Nursing Diagnosis and Nursing Intervention

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

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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
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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
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