Diverse drugs is associated with urinary incontinence such as sedative hypnotics, diuretics, anticholinergics, adrenergic and calcium channel blockers. Usually there is a connection to the time between the use of drugs with the onset or worsening of urinary incontinence who have chronic incontinence.<br />
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<b>Physical Examination</b><br />
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The goal is to identify the triggers physical examination of urinary incontinence and help establish pathophysiology. In addition to general physical examination should always be carried out, examination of the abdomen, genitalia, rectum, neurological function, and pelvis (in women) is necessary.<br />
<ul>
<li>Abdominal examination must recognize the existence of a full bladder, pain, mass, or a history of surgery.</li>
<li>Skin conditions and anatomic abnormalities should be identified when examining genitals.</li>
<li>Examination of the rectum is mainly done to obtain the obstipation, and evaluation of sphincter tone, perineal sensation, and reflexes bulbocavernosus. Prostate nodules can be identified at the time of examination of the rectum.</li>
<li>Pelvic examination to evaluate mucosal atrophy, atrophic vaginitis, mass, muscle tone, pelvic prolapse, and the cystocele or rectocele.</li>
<li>Neurological Evaluation partially obtained during examination of the rectum when the examination sensation perineum, anus tone, and refles bulbocavernosus. Neurological examination also need to evaluate diseases that can be treated as spinal cord compression and Parkinson's disease.</li>
</ul>
Physical examination should also include an assessment of functional and cognitive status, pay attention to whether the patient is aware of the desire to urinate and using the toilet.<br />
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<b>Examination of Urine Incontinence</b><br />
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1. Diagnostic tests in urinary incontinence<br />
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According Ouslander, diagnostic tests on the incontinence needs to be done to identify potential factors that lead to incontinence, identifying client needs and determine the type of incontinence.<br />
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Measuring residual urine after urination, done by:<br />
After urinating, attach the catheter, urinary catheter out through measured or using ultrasonic inspection of the pelvis, when the rest of the urine more dari100 cc means inadequate emptying of the bladder.<br />
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Urinalysis<br />
<ul>
<li>Carried out on a clean urine specimen to detect the presence of factors that contribute to the occurrence of urinary incontinence such as hematuria, polyuria, bacteriuria, glycosuria, and proteinuria. Advanced diagnostic tests need to be followed when diagnosed early evaluation is not yet clear. Further tests are:</li>
<li>Additional laboratory tests such as urine culture, blood urea nitrogen, creatinine, calcium, glucose cytology.</li>
<li>Urodynamic tests: to know the anatomy and function of the lower urinary tract.</li>
<li>Urethra pressure test: measuring the pressure in the urethra when at rest and dynamic.</li>
<li>Imaging: tests for urinary tract upper and lower parts.</li>
</ul>
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2. Investigations<br />
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Simple urodynamic test can be performed without the use of expensive tools. Remnants of urine after urination need is estimated at physical examination. Specific measurements can be performed with ultrasound or urinary catheterization. Leakage of urine when pressure is applied can also be done. The evaluation should also be done when the bladder is full and there is insistence urge to urinate. Asked to cough while being checked in the lithotomy position or standing. Leakage of urine can often be seen. Information that can be obtained include the first moment there is a desire to urinate, presence or absence of uncontrollable bladder contractions, and bladder capacity.<br />
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3. Laboratory<br />
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Electrolytes, urea, creatinine, glucose, and serum calcium assessed to determine kidney function and the conditions that cause polyuria.<br />
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4. Note urination (voiding record)<br />
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Note voiding was conducted to determine the pattern of urination. This record is used to record the time and the amount of urine when experiencing urinary incontinence and urinary incontinence, and symptoms associated with urinary incontinence. Recording the pattern of urination is done for 1-3 days. The records can be used to monitor therapeutic response and can also be used as a therapeutic intervention as it can sensitize patients the factors that trigger urinary incontinence.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-49838833516168497442015-04-28T23:20:00.001+07:002015-04-28T23:20:55.873+07:00Nursing Interventions for Conjunctivitis : Disturbed Sensory Perception (Visual)<b>Nursing Care Plan for Conjunctivitis - Nursing Diagnosis : Disturbed Sensory Perception (Visual) </b><br />
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<b>Definition </b><br />
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Conjunctivitis is an inflammation of the conjunctiva by viruses, bacteria, chlamydia, allergies, trauma (sunburn) (Barbara C. Long, 1996).<br />
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Conjunctivitis is inflammation of the conjunctiva and is characterized by swelling and exudates, eyes appear red so often called red-eye diseases (Brunner and suddarth, 2001).<br />
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<b>Etiology</b><br />
<ul>
<li>Can be infectious (bacterial, chlamydia, viruses, fungi, parasites).</li>
<li>Immunological (allergies).</li>
<li>Irritative (chemical, electrical temperature, radiation, for example due to ultraviolet light).</li>
</ul>
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<b>Clinical Manifestations:</b><br />
Signs and symptoms of conjunctivitis, could include:<br />
<ul>
<li>Hyperemia (redness).</li>
<li>Liquid.</li>
<li>Edema.</li>
<li>Spending tears.</li>
<li>Itching on the cornea.</li>
<li>Burning / taste scratched.</li>
<li>Feels like a foreign object.</li>
</ul>
<b><br /></b>
<b>Nursing Diagnosis : <a href="http://nanda-nursing-care-plan.blogspot.com/2012/10/nursing-interventions-for.html" target="_blank">Disturbed Sensory Perception </a>(Visual) </b>related to damage to the cornea<br />
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The expected goals:<br />
Improve visual acuity within the limits of individual situations.<br />
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Intervention :<br />
1. Determine acuity, note whether one or both eyes are involved.<br />
Rasionali: individual needs and choice of interventions varied causes vision loss occurs slowly and progressively, if bilateral, each eye may progress at different rates, however, usually only one eye fixed per procedure.<br />
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2. Orient the patient on the environment, staff, other people in the area.<br />
Rasionali: Provides increased comfort and familiarity, lowers anxiety and disorientation postoperatively (Marilynn E. Doenges, 2000).Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-52205935900814023882015-04-27T10:03:00.000+07:002015-04-27T10:03:19.107+07:00Decreased Cardiac Output and Ineffective Cerebral Tissue Perfusion related to Syncope<b>Nursing Care Plan for Syncope</b><br />
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<b>Definition of Syncope</b><br />
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Syncope is a body mechanism to anticipate changes in the blood supply to the brain and usually occurs suddenly and briefly or loss of consciousness and postural body strength and the ability to stand, because of the reduction of blood flow to the brain. Fainting, "<i>blacking out"</i>, or syncope can also be interpreted as a temporary loss of consciousness followed by the return of full alertness.<br />
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Syncope is a final establishment of the body in maintaining a lack of substances important for supply to the brain such as oxygen and other substances (glucose) from the damage that could be permanent.<br />
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<b>Causes of Syncope</b><br />
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Factors that can trigger syncope is divided into two, namely: psychogenic factors (fear, tension, emotional stress, severe pain that occurs suddenly and unexpectedly and fear the sight of blood or medical equipment such as syringes) and non-psychogenic factors (upright sitting position, hunger, poor physical condition, and the environment is hot, humid and dense).<br />
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The most frequent cause of syncope can be divided into several sections such as:<br />
<br />
<b>1. Cardiac (Heart) and blood vessels</b><br />
<ul>
<li>Heart Blockages: Disturbances in the heart can be caused by a blockage (obstruction) in the heart of this blockage can be caused by heart valve disorders, tumors and enlargement of the heart muscle and heart diseases.</li>
<li>Heart electricity: Electrical disorders of the heart, causing arrhythmia and cardiac pulsation frequency so that the volume of blood pumped to the body and to the brain will also be reduced.</li>
<li>Vertebrobasilar system: The narrowing of the blood vessels due to age, smoking, high blood pressure, high cholesterol, and diabetes. Vertebrobasilar system is risky for the narrowing, and if there is a temporary interruption in blood flow to the midbrain and reticular activating system, fainting or syncope may occur.</li>
</ul>
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<b>2. Innervation</b><br />
<ul>
<li>Vasovagal syncope: In the human body there are reflexes in the nervous system that are not aware, this nerve reflex can cause a sudden drop in blood pressure. Vasovagal syncope as a result of the action of the vagus nerve which then sends signals to the heart and then slow the heart rate so someone fainting. Vasovagal syncope is usually triggered by fear, pain, injury, fatigue and prolonged standing. Other situations generally cause the heart rate to slow down and cause fainting while as straining, coughing, sneezing (Ocupational syncope) that can cause vagal response.</li>
<li>Carotid Sinus: Carotid Sinus is a part of the blood vessels of the neck are very sensitive to physical changes and strain the blood vessels in the area. Because it is too sensitive, then this will result in impulse transmission in the central nervous system that stimulates nerves that make losing consciousness.</li>
</ul>
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<b>3. Influence of body position</b><br />
<ul>
<li>Orthostatic Hypotension.</li>
<li>Postural Hypotension: Blood vessels need to maintain their strength so that the body can withstand the effects of gravity with changes in position. When the body position change from lying to standing, autonomic nervous system increases the strength of the walls of blood vessels, making them shrink, and at the same time increasing the heart rate so that blood can be pumped went up to the brain that cause the blood pressure is relatively low at the moment stand. This is common in the elderly and pregnant women. Typically, fainting happens when a person stands with fast and there was not enough time for the body to compensate. This makes the heart beat faster, and occurs vasoconstriction of blood vessels to maintain the body's blood pressure and blood flow to the brain.</li>
</ul>
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<b>4. Lack of body components</b><br />
<ul>
<li>Hypoglycemia: Decreased blood sugar suddenly causes a decrease in glucose available to brain function. This can be seen in diabetics who tend to overdose of insulin. If people miss a dose, the dose may be tempted to take extra insulin to make up the missed dose. In such cases, blood sugar tends to suddenly fall, and get people into insulin shock.</li>
<li>Electrolyte imbalance: This is due to changes in the concentration of fluid in the body and also directly affects blood pressure in the body.</li>
<li>Anemia: Anemia is a condition of a lack of red blood cells (erythrocytes), more specifically, is a hemoglobin (Hb). This causes a lack of oxygen reaching the brain that causes fainting, because hemoglobin is to transport oxygen to the cells in this case the cells in the brain.</li>
</ul>
<b></b><br />
<b>5. Other causes</b><br />
<ul>
<li>Pregnancy: It is caused by the pressure of the inferior vena cava (the large vein that returns blood to the heart) by the enlarged uterus and by orthostatic hypotension.</li>
<li>Medications: Other medications may also cause potentially of fainting or syncope including those for high blood pressure that can dilate blood vessels, antidepressants which can affect the heart's electrical activity, and that affects the mental state such as pain medications, alcohol, and cocaine.</li>
</ul>
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<b>Clinical Manifestations of Syncope</b><br />
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Signs symptoms of syncope can be seen in three phases which pre-syncope, syncope and post syncope.<br />
<br />
<b>1. Pre syncope:</b><br />
Patients may feel nauseous, feeling uncomfortable, clammy and weak. There may be a feeling of dizziness or vertigo (the room spinning), hyperpnea (increased depth of breath), vision may be blurred, and there may dampen hearing and tingling sensations in the body. Pre-syncope or near-fainting, the same symptoms will occur, but at this stage the blood pressure and pulse down and the patient did not really lose consciousness.<br />
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<b>2. Syncope:</b><br />
Syncope is characterized by loss of consciousness of patients with clinical symptoms such as:<br />
Short breathing, shallow and irregular.<br />
Bradycardia and hypotension continues.<br />
Palpable pulse weak and convulsive movement in arm muscles, legs and face. In this phase the patient vulnerable to airway obstruction due to the occurrence of muscle relaxation due to loss of consciousness.<br />
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<b>3. Post syncope:</b><br />
The last phase is the post syncope is a recovery period where patients return to consciousness. In the early phases of post-syncope patients may experience disorientation, nausea, and sweating. On clinical examination obtained palpable pulse began to rise and stronger and the blood pressure starts to rise.<br />
After the episode of syncope, the patient should return to normal mental functioning, even though there may be signs and other symptoms depending on the underlying cause of syncope. For example, if the patient is in the midst of a heart attack, he may complain of chest pain or chest pressure.<br />
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<b>Nursing Diagnosis and Interventions for Syncope</b><br />
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<b>Nursing Diagnosis </b>: <a href="http://nanda-diagnosis.blogspot.com/2012/11/risk-for-decreased-cardiac-output-ncp.html"><b>Decreased cardiac output</b></a> related to the disruption of blood flow to the heart muscle.<br />
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Goal: inadequate blood flow to the heart.<br />
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Expected outcomes: strong pulse palpation, normal blood pressure.<br />
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Intervention:<br />
1. Check the ABC and if necessary freed airway and cardiac massage<br />
Rational: Addressing critical condition early may improve the prognosis of clients.<br />
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2. Monitor the pulse rate, respiratory rate, BP regularly.<br />
Rational: Vital signs as the reference condition the patient's circulation.<br />
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3. Check the state of the client's heart with ECG examination.<br />
Rational: ECG examination provides an overview heart condition and help determine further treatment alternatives.<br />
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4. Assess changes in skin color towards cyanosis and pallor.<br />
Rational: Pale showed a decrease in peripheral perfusion to inadequate cardiac output. Cyanosis occurs as a result of obstruction of blood flow to the ventricles.<br />
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5. Monitor intake and output every 24 hours.<br />
Rationale: The kidneys respond to lower cardiac output with production hold fluid and sodium.<br />
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6. Limit activities adequately.<br />
Rationale: Adequate rest is needed to improve the efficiency of cardiac contraction and lower oxygen consumption and excessive work.<br />
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<b>Nursing Diagnosis :</b> <a href="http://nanda-nursing-care-plan.blogspot.com/2012/06/nursing-management-ineffective-cerebral.html" target="_blank"><b>Ineffective Cerebral Tissue Perfusion</b></a> related to a decrease in the flow of oxygen to the cerebral.<br />
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Expected outcomes: Vital signs are stable, patient-oriented with good communication.<br />
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Interventions:<br />
1. Monitor vital signs<br />
Rational: Vital Signs is one indicator of the general state and the patient's circulation.<br />
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2. Position the patient in the shock position foot raised 45 degrees.<br />
Rationale: Helps improve venous return to the heart and subsequently increased cerebral blood flow.<br />
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3. Monitor the level of consciousness.<br />
Rationale: The level of a person's consciousness is also influenced by the perfusion of oxygen to the brain.<br />
<br />
4. Provide adequate oxygen therapy.<br />
Rationale: to prevent more severe brain hypoxia.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-25091797681727649912015-04-27T00:10:00.001+07:002015-04-27T00:10:55.266+07:003 Nursing Diagnosis and Interventions for Rheumatic FeverRheumatic fever is a multisystem collagen vascular disease that occurs after a <i>group A streptococcal </i>infection in individuals who have predisposing factors. This disease is still the most important cause of acquired heart disease in children and young adults in many countries, especially developing countries. The involvement of cardiovascular disease is characterized by inflammation of the endocardium and myocardium through an autoimmune process that causes tissue damage. The first attack of acute rheumatic fever occurs most often between the ages of 5-15 years. Rheumatic fever is rare in children under the age of 5 years.<br />
<br />
Although knowledge and research has been growing rapidly, but the mechanism of occurrence of rheumatic fever is certainly unknown. In general, experts agree that rheumatic fever is included in autoimmune diseases.<br />
<br />
The clinical course of rheumatic fever / rheumatic heart disease can be divided into :<br />
<br />
Stage I<br />
<br />
This stage in the form of upper respiratory tract infection by the bacteria <i>Group A β-hemolytic streptococcus</i>. Complaints typically include fever, cough, pain when swallowing, often accompanied by vomiting and even in young children diarrhea can occur. On physical examination often found in tonsillar exudate accompanying signs of inflammation. Submandibular lymph nodes are often enlarged. This infection usually lasts 2-4 days and can heal itself without treatment.<br />
The researchers noted 50-90% history of upper respiratory tract infections in patients with rheumatic fever / rheumatic heart disease, which usually occurs 10-14 days before the first manifestations of rheumatic fever / rheumatic heart disease.<br />
<br />
Stage II<br />
<br />
This stage is also called the latent period, is the period between <i>streptococcal infection</i>, with the onset of the symptoms of rheumatic fever, this period usually lasts 1-3 weeks, unless chorea that may arise 6 weeks or even months later.<br />
<br />
Stage III<br />
<br />
Rheumatic fever is an acute phase, when the emergence of various clinical manifestations of rheumatic fever / rheumatic heart disease. The clinical manifestations can be classified in the general inflammatory symptoms (symptom minor) and specific manifestations (major symptoms) rheumatic fever / rheumatic heart disease.<br />
<br />
<br />
<b>3 Nursing Diagnosis and Interventions for <a href="http://nanda-diagnosis.blogspot.com/2014/06/rheumatic-fever-care-plan-6-nursing.html">Rheumatic Fever</a></b><br />
<br />
<br />
1. <a href="http://nanda-diagnosis.blogspot.com/2012/11/risk-for-decreased-cardiac-output-ncp.html">Decreased cardiac output</a> related to the disturbances on the closure of the mitral valve.<br />
<br />
Goal: Decrease in cardiac output can be minimized.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Vital signs within normal limits,</li>
<li>Normal ECG,</li>
<li>Free from symptoms of <a href="http://nanda-nursing-care-plan.blogspot.com/2012/07/nursing-diagnosis-for-congestive-heart.html" target="_blank">heart failure</a>,</li>
<li>Adequate urine output of 0.5-2 ml / kg body weight,</li>
<li>Clients participate in activities that reduce the heart's workload.</li>
</ul>
<br />
Intervention:<br />
<ul>
<li>Assess pulse, respiration, blood pressure regularly every 4 hours.</li>
<li>Note the heart sounds.</li>
<li>Assess changes in skin color towards cyanosis and pallor.</li>
<li>Monitor intake and output every 24 hours.</li>
<li>Limit activities adequately.</li>
<li>Give psychological condition quiet environment.</li>
</ul>
<br />
<br />
2. <a href="http://nanda-nursing-care-plan.blogspot.com/2012/02/anemia-ineffective-tissue-perfusion.html" target="_blank">Ineffective Tissue perfusion</a> related to a decrease in peripheral blood circulation.<br />
<br />
Goal: adequate tissue perfusion.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Vital sign within acceptable limits,</li>
<li>Intake and output balance,</li>
<li>Acral felt warm, cyanosis (-), peripheral pulse strong,</li>
<li>Patients conscious / oriented,</li>
<li>No edema,</li>
<li>Free of pain / discomfort.</li>
</ul>
<br />
Intervention<br />
<ul>
<li>Monitor changes suddenly or continuous mental disorders (anxiety, confusion, lethargy, fainting).</li>
<li>Observation of pale, cyanosis, striped, skin cold / humid, record the strength of peripheral pulses.</li>
<li>Assess Homan's sign (pain in the calf with dorsiflexion), erythema, edema.</li>
<li>Encourage leg exercises active / passive.</li>
<li>Monitor breathing.</li>
<li>Assess GI function, record anorexia, decreased bowel sounds, nausea / vomiting, abdominal distension, constipation.</li>
<li>Monitor input and changes in urine output.</li>
</ul>
<br />
<br />
3. <a href="http://nanda-diagnosis.blogspot.com/2014/07/ineffective-airway-clearance-and.html" target="_blank">Activity intolerance</a> related to the swelling and pain in the joints, muscle weakness, decreased cardiac output (imbalance between myocardial oxygen supply and needs).<br />
<br />
Goal: The client can work within the limits of tolerance for that perfectly measured.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Showed an increase in activity, the heart rate / rhythm and pressure within normal limits, warm skin, pink and dry.</li>
</ul>
<br />
Intervention<br />
<ul>
<li>Assess the patient's tolerance for activity using the following parameters: pulse 20 beats / min above the resting pulse frequency, noted an increase in blood pressure, dyspnoea, chest pain, severe fatigue, weakness, sweating, dizziness or fainting.</li>
<li>Increase breaks, limit activity on the basis of pain / hemodynamic response, provide leisure activities that are not heavy.</li>
<li>Limit visitors or visits by patients.</li>
<li>Assess readiness to increase activities eg decrease weakness / fatigue, stable blood pressure / pulse rate, increased attention on the activities and self-care.</li>
<li>Suggest to promote activities / tolerance of self care.</li>
<li>Provide assistance as needed (eating, bathing, dressing, elimination).</li>
<li>Advise patients to avoid an increase in abdominal pressure, straining during defecation.</li>
<li>Describe the pattern of gradual increase of the activity, for example: sitting on the bed when no dizziness and no pain, getting up from the bed, learning to stand and so on.</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-63528410536226831452015-04-25T21:02:00.001+07:002015-04-25T21:02:39.924+07:00Nursing Interventions for Risk for Injury related to Seizure<b>Nursing Care Plan for Epilepsy</b><br />
<br />
Epilepsy is a symptom or manifestation of excessive loss of electrical charge in cells of the central nervous neurons that can cause loss of consciousness, involuntary movements, abnormal sensory phenomena, the increase in autonomic activity and a variety of physical disorders.<br />
<br />
The impact on children, usually occurs as follows.<br />
<ol>
<li>Long Term General Effect, generally for long-term effects of the seizures are very dependent on the cause. Children who have epilepsy will have an impact on specific conditions, such as head injury and neurological disorders that have a higher mortality than the normal population.</li>
<li>Effect on Memory and Learning. In general, children who experience seizures will be an impact pad expansion and brain disorders will occur ugliness. Children with uncontrolled seizures is a risk factor for the occurrence of intellectual decline.</li>
<li>Social and Behavioral Consequences. Knowledge and language disorders, and emotional and behavioral disorders, occurs in a number of children with partial epilepsy syndromes. Children are usually dressed with a bad attitude compared to other children.</li>
</ol>
<br />
Manifestations of seizures can vary from mild to severe. Light as discomfort in the abdomen, and the weight can be a disturbance of consciousness, impaired motor function, sensory, autonomic, behavioral disorders. Actually, any person having a seizure origin can be made sufficiently strong stimulus is given, for example, electro-shock. When these stimuli exceeded the seizure threshold then the seizures.<br />
<br />
<br />
<b>Nursing Interventions for Risk for Injury related to <a href="http://nanda-diagnosis.blogspot.com/2013/12/febrile-seizures-4-nursing-diagnosis.html">Seizure</a></b><br />
<br />
Goal: The client is not a seizure.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Clients do not have seizures.</li>
<li>Children and families demonstrate an understanding of the possible responses to the drug that is not good and appropriate intervention.</li>
<li>Patients do not get injured.</li>
<li>Child and family approve or modify the activity of an appropriate activity for children.</li>
<li>Individuals associated with giving children appropriate interventions during and after the seizure.</li>
<li>Normal vital signs (blood pressure, pulse, respiration rate, temperature).</li>
</ul>
<br />
<b>Interventions </b><br />
<br />
1. Encourage physical examination and laboratory periodically.<br />
R /: Specifies possible deviations from normal findings.<br />
<br />
2. Encourage good dental care during therapy.<br />
R /: Lose the gum hyperplasia.<br />
<br />
3. Encourage intake of vitamin D and folic acid adequate for therapy.<br />
R /: Prevents deficiency.<br />
<br />
4. Collaboration antilepsi in drug delivery.<br />
R /: Provide appropriate therapy.<br />
<br />
5. Stress the importance of complying with the therapeutic program.<br />
R /: Provide appropriate therapy procedures.<br />
<br />
6. Avoid situations that are known to trigger seizures, such as light flashes and fatigue.<br />
R /: Preventing the occurrence of seizures.<br />
<br />
7. Educate parents and children about appropriate activities for children (depending on the type, frequency, and severity of seizures).<br />
R /: Provides information about the disease process.<br />
<br />
8. Facilitate children during activities that are allowed, such as swimming, cycling.<br />
R /: To prevent injury in the event of a seizure.<br />
<br />
9. Instruct to shower with close supervision during bathing.<br />
R /: To prevent injury in the event of a seizure.<br />
<br />
10. Educate people closest to the client associated with the child about appropriate assistance during and after seizures.<br />
R /: To prevent injury in the event of seizures and convulsions can deal quickly and appropriately.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-41417064719864247222015-04-25T20:01:00.000+07:002015-04-25T20:01:03.436+07:00Measles - Prevention and Home Care<br />
<b>Measles</b> is caused by a virus that is easily transmitted. However, <a href="http://nanda-diagnosis.blogspot.com/2014/01/risk-for-infection-and-acute-pain.html">measles</a> is not a serious illness and dangerous. Caring for a child with measles alone at home. The important thing, always vigilant and take precautions against the dangers of complications, due to a decrease in endurance of the disease.<br />
<br />
Symptoms in the first level similar to the symptoms of flu or other diseases caused by viruses. At first it appears the distinctive sign, namely the emergence of grayish-white spots at the tip of the needle circled reddish color that appears on the mucous membranes of the cheeks, near the molars.<br />
<br />
After 4-5 days, raised red blotches on some parts of the body, such as face, neck, upper arms and legs. Symptoms are similar to flu, cold cough that is getting worse. In addition the mucous membranes in the mouth becomes reddish, so that the mouth and lips were red. Patients also feel itching on the whole body.<br />
<br />
Once that period is completed, the original body temperature up and down is not necessarily the body heat can be increased up to 40 degrees Celsius, will gradually return to normal. Similarly, the rash will disappear and leave scars dark.<br />
<br />
<br />
<b>Prevention</b><br />
<br />
To prevent children exposed to measles in the event of an epidemic, can ask the doctor to give immunizations. This preventive injections are usually given to children aged nine months. Had remains exposed to measles, it will cause milder symptoms than children who are not immunized.<br />
<br />
Giving good nutrition and appropriate for children need to be considered. Good endurance allows the child to avoid complications from measles.<br />
<br />
<br />
<b>Home Care</b><br />
<ul>
<li>In the first stage, the child feels dazzled when seeing bright light. Therefore extinguish or reduce the bedroom lights.</li>
<li>If the child's body temperature rose to 40 degrees Celsius for more than half an hour, try to compress with warm water. If the eyes feel hot, compressed with cold water. Better not to wrap the body of a child with a thick blanket.</li>
<li>If the third phase (recovery phase) child's body temperature does not decrease, it is necessary to be aware of the presence of complications, due to a decrease in child's immune system. Complications easily arise in children who from the beginning have low immunity. For example, children suffering from malnutrition. Circumstances worsened if the child is suffering from complications. Complications arise normally in the form of pneumonia and encephalitis. If such circumstances, the need for help physicians.</li>
<li>When the situation improves, and appetite recovered, try to give foods high in nutrients. There is a possibility of children suffering from malnutrition after measles disease and loss of appetite.</li>
<li>Children with measles will lose appetite and drinking. Seek child to drink fluids as often as possible.</li>
<li>Clean the body with warm water. Children with high body temperature, should not be bathed first, sufficiently cleaned with a cloth and warm water.</li>
<li>Can be given the powder on the child's body, to relieve itching.</li>
<li>Seek for children to stay at home and not playing around with friends, considering the disease is easily transmitted.</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-5854309487619299262015-04-24T13:26:00.002+07:002015-04-24T13:26:56.805+07:00NCP for Elderly with Hypertension (Diagnosis and Interventions)<b>Nursing Care Plan for Elderly with Hypertension</b><br />
<br />
Enter old age means deteriorated physically and psychologically. Physical deterioration characterized by the loosened skin, graying hair, hearing loss, vision deteriorates, slow movement, abnormalities of various functions of vital organs, increased emotional sensitivity and lack of passion.<br />
<br />
Although naturally a decline in the function of various organs, but not necessarily cause disease therefore must be healthy old age. Healthy in this case means:<br />
<ul>
<li>Free from physical illness, mental and social,</li>
<li>Able to perform activities to meet daily needs,</li>
<li>Social support from family and society (Rahardjo, 1996)</li>
</ul>
Elderly people also experience changes in interest. First of growing interest in self. Both interest in the appearance of diminishing returns. Third is increasing interest in the money, the last request for recreational activities do not change just tend to narrow. It required a high motivation to self-elderly to maintain their physical fitness in order to stay physically fit. The motivation needed to perform physical exercises properly and regularly to improve their physical fitness.<br />
<br />
In connection with the change, then Hurlock (1990) says that the changes experienced by every person will affect the interest in these changes and ultimately affects the lifestyle. What is the attitude shown whether satisfactory or unsatisfactory, it depends on the effect of changes to the role and personal experience. Changes in demand by the elderly is associated with changes in health improvement issues, economic / income and social roles (Goldstein, 1992)<br />
<br />
In the face of such changes necessary adjustments. The characteristics are not good adjustment of the elderly (Hurlock, 1979, Munandar, 1994) are:<br />
<ul>
<li>The narrow interests of the events in the environment.</li>
<li>Withdrawal into fantasy world.</li>
<li>Always recalls the past.</li>
<li>Always worried because of unemployment.</li>
<li>There is less motivation.</li>
<li>Sense of loneliness because of the relationship with the family is poor, and</li>
<li>Undesirable place to live.</li>
</ul>
On the other hand adjustment characteristics of good elderly include: a strong interest, economic independence, extensive social contacts, work and enjoy work, enjoy the activities carried out at this time and have minimal concern for self and others.<b><br /></b>
<a href="http://nanda-diagnosis.blogspot.com/2013/07/10-easy-ways-to-lower-hypertension.html"><b>Hypertension</b></a><br />
<br />
Hypertension is an increase in blood pressure that is persistent. In adults the average systolic blood pressure at or above 140 mm Hg and diastolic pressure equal to or above 90 mm Hg, according to the American Heart Association, the average of the two different tests in two weeks.<br />
<br />
Hypertension based on the cause can be divided into two major categories, namely:<br />
Essential hypertension (hypertension primary / idiopathic) that hypertension of unknown cause, as many as 90% of cases.<br />
Secondary hypertension is hypertension caused by other diseases, as much as 10%.<br />
<br />
Prevention efforts beneficial for patients with hypertension for the disease from getting worse, of course, must be accompanied by the use of drugs to be prescribed by a doctor. In order to avoid fatal complications of hypertension, precautions must be taken good (Stop high blood pressure), among others :<br />
<ul>
<li>Reduce salt intake.</li>
<li>Avoid obesity.</li>
<li>Limiting fat consumption.</li>
<li>Exercise regularly.</li>
<li>Eat plenty of fresh vegetables.</li>
<li>Do not smoke and do not drink alcohol.</li>
<li>Relaxation exercises or meditation.</li>
<li>Trying to build a positive life.</li>
</ul>
<br />
<b>NCP for Elderly with Hypertension (Diagnosis and Interventions)</b><br />
<br />
1. <a href="http://nanda-diagnosis.blogspot.com/2014/11/ncp-for-activity-intolerance-related-to.html">Activity intolerance</a> related to general weakness, imbalance between supply and demand of oxygen.<br />
<br />
Expected outcomes:<br /><ul>
<li>Participate in the activities of the desired / required.</li>
<li>Reported an increase in activity tolerance that can be measured.</li>
<li>Showed a decrease in signs of intolerance physiology.</li>
</ul>
Intervention:<br />
<ul>
<li>Assess response to activity.</li>
<li>Pay attention to blood pressure, pulse during / after the break.</li>
<li>Note chest pain, dyspnea, dizziness.</li>
<li>Advise on energy saving techniques, eg using a chair in the shower, comb the hair.</li>
<li>Activity slowly.</li>
<li>Give a boost to activity / self-care gradually if it can.</li>
<li>Give help as needed.</li>
</ul>
<br />
<br />
2. Pain (acute): headache related to an increase in cerebral vascular pressure.<br />
<br />
Expected outcomes: report pain / discomfort is reduced.<br />
<br />
Intervention:<br />
<ul>
<li>Maintain bed rest during the acute phase.</li>
<li>Give non-pharmacologic measures for the relief of pain such as back massage, neck, quiet, relaxation techniques.</li>
<li>Minimizing the vasoconstriction activity can increase headache, eg bending, straining during bowel movements.</li>
<li>Collaboration in the administration of analgesic, antianxiety.</li>
</ul>
<br />
3. Impaired physical mobility related to a decrease in motor function secondary to upper motor neuron damage.<br />
<br />
Expected outcomes: The client will indicate the action to improve mobility.<br />
<br />
Intervention:<br />
1) Teach the client to perform active range of motion exercises on a limb that is not sick at least four times a day.<br />
R /: active range of motion increase mass, tone and muscle strength and improve cardiac and respiratory function.<br />
2) Perform passive range of motion exercises on the affected extremity three to four times a day. Perform exercises slowly to allow time for the muscles to relax and prop limb above and below the joint to prevent strain on the joints and tissues.<br />
R /: voluntary muscles to lose tone and strength when not in use. Contracture of the flexor and adductor muscles can occur because the muscles are stronger than the extensor and abductor.<br />
3) If the client in bed doing the action to straighten posture.<br />
R /: Mobility and prolonged damage neurosensory function can cause permanent contractures.<br />
4) Prepare the progressive mobilization.<br />
R /: Bed rest long or decreased blood volume can cause a drop in blood pressure suddenly (orthostatic hypotension) because the blood back into the peripheral circulation. Increased activity will gradually decrease fatigue and increase in prisoners.<br />
5) Slowly help clients advance of active ROM to functional activity as indicated.<br />
R /: Giving a boost to the client to perform on a regular basis.<br />
<br />
<br />
4. Risk for injury related to visual field deficits, motor or perceptual.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Identifying factors that increase the risk of injury.</li>
<li>Demonstrating the safety measures to prevent injury.</li>
<li>Ask for help when needed.</li>
</ul>
Intervention:<br />
1) Take action to reduce environmental hazards.<br />
R /: Helps reduce injuries.<br />
2) If the decrease in tactile sensitivity becomes a problem teach clients to do:<br />
Assess the temperature of bath water and heating pads before use.<br />
Assess limb every day of the injury was detected.<br />
Keep feet warm and dry and soothed skin with lotion emoltion.<br />
R /: Damage to sensory post CVA may affect the client's perception of temperature.<br />
3) Take action to reduce the risks relating to the use of tools.<br />
R /: Use of improper tools or do not fit can cause strain or fall.<br />
4) Encourage clients and families to maximize security at home.<br />
R /: Client with mobility problems, requiring the installation of aids.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-57436028945680738002015-04-24T07:44:00.002+07:002015-04-24T07:44:48.733+07:00Nursing Care Plan for Heart Rhythm Disorders: Arrhythmia<b>Nursing Diagnosis and Intervention : Heart Rhythm Disorders: Arrhythmia</b><br />
<br />
<b>Definition</b><br />
<br />
Heart rhythm disorder or arrhythmia is a common complication of myocardial infarction. Arrhythmias or dysrhythmias is the change in frequency and heart rhythm caused by abnormal electrolyte conduction or automatic (Doenges, 1999).<br />
<br />
Arrhythmias arising from changes in the cells of the myocardium electrophysiology. The electrophysiological changes manifest as changes in action potential shape that is recording the electrical activity of the cell chart (Price, 1994). Heart rhythm disorders are not just limited to the irregularity of the heart rate but also including rate and conduction disturbances (Hanafi, 1996).<br />
<br />
<br />
<b>Etiology</b><br />
<br />
The etiology of cardiac arrhythmias in outline can be caused by:<br />
<ul>
<li>Inflammation of the heart, such as rheumatic fever, myocardial inflammation (myocarditis due to infection).</li>
<li>Impaired coronary circulation (coronary atherosclerosis or coronary artery spasm), for example; myocardial ischemia, myocardial infarction.</li>
<li>Because drugs (intoxication), among others, by; digitalis, quinidine and anti-arrhythmia drugs other.</li>
<li>Electrolyte balance disorders (hyperkalemia, hypokalemia).</li>
<li>Disorders of the autonomic nervous system settings that affect the work and heart rhythm.</li>
<li>Psychoneurotic disruption and central nervous system.</li>
<li>Metabolic disorders (acidosis, alkalosis).</li>
<li>Endocrine disorders (hyperthyroidism, hypothyroidism).</li>
<li>Arrhythmia due to cardiomyopathy or heart tumors.</li>
<li>Arrhythmia due to degeneration (fibrosis cardiac conduction system).</li>
</ul>
<br />
<br />
<b>Clinical Manifestations</b><br />
<br />
Changes in blood pressure (hypertension or hypotension); pulse may be irregular; pulse deficit; irregular heart rhythm sound, extra sound, rate decreases; pale skin, cyanosis, sweating; edema; Urine output decreases as weight decreases cardiac output.<br />
<br />
Syncope, dizziness, throbbing, headache, disorientation, confusion, lethargy, changes in the pupil. Mild to severe chest pain, may be lost or not with antianginal drugs, anxiety, shortness of breath, cough, change of velocity / depth of respiration; additional breath sounds (crackles, wheezing) may exist indicate respiratory complications such as left heart failure (pulmonary edema) or pulmonary thromboembolic phenomena; hemoptysis, fever; redness of the skin (drug reactions); inflammation, erythema, edema (siperfisial thrombosis); loss of muscle tone / strength.<br />
<br />
<br />
<b>Diagnosis and Tests</b><br />
<ul>
<li>ECG: shows the pattern of ischemic injury and conduction disturbances. Stating the type / source dysrhythmia and the effects of electrolyte imbalance and heart medications.</li>
<li>Holter monitor: Overview of ECG (24 hours) may be required to determine where dysrhythmia caused by specific symptoms when the patient is active (at home / work). Also can be used to evaluate the pacemaker function / effect of anti dysrhythmias.</li>
<li>Chest x-ray: Can show an enlarged cardiac silhouette in connection with ventricular dysfunction or valve.</li>
<li>Myocardial imaging scan: can indicate areas of ischemic / myocardial damage that could affect or disrupt the normal conduction wall motion and ability to pump.</li>
<li>Exercise stress test: can be done to demonstrate that exercise causes dysrhythmias.</li>
<li>Electrolytes: An increase or decrease in potassium, calcium and magnesium can cause dysrhythmias.</li>
<li>Examination of drugs: can declare cardiac drug toxicity, the presence of drugs or suspected instances of drug interactions; digitalis, quinidine.</li>
<li>Examination of the thyroid: an increase or decrease in serum thyroid levels can cause increase dysrhythmias.</li>
<li>Sedimentation rate: Elevation can demonstrate an acute inflammatory process instance; endocarditis as a precipitating factor dysrhythmias.</li>
<li>GDA / pulse oximetry: Hypoxemia can cause / exacerbate dysrhythmias.</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis and Intervention</b><br />
<br />
<b>Risk for decreased cardiac output</b> related to electrical conduction disturbances, decreased myocardial contractility.<br />
<br />
Expected outcomes:<br />
<ul>
<li>Maintain / improve cardiac output adequately evidenced by blood pressure / pulse in the normal range, adequate urine output, same palpable pulse, normal mental status.</li>
<li>Showed a decrease in the frequency / no presence of dysrhythmias.</li>
<li>Participate in activities that decrease myocardial work.</li>
</ul>
<br />
<br />
Intervention:<br />
<ul>
<li>Feel the pulse (radial, femoral, dorsalis pedis) record the frequency, regularity, amplitude and symmetrical.</li>
<li>Auscultation of heart sounds, record the frequency, rhythm. Note the extra heart rate, decreased pulse.</li>
<li>Monitor vital signs and examine the adequacy of cardiac output / reperfusion.</li>
<li>Determine the type of dysrhythmia and note rhythm: tachycardia; bradycardia; atrial dysrhythmias; ventricular dysrhythmias; heart block.</li>
<li>Provide quiet environment. Assess the reasons for limiting the activity during the acute phase.</li>
<li>Demonstrate / encourage the use of stress management behaviors such as deep breathing relaxation, guided imagery.</li>
<li>Investigate reports of pain, note the location, duration, intensity and factor relievers / ballast. Note the non-verbal instructions pain examples wrinkle face, crying, changes in blood pressure.</li>
<li>Prepare / do CPR as indicated.</li>
</ul>
Collaboration:<br />
<ul>
<li>Monitor laboratory tests, sample electrolyte.</li>
<li>Provide supplemental oxygen as indicated.</li>
<li>Give the drug as indicated: potassium, anti dysrhythmias.</li>
<li>Prepare for elective cardioversion help.</li>
<li>Help installing / maintaining the pacemaker function.</li>
<li>Enter / maintain input IV.</li>
<li>Prepare for invasive diagnostic procedures.</li>
<li>Prepare for the installation of automatic cardioverter or defibrillator</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-45054600709159782652014-12-06T10:59:00.000+07:002014-12-06T10:59:47.902+07:00Care Plan for Mitral Stenosis : Assessment and 6 Nursing Diagnosis<b>Nursing Care Plan for Mitral Stenosis </b><br />
<br />
Mitral stenosis (MS) is the obstruction of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral Stenosis typically have thickened mitral leaflets, commissura are fused, and the chordae tendineae were thickened and shortened. Transverse diameter of the heart usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen. <br />
<br />
<b>Assessment</b><br />
<ol>
<li>Main Complaint: patients with mitral stenosis usually complain of shortness of breath, cyanosis and coughing.</li>
<li>History of present illness: Clients are usually taken to hospital after shortness of breath, cyanosis or coughing is accompanied by high fever / no.</li>
<li>Past medical history: The client had suffered from rheumatic fever disease, SLE (Systemic Lupus Erithematosus), RA (rheumatoid Rhemautoid), myxoma (a benign tumor in the left atrium).</li>
<li>The family medical history: no hereditary factors that influence the occurrence of mitral stenosis.</li>
</ol>
<br />
<br />
<b>Review of System</b><br />
<ol>
<li>B1 (Breath): Shortness / respiration increases, low tone at the apex by using a bell on his side to the left, shortness of breath and fatigue, cough, orthopnea in venous congestion there.</li>
<li>B2 (Blood): an increase in the jugular vein, leg edema, atrial arrhythmias such as atrial fibrillation (rapid heart rate and irregular), hemoptysis, embolism and thrombosis, strength weakened pulse, tachycardia, peripheral edema (start happening right heart failure), BJ 1 loud systolic murmur, palpitations, hemoptysis, apical diastolic murmur.</li>
<li>B3 (Brain): chest and abdominal pain.</li>
<li>B4 (Bladder): excess fluid imbalance, oliguric.</li>
<li>B5 (Bowel): dysphagia, nausea, vomiting, no appetite.</li>
<li>B6 (Bone): weakness, sweating, tired .</li>
</ol>
<br />
<br />
<b>Psychosocial Assessment</b><br />
<ol>
<li>Shortness of breath affect the interaction.</li>
<li>Limited activity.</li>
<li>Afraid of surgery.</li>
<li>Stress due to the condition of the disease with a poor prognosis.</li>
</ol>
<br />
<b>Nursing Diagnosis:</b><br />
<ol>
<li>Impaired tissue perfusion r / t decrease in peripheral blood circulation; cessation of arterial-venous flow; decrease in activity.</li>
<li>Risk for fluid volume overload r / t the displacement pressure in the pulmonary venous congestive; Decreased perfusion of organs (kidney); increased retention of sodium / water; hydrostatic pressure increase or decrease in plasma proteins (absorbing fluid in the interstitial area / network).</li>
<li>Ineffective breathing pattern r / t permeation fluid, pulmonary congestion secondary to changes in alveolar capillary membrane and fluid retention intertestial.</li>
<li>Impaired gas exchange r / t changes in capillary-alveolar membrane (displacement of fluid into the interstitial area / alveoli).</li>
<li>Activity intolerance r / t decreased cardiac output to the tissue.</li>
<li>Acute pain r / t strain the left atrium.</li>
</ol>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-23209498468904525832014-12-04T21:42:00.001+07:002014-12-04T21:52:47.905+07:00Pediatric Nursing Care Plan - Asthma in Children<b>Nursing Care Plan for Asthma</b><br />
<br />
Asthma is the leading cause of chronic disease in children, which causes the majority of school days lost due to chronic diseases. Approximately 80-90% of children with asthma get the first symptoms before the age of 4-5 years. At one time during the child will have symptoms and signs in accordance with asthma.<br />
<br />
Severe asthma is difficult to predict. Most children who suffer a fraction will suffer severe asthma that is difficult to treat, usually more is chronic rather than seasonal. Which causes helplessness and significantly affect day-to-day school, play activities, and daily functioning. It is an unpleasant thing when in times of play and activity, children disturbed because of illness. This of course requires special attention in the form of care, treatment and prevention.<br />
<br />
Therefore asthma require special handling, especially in children who are always filled with joy in the days of play and activity in everyday life, with the involvement of health professionals from a variety of multidisciplinary fields. In nursing care, nurses have a role as professionals that act provides nursing care, health education to parents, provide information on the definition, signs and symptoms, and prevention independently or collaboratively with various parties.<br />
<br />
<br />
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Definition<br />
<br />
Asthma is a disease with a characteristic increase in the trachea and bronchi reaction by various originators accompanied by the onset of constriction outside the lower respiratory tract that can vary the degree spontaneously or with treatment.<br />
<br />
<br />
Cause<br />
<br />
Extrinsic factors : Found in a small number of adult patients and is caused by allergens that are known because of the sensitivity of individual, usually a protein, in the form of pollen that life, animal fuzz, lint or more rarely to food such as milk or chocolate, pollution.<br />
Intrinsic factor: This factor is often not found the trigger factors that clear. Nonspefisik factors, such as the common cold, physical or emotional exercise can trigger an asthma attack. This intrinsic asthma is usually due to heredity and also often develop after the age of 40 years. With attacks arising after nasal or sinus infection at trakeobronchial branching.<br />
<br />
<br />
Signs and Symptoms<br />
<br />
The classic symptoms of asthma consist of cough, breathlessness and wheezing and most patients with chest pain. These symptoms do not always occur together, so that there is some degree of asthmatics as follows:<br />
<br />
Level I: asthmatics clinically normal. Asthma symptoms occur when there is a trigger factor.<br />
<br />
Level II: asthmatics without complaint and without abnormalities on physical examination but lung function showed signs of airway obstruction.<br />
<br />
Level III: asthmatics without classes but on physical examination and lung function showed airway obstruction.<br />
<br />
Level IV: asthmatics are most often found complaining of shortness of breath, coughing and wheezing.<br />
On physical examination and spirometry will find airway obstruction. In severe asthma attack symptoms include: Compression respirator muscles, especially the muscles of the sternum, cyanosis, silent chest, disturbance of consciousness, patient looked tired, chest hyperinflation and tachycardia.<br />
<br />
Level V: status asthmaticus, namely; Severe acute asthma attacks are refrater while on treatment directly used.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-26462645691814547042014-11-30T22:51:00.001+07:002014-11-30T23:03:13.281+07:00Nursing Care Plan for Pulmonary Tuberculosis (Gordon's Functional Health Pattern)<b>Pulmonary Tuberculosis</b> - Definition, Etiology, Pathophysiology, Clinical Manifestations, Diagnostic Eexamination, Prevention, Management / Treatment, Assessment and Gordon's Functional Health Patterns<br />
<br />
<b>Definition</b><br />
Tuberculosis is a contagious infectious disease caused by <i>Mycobacterium tuberculosis</i>, an acid-resistant aerobic bacillus transmitted through the air (airborne). In almost all cases of tuberculosis infection acquired through inhalation of small particles of bacteria (approximately 1-5 mm).<br />
<br />
<br />
<b>Etiology</b><br />
The cause of pulmonary tuberculosis are germs (bacteria) that can only be seen with a microscope, the mycobacterium tuberculosis. <i>Mycobacterial </i>are aerobic bacteria, shaped stones that form spores.<br />
<br />
<br />
<b>Pathophysiology</b><br />
Causes of pulmonary tuberculosis occurs because germs coughed out into droplet nuclei in the air. The infectious particles can settle in free air for 1-2 hours, depending on the presence or absence of ultraviolet light, poor ventilation and moisture. In a humid atmosphere and dark germs can hold for days to months. BCG infection particle is inhaled by healthy people, it will stick to the airway or lungs. Germs will be encountered first by neutrophils, then just by macrophages. Most of these particles will die or cleared by macrophages out of tracheal bronchial branch, along with the movement of cilia in the secretions.<br />
When germs settle in the lung tissue, it will multiply in the cytoplasm of macrophages. Here germs can be brought into other organs. If, entered into the pulmonary artery occurs spreading to all parts of the lungs become miliary tuberculosis.<br />
Of primary nest will arise inflammation hilar lymph channels leading, and also followed by enlarged lymph nodes virus. All this process takes 3-8 weeks.<br />
<br />
<br />
<b>Clinical Manifestations</b><br />
<br />
Clinical symptoms of tuberculosis can be divided into two groups, namely respiratory symptoms and systemic symptoms.<br />
1. Respiratory symptoms<br />
<ul>
<li>Cough for more than 3 weeks.</li>
<li>Coughing up blood.</li>
<li>Chest pain.</li>
</ul>
2. Systemic symptoms<br />
<ul>
<li>Fever.</li>
<li>Other systemic symptoms: malaise, night sweats, anorexia and weight loss.</li>
</ul>
<br />
<b>Diagnostic Examination</b><br />
<ul>
<li>Sputum culture: positive for mycobacterium tuberculosis.</li>
<li>Ziehl-Neelsen: positive for acid fast bacilli.</li>
<li>Skin test (PPD, Mantoux, Pieces volumer) shows: past infection and the presence of anti-bodies, but does not necessarily reflect active disease.</li>
<li>X-ray of the thorax: early lesions showed infiltration in the lung area above.</li>
<li>Histology or tissue culture: positive for mycobacterium tuberculosis.</li>
<li>Examination of lung function: decreased vital capacity, an increase in dead space, increasing the ratio of residual air and total lung capacity, and decreased oxygen saturation secondary to parenchymal infiltration or fibrosis, loss of lung tissue and pleural disease.</li>
</ul>
<b>Management / Treatment</b><br />
<br />
Assessment of treatment success was based on the results of bacteriological and clinical examination. Good cure pulmonary tuberculosis will notice sputum smear (-), an improvement of radiology and relieve symptoms.<br />
<br />
<br />
<b>Complication</b><br />
<ul>
<li>Coughing up blood.</li>
<li>Pneumothorax.</li>
<li>Crushed lungs.</li>
<li>Respiratory failure.</li>
<li><a href="http://nanda-diagnosis.blogspot.com/2014/11/ncp-for-activity-intolerance-related-to.html">Heart failure</a>.</li>
<li>Pleural effusion.</li>
</ul>
<b>Prevention</b><br />
<ul>
<li>Can be done by;</li>
<li>BCG vaccination in infants and children.</li>
<li>Preventive therapy.</li>
<li>Diagnosis and treatment of tuberculosis treatment (+) to prevent transmission.</li>
</ul>
<br />
<br />
<b>Assessment</b><br />
<br />
1. Identity of the patient<br />
Consisting of name, age, gender, religion, and others.<br />
<br />
2. Health History<br />
The main complaint: Most cases encountered the client in with complaints of cough more than 3 weeks.<br />
The main complaint history: Usually cough experienced more than 1 week accompanied by an increase in body temperature, decreased appetite and body weakness.<br />
<br />
<br />
<b>Gordon's Functional Health Patterns</b><br />
<br />
1. Health Perception and Management<br />
View of the patient about the disease and how to deal with patients who carried the disease.<br />
<br />
2. Nutritional metabolic<br />
The ability of patients to consume food has decreased due to the lack of appetite / malaise.<br />
<br />
3. Elimination<br />
Patients with pulmonary TB is rare impaired bowel and bladder elimination.<br />
<br />
4. Activity exercise<br />
Usually, the patient experienced a decrease in activity associated with body weakness experienced.<br />
<br />
5. Sleep - rest<br />
Rest and sleep is often disturbed due to cough experienced at night.<br />
<br />
6. Cognitive-perceptual<br />
Memory pulmonary TB patients mostly found not impaired.<br />
<br />
7. Self perception / self concept<br />
Feelings receive from patients with the situation, most patients are not impaired self-concept.<br />
<br />
8. Role Relationship<br />
Changes in the pattern of relations role in responsibilities or changes in physical capacity to perform the role.<br />
<br />
9. Se-uality reproductive<br />
The patient's ability to perform in accordance with the gender roles. Most patients do not do se-ual because of the weakness of the body.<br />
<br />
10. Coping-stress tolerance<br />
Defense mechanism used by patients is to seek help from others.<br />
<br />
11. Value-Belief Pattern<br />
The religion of the patient and patient compliance in performing religious teachings usually not impaired in patients sisitem values and beliefs.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-91054812558202978082014-11-30T10:56:00.003+07:002014-11-30T10:56:57.512+07:00Meningitis - Nursing Implementation, Evaluation and Discharge Planning<br />
<b>Nursing Implementation</b><br />
<br />
Implementation is the initiative of a plan of action to achieve a specific goal. (Nursalam, 2001)<br />
<br />
This stage is the fourth stage in the nursing process, therefore implementation began after an action plan formulated and refer to the appropriate scale plan of action is urgent and not urgent.<br />
<br />
In the implementation of the action there are three stages that must be passed, namely preparation, planning, and documentation (Nursalam, 2001 quoted from Griffit 1968).<br />
<br />
1. Preparation phase, include:<br />
<ul>
<li>Review anticipation nursing actions.</li>
<li>Analyze the knowledge and skills required.</li>
<li>Knowing the complications that may arise.</li>
<li>Preparation tool.</li>
<li>Preparation of a conducive environment.</li>
<li>Identify the legal and ethical aspects.</li>
</ul>
2. Intervention phase, include:<br />
<ul>
<li>Independent: actions taken by nurses without instructions or orders of doctors and other health care team.</li>
<li>Interdependent: nurse actions that require cooperation with other health team (nutrition, doctors, laboratories, and others).</li>
<li>Dependent: associated with medical treatment or indicate where medical treatment is done.</li>
</ul>
3. Documentation phase<br />
<ul>
<li>Is a complete and accurate record of the actions that have been implemented. In the implementation of nursing care actions on the client, the nurse can act as executor of nursing, give support, educators, advocacy, and recording / data collection.</li>
</ul>
<br />
<br />
<br />
<b>Evaluation</b><br />
<br />
Evaluation is one of the planned and systematic comparison of the client's health status (Griffit and Cristensen, 1986). While Ignativicius and Bayne 1994 said evaluation is an intellectual action to complete the nursing process that indicates how far nursing diagnosis, plan of action and its implementation has been achieved.<br />
<br />
Evaluation consists of two types of formative evaluation and summative evaluation. Formative evaluation is also called the evaluation process, the evaluation of short-term, or evaluation runs, where the evaluation carried out immediately after nursing actions performed until the goal is reached. While summative evaluation is called the evaluation result, the final evaluation, evaluation of the long-term. The evaluation was conducted at the end of the plenary nursing actions performed and become a method of monitoring the quality and efficiency preformance given action. This evaluation forms typically use the format "SOAP" (Nursalam, 2001).<br />
<br />
The purpose of evaluation is to regain feedback nursing plan, the value and improve the quality of nursing care through the comparison of pre-determined standards.<br />
<br />
<br />
<b>Discharge Planning</b><br />
<br />
Plan provided to clients and families are as follows:<br />
<ol>
<li>As health professionals, we provide an explanation to the client's family, when his son raised signs and symptoms such as unconsciousness, seizures, fever and slow pulse to immediately go to the nearest health center or directly to a large hospital.</li>
<li>Instruct the client to comply with the treatment regimen required to take medication appropriate screening and follow-up report.</li>
<li>Advise the client to participate in preventive measures, eg encouraging the individuals in close contact to report themselves for examination.</li>
<li>Increasing consumption of nutrients and protein and consume vitamins that increase body strength.</li>
</ol>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-15348124933287663232014-11-30T10:34:00.001+07:002014-11-30T10:34:29.074+07:00Meningitis - Nursing Interventions, Goals / Outcomes and Rational<br />
<b>Nursing Diagnosis : Altered Levels of Consciousness </b>related to the process of infection and neurological impairment.<br />
<br />
Goals:<br />
<ul>
<li>Level of client awareness, getting back to normal.</li>
<li>No physical injury.</li>
</ul>
Expected outcomes:<br />
<ul>
<li>GCS within normal limits (Normal 15).</li>
<li>Good awareness.</li>
<li>Orientation to time, place and person.</li>
<li>Vital signs within normal limits.</li>
</ul>
Nursing Interventions:<br />
<ul>
<li>Monitor neurologic status regularly and compare it to the normal state, such as GCS.</li>
<li>Assess motor response to commands performed by nurses.</li>
<li>Evaluation of the ability to open the eyes, such as spontaneous (fully conscious), open only if given a painful stimulus or closed (comma).</li>
<li>Assess verbal response: note whether the client aware, orientation to person, place, and time well or even confused using words.</li>
</ul>
Rational :<br />
<ul>
<li>Assessment of the trend of changes in the level of awareness and increase the potential of ICT is very useful in determining the location, the spread. (Doenges, p. 273)</li>
<li>Measuring the overall situation and the best clue to the client state of consciousness that his eyes closed. (Doenges, p. 273)</li>
<li>Determining the level of consciousness. (Doenges, p. 273)</li>
<li>Measuring agreement in speech and show the level of consciousness. If damage occurs very little of the cerebral cortex, the client will probably respond well to verbal stimuli were given but may also exhibit such severe drowsiness or uncooperative. (Doenges, p. 273)</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis : Increased body temperature </b>related to the inflammatory response of the central nervous system.<br />
<br />
Goal :<br />
<ul>
<li>Maintain body temperature within normal limits.</li>
</ul>
<br />
Expected outcomes:<br />
<ul>
<li>The client no fever.</li>
<li>The body temperature of 36 ° C - 37.5 ° C</li>
<li>Vital signs within normal limits.</li>
<li>The cliens are not seizures because of a high fever.</li>
</ul>
<br />
Nursing Interventions:<br />
<ul>
<li>Monitor the client's body temperature (degrees and patterns).</li>
<li>Monitor the temperature of the environment, limit or add bed linen as indicated.</li>
<li>Give a cold compress on axila and groin when the fever.</li>
<li>Collaboration: administration of antipyretic drugs.</li>
</ul>
Rational:<br />
<ul>
<li>Temperature of 38 0 to 41.1 0 C showed an acute infectious disease process.</li>
<li>Fever patterns can help in the diagnosis. (Doenges, p. 875)</li>
<li>Room temperature or amount of blankets should be changed to maintain near-normal temperatures. (Doenges, p. 876)</li>
<li>With cold compresses can help reduce fever. (Doenges, p. 876)</li>
<li>To reduce fever in the hypothalamus, although the fever may be useful in limiting the growth of the organism and increase auto destruction of infected cells. (Doenges, p. 876)</li>
</ul>
<br />
<b>Nursing Diagnosis : Ineffective airway clearance</b> related to neuromuscular damage.<br />
<br />
Goal:<br />
<ul>
<li>Maintain normal breathing patterns or effective.</li>
</ul>
Expected outcomes:<br />
<ul>
<li>The client is not breathlessness.</li>
<li>The client does not cyanosis.</li>
<li>SaO2 normal (95-100%).</li>
</ul>
Nursing Interventions:<br />
<ul>
<li>Give oxygen, according to clients' requirements.</li>
<li>Change position periodically and ambulation and discharging.</li>
<li>Suction with extra careful not more than 10-15 seconds. Note the character, color and turbidity of secretions.</li>
</ul>
Rational:<br />
<ul>
<li>Maximizing oxygen in arterial blood and helps in the prevention in the prevention of hypoxia. (Doenges, p. 278)</li>
<li>Increasing the air filling the entire lung segment, mobilizing and discharging. (Doenges, p. 448)</li>
<li>Sucking is usually required if the client coma or in a state of immobilization and can not clear the airway. Sucking on a deeper trachea should be done with extra caution because it can cause or increase the hypoxic vasoconstriction in the end will cause considerable influence on cerebral perfusion. (Doenges, p. 278)</li>
</ul>
<br />
<b>Nursing Diagnosis : Imbalanced Nutrition Less than Body Requirements</b> related to changes in the ability to digest nutrients.<br />
<br />
Goals:<br />
<ul>
<li>Nutrition of the client are met.</li>
<li>Not experience signs of malnutrition.</li>
</ul>
Expected outcomes:<br />
<ul>
<li>The client may spend a portion of the food provided.</li>
<li>The increase in weight than before.</li>
</ul>
Nursing Interventions:<br />
<ul>
<li>Give fluids via IV or food through a tube.</li>
<li>Give nutritional therapy in a hospital treatment program as indicated.</li>
<li>Destroy and give food through any hose left on the tray after a period of time of administration as indicated.</li>
</ul>
<br />
Rational:<br />
<ul>
<li>To provide replacement fluids and eating well, if the client is not able to enter anything by mouth. (Doenges, p. 305)</li>
<li>Treatment of the basic problems do not occur without improvements in nutritional status. Hospitalizations provide an environment where the control input of food, vomiting or elimination, medication and activity can be monitored. (Doenges, p. 428)</li>
<li>Used as part of behavior change programs to provide your total calorie intake needed. (Doenges, p. 428)</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-20687931100533721772014-11-30T09:17:00.001+07:002014-11-30T09:17:52.870+07:00Assessment (functional health patterns) and Nursing Diagnosis for Meningitis<b>Nursing Care Plan for Meningitis</b><br />
<br />
Assessment is an early stage of the nursing process and is a systematic process of collecting data from various sources and to evaluate and identify the health status of patients (Nursalam, 2001).<br />
<br />
1. Identity<br />
Includes names, gender, occupation, address and so on.<br />
<br />
2. Health History<br />
a) Past medical history.<br />
Asked about the client's medical history that ever happened previously associated with the disease today. Is there any food allergies or certain drugs what immunizations are obtained when the client and the client habits at home.<br />
<br />
b) History of present illness<br />
Assessment of the course of the disease, ranging from the first until now, such as; fever, irritability, obstipation, and vomiting and apathy began when perceived. While the grievances felt from the beginning to today; Is there apathy, pupillary reflexes are slowed, weakened tendon reflexes, fever, and Kernig's sign, and positive Brudzinski, and what efforts have been made the client or family about this disease.<br />
<br />
c) Family medical history<br />
In the client's family, if anyone suffering from diseases such as those being suffered by the client.<br />
<br />
Health maintenance history<br />
<br />
1) Health Perception and Management<br />
Objective Data:<br />
<ul>
<li>Ask the client's medical history, which was once experienced before.</li>
<li>Are there any efforts made to maintain the health and self-protection.</li>
<li>Ask the efforts made when symptoms arise.</li>
<li>Are the expectations of clients or family admission to the hospital.</li>
</ul>
Objective Data :<br />
<ul>
<li>Observe the appearance or the physical state of the client.</li>
</ul>
2) Nutritional metabolic<br />
Subjective Data:<br />
<ul>
<li>The type, frequency and amount of food and drinks in a day.</li>
<li>Appetite and preferred food.</li>
<li>Difficulties arise when eating, such as: nausea, vomiting, heartburn.</li>
<li>Is there a certain adherence to the diet.</li>
</ul>
Objective Data :<br />
<ul>
<li>Observation of the client's ability to receive nutrients.</li>
<li>Interavena therapy, is there a nose hose.</li>
</ul>
3) Elimination<br />
Subjective Data:<br />
<ul>
<li>Bowel habits, such as regular or irregular frequency, consistency and a lot or a little.</li>
<li>Smoothness defecation: need drugs or certain foods.</li>
<li>Small bowel habits, such as: urine comes out smoothly or not, the color of urine.</li>
</ul>
Objective Data:<br />
<ul>
<li>Observation of the client's ability to defecate / urinate.</li>
<li>Installation folley catheter.</li>
<li>The client's Urine color.</li>
</ul>
4) Activity exercise<br />
Subjective Data:<br />
<ul>
<li>Ask the client's daily activities at home, are like: bathing, dressing, make up their own, walk, eat, defecate or urinate.</li>
</ul>
Objective Data:<br />
<ul>
<li>Observation of the client's ability level in the move.</li>
</ul>
5) Sleep rest<br />
Subjective Data:<br />
<ul>
<li>Ask the client's time to sleep and the number of hours of sleep a day.</li>
<li>Things that become barriers to the clients during sleep.</li>
<li>Ask the client to sleep atmosphere.</li>
<li>Efforts what the client when it is difficult to sleep.</li>
</ul>
Objective Data<br />
<ul>
<li>Observation clients sleep patterns.</li>
</ul>
6) Cognitive-perceptual<br />
Subjective Data:<br />
<ul>
<li>Ask if the client can try, calculate.</li>
<li>Ask if there are clients using the tools.</li>
<li>Ask if the client could hear the instruction of their parents.</li>
</ul>
Objective Data :<br /><ul>
<li>Observation of the client's ability to hear the nurse or doctor's instructions.</li>
</ul>
7) Self perception/self concept<br />
Subjective Data:<br />
<ul>
<li>The client's perception about themselves.</li>
<li>Does the client never feel inferior or lacking in confidence.</li>
</ul>
Data Objective:<br />
<ul>
<li>Is there an expression of the clients about the show disruption of perception and self-concept.</li>
</ul>
<br />
8) Role relationship<br />
Subjective Data:<br />
<ul>
<li>Ask if the client's role in the family.</li>
<li>Ask if the client can adapt to the environment.</li>
</ul>
Data Objective:<br />
<ul>
<li>Observation of the client's ability to play an active role with the nurses and doctors for pain.</li>
</ul>
9) Value-Belief Pattern<br />
Subjective Data:<br />
<ul>
<li>Ask the client to follow a religion.</li>
<li>Does the client to be diligent in religious activities.</li>
</ul>
Data Objective:<br />
<ul>
<li>Observation of the client or family, if ever prayed for the sick.</li>
</ul>
<br />
<b>Nursing Diagnosis for Meningitis</b><br />
<br />
Nursing diagnosis is a statement that describes the human responses of individuals or groups-where nurses can identify and provide accountability for certain information to maintain health status, lower, limit, stop and change. (Nursalam quoted from Carpenito, p 35, 2000)<br />
<br />
Nursing Diagnosis that may arise are:<br />
<ol>
<li>Altered Levels of Consciousness related to the process of infection and neurological impairment.</li>
<li>Increased body temperature related to the inflammatory response of the central nervous system.</li>
<li>Ineffective airway clearance related to neuromuscular damage.</li>
<li>Imbalanced Nutrition Less than Body Requirements related to changes in the ability to digest nutrients.</li>
</ol>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-2079147605632198942014-11-23T22:54:00.000+07:002014-11-23T22:54:08.095+07:00Basic Concepts of Nursing Care Plan for CHF<b>Nursing Assessment - Nursing Care Plan for <a href="http://nanda-diagnosis.blogspot.com/2014/11/ncp-for-activity-intolerance-related-to.html">Congestive Heart Failure</a></b><br />
<br />
Assessment is an early stage and the foundation of the nursing process. Required careful examination to know the patient's problem, in order to give direction to the nursing actions. The success of the nursing process is highly dependent on the precision and accuracy in the assessment phase (Lismidar, et al., 2005).<br />
<br />
1. Identity<br />
The client's identity consists of: name, age, gender, marital status, religion, ethnicity / race, education, occupation and address.<br />
The identity of the person in charge consists of: name, relationship with clients, education, occupation and address.<br />
<br />
2. Health history<br />
<br />
a. Main complaint<br />
The main complaint client with heart failure are shortness of breath, pain and weakness during the move.<br />
<br />
b. Current medical history<br />
Assessment that supports the main complaints made by asking a series of questions about physical weakness by using PQRST ways, namely:<br />
P: Provoking incidents, physical weakness occurs after mild to severe activity, according to the disturbance of the heart.<br />
Q: Quality of pain, such as what the complaints of weakness in an activity that is perceived by the client. Usually every move, clients feel shortness of breath.<br />
R: Region, whether physical weakness localized or affect the entire musculoskeletal system and is accompanied by the inability to perform the movement.<br />
S: Severity (scale) of pain, examine the range of the client's ability to perform daily activities. Usually the client's ability to move decreases the degree of interference experienced organ perfusion.<br />
T: Time, nature of early onset, complaints of weakness activity usually occurs slowly. Old onset of weakness when the move is usually all times, both at rest and during activity.<br />
<br />
c. Past medical history<br />
Assessment of the support assessed by asking whether previously been suffering from chest pain, hypertension, myocardial ischemia, diabetes mellitus, and hyperlipidemia.<br />
Ask about drugs commonly taken by the client in the past and are still relevant to current conditions. These drugs include drugs diuretics, nitrates, beta-blockers, and antihypertensives. Note the side effects that occurred in the past. Drug allergies and allergic reactions that arise. Often clients interpret an allergy as a side effect of medications.<br />
<br />
d. Family history<br />
The nurse asked about illnesses experienced by the family, the family members who died, especially in the productive age, and cause of death. Ischemic heart disease in the elderly who onset at a young age is a major risk factor for ischemic heart disease in the offspring.<br />
<br />
<br />
3. Requirement: Biology - Psychology -Sosial -Spiritual, include:<br />
<br />
a. Activity / rest<br />
Clients usually complain of fatigue / tiredness constantly throughout the day, insomnia, chest pain on exertion and dyspnea at rest.<br />
<br />
b. circulation<br />
Usually the client has a history of hypertension, recent myocardial infarction / acute episodes prior CHF, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.<br />
<br />
c. Ego Integrity<br />
Clients say anxiety, worry and fear. Stress related illnesses / financial concerns (job / medical care costs).<br />
<br />
d. Elimination<br />
Clients say a decrease in urination, dark colored urine, like urination at night (nocturia), diarrhea / constipation.<br />
<br />
e. Food / Fluid<br />
Clients say has no appetite, always nausea / vomiting, weight gain significantly.<br />
<br />
f. Hygiene<br />
Client states feel tired / weak, ie the client perceived fatigue during self-care activities.<br />
<br />
g. Neurosensory<br />
Client states weakened, like the feel dizzy, and sometimes experience fainting.<br />
<br />
h. Pain / comfort<br />
Clients complain of chest pain, acute or chronic angina, upper right abdominal pain and muscle pain.<br />
<br />
i. Breathing<br />
Clients expressed dyspnea on exertion, sleep sitting up or with a few pillows, cough with / without the formation of sputum, history of chronic diseases, use of rescue breathing.<br />
<br />
j. Security<br />
Clients say experience changes in mental function, loss of strength, muscle tone, skin abrasions.<br />
<br />
k. Social interaction<br />
Client states rarely follow the usual social activities.<br />
<br />
l. Learning / teaching<br />
Client states use / forget to use heart medications, eg calcium channel blockers.<br />
<br />
<br />
4. Physical Examination<br />
<br />
a. General circumstances:<br />
On examination of the general situation, the client's awareness of heart failure is usually good or composmentis and will change according to the level of perfusion disorders of the central nervous system.<br />
<br />
b. Vital signs: blood pressure, pulse, respiration, temperature.<br />
<br />
<br />
5. Examination Support<br />
Investigations in congestive heart failure, namely:<br />
<ul>
<li>Echocardiography,</li>
<li>Thoracic X-rays, and</li>
<li>Electrocardiography.</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-31812473337390553912014-11-20T15:33:00.000+07:002014-11-20T15:33:20.569+07:00NCP for Activity Intolerance related to Heart Failure<br />
<b>Nursing Care Plan for Heart Failure</b><br />
<br />
<b>Nursing Diagnosis : <a href="http://nanda-diagnosis.blogspot.com/2014/07/ineffective-airway-clearance-and.html">Activity Intolerance</a></b> low cardiac output, inability to meet the metabolism of skeletal muscle, pulmonary congestion leading to hypoxia, dyspnea and poor nutritional status during illness.<br />
<br />
<b>Activity intolerance</b> related to fatigue.<br />
<br />
Definition: Insufficient physiological or psychological energy to continue or complete the requested activity or daily activities.<br />
<br />
Defining characteristics:<br />
<ul>
<li>Verbally report the presence of fatigue or weakness.</li>
<li>Abnormal response of blood pressure or pulse of activity.</li>
<li>ECG changes indicating ischemia or arrhythmias.</li>
<li>The presence of dyspnea or discomfort during the move.</li>
</ul>
<br />
Related factors:<br />
<ul>
<li>Bed rest or immobilization.</li>
<li>Overall weakness.</li>
<li>The imbalance between oxygen supply needs.</li>
<li>Lifestyle is maintained.</li>
</ul>
<br />
<b>NOC:</b><br />
<ul>
<li>Energy conservation.</li>
<li>Self Care: ADLs.</li>
</ul>
<b><br /></b>
<b>Outcomes:</b><br />
<ul>
<li>Participating in physical activity without an increase in blood pressure, pulse and respiration.</li>
<li>Able to perform daily activities (ADLs) independently.</li>
</ul>
<br />
<b>NIC:</b><br />
<br />
<b>Energy Management</b><br />
<ul>
<li>Observe for client restrictions in activity.</li>
<li>Encourage the child to express feelings of limitation.</li>
<li>Assess the factors that cause fatigue.</li>
<li>Monitor nutrition and adequate sources of energy.</li>
<li>Monitor the patient of the existence of physical exhaustion and emotional excess.</li>
<li>Monitor cardiovascular response to activity.</li>
<li>Monitor sleep patterns and duration of sleep / rest patients.</li>
</ul>
<b>Activity Therapy</b><br />
<ul>
<li>Collaborate with the Medical Rehabilitation Workers in planning the program as appropriate therapy.</li>
<li>Help clients to identify activity that is able to do.</li>
<li>Help to choose appropriate activities consistent with the physical, psychological and social.</li>
<li>Help to identify and obtain the necessary resources for the desired activity.</li>
<li>Help to get aids such as wheelchairs activity.</li>
<li>Help to identify the preferred activity.</li>
<li>Help clients to make exercise schedule at leisure.</li>
<li>Help the patient / family to identify deficiencies in the move.</li>
<li>Provide positive reinforcement for active activities.</li>
<li>Help the patient to develop self-motivation and reinforcement.</li>
<li>Monitor response to physical, emotional, social and spiritual.</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-74986836354662136062014-11-20T15:14:00.002+07:002014-11-20T15:14:32.688+07:00NCP for Ineffective Tissue Perfusion related to Heart Failure<br />
<b>Nursing Diagnosis for Heart Failure : Ineffective Tissue Perfusion</b> related to decrease in cardiac output, tissue hypoxemia, acidosis and possible thrombus or embolism.<br />
<br />
Definitions:<br />
Decreased oxygen delivery, the failure to feed the tissue at the capillary level.<br />
<br />
Defining characteristics:<br />
<br />
Renal :<br />
<ul>
<li>Changes in blood pressure beyond the limits of the parameters.</li>
<li>Hematuria.</li>
<li>Oliguria / anuria.</li>
<li>Elevation / decrease in BUN / creatinine ratio.</li>
</ul>
Gastrointestinal :<br />
<ul>
<li>Intestinal hypoactive or absent.</li>
<li>Nausea.</li>
<li>Abdominal distention.</li>
<li>Abdominal pain or does not feel soft (tenderness).</li>
</ul>
Peripheral :<br />
<ul>
<li>Edema.</li>
<li>Positive Homan's sign.</li>
<li>Changes in skin characteristics (hair, nails, water / moisture).</li>
<li>The pulse is weak or non-existent.</li>
<li>Discoloration of the skin.</li>
<li>Changes in skin temperature.</li>
<li>Changes in sensation.</li>
<li>Bluish.</li>
<li>Changes in blood pressure in the extremities.</li>
<li>Bruit.</li>
<li>Too late to recover.</li>
<li>Reduced arterial pulsation.</li>
<li>Pale skin color in elevation, the color does not return to the decrease in the foot.</li>
</ul>
<br />
Cerebral:<br />
<ul>
<li>Abnormalities talk.</li>
<li>Limb weakness or paralysis.</li>
<li>Changes in mental status.</li>
<li>Changes in the motor response.</li>
<li>Changes in pupil reaction.</li>
<li>Difficulty in swallowing.</li>
<li>Changes in habits.</li>
</ul>
Cardiopulmonary :<br />
<ul>
<li>Changes in the frequency of respiration beyond the limits of the parameters.</li>
<li>The use of additional respiratory muscles.</li>
<li>Turn over three second capillary (capillary refill).</li>
<li>Abnormal arterial blood gases.</li>
<li>The feeling of "impending Doom" (Fate threatened).</li>
<li>Bronchospasm.</li>
<li>Dyspnea.</li>
<li>Arrhythmias.</li>
<li>Nose redness.</li>
<li>Chest retraction.</li>
<li>Chest pain.</li>
</ul>
<br />
<i><b>Related Factors :</b></i><br />
<ul>
<li>Hypovolemia.</li>
<li>Hypervolaemia.</li>
<li>Arterial flow was interrupted.</li>
<li>Exchange problems.</li>
<li>Venous flow is cut off.</li>
<li>Hypoventilation.</li>
<li>Mechanical reduction in venous or arterial blood flow.</li>
<li>Damage to transport oxygen through the alveolar and capillary membranes.</li>
<li>Not comparable between ventilation with blood flow.</li>
<li>Poisoning enzyme.</li>
<li>Changes in affinity / binding O2 with Hb.</li>
<li>The decline in Hb concentration in the blood.</li>
</ul>
<br />
<b>NOC:</b><br />
<ul>
<li>Circulation status.</li>
<li>Tissue Perfusion: cerebral.</li>
</ul>
<b>Outcomes:</b><br />
a. Demonstrating circulation status, which is characterized by:<br />
<ul>
<li>Systole and diastole the pressure within the expected range.</li>
<li>No orthostatic hypertension.</li>
<li>No signs of increased intracranial pressure (no more than 15 mm Hg).</li>
</ul>
b. Demonstrating cognitive ability, which is characterized by:<br />
<ul>
<li>Communicate clearly and in accordance with ability.</li>
<li>Shows attention, concentration and orientation.</li>
<li>Process the information.</li>
<li>Making the correct decision.</li>
</ul>
c. Showed intact cranial sensorimotor functions: level of consciousness improved, there is no involuntary movements.<br />
<br />
<br />
<b>NIC:</b><br />
<br />
<b>Peripheral Sensation Management.</b><br />
<ul>
<li>Monitor the presence of certain areas only sensitive to heat / cold / sharp / blunt.</li>
<li>Monitor the presence of paresthesia.</li>
<li>Instruct family to observe the skin, if there are lesions or lacerations.</li>
<li>Use gloves for protection.</li>
<li>Limit movement of the head, neck and back.</li>
<li>Monitor the ability of defecation.</li>
<li>Collaboration of analgesic.</li>
<li>Monitor the presence of thrombophlebitis.</li>
<li>Discuss about the causes of changes in sensation.</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-56713735415997520842014-11-04T08:34:00.004+07:002014-11-04T08:34:41.041+07:00NCP Knowledge Deficit related to Cesarean Section<b>Nursing Care Plan for Cesarean Section</b><br />
<br />
A Caesarean section is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies.<br />
<br />
Nursing Diagnosis : Knowledge Deficit : regarding physiological changes, periods of recovery, self-care, and baby care needs related to misinterpretation, did not know the sources.<br />
<br />
Goal:<br />
Expressing an understanding of the physiological changes, the needs of the individual, the results expected.<br />
Activities / procedures that need to be done correctly and describes the reasons for the action.<br />
<br />
Intervention:<br />
<br />
1. Assess the client's readiness and motivation to learn. Help clients / partners in identifying needs.<br />
Rational: the post-partum period can be a positive experience of education when given the opportunity to assist in the development / growth of the mother, malnutrition and competence.<br />
<br />
2. Assess the physical state of the client. Plan appropriate groups or individuals after administration of drug or when the client feel comfortable and rest.<br />
Rationale: Allows clients to concentrate more fully and receive counseling.<br />
<br />
3. Pay attention to psychological status and response to cesarean birth and the role of motherhood.<br />
Rationale: Anxiety related to the ability to care for themselves and their children, disappointment on the birth experience has a negative impact on learning ability and readiness of the client.<br />
<br />
4. Review the need for self-care needs. Encourage participation in self-care if the client can afford.<br />
Rationale: Facilitating autonomy. Help prevent infection and promote recovery.<br />
<br />
5. Discuss appropriate exercise program, according to the provisions.<br />
Rationale: progressive exercise program, usually can be started, if abdominal discomfort has diminished.<br />
<br />
6. Identify signs / symptoms that require the attention of a health care provider.<br />
Rationale: Evaluation intervene immediately to prevent / limit the development of complications.<br />
<br />
7. Demonstrate the techniques of infant care. Observations re demonstration by the client / partner.<br />
Rationale: Helping parents in mastering new tasks.<br />
<br />
8. Discuss contraception plan. Give informant about the methods available methods, including advantages and disadvantages.<br />
Rationale: The relationship is re-established as soon as possible when the client starts to feel comfortable and the recovery has progressed.<br />
<br />
9. Provide or reinforce information related to post-partum follow-up examination.<br />
Rationale: Evaluation of post-partum cesarean delivery, may be scheduled for the third week of the sixth week because of the increased risk of infection and slowing the recovery.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-11881715745670309532014-11-03T09:34:00.004+07:002014-11-03T09:34:59.462+07:00Nursing Care Plan for Cesarean Section - Risk for Infection<br />
<b>Nursing Diagnosis for Cesarean Section : Risk for Infection</b> related to tissue trauma / broken skin, decreased hemoglobin, invasive procedures, long membrane rupture, malnutrition.<br />
<br />
Goal:<br />
<ul>
<li>Demonstrate techniques to reduce risks and / or promote healing.</li>
<li>Showing the wound free of purulent drainage with early signs of healing.</li>
<li>Free of infection, no fever, no breath sounds adventius, and the color of urine clear.</li>
</ul>
<br />
Intervention:<br />
<br />
1. Encourage, and use careful hand washing techniques, and disposal of reviewers dirt, perineal pads, and contaminated linens appropriately.<br />
Rationale: Helps prevent or limit the spread of infection.<br />
<br />
2. Assess the client's nutritional status, consider the weight before pregnancy and prenatal weight gain.<br />
Rationale: Clients whose weight is 20% below normal weight are more susceptible to post-partum infection and require a special diet.<br />
<br />
3. Inspection of the exudate abdominal bandage or seepage. Remove the bandage as indicated.<br />
Rationale: A sterile dressing covering the wound in the first 24 hours of cesarean birth helps protect the wound from injury and contamination.<br />
<br />
4. Assess the temperature, pulse and white blood cell count.<br />
Rationale: Fever after postoperative day 3, leukocytosis, and tachycardia indicating infection. The increase in body temperature to 38 ° C within the first 24 hours so indicate infection.<br />
<br />
5. Assess the location and uterine contractility, consider the involution changes in the air or the presence of extreme tenderness.<br />
Rationale: Slowing involution increase the risk of endometritis. The development of extreme tenderness indicates the possibility of retained placental tissue or infection.<br />
<br />
6. Pay attention to the amount and smell of lochia discharge or change in the normal progress of rubra be serous.<br />
Rationale: In normal lochia smells fishy but in endometritis discharge, purulent possible, and foul smelling, and can fail to have indicated normal progress and lochia rubra be serous until alba.<br />
<br />
7. Assess the client in splinting the incision for lung exercise.<br />
Rationale: helps prevent stretching the incision, and decrease the possibility of injury dehidens.<br />
<br />
8. Collaboration oxytocin or ergot preparations.<br />
Rationale: Maintaining miometrial contractility, thus preventing the spread of bacteria through the wall of the uterus.<br />
<br />
9. Get the blood and urine cultures if infection is suspected.<br />
Rationale: Bacteremia is more common on clients who have ruptured membranes for 6 hours or more than the client remains intact amniotic prior cesarean birth.<br />
<br />
10. Collaboration of specific antibiotics for the infection were identified.<br />
Rationale: Need to kill the organism. Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-91811782806186069332014-11-02T12:58:00.000+07:002014-11-02T12:58:07.182+07:00NCP for Hydronephrosis - 4 Nursing Diagnosis with Interventions<b>Nursing Care Plan for Hydronephrosis</b><br />
<br />
<b>Definition</b><br />
<br />
Hydronephrosis is obstruction of urinary flow proximal to the bladder can lead to accumulation of fluid pressure in the renal pelvis and ureter can lead to intense absorption in the renal parenchyma (Sylvia, 1995).<br />
<br />
If this happens obstruction in the ureter or bladder, back pressure will affect both kidneys but if it occurs in one of ureteral obstruction due to stones or stiffness then only one kidney is damaged.<br />
<br />
<br />
<b>Etiology</b><br />
<ul>
<li>Scarring kidney / ureter.</li>
<li>Stone.</li>
<li>Neoplasms / Tomur.</li>
<li>Prostatic hypertrophy.</li>
<li>Konginetal abnormalities in the bladder neck and urethra.</li>
<li>Narrowing of the urethra.</li>
<li>Enlargement of the uterus in pregnancy. (Smeltzer and Bare, 2002).</li>
</ul>
<br />
<b>Pathophysiology</b><br />
<br />
Whatever the cause of hydronephrosis, caused by either partial or intermittent obstruction resulted in the accumulation of urine in the kidney cup. Causing dissertation trophy and renal colic. At this time renal atrophy occurs when one kidney is undergoing a gradual deterioration of the kidneys that would otherwise be gradually enlarged (compensatory hypertrophy), resulting in impaired renal function (Smeltzer and Bare, 2002).<br />
<br />
<b>Clinical Manifestations</b><br />
<br />
Patients may be asymptomatic if the onset is gradual. Acute obstruction may cause pain in the pelvis and hips. If an infection; dysuria, chills, fever and tenderness and pyuria will occur. Hematuria and pyuria may also exist. If both kidneys in contact with the signs and symptoms of chronic renal failure will arise, such as:<br />
<ul>
<li>Hypertension (due to fluid retention and sodium).</li>
<li>Congestive heart failure.</li>
<li>Pericarditis (due to irritation by toxic uremi).</li>
<li>Pruritis (itchy skin).</li>
<li>Uremic granules (urea crystals on the skin).</li>
<li>Anorexia, nausea, vomiting, hiccups.</li>
<li>Decreased concentration, muscle twitching and convulsions.</li>
<li>Amenorrhea, testicular atrophy.</li>
</ul>
<br />
<br />
<b>Nursing Diagnosis and Interventions for Hydronephrosis</b><br />
<br />
1. <b>Pain (acute / chronic) </b>related to acute obstruction.<br />
<br />
Goal: Pain is reduced until it disappears.<br />
Outcomes:<br />
<ul>
<li>The patient looks relaxed.</li>
<li>The patient revealed reduced pain.</li>
</ul>
Intervention:<br />
<ul>
<li>Assess the level of pain.</li>
<li>Give explanation of the cause of the pain.</li>
<li>Teach relaxation and distraction.</li>
<li>Collaboration of analgesic.</li>
</ul>
<br />
<br />
2. <a href="http://nanda-diagnosis.blogspot.com/2014/01/risk-for-infection-and-acute-pain.html"><b>Risk for infection</b></a> related to hemodialysis access.<br />
<br />
Goal: Infection does not occur.<br />
<b>O</b>utcomes:<br />
<ul>
<li>There are no signs of infection.</li>
<li>No sepsis and pus.</li>
</ul>
Interventions:<br />
<ul>
<li>Wash hands before and after the action.</li>
<li>Cover the wound with aseptic technique.</li>
<li>Monitor if there is inflammation.</li>
<li>Monitor vital signs.</li>
<li>Collaboration antibiotics.</li>
</ul>
<br />
3. <a href="http://nanda-diagnosis.blogspot.com/2014/07/ineffective-airway-clearance-and.html"><b>Activity intolerance</b></a> related to anemia.<br />
<br />
Goal: Needs unmet activity.<br />
<br />
Outcomes:<br />
<ul>
<li>Improve mobility.</li>
<li>Reported a decrease in symptoms of activity intolerance.</li>
</ul>
Intervention:<br />
<ul>
<li>Assess the individual response to activity, pain, dyspnea, vertigo. Increase activity gradually client.</li>
<li>Collaboration with physiotherapists.</li>
</ul>
<br />
4. I<b>mbalanced Nutrition Less than Body Requirements</b> related to nausea, vomiting.<br />
<br />
Goal: Nutrition met.<br />
Outcomes:<br />
<ul>
<li>Oral intake increased.</li>
<li>Body weight in the normal range.</li>
</ul>
Intervention<br />
<ul>
<li>Explain the importance of adequate nutrition.</li>
<li>Give small portions but frequently.</li>
<li>Create a pleasant atmosphere.</li>
<li>Encourage clients to eat with family members.</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-52042941050275529202014-08-27T11:17:00.002+07:002014-08-27T11:17:29.051+07:00Nursing Care Plan related to Infection<b>Assessment, Nursing Diagnosis, Interventions, Implementationa and Evaluation</b><br />
<br />
Assessment<br />
<br />
Nurses assess the following matters:<br />
<br />
1 Status defense mechanisms<br />
<br />
The primary defense is not adequacy (skin / mucosal damage, tissue trauma, obstruction of lymph flow, peristaltic disorders, decreased mobility).<br />
Secondary defense is not adequacy (decrease in Hb, WBC suppression, suppression of the inflammatory response, leukopenia).<br />
<br />
2 Vulnerability client<br />
<ul>
<li>Age : Babies have a weak defense against infection, at birth have antibodies from the mother, while the immune system is still immature. As the child grows, the more mature the immune system, but the baby is still susceptible to the organism causes fever, intestinal infections, and other infectious diseases (mumps and measles). Early adult immune system has given the defense the bacteria invade. In old age, because the function and decreased organ, the immune system is also changing.</li>
<li>Nutritional status : Reduction of the intake of protein and other nutrients such as carbohydrates and cause a decrease in the body's defenses. Nurses assess the dietary intake of the client and the client's ability to consume food (there is no interruption in the process of swallowing or digestive system).</li>
<li>Stress : The body responds to emotional or physical stess through the general adaptation syndrome. If stess continues, causing high levels of cortisone yan decreased immune system.</li>
<li>Heredity : Certain hereditary disorders interfere with an individual's defense against infection.</li>
<li>Disease process : Clients who are sick in the immune system, especially the risk of infection. Clients who are experiencing complex illness (complications) higher risk of infection.</li>
<li>Medical therapy : Some drugs and medical therapies affect the immune system. Nurses need to assess the client's drugs consumed.</li>
</ul>
3 Clinical appearance<br />
<br />
Signs and symptoms of infection can be either local or systemic infection. Nurses need to examine the sign that appears on the client.<br />
<br />
4 Laboratory data<br />
<br />
The nurse examines the client's laboratory results.<br />
<br />
<br />
Nursing Diagnosis related to Infection<br />
<ol>
<li><a href="http://nanda-diagnosis.blogspot.com/2014/01/risk-for-infection-and-acute-pain.html">Risk for infection</a> r / t impaired immunity.</li>
<li>Risk for infection r / t tissue damage.</li>
<li>Risk for injury r / t impaired immunity.</li>
<li><a href="http://nanda-diagnosis.blogspot.com/2014/08/altered-urinary-elimination-and.html">Impaired skin integrity</a> r / t interruption of circulation</li>
<li>Imbalanced nutrition less than body requirements r / t poor dietary habits that</li>
<li>Imbalanced nutrition less than body requirements r / t GI dysfunction.</li>
</ol>
<br />
Interventions<br />
<br />
The general objective:<br />
Prevention of exposure to infectious organisms.<br />
Monitor and reduce the spread of infection.<br />
Maintain resistance to infection.<br />
Clients and families learn about infection control.<br />
<br />
<br />
Implementation<br />
<ul>
<li>Prevention of disease (destroying the reservoir of infection, control the exit and entrance portals, avoiding the transmission of action, preventing bacteria find a place to grow).</li>
<li>Measures of acute treatment (administration of appropriate antibiotics in the treatment and other measures).</li>
</ul>
<br />
Control of infectious agents:<br />
<ul>
<li>Cleaning. Throw out all foreign material such as dirt and organic material of an object.</li>
<li>Disinfection. A process to destroy bacteria, but the spores</li>
<li>Sterilization. Destruction and destruction of all microorganisms, including spores.</li>
</ul>
<br />
Reservoir control <br />
<ul>
<li>Bathe regularly.</li>
<li>Changing bandages wet or dirty.</li>
<li>Contaminated objects, discarded at the right place.</li>
<li>Contaminated needles, discarded at the right place.</li>
<li>Surgical wounds treated correctly.</li>
<li>Nursing bottle and bag drainage.</li>
<li>Keep the solution in a bottle.</li>
</ul>
<br />
Infection control:<br />
<ul>
<li>Wash hands.</li>
<li>Avoiding the use of the same tool in some patients.</li>
<li>Avoid touching dirty objects nurse's uniform.</li>
<li>Instruct visitors to wash their hands before visiting a client.</li>
<li>Familiarize client to wash hands.</li>
</ul>
Control of the portal of entry<br />
<ul>
<li>Maintaining the integrity of the skin and mucous membranes.</li>
<li>Skin is kept moist.</li>
<li>Setting position.</li>
<li>Perform oral hygiene.</li>
<li>Be careful within taking care of the wound.</li>
<li>Be careful in removing medical devices disposable.</li>
</ul>
Protection of the vulnerable host:<br />
<ul>
<li>Isolation.</li>
<li>Maintain nutritional status.</li>
<li>Maintain personal hygiene.</li>
<li>Provide social support to clients who were isolated.</li>
<li>Protective environment.</li>
</ul>
Protection of workers:<br />
<ul>
<li>Gown.</li>
<li>Mask.</li>
<li>Gloves.</li>
<li>Protective goggles.</li>
<li>Collection of specimens.</li>
<li>Goods or linen wrap.</li>
</ul>
<br />
Evaluation<br />
<ul>
<li>Evaluation of the action / implementation has been done, if the action can not resolve the problem then forwarded nursing actions, if the problem is resolved, the action was stopped.</li>
<li>For example, do not forget to wash your hands before and after examining patients. Not use the tool in a row in some patients without first properly cleaned after use on a patient. Bathing and cleaning the patient should not be considered routine work that must be completed as soon as possible, but should be done with full responsibility for the safety of the patient against the threat of nosocomial infections.</li>
<li>To participate prevent fungal and bacterial resistance to antibiotics, use of antibiotics in a responsible manner, ie only against susceptible bacteria and fungi, and in sufficient quantity and under the supervision of a physician.</li>
</ul>
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-48821581025783758662014-08-27T10:51:00.003+07:002014-08-27T10:51:47.096+07:00Impaired Physical Mobility Care Plan<b>Nursing Care Plan for Impaired Physical Mobility</b><br />
<br />
Definition<br />
<ul>
<li>Mobilization is an irregular movement, organized and orderly.</li>
<li>Mobilization is an individual's ability to move freely, easily and regularly with the aim to meet the needs of the activity in order to maintain health.</li>
<li>Mobilization is the ability to move freely. (Musrifatul Uliyah and A. Aziz A. H., 2008; 10)</li>
<li>Mobilization is the ability to move freely and regularly to meet the needs of a healthy self-reliance and mobilization which refers to the inability of a person to move freely. (Perry and Potter, 1994)</li>
</ul>
<br />
<br />
Types of Mobility<br />
<br />
Full mobility<br />
<br />
Is a condition in which a person's ability to move fully and freely in order to make social interaction and run the day-to-day role. Full mobility is a function of the motor nerves, sensory voluntary and to be able to control all areas of a person's body.<br />
<br />
Partially mobility<br />
<br />
A person's ability to move with clear boundaries and are not able to move freely because it is influenced by the motor and sensory neurological disorders in areas of the body.<br />
Mobilization of this portion is divided into two parts, namely:<br />
<ul>
<li>Temporary part time mobility, an individual's ability to move with temporary restrictions. This can be caused by trauma to the musculoskeletal system such as reversible on any dislocation of joints and bones.</li>
<li>Permanent part time mobility, an individual's ability to move with boundaries that are fixed. It is caused by damage to the nervous system that is reversible. For example: the occurrence of hemiplegia due to stroke, spinal cord injury praplegi for and specific to poliolemitis due to disruption of sensory and motor nervous system. </li>
</ul>
<br />
<br />
Etiology<br />
<ul>
<li>Lifestyle</li>
<li>Process of disease / injury</li>
<li>Culture</li>
<li>Energy levels</li>
<li>Age and developmental status</li>
<li>Activity intolerance</li>
<li>Neuromuscular disorders</li>
<li>Muscular disorders</li>
</ul>
<br />
<br />
Signs and Symptoms<br />
1. Joint contracture<br />
Caused by disuse, muscle atrophy and neural approaches.<br />
2. Changes in urinary elimination<br />
Urinary elimination is changing due to the immobilization of the patient in the upright position, urine flows out of the renal pelvis and into the ureter and bladder due to the force of gravity.<br />
3. Changes in integument system<br />
Pressure sores are caused by tissue ischemia and anorexia. Depressed tissue, blood forming and strong constriction of the blood vessels due persistem pressure on the skin and under the skin structure so that cellular respiration becomes impaired and cell death.<br />
4. Changes in metabolic<br />
When injury or stress occur, endocrine system triggers a series of responses that aim to maintain blood pressure and maintain life.<br />
5. Changes in the musculoskeletal system<br />
Limitations affect the mobilization of clients through loss of muscle endurance, decreased muscle mass atrophy and decreased stability.<br />
6. Changes in the respiratory system<br />
Clients with postoperative immobilization and an increased risk of complications in the lungs.<br />
<br />
<br />
Benefits Mobilization<br />
1. Patients feel healthier and stronger with early ambulation.<br />
2. Reduce the pain so the patient feels healthy.<br />
3. Helps accelerate the body's organs to work as before.<br />
4. Mobilization allows us to quickly teach the patient to be able to care for himself.<br />
5. Prevent the occurrence of thrombosis and thromboembolism.<br />
6. Maintaining the flexibility of the bones and joints also increases muscle strength.<br />
<br />
<br />
<br />
Clinical Symptoms / Problems of Mobilization<br />
1. Diseases of the nervous system.<br />
2. muscular dystrophy.<br />
3. Tumors of the central nervous system.<br />
4. Increase in intra-cranial.<br />
5. connective tissue disease.<br />
<br />
<br />
ADL Scale (Activity Daily Living)<br />
0: Patients can stand.<br />
1: Patients need help / minimal equipment.<br />
2: Patients requiring assistance are being / with supervision.<br />
3: Patients requiring special assistance and the needed tools.<br />
4: It depends totally on the provision of care.<br />
<br />
<br />
Things to consider in mobilization<br />
<br />
Usually do assessments on time before mobilization and after mobilization like the signs that will be studied in intolerance among other activities (Goldon, 1976)<br />
<br />
<br />
Management<br />
1 Assist the patient sitting up in bed<br />
This action is one way of maintaining patient mobility.<br />
Purpose:<br />
Maintaining comfort.<br />
Maintain tolerance to activity.<br />
<br />
2 Adjust the position of the patient in bed<br />
a. Fowler position is the position of the patient half sitting / sitting<br />
Purpose:<br />
Maintaining comfort<br />
Facilitate respiratory function<br />
<br />
b. Sim's position is the patient lying on his side up to the right or to the left<br />
purpose:<br />
Blood circulation to the brain.<br />
Provide comfort.<br />
Doing an enema.<br />
Giving drugs per rectum.<br />
To examine the anal area.<br />
<br />
c. Trendelenburg position is to place the patient in bed with the head lower than the feet.<br />
Purpose: to improve blood circulation.<br />
<br />
d. Dorsal recumbent position is the position of the patient is placed in the supine position with flexed knees on the bed<br />
Purpose:<br />
Genetalia area treatment.<br />
Examination genetalia.<br />
The position on the delivery process.<br />
<br />
e. Lithotomy position is the position of the patient is placed in the supine position with both legs lifted and pulled to the top of the abdomen.<br />
Purpose:<br />
Examination genetalia.<br />
The delivery process.<br />
Installation of contraception.<br />
<br />
f. Genupectoral position, is the position with both legs bent and torso attached to the top of the bed.<br />
Transporting patients to the tdiur / to wheelchair<br />
Purpose:<br />
Doing skeletal muscles to prevent contractures.<br />
Maintain patient comfort.<br />
Maintaining self-control patients.<br />
Transferring patients for examination.<br />
<br />
Helping the patient to walk<br />
Purpose:<br />
Activity tolerance.Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-48615863171951928022014-08-26T19:06:00.002+07:002014-08-26T19:06:27.623+07:00Primary and Secondary Assessment for Myocardial Infarction<b>Nursing Care Plan for Acute Myocardial Infarction</b><br />
<br />
<br />
<b>Primary Assessment of <a href="http://nanda-diagnosis.blogspot.com/2012/11/what-is-myocardial-infarction-causes.html">Myocardial Infarction</a></b><br />
1. Airways<br />
<ul>
<li>Blockage or accumulation of secretions.</li>
<li>Wheezing or crackles.</li>
</ul>
2 Breathing<br />
<ul>
<li>Congested with light activity or rest.</li>
<li>RR is more than 24 times / minute, shallow irregular rhythm.</li>
<li>Ronchi, crackles.</li>
<li>Expansion of the chest is not full.</li>
<li>The use of accessory muscles of breath.</li>
</ul>
3 Circulation<br />
<ul>
<li>Weak pulse, irregular.</li>
<li>Tachycardia.</li>
<li>Blood pressure increases / decreases.</li>
<li>Edema.</li>
<li>Restless.</li>
<li>Cold acral.</li>
<li>Pale skin, cyanosis.</li>
<li>Decreased urine output.</li>
</ul>
<br />
<b>Secondary Assessment of <a href="http://nanda-diagnosis.blogspot.com/2012/11/acute-pain-nursing-care-plan-myocardial.html">Myocardial Infarction</a></b><br />
1 Activity<br />
<ul>
<li>Symptoms: Weakness, fatigue, can not sleep, sedentary lifestyles, irregular exercise schedule.</li>
<li>Signs: Tachycardia, dyspnea at rest or activity.</li>
</ul>
2 Circulation<br />
<ul>
<li>Symptoms: history of previous AMI, coronary artery disease, blood pressure problems, diabetes mellitus.</li>
<li>Signs: Blood pressure; can be normal / up / down. Postural changes recorded from sleeping to sitting or standing. pulse; can be normal, full or not strong or weak / strong quality with slow capillary refill, irregular (dysrhythmias). Heart sounds; Extra heart sounds: S3 or S4 may indicate heart failure or decreased ventricular kontraktilits or complaint. murmur; when there is a demonstrated failure of valves or heart muscle dysfunction. friction; suspected pericarditis. Heart rhythm can be regular or irregular. edema; juguler venous distention, edema dependent, peripheral, generalized edema, there may be crackles with heart failure or ventricular. color; Pallor or cyanosis, flat nails, mukossa membranes or lips.</li>
</ul>
3 Ego integrity<br />
<ul>
<li>Symptoms: Denying important symptoms or any condition fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family.</li>
<li>Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, attack behavior, focus on self, pain coma.</li>
</ul>
4 Elimination<br />
<ul>
<li>Signs: normal, decreased bowel sounds.</li>
</ul>
5. Food or fluid<br />
<ul>
<li>Symptoms: nausea, anorexia, belching, heartburn or a burning sensation.</li>
<li>Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes.</li>
</ul>
6 Hygiene<br />
<ul>
<li>Symptoms or signs: lesulitan perform maintenance tasks.</li>
</ul>
7 Neurosensory<br />
<ul>
<li>Symptoms: dizziness, throbbing during sleep or when you wake up (sitting or resting)</li>
<li>Signs: mental changes, weakness</li>
</ul>
8 Pain or discomfort<br />
<ul>
<li>Symptoms: sudden onset of chest pain (may or may not be related to the activity), not relieved by rest or nitroglycerin (although mostly in and visceral pain). Location: A typical on the anterior chest, substernal, precordial, can spread to the hands, ranhang, face. No specific location such as epigastric, elbows, jaw, abdomen, back, neck. Quality: "Crushing", narrowed, weight, sedentary, depressed. Intensity: Normally 10 (on a scale of 1 -10), may experience the worst pain ever experienced.</li>
<li>Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly.</li>
</ul>
9 Breathing:<br />
<ul>
<li>Symptoms: dyspnea on exertion or at rest, nocturnal dyspnea, cough with or without sputum production, history of smoking, chronic respiratory disease.</li>
<li>Signs: increased frequency of breathing, shortness of breath / strong, pale, cyanosis, breath sounds (clean, krekles, wheezing), sputum.</li>
</ul>
10. Social Interaction<br />
<ul>
<li>Symptoms: Stress, Difficulty coping with a stressor such as: disease, treatment in hospital.</li>
<li>Signs:. Difficulty rest in peace, too emotional response (constantly angry, scared), withdrew.</li>
</ul>
<br />
<a href="http://nanda-diagnosis.blogspot.com/2014/08/nursing-care-plan-for-cardiovascular.html">Nursing Care Plan for Cardiovascular Disease : Myocardial Infarction</a> Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.comtag:blogger.com,1999:blog-4842558050947736742.post-76103460362829942912014-08-26T18:26:00.004+07:002014-08-26T18:42:00.803+07:00Nursing Care Plan for Cardiovascular Disease : Myocardial Infarction<br />
<b>Nursing Care Plan for Myocardial Infarction</b><br />
<br />
Definition<br />
<br />
According to Brunner & Suddarth, 2002 myocardial infarction refers to the process of destruction of heart tissue due to inadequate blood supply so that coronary blood flow is reduced.<br />
While understanding according Suyono 1999 acute <a href="http://nanda-diagnosis.blogspot.com/2014/08/nursing-care-plan-for-cardiovascular.html">myocardial infarction</a> is myocardial necrosis due to blood flow to the heart muscle is interrupted.<br />
<br />
<br />
Causes<br />
<br />
According to Kasuari, 2002 there were some etiology / cause of acute myocardial infarction, namely: <br />
1) The cause:<br />
a) Reduced myocardial oxygen supply caused by three factors:<br />
<ul><li>Vascular factors: Atherosclerosis, spasm, arteritis.</li>
<li>Circulation factors: hypotension, aortic stenosis, insufficiency.</li>
<li>Blood factors: anemia, hypoxemia, polycythemia.</li>
</ul>b) Cardiac output increased:<br />
<ul><li>Excessive activity.</li>
<li>Eating too much.</li>
<li>Emotions.</li>
<li>Hyperthyroidism.</li>
</ul>c) Increased myocardial oxygen demand, at:<br />
<ul><li>Myocardial damage.</li>
<li>Myocardial hypertrophy.</li>
<li>Diastolic <a href="http://nanda-diagnosis.blogspot.com/2013/07/10-easy-ways-to-lower-hypertension.html">hypertension</a>.</li>
</ul><br />
2) Predisposing factors <br />
a) Biological risk factors that can not be changed:<br />
<ul><li>Age over 40 years.</li>
<li>Gender: high incidence in men, whereas in women increases after menopause.</li>
<li>Heredity.</li>
<li>Race: the incidence is higher in blacks.</li>
</ul>b) Risk factors that can be changed:<br />
<ul><li>Major: <a href="http://nanda-diagnosis.blogspot.com/2012/12/4-sample-of-nursing-diagnosis-for.html">Hypertension</a>, Hyperlipidemia, Obesity, Diabetes, Smoking, Diet: high in saturated fat, high in calories.</li>
<li>Minor: Personality type A (aggressive, ambitious, emotional, competitive), excessive psychological stress, physical inactivity.</li>
</ul><br />
<br />
<a href="http://nanda-diagnosis.blogspot.com/2012/11/what-is-myocardial-infarction-causes.html">Signs and Symptoms of Myocardial Infarction</a><br />
1 Pain :<br />
<ul><li>The main symptom is chest pain that occurs suddenly and constantly not subside, usually felt over the lower sternal region and upper abdomen.</li>
<li>Increased severity of pain can persist until the pain becomes unbearable.</li>
<li>Pain is very sick, like a punctured-pin that can spread to the shoulder and continues down to the arm (usually the left arm).</li>
<li>The pain began spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and not relieved by rest or nitroglycerin assistance.</li>
<li>The pain may spread to the direction of the jaw and neck.</li>
<li>Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.</li>
<li>Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompanies diabetes can interfere neuroreseptord.</li>
</ul><br />
2 Laboratory<br />
Cardiac enzyme tests:<br />
<ul><li>CPK-MB / CPK, Isoenzymes were found in heart muscle increased between 4-6 hours, peaks within 12-24 hours, returning to normal within 36-48 hours.</li>
<li>LDH / HBDH, Increased within 12-24 hours dam takes a long time to return to normal</li>
<li>AST / SGOT, Increased (less real / special) occurs within 6-12 hours, peaking within 24 hours, returning to normal within 3 or 4 days.</li>
</ul><br />
3 ECG<br />
<ul><li>ECG changes that occurred in the early phase of high T waves and symmetrical. After this there is ST segment elevation. Change happens then is the wave Q / QS indicating the presence of necrosis.</li>
</ul><br />
<br />
Test and Diagnosis<br />
<ol><li>ECG. To determine the function of the heart. It will be found an inverted T wave, ST depression, pathological Q.</li>
<li>Cardiac enzymes. CPKMB, LDH, AST.</li>
<li>Electrolytes. Imbalance can affect conduction and contractility, such as hypokalemia, hyperkalemia.</li>
<li>White blood cells. Leukocytes (10000-20000) usually appears on day 2 after AMI associated with inflammatory processes. </li>
<li>Sedimentation velocity. Increased on day 2 and 3 after AMI, indicating inflammation.</li>
<li>Chemistry. May be normal, depending on the function or organ perfusion abnormalities acute or chronic</li>
<li>Blood gas analysis. Hypoksia or process can be demonstrated acute or chronic lung disease.</li>
<li>Serum cholesterol or triglycerides. Increased, indicating arteriosclerosis as a cause of IMA.</li>
<li>Chest x-ray. May be normal or show an enlarged heart is suspected CHF or ventricular aneurysm.</li>
<li>Echocardiogram. Performed to determine the dimensions of the foyer, ventricular wall motion or valves and valve configurations or functionality.</li>
<li>Nuclear imaging tests. a. Thallium: evaluating myocardial blood flow and myocardial cell status such as the location or extent of AMI. b. Technetium: collected in ischemic cells around the necrotic area.</li>
<li>Blood imaging of the heart (MUGA). Evaluating appearance special and general ventricles, regional wall motion and ejection fraction (blood flow).</li>
<li>Coronary angiography. Illustrates the narrowing or blockage of the coronary arteries. Usually done in conjunction with pressure measurements porch and assess left ventricular function (ejection fraction). The procedure is not always done in the phase of AMI, except approaching emergency heart surgery or angioplasty.</li>
<li>Nuclear magnetic resonance (NMR), allows visualization of blood flow, cardiac or valve ventricular porch, lesivaskuler, plaque formation, areas of necrosis or infarction and blood clots.</li>
<li>Exercise stress test, Determining the cardiovascular response to the activities or often done in conjunction with thallium imaging in the healing phase.</li>
</ol><br />
<a href="http://nanda-diagnosis.blogspot.com/2012/11/acute-pain-nursing-care-plan-myocardial.html">Acute Pain - Nursing Care Plan Myocardial Infarction</a> <br />
Wibowo Adhehttp://www.blogger.com/profile/08053831226271234264noreply@blogger.com