Nurses Nanda: April 2012

Nursing Care Plan for Tetralogy of Fallot

Nursing Diagnosis Interventions Tetralogy of Fallot

Tetralogy of Fallot

Definition

Tetralogy of Fallot is a congenital heart disease with cyanosis, a combination of the four main symptoms are:

obstruction of the flow out of the right ventricle (pulmonary stenosis),
ventricular septal defect,
the position of the right of the aorta and
right ventricular hypertrophy together form a tetralogy of Fallot.

Clinical manifestations

cyanosis
dyspnoea
dyspnoea attacks paroksimal (blue anoxia attacks)
delay in growth and development
normal rate of blood vessels
systolic murmur

Assessment - Nursing Care Plan for Tetralogy of Fallot

Data that is commonly found in patients with tetralogy of Fallot are:

thorough cyanosis of mucous membranes or lips, tongue, conjunctiva. Cyanosis also occur at the time of crying, eating, tight, soak in water, can be peripheral or central.
dyspnoea usually accompanies the activity of eating, crying or tension / stress.
weakness, commonly in the legs.
growth and development not in accordance with age.
digital clubbing
headache
epistaxis

Nursing Diagnosis for Tetralogy of Fallot

Risk for Decreased cardiac output related to structural abnormalities of the heart.
Activity Intolerance related to imbalance in the fulfillment of oxygen to the body's needs.
Impaired growth and development related to inadequate oxygenation, tissue nutrisis needs, social isolation.
Risk for infection related to the general conditions is inadequate.

Nursing Care Plan Cholelithiasis Nursing Diagnosis

Nanda Nursing Diagnosis for Cholelithiasis

1. Acute Pain related to:

biological trauma obstruction / spasm tract inflammatory processes, iskhemia / tissue necrosis

characterized by:

Complaints of pain, colik billiary (pain frequency).
Facial expressions as pain, a cautious attitude.
Autonomic responses (changes in blood pressure, pulse).
Focus on self-limited.

2. Risk for Deficient Fluid Volume related to:

Increase in gastric fluid loss: vomiting, gastric distention and hipermolity.
Treatment has the effect of reducing the fluid.
The freezing process

characterized by:

Signs and symptoms of unstable can not be applied to the actual diagnosis.

3. Imbalanced Nutrition Less Than Body Requirements related to:
Risk factors that affect:

Imposed on themselves and given limited food, nausea, vomiting, dyspepsia, pain.
Loss of nutrients, affect digestion due to disturbance / narrowing of the bile duct.

4. Deficient Knowledge: about prognosis and treatment needs related to:

Re asking about information.
Imformasi misinterpretation.
Have not / do not know the source of information.

8 Nursing Diagnosis - Nursing Care Plan for Bladder Cancer

Nursing Care Plan for Bladder Cancer

Symptoms of Bladder Cancer are blood while passing urine, heavy hurt at times of urinating, sensation of urinating but no passage of urine.

During the early stages of the bowel cancer, there may not be any obvious symptoms, however as the Cancer Grows, one can notice blood in stools or rectal bleeding is common. When one notices a change in their normal bowel habits Such as diarrhea, Constipation or frequent visits to the toilet, It could be an indication of something not right.

Also Unexplained loss of weight or appetite and stomach pain can also occur. As the cancer Grows the bleeding in the bowel can lead to anemia Causing breathless and fatigue, as there is not enough oxygen in the body.

Bladder cancer has the which Various types of symptoms are determined by where the cancerous cells have started. The symptoms of bladder cancer can originate from bladder infection / UTI (urinary tract infection) and therefore require tests to find the true cause of the problem.

8 Nursing Diagnosis for Bladder Cancer

1. Anxiety
2. Acute Pain
3. Imbalanced Nutrition Less Than Body Requirements
4. Knowledge deficient
5. Fluid Volume Deficit
6. Risk for infection
7. Risk for Sexual Dysfunction
8. Risk for Impaired Skin Integrity

Anxiety related to Urinary Tract Cancers

Nursing Care Plan for Urinary Tract Cancers - Nursing Diagnosis Anxiety

Anxiety related to crisis situations (cancer), health change, socio-economics, the role and functions, form interaction, preparation of death, separation of the family

characterized by

increased stress,
fatigue,
clumsiness express the role,
feeling dependent,
inadequate ability to help themselves,
sympathetic stimulation.

Goals:

Patients can relieve anxiety
Relax and be able to see himself objectively
Demonstrate effective coping and able to participate in treatment

Interventions:

Determine the patient's experience prior to the illness.
Provide accurate information about prognosis
Give the client an opportunity to express anger, fear, confrontation. Give the information with reasonable emotion and expression of the corresponding
Explain the treatment, the purpose and side effects. Helps patients prepare for treatment
Note the ineffective coping such as lack of social interaction, impotence etc.
Encourage to develop interaction with the support system
Provide a quiet environment and comfortable
Maintain contact with patients, talk and touch with the fair.

1. Nursing Diagnosis for Herniated nucleus pulposus : Acute pain related to nerve compression, muscle spasm

Nursing Interventions for HNP:

Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10
Maintain bed rest, semi-Fowler position with spinal, hip and knee in flexion, supine position
Use logroll (board) during a change of position
Assist patients in the installation of brace / corset
Limit your activity during the acute phase according to the needs
Teach relaxation techniques
Collaboration: analgesics, traction, physiotherapy

2. Nursing Diagnosis: Impaired physical mobility related to pain, muscle spasm, restrictive therapy, and neuromuscular damage

Nursing Interventions:

Give / aids patients to perform passive range of motion exercises and active
Assist patients in ambulation activities progressive
Provide good skin care, massage point pressure after rehap change in position. Check the state of the skin under the brace with the periods of time.
Note the emotional responses / behaviors in immobilizing
Demonstrate the use of auxiliary equipment such as a cane.
Collaboration: analgesic

3. Nursing Diagnosis for HNP: Anxiety related to the ineffectiveness of individual coping

Nursing Interventions:

Assess the patient's anxiety level
Provide accurate information
Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities.
Review of the secondary problems that may hinder the desire to heal and may impede the healing process.
Involve the family.

4. Nursing Diagnosis for Herniated nucleus pulposus: Deficient knowledge related to the lack of information about the condition, prognosis

Nursing Interventions:

Explain the process of disease and prognosis, and restrictions on activities
Provide information about your own body mechanics to stand, lift and use ancillary shoes
Discuss the treatment and its side effects.
Recommend to use the board / mat is strong, a small pillow under the neck a bit flat, sloping bed with knees flexed, avoiding the tummy.
Avoid the use of heaters in a long time
Provide information about signs that need attention such as stab of pain, loss of sensation / ability to walk.

Ineffective Airway Clearance related to Tonlilitis

Nursing Diagnosis : Ineffective Airway Clearance related to Tonlilitis

Ineffective airway clearance related to presence of foreign bodies, excess production secret.

Characteristics:

Dyspnea
Orthopnea
Difficulty speaking
Changes in rhythm and respiratory frequency
Anxiety
Additional breath sounds
Cyanosis
Decreased breath sounds
Ineffective cough
The production of secret / sputum

Goal:

Dyspnoea, orthopnea, cyanosis does not exist
The rhythm and the respiratory frequency, within normal limits
Not nervous
No additional breath sounds.

Ineffective Airway Clearance related to Tonlilitis

Assess / monitor respiratory frequency
Auscultation of breath sounds, record the sound of breath
Note the presence of dyspnea, restlessness, anxiety, respiratory distress, use of auxiliary respiratory muscles.
Assess the patient to a comfortable position, eg: Elevation head of the bed, sitting on the back of the bed.
Do it with a regular oral hygiene.
If need to do suctioning
Oxygenation
Tachypnea can be found at the reception or during the acute infection process.
Airway obstruction may / not manifested adventisius of breath sounds.
Respiratory dysfunction is a variable that depends on the stage of a chronic process than the process leading to acute hospital care.
Bed elevation facilitate respiratory function using gravity
Oral hygiene can prevent the infection persists and can control the spending secret.
help the secret spending on patients who are unable to issue a secret self through an effective form.
Oxygen delivery to help clients meet the need of oxygen that may not be properly fulfilled due to airway obstruction.

6 Nursing Diagnosis for Tonsillitis

Nanda Nursing Diagnosis for Tonsillitis

Tonsillitis is inflammation of the tonsils. Become inflamed tonsils when then enlarge, Produce pain on swallowing, Produce fever, bad breath and can make-the neck lymph glands to Become tender. Patients complain of feeling unwell Often, reduced appetite and painful mouth opening.

Signs and Symptoms of tonsillitis. Patients are usually fever, sore skull, may be seriously ill and was very painful, especially when swallowing and opening the mouth accompanied by trismus (difficulty opening the mouth). When the larynx is affected, the voice will be hoarse. On examination of the pharynx appears hiperemis, swollen tonsils, hiperemis: there is detritus (tonsillitis folibularis), sometimes detritus adjacent to sati (laturasis tonsillitis) or a pseudo membrane. Palatinus anterior arch looks pushed out and pushed past the midline uvula. Sub-mandibular gland swelling and tenderness, especially in children.

Enlarged adenoids can cause mouth breathing, ear discharge, the head is often hot, bronchitis, noisy breathing breathing's baud.

Do a thorough physical examination, and a careful medical history collection to rule out systemic conditions or related conditions. Tonsillar swabs were cultured to determine the presence of bacterial infection. If the adenoid tonsils are infected, it can take lead suppurative otitis media resulting in hearing loss, patients should be given a thorough examination audiometik sensitivity / resistance can be made if necessary.

6 Nursing Diagnosis for Tonsillitis
1. Ineffective Airway Clearance related to obstruction of breath due to foreign bodies; excess production secret.

2. Acute Pain related to swelling of tissues; surgical incision.

3. Imbalanced Nutrition Less Than Body Requirements related to the anorexia; difficulty swallowing.

5. Knowledge deficit related to lack of understanding, pemajaran / recall.

6. Risk for Fluid Volume Deficit related to the risk of bleeding due tondilektomi operative action.

Ineffective Individual Coping related to Headaches

Nursing Diagnosis: Ineffective Individual Coping related to inadequate relaxation, coping methods are not adequate, excess workload.

Definition:
Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and / or inability to use available resources.

Goal : adequate individual coping

Expected outcomes are:

Identify behaviors that are not effective.
Reveals the awareness about the coping skills they have.
Assessing the current situation is accurate.
Demonstrate the necessary lifestyle changes or the right situation.

Nursing Interventions Ineffective Individual Coping related to Headaches

1. Assess physiological capacity.
     Rational: Knowing the extent and identify irregularities and facilitate the body's physiological functions in nursing action.

2. Advises the client to express his feelings.
     Rational: the client will feel relief after revealing all his feelings and become more calm.

3. Provide information about the cause of headaches, calming and expected results.
     Rational: so the client knows the condition and treatment received, and give clients hope and encouragement to recover.

4. Approach the patient with a friendly and attentive, take advantage of activities that can be taught.
     Rational: make the client feel more meaningful and appreciated.

Nursing Intervention for Infection

NANDA: Risk for Infection

Definition:

Circumstances where an individual is susceptible to the pathogenic and opportunistic agents (viruses, fungi, bacteria, protozoa, or other parasites) from external sources, the sources of exogenous and endogenous.

Expected outcomes are:

Individuals will:

Techniques showed a very careful hand washing.
Free of nosocomial infection during the hospitalization
Demonstrate the ability of the risk factors associated with infection and make the proper precautions to prevent infection.

Nursing Intervention for Risk for Infection:

1. Identification of individuals at risk for nosocomial infection

Assessed against the predictor
- Infection (pre-surgical)
- Abdominal or thoracic surgery
- Operating for more than 2 hours
- Procedures genitouranius
- Instrumentation (ventilator, suction, catheter, nebulizer, tracheostomy, invasive monitoring tool)
- Anesthetics
Assess the factors that disrupt
- Age younger than 1 year, or older than 65 years
- Obesity
- The conditions of the underlying disease (COPD, diabetes, cardiovascular disease)
- Drug abuse
- Nutritional Status
- Smokers

2. Reduce the organisms enter the body

Wash hands carefully
Antiseptic techniques
Isolation
Diagnostic or therapeutic procedures that need
Reduction of microorganisms that can be transmitted through the air.

3. Protect the immune-deficient individuals

Instruct individuals to request to all visitors and personnel to wash their hands before approaching the individual.
Limit visitors when possible
Limit of invasive devices (IV, laboratory specimen) to the really need it.
Teach individuals and family members for signs and symptoms of infection.

4. Reduce the individual susceptibility to infection

Encourage and maintain caloric intake and protein in the diet.
Monitor the use or overuse of antimicrobial therapy.
Give antimicrobial therapy was prescribed in 15 minutes of scheduled time
Minimize the length of hospital stay.

5. Observed for clinical manifestations of infection (eg fever, cloudy urine, purulent drainage)

6. Instruct individuals and families to know the causes, risks of infection and transmission power.

7. Report of infectious diseases.

Disturbed Sleeping Patterns related to Pain

Nursing Diagnosis and Interventions : Disturbed Sleeping Patterns related to Pain

Definition: Time-limited disruption of sleep (natural, periodic suspension of consciousness) amount and quality

Sleep is required to provide energy for physical and mental activities. The sleep-wake cycle is complex, consisting of different stages of consciousness: rapid eye movement (REM) sleep, nonrapid eye movement (NREM) sleep, and wakefulness. As persons age the amount of time spent in REM sleep diminishes. The amount of sleep that individuals require varies with age and personal characteristics.

Expected outcomes : Clients can meet the needs rest or sleep.

Nursing Interventions - Disturbed Sleeping Patterns related to Pain :

Independent:

Determine the normal and usual sleeping habits and changes.
Provide a comfortable bed
Create a new bedtime routine that included in the pattern of the old and new environments
Instruct the relaxation measures
Increase the comfort of sleep regimen, such as a warm bath and massage.
Use a bed rail as indicated: lowered bed if possible.
Avoid disturbing when possible, for example, awaken to a drug or therapy.

Collaboration

Give sedatives, hypnotics as indicated

Rational:

Assessing the need and identify appropriate interventions.
Improve sleeping comfort and support of the physiological / psychological
When the new routines contain as many aspects of old habits, stress and anxiety related to reduced
Help induce sleep
Enhance the relaxation effect
Can feel the fear of falling due to changes in the size and height of the bed, place a fence to help change the position
More uninterrupted sleep creates a feeling fresh and probably the patient may not be able to go back to sleep if awakened.
May be given to help the patient sleep or rest.

Nursing Interventions for Testicular Cancer: Imbalanced Nutrition

Nursing Interventions for Testicular Cancer: Imbalanced Nutrition Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements related to hypermetabolic associated with cancer, the consequences of chemotherapy, radiation, surgery (anorexia, gastric irritation, lack of taste, nausea), emotional distress, fatigue, inability to control the pain.

Goal:

Clients showed a stable weight, normal laboratory results and no sign of malnutrition.
Stated understanding of the need for adequate intake.
Participate in the management of diet-related illness.

Nursing Interventions for Testicular Cancer: Imbalanced Nutrition Less Than Body Requirements

Monitor food intake every day, whether eating in accordance with the needs of clients.
Measure weight, triceps size, and weight loss observed.
Assess pale, slow wound healing and parotid gland enlargement.
Encourage clients to consume high-calorie diet with adequate fluid intake. Also recommend that snacks for clients.
Control of environmental factors such as odor or noise. Avoid foods that are too sugary, fatty and spicy.
Create a pleasant dining atmosphere such as dinner with friends or family.
Encourage relaxation techniques, visualization, moderate exercise before eating.
Encourage open communication about the problem of anorexia experienced by the client.

Collaborative:

Observe laboratory studies such as total lymphocytes, serum transferrin and albumin
Give the medication as indicated
Attach a nasogastric tube for enteral feeding in, balanced with infusion.

Rational:

Provide information about the client's nutritional status.
Provide additional information about the client and weight loss.
Showed a very poor state of nutrition clients.
Calories are the energy source.
Prevent nausea and vomiting, distention, dyspepsia which causes a decrease in appetite and reduce harmful stimulus which can increase anxiety.
So that clients feel like being at home alone.
To create a feeling of wanting to eat / arouse your appetite.
In order to overcome together (with a dietician, nurse and the client).
To find / establish the occurrence of nutritional deficiencies as a result of the disease course, treatment and care to the client.
Helps relieve symptoms of the disease, side effects, improving the health status of clients.
Facilitate the intake of food / beverages with maximum results and as needed.

Myasthenia Gravis Definition

Myasthenia Gravis is a neuromuscular transmission disorder affecting the muscles of the body that works under a person's consciousness. Characteristics that appear in the form of excessive weakness and fatigue commonly occur in the muscles of voluntary and it is influenced by cranial nerve function (Brunner and Suddarth 2002).

Myasthenia Gravis is a neuromuscular disorder that affects the transmission of impulses to the voluntary muscles of the body (Sandra M. Neffina 2002).

Myasthenia Gravis Etiology

The cause of this disorder is unknown, but the possibility due to a disruption or destruction of acetylcholine receptors at the neuromuscular junction due to an autoimmune reaction. Damaged muscle contractions cause muscle weakness.

Myasthenia Gravis Clinic Manifestations

Extreme muscle weakness and prone to fatigue
Diplopia (double vision)
Ptosis (eyelid fall)
Dysphonia (voice disorders)
Weakness of the diaphragm and intercostal muscles causing progressive respiratory distress.

Pathophysiology

Basic abnormality in myasthenia gravis is the damage to the transmission of nerve impulses to the muscle cells due to loss of the ability or the loss of post-synaptic membrane of normal receptors at the neuromuscular junction. Research shows a 70-90% decrease in acetylcholine receptors at the neuromuscular junction of each individual. Myasthenia gravis is an autoimmune disease to be considered as being directed against the acetylcholine receptor (ACHR) that damages the neuromuscular transmission.

Nursing Diagnosis for Myasthenia Gravis

1. Ineffective breathing pattern related to respiratory muscle weakness.

2. Impaired physical mobility related to weakness of voluntary muscles.

3. Risk for aspiration related to the weakness of bulbar muscles.

Nursing Care Plan for Cerebral Palsy

Cerebral Palsy

Cerebral Palsy is a condition lasting damage to brain tissue and not progressive, occurring in a young (since birth) and hinder normal brain development, with the clinical picture may change throughout life and showed abnormalities in the attitude and movement, accompanied by neurological abnormalities in the form of spastic paralysis , ganglia disorders, basal, cereblum and mental disorders.

Etiology

Causes can be divided into three parts, namely:

a. prenatal

Infection occurs in the womb, causing abnormalities in the fetus, for example by Lues, toxoplasmosis, rubella and cytomegalic inclusion body disease. The disorder is usually marked movement disorder and mental retardation. Anoxia in the womb, exposed to X-ray radiation and toxicity of pregnancy may cause "cerebral palsy".

b. perinatal

1) anoxia / hypoxia
The cause of the most found in the perinatal period is a brain injury. Disorder that causes anoxia. It is found in the state percentage of abnormal babies, cephalopelvic disproportion, parturition length, placenta previa, placental infection, parturition using the help of certain instruments and born with caesarean sectio.

2) Bleeding brain
Hemorrhage and anoxia can occur together, that it is difficult to distinguish, for example, bleeding around the brain stem, the respiratory center and interrupt blood circulation, resulting in anoxia. Bleeding may occur in the subarachnoid space will cause a blockage of cerebrospinal fluid, causing hydrocephalus. Subdural bleeding, can suppress the cerebral cortex, causing spastic paralysis.

3) Prematurity
Preterm babies have suffered a brain hemorrhage is more likely than term infants, because the blood vessels, enzymes, clotting factors and others are still not perfect.

4) Jaundice
Jaundice in the newborn period can cause lasting damage to brain tissue caused by the entry of bilirubin into the basal ganglia, such as abnormalities in blood group incompatibility.

5) Meningitis purulenta
Purulenta meningitis in infancy when the late or improper treatment will result in residual symptoms of "cerebral palsy"

c. postnatal
Any damage to brain tissue that interferes with the development could cause "cerebral palsy". For example, in trauma capitis, encephalitis and meningitis scarring.

Nursing Diagnosis for Cerebral Palsy. Nursing Care Plan for Cerebral Palsy

a. Risk for injury

b. Impaired physical mobility

c. Growth and development alteration

d. Impaired verbal communication

e. Risk for aspiration

f. Thought processes disturbed

g. Self-Care Deficit

h. Knowledge Deficit

Nursing Diagnosis for Anemia: Impaired Tissue Perfusion

Definition: Decrease in oxygen resulting in damage to tissue maintenance.

Defining characteristics:
1. Cardiopulmonary

Changes in respiratory frequency
The use of additional respiratory muscles
Abnormal blood gas analysis
Dyspnea
Arrhythmias
Chest pain
Chest retraction
Capilary refill more than 3 seconds
Bronchospasm

2. Peripheral

Edema
Changes in skin characteristics
Changes in skin temperature
Bluish
Impaired sensation
Cold extremities
Wound healing is a long

3. Gastrointestinal

Voice intestinal hipoaktif
Nausea
Abdominal distention
Abdominal pain

4. Renal

Changes in blood pressure
Hematuria
Oliguria
Increased BUN and creatinine

5. Cerebral

Abnormal speech
Weakness of the extremities
Changes in mental status
Changes in pupil reaction
Difficulty swallowing
Changes in motor response

Related factors:

Decrease in hemoglobin in the blood

Diagnosis, Goals, Outcomes, Nursing Interventions:

Ineffective tissue perfusion related to decrease in hemoglobin in the blood

NOC 1:
Status of peripheral and cerebral tissue perfusion
Criteria:

Filling capilary refil
The power of peripheral pulse distal
The power of the proximal peripheral pulsation
Symmetry proximal peripheral pulsation
The level of normal sensation
The color of normal skin
The power of muscle function
Integrity of the skin
Warm skin temperature
There was no peripheral edema
There is no pain in the extremities

NOC 2:
Circulation status
Criteria:

Blood pressure was within normal limits
The power of the pulse within normal limits
The average blood pressure within normal limits
Central venous pressure within normal limits
There was no orthostatic hypotension
There is no additional heart sounds
There is no angina
There was no orthostatic hypotension
Analysis of blood within normal limits as
Difference in arterial and venous oxygen levels are normal
No additional breath sounds
The power of peripheral pulse
No widening of the veins
There was no peripheral edema

NIC:

1. Circulation treatment
activities:

Check the peripheral pulses
Record the color and temperature
Check the refill capilery
Record prosntase edema, especially in the extremities
Do not exceed the elevation of the hands of the heart
Keep the client warm
Monitor fluid status, input and output sesuaiMonitor lab Hb and HMT
Monitor bleeding
Monitor hemodynamic status, neurological and vital signs

2. Monitor vital signs
activities:

Monitor blood pressure, pulse, temperature and respiration
Note the fluctuations in blood pressure
Monitor blood pressure at the time the client lying down, sitting and standing
Measure blood pressure in both arms and compare
Monitor blood pressure, pulse, respiration, before, during and after activity
Monitor heart rate and rhythm
Monitor heart sound
Monitor respiratory rate and rhythm
Monitor lung sounds
Monitor abnormal rhythm of the breath
Monitor temperature, color and moisture
Monitor peripheral cyanosis

3. Monitor neurological status
activities:

Monitor the size, shape, kesmetrisan and pupillary reaction
Monitor level of consciousness
Monitor the level of orientation
Monitor GCS
Monitor vital signs
Monitor patient response to treatment

Nurses Nanda

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