How the influence of music for babies in the womb? Many experts give conflicting opinion or controversy about the influence of music for babies in the womb. There are studies showing that the fetus can react to the sound or the voice to move.
But other experts argue that no one knows for sure what is the meaning of the movement of the baby while listening to music; whether the baby should feel pleased or annoyed, because experts can not examine unborn babies, as easy as the baby is born. And other experts state that there is no direct research evidence that music can make your baby more resourceful and creative. And there are many opinions about the controversy mutual influence of music for babies in the womb.
There is a study that found that music helps better growth in premature infants, in which the quiet songs played in premature infants for 40 minutes every day, and the day-to-4 examination premature infants, who played music gaining weight, heartbeats become more powerful than those not listening to music. After assessing the many conflicts of opinion of several experts on the influence of music and the baby in the womb, whether music gives pleasure or disturb the fetus in the womb, then there remains the decision on your own whether making music for your baby or not.
And in fact we all know that music can provide a sense of calm and relaxed on someone so well, music can help pregnant women to be more relaxed, calm and will indirectly have a positive impact for the baby in the womb.
One type of music is recommended for listening to classical music such as "Mozart", because the music can give you peace and express no opinion classical music increases brain wave activity that can help build networks with better brain synapses. Listen to music on a regular basis so as not to over-stimulate your baby, as well as a voice that was not too hard because it will be painful and shocking your baby. Do not worry because your amniotic fluid is a conductor or a good conductor of sound. You need to know when you decide to play music on your unborn baby, is because you enjoy it and give peace, relaxed for you, not because you are trying to make a baby in your womb is more clever and creative.
Benefits of Classical Music for Mother and Baby's Brain
Classic song turned out to have a positive influence on the growth of the fetus in the womb of a mother. Classical music can stimulate the fetus in the womb. Regular and continuous stimulation will stimulate children's intelligence. Music can stimulate the right brain intelligence, brain right brain is associated with creativity, art, style, socialization and personality. A scientist from Europe and the United States found that classical music can give auditory stimuli that are good for the fetus, the fetus is helpful to education.
The study found that during the baby listening to the music of Mozart and Bach, could expand the volume of the brain, increase the main activities of the nerves, helping the abstract imagination of normal growth in children.
Research shows, conduct periodic sound stimuli to the fetus, eg soft light classical music and gently whisper parents and others, can promote the growth of the fetus and sensory nerve skin layer of the brain stem central flavorings, laid the foundation for the development of wisdom. Otherwise under modern music and sound stimuli bustle, the fetus can feel uneasy and worried, accelerated heart rate, shaking the content stronger.
As for women who are pregnant, classic songs can be freed from the stress of pregnancy. Emotional condition of a pregnant woman greatly influenced the development of the fetus.
Nursing Care Plan for Elderly with (Acute / Chronic) Gastritis
Gastritis is a common disease in the community, but once the disease is often underestimated and overlooked by the sufferer. In fact, gastritis disease can not be underestimated. Gastritis is a digestive disease of the stomach are caused by excessive stomach acid production. This resulted imflamasi or inflammation of the gastric mucosa. Sufferers feel will feel sore stomach and heartburn in the area around the solar plexus. If this is allowed and ignored protracted it will lead to erosion of the gastric mucosa. In some cases, gastritis can lead to ulcers in the stomach and an increase in stomach cancer.
Gastritis (dyspepsia / heartburn) is a disease caused by excess stomach acid or stomach acid resulting in increased inflammation of the gastric mucosa such as cut, or pain in the gut. Symptoms occurred, ie, the stomach was sore and heartburn. Mechanisms of gastric damage caused by an imbalance of digestive factors such as gastric acid and pepsin to the production of mucus bicarbonate blood flow.
There are two types of gastritis are:
Acute Gastritis
Acute Gatritis (inflammation of the gastric mucosa) is most often caused by faulty diet, eg. eating too much, too fast, eating too much food seasoning, or infected food. Other causes include alcohol, aspirin, bile reflux or radiation therapy. Gastritis can also be the first sign of acute systemic infection. Form a more severe acute gastritis caused by strong acid or alkali which can lead to gangrene or perforation of the mucosa.
Chronic Gastritis
Prolonged gastric inflammation caused by benign and malignant gastric ulcers or bacteria Helicobacter pylori. These bacteria colonize the place with the concentrated gastric acid. Chronic gastritis is classified as type A or type B. Type A disease associated with autoimunmis, pernicious anemia. Type A occurs in gastric fundus or corpus. Type B (H. pylori) on the antrum and pylorus. Associated with H. pylori. dietary factors like-iminum heat, seasoning, use of drugs, alcohol, smoking, or refluksisi intestine into the stomach.
Etiology
Clinical Manifestations
Acute Gastritis
Chronic Gastritis
Treatment
Treatment of gastritis in general is to eliminate the main factor etiology, gastric diet with small portions and often, as well as drugs. However, the specifics can be distinguished as follows:
Acute Gastritis
Chronic Gastritis
Gastritis (dyspepsia / heartburn) is a disease caused by excess stomach acid or stomach acid resulting in increased inflammation of the gastric mucosa such as cut, or pain in the gut. Symptoms occurred, ie, the stomach was sore and heartburn. Mechanisms of gastric damage caused by an imbalance of digestive factors such as gastric acid and pepsin to the production of mucus bicarbonate blood flow.
There are two types of gastritis are:
Acute Gastritis
Acute Gatritis (inflammation of the gastric mucosa) is most often caused by faulty diet, eg. eating too much, too fast, eating too much food seasoning, or infected food. Other causes include alcohol, aspirin, bile reflux or radiation therapy. Gastritis can also be the first sign of acute systemic infection. Form a more severe acute gastritis caused by strong acid or alkali which can lead to gangrene or perforation of the mucosa.
Chronic Gastritis
Prolonged gastric inflammation caused by benign and malignant gastric ulcers or bacteria Helicobacter pylori. These bacteria colonize the place with the concentrated gastric acid. Chronic gastritis is classified as type A or type B. Type A disease associated with autoimunmis, pernicious anemia. Type A occurs in gastric fundus or corpus. Type B (H. pylori) on the antrum and pylorus. Associated with H. pylori. dietary factors like-iminum heat, seasoning, use of drugs, alcohol, smoking, or refluksisi intestine into the stomach.
Etiology
- Gastritis is an inflammation of the gastric mucosa.
- Acute erosive gastritis: irritants that can heal itself caused by irritants (eg, NSAIDs, alcohol), severe physiological stress (eg, major surgery, burns, ventilator), or local trauma (eg NG tube).
- A type of chronic gastritis: inflammation of the proximal stomach as a result of pernicious anemia, atrophic gastritis, aclorhidria, autoimmune disorders, or radiation.
- Type B chronic gastritis: inflammation of the distal stomach or antrum as a result of Helicobacter pylori infection.
- Reflux gastritis: inflammation as a result of the bile and pancreatic lymph in the secondary hull as a result there is no pyloric or pyloric are nonfunctional (eg after partial gastrectomy).
- Hemorrhagic gastritis: gastritis with significant inflammation as a reaction to severe stress (eg ICU patients, hypoxia, ischemia, uremia).
Clinical Manifestations
- Epigastric pain or burning in bad taste that gain weight by eating.
- Dyspepsia
- Anorexia
- Nausea / vomiting
- Bleeding can occur resulting in hematemesis, melena.
Acute Gastritis
- Superficial ulceration may occur and lead to hemorrhage.
- Discomfort in the abdomen with headache, lethargy, nausea, and anorexia. Possible vomiting and hiccups.
- Some patients showed asymptomatic.
- Colic and diarrhea can occur if foods that irritate not vomited but instead reaches the intestine.
- Patients usually recover about a day, although the appetite may be lost for 2 to 3 days.
Chronic Gastritis
- Gastritis type A: essentially asymptomatic except for the symptoms of vitamin B12 deficiency.
- Gastritis type B: patients complain of anorexia, heartburn after eating, belching, a sour taste in the mouth or nausea and vomiting.
Treatment
Treatment of gastritis in general is to eliminate the main factor etiology, gastric diet with small portions and often, as well as drugs. However, the specifics can be distinguished as follows:
Acute Gastritis
- Reduce drinking alcohol and eating regular and healthy until the symptoms disappear; transformed into a diet that does not irritate.
- If symptoms persist, IV fluids may be required.
- If gastritis caused by ingesting strong acidic or alkaline, dilute and neutralize the acid with common antacids, such as aluminum hydroxide, H2 receptor antagonists, proton pump inhibitors, anticholinergics and sucralfate.
- If gastritis caused by ingesting a strong base, use citrus juice or vinegar diluted in dilute.
- If severe corrosion, avoid emetic and rinse the stomach because of the danger of perforation.
- Antacids: Antacids are drugs that can be liquid or tablet form and is a common drug used to treat mild gastritis. Antacids neutralize stomach acid and can relieve pain caused by stomach acid quickly.
- Acid inhibitors: When antacids are no longer able to cope with the pain, the doctor may recommend medications.
Chronic Gastritis
- Diet modification, stress reduction, and pharmacotherapy.
- Cytoprotective agents: Drugs of this class helps to protect the tissues that line the stomach and small intestine.
- Proton pump inhibitors: A more effective way to reduce stomach acid is to close the "pumps" within acid-producing cells of the stomach acid. Proton pump inhibitors reduce acid by covering the work of the "pumps" it.
- H. pylori may be treated with antibiotics. There are several regimens in overcoming the infection of H. pylori. The most commonly used is a combination of antibiotics and proton pump inhibitors. Sometimes also added bismuth subsalycilate. Antibiotics used to kill bacteria, proton pump inhibitor works to relieve pain, nausea, heals inflammation and improve the effectiveness of antibiotics. Treatment of infection of H. pylori is not always successful, the speed to kill H. pylori is extremely diverse, depending on the regimen used. However, a combination of three drugs seem more effective than a combination of two drugs. Therapy in the long term (for 2 weeks of therapy compared with 10 days) also seem to increase effectiveness. To ensure H. pylori is gone, it can be re-examined after the treatment carried out. Respiratory examination and stool examination were two types of checks are often used to ensure the absence of H. pylori. Blood tests will show positive results for several months or even more despite the fact that the bacteria is gone.
Some Causes of Nausea After Eating
Nausea after eating can be a sign of disorder (illness) are more serious. Nausea is a condition that refers to feelings of discomfort before throwing up, but it does not always lead to vomiting. Nausea after eating can be caused due to various circumstances, such as eating certain foods, eating contaminated food and also eat too fast, etc.. This can occur both in children and adults.
If nausea persists then you should get to the doctor to find the cause and treatment. Nausea is often associated with some other illnesses that either mild or serious.
Some Causes of Nausea After Eating
1. Content of food
Content of foods can also be the cause, some food that is not suitable for some people and cause digestion is not going well.
2. Diet
Consuming foods with quickly can cause nausea after eating. Heavy and fatty foods also tend to make people nauseous after eating. In some people, nausea can also occur due to eating too often.
3. Food poisoning
Nausea can be caused by food poisoning, food allergies or, in such cases, the patient may also experience headaches, body aches, fever, diarrhea, abdominal pain or cramping and vomiting. Parents and children are very vulnerable experience.
4. GERD (gastroesophageal reflux disease)
gastroesophageal reflux disease (gerd) conditions that can lead to a condition in which the level of stomach acid excesses that cause nausea after eating. Some of these symptoms can be controlled by antacids.
5. Blockage In Small Intestine
A blockage in the small intestine is the most serious cause of feeling nauseous after eating and usually requires immediate medical attention. Because it can cause a buildup of toxins in the bloodstream.
6. Gall Bladder pain
People, who suffer from gallbladder disease, especially in the early stages, may experience nausea after eating. Typically, the initial symptoms appear when the person is eating greasy foods or high fat.
7. Crohn's disease (Erosion In Intestine)
In some individuals, Crohn's disease or bowl disease may be prone to nausea after eating, the more common symptoms of inflammatory conditions including chronic diarrhea and abdominal cramps.
8. Symptoms of pregnancy
In the first half of pregnancy, nausea after eating is very common. You could say one of the signs of pregnancy are nausea after eating.
If nausea persists then you should get to the doctor to find the cause and treatment. Nausea is often associated with some other illnesses that either mild or serious.
Some Causes of Nausea After Eating
1. Content of food
Content of foods can also be the cause, some food that is not suitable for some people and cause digestion is not going well.
2. Diet
Consuming foods with quickly can cause nausea after eating. Heavy and fatty foods also tend to make people nauseous after eating. In some people, nausea can also occur due to eating too often.
3. Food poisoning
Nausea can be caused by food poisoning, food allergies or, in such cases, the patient may also experience headaches, body aches, fever, diarrhea, abdominal pain or cramping and vomiting. Parents and children are very vulnerable experience.
4. GERD (gastroesophageal reflux disease)
gastroesophageal reflux disease (gerd) conditions that can lead to a condition in which the level of stomach acid excesses that cause nausea after eating. Some of these symptoms can be controlled by antacids.
5. Blockage In Small Intestine
A blockage in the small intestine is the most serious cause of feeling nauseous after eating and usually requires immediate medical attention. Because it can cause a buildup of toxins in the bloodstream.
6. Gall Bladder pain
People, who suffer from gallbladder disease, especially in the early stages, may experience nausea after eating. Typically, the initial symptoms appear when the person is eating greasy foods or high fat.
7. Crohn's disease (Erosion In Intestine)
In some individuals, Crohn's disease or bowl disease may be prone to nausea after eating, the more common symptoms of inflammatory conditions including chronic diarrhea and abdominal cramps.
8. Symptoms of pregnancy
In the first half of pregnancy, nausea after eating is very common. You could say one of the signs of pregnancy are nausea after eating.
14 Causes and 6 Treatment of Vomiting
Vomiting is a symptom not a disease. Symptoms of this form of discharge of the contents of the stomach and intestines through the mouth by force or by force. Vomiting is a protective reflex against the body because it can serve accidentally ingested toxins. In addition, an attempt vomiting removing toxins from the body and can reduce the pressure caused by the blockage or enlargement of the organ that puts pressure on the digestive tract. In general, vomiting consists of three phases, namely nausea, retching or vomiting early to maneuver, and regurgitation of gastric contents or expenses, intestine into the mouth.
Note: The cause of frequent (No. 1-2) and rarely causes (no. 3-15)
1. Virus infection and acute gastroenteritis.
The most common cause is a viral infection include acute gastroenteristis usually by viruses, particularly rotavirus. Infectious diarrhea in children is most often caused by rotavirus infection. Diarrhea due to rotavirus infection is often termed diarrhea or vomiting and diarrhea. Symptoms of rotavirus or other viral infections such as mild fever, start vomiting frequently, severe diarrhea, or abdominal pain and. Vomiting and diarrhea are the main symptoms of rotavirus infection and can last for 3-7 days. Rotavirus infection can be accompanied by other symptoms of child loss of appetite, and signs of dehydration. Rotavirus infection can cause mild and severe dehydration, and even death. Rotavirus virus infection is not usually found only complaint followed by vomiting without diarrhea often great.
2. People with allergies and gastrointestinal hypersensitivity.
In children with allergies especially with gastrooesephageal reflux. In these patients, usually complaint vomit or spit up frequently when aged under the age of 6-12 months. After age was gradually reduced, and complaints will improve palaing long after the age of 5-7 years. In general, the age of 3-6 months of vomiting only 2-5 times per day and it improves with age. Attack would be severe disruption vomiting during acute respiratory tract infection or other viral infections. Complaints viral infection usually accompanied by complaints of fever, body warmer, body aches, muscle aches, headache, sore throat, cough or runny nose. Food in patients with food allergy can cause vomiting but only lighter and in a few moments will be reduced. Allergy sufferers with GER is usually accompanied by an allergic skin, nose and respiratory tract.
3. Pyloric stenosis
This is a disorder that occurs in infants be constriction at the end of the hole right food out into the small intestine. As a result of the narrowing, only a small amount of food can get into the intestine, the rest will be spewed out so that the child lost weight. This condition usually causes "projectile vomiting" is very strong and is an indication for urgent surgery.
4. Bowel obstruction (blockage in the gastrointestinal tract)
5. Too much to eat
6. Peritonitis (inflammation of the stomach lining that wraps around the organs of the abdomen and the abdominal cavity limit)
7. Ileus (temporary cessation of normal contractions of the intestinal wall)
8. Cholecystitis (inflammation of the gall bladder), pancreatitis (inflammation of the pancreas), appendicitis, hepatitis (inflammation of the liver)
9 . food poisoning
10 . Sensory systems and the brain
Cause of the sensory systems include motion , motion sickness ( which is caused by overstimulation of the labyrinth ear canals ) , and Ménière's disease ( disorder that affects the inner ear ) . Causes including brain , concussion , brain hemorrhage , migraine , brain tumor , which can cause damage chemoreceptors and benign intracranial hypertension and hydrocephalus .
11 . metabolic disorders
This may interfere with both the stomach and the parts of the brain that coordinate vomiting , hypercalcemia ( high calcium levels ) , uremia ( urea accumulation , usually due to renal failure ) , adrenal insufficiency , hypoglycemia and hyperglycemia .
12 . Hyperemesis ( excessive nausea during pregnancy ) , morning sickness .
13 . drug reactions
Vomiting may occur as an acute somatic response , the effects of alcohol , opioids , selective serotonin reuptake inhibitors . Many chemotherapy drugs and some entheogen ( such as peyote or ayahuasca ) cause vomiting .
14 Diseases caused by norwalk virus , swine flu and other infectious diseases .
Management
1. Giving fluids (drink) to replace the lost fluids and prevent dehydration.
2. Place the child in the prone or inclined (tilted to the left or to the right) to avoid vomit the contents into the airway.
3. Watch for signs of dehydration. Dehydration is a state body hydrated. Dehydration can occur if the child is vomiting continuously. Severe dehydration can be life threatening.
4. Still give fluids. Fluid administration (drinking) is very important to prevent dehydration child. If the child refuses, still persuaded the child to drink. For baby, if you are still breastfeeding, give breast milk. Your doctor may add a liquid electrolyte. If you get baby formula, your doctor may temporarily replace formula with ORS during the first 12-24 hours, or recommend to give the formula 2 times more dilute than the usual formula given.
5. Diet modification. Avoid feeding dense, fibrous and tough and fatty foods because these foods are relatively much longer to digest and can induce vomiting.
6. When excessive vomiting or exceed 5 times a day should be fasted while vomiting while taking medication. After 1 hour of new should sip but often.
Note: The cause of frequent (No. 1-2) and rarely causes (no. 3-15)
1. Virus infection and acute gastroenteritis.
The most common cause is a viral infection include acute gastroenteristis usually by viruses, particularly rotavirus. Infectious diarrhea in children is most often caused by rotavirus infection. Diarrhea due to rotavirus infection is often termed diarrhea or vomiting and diarrhea. Symptoms of rotavirus or other viral infections such as mild fever, start vomiting frequently, severe diarrhea, or abdominal pain and. Vomiting and diarrhea are the main symptoms of rotavirus infection and can last for 3-7 days. Rotavirus infection can be accompanied by other symptoms of child loss of appetite, and signs of dehydration. Rotavirus infection can cause mild and severe dehydration, and even death. Rotavirus virus infection is not usually found only complaint followed by vomiting without diarrhea often great.
2. People with allergies and gastrointestinal hypersensitivity.
In children with allergies especially with gastrooesephageal reflux. In these patients, usually complaint vomit or spit up frequently when aged under the age of 6-12 months. After age was gradually reduced, and complaints will improve palaing long after the age of 5-7 years. In general, the age of 3-6 months of vomiting only 2-5 times per day and it improves with age. Attack would be severe disruption vomiting during acute respiratory tract infection or other viral infections. Complaints viral infection usually accompanied by complaints of fever, body warmer, body aches, muscle aches, headache, sore throat, cough or runny nose. Food in patients with food allergy can cause vomiting but only lighter and in a few moments will be reduced. Allergy sufferers with GER is usually accompanied by an allergic skin, nose and respiratory tract.
3. Pyloric stenosis
This is a disorder that occurs in infants be constriction at the end of the hole right food out into the small intestine. As a result of the narrowing, only a small amount of food can get into the intestine, the rest will be spewed out so that the child lost weight. This condition usually causes "projectile vomiting" is very strong and is an indication for urgent surgery.
4. Bowel obstruction (blockage in the gastrointestinal tract)
5. Too much to eat
6. Peritonitis (inflammation of the stomach lining that wraps around the organs of the abdomen and the abdominal cavity limit)
7. Ileus (temporary cessation of normal contractions of the intestinal wall)
8. Cholecystitis (inflammation of the gall bladder), pancreatitis (inflammation of the pancreas), appendicitis, hepatitis (inflammation of the liver)
9 . food poisoning
10 . Sensory systems and the brain
Cause of the sensory systems include motion , motion sickness ( which is caused by overstimulation of the labyrinth ear canals ) , and Ménière's disease ( disorder that affects the inner ear ) . Causes including brain , concussion , brain hemorrhage , migraine , brain tumor , which can cause damage chemoreceptors and benign intracranial hypertension and hydrocephalus .
11 . metabolic disorders
This may interfere with both the stomach and the parts of the brain that coordinate vomiting , hypercalcemia ( high calcium levels ) , uremia ( urea accumulation , usually due to renal failure ) , adrenal insufficiency , hypoglycemia and hyperglycemia .
12 . Hyperemesis ( excessive nausea during pregnancy ) , morning sickness .
13 . drug reactions
Vomiting may occur as an acute somatic response , the effects of alcohol , opioids , selective serotonin reuptake inhibitors . Many chemotherapy drugs and some entheogen ( such as peyote or ayahuasca ) cause vomiting .
14 Diseases caused by norwalk virus , swine flu and other infectious diseases .
Management
1. Giving fluids (drink) to replace the lost fluids and prevent dehydration.
2. Place the child in the prone or inclined (tilted to the left or to the right) to avoid vomit the contents into the airway.
3. Watch for signs of dehydration. Dehydration is a state body hydrated. Dehydration can occur if the child is vomiting continuously. Severe dehydration can be life threatening.
4. Still give fluids. Fluid administration (drinking) is very important to prevent dehydration child. If the child refuses, still persuaded the child to drink. For baby, if you are still breastfeeding, give breast milk. Your doctor may add a liquid electrolyte. If you get baby formula, your doctor may temporarily replace formula with ORS during the first 12-24 hours, or recommend to give the formula 2 times more dilute than the usual formula given.
5. Diet modification. Avoid feeding dense, fibrous and tough and fatty foods because these foods are relatively much longer to digest and can induce vomiting.
6. When excessive vomiting or exceed 5 times a day should be fasted while vomiting while taking medication. After 1 hour of new should sip but often.
Nursing Diagnosis for Premature Rupture of Membranes
Nursing Care Plan for PROM
Premature rupture of membranes (PROM) is the rupture of the membranes prior to the onset of labour.
Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous premature rupture of the membranes (SPROM) is ROM after or with the onset of labor. Prolonged ROM is any ROM that persists for more than 24 hours and prior to the onset of labor.
Risk factors for PPROM are:
The following are the most common symptoms of PROM. However, each woman may experience symptoms differently.
Symptoms of PROM:
Prevention of premature rupture of membranes:
Unfortunately, there is no way to actively prevent PROM. However, this condition does have a strong link with cigarette smoking and mothers should stop smoking as soon as possible.
Nursing Diagnosis for Premature Rupture of Membranes
1. Risk for Infection: maternal
related to:
2. Impaired gas exchange: fetus
related to: the presence of disease.
3. Acute pain
related to: the rhythmic contraction of uterine smooth muscle.
4. Anxiety
related to:
6. Activity intolerance
related to: muscle hypersensitivity.
Premature rupture of membranes (PROM) is the rupture of the membranes prior to the onset of labour.
Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous premature rupture of the membranes (SPROM) is ROM after or with the onset of labor. Prolonged ROM is any ROM that persists for more than 24 hours and prior to the onset of labor.
Risk factors for PPROM are:
- Smoking. Heavy cigarette smoking increases the risk of PPROM more at early gestational age than at term.]
- Previous preterm delivery.
- Vaginal bleeding (at any time during the pregnancy).
- There is an association between lower genital tract infection and PPROM.
- Around a third of women with PPROM have positive amniotic fluid cultures.
The following are the most common symptoms of PROM. However, each woman may experience symptoms differently.
Symptoms of PROM:
- leaking or a gush of watery fluid from the vagina
- constant wetness in panties
Prevention of premature rupture of membranes:
Unfortunately, there is no way to actively prevent PROM. However, this condition does have a strong link with cigarette smoking and mothers should stop smoking as soon as possible.
Nursing Diagnosis for Premature Rupture of Membranes
1. Risk for Infection: maternal
related to:
- invasive procedures,
- recurrent vaginal examination,
- amniotic membrane rupture.
2. Impaired gas exchange: fetus
related to: the presence of disease.
3. Acute pain
related to: the rhythmic contraction of uterine smooth muscle.
4. Anxiety
related to:
- crisis situation,
- threat to the mother / fetus.
6. Activity intolerance
related to: muscle hypersensitivity.
Geriatric Nursing - Alzheimer's Disease Assessment
Assessment in Alzheimer's disease
1 . Activity / rest
Symptoms : Feeling tired
Signs : Day / night restless , helpless , disruption of sleep patterns
lethargy : decreased interest or concern in usual activities , hobbies , inability restates what is read / follow event television programs .
Motor skills disorder , inability to do normal things that have been done , the movement is very useful .
2 . Circulation
Symptoms: History of cerebral vascular disease / systemic . hypertension , embolic episodes ( a predisposing factor ) .
3 . Ego integrity
Symptoms : Suspicious or fear of the situation / person fantasies , misperceptions about the environment , identification of objects and faults of people , hoarding objects : objects that one believes that placement has been stolen , lost multiple , changes in body image and self-esteem perceived .
Signs : Hiding disability ( many reasons are unable to perform an obligation , it may also open the hand without reading the book yet ) , sit and watch the others , the first activity may accumulate objects are not moving and emotionally stable , repetitive movements ( folded unfolded folded cloth ) , hide stuff , or take a walk .
4 . Elimination
Symptoms : Encouragement urination
Signs : Incontinence of urine / feaces , tend to constipation .
5 . Food / fluid
Symptoms : History of hypoglycemia episodes ( a predisposing factor ) changes in taste , appetite , weight loss , denying the hunger / need to eat .
Symptoms: Loss of ability to chew , avoiding / refusing to eat ( probably trying to hide skill ) . and looking increasingly thin ( advanced stage ) .
6. Hiygene
Symptoms: Need help / dependent people
Signs: not able to maintain the appearance, personal habits are lacking, poor cleaning habits, forgetting to go to the bathroom, forget the steps for waste water, unable to find a bathroom, and less interested in or have forgotten at meal time: dependent on others for over the kitchen to cook and prepare food, eat, use cutlery.
7. Neuro-sensory
Symptoms: The denial of the presenting symptoms, especially cognitive changes, and blurred or picture, hypochondria complaints about fatigue, dizziness or headache sometimes. Complaints in cognitive abilities, decision-making, given the pass, drop behavior (observed by nearby). Loss of sensation of proprioception (body position or a certain part of the body in space), and a history of cerebral vascular disease / systemic embolism or hypoxia that lasted periodically (as a predisposing factor) as well as seizure activity (secondary to the brain damage).
Symptoms: Damage communication: aphasia and dysphasia; difficulty in finding the right words (especially nouns); asked repeatedly or conversations with the substance of the word that has no meaning; fragmented, or speech not audible. Lose the ability to read and write stages (loss of fine motor skills).
8. Comfort
Symptoms: A history of serious head trauma (may be a predisposing factor or acceleration factor), traumatic accidents (falls, burns, and so on).
Sign: ecchymoses, lacerations and hostile / attack others.
9. Social interaction
Symptoms: Feeling lost power. psychosocial factors previously; influence of personal and individual that appears to change patterns of behavior that emerge.
Symptoms: Loss of social control, the behavior was not appropriate.
1 . Activity / rest
Symptoms : Feeling tired
Signs : Day / night restless , helpless , disruption of sleep patterns
lethargy : decreased interest or concern in usual activities , hobbies , inability restates what is read / follow event television programs .
Motor skills disorder , inability to do normal things that have been done , the movement is very useful .
2 . Circulation
Symptoms: History of cerebral vascular disease / systemic . hypertension , embolic episodes ( a predisposing factor ) .
3 . Ego integrity
Symptoms : Suspicious or fear of the situation / person fantasies , misperceptions about the environment , identification of objects and faults of people , hoarding objects : objects that one believes that placement has been stolen , lost multiple , changes in body image and self-esteem perceived .
Signs : Hiding disability ( many reasons are unable to perform an obligation , it may also open the hand without reading the book yet ) , sit and watch the others , the first activity may accumulate objects are not moving and emotionally stable , repetitive movements ( folded unfolded folded cloth ) , hide stuff , or take a walk .
4 . Elimination
Symptoms : Encouragement urination
Signs : Incontinence of urine / feaces , tend to constipation .
5 . Food / fluid
Symptoms : History of hypoglycemia episodes ( a predisposing factor ) changes in taste , appetite , weight loss , denying the hunger / need to eat .
Symptoms: Loss of ability to chew , avoiding / refusing to eat ( probably trying to hide skill ) . and looking increasingly thin ( advanced stage ) .
6. Hiygene
Symptoms: Need help / dependent people
Signs: not able to maintain the appearance, personal habits are lacking, poor cleaning habits, forgetting to go to the bathroom, forget the steps for waste water, unable to find a bathroom, and less interested in or have forgotten at meal time: dependent on others for over the kitchen to cook and prepare food, eat, use cutlery.
7. Neuro-sensory
Symptoms: The denial of the presenting symptoms, especially cognitive changes, and blurred or picture, hypochondria complaints about fatigue, dizziness or headache sometimes. Complaints in cognitive abilities, decision-making, given the pass, drop behavior (observed by nearby). Loss of sensation of proprioception (body position or a certain part of the body in space), and a history of cerebral vascular disease / systemic embolism or hypoxia that lasted periodically (as a predisposing factor) as well as seizure activity (secondary to the brain damage).
Symptoms: Damage communication: aphasia and dysphasia; difficulty in finding the right words (especially nouns); asked repeatedly or conversations with the substance of the word that has no meaning; fragmented, or speech not audible. Lose the ability to read and write stages (loss of fine motor skills).
8. Comfort
Symptoms: A history of serious head trauma (may be a predisposing factor or acceleration factor), traumatic accidents (falls, burns, and so on).
Sign: ecchymoses, lacerations and hostile / attack others.
9. Social interaction
Symptoms: Feeling lost power. psychosocial factors previously; influence of personal and individual that appears to change patterns of behavior that emerge.
Symptoms: Loss of social control, the behavior was not appropriate.
Stages of The Process of Hallucinations
Changes in sensory perception: hallucinations influenced by multifactorial, both external and internal, including: inadequate individual coping, individuals who isolate themselves from the environment, there is trauma which causes low self-esteem, ineffective family coping, and chronic problems are not resolved.
Perception is the identification and interpretation of the stimulus based on information received through the five senses, namely sight, hearing, touch, smell and taste (Stuart & Laraia, 2001) Meanwhile, according Varcarolis (2006) disruption of sensory perception is a perception that there is no stimulus. Perception is the basis of how one feels his experience, every person has a different perception of the same experience.
Hallucinations and illusions is a sensory perception changes that occur in response to maladaptive neurobiology. Hallucinations are defined as disorders that may give rise to the perception of schizophrenia, psychosis, organic brain syndrome, epilepsy, nerosa histrionic, atropine intoxication or amethyst and hallucinogenic substances. Hallucinations are perceptions of the client's environment without a real stimulus, meaning that individuals interpret the real thing without any external stimulus.
Hallucinations consist of 4 stages:
The first is the stage where the client was happy and hallucinations provide a sense of comfort, the client is still in the moderate anxiety, the characteristics of this stage the client is experiencing anxiety, loneliness, guilt and fear is a behavior that is often seen among clients smiling and laughing to himself, moving his lips noiselessly, rapid eye movements, verbal responses were slow, silent and concentrate.
Second. Hallucinations be faulted, the client will be at the level of severe anxiety, and cause resentment. This stage is characterized by sensory experiences and withdraw from others. Clients will exhibit behaviors: the concentration of sensory experience, narrowing attention span, increased heart rate, respiration and blood pressure, and can not distinguish between hallucination and reality.
Third. The client is in severe anxiety, hallucinations client control, and sensory experience can not be denied anymore characteristics. Clients give and receive sensory experience, content becomes active hallucinations, and loneliness ended when the sensory experience. Ditahap client's behavior; client will comply with hallucinations, difficulty relating to others about the attention that only a few seconds per minute and severe anxiety symptoms (sweating, tremor, was not able to follow commands).
Fourth. Hallucinations have mastered the client, and anxiety panic occurs. At this stage has the characteristics: experience sensory hallucinations threatening and may take several hours or days the behavior that emerges is a high risk of panic behavior suicide, murder, agitation, withdrawal, and not able to respond to commands, and more than one complex.
Hallucinations are also influenced by predisposing factors, the first is a biological factor which includes interference / obstacles frontal and temporal brain development; lesions in the frontal cortex, limbic, temporal, growth disorders in prenatal, neonatal and childhood. Psychological factors that helped influence is rejection and violence in the lives of clients. caregiver or friend that cold, anxious not sensitive, or even over-protective; conflict and violence in the family (parents quarrel, mayhem and domestic violence).
Another factor which is a predisposing factor is the state of social culture hallucinations such as poverty, disharmony, social culture (war, riots, insecurity) an isolated life with the stress that builds up. Stress precipitation hallucinations are biological factors involving brain function in regulating the amount of information that can be processed at a function that occurs dilobus waktu.Penurunan frontal process resulted in information overload and neurobiologik maladaptive response. Environmental stresses that have exceeded the threshold of an individual being a reality orientation precipitation occurrence.
The last precipitation factors that trigger the onset of hallucinations is the state of the environment (the difficulties of life / relate to other people, poverty), health (poor nutrition, lack of sleep, infection, central nervous system drugs, moderate to high anxiety), behavioral (low self-esteem , loss of self-confidence).
Maladaptive behaviors that arise include: changes in thought processes such as delusions or delusional disorder is a form of mind (any ideas / beliefs are wrong), a misperception though no stimulus but clients feel it, the inability to experience emotions, disorganized behavior is neurobiological responses that lead to disruption of key functions such as the central nervous system so that there is no coordination between the thoughts, feelings and behavior and the behavior of the latter is maladaptive social isolation inability client relationships, cooperation and interdependence with others.
Perception is the identification and interpretation of the stimulus based on information received through the five senses, namely sight, hearing, touch, smell and taste (Stuart & Laraia, 2001) Meanwhile, according Varcarolis (2006) disruption of sensory perception is a perception that there is no stimulus. Perception is the basis of how one feels his experience, every person has a different perception of the same experience.
Hallucinations and illusions is a sensory perception changes that occur in response to maladaptive neurobiology. Hallucinations are defined as disorders that may give rise to the perception of schizophrenia, psychosis, organic brain syndrome, epilepsy, nerosa histrionic, atropine intoxication or amethyst and hallucinogenic substances. Hallucinations are perceptions of the client's environment without a real stimulus, meaning that individuals interpret the real thing without any external stimulus.
Hallucinations consist of 4 stages:
The first is the stage where the client was happy and hallucinations provide a sense of comfort, the client is still in the moderate anxiety, the characteristics of this stage the client is experiencing anxiety, loneliness, guilt and fear is a behavior that is often seen among clients smiling and laughing to himself, moving his lips noiselessly, rapid eye movements, verbal responses were slow, silent and concentrate.
Second. Hallucinations be faulted, the client will be at the level of severe anxiety, and cause resentment. This stage is characterized by sensory experiences and withdraw from others. Clients will exhibit behaviors: the concentration of sensory experience, narrowing attention span, increased heart rate, respiration and blood pressure, and can not distinguish between hallucination and reality.
Third. The client is in severe anxiety, hallucinations client control, and sensory experience can not be denied anymore characteristics. Clients give and receive sensory experience, content becomes active hallucinations, and loneliness ended when the sensory experience. Ditahap client's behavior; client will comply with hallucinations, difficulty relating to others about the attention that only a few seconds per minute and severe anxiety symptoms (sweating, tremor, was not able to follow commands).
Fourth. Hallucinations have mastered the client, and anxiety panic occurs. At this stage has the characteristics: experience sensory hallucinations threatening and may take several hours or days the behavior that emerges is a high risk of panic behavior suicide, murder, agitation, withdrawal, and not able to respond to commands, and more than one complex.
Hallucinations are also influenced by predisposing factors, the first is a biological factor which includes interference / obstacles frontal and temporal brain development; lesions in the frontal cortex, limbic, temporal, growth disorders in prenatal, neonatal and childhood. Psychological factors that helped influence is rejection and violence in the lives of clients. caregiver or friend that cold, anxious not sensitive, or even over-protective; conflict and violence in the family (parents quarrel, mayhem and domestic violence).
Another factor which is a predisposing factor is the state of social culture hallucinations such as poverty, disharmony, social culture (war, riots, insecurity) an isolated life with the stress that builds up. Stress precipitation hallucinations are biological factors involving brain function in regulating the amount of information that can be processed at a function that occurs dilobus waktu.Penurunan frontal process resulted in information overload and neurobiologik maladaptive response. Environmental stresses that have exceeded the threshold of an individual being a reality orientation precipitation occurrence.
The last precipitation factors that trigger the onset of hallucinations is the state of the environment (the difficulties of life / relate to other people, poverty), health (poor nutrition, lack of sleep, infection, central nervous system drugs, moderate to high anxiety), behavioral (low self-esteem , loss of self-confidence).
Maladaptive behaviors that arise include: changes in thought processes such as delusions or delusional disorder is a form of mind (any ideas / beliefs are wrong), a misperception though no stimulus but clients feel it, the inability to experience emotions, disorganized behavior is neurobiological responses that lead to disruption of key functions such as the central nervous system so that there is no coordination between the thoughts, feelings and behavior and the behavior of the latter is maladaptive social isolation inability client relationships, cooperation and interdependence with others.
Nursing Assessment for Malignant Lymphoma (Signs and Symptoms)
Nursing Assessment for malignant lymphoma by Doenges, (1999) obtained the following data:
1. Activity / rest
2. Circulation
3. Ego integrity
4. Elimination
5. Food / fluid
6. Neuro-sensory
7. Pain / comfort
8. Breathing
9. Security
10. Sexuality
1. Activity / rest
- Symptoms: fatigue, weakness, or general malaise, loss of productivity and decreased exercise tolerance.
- Signs: decreased strength, shoulders slumped, slow road, and other signs that show fatigue.
2. Circulation
- Symptoms: palpitations, angina / chest pain.
- Signs: tachycardia, dysrhythmias, cyanosis face and neck (venous drainage obstruction due to enlarged lymph nodes is a rare occurrence), sclera jaundice and jaundice common in connection with damage to the liver and bile duct obstruction by enlarged lymph nodes, pallor (anemia), diaphoresis, perspiration evening.
3. Ego integrity
- Symptoms: stress factor, fear / anxiety in connection with the diagnosis and possible fear of death, diagnostic tests and treatment modalities (chemotherapy and radiation therapy).
- Signs: various behaviors, such as withdrawing angry, passive.
4. Elimination
- Symptoms: changes in urine and stool characteristics, history of intussusception obstruction, or malabsorption syndrome (infiltration of retro-peritoneal lymph nodes)
- Signs: tenderness in the right upper quadrant on palpation and enlargement (hepatomegaly), tenderness in the left upper quadrant on palpation and enlargement (splenomegaly), decreased urine output, dark urine, anuria (urethral obstruction / renal failure), bowel dysfunction and bladder.
5. Food / fluid
- Symptoms: anorexia / loss of appetite, dysphagia (esophageal pressure) weight loss.
- Signs: swelling of the face, neck, jaw, or right hand (secondary to superior vena cava compensated by enlarged lymph nodes), lower extremity edema in relation to the inferior vena cava obstruction of intra-abdominal lymph node enlargement (non-Hodgkin), ascites (obstruction in the inferior vena cava, in connection with intra-abdominal lymph node enlargement)
6. Neuro-sensory
- Symptoms: nerve pain (neuralgia) indicates nerve root compression by enlarged lymph nodes in the brachial, lumbar, and sacral plexus, muscle weakness, paresthesias.
- Signs: mental status; lethargy, withdrawal, lack of interest in the general vicinity, paraplegia (spinal rod compression of the vertebral body, disc involvement in compression / degeneration or compression of the blood supply to the spinal rod).
7. Pain / comfort
- Symptoms: tenderness / pain on the affected lymph nodes, eg at about mediastinum, chest pain, back pain (vertebral compression) general bone pain (bone involvement limfomatus), pain in the affected area immediately after drinking alcohol.
- Signs: focus on yourself, cautious behavior.
8. Breathing
- Symptoms: dyspnea at work or rest; chest pain
- Symptoms: dyspnea; tachycardia, dry non-productive cough, respiratory distress signal; increased respiratory rate and depth, use of accessory muscles, stridor, cyanosis, husky / laryngeal paralysis (pressure of enlarged nodes in laryngeal nerve).
9. Security
- Symptoms: a history of frequent / infection, mononukleus history, history of ulcer / perforation gastric bleeding, fever, night sweats without chills, redness / general pruritus.
- Symptoms: fever settled without any symptoms of infection, lymph node symmetric, no pain, swollen / enlarged, enlarged tonsils, general pruritus, most areas of melanin pigmentation loss (vitilago).
10. Sexuality
- Symptoms: problem about fertility / pregnancy (while the disease does not affect, but affect treatment), decreased libido.
Nursing Management for Malignant Lymphoma
Lymphomas are a group of cancers in which cells of the lymphatic system become abnormal and start to grow uncontrollably. Because there is lymph tissue in many parts of the body, lymphomas can start in almost any organ of the body.
The two main types of lymphoma are Hodgkin and non-Hodgkin lymphoma (NHL).
The diagnosis of malignant lymphoma requires the presence of malignant lymphocytes in a biopsy of lymph node or extra-lymphatic tissue. An excisional lymph node biopsy is essential for complete diagnostic assessment. If a whole lymph node is not obtainable, sufficient incised tissue from an extra-lymphatic site can be diagnostic but is less desirable. Fine needle aspiration biopsy is not sufficient for the initial diagnosis of malignant lymphoma.
Malignant lymphoma is derived from lymphocytes. These tumors usually stems from lymph nodes, but can involve the lymphoid tissue in the spleen, gastrointestinal tract (eg, stomach wall), liver, or bone marrow. Lymphocytes in lymph nodes is also derived from multipotential stem cells in the bone marrow. Multipotential stem cells in the early stages of transformation into a lymphocyte progenitor cells that subsequently differentiate along two parallel paths.
Partial maturation in the thymus gland to become T lymphocytes, and partly to the lymph nodes or remain in the bone marrow and differentiate into B lymphocytes cells
If there is an appropriate antigen stimulation by the T and B lymphocytes will be transformed into an active form and proliferating. Activated T lymphocytes functioning cellular immune response. Whereas B lymphocytes are then activated to imunoblas into plasma cells that form the immunoglobulins. Changes in normal lymphocytes into cell lymphoma is caused by a gene mutation on one of the cells of a group of old cell lymphocytes are in the process of transformation into imunoblas (the result of the stimulation of immunogen). This occurs in the lymph nodes, where lymphocytes are outside centrum old germinativum while imunoblast be the most central part germinativum centrum. If the tumor enlarges, it can cause and if not treated early it causes malignant lymphoma.
Cause of these tumors is unknown, but there are some risk factors include: immunodeficiency, infectious agents, environmental and occupational exposures (such as forest workers, farmers and agriculture), ultraviolet exposure, smoking, and eating foods high in animal fat. Signs and symptoms include fatigue, malaise weight loss, increased temperature, infection susceptibility, dysphagia, anorexia, nausea, vomiting, constipation, anemia, edema arising anasarka, drop in blood pressure, shortness of breath when grown in the chest area and disorders / enlargement organ. If this condition is ongoing, it can cause complications of pleural effusion, bone fracture, paralysis and kematin certainly occur within 1 to 3 years if no treatment.
Nursing Management for Malignant Lymphoma
According to Brunner and Suddarth (2000), in providing care and client education. Clients often feel afraid to drugs that are radioactive and requires maintenance action and follow-up monitoring is special because it is the nurse should convey information about the therapeutic and soothing feelings of clients and families. For clients with postoperative laparotomy, clients are encouraged to rest and to avoid strain on the stitches. Gauze covering the wound should be reviewed periodically to determine the presence or not and do peradahan wound care according to the program every day, to observe signs of infection.
The two main types of lymphoma are Hodgkin and non-Hodgkin lymphoma (NHL).
The diagnosis of malignant lymphoma requires the presence of malignant lymphocytes in a biopsy of lymph node or extra-lymphatic tissue. An excisional lymph node biopsy is essential for complete diagnostic assessment. If a whole lymph node is not obtainable, sufficient incised tissue from an extra-lymphatic site can be diagnostic but is less desirable. Fine needle aspiration biopsy is not sufficient for the initial diagnosis of malignant lymphoma.
Malignant lymphoma is derived from lymphocytes. These tumors usually stems from lymph nodes, but can involve the lymphoid tissue in the spleen, gastrointestinal tract (eg, stomach wall), liver, or bone marrow. Lymphocytes in lymph nodes is also derived from multipotential stem cells in the bone marrow. Multipotential stem cells in the early stages of transformation into a lymphocyte progenitor cells that subsequently differentiate along two parallel paths.
Partial maturation in the thymus gland to become T lymphocytes, and partly to the lymph nodes or remain in the bone marrow and differentiate into B lymphocytes cells
If there is an appropriate antigen stimulation by the T and B lymphocytes will be transformed into an active form and proliferating. Activated T lymphocytes functioning cellular immune response. Whereas B lymphocytes are then activated to imunoblas into plasma cells that form the immunoglobulins. Changes in normal lymphocytes into cell lymphoma is caused by a gene mutation on one of the cells of a group of old cell lymphocytes are in the process of transformation into imunoblas (the result of the stimulation of immunogen). This occurs in the lymph nodes, where lymphocytes are outside centrum old germinativum while imunoblast be the most central part germinativum centrum. If the tumor enlarges, it can cause and if not treated early it causes malignant lymphoma.
Cause of these tumors is unknown, but there are some risk factors include: immunodeficiency, infectious agents, environmental and occupational exposures (such as forest workers, farmers and agriculture), ultraviolet exposure, smoking, and eating foods high in animal fat. Signs and symptoms include fatigue, malaise weight loss, increased temperature, infection susceptibility, dysphagia, anorexia, nausea, vomiting, constipation, anemia, edema arising anasarka, drop in blood pressure, shortness of breath when grown in the chest area and disorders / enlargement organ. If this condition is ongoing, it can cause complications of pleural effusion, bone fracture, paralysis and kematin certainly occur within 1 to 3 years if no treatment.
Nursing Management for Malignant Lymphoma
According to Brunner and Suddarth (2000), in providing care and client education. Clients often feel afraid to drugs that are radioactive and requires maintenance action and follow-up monitoring is special because it is the nurse should convey information about the therapeutic and soothing feelings of clients and families. For clients with postoperative laparotomy, clients are encouraged to rest and to avoid strain on the stitches. Gauze covering the wound should be reviewed periodically to determine the presence or not and do peradahan wound care according to the program every day, to observe signs of infection.
Preoperative Nursing Interventions for Apendicitis
Appendicitis is an inflammation of the appendix, a sac that no such additional functions located in the inferior and cecum. The most common cause of appendicitis is obstruction of the lumen by fecal eventually damage erode supply and mucosal blood flow, causing inflammation (Wilson & gold man, 1989).
Appendicitis is caused by blockage of the lumen of the appendix by fecalit, foreign objects, because there are previous inflammation. The obstruction causes mucus-producing mucosa, having the dam. However, the elasticity of the walls of the appendix has limitations that cause intra-luminal pressure. The increased pressure will inhibit the flow of lymph which will cause edema and ulceration of the mucosa, this occurs when the local acute appendicitis is characterized by the presence of pain.
Appendix unknown function, is part of the cecum. Inflammation of the appendix may occur by the presence of mucosal ulceration or obstruction of the lumen wall (usually by fecalit / hardened feces). Penymbatan spending mucus resulting in adhesions, and inhibition of bloodstream infections. Of hypoxia, resulting gangreng or rupture within 24-36 hours. If this process continues around the walls of organs appendix adhesions will occur that will cause an abscess (chronic). If the infection process is very fast will cause peritonitis.
Perforation signs include increased pain, muscle spasm right lower quadrant abdominal wall with a sign that generalized peritonitis or abscess localized, ileus, fever, malaise, leukocytosis increasingly clear. When perforation with generalized peritonitis or abscess formation has occurred since the increment clients outsmart come, the diagnosis can be established with certainty.
If peritonitis occurs, specific therapy is surgery performed to close the perforation origin. While the other acts as a support: Fowler position bed rest in the medium, the installation of NGT, fasting, correction fluids and electrolytes, giving tranquilizers, antibiotics with broad-spectrum antibiotics are continued in accordance with the culture, transfusion to treat anemia, and treatment of septic shock in the intensive , if any.
Preoperative Nursing Interventions for Apendicitis
1. Risk for Infection related to an inadequate immune.
Characterized by:
Goal: Not an infection
Outcomes: There are no signs of postoperative infection.
Intervention:
2. Acute Pain related to intestinal distension
Characterized by: respiratory tachypnea, tachycardia circulation, epigastric pain radiating to the local area Mc Burney, the client complained of feeling pain lower right area.
Goal: pain is resolved
Outcomes:
Appendicitis is caused by blockage of the lumen of the appendix by fecalit, foreign objects, because there are previous inflammation. The obstruction causes mucus-producing mucosa, having the dam. However, the elasticity of the walls of the appendix has limitations that cause intra-luminal pressure. The increased pressure will inhibit the flow of lymph which will cause edema and ulceration of the mucosa, this occurs when the local acute appendicitis is characterized by the presence of pain.
Appendix unknown function, is part of the cecum. Inflammation of the appendix may occur by the presence of mucosal ulceration or obstruction of the lumen wall (usually by fecalit / hardened feces). Penymbatan spending mucus resulting in adhesions, and inhibition of bloodstream infections. Of hypoxia, resulting gangreng or rupture within 24-36 hours. If this process continues around the walls of organs appendix adhesions will occur that will cause an abscess (chronic). If the infection process is very fast will cause peritonitis.
Perforation signs include increased pain, muscle spasm right lower quadrant abdominal wall with a sign that generalized peritonitis or abscess localized, ileus, fever, malaise, leukocytosis increasingly clear. When perforation with generalized peritonitis or abscess formation has occurred since the increment clients outsmart come, the diagnosis can be established with certainty.
If peritonitis occurs, specific therapy is surgery performed to close the perforation origin. While the other acts as a support: Fowler position bed rest in the medium, the installation of NGT, fasting, correction fluids and electrolytes, giving tranquilizers, antibiotics with broad-spectrum antibiotics are continued in accordance with the culture, transfusion to treat anemia, and treatment of septic shock in the intensive , if any.
Preoperative Nursing Interventions for Apendicitis
1. Risk for Infection related to an inadequate immune.
Characterized by:
- body temperature above normal,
- increased respiratory frequency,
- abdominal distension,
- leukocytes> 10.000/mm3
Goal: Not an infection
Outcomes: There are no signs of postoperative infection.
Intervention:
- Clean the field operations of several organisms that may be present through the principles of shearing.
- Give laxatives 1 day before surgery.
- Encourage clients with the perfect bath.
- Do a good hand washing and aseptic wound care.
2. Acute Pain related to intestinal distension
Characterized by: respiratory tachypnea, tachycardia circulation, epigastric pain radiating to the local area Mc Burney, the client complained of feeling pain lower right area.
Goal: pain is resolved
Outcomes:
- normal breathing,
- normal circulation
- Assess the level of pain, location and characteristics.
- Encourage deep breathing.
- Give analgesics.
5 Types and Function of Essential Nutrients
Nutrition is the process of making essential nutrients (Nancy Nuwer Konstantinides).
The sum of all interactions between organisms and the food consumed (Cristin and Gregar 1985).
In other words, nutrition is what people eat and how to use the body.
Communities obtain food or nutrients essential to the growth and defense of all body tissues and normalize the function of all body processes.
Nutrition is an organic substance required for normal functioning of the organism body systems, growth, maintenance of health. Nutrients obtained from food and liquids are subsequently assimilated by the body.
Research in the field of nutrition studies the relationship between food and drink to health and disease, especially in determining an optimal diet. In the past, only limited research on nutrient malnutrition on disease prevention and benchmark the basic nutritional needs of living things. Figures nutritional needs (nutrients) the basic known internationally in terms of the Recommended Daily Allowance (RDA).
Along with medical and scientific developments in the field of molecular biology, medical evidence suggests that the RDA has not been sufficient to maintain optimal body function and prevent or help treat chronic diseases. Medical evidence suggests that the root of many chronic diseases is oxidative stress caused by excess free radicals in the body. The use of nutrients in optimum level, known as Optimal Daily Allowance (ODA), proven to prevent and deal with oxidative stress which helps the prevention of chronic diseases. This optimal level can be achieved when the number and composition of nutrients used appropriately. In the treatment of disease, the use of nutrition as a complementary treatment can help the effectiveness of treatment and at the same time cope with the side effects of treatment. Therefore, nutrition / nutrition is closely associated with optimal health and improved quality of life. Measurement results can be carried out by the method of anthropometry.
ESSENTIAL NUTRIENTS
Nutrients are organic and inorganic chemicals found in food and is obtained for the use of bodily functions.
Types of Nutrients
1. Carbohydrate
Carbohydrates are the elements of a composition comprising carbon, hydrogen and oxygen.
Carbohydrates are divided into:
2. Fat
Fat is an energy source that is compacted. Fats and oils consist of glycerol combined with fatty acids.
Fat function:
3. Protein
Protein is an important constituent of all cell types of nutrients in the form of nutrient complex structure consisting of amino acids. Be hydrolyzed protein by proteolytic enzymes. To release amino acids which will then be absorbed by the intestine.
Protein function:
4. Vitamin
Vitamins are organic materials that can not be formed by the body and serves as a catalyst for the body's metabolic processes.
There are two types of vitamins:
5. Minerals and Water
Minerals are essential elements for the normal function of most enzymes, and is essential in the control of body fluid system. Minerals are essential constituents of the soft tissues, fluids and order. Order to contain most of the minerals. The body can not synthesize that must be provided by food.
Three mineral functions:
MALNUTRITION
Shortage of intake of nutrients, especially protein and carbohydrates. Can affect the growth, development, and cognition and may slow the healing process.
Types of malnutrition:
MALNUTRITION EFFECTS OF BODY SYSTEM
PLANNING FOOD
Dishes are generally planned to provide a mix of different types of foods to suit your taste but nutritional knowledge must be translated into the practical things.
Dietary guidelines can be realized in the following ways:
• Eat a wide variety of foods. This will ensure that your diet contains all the nutrients in adequate amounts.
• Reduce the consumption of sugar.
• Increase fiber and starch in the diet with more food mashed rice, potatoes, vegetables and fruits.
• Reduce the salt content in the diet by reducing processed foods and do not put excessive seasoning.
• Reduce consumption of fat by eating less butter, replacing the burning frying or boiling.
The sum of all interactions between organisms and the food consumed (Cristin and Gregar 1985).
In other words, nutrition is what people eat and how to use the body.
Communities obtain food or nutrients essential to the growth and defense of all body tissues and normalize the function of all body processes.
Nutrition is an organic substance required for normal functioning of the organism body systems, growth, maintenance of health. Nutrients obtained from food and liquids are subsequently assimilated by the body.
Research in the field of nutrition studies the relationship between food and drink to health and disease, especially in determining an optimal diet. In the past, only limited research on nutrient malnutrition on disease prevention and benchmark the basic nutritional needs of living things. Figures nutritional needs (nutrients) the basic known internationally in terms of the Recommended Daily Allowance (RDA).
Along with medical and scientific developments in the field of molecular biology, medical evidence suggests that the RDA has not been sufficient to maintain optimal body function and prevent or help treat chronic diseases. Medical evidence suggests that the root of many chronic diseases is oxidative stress caused by excess free radicals in the body. The use of nutrients in optimum level, known as Optimal Daily Allowance (ODA), proven to prevent and deal with oxidative stress which helps the prevention of chronic diseases. This optimal level can be achieved when the number and composition of nutrients used appropriately. In the treatment of disease, the use of nutrition as a complementary treatment can help the effectiveness of treatment and at the same time cope with the side effects of treatment. Therefore, nutrition / nutrition is closely associated with optimal health and improved quality of life. Measurement results can be carried out by the method of anthropometry.
ESSENTIAL NUTRIENTS
Nutrients are organic and inorganic chemicals found in food and is obtained for the use of bodily functions.
Types of Nutrients
1. Carbohydrate
Carbohydrates are the elements of a composition comprising carbon, hydrogen and oxygen.
Carbohydrates are divided into:
- Simple carbohydrates (sugar), can be a monosaccharide (single molecule consisting of glucose, fructose, and galactose). Could also be a disaccharide (double molecules), an example sucrose (glucose + fructose), maltose (glucose + glucose), lactose (glucose + galactose).
- Complex carbohydrates (starch) are polysaccharides have drawn many glucose molecules.
- Fiber is a type of carbohydrate derived from plants, can not be digested by the body with little or no calories but can increase stool volume.
2. Fat
Fat is an energy source that is compacted. Fats and oils consist of glycerol combined with fatty acids.
Fat function:
- As a source of energy, an energy source that is compacted to provide 9 calories / gram.
- Participate and build body tissues.
- Protection.
- Insulation / isolation, the fat will prevent loss of body heat.
- Feeling of fullness, fat may delay gastric emptying time and prevent hunger arise again soon after eating.
- Fat-soluble vitamins.
3. Protein
Protein is an important constituent of all cell types of nutrients in the form of nutrient complex structure consisting of amino acids. Be hydrolyzed protein by proteolytic enzymes. To release amino acids which will then be absorbed by the intestine.
Protein function:
- Protein replace protein lost during normal metabolic processes and the normal wear.
- Proteins generate new tissue.
- Protein is needed in the manufacture of new proteins with specific functions in the body, namely enzymes, hormones and hemoglobin.
- Protein as an energy source.
4. Vitamin
Vitamins are organic materials that can not be formed by the body and serves as a catalyst for the body's metabolic processes.
There are two types of vitamins:
- Fat-soluble vitamins are vitamins A, D, E, K.
- Water-soluble vitamins are vitamin B and C (not stored in the body so it must be in the diet each day).
5. Minerals and Water
Minerals are essential elements for the normal function of most enzymes, and is essential in the control of body fluid system. Minerals are essential constituents of the soft tissues, fluids and order. Order to contain most of the minerals. The body can not synthesize that must be provided by food.
Three mineral functions:
- Constituent of bones and teeth; example: calcium, magnesium, phosphorus.
- Formation of soluble salts and controlling the composition of body fluids; example Na, Cl (extracellular), K, Mg, P (intracellular).
- The basic ingredients of enzymes and proteins.
MALNUTRITION
Shortage of intake of nutrients, especially protein and carbohydrates. Can affect the growth, development, and cognition and may slow the healing process.
Types of malnutrition:
- Nutrient deficiency. Examples: eating less fruit and vegetables cause vitamin C deficiency can cause bleeding of the gums.
- Marasmus: Lack of protein and calories so that the body fat and muscle unloading. Clinical features: muscle atrophy, disappearance of the subcutaneous fat layer, growth retardation, belly fat, very thin as bones wrapped in skin.
- Kwashiorkor: protein deficiency due to a lack of dietary protein or protein that is lost due to physiological (eg state of injury and infection). Characteristics: weak, apathetic, enlarged liver, weight loss, muscle atrophy, mild anemia, changes in skin and hair pigmentation.
MALNUTRITION EFFECTS OF BODY SYSTEM
- Neurological / temperature regulation. Lowered basal metabolism and body temperature.
- Mental status. Apathy, depression, easily aroused, cognitive impairment, difficulty making decisions.
- Immune system. Production of white blood cells: The risk of infectious disease when leukocytes down.
- Musculoskeletal. Decreased muscle mass, impaired coordination and dexterity.
- Cardiovascular. Heart rhythm disorders, cardiac atrophy, cardiac pump down.
- Respiratory. Respiratory muscle atrophy, pneumonia.
- Gastrointestinal. Stool mass loss, decreased digestive enzymes, decreased absorption process, shorten the transit time, increase the growth of bacteria, diarrhea, reduce peristalsis.
- Urinary system. Renal atrophy, change the filtration and fluid and electrolyte balance.
- Liver and biliary system. Reduces glucose storage, reduces the production of glucose from amino acids, reducing protein synthesis.
PLANNING FOOD
Dishes are generally planned to provide a mix of different types of foods to suit your taste but nutritional knowledge must be translated into the practical things.
Dietary guidelines can be realized in the following ways:
• Eat a wide variety of foods. This will ensure that your diet contains all the nutrients in adequate amounts.
• Reduce the consumption of sugar.
• Increase fiber and starch in the diet with more food mashed rice, potatoes, vegetables and fruits.
• Reduce the salt content in the diet by reducing processed foods and do not put excessive seasoning.
• Reduce consumption of fat by eating less butter, replacing the burning frying or boiling.
Nursing Care Plan for Glaucoma - 5 Nursing Diagnosis
Glaucoma is a disease of the optic nerve can cause visual field abnormalities and can end up with permanent total blindness.
Cause
Mainly due to high eye pressure (normal value: 10-22 mmHg)
Risk Factors
Chronic glaucoma :
Acute glaucoma
Congenital glaucoma
Complication
Blindness occurs that can not be cured but can be prevented.
Prevention
Treatment
5 Nursing Diagnosis for Glaucoma
Cause
Mainly due to high eye pressure (normal value: 10-22 mmHg)
Risk Factors
- Age over 40 years.
- Families who have suffered from glaucoma.
- History of trauma to the eye.
- Myopia (nearsightedness)
- Hypermetropia (farsightedness)
- Have systemic disease (diabetes, heart disease)
- The use of drugs (steroids)
- Cataracts.
Chronic glaucoma :
- Nerve damage occurs slowly.
- Painless.
- Narrowing the field of vision is not realized.
- Permanent blindness.
- Commonly called thief of sight.
Acute glaucoma
- Due to the sudden eye pressure high.
- Severe headache.
- Nausea vomiting
- Red eye
- Blurred vision
- Rainbow appear when viewing the lights.
- If not promptly treated, it will cause blindness.
Congenital glaucoma
- In infants or children
- Very rare
- Congenital abnormality
- Eyeball bigger than normal
- Cornea is not clear
- Watery eyes
- Afraid to see the light
Complication
Blindness occurs that can not be cured but can be prevented.
Prevention
- Regular eye examinations, especially over the age of 40 years.
- Regular control for patients with glaucoma.
Treatment
- Lowering drugs eye pressure, is used regularly and continuously to prevent further damage to the optic nerve.
- Surgery or laser to create a new channel in order to decrease eye pressure.
5 Nursing Diagnosis for Glaucoma
- Disturbed Sensory Perception
- Anxiety
- Acute pain
- Disturbed Body Image
- Self-care Deficit
Pleural Effusion Care Plan - Nursing Diagnosis and Interventions
What is a Pleural Effusion?
Pleural effusion is a condition in which there is fluid in the chest cavity that should not exist (there is normally very little fluid as a lubricant), where the fluid will suppress lung and heart that will cause shortness.
Symptoms
How does this happen?
Pleural effusion occurs because: An imbalance between the production and disposal of the lubricating fluid, so fluid accumulates.
Some diseases that often cause complications pleural effusion is:
What danger??
Nursing Diagnosis for Pleural Effusion
Analysis can be expressions of the nursing diagnoses that include:
Nursing Interventions for Pleural Effusion
1). Ineffective airway clearance related to decreased lung expansion.
Goal: a patent airway / inadequate
Nursing Intervention:
2). Fluid volume deficit related to diaphoresis
Goal: balance of body fluids
Nursing Intervention:
3). Activity Intolerance related to dyspnea and fatigue
Goal: clients obtain energy
Nursing Intervention:
Pleural effusion is a condition in which there is fluid in the chest cavity that should not exist (there is normally very little fluid as a lubricant), where the fluid will suppress lung and heart that will cause shortness.
Symptoms
- Shortness of breath that is increasingly severe, usually felt on one side.
- cough
- Sometimes accompanied by chest pain
- Stomach feel full / bloated
- Some patients hear the sound of moving water when the whisk.
How does this happen?
Pleural effusion occurs because: An imbalance between the production and disposal of the lubricating fluid, so fluid accumulates.
Some diseases that often cause complications pleural effusion is:
- Pulmonary TB
- Lung tumors
- Hypo-albumin, a state in which the albumin / protein in blood is very low such as in cirrhosis of the liver disease, kidney failure, etc..
- Heart failure
- Breast tumor
- Ovarian cysts
- etc..
What danger??
- Although not including gravity, in most cases, the fluid should be removed because:
- Polynomial, so that pressing the lungs, disrupting breathing and encourage the heart (cardiac pump is compromised, it can be fatal).
- The fluid can harden / solidify (organization) that reduced lung volume, (tightness) and cause permanent disability which continues to appear on x-rays.
- If infected, the liquid turns into pus. This became another disease that is empyema, different handling.
- If the liquid is in the form of blood, for example due to an accident, his name: haemothorax, need immediate attention.
Nursing Diagnosis for Pleural Effusion
Analysis can be expressions of the nursing diagnoses that include:
- Ineffective airway clearance related to decreased lung expansion.
- Fluid volume deficit related to diaphoresis.
- Activity Intolerance related to dyspenia and fatigue
Nursing Interventions for Pleural Effusion
1). Ineffective airway clearance related to decreased lung expansion.
Goal: a patent airway / inadequate
Nursing Intervention:
- Give oxygenation in accordance with the program.
- Provide a comfortable sleeping position.
- Monitor vital signs.
- Teach effective cough.
- Teach resistant chest when coughing.
2). Fluid volume deficit related to diaphoresis
Goal: balance of body fluids
Nursing Intervention:
- Vital signs every 6 hours.
- Compress with warm water.
- Record intake and output.
- Collaboration with doctors for antibiotics.
3). Activity Intolerance related to dyspnea and fatigue
Goal: clients obtain energy
Nursing Intervention:
- Assess the activity patterns.
- Limit activity.
- Aids to overcome weaknesses.
- Schedule breaks.
- Physiotherapy consultation.
Pediatric Nursing
Pediatric Nursing Demystified (Demystified Nursing)
The quick and easy way to learn the concepts and major theories of pediatric nursing – and how to apply them to real-world situations
If you’re looking for a fun, fast review that boils pediatric nursing down to its most essential, must-know points your search ends here! Pediatric Nursing Demystified is a complete yet concise overview of all the important pediatric nursing concepts and the disorders that most often afflict infants to adolescents. You’ll also learn how to apply those principles to real-life clinical situations.
In order to make the learning process as easy and effective as possible, you’ll find learning aids such as chapter objectives, key terms, a brief overview of each topic, content summaries, chapter-ending questions, numerous tables and diagrams, and a comprehensive final exam that includes NCLEX-style questions covering all the content found in the book.
Great for course exams and as an NCLEX review!
Wong's Essentials of Pediatric Nursing, 9e
When it comes to caring for children, no other resource better prepares you for practice than Wong's Essentials of Pediatric Nursing. Authored by Marilyn Hockenberry and David Wilson, two of the most well-known and respected names in the field, Wong's features the most readable, up-to-date, and accurate content available. An abundance of full-color illustrations helps you visualize key concepts, and highlighted boxes and tables offer quick access to vital facts and information. Plus, when you buy this book, you get unlimited access to hands-on study tools that help you learn pediatric nursing essentials with ease!
Pediatric Success: A Course Review Applying Critical Thinking Skills to Test Taking (Davis Success Series)
Over 900 NCLEX-style questions on pediatrics and growth and development into body system chapters. Add a 100- question comprehensive exam at the end of the book, plus two 75-question final exams on the bonus CD-ROM, and learning and studying become easier...and measurable. Students use the RACE model to apply critical thinking to the question types they’ll encounter in class and on the NCLEX.
Pediatric Nursing: An Introductory Text, 11e
Covering evidence-based pediatric nursing care from infancy through adolescence, Pediatric Nursing: An Introductory Text, 11th Edition provides a clear, easy-to-read guide to pediatric nursing for LPN/LVN students. Content in this edition is reorganized for a "best of both worlds" approach to pediatric nursing, with early chapters devoted to normal growth and development by age group followed by chapters covering the most common childhood disorders grouped by body system. Updated coverage reflects the latest issues in pediatric nursing care, including childhood obesity and teenage pregnancy. Clinical Snapshots and Nursing Care Plans with critical thinking questions show how to apply the nursing process in real patient care scenarios. Written by noted pediatric nursing educators Debra L. Price and Julie F. Gwin, this market-leading textbook provides the essential knowledge you need to succeed in LPN/LVN practice.
Pediatric Nurse's Survival Guide (Rebeschi, The Pediatric's Nurse's Survival Guide)
Practical and convenient, the thoroughly updated third edition of The Pediatric Nurse's Survival Guide is the perfect clinical reference! This handy resource offers quick answers to your pediatric nursing questions concerning assessment, clinical values and standards, and the most common conditions and diseases seen in the pediatric population.
The quick and easy way to learn the concepts and major theories of pediatric nursing – and how to apply them to real-world situations
If you’re looking for a fun, fast review that boils pediatric nursing down to its most essential, must-know points your search ends here! Pediatric Nursing Demystified is a complete yet concise overview of all the important pediatric nursing concepts and the disorders that most often afflict infants to adolescents. You’ll also learn how to apply those principles to real-life clinical situations.
In order to make the learning process as easy and effective as possible, you’ll find learning aids such as chapter objectives, key terms, a brief overview of each topic, content summaries, chapter-ending questions, numerous tables and diagrams, and a comprehensive final exam that includes NCLEX-style questions covering all the content found in the book.
Great for course exams and as an NCLEX review!
Wong's Essentials of Pediatric Nursing, 9e
When it comes to caring for children, no other resource better prepares you for practice than Wong's Essentials of Pediatric Nursing. Authored by Marilyn Hockenberry and David Wilson, two of the most well-known and respected names in the field, Wong's features the most readable, up-to-date, and accurate content available. An abundance of full-color illustrations helps you visualize key concepts, and highlighted boxes and tables offer quick access to vital facts and information. Plus, when you buy this book, you get unlimited access to hands-on study tools that help you learn pediatric nursing essentials with ease!
- Developmental approach clearly identifies key issues at each stage of a child's growth to help you provide appropriate, individualized care for each child.
- UNIQUE! Family focus includes a separate chapter on the role of the family in child health, family content throughout the text, and Family-Centered Care boxes that highlight information on patient teaching, home care, and incorporating the family in the child's care.
- An emphasis on wellness offers health promotion and injury prevention strategies for each age group.
- UNIQUE! Evidence-Based Practice boxes demonstrate how research is applied to nursing care in the clinical setting.
- UNIQUE! Atraumatic Care boxes provide guidance for administering nursing care with minimal pain or stress to the child, family, and nurse.
- NEW! Safety Alerts call your attention to important patient safety considerations and support the QSEN initiative for better outcomes of nursing care..
Pediatric Success: A Course Review Applying Critical Thinking Skills to Test Taking (Davis Success Series)
Over 900 NCLEX-style questions on pediatrics and growth and development into body system chapters. Add a 100- question comprehensive exam at the end of the book, plus two 75-question final exams on the bonus CD-ROM, and learning and studying become easier...and measurable. Students use the RACE model to apply critical thinking to the question types they’ll encounter in class and on the NCLEX.
Pediatric Nursing: An Introductory Text, 11e
Covering evidence-based pediatric nursing care from infancy through adolescence, Pediatric Nursing: An Introductory Text, 11th Edition provides a clear, easy-to-read guide to pediatric nursing for LPN/LVN students. Content in this edition is reorganized for a "best of both worlds" approach to pediatric nursing, with early chapters devoted to normal growth and development by age group followed by chapters covering the most common childhood disorders grouped by body system. Updated coverage reflects the latest issues in pediatric nursing care, including childhood obesity and teenage pregnancy. Clinical Snapshots and Nursing Care Plans with critical thinking questions show how to apply the nursing process in real patient care scenarios. Written by noted pediatric nursing educators Debra L. Price and Julie F. Gwin, this market-leading textbook provides the essential knowledge you need to succeed in LPN/LVN practice.
- Reading Level: 9.6
- Nursing Care Plans with critical thinking questions reinforce problem-solving skills as the nursing process is applied to pediatric nursing, with NEW critical thinking answer guidelines provided on the companion Evolve website Evolve to help you understand how a care plan is developed and how to evaluate care of a patient.
- UNIQUE! Free, built-in Study Guide includes scenario-based clinical activities and practice questions for each chapter.
Pediatric Nurse's Survival Guide (Rebeschi, The Pediatric's Nurse's Survival Guide)
Practical and convenient, the thoroughly updated third edition of The Pediatric Nurse's Survival Guide is the perfect clinical reference! This handy resource offers quick answers to your pediatric nursing questions concerning assessment, clinical values and standards, and the most common conditions and diseases seen in the pediatric population.
Physical Examination and Health Assessment
Physical Examination and Health Assessment, 6th Edition
With an easy-to-read approach and unmatched learning support, Physical Examination & Health Assessment, 6th Edition offers a clear, logical, and holistic approach to physical exam across the lifespan. Detailed illustrations, summary checklists, and new learning resources ensure that you learn all the skills you need to know. This gold standard in physical exam reflects what is going on in nursing today with coverage of emerging trends and new evidence-based content. It's easy to see why this text is, far and away, #1 in this market!
This item is a stand-alone text.
Pocket Companion for Physical Examination and Health Assessment, 6e (Jarvis, Pocket Companion for Physical Examination and Health Assessment)
Ideal for quick reference in the clinical setting, this portable companion to Carolyn Jarvis' Physical Examination and Health Assessment, 6th Edition summarizes essential assessment skills and techniques for the most effective physical examinations. Access full-color pathology photos and illustrations, health history, examination steps for each body system, normal versus abnormal findings, lifespan and cross-cultural considerations, related nursing diagnoses, and summary checklists anytime you need them with this convenient clinical tool.
Health Assessment and Physical Examination
Gain confidence and competence with HEALTH ASSESSMENT & PHYSICAL EXAMINATION, fifth edition! Promoting healthy outcomes in patients begins with thorough and knowledgeable assessment, a key nursing responsibility. As you develop and refine your examination skills, you will learn to view the patient from a holistic perspective of not only physical well-being, but social, spiritual, emotional, and psychological health as well. With HEALTH ASSESSMENT & PHYSICAL EXAMINATION fifth edition you will gain the confidence and technical skills required of a competent and well-trained professional.
Physical Examination and Health Assessment - Text and Mosby's Nursing Video Skills: Physical Examination and Health Assessment, 2e Package, 6e
This money saving package includes the 6th edition of Physical Examination and Health Assessment and Mosby's Nursing Video Skills: Physical Examination and Health Assessment.
With an easy-to-read approach and unmatched learning support, Physical Examination & Health Assessment, 6th Edition offers a clear, logical, and holistic approach to physical exam across the lifespan. Detailed illustrations, summary checklists, and new learning resources ensure that you learn all the skills you need to know. This gold standard in physical exam reflects what is going on in nursing today with coverage of emerging trends and new evidence-based content. It's easy to see why this text is, far and away, #1 in this market!
This item is a stand-alone text.
- A clear, conversational writing style makes learning easier.
- A two-column format distinguishes normal findings from abnormal findings, and uses color, step-by-step photos to clarify examination techniques and expected findings.
- Over 1,000 full-color illustrations present anatomy and physiology, examination techniques, and abnormal findings.
- Developmental considerations help in caring for patients across the lifespan with age-specific assessment techniques for infants, children, adolescents, pregnant females, and older adults.
- Abnormal findings tables include over 300 pathology photos to help in recognizing, sorting, and describing abnormalities.
- Promoting a Healthy Lifestyle boxes enable patient teaching and health promotion while performing the health assessment.
Pocket Companion for Physical Examination and Health Assessment, 6e (Jarvis, Pocket Companion for Physical Examination and Health Assessment)
Ideal for quick reference in the clinical setting, this portable companion to Carolyn Jarvis' Physical Examination and Health Assessment, 6th Edition summarizes essential assessment skills and techniques for the most effective physical examinations. Access full-color pathology photos and illustrations, health history, examination steps for each body system, normal versus abnormal findings, lifespan and cross-cultural considerations, related nursing diagnoses, and summary checklists anytime you need them with this convenient clinical tool.
- Convenient, color-coded design helps you easily locate the information you need.
- More than 160 full-color illustrations clearly demonstrate important anatomy and physiology concepts, examination steps, and normal and abnormal findings.
- Age-specific developmental competencies highlight important considerations for pediatric, pregnant, and aging patients.
- Cultural competency icons alert you to relevant cultural distinctions you may encounter in the clinical setting.
Health Assessment and Physical Examination
Gain confidence and competence with HEALTH ASSESSMENT & PHYSICAL EXAMINATION, fifth edition! Promoting healthy outcomes in patients begins with thorough and knowledgeable assessment, a key nursing responsibility. As you develop and refine your examination skills, you will learn to view the patient from a holistic perspective of not only physical well-being, but social, spiritual, emotional, and psychological health as well. With HEALTH ASSESSMENT & PHYSICAL EXAMINATION fifth edition you will gain the confidence and technical skills required of a competent and well-trained professional.
Physical Examination and Health Assessment - Text and Mosby's Nursing Video Skills: Physical Examination and Health Assessment, 2e Package, 6e
This money saving package includes the 6th edition of Physical Examination and Health Assessment and Mosby's Nursing Video Skills: Physical Examination and Health Assessment.
2 Nursing Interventions for Shock
Shock is a life-threatening medical condition in which the body suffers from insufficient blood flow throughout the body. Shock often accompanies severe injury or illness. Medical shock is a medical emergency and can lead to other conditions such as lack of oxygen in body tissues (hypoxia), heart attack (cardiac arrest) or organ damage. It requires immediate treatment because the symptoms can worsen quickly.
Medical shock is a shock is different than emotional or psychological shock that can occur after a traumatic emotional event or scary.
Etiology
1. Hypovolemic shock
2. Cardiogenic shock
3. Vasogenic shock
4. Septic shock
Signs of shock :
2 Nursing Interventions for Shock
1. Fluid Volume Deficit
a. Intravenous therapy (according to type of shock):
Crystalloid (to restore the liquid electrolyte).
b. Colloid (to restore plasma volume and restore the osmotic pressure): WB, PRC, plasma.
2. Decrease Cardiac Output
Goal:
Medical shock is a shock is different than emotional or psychological shock that can occur after a traumatic emotional event or scary.
Etiology
1. Hypovolemic shock
- Bleeding
- Loss of fluid volume
- Displacement of fluid from the vascular to the interstitial cells
2. Cardiogenic shock
- Impaired the ability of the heart pump (cardiac arrest, arrhythmia, valve disease, myocardial degeneration, systemic infection drugs.
3. Vasogenic shock
- Decrease simpatic tone, vasodilatation, increased capillary permeability
4. Septic shock
- Cause of gram-negative organisms (P. aerogenosa, Escherichia coli, Klebseilla pneomoni, Staphylococcus, Streptococcus).
- Predisiposisi: malnutrition, large open wounds, ischemia of the gastrointestinal tract (GI), immunosuppression.
- Host interactions - toxin stimulates systemic complement activity - changes in organ microcirculation, increased capillary permeability, cell injury, increased cell metabolism.
Signs of shock :
- General state: weak.
- Perfusion: pale skin, cold, wet.
- Tachycardia.
- Peripheral vein is not visible.
- Decreased blood pressure, systolic less than 90 mmHg or a fall of more than 50 mm Hg of pressure before.
- Hyperventilation.
- Peripheral cyanosis.
- Restlessness, decreased consciousness.
- Decreased urine production.
2 Nursing Interventions for Shock
1. Fluid Volume Deficit
a. Intravenous therapy (according to type of shock):
Crystalloid (to restore the liquid electrolyte).
b. Colloid (to restore plasma volume and restore the osmotic pressure): WB, PRC, plasma.
2. Decrease Cardiac Output
Goal:
- Increase the vascular fluid.
- Support the compensatory mechanisms.
- Prevent ischemic complications.
- Improve venous return.
- Improve myocardial contraction.
- Ensure adequate myocardial perfusion:
- Vasoconstrictor agents.
- Agents that increase myocardial contraction.
- Myocardial perfusion agent adds.
Dysentery - Nursing Diagnosis and Interventions
1. Nursing Diagnosis for Dysentery : Imbalanced Nutrition: less than body requirements
related to: inadequate intake and output
Goal: nutritional needs are met
Expected outcomes:
Nursing Interventions for Dysentery:
1. Discuss and explain about the diet restrictions of patients (high fiber foods, fatty and water is too hot or cold)
R / high fiber, fat, water is too hot / cold can stimulate irritate the stomach and intestinal tract.
2. Create a clean environment, away from the smell of the odor or litter, serve food in a warm state.
R / situation comfortable, relaxed to stimulate appetite.
3. Provide hours of rest (sleep) and reduce excessive activity.
R / Reducing energy consumption is excessive
4. Monitor intake and output within 24 hours.
R / Knowing the amount of output can merencenakan amount of food.
5. Collaboration with other health care team:
a. Nutritional therapy: A diet high in calories and high in protein, low in fiber, milk.
b. medications or vitamins (A)
R / Containing substances necessary for the growth process.
2. Nursing Diagnosis for Dysentery: Imbalanced Body Temperature
related to: the impact of infection secondary to diarrhea.
Goal: no increase in body temperature
Expected outcomes:
Nursing Interventions for Dysentery:
1. Monitor body temperature every 2 hours.
R / Early detection of abnormal changes in body function (an infection)
2. Give warm compresses.
R / stimulate heat regulating center to reduce the production of body heat
3. Collaboration of antipyretic
R / Stimulate the heat regulating center in the brain.
3. Nursing Diagnosis for Dysentery: Risk for Impaired Skin Integrity: perianal
related to: increased frequency of bowel movements (diarrhea)
Goal: skin integrity is not compromised
Expected outcomes :
Nursing Interventions for Dysentery:
1. Discuss and explain the importance of keeping the beds.
R / Hygiene prevent the proliferation of germs.
2. Demontrasikan and involve families in the treatment of perianal (if wet clothing and replace the bottom as well as the base).
R / Preventing skin iritassi unexpected because kelebaban and stool acidity.
3. Adjust the position of sleep or sit with an interval of 2-3 hours.
R / Smooth vascularization, reducing the emphasis that long so did not happen ischemia and irritation.
4. Nursing Diagnosis for Dysentery: Anxiety: children
related to: invasive measures
Goal: the client is able to adapt
Expected outcomes:
Nursing Interventions for Dysentery:
1. Involve the family in performing maintenance actions.
R / initial approach to the child through the mother or family.
2. Avoid the wrong perception on nurses and hospitals.
R / reduce the fear of the child to the nurse and the hospital environment.
3. Give kudos if the client would be given care and treatment measures.
R / increase the child's confidence will courage and ability.
4. Make contact as often as possible and do communication both verbal and non-verbal (touching, fondling, etc.).
R / Love and the introduction of self saying nurses would menunbuhkan sense of security on the client.
5. Give children toys as sensory stimuli.
related to: inadequate intake and output
Goal: nutritional needs are met
Expected outcomes:
- Increased appetite.
- Increased or normal weight according to age.
Nursing Interventions for Dysentery:
1. Discuss and explain about the diet restrictions of patients (high fiber foods, fatty and water is too hot or cold)
R / high fiber, fat, water is too hot / cold can stimulate irritate the stomach and intestinal tract.
2. Create a clean environment, away from the smell of the odor or litter, serve food in a warm state.
R / situation comfortable, relaxed to stimulate appetite.
3. Provide hours of rest (sleep) and reduce excessive activity.
R / Reducing energy consumption is excessive
4. Monitor intake and output within 24 hours.
R / Knowing the amount of output can merencenakan amount of food.
5. Collaboration with other health care team:
a. Nutritional therapy: A diet high in calories and high in protein, low in fiber, milk.
b. medications or vitamins (A)
R / Containing substances necessary for the growth process.
2. Nursing Diagnosis for Dysentery: Imbalanced Body Temperature
related to: the impact of infection secondary to diarrhea.
Goal: no increase in body temperature
Expected outcomes:
- Body temperature within normal limits (36-37,5 C)
- There are no signs of infection (rubur, dolor, calor, tumor, fungtio leasa)
Nursing Interventions for Dysentery:
1. Monitor body temperature every 2 hours.
R / Early detection of abnormal changes in body function (an infection)
2. Give warm compresses.
R / stimulate heat regulating center to reduce the production of body heat
3. Collaboration of antipyretic
R / Stimulate the heat regulating center in the brain.
3. Nursing Diagnosis for Dysentery: Risk for Impaired Skin Integrity: perianal
related to: increased frequency of bowel movements (diarrhea)
Goal: skin integrity is not compromised
Expected outcomes :
- No irritation: redness, blisters, hygiene maintained.
- Families are able to demonstrate perianal care properly.
Nursing Interventions for Dysentery:
1. Discuss and explain the importance of keeping the beds.
R / Hygiene prevent the proliferation of germs.
2. Demontrasikan and involve families in the treatment of perianal (if wet clothing and replace the bottom as well as the base).
R / Preventing skin iritassi unexpected because kelebaban and stool acidity.
3. Adjust the position of sleep or sit with an interval of 2-3 hours.
R / Smooth vascularization, reducing the emphasis that long so did not happen ischemia and irritation.
4. Nursing Diagnosis for Dysentery: Anxiety: children
related to: invasive measures
Goal: the client is able to adapt
Expected outcomes:
- Want to receive care measures, the client seems quiet and no fuss
Nursing Interventions for Dysentery:
1. Involve the family in performing maintenance actions.
R / initial approach to the child through the mother or family.
2. Avoid the wrong perception on nurses and hospitals.
R / reduce the fear of the child to the nurse and the hospital environment.
3. Give kudos if the client would be given care and treatment measures.
R / increase the child's confidence will courage and ability.
4. Make contact as often as possible and do communication both verbal and non-verbal (touching, fondling, etc.).
R / Love and the introduction of self saying nurses would menunbuhkan sense of security on the client.
5. Give children toys as sensory stimuli.
Nursing Care Plan for Dysentery
Cause of Dysentery
Dysentery is usually caused by a bacterial or protozoan infection or infestation of parasitic worms, but can also be caused by chemical irritants or viral infection. The two most common causes are infection with a bacillus of the Shigella group, and infestation by an amoeba, Entamoeba histolytica. When it is caused by a bacillus called bacillary dysentery, and when it is caused by an amoeba called amoebic dysentery.
Symptoms of Dysentery
Dysentery symptoms can last for five days or even more. For some cases, the symptoms may be mild, while others suffer from severe diarrhea and vomiting or potentially cause dehydration. The following symptoms when exposed to dysentery:
- Flatulence
- Pain in the abdomen
- Bloody diarrhea
- Nausea, with or without vomiting
However, if the infection is severe, people may experience other symptoms caused by dehydration:
- Decreased urine production
- Dry skin and mucous membranes
- Excessive thirst
- Fever and chills
- Muscle spasms
- Limp
- Weight loss
- Yellowish white mucus
In cases of chronic dysentery, no effects after an acute attack. In severe cases, the body temperature will rise to 40 degrees Celsius to 40.6 degrees Celsius.
Prevention of Dysentery
Dysentery is spread as a result of poor hygiene. To minimize the risk of these conditions, then it should be done on the prevention of dysentery:
- Avoid swallowing water in swimming pools or recreational water sources
- Make sure you drink water that has been purified or boiled water
- Drink bottled water when traveling
- Wash your hands with anti-bacterial soap after using the bathroom, changing diapers, before preparing and eating food.
- Avoid sharing towels with others
- Wash clothing or eating utensils of an infected person.
Nursing Care Plan for Dysentery
Assessment
1. Identity
Noteworthy is the age. Episodes of diarrhea occurred in the first 2 years of life. Highest incidence is the age group 6-11 months. Most bacteria stimulate gut immunity against infection, it helps explain the decline insidence disease in older children. At the age of 2 years or more of active immunity begins to form. Most cases are due to an intestinal infection and asymptomatic enteric bacteria spread mainly clients are not aware of the infection. Economic status also influential, especially from the diet and treatment.
2. Main complaint
Defecation is more than 3 x
3. History of present illness
Defecation greenish yellow color, mixed with mucus and blood or mucus alone. Watery consistency, frequency is more than 3 times, spending time : 3-5 days (acute diarrhea), more than 7 days (prolonged diarrhea), more than 14 days (chronic diarrhea).
4. Past medical history
Never had diarrhea before, to those on long-term antibiotics or corticosteroids (candida albicans changes from saprophyte to parasite), food allergies, respiratory infections, UTI, OMA measles .
5. History of Nutrition
At toddler age children are given food as in adults, the portion given 3 times per day with additional fruit and milk. Malnutrition in toddler age children are particularly vulnerable. Way better food management, food hygiene and sanitation, hand-washing habits.
6. Family health history
There is one family that has diarrhea.
7. Environmental Health History
Food storage at room temperature, lacking hygiene, neighborhood .
8. Growth and development history
a. growth
- Weight gain since age 1 -3 years ranged between 1.5-2.5 kg (average of 2 kg), a body length of 6-10 cm (mean 8 cm) per year.
- The increase in head circumference: 12cm 2 cm in the first year and second year and so on.
- Teething 8 pieces: additional milk teeth; first molars and canines, totaling 14-16 pieces
- Eruption of teeth: molars perama menusul canines.
- Psychosexual stages of development according to Sigmund Freud.
5 Nursing Diagnosis related to Acute Diarrhea
Acute diarrhea is defined as the discharge of bowel movements once or more in the form of a liquid in a day and lasted less than fourteen days. Diarrhea is a condition that is not normal stool expenditure, usually characterized by increased volume, dilution and frequency of bowel movements more than 3 times a day with or without mucus and blood.
The presence of food that can not be absorbed by the intestinal lumen will cause osmotic pressure in the cavity resulting in increased intestinal absorption of water and electrolytes into the intestinal cavity. Excessive intestinal cavity contents will stimulate the intestine to release it, causing diarrhea. Non-pathogenic bacteria in the intestinal lumen (often called intestinal flora) can cause diarrhea. Normally through the process of fermentation of non-pathogenic intestinal bacteria metabolize a variety of substrates, especially of food substances with the end result of fatty acids and gases.
The anaerobic metabolism will provide additional energy for the body. Due to intestinal stasis, obstruction and malnutrition lead to an increase in the number of non-pathogenic bacteria so that the fermentation process food substances produce metabolites that are not wanted by the body. For example: lactose (from milk) is a good food for the non-pathogenic bacteria. Lactose will be fermented to produce gas and cause gastric distension.
Result of the high concentration of lactose causes an osmotic pressure in the intestinal lumen increases. Hyperosmolar state will absorb water from the intra-cellular, followed by an increase in intestinal peristalsis resulting in diarrhea.
5 Nursing Diagnosis related to Acute Diarrhea
1. Nursing Diagnosis : Deficient Fluid Volume
related to excessive fluid loss through the stool or vomit
characterized by :
Subjective data :
Objective data :
2. Nursing Diagnosis : Imbalanced Nutrition: less than body requirements
related to loss of fluids through diarrhea, inadequate intake is
characterized by :
Subjective data :
Objective data :
3. Nursing Diagnosis : Risk for infection
related to microorganisms that penetrate the gastrointestinal tract .
4. Nursing Diagnosis : Impaired skin integrity : perianal
related to irritation from diarrhea
characterized by :
Subjective data :
Data obtektif :
5. Nursing Diagnosis : Anxiety / fear
relatde to separation from parents , unfamiliar environment , stressful procedure
characterized by :
Subjective data :
Objective data :
The presence of food that can not be absorbed by the intestinal lumen will cause osmotic pressure in the cavity resulting in increased intestinal absorption of water and electrolytes into the intestinal cavity. Excessive intestinal cavity contents will stimulate the intestine to release it, causing diarrhea. Non-pathogenic bacteria in the intestinal lumen (often called intestinal flora) can cause diarrhea. Normally through the process of fermentation of non-pathogenic intestinal bacteria metabolize a variety of substrates, especially of food substances with the end result of fatty acids and gases.
The anaerobic metabolism will provide additional energy for the body. Due to intestinal stasis, obstruction and malnutrition lead to an increase in the number of non-pathogenic bacteria so that the fermentation process food substances produce metabolites that are not wanted by the body. For example: lactose (from milk) is a good food for the non-pathogenic bacteria. Lactose will be fermented to produce gas and cause gastric distension.
Result of the high concentration of lactose causes an osmotic pressure in the intestinal lumen increases. Hyperosmolar state will absorb water from the intra-cellular, followed by an increase in intestinal peristalsis resulting in diarrhea.
5 Nursing Diagnosis related to Acute Diarrhea
1. Nursing Diagnosis : Deficient Fluid Volume
related to excessive fluid loss through the stool or vomit
characterized by :
Subjective data :
- thirst , nausea , anorexia .
Objective data :
- Inadequacy of oral fluid intake
- Negative balance between intake and output
- Weight loss
- Dry mucous membranes
- Decreased urine output
- Decrease in skin turgor
- Increase in serum sodium
2. Nursing Diagnosis : Imbalanced Nutrition: less than body requirements
related to loss of fluids through diarrhea, inadequate intake is
characterized by :
Subjective data :
- Family clients reported a portion of food that is spent.
- Abdominal cramps.
Objective data :
- Weight loss below ideal body weight.
- Upper arm circumference below the ideal.
- Anemic conjunctiva.
- Anorexia.
- Muscle weakness.
- Decrease in serum albumin.
3. Nursing Diagnosis : Risk for infection
related to microorganisms that penetrate the gastrointestinal tract .
4. Nursing Diagnosis : Impaired skin integrity : perianal
related to irritation from diarrhea
characterized by :
Subjective data :
- Changes in comfort : pain, itching
Data obtektif :
- Damage to the skin layer ( dermis ) : lesions and skin irritation due to diaper.
- Perianal area moist and redness.
5. Nursing Diagnosis : Anxiety / fear
relatde to separation from parents , unfamiliar environment , stressful procedure
characterized by :
Subjective data :
- Reported feelings of anxiety , fear
Objective data :
- Restless
- Focus on yourself
- Less eye contact
- Choleric
- Tremor
- Facial tension
- Increased respiratory and pulse
- Sweat
Activity Intolerance NIC NOC
Insufficient physiological or psychological energy to endure or complete required or desired daily activities
Defining Characteristics:
Related Factors:
NOC
Suggested NOC Labels
NIC
Suggested NIC Labels
Nursing Interventions and Rationales
1. Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational.
Determining the cause of a disease can help direct appropriate interventions.
2. Assess client daily for appropriateness of activity and bed rest orders.
Inappropriate prolonged bed rest orders may contribute to activity intolerance. A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999).
3. Minimize cardiovascular deconditioning by positioning clients as close to the upright position as possible several times daily.
The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998).
4. If appropriate, gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to chair sitting, to standing, to ambulation.
Increasing activity helps to maintain muscle strength, tone, and endurance. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous, 1998).
5. Ensure that clients change position slowly. Consider using a chair-bed (stretcher-chair) for clients who cannot get out of bed. Monitor for symptoms of activity intolerance.
Bed rest in the supine position results in loss of plasma volume, which contributes to postural hypotension and syncope (Creditor, 1993).
6. When getting clients up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs.
Heart rate and blood pressure responses to orthostasis vary widely. Vital sign changes by themselves should not define orthostatic intolerance (Winslow, Lane, Woods, 1995).
7. Perform range-of-motion exercises if client is unable to tolerate activity.
Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Creditor, 1994).
8. Refer client to physical therapy to help increase activity levels and strength.
9. Monitor and record client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (ACSM, 1995):
10. Instruct client to stop activity immediately and report to physician if experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort, tightness, or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger.
These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician (McGoon, 1993). The client should be evaluated before resuming activity (Thompson, 1988).
11. Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).
12. Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers.
Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998).
13. Assess urinary incontinence related to functional ability. Assess independent ability to get to the toilet and remove and adjust clothing.
The loss of functional ability that accompanies disease often leads to continence problems. The cause may not be the person's bladder instability but his or her ability to get to the toilet quickly (Nazarko, 1997).
14. Assess for constipation.
Impaired mobility is associated with increased risk of bowel dysfunction, including constipation. Constipation increases the risk of urinary tract infection and urge incontinence (Nazarko, 1997).
15. Consider dietitian referral to assess nutritional needs related to activity intolerance.
Severe malnutrition can lead to activity intolerance. Dietitians can recommend dietary changes that can improve the client's health status (Peckenpaugh, Poleman, 1999).
16. Refer the cardiac client to cardiac rehabilitation for assistance in developing safe exercise guidelines based on testing and medications.
Cardiac rehabilitation exercise training improves objective measures of exercise tolerance in both men and women, including elderly patients with coronary heart disease and heart failure. This functional improvement occurs without significant cardiovascular complications or other adverse outcomes (Wenger et al, 1995).
17. Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity.
Supplemental oxygen increases circulatory oxygen levels and improves activity tolerance (Petty, Finigan, 1968; Casaburi, Petty, 1993).
18. Monitor a chronic obstructive pulmonary disease (COPD) client's response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, and skin tone changes such as pallor and cyanosis.
19. Instruct and assist COPD clients in using conscious controlled breathing techniques such as pursing their lips and diaphragmatic breathing.
Training clients with COPD to slow their respiratory rate with a prolonged exhalation (with or without pursed lips) helps control dyspnea and results in improved ventilation, increased tidal volume, decreased respiratory rate, and a reduced alveolar-arterial oxygen difference. This breathing pattern not only helps relieve dyspnea but can improve the ability to exercise and carry out ADLs (Mueller, Petty, Filley, 1970; Casaburi, Petty, 1993).
20. Provide emotional support and encouragement to client to gradually increase activity.
Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
21. Refer the COPD client to a pulmonary rehabilitation program.
Pulmonary rehabilitation has been shown to improve exercise capacity, walking ability, and sense of well-being (Fishman, 1994).
22. Observe for pain before activity. If possible, treat pain before activity, and ensure that client is not heavily sedated.
Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
23. Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen).
Assistive devices can increase mobility by helping the client overcome limitations.
24. Use a walking belt when ambulating a client who is unsteady.
With a walking belt the client can walk independently, but the nurse can provide support if the client's knees buckle.
25. Work with client to set mutual goals that increase activity levels.
Geriatric
1. Slow the pace of care. Allow client extra time to carry out activities.
2. Encourage families to help/allow elder to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary.
Encouraging activity not only enhances good functioning of the body's systems but also promotes a sense of worth by providing an opportunity for productivity (Eliopoulous, 1997).
3. When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting.
Orthostatic hypotension is common in the elderly as a result of cardiovascular changes, chronic diseases, and medication effects (Mobily, Kelley, 1991).
Home Care Interventions
1. Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services.
2. Assess the home environment for factors that precipitate decreased activity tolerance: presence of allergens such as dust, smoke, and those associated with pets; temperature; energy-intensive activity patterns; and furniture placement. Refer to occupational therapy if needed to assist the client in restructuring the home and activity of daily living patterns.
Clients and families often estimate energy requirements inaccurately during hospitalization because of the availability of support.
3. Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events).
4. Provide client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity.
Social isolation can contribute to activity intolerance.
5. Discuss the importance of sexual activity as part of daily living. Instruct the client in adaptive techniques to conserve energy during sexual interactions.
Families may make unsafe choices for sexual activity or place added stress on themselves trying to cope with this issue without proper support or teaching.
6. Instruct the client and family in the importance of maintaining proper nutrition and rest for energy conservation and rehabilitation.
7. Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living.
8. Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g., assistive devices, oxygen, medication, catheters, massage), especially for hospice patients. Evaluate intermittently.
Assessments ensure the safety and appropriate use of these supports.
9. Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated.
Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).
10. Be aware of increased risk of bone fracture even after muscle strength is normalized, especially in osteopenic-prone individuals such as estrogen-deficient women and the elderly.
Reduction in weight bearing muscle activity during bed rest invariably produces significant changes in calcium balance and, in weeks, changes in bone mass (Bloomfield, 1997)
11. Allow terminally ill clients and their families to guide care.
Control by the client or family promotes effective coping.
12. Provide increased attention to comfort and dignity of the terminally ill client in care planning. For example, oxygen may be more valuable as a support to the client's psychological comfort than as a booster of oxygen saturation.
Client/Family Teaching
1. Instruct client on rationale and techniques for avoiding activity intolerance.
2. Teach client to use controlled breathing techniques with activity.
3. Teach client the importance and method of coughing, clearing secretions.
4. Instruct client in the use of relaxation techniques during activity.
5. Help client with energy conservation and work simplification techniques in ADLs.
6. Teach client the importance of proper nutrition.
7. Describe to client the symptoms of activity intolerance, including which symptoms to report to the physician.
8. Explain to client how to use assistive devices or medications before or during activity.
9. Help client set up an activity log to record exercise and exercise tolerance.
Defining Characteristics:
- Verbal report of fatigue or weakness,
- abnormal heart rate or blood pressure response to activity,
- exertional discomfort or dyspnea,
- electrocardiographic changes reflecting dysrhythmias or ischemia
Related Factors:
- Bed rest or immobility;
- generalized weakness;
- sedentary lifestyle;
- imbalance between oxygen supply and demand
NOC
Suggested NOC Labels
- Endurance
- Energy Conservation
- Activity Tolerance
- Self-Care: Activities of Daily Living (ADLs)
- Participates in prescribed physical activity with appropriate increases in heart rate, blood pressure, and breathing rate; maintains monitor patterns (rhythm and ST segment) within normal limits
- States symptoms of adverse effects of exercise and reports onset of symptoms immediately
- Maintains normal skin color and skin is warm and dry with activity
- Verbalizes an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms
- Expresses an understanding of the need to balance rest and activity
- Demonstrates increased activity tolerance
NIC
Suggested NIC Labels
- Energy Management
- Activity Therapy
Nursing Interventions and Rationales
1. Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational.
Determining the cause of a disease can help direct appropriate interventions.
2. Assess client daily for appropriateness of activity and bed rest orders.
Inappropriate prolonged bed rest orders may contribute to activity intolerance. A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999).
3. Minimize cardiovascular deconditioning by positioning clients as close to the upright position as possible several times daily.
The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998).
4. If appropriate, gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to chair sitting, to standing, to ambulation.
Increasing activity helps to maintain muscle strength, tone, and endurance. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous, 1998).
5. Ensure that clients change position slowly. Consider using a chair-bed (stretcher-chair) for clients who cannot get out of bed. Monitor for symptoms of activity intolerance.
Bed rest in the supine position results in loss of plasma volume, which contributes to postural hypotension and syncope (Creditor, 1993).
6. When getting clients up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs.
Heart rate and blood pressure responses to orthostasis vary widely. Vital sign changes by themselves should not define orthostatic intolerance (Winslow, Lane, Woods, 1995).
7. Perform range-of-motion exercises if client is unable to tolerate activity.
Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Creditor, 1994).
8. Refer client to physical therapy to help increase activity levels and strength.
9. Monitor and record client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (ACSM, 1995):
- Excessive fatigue
- Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency
- Onset of angina with exercise
- Palpitations
- Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced left bundle block, second- or third-degree atrioventricular block, frequent premature ventricular contractions)
- Exercise hypotension (drop in systolic blood pressure of more than 10 mm Hg from baseline blood pressure despite an increase in workload, when accompanied by other evidence of ischemia)
- Excessive rise in blood pressure (systolic greater than 220 mm Hg or diastolic greater than 110 mm Hg); NOTE: these are upper limits; activity may be stopped before reaching these values
- Inappropriate bradycardia (drop in heart rate greater than 10 beats/min) with no change or increase in workload
- Increased heart rate above the prescribed limit
10. Instruct client to stop activity immediately and report to physician if experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort, tightness, or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger.
These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician (McGoon, 1993). The client should be evaluated before resuming activity (Thompson, 1988).
11. Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).
12. Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers.
Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998).
13. Assess urinary incontinence related to functional ability. Assess independent ability to get to the toilet and remove and adjust clothing.
The loss of functional ability that accompanies disease often leads to continence problems. The cause may not be the person's bladder instability but his or her ability to get to the toilet quickly (Nazarko, 1997).
14. Assess for constipation.
Impaired mobility is associated with increased risk of bowel dysfunction, including constipation. Constipation increases the risk of urinary tract infection and urge incontinence (Nazarko, 1997).
15. Consider dietitian referral to assess nutritional needs related to activity intolerance.
Severe malnutrition can lead to activity intolerance. Dietitians can recommend dietary changes that can improve the client's health status (Peckenpaugh, Poleman, 1999).
16. Refer the cardiac client to cardiac rehabilitation for assistance in developing safe exercise guidelines based on testing and medications.
Cardiac rehabilitation exercise training improves objective measures of exercise tolerance in both men and women, including elderly patients with coronary heart disease and heart failure. This functional improvement occurs without significant cardiovascular complications or other adverse outcomes (Wenger et al, 1995).
17. Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity.
Supplemental oxygen increases circulatory oxygen levels and improves activity tolerance (Petty, Finigan, 1968; Casaburi, Petty, 1993).
18. Monitor a chronic obstructive pulmonary disease (COPD) client's response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, and skin tone changes such as pallor and cyanosis.
19. Instruct and assist COPD clients in using conscious controlled breathing techniques such as pursing their lips and diaphragmatic breathing.
Training clients with COPD to slow their respiratory rate with a prolonged exhalation (with or without pursed lips) helps control dyspnea and results in improved ventilation, increased tidal volume, decreased respiratory rate, and a reduced alveolar-arterial oxygen difference. This breathing pattern not only helps relieve dyspnea but can improve the ability to exercise and carry out ADLs (Mueller, Petty, Filley, 1970; Casaburi, Petty, 1993).
20. Provide emotional support and encouragement to client to gradually increase activity.
Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
21. Refer the COPD client to a pulmonary rehabilitation program.
Pulmonary rehabilitation has been shown to improve exercise capacity, walking ability, and sense of well-being (Fishman, 1994).
22. Observe for pain before activity. If possible, treat pain before activity, and ensure that client is not heavily sedated.
Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
23. Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen).
Assistive devices can increase mobility by helping the client overcome limitations.
24. Use a walking belt when ambulating a client who is unsteady.
With a walking belt the client can walk independently, but the nurse can provide support if the client's knees buckle.
25. Work with client to set mutual goals that increase activity levels.
Geriatric
1. Slow the pace of care. Allow client extra time to carry out activities.
2. Encourage families to help/allow elder to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary.
Encouraging activity not only enhances good functioning of the body's systems but also promotes a sense of worth by providing an opportunity for productivity (Eliopoulous, 1997).
3. When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting.
Orthostatic hypotension is common in the elderly as a result of cardiovascular changes, chronic diseases, and medication effects (Mobily, Kelley, 1991).
Home Care Interventions
1. Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services.
2. Assess the home environment for factors that precipitate decreased activity tolerance: presence of allergens such as dust, smoke, and those associated with pets; temperature; energy-intensive activity patterns; and furniture placement. Refer to occupational therapy if needed to assist the client in restructuring the home and activity of daily living patterns.
Clients and families often estimate energy requirements inaccurately during hospitalization because of the availability of support.
3. Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events).
4. Provide client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity.
Social isolation can contribute to activity intolerance.
5. Discuss the importance of sexual activity as part of daily living. Instruct the client in adaptive techniques to conserve energy during sexual interactions.
Families may make unsafe choices for sexual activity or place added stress on themselves trying to cope with this issue without proper support or teaching.
6. Instruct the client and family in the importance of maintaining proper nutrition and rest for energy conservation and rehabilitation.
7. Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living.
8. Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g., assistive devices, oxygen, medication, catheters, massage), especially for hospice patients. Evaluate intermittently.
Assessments ensure the safety and appropriate use of these supports.
9. Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated.
Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).
10. Be aware of increased risk of bone fracture even after muscle strength is normalized, especially in osteopenic-prone individuals such as estrogen-deficient women and the elderly.
Reduction in weight bearing muscle activity during bed rest invariably produces significant changes in calcium balance and, in weeks, changes in bone mass (Bloomfield, 1997)
11. Allow terminally ill clients and their families to guide care.
Control by the client or family promotes effective coping.
12. Provide increased attention to comfort and dignity of the terminally ill client in care planning. For example, oxygen may be more valuable as a support to the client's psychological comfort than as a booster of oxygen saturation.
Client/Family Teaching
1. Instruct client on rationale and techniques for avoiding activity intolerance.
2. Teach client to use controlled breathing techniques with activity.
3. Teach client the importance and method of coughing, clearing secretions.
4. Instruct client in the use of relaxation techniques during activity.
5. Help client with energy conservation and work simplification techniques in ADLs.
6. Teach client the importance of proper nutrition.
7. Describe to client the symptoms of activity intolerance, including which symptoms to report to the physician.
8. Explain to client how to use assistive devices or medications before or during activity.
9. Help client set up an activity log to record exercise and exercise tolerance.
Subscribe to:
Posts (Atom)