Nursing Diagnosis and Nursing Intervention


Meningitis Definition, Etiology and Clinical Manifestations

Definition of Meningitis

Meningitis is inflammation of the meninges (the membranes that surround the brain and spinal cord) and is caused by a virus, bacteria or fungus organs (Smeltzer, 2001).

Meningitis is an infection of the fluid of the brain with inflammatory piamater, arachnoid and in a milder degree of the brain and spinal cord tissues were superficial. (Neurology capita selekta, 1996)

Meningitis is an inflammation of the arachnoid and pia mater (lepto meningens) of the brain and spinal cord. Bacteria and viruses are the most common cause of meningitis, although fungi can also cause. Bacterial meningitis is more common. Early detection and treatment will give more better results according to Revelation Widagdo et al (2008:105)

Etiology of Meningitis

Meningitis caused by a virus is generally harmless, will recover without specific treatment and care. But bacterial meningitis can lead to serious conditions, such as brain damage, hearing loss, lack of ability to learn, can even cause death. While meningitis is caused by a fungus is very rare, this type generally affects people with damaged immune (immune system) as in patients with AIDS.

Bacteria that can cause meningitis attack include:
1. Streptococcus pneumoniae (pneumococcus).
These bacteria are the most common cause of meningitis in infants or children. This type of bacteria can also cause pneumonia, ear and nasal cavity (sinus).

2. Neisseria meningitidis (meningococcus).
This bacterium is the second most after Streptococcus pneumoniae meningitis caused by an infection of the upper respiratory tract and then the bacteria enter the bloodstream.

3. Haemophilus influenzae (Haemophilus).
Haemophilus influenzae type b (Hib) is a type of bacteria that can also cause meningitis. This type of virus as the cause upper respiratory infections, middle ear and sinuses. Vaccine (Hib vaccine) has shown a decrease in the number of cases of meningitis caused by these bacteria.

4. Listeria monocytogenes (listeria).
This is one type of bacteria that can cause meningitis. These bacteria can be found in many places, in the dust and in contaminated food. Food is usually a type of cheese, hot dogs and bacon sandwich which is derived from the bacterium local animal (pet).

5. Other bacteria that can also cause meningitis are Staphylococcus aureus and Mycobacterium tuberculosis.

Clinical Manifestations of Meningitis
  • Early in the disease, fatigue, changes in power to remember, change in behavior
  • In accordance with the rapid course of the disease the patient becomes stuporous
  • Headache
  • Sore muscle pain
  • Pupillary reaction to light. Photofobia when light is directed at the patient's eye.
  • Dysfunction of the nerves III, IV, VI
  • Motor movement at the beginning of the disease is usually normal and common in the advanced stages of hemiparesis, hemiplagia, and decreased muscle tone
  • Reflex positive Brudzinski and Kernig reflex
  • Nausea
  • Vomiting
  • Tachycardia
  • Convulsions
  • Patients feel fear and anxiety

Risk for Injury - Nursing Care Plan Meningitis


Nursing Diagnosis for Meningitis: Risk for Injury related to general weakness.

The expected outcomes / evaluation criteria pediatric patients: No seizures or comorbidities or other injury.

intervention
a. Monitor the spasms / twitching of the hands, feet and mouth or other facial muscles.
Rational: reflecting on the CNS in general irritation that require immediate evaluation and possible intervention to prevent complications.

b. Provide security for patients by providing assistance on the bed and keep the barrier remained in place and attach the plastic artificial airway or soft rolls and a suction bulb.
Rationale: protect patients when seizures. Note; enter the airway assistance / soft rolls if only jaw relaxation, not forced to enter as his teeth shut and soft tissue will be damaged.

c. Maintain bed rest during the acute phase. Move. Moving with the help of corresponding improvement in the situation.
Rational: reducing the risk of falls / trauma case vertigo, syncope or ataxia.

d. Give medication as indicated as phenytoin (Dilantin), diazepam, phenobarbital.
Rational: an indication for the treatment and prevention of seizures. Records: Phenobarbital may cause respiratory and sedative defresi and mask the signs / symptoms of increased ICP.

Retropharyngeal Abscess Prevention and Treatment

Retropharyngeal abscess Prevention and Treatment

Definition of retropharyngeal abscess

Retrofaringeal abscess is a pus accumulation in the back of the throat tissues.

Cause of retropharyngeal abscess
  • Abscesses are usually caused by streptococcal infection from the tonsils, throat, sinuses, adenoids, nasal or middle ear.
  • Sometimes an injury to the back of the throat caused by thorn fish can also cause abscesses retrofaringeal.
  • Although rare, retrofaringel abscess can also be caused by tuberculosis.
  • Retrofaringeal abscess usually affects children aged less than 5 years.
  • Networking on the back of the throat allows the formation of children's cavity containing pus (which this does not occur in adults).
  • Infection in these areas can occur during or shortly after by a bacterial throat infection.

Symptoms of retropharyngeal abscess

Symptoms include:
  • History of sore throat, nasal infection or tooth abscess
  • High fever
  • Severe sore throat
  • Swollen neck lymph nodes
  • Difficulty swallowing
  • Salivating
  • Respiratory Disorders
  • Intercostal retraction (withdrawal of muscles between the ribs when people try so hard to breathe)
  • Stridor (harsh breathing sound).

Complications of retropharyngeal abscess
  • Bleeding around the abscess
  • Rupture of the abscess into the airways (which can cause airway obstruction)
  • Pneumonia
  • The spread of infection to the chest.
Diagnosis of retropharyngeal abscess
  • Diagnosis is based on symptoms and physical examination.
  • X-rays or a CT scan of the neck showed a cavity containing pus between the throat and cervical spine.
  • Blood tests showed an increase in the number of white blood cells.
  • Breeding throat mucus can indicate the presence of the causative organism.

Treatment of retropharyngeal abscess
  • To overcome infection drainage surgery (to remove the pus) and high doses of antibiotics given intravenously.

Prevention of retropharyngeal abscess
  • Diagnosis and treatment in pharyngitis and nasopharyngeal infection usually can prevent abscess retrofaringeal.

Physical Examination, Laboratory, and Radiology for Acute Appendicitis

Physical Examination, Laboratory, and Radiology for Acute Appendicitis

There are several tests that can be performed by a medical team to determine and diagnose the presence of Appendicitis by patients. Among them is the physical examination, laboratory tests and radiology examinations:

1. Physical Examination of Acute Appendicitis

Physical Examination of Acute Appendicitis

In acute appendicitis, the observation would seem the swelling of the abdominal cavity which seemed to tighten the abdominal wall (distended). On palpation of the right lower abdominal area, often when pressed will feel pain when pressure is released and also will feel pain (Blumberg sign), which is the key to the diagnosis of acute appendicitis.

By the action of the right leg bent and thighs strong / leg high in the lift, the abdominal pain is getting worse. Suspicion of an inflammation of the appendix is ​​enhanced when an anal or vaginal and cause pain as well. Rectal temperature (rectal) temperatures are higher than the armpits, over longer support the existence of appendicitis.

2. Laboratory Examination of Acute Appendicitis

In laboratory tests of blood, which can be found is an increase of white blood cells (leukocytes) to about 10,000 - 18.000/mm3. If an increase is more than that, then it is likely the appendix had been perforated (ruptured).

3. Radiological Examination of Acute Appendicitis

Radiological Examination of Acute Appendicitis

Plain abdomen may show a fecalith. However, this examination is rarely helpful in diagnosing appendicitis. Ultrasonography (USG) is quite helpful in the diagnosis of appendicitis enforcement (71-97%), especially for pregnant women and children. The highest level of accuracy is by CT scan (93-98%). With a CT scan can be seen clearly picture the appendix.

Risk for Infection - Nursing Care Plan for Appendicitis

Risk for Infection - Nursing Care Plan for Appendicitis
Risk for Infection Appendicitis

Nursing Diagnosis Interventions for Appendicitis: Risk for Infection

Risk factors include:
  • Inadequate primary defense, perforation / rupture of the appendix; peritonitis; abscess formation.
  • Invasive procedures, surgical incisions.
Intervention:

Independent:
  • Monitor vital signs noticed fever, chills, sweating, mental changes, increased abdominal pain.
  • Do a good hand washing and aseptic wound care. Provide complete care.
  • See incision and bandage. Write down the characteristics and wound drainage / drain (if included), the erythema.
  • Provide appropriate information, be honest with the patient / parent close.
Collaboration
  • Take for example the drainage when indicated.
  • Give antibiotics, are as indicated.

Clinical Manifestations of Appendicitis

Clinical Manifestations of Appendicitis
Clinical Manifestations of Appendicitis
Clinical Manifestations of Appendicitis

  • Right lower quadrant pain felt and is usually accompanied by mild fever, nausea, vomiting, and loss of appetite.
  • Local tenderness at the point Mc.burney, when done pressure.
  • Tenderness may be encountered off.
  • The degree of muscle spasm and tenderness if there is constipation or diarrhea are not depending on the severity of the infection and the location of the appendix.
  • If the appendix behind the caecum circular, pain and tenderness can feel the lumbar region: when the tip is in the pelvis, these signs can be detected only by examination of the rectal examination.
  • Pain on defecation show ends appendix is near the rectum; pain during urination indicates that the tip of the appendix is close to the bladder or ureter.
  • There is stiffness in the bottom of the right testis muscles can occur.
  • Signs Rovsing can arise with left lower quadrant palpation paradoxical that causes pain felt in the lower right quadrant. If paralytic ileus, and the patient's condition deteriorated.
  • In elderly patients, the signs and symptoms of appendicitis can vary greatly. The signs can be very dubious, suggesting destruction of the bowel or other disease processes. Patients may have no symptoms until he suffered a ruptured appendix. The incidence of perforation of the appendix is higher in the elderly, because many of these patients do not seek medical care as soon as patients are younger.

Clinical Manifestations of Acute Gastritis and Chronic Gastritis

Clinical Manifestations of Acute Gastritis and Chronic Gastritis
Acute Gastritis and Chronic Gastritis

Clinical Manifestations of Acute Gastritis and Chronic Gastritis

Acute Gastritis

Acute Gastritis is very varied, ranging from very mild, asymptomatic, up to very heavy, which can lead to death. In the case of very heavy, very prominent symptoms are:
  1. Hematemetis and melena that can last a very great shock to occur due to blood loss.
  2. In most cases, symptoms are very mild and even asymptomatic. Complaints such as pain that arises in the gut, usually mild and can not be appointed to the appropriate location.
  3. Sometimes accompanied by nausea and vomiting.
  4. GI bleeding is often the only symptom.
  5. In the case of very light bleeding, manifests as occult blood in the stool and will be found in physical signs of deficiency anemia with no apparent etiology.
  6. On physical examination found no abnormalities except usually those with severe bleeding, causing signs and symptoms of hemodynamic disorders as real as hypotension, pallor, cold sweat, tachycardia until the disturbance of consciousness.
Chronic Gastritis
  1. Varied and unclear.
  2. Feeling of fullness, anorexia.
  3. Epigastric distress that is not real.
  4. Early satiety.

Pathophysiology of Chronic Gastritis

Pathophysiology of Chronic Gastritis
Pathophysiology of Chronic Gastritis
Chronic gastritis can be classified as type A or type B.

Type A (often referred to as autoimmune gastritis) resulting from changes in parietal cells, leading to atrophy and cell infiltration. It is associated with autoimmune diseases, such as pernicious anemia and occurs in the fundus or corpus of the stomach.

Type B (sometimes referred to as Helicobacter pylori, also known as H. pylori) is associated with the bacteria H. pylori, dietary factors such as heat or spicy drink, use drugs and alcohol, smoking or reflux of intestinal contents into the stomach. H. Pylori includes bacteria that are not acid resistant, but this kind of bacteria are able to secure himself in the mucosal lining of the stomach. The presence of this bacterium in gastric mucosa of the stomach lining causing weakening and brittle so that stomach acid can penetrate the layer. Thus both gastric acid and the bacteria causing wound or ulcer. The immune system will respond to bacterial infection H. Pylori by sending beads of leukocytes, killer T cells, and other infection-fighting. However, it is not able to fight infection H. The reason pylori can not penetrate the stomach lining. But also can not be removed so that the immune response continues to increase and grow. Polymorph die and release of superoxide radicals damaging compounds in the cells lining the stomach. Extra nutrients are sent to strengthen the leukocyte cells, but nutrition is also a source of nutrients for H. Pylori. Finally, the state of the damaged epithelium of the stomach, forming a superficial ulceration and can cause hemorrhage (bleeding). Within a few days gastritis and even peptic ulcers are formed.

Acute Pain related to Constipation

Acute Pain related to Constipation
Acute pain related to Constipation

Nursing Diagnosis for Constipation : Acute Pain related to the accumulation of hard stool in the abdomen

Goal:
  • Show the pain has diminished

Expected outcomes are:
  • Shows relaxation techniques, individually effective to achieve comfort.
  • Maintain the level of pain on a small scale
  • Reported physical and psychological health.
  • Recognize the causes and the use of measures to prevent pain.
  • Using action to reduce the pain with analgesics and non-analgesics as appropriate.
Nursing Intervention for Acute Pain - NCP Constipation:
Independent:
  • Help the patient to focus more on activities rather than pain, to make of switching via television or radio.
  • Note that the elderly have increased sensitivity to the analgesic effects of opiates.
  • Consider the possibility of drug-drug interactions and drug disease in the elderly.
Rational:
  • Clients can distract from pain.
  • Be careful in giving anlgesik opiates.
  • Be careful in the provision of drugs in the elderly.
Observation:
  • Ask the patient to assess pain or lack of comfort on a scale of 0-10.
  • Use the pain flow sheet.
  • Perform a comprehensive pain assessment.
Rational:
  • Knowing the client's level of pain experienced.
  • Knowing the characteristics of the pain.
  • Knowing the specific pain.

Health education
  • Instruct patient to inform the nurse, if the reduction of pain, less is reached.
  • Provide information about the pain.
Rational:
  • Nurses can perform the right actions, overcoming the client's pain.
  • So that patients do not feel anxious.

Imbalanced Nutrition Less Than Body Requirements related to Loss of Appetite

Imbalanced Nutrition Less Than Body Requirements related to Loss of Appetite
Imbalanced Nutrition Less Than Body Requirements related to Loss of Appetite
Nursing Care Plan

Imbalanced Nutrition Less Than Body Requirements related to loss of appetite

Goal:
  • Showed good nutritional status.

Expected outcomes are:
  • Tolerance to dietary needs.
  • Retain lean body mass and body weight within normal limits.
  • Laboratory values ​​within normal limits.
  • Reported adequacy of energy levels.
Imbalanced Nutrition Less Than Body Requirements related to loss of appetite - Intervention:
Independent:
  • Create a meal plan with the patient, to put in a feeding schedule.
  • Support family members to bring the patient's favorite food from home.
  • Large portions of food offered during the day when a high appetite.
  • Make sure the diet meets the needs of the body as indicated.
  • Make sure the patient's diet is liked or disliked.
  • Monitor input and expenditure and body weight periodically.
  • Assess the patient's skin turgor.
Rational:
  • Keeping the diet of patients so that patients eat regularly.
  • Patients feel comfortable with food brought from home and can improve the appetite of the patient.
  • By administering a large portion can maintain adequacy of nutrition intake.
  • High carbohydrate, protein, and calories needed or required during treatment.
  • To support the increasing appetite of the patient.
  • Knowing the balance of intake and expenditure of food intake.
  • As the data supporting a change of less nutritional needs.
Observation
  • Monitor laboratory values​​, such as hemoglobin, albumin, and blood glucose levels.
  • Teaches a method for meal planning.
Rational:
  • In order to determine the level of Hb content deficiencies, albumin, and glucose in the blood.
  • Clients used to eat in a planned and orderly.

Health Education
  • Teach patients and families about nutritious food and not expensive.
Rational:
  • Maintain the adequacy of intake of nutrients needed.

Constipation related to the irregular pattern of defecation

Constipation related to the irregular pattern of defecation
Nursing Care Plan for Constipation

Constipation related to the irregular pattern of defecation

Objectives:
Patients can defecate regularly (every day)

Expected outcomes are:
  • Defecation can be done once a day.
  • The consistency of soft stool.
  • Elimination of excess stool without straining.
Intervention:
Independent:
  • Determine the pattern of defecation for clients and train clients to do.
  • Set the time for clients such as defecation after meals.
  • Give the range of fibrous nutrients according to the indication.
  • Give fluids if not contraindicated 2-3 liters per day.
Collaboration:
  • Giving a laxative or enema as indicated.
Rational:
  • To restore order to the client defecation pattern.
  • To facilitate the defecation reflex.
  • High fiber nutrients to carry fecal elimination.
  • To soften the stool elimination.
  • To soften the stool.

2 Nursing Diagnosis and Interventions for Abdominal Typhoid

2 Nursing Diagnosis and Interventions for Abdominal Typhoid
Nursing Diagnosis and Interventions for Abdominal Typhoid

Nursing Care Plan for Abdominal Typhoid : 2 Nursing Diagnosis and Interventions

1. Imbalanced Nutrition Less Than Body Requirements related to no appetite, nausea and bloating.

Purpose: Improve the nutritional and fluid needs.

Nursing Interventions:
  • Assess nutritional status of children.
  • Allow children to foods that can be tolerated child, plan to improve the nutritional quality at the child's appetite increases.
  • Give the food is accompanied by a nutritional supplement to improve the quality of nutritional intake.
  • Encourage parents to provide food to the technique of small but frequent portions.
  • Weigh weight every day at the same time and with the same scale.
  • Maintain cleanliness of the child's mouth.
  • Explain the importance of adequate nutritional intake for the cure of disease.
  • Collaboration for parenteral feeding through. If feeding via oral did not meet the nutritional needs of children.

2. Risk for Fluid Volume Deficit related to the lack of fluid intake and increased body temperature.

Purpose: To prevent the lack of fluid volume.

Nursing Interventions:
  • Observation of vital signs (body temperature) at least every four hours.
  • Monitor the increasing signs of dehydration: inelastic turgor, sunken fontanel, decreased urine output, dry mucous membranes, cracked lips.
  • Observation and record intake and output and maintain an adequate intake and output.
  • Monitor and record the weight at the same time and with the same scale.
  • Monitor the provision of intravenous fluids through an IV every hour.
  • Reduce the loss of fluid that is not visible (insensible water loss / IWL) to give a cold compress or a tepid sponge.
  • Give antibiotics according to the program.

Nursing Management of Varicella

Nursing Management of Varicella
Nursing Management of Varicella

Nursing Management of Varicella

Patients should be isolated from others, as well as for their daily needs. such as:
  • Isolation to prevent transmission.
  • Nutritious diet (high in calories and protein).
  • If a high fever, compress with warm water.
  • Strive to avoid infection of the skin such as the provision of antiseptic in the water.
  • Strive to vesicles did not rupture
    • Do not scratch the vesicles.
    • Long nails should not be allowed.
    • If want to dry off, just a towel on the skin and do not rub.

The provision of drugs to reduce symptoms such as itching, fever, weight is required in order to reduce the level of disease. Antiviral drug, is recommended within 48 hours of patients complaining of symptoms of varicella.

Giving varicella zooster immuno-globulin (VZIG) is given less than 96 hours after exposure, namely on:
  • Women with pregnancy.
  • Children with impaired immune systems.
  • Newborns whose mothers contracted varicella within 5 days before delivery or 48 hours after birth.
  • Premature infants 28 weeks of age or younger with a parent without a history of previous varicella.

Nursing Diagnosis for Pharyngitis

Nursing Diagnosis for Pharyngitis
Nursing Diagnosis for Pharyngitis

Pharyngitis

Pharyngitis is the commonest cause of simple "sore throat". It may be due to infective or other causes. Viral infections include coryza, influenza, adenovirus, herpes simplex, measles, rubella, chickenpox, Coxsackie and echoviruses. Bacterial pathogens such as streptococci, Staphylococci, Penumococci, H. Influenzae, C. diphtheriae, fusobacterium, gonococci and T. Pallidum and fungi such as Candida albicans may lead to pharyngitis. In agranulocytosis and acute leukemia, necrotic ulceration of the tonsils and pharynx may be the presenting symptom. Excessive smoking, noxious fumes, corrosive and unaccustomed spicy foods are common irritants. Pharyngitis may also be caused by allergy to inhaled or ingested allergens.


Nursing Diagnosis for Pharyngitis

1. Acute pain related to inflammation of the throat.

2. Ineffective airway clearance related to thick secretions characterized by difficulty in breathing.

3. Imbalance nutrition less than body requirements related to difficulty swallowing.

4. Knowledge Deficit related to not familiar with the sources of information.

Pathophysiology of Pharyngitis

Pathophysiology of Pharyngitis
Pathophysiology of Pharyngitis

Pathophysiology of Pharyngitis

Transmission is by droplet. Germs infiltrate the epithelial layer, then the epithelium is eroded, then the superficial lymphoid tissue inflammatory reaction occurs with the damming of polymorphonuclear leukocyte infiltration. In the early stages there is hyperemia and edema and increased secretions. Serous exudate at first, but tends to become thickened and dry and can be attached to the pharyngeal wall. By hyperemia, blood vessel walls of the pharynx to the width. Blockage forms a yellow, white, or gray present in follicles or lymphoid tissue. It appears that the lymphoid follicles and blotches on the posterior pharyngeal wall or located more laterally to become inflamed and swollen causing inflammation of the throat or pharyngitis.

NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

NCP Stroke: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow

Ineffective Cerebral Tissue Perfusion related to interruption of blood flow: occlusive disease, hemorrhage, cerebral vascular spasm, cerebral edema.

Expected outcomes are:
  • Maintained and increased the level of consciousness, cognition and function of sensory / motor.
  • Reveals stabilization of vital signs and no increase in intracranial pressure.
  • The role of the patient reveals no deterioration / recurrence.

Nursing Intervention:

Independent
  • Determine the factors related to individual situations / causes of coma / decreased cerebral perfusion and a potential increase in intracranial pressure.
  • Monitor and record neurological status on a regular basis.
  • Monitor vital signs.
  • Pupil evaluation (size, shape similarity and reaction to light).
  • Help to change the view, misalnay blurred vision, visual field changes / perceptual field of view.
  • Increasing auxiliary functions, including speech if the patient has impaired function.
  • And gradual elevation of the head in neutral position.
  • Maintain bed rest, provide a quiet environment, set visits as indicated.
  • Provide supplemental oxygen as indicated.
  • Give medications as indicated.

Medical Management of Scoliosis

Medical Management of Scoliosis
Medical Management of Scoliosis

Medical Management of Scoliosis

Treatment depends on the cause, degree and location of the curve and the stage of bone growth.

If the curvature is less than 20%, usually require no treatment, but patients should perform regular checks every 6 months.

In children who are still growing, the curvature usually increased up to 25-30%, because it is usually advisable to use braces to help slow the progression of the curvature of the spine.

Braces of the "Milwaukee and Boston" is effective in controlling the progression of scoliosis, but must be installed for 23 hours / day until the child stops growing.
Brace ineffective in congenital and neuromuscular scoliosis.

If the curvature reached 40% or more, usually with surgery. In the surgery done to improve the curvature and fusion of the bones. Bone is maintained in place with the help of 1-2 metal tool attached to the bones recovered (less than 20 years). After the surgery may need to be fitted brace to stabilize the spine.

Sometimes given elektrospinal stimulation, in which the spinal muscles were stimulated with a low electrical current to straighten the spine.

Pathophysiology of Scoliosis

Pathophysiology of Scoliosis
Pathophysiology of Scoliosis

Pathophysiology of Scoliosis

Deformity of the spine called scoliosis, originated from the nerves of weak or even paralyzed attractive segments of the spine. This serves to keep the pull of the vertebrae are in the normal lines of its shape like a ruler or straight. But for some reason, such as the habit of sitting the oblique, make the most of the work to be weak nerves. If this continues over and over becomes a habit, then the nerve will even die. This results in an imbalance of pull on the vertebrae. Therefore, suffering from scoliosis of the spine is curved like the letter or the letter S or C.

Nursing Assessment for Scoliosis

Nursing Assessment for Scoliosis
Nursing Assessment for Scoliosis

Nursing Care Plan for Scoliosis : Nursing Assessment for Scoliosis

The physical examination includes:

a. Assessing the body's skeletal
The presence of deformity and alignment. Abnormal bone growth due to bone tumors. Shortening of the extremities, amputation and body parts that are not in anatomic alignment. Abnormal angulation of the long bones or motion at a point other than the joints usually indicate a fracture.

b. Assessing the spine
Scoliosis (lateral curvature of the spine deviation)

c. Assessing the joint system
Extensive movement are evaluated either actively or passively, deformity, stability, and bruising, stiffness of joints.

d. Assessing the muscle system
The ability to change position, muscle strength and coordination, and the size of each limb to mementau otot.Lingkar edema or atropfi, muscle pain.

e. Examine how to walk
The existence of irregular movements are not considered normal. If one limb shorter than the others. A variety of neurological conditions associated with abnormal gait (eg walking spastic hemiparesis - stroke, how to go step by step - lower motor neuron disease, how to walk vibrate - Parkinson's disease).

f. Examine the skin and peripheral circulation
Palpation of the skin may indicate a yanglebih temperature hotter or colder than others and adanyaedema. Peripheral circulation was evaluated by assessing peripheral pulses, color, temperature and capillary refill time.

Analysis of data
Subjektif Data :
  • Back pain patients say
  • Patients said fatigue in the spine after sitting or standing for long
  • Patients say trouble breathing

Objective Data :
  • That looks are not the same shoulder height
  • Visible protrusion of the scapula is not the same
  • Looks are not the same hip

Nursing Diagnosis

Nursing Diagnosis

NANDA NURSING DIAGNOSIS

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