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

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Assessment in patients with CHF

Congestive heart failure (CHF) is generally classified as systolic or diastolic heart failure and becomes progressively more common with increasing age.

Systolic heart failure: The pumping action of the heart is reduced or weakened. A common clinical measurement is the ejection fraction (EF). The ejection fraction is a calculation of how much blood is ejected out of the left ventricle (stroke volume), divided by the maximum volume remaining in the left ventricle at the end of diastole or relaxation phase. A normal ejection fraction is greater than 50%. Systolic heart failure has a decreased ejection fraction of less than 50%.

Diastolic heart failure: The heart can contract normally but is stiff, or less compliant, when it is relaxing and filling with blood. This impedes blood filling into the heart and produces backup into the lungs and CHF symptoms. Diastolic heart failure is more common in patients older than 75 years, especially in women with high blood pressure. In diastolic heart failure, the ejection fraction is normal.

Heart failure affects 1% of people aged 50 years, about 5% of those aged 75 years or older, and 25% of those aged 85 years or older.
Heart failure is the most common reason for Medicare patients to be admitted to the hospital.
As the number of elderly people continues to rise, the number of people diagnosed with this condition will continue to increase.


Nursing Assessment for Congestive Heart Failure (CHF)

1. Activity / rest
Symptoms: Fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
Signs: Restlessness, changes in mental status such as: lethargy, changes in vital signs of activity.

2. Circulation
Symptoms: history of hypertension, new myocardial infarction / acute, previous episodes of congestive heart failure, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
Signs: blood pressure may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia,

3. Ego integrity
Symptoms: Anxiety, worry and fear. Stress related to illness / financial keperihatinan (work / cost of medical care)
Signs: A variety of behavioral manifestations, such as: anxiety, anger, fear and irritability.

4. Elimination
Symptoms: Decreased urination, dark colored urine, nighttime urination (nocturia), diarrhea / constipation.

5. Food / fluid
Symptoms: Loss of appetite, nausea / vomiting, significant weight gain, swelling of the lower extremities, clothes / shoes felt tight, high-salt diet / food that has been processed and the use of diuretics.
Signs: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, stress and pitting).

6. Hygiene
Symptoms: Fatigue / weakness, fatigue during Self-care activities.
Signs: Appearances indicate neglect of personal care.

7. Neuro Sensory
Symptoms: weakness, dizziness, fainting episodes.
Symptoms: Lethargy, tangled thought, oriented, behavior changes and irritability.

8. Pain / Leisure
Symptoms: Chest pain, acute or chronic angina, right upper abdominal pain and muscle pain.
Signs: No quiet, restless, the focus narrows danperilaku protect themselves.

9. Breathing
Symptoms: Dyspnea on exertion, while sitting or sleeping with several pillows, cough with / without the formation of sputum, history of chronic disease, use of rescue breathing.
Signs: Respiratory: tachypnea, shallow breathing, use of accessory respiratory muscles. Cough: Dry / loud / non-productive or persistent cough may be with / without pemebentukan sputum. Sputum; Perhaps blood Flushed, pink / frothy (pulmonary edema). Breath sounds; may not be heard. Mental function; may decrease, anxiety, lethargy. Skin color; Pallor and cyanosis.

10. Security
Symptoms: Changes in mental function, kehilangankekuatan / muscle tone, skin abrasions.

11. Social interaction
Symptoms: Decreased participation in social activities are wont to do.

12. Learning / teaching
Symptoms: use / forgot to use cardiac drugs, such as: calcium channel blockers.
Signs: Evidence of the lack of success to improve.

Nursing Assessment Nursing Care Plan for Congestive Heart Failure (CHF)

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Asthma Nursing Assessment

Nursing Assessment for Asthma

Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm.

Symptoms include wheezing, coughing, chest tightness, and shortness of breath.

Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate. Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic).


Nursing Assessment for Asthma


Assessment of nursing in asthma patients, as follows:

Past medical history:

Assess personal or family history of previous lung disease.
Assess history of allergic reaction or sensitivity to the substances / environmental factors.
 Assess patient's employment history.

Activities:

The inability to perform activities because of difficulty breathing.
The decline in the ability / improvement needs help doing daily activities.
Sleep in a sitting position higher.

Respiratory:

Dipsnea at rest or in response to activity or exercise.
Breath worsened when the patient lay supine in bed.
Using the breathing aids drug, for example: raising the shoulders, widen the nose.
The existence of wheezing breath sounds.
The recurrent coughing.

Circulation:

There is an increasing blood pressure.
There is an increasing frequency of heart.
The color of skin or mucous membranes normal / gray / cyanosis.
Flushing or sweating.

Integrity ego:

Anxiety
Fear
Sensitive stimulation
Fidget


Nutrient intake:

Inability to eat due to respiratory distress.
Weight loss due to anorexia.


Social relations:

The limited physical mobility.
Hard talk
The existence of dependence on others.

Sexuality:

Decrease in libido

Source : http://nursing-assessment.blogspot.com/2011/06/nursing-assessment-for-asthma.html

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