Assessment in patients with CHF

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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)

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

Acute Pain - Chronic Pain Nursing Diagnosis

There are many things that can cause a person pain and different people have different tolerances for types of pain. Someone with a low tolerance may find many things very painful. Someone with a higher tolerance may be able to withstand these things.

There is the pain of a headache and there are many kinds of headaches that produce vaious degrees and quality of pain. There is organ pain when something is wrong inside and muscle pain when they are pushed beyond the norm either by exercise or emergency. Pain can be mild and a mere annoyance, or brutal and debilitating.

Acute pain is a pain that is recent, a sudden onset of pain, something that has been caused by an accident, a fall, an injury, or something of that nature. Acute pain is usually quite strong and ranges from a sharp nerve pain or shooting pain, to a very strong ache. It can be made worse by certain movements and may restrict you from doing things.

These are some of the obvious things that cause instant pain but sometimes acute pain seems to appear out of nowhere. For example, the sudden onset of lower back pain or neck spasms.

Generally the majority of acute pain conditions are caused by muscle spasms. Sure they may feel like they are incredibly painful because when muscles spasm they can also entrap and irritate nerves. Acute pain conditions are generally easy to treat and do not leave any residual problems. Massage therapy is the treatment used to alleviate muscular problems. Remedial massage acts by stimulating the muscles that are in spasm so they release. By stimulating the right muscles the body will then correct itself, releasing the muscle spasms and bringing your body back to normal.

Nursing Diagnosis for Pain – Acute

Acute Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

Nursing Diagnosis for Pain – Chronic

Chronic Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.
Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult.

Nursing Diagnosisi Nursing Care Plan for Pain

Acute Pain - Pyelonephritis Nursing Care Plan

Acute pyelonephritis is a potentially organ- and/or life-threatening infection that characteristically causes scarring of the kidney. An episode of acute pyelonephritis may lead to significant renal damage; kidney failure; abscess formation (eg, nephric, perinephric); sepsis; or sepsis syndrome, septic shock, and multiorgan system failure.

Acute pyelonephritis is complex, and there is no consistent set of signs and symptoms that is both sensitive and specific for the diagnosis. Therefore, clinicians must maintain a high index of suspicion.

In contrast to the plethora of data available for the treatment of cystitis, less substantial data are available regarding the appropriate antibiotic choice or duration of therapy for acute pyelonephritis. An additional cause for concern is the growing resistance of uropathogens to standard agents. Nevertheless, useful recommendations can be made. (emedicine)

Nursing Care Plan for Pyelonephritis

Nursing Diagnosis for Pyelonephritis : Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

Evaluation criteria: no pain when urinating, no pain on percussion of the pelvis.

Nursing Interventions and Rational for Pyelonephritis

Independent

1. Monitor urine output to changes in color, odor and voiding pattern, input and output every 8 hours and monitor the results of repeated urinalysis.
Rational: To identify indications of progress or deviations from expected results.

2. Record the location, duration, intensity scale (1-10) the spread of pain.
Rational: To help evaluate the obstroksi and cause pain.

3. Provide comfort measures, such as back massage, environment, rest, sleep.
Rational: Increase relaxation, reduce muscle tension.

4. Help or encourage the use of focused relaxation breathing.
Rational: Helps to redirect attention and for muscle relaxation.

5. Give perianal care.
Rational: To prevent contamination of the urethra.

6. If mounted catheter, catheter care provided 2 times per day.
Rational: The catheter provides a way for bacteria to enter the bladder and up into the urinary tract.

Collaboration

1. Consul doctor if: previous urine yellow, ivory, yellow urine, dark orange, hazy or cloudy. Micturition pattern changes, frequent urination in small amounts, feeling the urge to urinate. Persistent pain or increasing pain.
Rational: These findings could signal further tissue damage and needs extensive examination.

2. Give analgesics as needed and evaluate its success.
Rational: Analgesic block the path of pain, thereby reducing pain.

3. Giving antibiotics. Create a variety of drink preparations, including fresh water. Provision of water to 2400 ml / day.
Rational: As a result of urine output makes it easy to urinate often and help flush urinary tract.

Source : http://careplannursing.blogspot.com/2012/01/acute-pain-nursing-care-plan-for_31.html

Uterine Fibroids - Nursing Interventions Acute Pain

A uterine fibroid is a leiomyoma (benign (non-cancerous) tumor from smooth muscle tissue) that originates from the smooth muscle layer (myometrium) of the uterus. Fibroids are often multiple and if the uterus contains too many leiomyomata to count, it is referred to as diffuse uterine leiomyomatosis. The malignant version of a fibroid is extremely uncommon and termed a leiomyosarcoma.

Other common names are uterine leiomyoma,myoma, fibromyoma, fibroleiomyoma.

Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. While most fibroids are asymptomatic, they can grow and cause heavy and painful menstruation, painful sexual intercourse, and urinary frequency and urgency. Some fibroids may interfere with pregnancy although this appears to be very rare. (wikipedia)

Nursing Diagnosis Acute Pain related to inflammation due to the addition of mass in the uterus

Objectives:

Pain can be reduced or lost

Expected outcomes are:

Pain scale (1-10) = 1-3.
Respiration = 16-24 beats / minute.
Pulse = 60 -100 beats / min.
Expression showed no signs of pain and seemed to relax.

Nursing Interventions Acute Pain related to Uterine Fibroids

1. Observation of a pain scale (1-10)

Rational: Observation of a pain scale is necessary for us to know the level of pain experienced by the client so that we can provide appropriate interventions for clients.

2. Find the area, location, and intensity of pain

Rational: To determine the location of pain, pain in the abdomen may indicate the likelihood of complications

3. Give a sitting position while hugging a pillow or a position in the sense of comfort by the client

Rational: It can provide comfort to the client.

4. Give instruction in relaxation techniques and deep breathing techniques

Rational: relaxation and deep breathing techniques to increase comfort and reduce the level of pain experienced by the client

5. Encourage clients to use a warm compress

Rational: Warm compresses can increase vasodilation of blood vessels at the site of pain so that pain can be reduced.

6. Collaboration in the delivery of analgesics and antiemetics, as indicated when necessary.

Rational: The provision of analgesia is necessary if the client is a pain scale of 7-10, this analgesic increase relaxation, decrease attention to pain, and control the adverse action.

7. Provide information about the use of analgesics that are prescribed or not prescribed

Rational: The specific instructions about the use of drugs, increasing awareness of safe use and side effects.

8. Evaluation of vital signs.

Rational: To determine the condition of clients after the intervention so that it can be done to determine further action.

Source : http://careplannursing.blogspot.com/2012/02/nursing-interventions-acute-pain.html

Fatigue Nursing Interventions - Activity Intolerance

Activity intolerance related to fatigue

Definition: Insufficient physiological or psychological energy to continue or complete the requested activity or daily activities.

Defining characteristics:

Verbal report of fatigue or weakness.
Abnormal response of blood pressure or pulse of activity
ECG changes indicating ischemia or arrhythmia
Presence of dyspnea or discomfort on exertion.

Related factors:

Bed rest or immobilization Baring
Overall weakness
Imbalance between oxygen suplei needs
Lifestyle is maintained.

NOC:

Energy conservation
Self Care: ADLs

Expected Result:
Participate in physical activity without an accompanying increase in blood pressure, pulse and respiration
Able to perform daily activities (ADLs) independently

NIC:

Energy Management

Observation of client restrictions in activities
Encourage the child to express feelings of limitations
Assess the factors that cause fatigue
Monitor nutrition and adequate sources of energy
Monitor the patient's physical and emotional exhaustion are excessive
Monitor cardiovascular response to activity
Monitor sleep patterns and duration of sleep / rest patients

Activity Therapy

Collaborate with the Medical Rehabilitation Workers dalammerencanakan progran appropriate therapy.
Help clients to identify activities that can be done
Helps to choose activities consistent with the ability yangsesuai physical, psychological and social
Helps to identify and obtain resources needed for the desired activity
Mendpatkan auxiliary aids for activities such as wheelchairs, crick
Bantu untu identify a preferred activity
Help clients to exercise their free time schedule
Help the patient / family to identify deficiencies in the activity
Provide positive reinforcement for active move
Help the patient to develop self-motivation and reinforcement
Monitor physical response, EMOI, social and spiritual

Source : http://careplannursing.blogspot.com/2012/03/activity-intolerance-related-to-fatigue.html

Nursing Intervention for Diabetes Mellitus - Deficient Fluid volume

Nursing Intervention - Deficient Fluid volume for Diabetes Mellitus
1.Monitor orthostatic blood pressure changes.
Rational : Hypovolemia may be manifested by hypotension and tachycardia.
2.Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane.
Rational : Indicators of level of dehydration, adequacy of circulating volume.
3.Monitor respiratory pattern like Kussmaul’s respirations and acetone breath.
Rational : Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis.
4. Monitor input and output. Note urine specific gravity.
Rational : Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy.
5. Promote comfortable environment. Cover patient with light sheets.
Rational : Avoids overheating, which could promote further fluid loss.
6. Monitor temperature, skin color and moisture.
Rational : Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration.

6 Nursing Diagnosis - Care Plan for Dengue Fever

6 Nursing Diagnosis for Dengue Fever - Care Plan for Dengue Fever
Dengue haemorrhagic fever (DHF) is a disease caused by dengue virus of a virus belonging to arbovirus and entered into the patient's body through the bite of a mosquito "Aedes aegypty" (Christantie Efendy, 1995).

Dengue haemorrhagic fever (DHF) is a disease found in children and adults with primary symptoms of fever, muscle aches and joint pain accompanied by rash or without a rash. DHF is classified as a type of virus arbo virus and entered into the patient's body through the bite of a mosquito "Aedes aegypty" (female) (Seoparman, 1990).

Signs and Symptoms of Dengue Haemorrhagic Fever (DHF)

High fever for 5-7 days
Nausea, vomiting, no appetite, diarrhea, constipation.
Bleeding, especially bleeding under the skin, ptechie, echymosis, hematoma.
Epistaxis, hematemisis, melena, hematuri.
Sore muscles, joints, abdomen, and heartburn.
Headache.
Swelling around the eyes.
Enlarged liver, spleen, and lymph nodes.
Signs of shock (cyanosis, clammy skin, decreased blood pressure, anxiety, capillary refill of more than two seconds, fast and weak pulse.)

Complication of Dengue Haemorrhagic Fever

The complication of dengue fever include:

Extensive bleeding.
Shock or shock.
Effuse pleural
Impairment of consciousness.

Classification of Dengue Haemorrhagic Fever

a. Degree I:
Fever accompanied by other clinical symptoms or spontaneous bleeding, positive tourniquet test, thrombocytopenia and Hemo concentration.

b. Degree II:
Clinical manifestations of degree I with the manifestation of spontaneous bleeding under the skin like petekhie, hematoma and bleeding from other places.

c. Degree III:
Clinical manifestations of degree II, coupled with the circulation system failure was found manifestation in the form of a rapid and weak pulse, hypotension with moist skin, cold and anxious patients.

d. Degree IV:
Clinical manifestations in patients with degree III coupled with a heavy shock was found manifestations with marked tension was measured and no palpable pulse.

Nursing Assessment Nursing Care Plan for Dengue Fever

Review the basic data, the need for bio-psycho-social-spiritual patients from various sources (patients, families, medical records and other health team members).
Identify potential sources and available to meet patient needs.
Review the history of nursing.
Assess the increase in body temperature, signs of bleeding, nausea, vomiting, no appetite, heartburn, sore muscles and joints, signs of shock (rapid and weak pulse, hypotension, cold and moist skin, especially on the extremities, cyanosis , restlessness, decreased consciousness).

6 Nursing Diagnosis for Dengue Fever - Care Plan for Dengue Fever

Hypovolemic shock related to hemorrhage
Imbalanced Nutrition: Less than body requirements related to nausea, vomiting, no appetite.
Increased body temperature related to the process of dengue virus infection.
Risk for bleeding related to thrombocytopenia.
Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting and fever.
Deficient Knowledge: about the disease process related to a lack of information.

Nursing Intervention and Rational for Asthma

Nursing Intervention and Rational for Asthma

a. Auscultation of breath sounds, record the presence of breath sounds, such as: wheezing, ronkhi.

Rationale: Some degree of bronchial spasms occur with airway obstruction. Faint breath sounds with expiratory wheezing (empysema), there is no breathing function (severe asthma).

b. Review / monitor the frequency of recorded respiratory inspiration and expiration ratio.

Rational: Tachypnea is usually present in some degree and can be found at the reception during strest / presence of acute infectious process. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.

c. Assess the patient to a safe position, such as: elevation head is not sitting on the backrest.

Rational: Elevation head is not easier for respiratory function by using gravity.

d. Observation of the characteristic cough, persistent, hacking cough, wet. Auxiliary measures to improve the effectiveness of cough effort.

Rational: cough may persist but are not effective, especially on elderly clients, acute pain / weakness.

e. Give warm water.

Rational: the use of warm fluids can decrease bronchial spasms.

f. Collaboration drugs as indicated.

Spiriva bronchodilator 1 × 1 (inhalation).

Rational: Freeing spasm of the airway, wheezing and mucus production.

http://blog-nursingcareplan.blogspot.com/2011/06/nursing-care-plan-for-asthma.html

Nursing Care Plan for COPD

Anemia

Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status.

The word anemia is taken from a Greek word meaning lack of blood as hemoglobin deficiency prevails in the blood. Hemoglobin present inside the red blood cells normally carries oxygen from lungs to the tissues and anemia causes hypoxia in organs.

Anemia can be mild, moderate, or severe, and this condition can be caused by many different factors. In this condition your body does not have an adequate number of red blood cells present, and if the condition is severe it can lead to serious complications or even be fatal in some cases.

Anemia signs and symptoms are:
1. Paleness
2. Headache
3. Irritability

Symptoms of more severe iron deficiency anaemia include:
1. Dyspnea
2. Rapid heartbeat
3. Brittle hair and nails

Nursing Diagnosis for Anemia

1. Ineffective Tissue Perfusion related to decrease in the cellular components required for the delivery of oxygen / nutrients to the cells.

2. Fatigue related to an imbalance between oxygen supply (delivery) and demand.

3. Risk for infection related to inadequate secondary defenses.

4. Anxiety related to change in health status.

http://blog-nursingcareplan.blogspot.com/2011/04/nursing-care-plan-for-anemia.html

Nursing Diagnosis Intervention