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Nursing Diagnosis related to Fluid and Electrolyte

Fluid and Electrolyte

1. Deficient Fluid volume: less than body requirements related to excessive fluid output.

Intervention:

Observation of vital signs.
Observed signs of dehydration.
Measure the input and output of fluid (fluid balance).
Provide and encourage families to give drink plenty of approximately 2000 - 2500 cc per day.
Collaboration with physicians in the delivery of fluid therapy, electrolyte laboratory examination.
Collaboration with a team of nutrition in low-sodium fluid administration.

2. Risk for Deficient fluid volume related to insufficient fluid intake, excessive discharge (vomiting / nausea).

Intervention:

Record the number of vomiting and bleeding characteristics.
Assess vital signs (BP, pulse, temperature).
Monitor fluid intake and output.
Elevate the head for taking medication.
Give saturated liquid / soft if the input starts again, avoid caffeinated and carbonated beverages.
Maintain bed rest.
Collaboration with fluid administration as indicated.

3. Risk for ineffective airway clearance related to the operative incision site.

Intervention:

Give analgesics as prescribed.
Fixation incision with both hands or a pillow to help patients when they cough.
Encourage the use of Incentive spirometer if there is an indication.
Help and encourage early ambulation.
Help the patient to change positions frequently.

4. Disturbed Body Image related to changes in appearance secondary to loss of body parts.

Intervention:

Encourage the patient to express feelings, especially about the thoughts, feelings, views of self. Rational: Helping patients to be aware of unusual feelings.
Note withdrawing behavior. Increased dependency, manipulation or not involved in treatment. Rational: Alleged problems in assessment can require follow-up evaluation and more rigorous therapy.
Maintain a positive approach during maintenance activities. Rational: Help the patient / person closest to accept changes in their own bodies and feel good about themselves.

Nursing Diagnosis for Urinary / Bowel Elimination : Diarrhea, Constipation

Nanda Nursing Diagnosis for Urinary / Bowel Elimination : Diarrhea, Constipation

1. Alteration in Bowel Elimination : Diarrhea

Intervention:

Help need for defecation (if bed rest to prepare the necessary tools near the bed, attach the curtains and immediately dispose of faeces after defecation).
Increase / maintain fluid intake by mouth.
Teach about the foods and drinks that can worsen / precipitate diarrhea.
Observation and record the frequency of defecation, fecal volume and characteristics.
Observation fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety and lethargy.
Collaboration of appropriate medication therapy program (antibiotics, anticholinergics, corticosteroids).

2. Alteration in Bowel Elimination : Constipation

Intervention:

Encourage lots of drinking with ambulation dinikolab laxative administration.
Rationalization:
Many drinks can help dissolve the stool with ambulation reduce constipation.
Formation of stools soft launch.

3. Alteration in Bowel Elimination: Constipation related to neurological disorders of the intestine and rectum.

Intervention:

Auscultation of bowel sounds, note the location and characteristics. Rational: bowel sounds may be absent during spinal shock.
Observe for abdominal distention.
Note the presence of complaints of nausea and want to vomit, pairs of NGT. Rational: gantrointentinal and gastric bleeding may occur due to trauma and stress.
Provide a balanced diet high in calories and protein; Liquid. Rational: improving stool consistency.
Give laxatives to order. Rational: stimulate the intestines.

4. Altered Urinary Elimination related to the drainage of urine.

Intervention:

Assess urine drainage system immediately.
Assess the adequacy of urine output and drainage system patency.
Use aseptic procedures and washing hands when providing care and action.
Maintain a closed urine drainage system.
If irrigation is needed and prescribed, do this action carefully using sterile saline.
Assist patients in the mobilization.
Observation of color, smell and consistency of urine volume.
Reduce trauma and manipulation of catheters, drainage system and urethra.
Clean the catheter carefully.
Maintain adequate fluid intake.

5. Impaired Urinary Elimination

Intervention:

Observation of the bladder.
Encourage regular bowel movements.
Give warm compresses.
Rationalization:
The content of urinary maintain contractions or uterine involution.
Urine retained causes infection.
Relaxation springter urine.

6. Altered Urinary Elimination related to paralysis of the urinary condition.

Intervention:

Assess the pattern of urination, and record urine output per hour.
Rationale: determine kidney function.
Palpation of the possibility of bladder distension.
Instruct the patient to drink a 2000 cc / day.
Rationale: helps maintain kidney function.
Attach the catheter Dower.
Rational assist the process of urine.

7. Constipation
Intervention:

Observation bowel sounds periodically.
Suggest to increase fluid intake at least 2 liters a day when no contra indications.
Increase activity on a regular basis.
For the provision of appropriate therapy, investigation is needed.
Dietis team collaboration for the provision of a balanced diet and high in fiber.

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.

Read More : http://nandahealth.blogspot.com/2013/09/imbalanced-nutrition-related-to.html

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

Intervention:

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.

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)

Goal:

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

Outcomes:

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

Interventions:

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)

Collaboration:

Give medication as indicated

Rational:

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

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

Goals:

Clean and effective airway after the treatment, the criteria:

No dypsnoe, cyanosis, Ronchi
BGA mormal

Intervention:

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

Rational:

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.
Airway clearance ineffective may be manifested in the presence of breath sounds adventisius.
Semi-Fowler position will make it easier for patients to breathe.
Hydration decrease the viscosity of secretions and facilitate expenditure.
Provision of medicines pengerncer sputum airway facilitate the evacuation process.

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

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

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 Diagnosis Intervention