Thursday, August 21, 2014

Nursing Diagnosis related to Fluid and Electrolyte

Fluid and Electrolyte

1. Deficient Fluid volume: less than body requirements related to excessive fluid output.

  • Observation of vital signs.
  • Observed signs of dehydration.
  • Measure the input and output of fluid (fluid balance).
  • Provide and encourage families to give drink plenty of approximately 2000 - 2500 cc per day.
  • Collaboration with physicians in the delivery of fluid therapy, electrolyte laboratory examination.
  • Collaboration with a team of nutrition in low-sodium fluid administration.

2. Risk for Deficient fluid volume related to insufficient fluid intake, excessive discharge (vomiting / nausea).

  • Record the number of vomiting and bleeding characteristics.
  • Assess vital signs (BP, pulse, temperature).
  • Monitor fluid intake and output.
  • Elevate the head for taking medication.
  • Give saturated liquid / soft if the input starts again, avoid caffeinated and carbonated beverages.
  • Maintain bed rest.
  • Collaboration with fluid administration as indicated.

3. Risk for ineffective airway clearance related to the operative incision site.

  • Give analgesics as prescribed.
  • Fixation incision with both hands or a pillow to help patients when they cough.
  • Encourage the use of Incentive spirometer if there is an indication.
  • Help and encourage early ambulation.
  • Help the patient to change positions frequently.

4. Disturbed Body Image related to changes in appearance secondary to loss of body parts.

  • Encourage the patient to express feelings, especially about the thoughts, feelings, views of self. Rational: Helping patients to be aware of unusual feelings.
  • Note withdrawing behavior. Increased dependency, manipulation or not involved in treatment. Rational: Alleged problems in assessment can require follow-up evaluation and more rigorous therapy.
  • Maintain a positive approach during maintenance activities. Rational: Help the patient / person closest to accept changes in their own bodies and feel good about themselves.
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Nursing Diagnosis for Urinary / Bowel Elimination : Diarrhea, Constipation

Nanda Nursing Diagnosis for Urinary / Bowel Elimination : Diarrhea, Constipation

1. Alteration in Bowel Elimination : Diarrhea

  • Help need for defecation (if bed rest to prepare the necessary tools near the bed, attach the curtains and immediately dispose of faeces after defecation).
  • Increase / maintain fluid intake by mouth.
  • Teach about the foods and drinks that can worsen / precipitate diarrhea.
  • Observation and record the frequency of defecation, fecal volume and characteristics.
  • Observation fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety and lethargy.
  • Collaboration of appropriate medication therapy program (antibiotics, anticholinergics, corticosteroids).

2. Alteration in Bowel Elimination : Constipation

  • Encourage lots of drinking with ambulation dinikolab laxative administration.
  • Rationalization:
  • Many drinks can help dissolve the stool with ambulation reduce constipation.
  • Formation of stools soft launch.

3. Alteration in Bowel Elimination: Constipation related to neurological disorders of the intestine and rectum.

  • Auscultation of bowel sounds, note the location and characteristics. Rational: bowel sounds may be absent during spinal shock.
  • Observe for abdominal distention.
  • Note the presence of complaints of nausea and want to vomit, pairs of NGT. Rational: gantrointentinal and gastric bleeding may occur due to trauma and stress.
  • Provide a balanced diet high in calories and protein; Liquid. Rational: improving stool consistency.
  • Give laxatives to order. Rational: stimulate the intestines.

4. Altered Urinary Elimination related to the drainage of urine.

  • Assess urine drainage system immediately.
  • Assess the adequacy of urine output and drainage system patency.
  • Use aseptic procedures and washing hands when providing care and action.
  • Maintain a closed urine drainage system.
  • If irrigation is needed and prescribed, do this action carefully using sterile saline.
  • Assist patients in the mobilization.
  • Observation of color, smell and consistency of urine volume.
  • Reduce trauma and manipulation of catheters, drainage system and urethra.
  • Clean the catheter carefully.
  • Maintain adequate fluid intake.

5. Impaired Urinary Elimination

  • Observation of the bladder.
  • Encourage regular bowel movements.
  • Give warm compresses.
  • Rationalization:
  • The content of urinary maintain contractions or uterine involution.
  • Urine retained causes infection.
  • Relaxation springter urine.

6. Altered Urinary Elimination related to paralysis of the urinary condition.

  • Assess the pattern of urination, and record urine output per hour.
  • Rationale: determine kidney function.
  • Palpation of the possibility of bladder distension.
  • Instruct the patient to drink a 2000 cc / day.
  • Rationale: helps maintain kidney function.
  • Attach the catheter Dower.
  • Rational assist the process of urine.

7. Constipation
  • Observation bowel sounds periodically.
  • Suggest to increase fluid intake at least 2 liters a day when no contra indications.
  • Increase activity on a regular basis.
  • For the provision of appropriate therapy, investigation is needed.
  • Dietis team collaboration for the provision of a balanced diet and high in fiber.
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Wednesday, August 20, 2014

Causes of Diarrhea : Virus, Bacteria, Protozoa and Helminth

Causes of Diarrhea : Virus, Bacteria, Protozoa and Helminth
Cause of Diarrhea: (Tantivanich, 2002; Sirivichayakul, 2002; Pitisuttithum, 2002)

1. Virus:
Is the highest cause of acute diarrhea in children (70-80%). Some types of viruses that cause acute diarrhea:
  • Rotavirus serotypes 1,2,8, and 9: in humans. Serotype 3 and 4 were found in animals and humans. And serotypes 5,6, and 7 were found only in animals.
  • Norwalk virus: present in all ages, generally due to food borne or water borne transmission, and the transmission can also occur person to person.
  • Astrovirus, found in children and adults
  • Adenovirus (type 40, 41)
  • Small bowel structured viruses
  • Cytomegalovirus

2 Bacteria:
    Enterotoxigenic E. coli
  • Enterotoxigenic E. coli (ETEC). Have two important virulence factor is a factor that causes bacterial colonization is attached to the enterocytes of the small intestine and enterotoxin (heat labile (HL) and heat stabile (ST) which causes the secretion of fluid and electrolytes that produce watery diarrhea. ETEC causes no damage to brush border or invade the mucosa.
  • Enterophatogenic E. coli (EPEC). The mechanism of diarrhea is not clear. Found the process of attachment of EPEC to intestinal epithelial damage of membrane micro-villi which would disturb the surface absorption and disaccharidase activity.
  • Enteroaggregative E. coli (EAggEC). These bacteria are strongly attached to the mucosa of the small intestine and causes typical morphological changes. How does the mechanism of the onset of diarrhea is still unclear, but it may play a role cytotoxins.
  • Enteroinvasive E. coli (EIEC). In serologic and biochemical similar to Shigella. Such as Shigella, EIEC penetrate and multiply within colonic epithelial cells.
  • Enterohemorrhagic E. coli (EHEC). EHEC producing verocytotoxin (VT) 1 and 2, which is also called Shiga-like toxin that causes diffuse edema and bleeding in the colon. In children often progress to hemolytic-uremic syndrome.
  • Shigella spp. Shigella invade and multiply within colonic epithelial cells, causing cell death and the onset of mucosal ulceration. Shigella rarely enter into the bloodstream. Virulence factors including: smooth cell-wall lipopolysaccharide antigen and endotoxin activity has helped the process of invasion and toxin (Shiga toxin and Shiga-like toxin) that are cytotoxic and neurotoxic and may cause watery diarrhea.
  • Campylobacter jejuni (Helicobacter jejuni). Humans become infected through direct contact with animals (birds, dogs, cats, sheep and pigs) or with animal feces through contaminated food such as chicken and water. Sometimes the infection can be spread through direct person to person contact. C.jejuni may cause diarrhea by invasion into the small intestine and colon great.There 2 types of toxin produced, the heat-labile cytotoxin and enterotoxin. Histopathological changes that occur similar to the process of ulcerative colitis.
  • Vibrio cholerae 01 and V.cholerae 0139. water or food contaminated with this bacteria will transmit cholera. Through person to person transmission is rare.
  • V.cholerae attached and proliferated on the mucosa of the small intestine and produces an enterotoxin that causes diarrhea. Cholera toxin is very similar to the heat-labile toxin (LT) of ETEC. The last discovery of the existence of other enterotoxin that has its own characteristics, such as the accessory cholera enterotoxin (ACE) and zonular occludens toxin (ZOT). Both of these toxins cause fluid secretion into the intestinal lumen.
  • Salmonella (non-typhoid). Salmonella can invade intestinal epithelial cells. Produced enterotoxin causing diarrhea. If there is damage that causes mucosal ulcers, bloody diarrhea will occur.

3. Protozoa:
    Giardia lamblia
  • Giardia lamblia. This parasite infects the small intestine. Patogensis mechanism remains unclear, but is believed to affect the absorption and metabolism of bile acids. Transmission through the fecal-oral route. Host-parasite interactions is affected by age, nutritional status, endemicity, and immune status. Areas with high endemicity, giardiasis can be asymptomatic, chronic, persistent diarrhea with or without malabsorption. In areas with low endemicity, outbreaks can occur within 5-8 days after exposure to the manifestation of acute diarrhea is accompanied by nausea, epigastric pain and anorexia. Sometimes encountered malabsorption with faty stools, abdominal pain and bloated.
  • Entamoeba histolytica. Dysentery amoeba prevalence varies, but its spread throughout the world. The incidence increases with age, and teranak in adult males. Approximately 90% of asymptomatic infections caused by non-pathogenic E.histolytica (E.dispar). Symptomatic amebiasis can be mild and persistent diarrhea to fulminant dysentery.
  • Cryptosporidium. In developing countries, cryptosporidiosis 5-15% of cases of diarrhea in children. The infection is usually symptomatic and asymptomatic infants in older children and adults. Clinical symptoms of acute diarrhea with watery type of diarrhea, usually mild and self-limited. In people with impaired immune systems such as AIDS patients, cryptosporidiosis is a reemerging disease with more severe diarrhea and resistant to some antibiotics.
  • Microsporidium spp
  • Isospora belli
  • Cyclospora cayatanensis

4. Helminths:
  • Strongyloides stercoralis. Abnormalities in intestinal mucosa caused by adult worms and larvae, causing diarrhea.
  • Schistosoma spp. The blood worms cause abnormalities in various organs including the intestinal manifestations, including diarrhea and intestinal bleeding.
  • Capilaria philippinensis. This worm is found in the small intestine, especially jejunu, causing inflammation and villous atrophy with clinical symptoms of watery diarrhea and abdominal pain.
  • Trichuris trichuria. Adult worms live in the colon, caecum, and appendix. Severe infections can cause bloody diarrhea and abdominal pain.
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