Activity Intolerance related to Anemia

Anemia is a term that indicates a low red blood cell and hemoglobin level, and hematocrit below the normal. Anemia is not a disease, but rather a reflection of the state of a disease or disorder of the body functions. Physiologically anemia occurs when there is a shortage of hemoglobin to carry oxygen to the tissues.
(Brunner & Suddarth, 2001)

This oxygen will be used to burn sugars and fats into energy. This may explain why anemia can cause symptoms of weakness and lethargy are not uncommon. Lungs and heart were also forced to work harder to get oxygen from the blood that causes shortness of breath.

Symptoms of anemia :

• Weakness, lethargy, dizziness, irritability, or trouble concentrating.
• Especially in the pale gums and eyelids or under the nails.
• Heart palpitations shortness of breath.
• Thrush of the mouth or tongue, welts or unusual bleeding.
• Numbness or tingling in the legs.
• Nausea and diarrhea.

Activity intolerance related to imbalance between the oxygen supply (delivery) and needs.

Goal: to maintain / improve ambulation / activity.

Expected outcomes:

• Reported increased exercise tolerance (including activities of daily living).
• Showed a decrease in the physiological signs of intolerance, such as pulse, respiration, and blood pressure is still within normal range.

Interventions:

• Assess the patient's ability to ADL.
• Assess lost or impaired balance, gait and muscle weakness.
• Observation of vital signs before and after the activity.
• Provide quiet environment, limit visitors, and reduce noise, keep bedrest when indicated.
• Use energy-saving techniques, advise patients to rest, in case of fatigue and weakness, advise patients to do his best activity (without imposing themselves).

Rationale:

• Affect the choice of intervention / assistance.
• Show neurological changes due to vitamin B12 deficiency affects patient safety / risk of injury.
• Cardiopulmonary manifestations of heart and lung efforts to bring an adequate amount of oxygen to the tissues.
• Increase rest to lower the oxygen needs of the body and lowers the strain the heart and lungs.
• Increase activity gradually, until normal and improve muscle tone / stamina without drawbacks. Boost self-esteem and sense of control.

Nursing Diagnosis for Skin Infections related to Fungi, Bacteria and Viruses

Infection is the process of invasive organisms and proliferate in the body that cause disease (Potter & Perry, 2005). Meanwhile, the skin infection is a disease caused by a bacteria / germs, viruses, fungi.

Bacterial Infections (Pyoderma)

Bacterial infections of the skin can be primary or secondary. Primary skin infections originated from previous skin looks normal, and usually these infections are caused by one type of microorganisms. Secondary skin infections caused by skin disorders preexisting or due to disruption of the integrity of the skin due to injury or surgery. In both these circumstances, some types of microorganisms can be involved, such as Staphylococcus aureus or group streptokus A. Primary bacterial infection that most often the case, among others:

• Bullous impetigo. Is a superficial infection of the skin caused by Staphylococcus aureus, characterized by bullae formation of vesicles origin. The bullae rupture and leave red lesions as well as wet.
• Folliculitis. A staphylococcal infections arising in the hair follicle. Lesions can be either superficial or deep. Often seen on the chin area men who shave the beard and the limbs of women.
• Pseudofolliculitis barbae ("shaving bumps"). An inflammatory reaction in the face of curly haired man who happens because hair growth inward, piercing the skin and trigger irritating reactions.
• Furuncles (boils). Is an acute skin inflammation resulting in one or more hair follicles and spread to the surrounding dermis layer. More often occurs in areas of irritation, such as: posterior neck, axilla or gluteus.
• Carbuncles. An abscess on the skin and subcutaneous tissue depicting expansion of a furuncle that have invaded several pieces of hair follicles. Carbuncles most often found in areas where the skin is thick and inelastic.

Virus Infection

The most common infection is herpes zoster. Shingles is a viral inflammatory disorder, in which the virus causes vesicular eruptions that cause pain along the sensory nerve distribution of one or more posterior ganglion.


Mycotic Infection (Fungus)

Fungus (mushroom) which is a member of the plant world are small and eating of organic matter, is the cause of various types of skin infections which are often found, among other things:

• Tinea pedis (foot fungus / athlete's foot). Is a fungal infection that most often found. These infections often affects adolescents and young adults although can occur in any age group as well as male and female.
• Tinea corporis (body fungal disease). Affects the face, neck, trunk and extremities. At the infected part will look ring-shaped lesions, or circle typical.
• Tinea capitis (scalp fungal disease). Is a contagious fungal infection that attacks the hair shaft and causes of hair loss are often found among children.
• Tinea cruris (groin fungal disease). Is a fungal infection of the groin that extends to the inner thighs and buttocks. Most often occurs in younger runners, people who are obese and who wear underwear too tight.
• Tinea unguium (onychomycosis). Is a chronic fungal infection of the toenails or fingernails. Usually accompanied by a fungal infection that is long in the legs.

Nursing Diagnosis for Skin Infections related to Fungi, Bacteria and Viruses

1. Acute Pain related to peripheral nerve damage.
2. Hyperthermia related to the inflammatory process.
3. Impaired skin integrity related to damage to the structure of the dermis layer.
4. Disturbed body image related to the lesions and skin structure changes.
5. Anxiety related to the disease process.

Nursing Diagnosis for Acute and Chronic Pancreatitis

Acute and Chronic Pancreatitis

Pancreatitis is inflammation in the pancreas.
There are two types of pancreatitis, acute and chronic.

Acute pancreatitis
Acute pancreatitis is a serious condition where the pancreas becomes inflamed over a short period of time.

Symptoms most commonly begins with abdominal pain in the middle or upper left part of the abdomen and may increase after eating or lying flat the back.
Other symptoms :

• nausea,
• fever,
• rapid heartbeat, and
• dehydration.
• severe acute pancreatitis symptoms and signs may show skin discoloration around the belly button or the side of the body between the ribs and hip (flank), or small erythematous skin nodules.

Chronic pancreatitis
Chronic pancreatitis is a condition where the pancreas becomes permanently damaged due to inflammation.

Symptoms may or may not include abdominal pain that may include :

• bleeding due to anemia,
• liver problems (jaundice),
• weight loss,
• nutritional deficiencies, and
• inability to produce insulin resulting in diabetes.

Causes of acute and chronic pancreatitis are similar; about 80%-90% are caused by alcohol abuse and gallstones (about 35%-45% for each); while the remaining 10%-20% are caused by

• medications,
• chemical exposures,
• trauma,
• hereditary diseases,
• infections,
• surgical procedures, and
• high fat levels in the blood and genetic abnormalities with pancreas or intestine

Nursing Diagnosis for Acute and Chronic Pancreatitis

1. Ineffective breathing pattern related to a decrease in oxygen entering the lungs.
2. Impaired tissue perfusion related to a decrease in blood supply to the tissues.
3. Fluid volume deficit related to a decrease in the amount of fluid in the intravascular.
4. Acute pain related to abdominal distention capsule.
5. Fluid volume related to the buildup of excess fluid in the peritoneal cavity.
6. Hyperthermia related to an infection of the peritoneum and gallbladder.

Altered urinary elimination related to a decrease in urine output.
Risk for imbalanced nutrition: less than body requirements related to nausea and vomiting.
Activity intolerance related to a decrease in the formation of energy.

Risk for Aspiration related to GERD (Gastroesophageal Reflux Disease)

Nursing Care Plan for GERD (Gastroesophageal Reflux Disease)
 
Gastroesophageal reflux disease (GERD) is a chronic digestive disease. GERD occurs when stomach acid or, occasionally, stomach contents flowing back into the food pipe (esophagus). Backwash (reflux) irritate the lining of the esophagus and causes GERD.

Both disorders stomach acid and heartburn is a common digestive condition that many people experience from time to time.

Signs or symptoms of GERD:

• A burning sensation in the chest (heartburn), sometimes spreading to the throat, along with a sour taste in the mouth.
• Chest pain.
• Difficulty swallowing (dysphagia).
• Dry cough.
• Hoarseness or sore throat.
• Regurgitation of food or sour liquid (acid reflux).
• Sensation of a lump in the throat.

Nursing Diagnosis and Interventions for GERD (Gastroesophageal Reflux Disease)

Risk for aspiration related to barriers to swallow, decreased reflexes of the larynx and glottis to liquid reflux.

Goals: None of aspiration.

Expected outcomes:

• The client can breathe easy, normal breathing frequency.
• The client is able to swallow, chew without aspiration, and capable of performing oral hygiene.
• Patent airway, breathing easily, do not feel suffocated and no abnormal breath sounds.

Interventions:

• Monitor the level of consciousness, cough reflexes and the ability to swallow.
• Raise the head of 30-45 degrees after eating.
• Cut food into small pieces.
• Avoid eating when residue is still a lot.

Rationale:

• Increase the maximum lung expansion and airway clearance.
• Increase air filling the entire segment of the lung, mobilize and remove secretions.
• Avoid the risk of aspiration is too high.
• Gastroesophageal may limit expansion.

Assessment and Nursing Diagnosis for UTI

Urinary Tract Infection

Urinary tract infection is the development of microorganisms in the urinary tract, but under normal circumstances does not contain bacteria, viruses, or other microorganisms. Urinary tract infections can occur anywhere, from the urethra, uterus bladder, ureters (fibromuskuler channel that drains urine from the kidney to the urinary contents) or kidney.

Symptoms of Urinary Tract Infection

• Frequent urination along with the feeling of need to urinate even though there may be a little urine to pass.
• Nocturia: Need to urinate at night.
• Urethritis: Discomfort, irritation or pain in meatus or a burning sensation along anyway urethra with urination (dysuria).
• Pain in the midline suprapubic region.
• Pyuria: Pus in urine or urethral discharge.
• Hematuria: Blood in the urine (not always visible to the eye, but often revealed during urine tests).
• Pyrexia: Mild fever
• Cloudy and foul-smelling urine

Nursing Assessment of Urinary Tract Infection

1. Physical examination : do head to toe
2. History or presence of risk factors :

• Is there a history of previous infections ?
• Is there a history of obstruction of the urinary tract ?

3. The presence of factors predisposing patients to nosocomial infections .

• What about mounting folley catheter ?
• Immobilization in a long time ?
• Is urinary incontinence occurs ?

4. Assessment of clinical manifestations of urinary tract infections

• How voiding pattern ? to detect the occurrence of UTI predisposing factors (encouragement, frequency, and amount)
• Is there dysuria ?
• Is there urgency ?
• Is there hesitancy ?
• Is there a pungent smell of urine ?
• How orine output of volume, color ( grayish ) and the concentration of urine ?
• Is there a suprapubic pain - usually on lower urinary tract infection ?
• Are there any pelvic pain or waist - usually the upper urinary tract infection ?
• Increased body temperature is usually in the upper urinary tract infections.

5. Psychological assessment of patients :
How feelings toward patients and treatment outcome measures that have been done ?
Is there any sense of shame or fear of recurrence of the disease.


Nursing Diagnosis of Urinary Tract Infection

1. Impaired sense of comfort: Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

2. Altered Urinary Elimination related to mechanical obstruction of the bladder or other urinary tract structures.

3. Deficient Knowledge: about condition, prognosis, and treatment needs related to lack of resources.

Nursing Diagnosis for Vomiting - Risk for Fluid Volume Deficit

Vomiting is defined as the discharge of the contents of the stomach up into the mouth by force. Vomiting can be an attempt removing toxins from the gastrointestinal tract such as diarrhea, lower gastrointestinal tract.

Vomiting can be caused by many things such as the following:

• Congenital abnormalities
• Infection of the digestive tract
• Feeding the wrong way
• Poisoned

Complications of vomiting are as follows :

• Dehydration or alkalosis, due to loss of body fluid / electrolyte
• Ketosis from not eating and drinking
• Acidosis caused a sustained ketosis can be a shock even to seizures
• Abdominal muscle tension, conjunctival hemorrhage, esophageal rupture, aspirations, caused by severe vomiting.

Persistent vomiting can lead to complications of dehydration, electrolyte disturbances, rips Mallory Wiess, aspiration of gastric fluid.


Nursing Diagnosis for Vomiting

Risk for Fluid Volume Deficit related to the feeling of nausea and vomiting

Goal: Maintain the balance of fluid volume.

Outcomes: The client does not nausea and vomiting.

Intervention:
1. Monitor vital signs.
Rationale: An early indicator of hypovolemia.

2. Monitor intake and output and urine concentration.
Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one impression of dehydration and require increased fluids.

3. Give fluid little by little but often.
Rationale: To minimize the loss of fluids.

4. The risk of infection associated with an inadequate immune, characterized by: body temperature above normal. Increased respiratory rate.

NCP - Nursing Diagnosis of Acute Pain related to BPH

Nursing Care Plan for Benign Prostatic Hyperplasia

BPH is a progressive enlargement of the prostate gland (in general in men older than 50 years) causes various degrees of urethral obstruction and urinary flow restriction (Marilynn, ED, 2000: 671).

The exact cause of the occurrence of BPH as yet unknown. But certainly the prostate gland depends on androgens. Another factor which is closely related to BPH are aging There are several possible causes of factors, among others:

1). Dihydrotestosterone (DHT)
Increased 5 alpha reductase and androgen receptor causes epithelial and stromal hyperplasia of the prostate gland experience.

2). Changes in the balance of estrogen - testosterone
The aging process in men increased estrogen and decreased testosterone resulting in stromal hyperplasia.

3). Interaction stromal - epithelial
Increased epidermal gorwth factor or fibroblast growth factor and transforming growth factor beta reduction causes stromal and epithelial hyperplasia.

4). Reduced cell death
Increased estrogen causes increased longevity stroma and epithelium of the prostate gland.

5). Back resurrection theory (reawakening) of urogenital sinus mesenchyme ability to proliferate and form the prostate tissue.


Symptoms of Benign Prostatic Hyperplasia

Based on the grade, divided into 4 grades as follows:

1st Grade : Congestic

• Patients early months or years of hard-urinary and began straining.
• If micturition was satisfied.
• Urine drips out and poor stream.
• nocturia
• Urine out at night more than normal.
• Longer than normal erection and more libido than normal.
• On hyperemia cytoscopy visible from the internal urethral orifice. Occurs slowly bleeding varices could eventually happen (blooding).

2nd Grade : Residual

• When micturition is hot.
• Nocturia Dysuria gain weight.
• Can not urinate (urinary dissatisfied).
• Infection can occur because of residual urine.
• High heat can occur and chills.
• Pain in the lumbar region (spreading to the kidneys).

3rd Grade : Urinary retention

• Ischuria paradosal.
• Incontinensia paradosal.

4th Grade

• Full bladder.
• Patients feel pain.
• Urine dripped periodically called over flow incontinensia.
• On physical examination, palpation of the lower abdomen to feel there is a tumor, because of a great dam.
• Patients with an infection and high fever can shiver around 40-41 ° C.
• Then the patient could commas.

Nursing Diagnosis for Benign Prostatic Hyperplasia : Acute Pain related to irritation of the bladder mucosa, bladder distension, renal colic, urinary infection.

Goal: Pain is lost / controlled.

Outcomes:
Clients reported pain relief / control, relaxation skills and demonstrate therapeutic activity as indicated for individual situation. Seemed to relax, sleep / rest appropriately.

Nursing Interventions :

1 . Assess pain , note the location , intensity ( scale of 0-10 ) .
R / : sharp pain , intermittent with the urge to urinate / massage urine around the catheter showed spasm of the bladder , which tend to be heavier on the approach TURP ( usually decreases within 48 hours ) .

2 . Maintain patency of the catheter and drainage system . Keep the hose free of grooves and clot .
R / : Maintaining the function of the catheter and drainage system , reduce the risk of distension / bladder spasm .

3 . Maintain bed rest when indicated
R / : Required during the initial phase during the acute phase .

4 . Provide comfort measures ( therapeutic touch , changing position , back massage ) and therapeutic activity .
R / : Reduce muscle tension , back memfokusksn attention and can improve coping skills .

5 . Give soak sit or heating lamps when indicated .
R / : Improving tissue perfusion and improvement of edema and promote healing ( perineal approach ) .

6 . Collaboration in the provision antispasmodic
R / : Eliminates spasm .

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:

• 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

If you notice any symptoms of PROM, be sure to call your physician as soon as possible. The symptoms of PROM may resemble other medical conditions. Consult your physician for a diagnosis.

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.

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:

• 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:

1. Clean the field operations of several organisms that may be present through the principles of shearing.
2. Give laxatives 1 day before surgery.
3. Encourage clients with the perfect bath.
4. 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

Intervention:

1. Assess the level of pain, location and characteristics.
2. Encourage deep breathing.
3. Give analgesics.

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

• 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.

Symptom

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

1. Disturbed Sensory Perception
2. Anxiety
3. Acute pain
4. Disturbed Body Image
5. 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

• 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:

1. Ineffective airway clearance related to decreased lung expansion.
2. Fluid volume deficit related to diaphoresis.
3. 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.

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

• 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

neurogenic, or chemicals (anaphylactic), severe pain, psychological stress, neurological damage, cholinergic drugs, alpha adrenergic blocker agent.

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.

Drug therapy:

• 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:

• 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.

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 :

• 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