Nursing Diagnosis and Nursing Intervention

Risk for Fluid Volume Deficit related to Vomiting

Risk for Fluid Volume Deficit related to Vomiting
Vomiting is defined as the discharge of the contents of the stomach up into the mouth by force. Vomiting can be an attempt removing toxins from the gastrointestinal tract such as diarrhea, lower gastrointestinal tract.

Vomiting can be caused by many things such as the following:

  • Congenital abnormalities
  • Infection of the digestive tract
  • Feeding the wrong way
  • Poisoned

Complications of vomiting are as follows :
  • Dehydration or alkalosis, due to loss of body fluid / electrolyte
  • Ketosis from not eating and drinking
  • Acidosis caused a sustained ketosis can be a shock even to seizures
  • Abdominal muscle tension, conjunctival hemorrhage, esophageal rupture, aspirations, caused by severe vomiting.

Persistent vomiting can lead to complications of dehydration, electrolyte disturbances, rips Mallory Wiess, aspiration of gastric fluid.

Nursing Diagnosis for Vomiting

Risk for Fluid Volume Deficit related to the feeling of nausea and vomiting

Goal: Maintain the balance of fluid volume.

Outcomes: The client does not nausea and vomiting.

1. Monitor vital signs.
Rationale: An early indicator of hypovolemia.

2. Monitor intake and output and urine concentration.
Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one impression of dehydration and require increased fluids.

3. Give fluid little by little but often.
Rationale: To minimize the loss of fluids.

4. The risk of infection associated with an inadequate immune, characterized by: body temperature above normal. Increased respiratory rate.

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Nursing Interventions for Encephalitis : Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to increased intracranial pressure.


  • Patient's neurological status returned to the state before the illness.
  • Increased patient awareness and sensory function.

  • Vital signs within normal limits.
  • Reduced headache pain.
  • Increased awareness.
  • No signs or loss of increased intracranial pressure.


1. Total bedrest patients, with supine sleeping position without a pillow.
Rationale: Changes in inta-cranial pressure will be able to mislead the risk for brain herniation.

2. Monitor signs of neurological status with GCS.
Rational: It can reduce further brain damage.

3. Monitor vital signs such as blood pressure, pulse, temperature, respiration and caution in systolic hypertension.
Rational: In normal circumstances autoregulation maintains a state of altered systemic blood pressure fluctuation. Autoregulation failure will cause a cerebral vascular damage can be manifested by an increase followed by a decrease in systolic and diastolic pressure. While the increase in temperature can describe the course of infection.

4. Monitor intake and output
Rational: Hyperthermia can lead to increased IWL and increase the risk of dehydration, especially in patients who are not aware, and nausea were lower intake by mouth

5. Help the patient to limit vomiting, coughing. Instruct the patient to exhale when moving or turning in bed.
Rationale: Activity vomiting or coughing can increase intracranial and intra-abdominal pressure. Exhale when moving or changing position can protect themselves from the effects of Valsalva.

6. Give fluids per infusion with strict attention.
Rationale: Minimize the burden of vascular and fluctuations in intracranial pressure, fluid and fluid vetriksi can reduce cerebral edema.

7. Monitor blood gas analysis of oxygen delivery when needed.
Rational: The possibility of acidosis is accompanied by the release of oxygen at the cellular level may lead to the occurrence of cerebral ischemic.

8. Provide appropriate therapy such as physician advice: Steroids, Aminofel, Antibiotics
Rational Therapy given to decrease capillary permeability.
Lowering of cerebral edema
Lowered metabolic cells / consumption and seizures.

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Nursing Diagnosis : Imbalanced Nutrition related to Hyperemesis Gravidarum

Nursing Care Plan for Hyperemesis Gravidarum - Nursing Diagnosis : Imbalanced Nutrition: less than body requirements

Hyperemesis Gravidarum

Nausea and vomiting (emesis gravidarum) is a natural phenomenon and is often caught in the first trimester of pregnancy. Nausea usually occurs in the morning, but can arise at any time and at night. These symptoms occur approximately 6 weeks after the first day of the last menstrual period and lasts for approximately 10 weeks. Nausea and vomiting occur in 60-80% primi gravida and 40-60% multi gravida. One in every thousand pregnancies, these symptoms become more severe.

Nausea is largely attributable because of increased levels of estrogen and HCG (Human Chorionic Gonadrotropin) in serum. Physiological effect of the hormone increase is not clear, probably because the central nervous system or the gastric emptying of the stomach is reduced. In general, women can adapt to this situation, though symptoms of severe nausea and vomiting that can last up to 4 months. Daily work was interrupted, and the general condition became worse. This condition is called hyperemesis gravidarum. Complaints of symptoms and physiological changes determine the severity of the disease. (Prawirohardjo, 2002)

Hyperemesis gravidarum is defined as excessive vomiting or uncontrolled during pregnancy, which causes dehydration, electrolyte imbalance, or nutritional deficiencies, and weight loss. The incidence of this condition is approximately 3.5 per 1000 births. Although most cases of missing and disappeared over time, one out of every 1,000 pregnant women will undergo hospitalization. Hyperemesis gravidarum usually disappear on their own (self-limiting), but healing is slow and frequent relapses are common. The condition often occurs among primigravida women and tends to recur in subsequent pregnancies. (Lowdermilk, 2004).

Nursing Diagnosis for Hyperemesis Gravidarum : Imbalanced Nutrition: less than body requirements related to excessive frequency of nausea and vomiting.

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Nursing Interventions for Apendicitis

Appendicitis is an inflammation of the appendix, a sac that no such additional functions located in the inferior and cecum. The most common cause of appendicitis is obstruction of the lumen by fecal eventually damage erode supply and mucosal blood flow, causing inflammation (Wilson & gold man, 1989).

Appendicitis is caused by blockage of the lumen of the appendix by fecalit, foreign objects, because there are previous inflammation. The obstruction causes mucus-producing mucosa, having the dam. However, the elasticity of the walls of the appendix has limitations that cause intra-luminal pressure. The increased pressure will inhibit the flow of lymph which will cause edema and ulceration of the mucosa, this occurs when the local acute appendicitis is characterized by the presence of pain.

Appendix unknown function, is part of the cecum. Inflammation of the appendix may occur by the presence of mucosal ulceration or obstruction of the lumen wall (usually by fecalit / hardened feces). Penymbatan spending mucus resulting in adhesions, and inhibition of bloodstream infections. Of hypoxia, resulting gangreng or rupture within 24-36 hours. If this process continues around the walls of organs appendix adhesions will occur that will cause an abscess (chronic). If the infection process is very fast will cause peritonitis.

Perforation signs include increased pain, muscle spasm right lower quadrant abdominal wall with a sign that generalized peritonitis or abscess localized, ileus, fever, malaise, leukocytosis increasingly clear. When perforation with generalized peritonitis or abscess formation has occurred since the increment clients outsmart come, the diagnosis can be established with certainty.

If peritonitis occurs, specific therapy is surgery performed to close the perforation origin. While the other acts as a support: Fowler position bed rest in the medium, the installation of NGT, fasting, correction fluids and electrolytes, giving tranquilizers, antibiotics with broad-spectrum antibiotics are continued in accordance with the culture, transfusion to treat anemia, and treatment of septic shock in the intensive , if any.

Preoperative Nursing Interventions for Apendicitis

Pediatric Nursing

Pediatric nursing or child health nursing is the specialty nursing care of babies, children and adolescents. A nurse who specializes in this area is usually referred to as a pediatric nurse. Although there are many regional and sub-specialty variations in title. The spelling paediatric nursing is more common in English-speaking countries outside the United States. (wikipedia)

Pediatric Nurses provide care to infants, children and adolescents. After graduating from nursing school (at a college, university, or hospital) with either an associate or bachelor's degree in nursing, they take an exam called the NCLEX to become licensed as a registered nurse (RN). The nurse then specializes in pediatrics by finding employment in a healthcare setting that serves pediatric patients. This setting could be a hospital clinic, school, doctor's office, emergency room, hospital floor or intensive care unit. Pediatric nurses know a lot about the growth and development of children, and they need to be skilled at communication with both their patients and caregivers. (

Nanda Nursing Diagnosis

Simple Ways to Eliminate Acne at Home

Simple Ways to Eliminate Acne at Home
All human dreams is like to have a clean face, smooth, and free from acne. It looks like acne is deeply ivory in humans, because almost everyone in this world can not be separated with this one issue, namely acne. It was difficult to accept these skin problems on the face, because the appearance of acne can change everything in terms of looks, a sense of lack of confidence, a sense of inferiority and shame with face full of acne. Usually acne is prone to oily face, because the face is oily when touched with dirty hands then, little by little pimples appear on the face like that. A lot of people who gave up his money was gone for treatment for acne on his face, but there are also people who do simple cure to get rid of acne. With treatment and spend money to disappear acne, acne seems to be quickly lost, because it is handled by a professional person, whereas with a simple way of pimples healing properties are no different to people who went to the doctor, but aga long to get rid of acne between 1 to 14 the acne will disappear in a simple way.

The appearance of acne can be caused by two factors, among others:

The first factor, acne will come through heredity, Why? If one parent either father or mother who has acne on his face, then his chances will experience acne age range 13 to 16/17 years.

The second factor, acne also will appear with lifestyle, means? Someone who can not control include lifestyle, irregular diet, eating foods that can cause acne, such as fried foods, meats, and foods containing oils, and irregular sleep patterns, means? Incompatibility with activity breaks conclusion, someone who is more activity to stay up and rested only 1 to 2 hours will trigger the appearance of acne.

Both of these factors were significantly associated with the appearance of acne .

Now we will discuss methods of healing acne from simpl.
  • Reduce foods containing oils , such as eggs , fried foods , meat , satay , and all foods containing oil , as it can trigger acne .
  • Begin meals with nutritious foods and start with vegetarians , such as vegetables , fruits , little by little acne goes away by itself .
  • Reduce or sleep staying up too late , get used to sleep between the hours of 9 am to 10 pm , and more sleep during the day .
  • Avoid solving acne with dirty hands and do not solve the acne that will break by itself ( Acne , which is white ) because it can cause the face to be damaged and perforated . Let stand for acne it will break by itself and do not solve the acne memakasakan our hands .
  • Not too much mind , it is one of the causes of acne triggers .
  • Try eating garlic before afternoon showers if you can not eat garlic , try garlic slices to small and apply on acne affected face and wait for 3 to 4 minutes , then rinse with water and soap . it is very helpful to eliminate acne fairly quickly with time .
  • Apply toothpaste on acne affected face before bed and leave overnight toothpaste attach to the front of you , the next day rinse with water and soap . Do not use the transparent toothpaste.
  • Pluck the strings skillfully Aloe Vera plant , Abillah mucus from the aloe vera and apply on acne affected face , wait for 3 to 4 minutes , then rinse with water and soap .
  • This is the most important thing , especially oily face usually in the afternoon or evening to face felt sticky and shiny face when exposed to sunlight during the day and evening , you do not touching the face when the crate situation , but washing your hands and rinse your face with water and soap until it looks clean .

Nursing Diagnosis - Impaired Swallowing related to Dysphagia

Dysphagia is difficulty in swallowing process and skip the food from the esophagus to the stomach. Causes of dysphagia can be various kinds. It is important to know the difference dysphagia due to oropharyngeal and esophageal disorders.

Dysphagia can be found on some of the causes that can cause the condition include:
  • Stroke
  • Progressive neurological disease
  • The lapse trachestomy
  • Paralise or absence of movement of the vocal cords
  • Tumors in the mouth
  • Head surgery
At regurgitation is often caused by acid that rises from the stomach (acid reflux). Regurgitation can also be caused by a narrowing (stricture) or blockage of the esophagus. Where blockage can occur due to several causes, including cancer of the esophagus, by impaired nerve control valve in the esophagus and the mouth of the stomach.

Impaired Swallowing Definition :
Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function

Nursing Diagnosis for Dysphagia

Impaired swallowing related to weakness of the muscles due to paralise.

Expected results:
Patients can demonstrate the proper method of ingest food without causing despair

  • Review the patient's ability to swallow, note the extent of facial paralysis.
  • Increase efforts to be able to perform effective ingestion such as helping the patient hold his head.
  • Place the patient in a sitting position / upright during and after eating.
  • Stimulation lips to open and close the mouth manually by pressing lightly on the lips / under the chin.
  • Place the food in the mouth is not sick / impaired.
  • Most in touch with the cheeks spatel tongue to detect weaknesses.
  • Give eat slowly in a quiet environment.
  • Start by giving oral semi-liquid foods, soft foods when the patient can swallow water.
  • Help the patient to choose foods that are small or do not need to chew and easy to swallow.
  • Instruct the patient to use a straw to drink liquids.
  • Encourage you to participate in an exercise program.

Acne - 5 Nursing Interventions

Acne - 5 Nursing Interventions
NCP - Acne Nursing Diagnosis and Interventions

1. Disturbed Body Image related to inflammation.

  • Encourage clients to express feelings about his illness. Maintain a positive approach, avoid insulting expression or reaction suddenly changes.
  • Be realistic and positive during treatment, the health education.

2. Anxiety related to Acne.

  • Encourage the patient to express his thoughts and feelings.
  • Provide an open environment where the patient feels safe to discuss feelings.

3. Impaired Skin Integrity is characterized by erythematous papules, pustules, and cysts inflammatory.

  • The client that the treatment generally takes 4-6 weeks or more.
  • Encourage clients to avoid all forms of friction (scratch by hand, etc.) encourage the client to avoid any skin cream.

5. Risk for infection related to bacterial skin infections.

  • Emphasize the client to not rub or messing ngatiknya acne.
  • Maintain personal hygiene, especially in the area of ​​the hand.

6. Knowledge Deficit related to the triggering factors and the treatment of acne.

  • Emphasize the client that his problems are not associated with uncleanness, error eating, sexual activity, or other misconceptions that are often encountered.
  • Inform about oral medications and topical along with potential side effects.

Clinical Manifestations of Vertigo

Clinical Manifestations of Vertigo
Clinical manifestations in patients with vertigo is spinning feeling that is sometimes accompanied by symptoms of nausea, vomiting, severe headache taste, appetite down, tired, pale tongue with sticky white membrane, weak pulse, headache (dizziness), blurred vision, tinnitus, mouth bitter, red eyes, irritability, restlessness, red tongue with thin membrane.

Vertigo patients will complain if the position of head turns on its specific circumstances. Patients will feel rotating or spinning around him feel when going to bed, rolling from side to side, get out of bed in the morning, reaching something high or if the head is moved to the back. Vertigo usually lasts only 5-10 seconds. Sometimes accompanied by nausea and patients often feel anxious. Patients are usually able to recognize this situation and try to avoid it by not doing movements that can cause vertigo. Vertigo is not going to happen if the head upright or rotated axially without extension, in a majority of patients, vertigo will diminish and eventually cease spontaneously within a few days or a few months, but can sometimes be as much as several years.

In the anamnesis, the patient complained of head feels dizzy, spinning on changes in head position with a certain position. Clinically vertigo occurs in changes in head position and will be reduced and eventually stopped spontaneously after some time. On ENT examination is generally not found significant abnormalities, and the caloric test no canal paresis.

Position test can help diagnose vertigo, it is best to Hallpike maneuver: the patient sitting upright, his head is held on both sides by the examiner, then head dropped suddenly as he turned to one side. In this test we will get the position nystagmus symptoms:
  1. Vertigo sufferers will feel the sensation of movement such as spinning, either himself or the environment.
  2. Nausea incredible.
  3. Frequent vomiting as a result of nausea.
  4. Abnormal eye movements.
  5. Suddenly a cold sweat.
  6. Was ringing in the ears frequently.
  7. Have difficulty talking.
  8. Have difficulty walking due to feel the sensation of spinning motion.
  9. In certain circumstances, the patient may also experience vision disorder.

10 Causes of Pressure Sores

Braden and Bergstrom (2000) developed a scheme for describing the risk factors for the occurrence of pressure sores. There are two main things that relate to the risk of pressure sores, the pressure factor and tissue tolerance. Factors that influence the duration and intensity of pressure on the protruding bone is immobility, inactivity, and decreased sensory perception. While the factors that affect tissue tolerance divided into two factors : extrinsic and intrinsic factors.

1. Intrinsic factors: aging (weak cell regeneration), number of diseases that cause such as diabetes, nutritional status, underweight or overweight, anemia, hypoalbuminemia, neurological diseases and diseases that damage the blood vessels, state of hydration / body fluids.

2. Extrinsic factors: Cleanliness bed, weaving tools are matted and dirty, or medical equipment that causes sufferers fixed on a certain attitude, a poor Sitting, improper position, position changes less. Below is an explanation of each of these factors:

Cleanliness of the beds, weaving tools are matted and dirty, or medical equipment that causes sufferers fixed on a certain attitude, a poor Sitting, improper position, position changes less. Below is an explanation of each of these factors:

1. Mobility and activity
Mobility is the ability to change and control the position of the body, while the activity is the ability to move. Patients who continue to lie in bed without being able to change the position of high risk for developing pressure sores. Immobility is the most significant factor in the incidence of pressure sores.

2) Decrease in sensory perception
Patients with decreased sensory perception of decreased sensation to feel the pain caused by pressure on the protruding bone. When this happens in a long duration, the patient will be susceptible to pressure sores.

3. Humidity
Moisture caused by incontinence can result in tissue maceration on the skins. Tissue maceration experience will be susceptible to erosion. In addition it also resulted in moisture prone skin friction and tearing tissue (shear). Faecal incontinence is more significant in the development of pressure sores than urinary incontinence because the bacteria and enzymes in the stool can damage the surface of the skin.

4. Tearing energy (shear)
A mechanical force that stretch and tear the tissue, blood vessels and the deeper tissue structures adjacent to the protruding bone. The most common example of this is the force that ripped when the patient is positioned in a semi-Fowler position in excess of 30 degrees. In this position, the patient can be dropped down, thus resulting in the bones to move downward, but her skin is still lagging. This can lead to occlusion of blood vessels, as well as damage to internal tissue such as muscle, but caused little damage to the skin surface.

5. Friction
Friction occurs when two surfaces move in the opposite direction. Friction can cause abrasion and damage the surface of the skin epidermis. Friction could occur when changing bed linen patients who are not careful.

6. Nutrition
Hypoalbuminemia, weight loss, and malnutrition is generally identified as a predisposing factor for the occurrence of pressure sores. According to research Guenter (2000) stage three and four of the cuts hit the parents associated with weight loss, low albumin levels, and inadequate food intake.

7. Age
Older patients have a high risk of developing pressure sores because the skin and tissue will change with aging. Aging result in muscle loss, decreased serum albumin levels, decreased inflammatory response, decreased skin elasticity, as well as decrease the cohesion between the epidermis and dermis. This change combined with other aging factors will make the skin become less tolerance to pressure, friction, and energy tearing.

8. Arteriolar pressure is low
Arteriolar pressure is low will reduce skin tolerance to pressure so that the low pressure application is able to cause tissue to ischemia. Studies conducted by Nancy Bergstrom (1992) found that the systolic pressure and low diastolic pressure contribute to the development of pressure sores.

9. Emotional stress
Depression and chronic emotional stress such as in psychiatric patients is also a risk factor for the development of pressure sores.

10. Skin temperature
According to the research Sugama (1992) an increase in temperature is a significant factor in the risk of pressure sores. According to the research, other important factors that also influence the risk of pressure sores is the interface pressure). Interfacial pressure is force per unit area between the body surface of the mat. If the interfacial tension is greater than the average capillary pressure, the capillaries will easily collapse, the area becomes easier to ischemia and necrotic. Average capillary pressure is about 32 mmHg. According to research Sugama (2000) and Suriadi (2003) high-pressure interface is a significant factor for the development of pressure sores. Interface pressure is measured by placing a pressure gauge interface (pad pressure evaluator) between the depressed area with a mattress.

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Nursing Diagnosis - Acute Pain related to Gastritis

Gastritis is an inflammation of the lining of the stomach, and has many possible causes. Is a major cause of acute excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs such as aspirin or ibuprofen.

Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in ribbon or reconstruction of the gastrointestinal tract.

Cause of chronic gastritis is infection with bacteria, primarily Helicobacter pylori''''. Certain diseases, such as pernicious anemia, chronic bile reflux, stress and certain autoimmune disorders can cause gastritis as well.

The most common symptom is abdominal upset or pain. Other symptoms are indigestion, flatulence, nausea, and vomiting.

Some people may have a feeling of fullness or burning in the upper abdomen. A gastroscopy, blood test, complete blood count tests, or stool tests can be used to diagnose gastritis. Treatment includes taking antacids or other medications, such as proton pump inhibitors or antibiotics, and avoiding hot or spicy foods. For those with pernicious anemia, B12 injections are given.

Nursing Diagnosis - Acute Pain related to Gastritis

Acute Pain related to inflammation of the mucosal lining of the stomach (gastric)

  • Pain is reduced with no inflammation or irritation of the gastric mucosa.

  • Pain scale is reduced
  • Do not feel pain in the epigastric
  • Not grimace (no abdominal tenderness)

  • Record complaints of pain, including the location, duration, intensity (scale of 0-10)
  • Review the factors that increase or decrease pain
  • Give food a little but often as an indication for patients
  • Assistive range of motion exercises active / passive
  • Provide frequent oral care and comfort measures (back massage, change of positions)
  • Give medication as indicated

  • Pain is not always there but if there is to be compared with the previous patient's symptoms of pain, which can help diagnose the etiology and occurrence of bleeding complications.
  • Assist in making the diagnosis and therapeutic needs.
  • Have the effect of neutralizing acidic foods, it also destroyed the womb gaster.Makan little gastrin prevent distension and output
  • Lowering joint stiffness, pain minimizing discomfort.
  • Bad breath because tertahanya oral secretions cause no appetite and can increase nausea. Gingivitis and dental problems can increase

Self-Care Deficit - NCP Stroke

Self-Care Deficit - NCP Stroke
Nursing Diagnosis for Stroke

Stroke is a clinical syndrome that initial sudden onset, rapid progression, a focal neurological deficits and / or global, which lasted 24 hours or more or the direct cause of death, and solely caused by circulatory disorders non-traumatic brain. When the brain's circulatory disorder lasts a while, a few seconds to several hours (mostly 10-20 minutes), but less than 24 hours, referred to as the face of brain ischemia attack (TIA = transient attack ischamia).

Types of stroke

There are two main causes of strokes:
  • ischaemic (accounting for over 80% of all cases) – the blood supply is stopped due to a blood clot
  • haemorrhagic – a weakened blood vessel supplying the brain bursts and causes brain damage

Treatment of stroke

Treatment depends on the type of stroke you have, including which part of the brain was affected and what caused it.

Most often, strokes are treated with medicines. This generally includes drugs to prevent and remove blood clots, reduce blood pressure and reduce cholesterol levels.

In some cases, surgery may be required. This is to clear fatty deposits in your arteries or to repair the damage caused by a haemorrhagic stroke.

Nursing Diagnosis for Stroke : Self-care deficit related to physical weakness

NOC: Self Care Assistance (bathing, dressing, eating, toileting).

Goal: The client can meet the needs of self-care

Clients are free from odor, can feed themselves, and dress himself.

NIC: Self Care
1. Observation of the client's ability to bathe, dress and eat.
2. Assist the client in a sitting position, make sure the head and shoulders upright for eating and 1 hour after meals.
3. Avoid exhaustion before eating, bathing and dressing.
4. Encourage clients to continue to eat little but often.

1. By using direct intervention to determine appropriate interventions for clients.
2. Seated position helps prevent ingestion and aspiration.
3. Improve energy conservation and activity tolerance improved self-care ability.
4. To increase appetite.

Types, Causes and Symptoms of Vertigo

Types, Causes and Symptoms of Vertigo
Disease which is also called vestibulars disorders are health problems associated with our balance system, usually the symptoms is feeling spinning (like falling), ear buzzing and sometimes with nausea.

Basically vertigo is a complaint, not a disease. However, this complaint could be a sign of serious illness. So, although not a disease, vertigo should not be underestimated. Vertigo can be a sign of diseases like brain tumor, hypertension (high blood pressure), diabetes mellitus (diabetes), heart, and kidneys. The earlier vertigo will be handled more quickly be overcome.

Types of vertigo

Vertigo is classified into two categories based on the damaged vestibular channels, namely peripheral vertigo and central vertigo. Vestibular canal is one of the organs of the inner ear that always sends information to the brain about the position of the body to maintain balance.

Peripheral vertigo occurs if there is interference on a channel called semicircular canal, the middle ear in charge of controlling the balance.

This type of vertigo is usually followed by symptoms such as:
  • dark outlook
  • fatigue and decreased stamina
  • palpitations
  • loss of balance
  • unable to concentrate
  • feeling like a hangover
  • muscle pain
  • nausea and vomiting
  • memory and thinking power to decline
  • sensitive to bright light and sound
  • sweat

While central vertigo occurs if there is something not normal in the brain, especially in the balance nerve, the area of ​​the brain and cerebellum branching (small brain). Central vertigo symptoms usually occur gradually, the patient will experience things like:
  • double vision
  • hard to swallow
  • paralysis of the facial muscles
  • severe headache
  • impaired consciousness
  • not speechless
  • loss of coordination
  • nausea and vomiting
  • body feels weak

Causes and Symptoms

Complaints usually come sudden vertigo, followed by clinical symptoms of discomfort such as sweating, nausea, and vomiting. Factors causing vertigo are: systemic, neurologic, ophtalmologik, otolaryngology, psychogenic.

Vertigo is often caused by a disturbance in the area centered balance labyrinth or the cochlea in the ear cavity. Possible causes of vertigo include:
  • Infections such as influenza virus that attacks the maze area.
  • Bacterial infection in the middle ear.
  • Arthritis in the neck area.
  • Migraine attack.
  • Too little blood circulation, causing blood flow to decrease brain balance centers.
  • Drunk vehicle.
  • Alcohol and certain drugs.

Ineffective Airway Clearance related to Bronchopneumonia

Ineffective Airway Clearance related to Bronchopneumonia

Nursing Care Plan for Bronchopneumonia

Ineffective Airway Clearance : Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Bronchopneumonia is a type of pneumonia. Pneumonia is inflammation of the lungs, caused by infection from viruses, bacteria, or fungi. The infection causes inflammation in the alveoli (also known as air sacs) in the lungs, causing the alveoli to become filled with pus or fluid.

Both forms of pneumonia are often caused by coming into contact with viruses and bacteria in your day-to-day routine. Most cases of bacterial pneumonia are caused by the bacterium Streptococcus pneumonia; however, it is not uncommon for pneumonia to be caused by more than one type of bacteria. Other possible culprits include:
  • Staphylococcus aureus
  • Haemophilus influenzae
  • Klebsiella pneumoniae
Most cases of viral pneumonia are caused by the same viruses that cause cold and flu.

Nursing Diagnosis for Bronchopneumonia

Ineffective Airway clearance related to increased sputum production

Subjective Data
  • Patients complain of fuss
  • Patients complain of shortness of breath
  • Patients do not want to eat
  • Parents expressed not understand about his illness

Objective Data
  • Breathing fast and shallow
  • Nostril breathing
  • Ronchi and cyanosis
  • Coughing purulent sputum
  • The use of auxiliary respiratory muscles
  • Breath sounds bronchovesikuler
  • vomiting vomiting
  • Malaise
  • Decreased appetite and weight loss
  • Increased respiration


Clean and effective airway after the treatment, the criteria:
  • No dypsnoe, cyanosis, Ronchi
  • BGA mormal

  1. Assess the respiratory rate, record the ratio of inspiration / expiration.
  2. Perform auscultation of breath sounds, note the presence of breath sounds. For example: wheezing, crackles.
  3. Provide semi-Fowler position.
  4. Provide a warm drink a little bit but it often.
  5. Implement the discretionary actions: bronchodilator, mucolytics, to liquefy phlegm so easily removed.

  1. Tachypnea is usually present in some degree and can be found at the reception or during stress / presence of acute infectious process. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.
  2. Airway clearance ineffective may be manifested in the presence of breath sounds adventisius.
  3. Semi-Fowler position will make it easier for patients to breathe.
  4. Hydration decrease the viscosity of secretions and facilitate expenditure.
  5. Provision of medicines pengerncer sputum airway facilitate the evacuation process.

Pathophysiology of Thyroid Carcinoma

Thyroid Carcinoma usually capture radioactive iodine than normal thyroid gland located around the perimeter. Therefore, when done scintiscan, nodules will appear as an area with less decision, a cold lesion. Other diagnostic techniques that can be used for differential diagnosis of thyroid nodules are thyroid echography. This technique allows to distinguish carefully between the mass of solid and cystic masses. Thyroid carcinoma is usually solid, while the cystic mass is usually a benign cyst.

Thyroid carcinoma should be suspected based on clinical signs if there is only one palpable nodules, hard, basically can not be moved, and is associated with satellite lymphadenopathy.

In general it was agreed that clinical thyroid cancer can be divided into a large group of well differentiated neoplasm with a slow growth rate and high probability of healing, and a small group of anaplastic tumor with possible fatal. There are four types of thyroid cancer according to morphologic and biological: papillary, folikularis, medularis, and anaplastic. (Price, 1995, p: 1078)

Papillary carcinoma of the thyroid gland is usually a hard nodule, single, "cold" on the isotope scan, and "solid" on thyroid ultrasonography, which is very different from other parts of the gland. At multinodular goiter, cancer is a "dominant nodule" bigger, louder and clearer than the surrounding parts. Approximately 10% of papillary carcinomas, especially in children, with enlarged cervical lymph nodes, but careful inspection will usually reveal nodule "cold" on the thyroid. Rarely, will hemorrhage, necrosis and cyst formation in malignant nodules but on thyroid ultrasonography, there will be clearly bounded internal echo is useful for semi malignant cystic lesions of "pure cyst" is not malignant. Finally, papillary carcinoma can be found accidentally as a fakus microscopic cancer in the middle of the gland removed for other reasons such as: Graves' disease or multinodular goiter.

Microscopically, the tumor consists of a single layer of thyroid cells organized in "vascular stalk", by highlighting papil into microscopic spaces such as cysts. Nucleus of the cell and often pale nucleus containing inclusion bodies intra clear as glass san. Approximately 40% of papillary carcinoma forming a layered spheres classification, often at the end of both the optic disc bulge called "psammoma body", is usually diagnostic for papillary carcinoma. This cancer is usually spread by metastasis in the glands and the thyroid gland invasion and local lymph nodes. In elderly patients, they can be more aggressive and invade locally into the muscle and trachea. In stage further, they can spread to the lungs. Death is usually due to local disease, with invasion into the neck, more rarely death could disebabka extensive pulmonary metastases. In some elderly patients, a papillary carcinoma that grows slowly will begin to grow rapidly and turn into anaplastic carcinoma. Further anaplastic changes are the cause of death other than papillary carcinoma, papillary carcinoma secreting many thyroglobulin, which can be used as a sign of recurrence or metastasis of cancer.

Follicular carcinoma is characterized by the persistence of small follicles, although the formation of colloidal bad. Indeed, follicular carcinoma can not be distinguished from follicular adenomas except with capsule invasion or vascular invasion. The tumor is slightly more aggressive than papillary carcinoma and spreads either by local invasion or lymph node invasion of blood vessels accompanied by distant metastases to bone or lung. Microscopically, these cells are cuboidal shaped with large nuclei were irregular around the follicle, often containing colloid. These tumors are often still have the ability to concentrate radioactive iodine to form tiroglubulin and rarely, to synthesize T3 and T4. Thus, the function of thyroid cancer that is almost always a rare follicular carcinoma. This characteristic makes these tumors more it is likely to give good results against radioactive iodine treatment. In patients who were not treated, death due to local extension or distant metastases as the flow of blood to the extensive involvement of the bones, lungs, and viscera.

A variant of follicular carcinoma is carcinoma "Hurthle cell" which is characterized by cells individually with a huge pink cytoplasm contains mitochondria. They behave more like papillary carcinoma are rare unless they radioiodin uptake. Mixed papillary and follicular carcinoma is more like papillary carcinoma. Thyroglobulin secretion produced by follicular carcinoma can be used to follow the course of the disease.

Medullary carcinoma is a disease of the cell C (parafolikular cells) derived from primary branchial body and capable of secreting calcitonin, histaminase, prostaglandins, serotonir, and other peptides. In mikoroskopis, tumor composed of layers of cells separated by a substance that stained with red. Amyloid consists of a chain of calcitonin fibrils that are arranged in a pattern or contrast with other forms of amyloid, which can have a light chain immunoglobulins or other proteins that are deposited with a pattern Fibri.

Medullary carcinoma is more aggressive than papillary or follicular carcinomas but not as aggressive as undifferentiated thyroid cancer. This extends locally to the lymph nodes and into the surrounding muscle and trachea. Can lymphatic and vascular invasion and metastasisi to the lungs, and calcitonin viscera, and carsinoembryonic antigen (CEA) is secreted by the tumor is of clinical signs that help the diagnosis and follow-up. Approximately one-third are familial medullary carcinoma, involving multiple nodes (Multiple endocrine neoplasia type II = MEN II, Sipple syndrome). MEN II is characterized by medullary carcinoma, pheochromocytoma, and multiple neuromas on the tongue, lips, and intestines. Approximately one-third of cases of malignancy dalah alone. If medullary carcinoma at diagnosis with fine-needle aspiration biopsy or during surgery, it is important for patients examined other endocrine disorders encountered in MEN II and members examined for the presence of medullary carcinoma and MEN II. Measurement of serum calcitonin after pentagastrin stimulation or infusion of calcium can be used to screen for medullary carcinoma. Pentagastrin administered intravenously in the form of bolus 0.5 mg / kg, and venous blood samples were taken at minutes 1, 3, 5, and 10. Abnormal increase in serum calcitonin in minutes to 3 or 5 is indicative of malignancy. MEN IIA gene has been localized to chromosome 10, and it is now possible to use checks and polymorphic DNA fragment length polymorphism is limited to the identification of this syndrome gene career. So the family members who carry this gene can be identified and examined as a high risk for the onset of this syndrome.

Anaplastic carcinoma, undifferentiated thyroid gland tumors including small cell carcinoma, giant cells, and spindle cells. It usually occurs in elderly patients with a long history of goiter in which the nodes of a sudden within a few weeks or months started to grow and produce pressure symptoms, dysphagia or vocal cord paralysis, death due to local expansion which usually occurs within 6-36 months . These tumors are highly resistant to treatment.

Nursing Interventions for Acute Tonsillitis

Acute tonsillitis is an inflammation of the tonsils is still mild. Inflammation of the tonsils in children is almost always involve the surrounding organs so that the infection of the pharynx is usually also the tonsils, so called as tonsillopharyngitis.

Signs and symptoms of Acute Tonsillitis are:
  • Sore throat
  • Pain swallow
  • Difficulty in swallowing
  • Fever
  • Nausea
  • Anorexia
  • Swollen neck lymph nodes
  • Pharyngeal hyperemia
  • Pharyngeal edema
  • Enlarged tonsils
  • Tonsil hyperemia
  • Halitosis
  • Otalgia (ear pain)
  • Malaise

Nursing Interventions for Acute Tonsillitis

1. Hyperthermia related to inflammatory processes in the tonsils

  • Monitor your child's temperature (degrees and patterns), note the presence of shivering.
  • Monitor the temperature of the environment.
  • Limit the use of linen, clothing worn clients.
  • Give warm compresses.
  • Give plenty of fluids (1500 - 2000 cc / day).
  • Collaboration of antipyretics.

2. Acute pain related to swelling of the tonsils

  • Monitor the client's pain (scale, intensity, depth, frequency).
  • Assess vital signs.
  • Provide a comfortable position.
  • Give relaxation techniques with a long deep breath through your nose and release it slowly through your mouth.
  • Give a distraction technique to distract the child.
  • Collaboration of analgesics.

3. Imbalanced Nutrition: less than body requirements related to related to the existence of anorexia

  • Assess conjungtiva, sclera, skin turgor.
  • Weigh weight each day.
  • Provide food in a warm state.
  • Provide food in small portions but often serve food in the form of interest.
  • Increase comfort when eating environment.
  • Collaboration of appetite enhancer vitamins.

4. Activity intolerance related to weakness

  • Assess the client's ability to perform activities.
  • Observation of fatigue in the activity.
  • Monitor vital signs before, during and after the activity.
  • Provide a quiet environment.
  • Increase activity as tolerated clients.

5. Disturbed Sensory Perception: hearing related to obstruction

  • Review the client's hearing loss.
  • Do ear irrigation.
  • Speak clearly and slowly.
  • Use the white board / paper to communicate if there is difficulty in communicating.
  • Collaboration audiometric examination.
  • Collaboration of ear drops.

Nursing Diagnosis for Thyroid Cancer

Nursing Diagnosis for Thyroid Cancer
Thyroid cancer is a depressing malignancy in thyroid which has 4 types, namely: papillary, follicular, medullary and anaplastic. Thyroid cancer rarely causes enlargement of the gland, often causing small growth (nodule) in the gland. The majority of thyroid nodules are benign, thyroid cancer is usually curable.

Thyroid cancer often limits the ability to absorb iodine and limit the ability to produce thyroid hormone, but sometimes produce enough thyroid hormone, causing hyperthyroidism.

Thyroid cancer occurs in the cells of the thyroid gland (an organ shaped like a butterfly located on the nape of the neck), which serves to produce hormones to regulate the speed of the heart beat, blood pressure, body temperature and weight.

According to WHO, malignant epithelial thyroid tumors are divided into:

1. Follicular carcinoma.
There are roughly 25% of all thyroid carcinomas exist, especially regarding the age group above 50 years. Invade the bloodstream and then spread to the bone and lung tissue. Rarely spread to regional lymph nodes but can be attached / stuck in the trachea, neck muscles, and blood vessels of the skin, which then causes dyspnea and dysphagia. When the tumor on "The recurrent laryngeal Nerves", a hoarse voice clients. The prognosis is good if metastasenya still a bit by the time the diagnosis is set.

2. Papillary carcinoma.
Is a type of thyroid cancer that is often found, a lot of women or the age group above 40 years. Papillary carcinoma is a tumor that progress has been slow and can appear many years before spreading to regional lymph nodes. When the tumor is localized in the thyroid gland, the prognosis is good if the action Thyroidectomy partial or total.

3. Medullary carcinoma.
Parafolikular arising in thyroid tissue. Amount of 5-10% of all thyroid carcinomas and generally the people aged over 50 years. Spread through the lymph nodes and invade surrounding structures. These tumors often occur and are part of the Multiple Endocrine Neoplasia (MEN) Type II which is also part of the endocrine disease, where there is excessive secretion of calcitonin, ACTH, prostaglandin and serotonin.

4. Poorly differentiated carcinoma (anaplastic).
Tumor is growing quickly and outstanding aggressive. This type of cancer is directly attacking adjacent structures, which cause symptoms such as:
  • Stridor (sound raspy / hoarse, loud audible breath sounds).
  • Hoarseness.
  • Dysphagia
The prognosis is poor and most of the clients died about 1 year after diagnosis set. Clients with a diagnosis of anaplastic carcinoma can be treated with palliative surgery, radiation and chemotherapy.

Etiology of the disease is uncertain, whose role is to occur particularly well differentiated (papillary and follicular) are radiation and endemic goiter, and for medullary type is a genetic factor. Carcinoma who have not known a role for anaplastic and medullary cancers. Estimated cancer types derived from anaplastic thyroid cancer changes berdiferensia good (papillary and follicular), with the possibility of the follicular type twice as large.

Radiation is one of the etiologic factors of thyroid cancer. Many cases of cancer in children previously received radiation to the head and neck due to other diseases. Radiation effects usually appear after 5-25 years, but an average of 9-10 years. The old TSH stimulation is also one of etiological factors of thyroid cancer. Other risk factors are a family history of thyroid cancer and chronic goiter.

There are also factors such as genetic abnormalities predisposisilainnya, age, sex, race, and place of residence (coastal area).

Clinical suspicion of thyroid carcinoma is based on the observation that was confirmed by pathological examination and suspicion are divided into high, medium and low. Which includes high suspicion are:
  • Multiple endocrine neoplasia history in the family.
  • Rapid tumor growth.
  • Hard palpable nodules.
  • Fixation surrounding area.
  • Paralysis of the vocal cords.
  • Enlargement of regional lymph nodes.
  • The presence of distant metastases.

Nursing Diagnosis for Thyroid Cancer
  1. Ineffective airway clearance related to obstruction of the trachea by the pressure of the tumor mass
  2. Acute pain related to the pressure / swelling by tumor nodule
  3. Impaired verbal communication related to vocal cord injury
  4. Anxiety related to changes in health
  5. Imbalanced Nutrition: less than body requirements related to swallowing disorders
  6. Disturbed Body Image related to the incision secondary to thyroid cancer surgery
  7. Knowledge Deficit related to lack of information about the disease.

Nursing Care Plan for Cerebral Palsy

Nursing Care Plan for Cerebral Palsy
  1. Assess the mother's pregnancy history
  2. Assess history of childbirth
  3. Identification of children who are at risk
  4. Assess the child irritable, difficulty in eating / swallowing, delayed development of normal children, the development of less movement, abnormal posture, lack of movement development, abnormal posture, persistent infant reflexes, ataxic, lack of muscle tone.
  5. Monitor response to child's play
  6. Assess intellectual functioning
  7. No muscle coordination when performing movement (loss of balance)
  8. Stiff muscles and exaggerated reflexes (spasticas)
  9. Difficulty chewing, swallowing and sucking, and difficulty speaking.
  10. body shaking
  11. Difficulty moving exactly like menulus or pressing a button.
  12. Children with cerebral palsy may have additional problems, including the following: seizures, problems with vision and hearing as well as in speaking, there are learning disabilities and behavioral disorders, mental retardation, problems related to respiratory problems, problems in defecation and waste little water, and there are re-shape abnormalities such as scoliosis.
  13. Past medical history: premature birth, and birth trauma.
  14. History of present illness: muscle weakness, mental retardation, severe disorders-hypotonia, Throwing / Suction eating, impaired speech / voice, visual and hearing.

Subjective data :
  1. Parents say that when pregnant mothers experienced tooplasmosis, their children's growth rather late.
  2. Parents say son can not walk seendiri, can not feed themselves, can not brush your teeth with help.
  3. Parents also say that children can not do the things kids his age do.
  4. Parents feel the burden of caring for their children and embarrassed by her condition. Parents worried about their future.

Objective data :
  1. Test results showed the body feel warm.
  2. Sweat a lot
  3. There are involuntary movements (not coordinated)
  4. posture opistotonik
  5. Children difficulty to eat
  6. Often ceguken, and irritabel.

Nursing Care Plan for Cerebral Palsy - Nursing Diagnosis
  1. Hypertermia
  2. Risk for injury
  3. Imbalanced Nutrition, Less Than Body Requirements
  4. Impaired verbal communication
  5. Activity intolerance
  6. Delayed growth and development
  7. Knowledge deficit
  8. Ineffective breathing pattern

Abdominal Typhoid - Clinical Manifestations and Pathophysiology

Abdominal Typhoid - Clinical Manifestations and Pathophysiology
Clinical Manifestation of Abdominal Typhoid

Clinical manifestations of abdominal typhoid in adult patients is usually more severe than in children. Average incubation period of 10-20 days. The shortest 4 days if the infection through food, whereas the longest up to 30 days if the infection through drink. During the incubation period found that prodromal symptoms of feeling unwell, lethargy, headache, dizziness, decreased appetite, and not excited.

Clinical symptoms commonly found are:
1. Fever.
In the typical case the fever lasts 3 weeks. Remitens and is febrile temperature is not too high. During the first week, body temperature gradually rose faithful day, usually down in the morning and rose again in the afternoon and evening. In the second week the patient continues to be in a state of fever. In the third week and the body temperature gradually fall back to normal by the end of the fourth week.

2. Disorders of the gastrointestinal tract.
In the mouth there is a smell of bad breath (halitosis), dry lips and chapped (rhagaden). Tongue covered with dirty white membrane (coated tongue), reddish tongue tip and edges, often accompanied by tremors. Abdominal bloating discovered circumstances (meteorismus). Enlarged liver and spleen pain accompanied palpability. Defecation usually constipation, may be normal and sometimes diarrhea.

3. Disorders of consciousness.
Generally, patients with decreased consciousness, although not in, that is apathetic to somnolence, sopor rare, coma or restless (except severe illness and delayed treatment).

4. Besides the above symptoms, on the back or limbs can be found roseola, which is reddish spots due to emboli bacilli in skin capillaries are mainly found in the first week of fever. Sometimes also found bradycardia and epistaxis.

Pathophysiology of Abdominal Typhoid

Foods or beverages that have been contaminated by the bacteria Salmonella typhosa into the stomach, then escapes from the stomach's defense system, then enter the small intestine, spleen follicles go through kesaluran systemic lymphatic and blood circulation, resulting in bacteremia. Bacteremia first attack Endoteleal reticulo Systems (RES) are: liver, spleen and bone, then later on all organs in the body such as the central nervous system, kidneys and spleen tissue. Bile produced by the liver into the gallbladder, causing cholecystitis. Bile will go into the duodenum and the high virulence of the bacteria will infect the intestine back especially illeum which will form part of the oval and the ulcer. Entry of bacteria into the intestine occurs in the first week with signs and symptoms of body temperature fluctuates in particular the temperature will go up at night and will decrease late morning. Fever that occurred in this period is called intermittent fever (high temperature, up and down and the downs can reach normal). Besides an increase in body temperature, will also happen obstipation, as a result of decreased motility temperature, but this is not always the case can also occur otherwise. Once past the initial phase of intestinal bacteria, then enter the systemic circulation with a sign of increased body temperature is very high and signs of infection in the RES as upper right abdominal pain, splenomegaly and hepatomegaly. In the next week where Focal Intestinal infections occur with signs of body temperature remains high, but the value is lower than the phase of bacteremia and continuous (continuous fever), dirty tongue, the tongue edge hyperemia, decreased peristalsis, impaired digestion and absorption so that it will occurred distension, diarrhea and patients feel uncomfortable, this may occur during intestinal bleeding, perforation and peritonitis with severe abdominal distension sign, decreased peristalsis even disappear, melena, syock and loss of consciousness.

Nursing Management of Post-Operative Colorectal Cancer

Colorectal cancer is a malignant tumor arising in the epithelial tissue of the colon / rectum.

Colorectal tumors are generally adenocarcinomas that develop from adenoma polyp.

Cause of Colorectal Cancer is not known for certain, but there are predisposing factors consisting of:

  • Age over 40 years
  • Family history
  • History of cancer in other parts of the body
  • Benign polyps, colorectal polyps, adenomatous polyps, or adenomas villus
  • Ulcerative colitis is more than 20 years
  • Sedentary Life style, smoking, obesity.
  • Eating habits of high cholesterol / fat and protein (meat) and low in fiber / Refined Carbohydrates that cause changes in faecal flora and the change of bile salts degradation or breakdown products of protein and fat which are carcinogenic.

Post-Operative of Colorectal Cancer
  1. Routine care for the surgical client. Monitor vital signs and intake and output, including gastric and other drainage from the wound drain. Assess bleeding from abdominal and perineal incision, colostomy, or anus. Evaluation of the other wound complications and maintain the integrity of psychology.
  2. Monitor bowel sounds and abdominal distension degrees. Surgical manipulation of the intestinal peristaltic manghentikan, cause ileus. Absence of bowel sounds and passage of flatus indication of the return of peristaltic.
  3. Drugs reduce pain and provide a sense of comfort as checking the position change
  4. Assess respiratory status, prop abdomen with a blanket or pillow to help cough
  5. Assess the position and patency of NGT, linkage suction. When folded hoses, irrigation with sterile saline carefully.
  6. Assess the color, number, and the smell of drainage and colostomy (if any) noted various changes or clot or bleeding bright red.
  7. Avoid mounting rectal temperature, rectal suppository or other procedure might damage the anal suture line, causing bleeding, infection or impaired healing.
  8. Maintain intravenous fluids when they do naso gastric suction
  9. Giving antacid, histamine 2 receptor antagonists and antibiotic therapy is recommended. Depending on the procedure performed. Antibiotic therapy to prevent infection due to contamination of the abdominal cavity with bowel contents.
  10. Encourage ambulation to stimulate peristaltic
  11. Began teaching and discharge planning. Consult with a nutritionist for diet instructions and menus, give reinforcement teaching.

The purpose of post-operative care:
  1. Wound care
  2. Client education and home care considerations
  3. Positive body image
  4. Monitoring and management of complications

Read More :

Anthrax Nursing Diagnosis

Anthrax is an infectious disease caused by Bacillus anthracis. The disease is a zoonosis especially grazing animals such as sheep, goats, and cattle. Humans infected with the disease when endospores enter the body through skin abrasions or wounds, inhalation or contaminated food. Naturally humans can be infected if it comes in contact with anthrax-infected animals or contaminated animal products anthrax germs. Although rare, transmission through insect bites can also occur. Potential spread of spores by aerosol used in warfare and bioterrorism.

Nursing Diagnosis for Anthrax

1. Ineffective Airway Clearance related to airway obstruction
characterized by: audible stridor, dyspnea, cough with purulent sputum, radiological examination looks mediastinal widening, pleural effusion.

2. Ineffective breathing pattern related to decreased lung expansion
characterized by: dyspnea, use of accessory muscles, increased respiration.

3. Acute pain related to the injury of biological agents
characterized by: the client complains of pain, dyspnea, rapid pulse, looked nervous.

4. Impaired swallowing related to mechanical obstruction (oropharyngeal edema)
characterized by: the client indicates difficulty in swallowing, complain of pain when swallowing.

5. Constipation related to decreased motility of the GI tract
characterized by: the client said it was difficult defecation, hypoactive bowel sounds, presence of blood in stools, hard stools.

6. Diarrhea related to an increase in GI motility
characterized by: liquid bowel movements difficult and more than 3 times / day, hyperactive bowel sounds and abdominal pain.

7. Impaired Skin Integrity related to irritant toxin anthrax bacteria
characterized by: The primary skin lesions are not painful and itchy papules, vesicles containing fluid jerni, vesicles give rise eskar central necrosis (necrotic ulcer) surrounded by edema distinctive black and purple vesicles.

8. Hyperthermia related to increased metabolic
characterized by: an increase in body temperature above the normal range (36.5 to 37.5), resipiirasi increased, and red skin.

Nursing Management : Pre-Operative of Colorectal Cancer

Nursing Management of Colorectal Cancer

Client care with bowel surgery:

A. Pre-Operative of Colorectal Cancer

  • Ensure valid signs for the procedure. This is useful for patients and family members to understand the procedures and possible risks and advantages, should alternatives to the preparation procedure. Format signing consent for procedures especially as documentation that the client and the family agreed.
  • Assess the client and family understanding about the procedure, clarification and interpret as needed. Give instructions on what to expect during the postoperative period, covering pain management, hose fitting NGT / IVFD, breathing exercises, reintroduction of oral intake of food and fluids. Clients are well prepared for preoperative usually not anxious and better able to support the post-operative care. Adequate preparation also reduced the need for narcotic analgesics and enhance client recovery.
  • NGT installation. Although the installation is often done in an operating room just for surgery, preoperative NGT can be fitted to throw secretion and gastric emptying.
  • Bowel preparation procedure. Antibiotic should kathartik oral and parenteral and enema / swallow can be given preoperatively to cleanse the colon and reduce the risk of peritoneal contamination by intestinal contents during surgery.

Pre-operative treatment goals:
  1. Relief of pain
  2. Increase activity tolerance
  3. Provide nutritional measures
  4. Maintain fluid and electrolyte balance
  5. Lowers Anxiety
  6. Prevent Infection
  7. Client Pre-operative education
Read More :

Nursing Diagnosis for Uncomplicated Malaria

Uncomplicated Malaria

The classical (but rarely observed) malaria attack lasts 6-10 hours. It consists of
  • a cold stage (sensation of cold, shivering)
  • a hot stage (fever, headaches, vomiting; seizures in young children)
  • and finally a sweating stage (sweats, return to normal temperature, tiredness).
More commonly, the patient presents with a combination of the following symptoms: fever, chills, sweats, headaches, nausea and vomiting, body aches, general malaise.

Nursing Diagnosis for Uncomplicated Malaria

  1. Hyperthermia related to the disease, characterized by a body temperature of clients more than 37.5 degrees Celsius, acral palpable warmth.
  2. Risk for fluid volume deficit related to active fluid output (vomiting, sweating, fever)
  3. Acute pain related to injury biological agent, characterized by a client complains of pain in the head, and pain in the body, the client looks grimace.
  4. Hypothermia related to the disease, characterized by the client looks chills, body temperature below 36.5 degrees Celsius, the client looks sweaty.
  5. Risk for imbalanced Body Temperature related to the disease.
  6. Nausea related to toxin (plasmodium infection in an area that affects the central nervous vomiting), characterized by clients complaining of nausea, anorexia.
  7. Fatigue related to energy imbalance, characterized by the client looks tired, the client looks sleepy.
  8. Risk for infection related to increased exposure to the environment.

Nursing Care Plans: Diagnoses, Interventions, and Outcomes

The bestselling nursing care planning book on the market, Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8th Edition covers the most common medical-surgical nursing diagnoses and clinical problems seen in adults. It includes 217 care plans, each reflecting the latest evidence and best practice guidelines. NEW to this edition are 13 new care plans and two new chapters including care plans that address health promotion and risk factor management along with basic nursing concepts that apply to multiple body systems. Written by expert nursing educators Meg Gulanick and Judith Myers, this reference functions as two books in one, with 147 disorder-specific and health management nursing care plans and 70 nursing diagnosis care plans to use as starting points in creating individualized care plans.

Read More : Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e

  • 217 care plans --- more than in any other nursing care planning book.
  • 70 nursing diagnosis care plans include the most common/important NANDA-I nursing diagnoses, providing the building blocks for you to create your own individualized care plans for your own patients.
  • 147 disorders and health promotion care plans cover virtually every common medical-surgical condition, organized by body system.
  • Prioritized care planning guidance organizes care plans from actual to risk diagnoses, from general to specific interventions, and from independent to collaborative interventions.
  • Nursing diagnosis care plans format includes a definition and explanation of the diagnosis, related factors, defining characteristics, expected outcomes, related NOC outcomes and NIC interventions, ongoing assessment, therapeutic interventions, and education/continuity of care.
  • Disorders care plans format includes synonyms for the disorder (for easier cross referencing), an explanation of the diagnosis, common related factors, defining characteristics, expected outcomes, NOC outcomes and NIC interventions, ongoing assessment, and therapeutic interventions.
  • Icons differentiate independent and collaborative nursing interventions.
  • Student resources on the Evolve companion website include 36 of the book's care plans - 5 nursing diagnosis care plans and 31 disorders care plans.
  • Three NEW nursing diagnosis care plans include Risk for Electrolyte Imbalance, Risk for Unstable Blood Glucose Level, and Risk for Bleeding.
  • Six NEW health promotion/risk factor management care plans include Readiness for Engaging in a Regular Physical Activity Program, Readiness for Enhanced Nutrition, Readiness for Enhanced Sleep, Readiness for Smoking Cessation, Readiness for Managing Stress, and Readiness for Weight Management.
  • Four NEW disorders care plans include Surgical Experience: Preoperative and Postoperative Care, Atrial Fibrillation, Bariatric Surgery, and Gastroenteritis.
  • NEW Health Promotion and Risk Factor Management Care Plans chapter emphasizes the importance of preventive care and teaching for self-management.
  • NEW Basic Nursing Concepts Care Plans chapter focuses on concepts that apply to disorders found in multiple body systems.
  • UPDATED care plans ensure consistency with the latest U.S. National Patient Safety Goals and other evidence-based national treatment guidelines.
  • The latest NANDA-I taxonomy keeps you current with 2012-2014 NANDA-I nursing diagnoses, related factors, and defining characteristics.
  • Enhanced rationales include explanations for nursing interventions to help you better understand what the nurse does and why.

Read More : Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e

NANDA Impaired Swallowing Nursing Diagnosis

NANDA Definition: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function

Defining Characteristics:

Oral phase impairment

  • Lack of tongue action to form bolus; 
  • weak suck resulting in inefficient nippling; 
  • incomplete lip closure; 
  • food pushed out of mouth; 
  • slow bolus formation; 
  • food falls from mouth; 
  • premature entry of bolus; 
  • nasal reflux; 
  • inability to clear oral cavity;
  • long meals with little consumption; 
  • coughing, choking, or gagging before a swallow; 
  • abnormality in oral phase of swallow study; 
  • piecemeal deglutition; 
  • lack of chewing; 
  • pooling in lateral sulci; 
  • sialorrhea or drooling
Pharyngeal phase impairment
  • Altered head positions; 
  • inadequate laryngeal elevation; 
  • food refusal; 
  • unexplained fevers; 
  • delayed swallow; 
  • recurrent pulmonary infections; 
  • gurgly voice quality; 
  • nasal reflux; 
  • choking, coughing, or gagging;
  • multiple swallows; 
  • abnormality in pharyngeal phase by swallowing study
Esophageal phase impairment
  • Heartburn or epigastric pain; 
  • acidic smelling breath; 
  • unexplained irritability surrounding mealtime; 
  • vomitous on pillow; 
  • repetitive swallowing or ruminating; 
  • regurgitation of gastric contents or set burps; 
  • bruxism; 
  • nighttime coughing or awakening; 
  • observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing, or choking); 
  • hyperextension of head, arching during or after meals; 
  • abnormality in esophageal phase by swallow study; 
  • odynophagia; 
  • food refusal or volume limiting; 
  • complaints of "something stuck"; 
  • hematemesis; 
  • vomiting

Related Factors:
  • Congenital deficits; 
  • upper airway anomalies; 
  • failure to thrive; 
  • protein energy malnutrition; 
  • conditions with significant hypotonia; 
  • respiratory disorders; 
  • history of tube feeding; 
  • behavioral feeding problems; 
  • self-injurious behavior; 
  • neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, or facial paralysis); 
  • mechanical obstruction (e.g., edema, tracheotomy tube, or tumor); 
  • congenital heart disease; 
  • cranial nerve involvement; 
  • neurological problems; 
  • upper airway anomalies; 
  • laryngeal abnormalities; 
  • achalasia; 
  • gastroesophageal reflux disease; 
  • acquired anatomic defects; 
  • cerebral palsy;
  • internal or external traumas; tracheal, laryngeal, esophageal defects; 
  • traumatic head injury; 
  • developmental delay; 
  • nasal or nasopharyngeal cavity defects; 
  • oral cavity or oropharynx abnormalities; 
  • premature infants

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Swallowing Status
  • Swallowing Status: Esophageal Phase, Oral Phase, Pharyngeal Phase
Client Outcomes
  • Demonstrates effective swallowing without choking or coughing
  • Remains free from aspiration (e.g., lungs clear, temperature within normal range)
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Aspiration Precautions
  • Swallowing Therapy
Read More :

NANDA Risk for Falls Nursing Diagnosis

NANDA Definition: Increased susceptibility to falling that may cause physical harm

Related Factors: See Risk Factors

Risk Factors:


  • History of falls; 
  • wheelchair use; 
  • (65 years of age; 
  • female (if elderly); 
  • lives alone; 
  • lower limb prosthesis; 
  • use of assistive devices (e.g., walker, cane)
  • Presence of acute illness; 
  • postoperative conditions; 
  • visual difficulties; 
  • hearing difficulties; 
  • arthritis; 
  • orthostatic hypotension; 
  • sleeplessness; 
  • faintness when turning or extending neck; 
  • anemias; 
  • vascular disease; 
  • neoplasms (i.e., fatigue/limited mobility, urgency and/or incontinence, diarrhea, decreased lower extremity strength, posprandial blood sugar changes, foot problems, impaired physical mobility, impaired balance, difficulty with gait, unilateral neglect, proprioceptive deficits, neuropathy)
  • Diminished mental status (e.g., confusion, delerium, dementia, impaired reality testing)
  • Antihypertensive agents; 
  • ACE-inhibitors; 
  • diuretics; 
  • tricyclic antidepressants; 
  • alcohol use; 
  • antianxiety agents; 
  • opiates; 
  • hypnotics or tranquilizers
  • Restraints; 
  • weather conditions (e.g., wet floors/ice); 
  • throw/scatter rugs; 
  • cluttered environment; 
  • unfamiliar, dimly lit room; 
  • no antislip material in bath and/or shower
Children (<2 years of age)
  • Male gender when <1 year of age; 
  • lack of auto restraints; lack of gate on stairs; 
  • lack of window guard; bed located near window; 
  • unattended infant on bed/changing table/sofa; 
  • lack of parental supervision

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Safety Behavior: Fall Prevention
  • Knowledge: Child Safety
Client Outcomes
  • Remains free of falls
  • Changes environment to minimize the incidence of falls
  • Explains methods to prevent injury

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Fall Prevention
  • Dementia Management
  • Safety
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NANDA Urinary Retention Nursing Diagnosis

NANDA Definition: Incomplete emptying of the bladder

Defining Characteristics:

  • Measured urinary residual >150 to 200 ml or 25% of total bladder capacity; 
  • obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying); 
  • irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia); 
  • overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)

Related Factors:
  • Bladder outlet obstruction: benign prostatic hyperplasia, prostate cancer, prostatitis, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication
  • Deficient detrusor contraction strength: sacral level spinal lesions, cauda equina syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Urinary Elimination
  • Urinary Continence
Client Outcomes
  • Completely and regularly eliminates urine from the bladder; measured urinary residual volume is <150 to 200 ml or 25% of total bladder capacity (voided volume plus urinary residual volume) 
  • Correction or relief from obstructive symptoms 
  • Correction or alleviation of irritative symptoms
  • Client is free of upper urinary tract damage (renal function remains sufficient; absence of febrile urinary infections)
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Urinary Catheterization
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NANDA Wandering Nursing Diagnosis

NANDA Definition:
Meandering; aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles

Defining Characteristics:

  • Frequent or continuous movement from place to place, often revisiting the same destinations; 
  • persistent locomotion in search of "missing" or unattainable people or places; 
  • haphazard locomotion; 
  • locomotion in unauthorized or private spaces; 
  • locomotion resulting in unintended leaving of a premise; 
  • long periods of locomotion without an apparent destination; 
  • fretful locomotion or pacing;
  • inability to locate significant landmarks in a familiar setting; 
  • locomotion that cannot be easily dissuaded or redirected; 
  • following behind or shadowing a caregiver's locomotion; 
  • trespassing; 
  • hyperactivity; 
  • scanning, seeking, or searching behaviors; 
  • periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping); 
  • getting lost

Related Factors:
  • Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, and language (primarily expressive) defects; 
  • cortical atrophy; 
  • premorbid behavior (e.g., outgoing, sociable personality); 
  • premorbid dementia; 
  • separation from familiar people and places; 
  • sedation; 
  • emotional state, especially frustration, anxiety, boredom, or depression (agitation); 
  • overstimulating/understimulating social or physical environment; 
  • physiological state or need (e.g., hunger/thirst, pain, urination, constipation); 
  • time of day

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Safety Status: Falls Occurrence
  • Safety Behavior: Fall Prevention
  • Caregiver Home Care Readiness
Client Outcomes
  • Decreased incidence of falls (preferably free of falls)
  • Decreased incidence of elopements
  • Appropriate body weight maintained
  • Caregiver able to explain interventions can use to provide a safe environment for care receiver who displays wandering behavior
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Dementia Management
Read More :
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