Nanda Nursing Diagnosis

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

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.

Acne - 5 Nursing Interventions

NCP - Acne Nursing Diagnosis and Interventions

1. Disturbed Body Image related to inflammation.

Interventions:

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.

Interventions:

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.

Interventions:

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.

Interventions:

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.

Interventions:

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 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:

Vertigo sufferers will feel the sensation of movement such as spinning, either himself or the environment.
Nausea incredible.
Frequent vomiting as a result of nausea.
Abnormal eye movements.
Suddenly a cold sweat.
Was ringing in the ears frequently.
Have difficulty talking.
Have difficulty walking due to feel the sensation of spinning motion.
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.

Source : http://nursing-diagnosis-intervention.blogspot.com/2013/08/10-causes-of-pressure-sores.html

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

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

Outcomes:
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.

Rational:
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

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

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.