Risk for Latex Allergy Response Nursing Diagnosis and Interventions

Risk for Latex Allergy Response

Definition: Risk of hypersenitivity to natural latex rubber products

Risk Factors

• History of reactions to latex
• Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plants
• History of allergies and asthma
• Professions with daily exposure to latex
• Multiple surgical procedures, especially from infancy

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Sample Clinical Applications :

Multiple allergies, neural tube defects (e.g., spina bifida, myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g., neurogenic bladder, exstrophy of bladder), spinal cord trauma

Desired Outcomes / Evaluation Criteria
Client Will (Include Specific Time Frame)

• Identify and correct potential risk factors in the environment.
• Demonstrate appropriate lifestyle changes to reduce risk of exposure.
• Identify resources to assist in promoting a safe environment.
• Recognize need for/seek assistance to limit response/complications.

http://nandadiagnosis.blogspot.com/2011/09/nursing-diagnosis-for-risk-for-latex.html

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Risk for Suicide Nursing Diagnosis Interventions

Suicide

Suicide is one form of emergency psychiatry. Although suicide is a behavior that requires a comprehensive assessment of depression, drug abuse, schizophrenia, personality disorders (paranoid, borderline, antisocial), suicide can not be equated with mental illness. There are 4 crucial things that need to be considered by nurses as the health care team are: First, suicide is a behavior that can be deadly in the inpatient setting in a mental hospital. Secondly, factors related to staff include: lack of inadequate patient assessment performed by nurses, the staff were weak communication, lack of orientation and training and inadequate information about the patient. Third, suicide assessment should be done continuously during in-patient at the hospital either at admission, home or any change in medication or other treatments. Fourth, the relationship of trust between nurses and patients and caregivers self-awareness of patient behavior cues that support the occurrence of suicide risk is important in reducing the suicide rate in the hospital. Therefore suicide in hospitalized patients is a problem that needs quick and accurate handling. This paper will be presented on suicide risk factors, assessment instruments and management of nursing with nursing process approach.


Nursing Diagnosis Risk for Suicide

Definition: The risk for life-threatening self harm

NOC
Impulse Control, Suicide Self-Restraint

Goal
Clients do not make a suicide attempt

Indicator
Expressed his hope for life
Expressing feelings of anger, loneliness and despair are assertive.
Identify another person as a source of support when thoughts of suicide arise.
Identify coping mechanisms alaternatif

NIC
Active Listening, Coping Enhancement, Suicide Prevention, Impulse Control Training, Behavior Management: Self-Harm, Hope Instillation, Contracting, Surveillance: Safety.

Source : http://nandanursing-blog.blogspot.com/2011/05/nursing-diagnosis-risk-for-suicide.html

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Self-Care Deficit - Nursing Diagnosis and Interventions

Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

NANDA Definition: Impaired ability to perform or complete activities of daily living, such as feeding, dressing, bathing, toileting

The nurse may encounter the patient with a self-care deficit in the hospital or in the community. The deficit may be the result of transient limitations, such as those one might experience while recuperating from surgery; or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the activities required to care for himself or herself. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing at self-care because of a lack in material resources or a problem with arranging the environment to suit the patient’s physical limitations. The nurse coordinates services to maximize the independence of the patient and to ensure that the environment that the patient lives in is safe and supportive of his or her special needs.

Defining Characteristics:

• Inability to feed self independently
• Inability to dress self independently
• Inability to bathe and groom self independently
• Inability to perform toileting tasks independently
• Inability to transfer from bed to wheelchair
• Inability to ambulate independently
• Inability to perform miscellaneous common tasks such as telephoning and writing

Related Factors :

• Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
• Musculoskeletal disorder such as rheumatoid arthritis
• Cognitive impairment
• Energy deficit
• Pain
• Severe anxiety
• Decreased motivation
• Environmental barriers
• Impaired mobility or transfer ability

Expected Outcomes

• Patient safely performs (to maximum ability) self-care activities.
• Resources are identified which are useful in optimizing the autonomy and independence of the patient.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Self-Care: Eating
• Self-Care: Bathing
• Self-Care: Dressing
• Self-Care: Grooming
• Self-Care: Hygiene
• Self-Care: Toileting

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Self-Care Assistance: Bathing/Hygiene
• Self-Care Assistance
• Dressing/Grooming
• Self-Care Assistance: Feeding
• Self-Care Assistance: Toileting
• Environment Management

Ongoing Assessment

• Assess ability to carry out ADLs (e.g., feed, dress, groom, bathe, toilet, transfer, and ambulate) on regular basis. Determine the aspects of self care that are problematic to the patient. The patient may only require assistance with some self-care measures.
• Assess specific cause of each deficit (e.g., weakness, visual problems, cognitive impairment). Different etiological factors may require more specific interventions to enable self-care.
• Assess patient’s need for assistive devices. This increases independence in ADLs performance.
• Assess for need of home health care after discharge. Shortened hospital stays mean that patients are more debilitated on discharge from the hospital, and that patients need more assistance after discharge.
• Identify preferences for food, personal care items, and other things. These support patient’s individual and personal preferences.

Therapeutic Interventions

• Assist patient in accepting necessary amount of dependence. If disease, injury, or illness resulting in self-care deficit is recent, patient may need to grieve before accepting that dependence is possible.
• Set short-range goals with patient. Assisting the patient to set realistic goals will decrease frustration.
• Encourage independence, but intervene when patient cannot perform. An appropriate level of assistive care can prevent injury with activities without causing frustration.
• Use consistent routines and allow adequate time for patient to complete tasks. This helps patient organize and carry out self-care skills.
• Provide positive reinforcement for all activities attempted; note partial achievements. This provides the patient with an external source of positive reinforcement.
• Feeding: Encourage patient to feed self as soon as possible (using unaffected hand, if appropriate). Assist with setup as needed. It is probable that the dominant hand will also be the affected hand if there is upper extremity involvement.
• Ensure that patient wears dentures and eyeglasses if needed. Deficits may be exaggerated if other senses or strengths are not functioning optimally.
• Assure that consistency of diet is appropriate for patient’s ability to chew and swallow, as assessed by speech therapist. Mechanical problems may prohibit the patient from eating.
• Provide patient with appropriate utensils (e.g., drinking straw, food guard, rocking knife, nonskid place mat) to aid in self-feeding. These items increase opportunities for success.
• Place patient in optimal position for feeding, preferably sitting up in a chair; support arms, elbows, and wrists as needed.
• Consider appropriate setting for feeding where patient has supportive assistance yet is not embarrassed. Embarrassment or fear of spilling food on self may hinder patient’s attempts to feed self.
• If patient has visual problems, advise the patient of the placement of food on the plate. Following CVA, patients may have unilateral neglect, and may ignore half the plate.
• Dressing/grooming: Provide privacy during dressing. Patients may take longer to dress and may be fearful of breaches in privacy.
• Provide frequent encouragement and assistance as needed with dressing. These reduce energy expenditure and frustration.
• Plan daily activities so patient is rested before activity.
• Provide appropriate assistive devices for dressing as assessed by nurse and occupational therapist. The use of a button hook or of loop and pile closures on clothes may make it possible for a patient to continue independence in this self-care activity.
• Place the patient in wheelchair or stationary chair. This assists with support when dressing. Dressing can be fatiguing.
• Encourage use of clothing one size larger. This ensures easier dressing and comfort.
• Suggest front-opening brassiere and half slips. These may be easier to manage.
• Suggest elastic shoelaces or loop and pile closures on shoes. These eliminate tying.
• Provide makeup and mirror; assist as needed. Fine motor activities may take more coordinated actions and may be beyond the abilities of the patient.
• Bathing/hygiene: Maintain privacy during bathing as appropriate. The need for privacy is fundamental for most patients.
• Ensure that needed utensils are close by. This conserves energy and optimizes safety.
• Instruct patient to select bath time when he or she is rested and unhurried. Hurrying may result in accidents and the energy required for these activities may be substantial.
• Provide patient with appropriate assistive devices (e.g., long-handled bath sponge; shower chair; safety mats for floor; grab bars for bath or shower). These aid in bed bathing.
• Encourage patient to comb own hair (a one-handed task). Suggest hairstyles that are low-maintenance. This enables the patient to maintain autonomy for as long as possible.
• Encourage patient to perform minimal oral-facial hygiene as soon after rising as possible. Assist with brushing teeth and shaving, as needed.
• Assist patient with care of fingernails and toenails as required. Patients may require podiatric care to prevent injury to feet during nail trimming or because special implements are required to cut nails.
• Offer frequent encouragement. Patients often have difficulty seeing progress.
• Toileting: Evaluate or document previous and current patterns for toileting; institute a toileting schedule that factors these habits into the program. The effectiveness of the bowel or bladder program will be enhanced if the natural and personal patterns of the patient are respected.
• Provide privacy while patient is toileting. Lack of privacy may inhibit the patient’s ability to evacuate bowel and bladder.
• Keep call light within reach and instruct patient to call as early as possible. This enables staff members to have time to assist with transfer to commode or toilet.
• Assist patient in removing or replacing necessary clothing. Clothing that is difficult to get in and out of may compromise a patient’s ability to be continent.
• Encourage use of commode or toilet as soon as possible. Patients are more effective in evacuating bowel and bladder when sitting on a commode. Some patients find it impossible to toilet on a bedpan.
• Offer bedpan or place patient on toilet every 1 to 1½ hours during day and three times during night. This eliminates incontinence. Time intervals can be lengthened as the patient begins to express the need to toilet on demand.
• Closely monitor patient for loss of balance or fall. Keep commode and toilet tissue near the bedside for nighttime use. Patients may rush readiness to ambulate to the toilet or commode during the night because of fear of soiling themselves and may fall in the process.
• Transferring/ambulation: Plan teaching session for transferring/walking when patient is rested. Tasks require energy. Fatigued patients may have more difficulty and may become unnecessarily frustrated.
• Assist with bed mobility by doing the following:
• Encourage patient to use the stronger side (if appropriate) as best as possible. Stroke patients experience weakness in their dominant side; therefore it will be necessary for them to develop muscle strength and coordination on the stronger side.
• Allow patient to work at own rate of speed. Many factors may influence a patient’s ability to move freely, and each of these factors must be considered when developing/teaching a patient a new system for self-care. It will take time for the patient to learn and then gain confidence in his or her ability to perform these new self-care measures.
• When patient is sitting up at side of bed, instruct him or her not to pull on caregiver. This may cause caregiver to lose balance and fall.
• This prevents disabling contractures, pressure sores, and muscle weakness from disuse.
• When transferring to wheelchair, always place chair on patient’s stronger side at slight angle to bed and lock brakes. Patient will weight-bear on the stronger side.
• When minimal assistance is needed, stand on patient’s weak side and place nurse’s hand under patient’s weak arm. (CAREGIVER: Keep your feet well apart; lift with legs, not back, to prevent back strain.)
• For moderate assistance, place caregiver’s arms under both armpits with caregiver’s hands on patient’s back. This forces patient to keep his or her weight forward.
• For maximum assistance, place right knee against patient’s strong knee, grasp patient around waist with both arms, and pull him or her forward; encourage patient to put weight on strong side. This stance maximizes patient support while protecting the care provider from back injury.
• Assist with ambulation; teach the use of ambulation devices such as canes, walkers, and crutches:
• Stand on patient’s weak side. This enhances patient safety.
• If using cane, place cane in patient’s strong hand and ensure proper foot-cane sequence. This assists with balance and support.
• Miscellaneous skills: Telephone: Evaluate need for adaptive equipment through therapy department (e.g., pushbutton phone, larger numbers, increased volume). Patients will require an effective tool for communicating needs from home.
• Writing: Supply patient with felt-tip pens. These mark with little pressure and are easier to use. Evaluate need for splint on writing hand. This assists in holding the writing device.
• Provide supervision for each activity until patient performs skill competently and is safe in independent care; reevaluate regularly to be certain that the patient is maintaining skill level and remains safe in environment. The patient’s ability to perform self-care measures may change often over time and will need to be assessed regularly.
• Encourage maximum independence.

Education/Continuity of Care

• Plan teaching sessions so patient has time to practice tasks.
• Instruct patient in use of assistive devices as appropriate.
• Teach family and caregivers to foster independence and to intervene if the patient becomes fatigued, is unable to perform task, or becomes excessively frustrated. This demonstrates caring and concern but does not interfere with patient’s efforts to achieve independence.

Nursing Diagnosis for Self-Care Deficit
Source :
http://nandadiagnosis.blogspot.com/2011/08/nursing-diagnosis-for-self-care-deficit.html
 http://nursingcareplan.blogspot.com

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Nursing Diagnosis for Ischemic Heart Disease

Nursing Diagnosis for Ischemic Heart Disease


1. Acute pain related to an imbalance of oxygen supply to myocardial demands.

2. Decreased cardiac output related to electrical factors (dysrhythmias), decrease in myocardial contraction, structural abnormalities (papillary muscular dysfunction and ventricular septal rupture)

3. Anxiety related to the needs of the body is threatened.

4. Activity intolerance related to insufficient oxygen for life activities secondary to cardiac ischemia.


Source : http://nursingdiagnosis-nursinginterventions.blogspot.com/2012/03/nursing-diagnosis-and-interventions-for.html

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Nursing Interventions for Ischemic Heart Disease - Acute Pain

Nursing Interventions for ischemic Heart Disease

Acute Pain related to an imbalance of oxygen supply to myocardial demands.

Outcome: The patient will express pain decreased

Intervention:
• Assess pain location, duration, radiation, occurrence, a new phenomenon.
• Review of previous activities that cause chest pain.
• Create a 12 lead ECG during anginal pain episodes.
• Assess signs of hypoxemia, give oxygen therapy if necessary.
• Give analgesics as directed.
• Maintain a rest for 24-30 hours during episodes of illness
• Check vital signs, during periods of illness.

2. Decreased cardiac output related to electrical factors (dysrhythmias), Decrease in myocardial contraction, structural abnormalities (papillary muscular dysfunction and ventricular septal rupture)

Outcome: The patient will demonstrate a stable cardiac condition or better.

Intervention:
• Maintain bed rest with head elevation of 30 degrees during the first 24-48 hours
• Assess and monitor vital signs and hemodynamic per 1-2 hours
• Monitor and record ECG continue to assess the rate, rhythm, and order to each change per 2 or 4 hours.
• Review and report signs of CO reduction.

3. Anxiety related to the needs of the body is Threatened.

Objectives: The patient will demonstrate reduced anxiety after nursing actions.
Intervention:
• Assess signs and verbal expressions of anxiety
• Take action to reduce anxiety by creating a calm environment
• Accompany patient during periods of high anxiety
• Provide an explanation of procedures and treatments
• Encourage patients to express feelings
• Refer to the spiritual adviser if necessary

Source : http://nursingdiagnosis-nursinginterventions.blogspot.com/2012/03/nursing-diagnosis-and-interventions-for.html

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Nursing Interventions for Delusional Disorders

Nursing Interventions for Delusional Disorders

• In dealing with the patient, be direct, straightforward, and dependable. Whenever possible, elicit his feedback. Move slowly, with a matter-of-fact manner, and respond without anger or defensiveness to his hostile remarks.
• Accept the patient's delusional system. Don't attempt to argue with him about what's real.
• Respect the patient's privacy and space needs. Avoid touching him unnecessarily.
• Take steps to reduce social isolation, if the patient allows. Gradually increase social contacts after he has become comfortable with the staff.
• Watch for refusal of medication or food, resulting from the patient's irrational fear of poisoning.
• Monitor the patient carefully for adverse effects of neuroleptic drugs: drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome.

Source : http://ncp-blog.blogspot.com/2010/11/ncp-for-delusional-disorders.html

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15 Nursing Diagnoses for Delusional Disorders

15 Nursing Diagnoses for Delusional Disorders

1. Anxiety
2. Disabled family coping
3. Disturbed personal identity
4. Disturbed sensory perception (visual, auditory)
5. Disturbed thought processes
6. Fear
7. Imbalanced nutrition: Less than body requirements
8. Impaired home maintenance
9. Impaired social interaction
10. Ineffective coping
11. Powerlessness
12. Risk for injury
13. Risk for other-directed violence
14. Risk for self-directed violence
15. Social isolation

http://ncp-blog.blogspot.com/2010/11/ncp-for-delusional-disorders.html

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Hyperthermia : Nursing Care Plan - Nursing Diagnosis and Nursing Interventions

Hyperthermia

Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death.

The most common causes are heat stroke and adverse reactions to drugs. Heat stroke is an acute condition of hyperthermia that is caused by prolonged exposure to excessive heat or heat and humidity. The heat-regulating mechanisms of the body eventually become overwhelmed and unable to effectively deal with the heat, causing the body temperature to climb uncontrollably. Hyperthermia is a relatively rare side effect of many drugs, particularly those that affect the central nervous system. Malignant hyperthermia is a rare complication of some types of general anesthesia.

Hyperthermia can be created artificially by drugs or medical devices. Hyperthermia therapy may be used to treat some kinds of cancer and other conditions, most commonly in conjunction with radiotherapy.

Hyperthermia differs from fever in the mechanism that causes the elevated body temperatures: a fever is caused by a change in the body's temperature set-point.

The opposite of hyperthermia is hypothermia, which occurs when an organism's temperature drops below that required for normal metabolism. Hypothermia is caused by prolonged exposure to low temperatures and is also a medical emergency requiring immediate treatment.

Signs and symptoms

Hot, dry skin is a typical sign of hyperthermia. The skin may become red and hot as blood vessels dilate in an attempt to increase heat dissipation, sometimes leading to swollen lips. An inability to cool the body through perspiration causes the skin to feel dry.

Other signs and symptoms vary depending on the cause. The dehydration associated with heat stroke can produce nausea, vomiting, headaches, and low blood pressure. This can lead to fainting or dizziness, especially if the person stands suddenly.

In the case of severe heat stroke, the person may become confused or hostile, and may seem intoxicated. Heart rate and respiration rate will increase (tachycardia and tachypnea) as blood pressure drops and the heart attempts to supply enough oxygen to the body. The decrease in blood pressure can then cause blood vessels to contract, resulting in a pale or bluish skin color in advanced cases of heat stroke. Some victims, especially young children, may have seizures. Eventually, as body organs begin to fail, unconsciousness and coma will result.


Hyperthermia

Related To :

• Infection
• Inflammation
• Dehydration
• CNS Pathology
• Exposure to heat/sun
• Impaired physical environment
• Vigorous activity

Evidenced by :

• Temperature over 37.8 C (100 F) orally, or 38.8 C (101 F) rectally.
• Malaise/weakness
• Loss of appetite
• Tachycardia
• Shivering/goose pimples
• Dehydration
• Flushed skin/li>
• Warm to touch
• Increased respiratory rate

Goal : The patient will : Maintian normal body temperature.


Nursing Interventions :

• Administer antipyretics per physician's order.
• Remove excess clothing or blankets.
• Assess possible etiology of increased temperature.
• Encourage fluids when indicated.
• Assess temperature q ___ hours.
• Provide air condition/fan if appropriate.

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Ineffective Airway Clearance related to the buildup of secretions

Nursing Diagnosis for Bronchopneumonia

Ineffective Airway Clearance related to the buildup of secretions

Goal : return effective airway clearance.

Expected outcomes : discharge to exit.

Nursing Intervention for Bronchopneumonia

• Monitor respiratory status every 2 hours, examine an increase in breathing and abnormal breath sounds.
• Apply suction as indicated.
• Give oxygen therapy every 6 hours.
• Create an environment / so patients can sleep comfortably.
• Give a comfortable position for the patient.
• Monitor blood gas analysis to assess respiratory status.
• Perform chest percussion.
• Provide sputum for culture / sensitivity test.

Source : http://nanda-nursing.blogspot.com/2011/07/nursing-diagnosis-and-nursing.html

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Nursing Diagnosis for Bronchopneumonia - Imbalanced Nutrition: Less than Body Requirements

Nursing Diagnosis for Bronchopneumonia

Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of nutrients

Goal : Kebuituhan nutrients are met.

Expected outcomes : The client can maintain / improve nutritional intake ..

Nursing Intervention for Bronchopneumonia

• Assess client's nutritional status.
• Perform a physical examination the abdomen client (auscultation, percussion, palpation, and inspection).
• Measure the client's body weight per day.
• Assess the presence of nausea and vomiting.
• Give diet a little but often.
• Provide food in a warm state.
• Collaboration with a dietitian.

Source : http://nanda-nursing.blogspot.com/2011/07/nursing-diagnosis-and-nursing.html

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Nursing Diagnosis for Benign Prostatic Hyperplasia (BPH)

Nursing Diagnosis for Benign Prostatic Hyperplasia (BPH)

Here are examples of Nursing Diagnosis for Benign Postatic Hyperplasia (BPH) :

1. Impaired sense of comfort : (pain) are associated with muscle spasm spincter.
2. Changes in patterns of elimination: urinary retention associated with secondary obstruction.
3. Sexual dysfunction associated with loss of body function.
4. Potential occurrence of infection associated with port de entrée microorganisms through catheterization.
5. Lack of knowledge related to the missing information about the disease and treatment.

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Management of Anemia

Management of Anemia is shown to find the cause and replace lost blood:

• Antibiotics given to prevent infection.
• Folic acid supplements can stimulate the formation of red blood cells.
• Avoid situations of oxygen deficiency or activity that requires oxygen.
• Treat the cause of abnormal bleeding if any.
• Iron-rich diet containing meat and green vegetables.

Treatment (for treatment depends on the cause):

1. Iron deficiency anemia
Management:
• Set the iron-containing foods, try the food provided, such as fish, meat, eggs and vegetables.
• Giving preparations FE
• Perrosulfat 3x 200 mg / day / per oral after meals
• Peroglukonat 3x 200 mg / day / per oral after meals.
2. Pernicious Anemia: vitamin B12
3. Folic acid Anemia : Folic acid 5 mg / day / orally
4. Anemia due to bleeding: bleeding and shock overcome by giving fluids and blood transfusions.

Source : http://ncp-blog.blogspot.com/2011/04/management-of-anemia.html

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NCP for Anemia

Nursing Care Plan for Anemia



Definition of Anemia

Anemia is a medical condition in which the red blood cell count or hemoglobin is less than normal. The normal level of hemoglobin is generally different in males and females. For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the source and the laboratory reference used.

Anemia Symptoms

Clinical symptoms that appear to reflect dysfunction of various systems in the body such as decrease in physical performance, impaired neurologic (nerve), which is manifested in changes in behavior, anorexia (emaciated body), and abnormal cognitive development in children. Often, too, growth abnormality, epithelial dysfunction, and reduced gastric acidity.

An easy way to know anemia with 5 signs: weak, tired, lethargic, tired, negligent. If it appears five of these symptoms, we can be sure a person has anemia. Another symptom is the appearance of sclera (white color on the lower eyelid).

Anemia can cause fatigue, weakness, lack of energy and the head was floating. If the anemia gets worse, can cause a stroke or heart attack.
Source : http://signssymptoms.blogspot.com/2011/04/anemia-symptoms.html

Nursing Assessment for Anemia
Assessment of patients with anemia (Doenges, 1999) include :

1. Activity / rest
   Symptoms :
   fatigue, weakness, general malaise. Lost productivity: a reduction in enthusiasm for work. Low exercise tolerance. The need for sleep and rest more.
   Signs :
   tachycardia / takipnae; dyspnea during work or rest. Lethargy, withdrawn, apathetic, lethargic, and less interested in its surroundings. Muscle weakness, and decreased strength. Ataxia, the body is not upright. Shoulders down, slumped posture, slow, and other signs that indicate fatigue.
2. Circulation
   Symptoms :
   A history of chronic blood loss, such as chronic gastrointestinal bleeding, heavy menstruation, angina, CHF (due to excessive cardiac work). History of chronic infective endocarditis. Palpitations (tachycardia compensation).
   Signs :
   Blood pressure: systolic to diastolic steady improvement, and widening pulse pressure, postural hypotension. Dysrhythmias: ECG abnormality, ST segment depression and T wave leveling or depression; tachycardia. The sound of the heart: systolic murmur. Extremity (color): pale skin and mucous membranes (conjunctiva, mouth, pharynx, lips) and the base of the nail. (Note: in black patients, white may appear to be grayish). Leather like waxy, pale or bright lemon yellow. Sclera: blue or pearly white. Slow capillary filling (decreased blood flow to the capillary and vasoconstriction compensation) nails: easily broken, shaped like a spoon (koilonikia). Hair: dry, easily breaking, thinning, gray hair grow prematurely.
3. Integrity ego
   Symptoms :
   Religious beliefs / cultural influence treatment options, such as refusal of blood transfusions.
   Signs :
   depression.
4. Elimination
   Symptoms :
   A history of pyelonephritis, kidney failure. Flatulen, malabsorption syndrome. Hematemesis, stool with fresh blood, melena. Diarrhea or constipation. Decrease in urine output.
   Signs :
   Abdominal distension.
5. Food / fluid
   Symptoms :
   Decreased dietary input. Painful mouth or tongue, difficulty swallowing (pharyngeal ulcers). Nausea / vomiting, dyspepsia, anorexia. The presence of weight loss. Never satisfied to chew or sensitive to ice, dirt, corn flour, paint, clay, and so forth.
   Signs :
   Tongue looks red meat / subtle deficiency of folic acid and vitamin B12. Dry mucous membranes, pale. Skin turgor: ugly, dry, looks shriveled / lost elasticity. Stomatitis and glositis (deficiency status). Lips: selitis, such as inflammatory lips with the corner of his mouth cracked.
6. Neurosensori
   Symptoms :
   Headache, throbbing, vertigo, tinnitus, inability to concentrate. Insomnia, decreased vision, and shadows on the eyes. Weakness, poor balance, unsteady legs, paresthesias hands / feet; klaudikasi. The sensation of being cold.
   Signs :
   Sensitive to stimuli, anxiety, depression tend to sleep, apathy. Mental: not able to respond, slow and shallow. Ophthalmic: hemoragis retina. Epitaksis: bleeding from the holes (aplastic). Impaired coordination, ataxia, decreased sense of vibration, and position, positive Romberg sign, paralysis.
7. Pain / comfort
   Symptoms: abdominal pain, headache
8. Breathing
   Symptoms :
   A history of tuberculosis, lung abscess. Short of breath at rest and activity.
   Signs :
   Tachypnoea, orthopnea, and dyspnea.
9. Security
   Symptoms :
   A history of work exposure to chemicals,. History of exposure to radiation, either to treatment or accident. History of cancer, cancer therapy. Not tolerant of cold and heat. Previous blood transfusion. Impaired vision, poor wound healing, frequent infections.
   Signs :
   A low fever, chills, night sweats, general lymphadenopathy. Ptekie and ekimosis(aplastic).
10. Sexuality
    Symptoms :
    Changes in menstrual flow, such as menorrhagia or amenorrhea. Lost libido (male and female). Imppoten.
    Signs :
    Pale vaginal walls.

Source : http://ncp-blog.blogspot.com/2011/05/ncp-for-anemia.html

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Nursing Care Plan for Anemia

Nursing Care Plan for Anemia

Anemia

Anemia (uh-NEE-me-uh) is a condition in which your blood has a lower than normal number of red blood cells.

Anemia also can occur if your red blood cells don't contain enough hemoglobin (HEE-muh-glow-bin). Hemoglobin is an iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygen from the lungs to the rest of the body.

If you have anemia, your body doesn't get enough oxygen-rich blood. As a result, you may feel tired and have other symptoms. Severe or long-lasting anemia can damage the heart, brain, and other organs of the body. Very severe anemia may even cause death.


Overview
Blood is made up of various parts, including red blood cells, white blood cells, platelets (PLATE-lets), and plasma (the fluid portion of blood).

Red blood cells are disc-shaped and look like doughnuts without holes in the center. They carry oxygen and remove carbon dioxide (a waste product) from your body. These cells are made in the bone marrow—a sponge-like tissue inside the bones.

White blood cells and platelets (PLATE-lets) also are made in the bone marrow. White blood cells help fight infection. Platelets stick together to seal small cuts or breaks on the blood vessel walls and stop bleeding. With some types of anemia, you may have low numbers of all three types of blood cells.

Anemia has three main causes: blood loss, lack of red blood cell production, or high rates of red blood cell destruction. These causes may be due to many diseases, conditions, or other factors.


Outlook
Many types of anemia can be mild, short term, and easily treated. You can even prevent some types with a healthy diet. Other types can be treated with dietary supplements.

However, certain types of anemia may be severe, long lasting, and life threatening if not diagnosed and treated.

If you have signs and symptoms of anemia, see your doctor to find out whether you have the condition. Treatment will depend on the cause and severity of the anemia.
Source : http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_whatis.html

Nursing Care Plan for Anemia

Nursing Assessment for Anemia

Assessment of patients with anemia (Doenges, 1999) include :

1. Activity / rest
   Symptoms :
   fatigue, weakness, general malaise. Lost productivity: a reduction in enthusiasm for work. Low exercise tolerance. The need for sleep and rest more.
   
   Signs :
   tachycardia / takipnae; dyspnea during work or rest. Lethargy, withdrawn, apathetic, lethargic, and less interested in its surroundings. Muscle weakness, and decreased strength. Ataxia, the body is not upright. Shoulders down, slumped posture, slow, and other signs that indicate fatigue.
2. Circulation
   Symptoms :
   A history of chronic blood loss, such as chronic gastrointestinal bleeding, heavy menstruation, angina, CHF (due to excessive cardiac work). History of chronic infective endocarditis. Palpitations (tachycardia compensation).
   
   Signs :
   Blood pressure: systolic to diastolic steady improvement, and widening pulse pressure, postural hypotension. Dysrhythmias: ECG abnormality, ST segment depression and T wave leveling or depression; tachycardia. The sound of the heart: systolic murmur. Extremity (color): pale skin and mucous membranes (conjunctiva, mouth, pharynx, lips) and the base of the nail. (Note: in black patients, white may appear to be grayish). Leather like waxy, pale or bright lemon yellow. Sclera: blue or pearly white. Slow capillary filling (decreased blood flow to the capillary and vasoconstriction compensation) nails: easily broken, shaped like a spoon (koilonikia). Hair: dry, easily breaking, thinning, gray hair grow prematurely.
3. Integrity ego
   Symptoms :
   Religious beliefs / cultural influence treatment options, such as refusal of blood transfusions.
   
   Signs :
   depression.
4. Elimination
   Symptoms :
   A history of pyelonephritis, kidney failure. Flatulen, malabsorption syndrome. Hematemesis, stool with fresh blood, melena. Diarrhea or constipation. Decrease in urine output.
   
   Signs :
   Abdominal distension.
5. Food / fluid
   Symptoms :
   Decreased dietary input. Painful mouth or tongue, difficulty swallowing (pharyngeal ulcers). Nausea / vomiting, dyspepsia, anorexia. The presence of weight loss. Never satisfied to chew or sensitive to ice, dirt, corn flour, paint, clay, and so forth.
   
   Signs :
   Tongue looks red meat / subtle deficiency of folic acid and vitamin B12. Dry mucous membranes, pale. Skin turgor: ugly, dry, looks shriveled / lost elasticity. Stomatitis and glositis (deficiency status). Lips: selitis, such as inflammatory lips with the corner of his mouth cracked.
6. Neurosensori
   Symptoms :
   Headache, throbbing, vertigo, tinnitus, inability to concentrate. Insomnia, decreased vision, and shadows on the eyes. Weakness, poor balance, unsteady legs, paresthesias hands / feet; klaudikasi. The sensation of being cold.
   
   Signs :
   Sensitive to stimuli, anxiety, depression tend to sleep, apathy. Mental: not able to respond, slow and shallow. Ophthalmic: hemoragis retina. Epitaksis: bleeding from the holes (aplastic). Impaired coordination, ataxia, decreased sense of vibration, and position, positive Romberg sign, paralysis.
7. Pain / comfort
   Symptoms: abdominal pain, headache
8. Breathing
   Symptoms :
   A history of tuberculosis, lung abscess. Short of breath at rest and activity.
   
   Signs :
   Tachypnoea, orthopnea, and dyspnea.
9. Security
   Symptoms :
   A history of work exposure to chemicals,. History of exposure to radiation, either to treatment or accident. History of cancer, cancer therapy. Not tolerant of cold and heat. Previous blood transfusion. Impaired vision, poor wound healing, frequent infections.
   
   Signs :
   A low fever, chills, night sweats, general lymphadenopathy. Ptekie and ekimosis(aplastic).
10. Sexuality
    Symptoms :
    Changes in menstrual flow, such as menorrhagia or amenorrhea. Lost libido (male and female). Imppoten.
    
    Signs :
    Pale vaginal walls. 

Source : http://nanda-nursing.blogspot.com/2011/01/nursing-care-plan-for-anemia.html

Nursing Diagnosis Intervention Read more »

Activity intolerance related to imbalance between oxygen supply (delivery) and demand

Activity intolerance related to imbalance between oxygen supply (delivery) and demand.


Goal :
Able to maintain / improve ambulation / activity.

Expected Outcomes :

Reported an increase in activity tolerance (including daily activities).
Indicates decrease in physiological signs of intolerance, such as pulse, respiration, and blood pressure is still within the normal range.

Nursing Intervention :

Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity.
Rational : Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues.
Assess patient ability to perform ADLs
Rational : Influences choice of interventions and needed assistance.
Provide or recommend assistance with activities and ambulation as necessary, allowing client to be an active participant as much as possible.
Rational : Although help may be necessary, self-esteem is enhanced when client does some things for self.
Suggest client change position slowly; monitor for dizziness.
Rational : Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
Identify and implement energy-saving techniques
Rational : Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.
Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.
Rational : Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary strain and stress may lead to decompensation and failure.

Source : http://nanda-list.blogspot.com/2011/11/nursing-intervention-for-anemia.html

Nursing Diagnosis Intervention Read more »