Autism is a cognitive disorder that affects the developmental or learning ability of an individual. The manifestations of the disorder usually appear as early as the first three years of life. As a result of the neurological disorder, it disrupts the normal functioning of the brain affecting the development of the communication skills and social interaction skills of the person. Difficulties in verbal and non-verbal communication, leisure activities, and social interaction are seen in both children and adults with the disorder.
Causes of Autism
The actual cause of autism is still unknown. However, following are some of the known causes of autism:
- Structural or functional damage of central nervous system
- Genetic conditions
- Abnormal development of brain
- Rett syndrome
- Biochemical defects
- Seizure
- Landau kleffner syndrome
The symptoms of autism differ from person to person. However, following are some of the symptoms of autism:
- Problem in non-verbal communication
- Difficulty in interacting with people
- Problem in expressing emotions
- Ritualistic behavior
- Repetitive body movements
- Resisting changes
- Restricted interests
- Seizures
- Self injurious and aggressive behavior
Diagnosis of Autism
There is no lab test that can detect autism. Autism is often diagnosed when a baby or toddler doesn’t behave as expected for his or her age. If your doctor thinks your child has autism, he or she will probably suggest that your child see a child psychiatrist or other specialist. The specialist will probably test your child to see if he or she shows signs of autism.
Treatments for Autism
Different autism professionals practice different procedures for treating autism. However, following are some of the treatments for autism:
- Special education for the child
- Behavioral management
- Medications
- Biomedical and complementary therapies
- Antipsychotic drugs
- Minerals, vitamins and dietary interventions
NANDA Nursing Diagnosis for Autism
According to Townsend, MC (1998) can be formulated nursing diagnosis in patients / children with pervasive developmental disorder of autism include:
1. Risk for Self-Mutilation related to:
- Developmental tasks that are not resolved from trust to distrust.
- Fixation on pre-symbiotic phase of development.
- Pathophysiological changes that occur in response to physical conditions such as maternal rubella, phenylketonuria is not resolved, encephalitis, tuberculosis sclerosis, anoxia during birth and syndrome X fragilis.
- Maternal deprivation.
- Sensory stimulation that is not appropriate.
- History behaviors mutilation / injure themselves in response to the increasing anxiety.
- Obvious indifference to the environment or the hysterical reactions to changes in the environment.
- Impaired self-concept.
- The absence of people nearby.
- Unresolved developmental task of believers versus unbelievers.
- Pathophysiological changes that occur in response to physical conditions such as maternal phenylketonuria rubella is not resolved, encephalitis, tuberous sclerosis, anoxia during birth syndrome X. fragilis
- Maternal deprivation.
- Sensory stimulation that is not appropriate.
- The inability to trust.
- Withdrawal from self.
- Pathophysiological changes that occur in response to physical conditions such as maternal phenylketonuria rubella is not resolved, encephalitis, tuberous sclerosis, anoxia during birth fragilis X syndrome
- Maternal deprivation.
- Sensory stimulation that is not appropriate.
- Prasimbiotik fixation phase of development.
- Uncompleted tasks of trust versus mistrust.
- Maternal deprivation.
- Sensory stimulation that is not appropriate.
Nursing Care Plan for Diarrhea – Nursing Diagnosis: Fluid Volume Deficit related to frequent bowel movements
Goal:
- Fluid balance can be maintained within normal limits
characterized by:
- Urine output in accordance
- Capillary refilling less than 2 seconds
- Elastic skin turgor
- Mukusa membranes moist
- Showed no weight loss
Expected outcomes
- Children get enough fluids to replace lost fluids.
- Children show signs of adequate hydration is characterized by moist mucous membranes, good skin turgor, the normal eye, vital signs within normal limits.
Nursing Interventions: Fluid Volume Deficit – Nursing Diagnosis for Diarrhea
Independent
1. Assess hydration status
Rational: direct indicator of fluid status / repair imbalances.
2. Assess fluid intake and output.
Rationale: Shows the overall hydration status.
3. Monitor vital signs.
rational:
Assist in the evaluation of the degree of fluid deficit / effectiveness of fluid replacement therapy and response to treatment.
Collaboration
1. Laboratory tests according to the program; electrolytes, hematocrit, pH, serum albumin.
Rationale: Provides information on hydration, organ function.
2. Fluid and electrolyte suitable protocol (with oralit and parenteral fluids).
Rationale: Fill / maintain circulating volume and electrolyte balance.
Definition
Intussusception is the inclusion of part of the intestine into the
border or the more distal parts of the intestine (general, ileal
invagination into the descending colon). (Nettina, 2002)
Invagination or intussusception occurs when some gastrointestinal
driven such that a portion of it will cover most of the other to shrink
or retracts fully into a segment that is located next to the caudal.
(Nelson, 1999).
An intussusception is a medical condition in which a part of the
intestine has invaginated into another section of intestine, similar to
the way in which the parts of a collapsible telescope slide into one
another. This can often result in an obstruction. The part that
prolapses into the other is called the intussusceptum, and the part that
receives it is called the intussuscipiens. (wikipedia)
Clinical Manifestations
Early symptoms can include nausea, vomiting (sometimes bile stained
(green color)), pulling legs to the chest area, and intermittent
moderate to severe cramping abdominal pain. Pain is intermittent not
because the intussusception temporarily resolves, but because the
intussuscepted bowel segment transiently stops contracting. Later signs
include rectal bleeding, often with “red currant jelly” stool (stool
mixed with blood and mucus), and lethargy. Physical examination may
reveal a “sausage-shaped” mass felt upon palpation of the abdomen.
In children or those too young to communicate their symptoms
verbally, they may cry, draw their knees up to their chest or experience
dyspnea (difficult or painful breathing) with paroxysms of pain.
Fever is not a symptom of intussusception. However, intussusception
can cause a loop of bowel to become necrotic, secondary to ischemia due
to compression to arterial blood supply. This leads to perforation and
sepsis, which causes fever.
Nursing Care Plan for Intussusception
Nursing Assessment – Nursing Care Plan for Intussusception
1. Assessment of general physical
2. Medical history
3. Observation stool patterns and behavior before and after surgery
4. Observations of behavior of children / infants
5. Observation manifestations occur intussusception:
- Paroxysmal abdominal pain.
- Children screamed and fold knees toward your chest.
- Children seem normal and comfortable during the interval between episodes of pain.
- Vomiting.
- Lethargy.
- Currant jelly-like stool containing blood and mucus, hemocculi test positive.
- Feces no increase.
- Abdominal distention and tenderness.
- Palpable mass in the abdomen are like sausages.
- The anus that looks unusual, it can seem like a rectal prolapse.
- Dehydration and fever to rise 41 0C.
- Things like shock with rapid pulse, pale and sweating a lot.
6. Observation of the chronic manifestations of intussusception:
- Diarrhea.
- Anorexia.
- Losing weight.
- Sometimes vomiting.
- Periodic pain.
- Pain without other symptoms.
7. Assess the diagnostic procedures and tests such as plain abdominal examination, barium enema and ultrasonogram.
Nursing Diagnosis – Nursing Care Plan for Intussusception
1. Acute Pain related to bowel invagination.
2. Ineffective Tissue Perfusion: shock hipolemik related to vomiting, bleeding and accumulation of fluid and electrolytes in the lumen.
3. Anxiety related to lack of knowledge, foreign environment.
4. Ineffective Thermoregulation related to the process of inflammation, fever.
5. Acute Pain related to surgical incision.
Definition of Nasopharyngeal Carcinoma
Nasopharyngeal carcinoma is a malignant tumor that grows in the
nasopharynx with a predilection in Rossenmuller fossa and roof of the
nasopharynx.
Etiology of Nasopharyngeal Carcinoma
High incidence of nasopharyngeal carcinoma is associated with eating
behavior, environment and Epstein-Barr virus. Besides geographic
factors, racial, gender, genetics, occupation, habits of life, culture,
socio-economic, bacteria or parasite infections also affect the
likelihood of this tumor.
Signs and Symptoms of Nasopharyngeal Carcinoma
Symptoms of nasopharyngeal carcinoma can be divided into 4 sections, which include:
1. Symptoms of nasopharyngeal
Nasopharyngeal Symptoms can be mild epistaxis or nasal obstruction.
2. Disorders of the ear
An early warning because the place of origin of the tumor near the mouth
of the Eustachian tube (Rosenmuller fossa). Disruption resulting from
blockage of the Eustachian tube, such as tinnitus, deafness, ear
discomfort until the pain in the ear.
3. Eye and neurological disorders
Because of the proximity to the cranial cavity, then there is spreading
through the foramen lacerum, which will hit the brain to nerves III, IV,
VI thus encountered diplopia, squint, exoftalmus, and nerves to the V
form of motor and sensory disturbances.
4. Metastasis to the cervical lymph
Namely in the form of lump medial to the sternocleidomastoid muscular that eventually form large masses to the skin shiny.
Nursing Assessment – Nursing Care Plan for Nasopharyngeal Carcinoma
1. Hereditary factors or a history of cancer in the family eg mother or grandmother with a history of breast cancer.
2. Spheres of influence, such as chemical irritants, smoke a certain kind of wood.
3. The habit of cooking with certain ingredients or spices and eating
foods that are too hot and preserved foods (meat and fish).
4. Low socioeconomic classes will also be related to the environment and living habits.
5. Signs and symptoms:
Activity
Weakness or fatigue. Changes in the patterns of rest; presence of factors that affect sleep such as pain, anxiety.
Circulation
As a result of tumor metastases are palpitations, chest pain, decreased blood pressure, epistaxis / nose bleeding.
Ego integrity
Stress factors, concerns about appearance changes, deny the diagnosis,
feelings of helplessness, loss of control, depression, withdrawal,
anger.
Elimination
Changes in bowel habit constipation or diarrhea, urinary elimination alteration, change of bowel sounds, abdominal distension.
Food / fluid
Poor dietary habits (low fiber, additives, preservatives), anorexia,
nausea / vomiting, mouth dryness, food intolerance, weight changes,
cachexia, changes in humidity / skin turgor.
Neuro-sensory
Headache, tinnitus, deafness, diplopia, squint, eksoftalmus
Pain / comfort
Discomfort in the ear to ear pain (otalgia), stiffness in the neck area due to tissue fibrosis caused by radiation
Breathing
Smoking (tobacco, marijuana, living with someone who smokes), exposure
Security
Exposure to toxic chemicals, carcinogens, exposure to the sun old / redundant, fever, skin rash.
Sexuality
Sexual problems such as the impact of the relationship, changes in the level of satisfaction.
Social interaction
Inadequate / support system weaknesses
Nursing Diagnosis for Cirrhosis :
Risk for Injury related to portal hypertension, changes in clotting mechanisms and disruption in the process of drug detoxification.
Goal : Reducing the risk of injury.
Nursing Interventions, Rational and Outcome criteria – Risk for Injury related to Cirrhosis:
1. Notice any feces excreted to check the color, consistency and amount.
Rational : Allows detection of bleeding in the gastrointestinal tract.
2. Be aware of the symptoms of anxiety, a feeling of fullness in the epigastrium, weakness and restlessness.
Rational : Can show early signs of bleeding and shock.
3. Check each stool and vomit to detect occult blood.
Rational : detecting early signs that prove the bleeding.
4. Observe hemorrhagic manifestations: ecchymosis, epistaxis, petechiae and bleeding gums.
Rational : Shows the changes in the blood clotting mechanism.
5. Record vital signs at regular intervals.
Rational : Provide the basis and evidence of hypovolemia and shock.
6. Keep the patient calm and restrict activity.
Rational : Minimizing the risk of bleeding and straining.
7. Observations conducted during blood transfusion.
Rational : Allows detection of transfusion reactions (risk will increase
with the implementation of more than one transfusion is needed to
address the active bleeding from esophageal varices).
8. Measure and record the nature, timing and amount of vomit.
Rational : Help evaluate the extent of bleeding and blood loss.
9. Keep the patient in a state of fasting if needed.
Rational : Reduce the risk of aspiration of gastric contents and
minimize the risk of further injury to the esophagus and stomach.
10. Give vitamin K as prescribed.
Rational : Improve freezing by providing fat-soluble vitamins are necessary for blood clotting mechanism.
11. Accompany patients continuously for bleeding episodes.
Rational : Calming anxious patients and enable monitoring and detection of subsequent patient needs.
12. Offer a cold drink by mouth when bleeding is resolved (if instructed).
Rational : Reduce the risk of further bleeding by vasoconstriction of blood vessels increases the esophagus and stomach.
13. Take action to prevent injury:
a. Maintaining a safe environment.
Rational : Reducing the risk of trauma and bleeding to avoid injuries, falls, cuts, etc..
b. Encourage patient to blow his nose slowly.
Rational : Reduce the risk of epistaxis secondary to trauma and decrease blood clotting.
c. Provides a soft toothbrush and avoid using toothpicks.
Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.
d. Encourage consumption of foods with a high vitamin C content.
Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.
e. Perform a cold compress if necessary.
Rational : Reduce bleeding into the tissues by increasing local vasoconstriction.
f. Take note of the location where the bleeding.
Rational : Allows detection of new and bleeding where monitoring of previous bleeding.
g. Using a smaller needle when injecting.
Rational : Minimizing blood loss due to seepage and injecting many times.
14. Give drug with caution; monitor adverse drug delivery.
Rational : Reduce the risk of side effects that occur secondary to the
inability of the damaged liver to detoxify (metabolize) the drug
normally.
Outcome criteria :
- Show no significant bleeding from the gastrointestinal tract.
- Show no anxiety, a feeling of fullness in the epigastrium and other indicators that show hemorrhage and shock.
- Shows the results of the examination were negative for occult gastrointestinal bleeding.
- Free from areas that experienced ecchymosis or hematoma formation.
- Showed vital signs were normal.
- Maintaining a break in a state of calm when there is active bleeding.
- Recognizing the rationale for a blood transfusion and action to overcome the bleeding.
- Take action to prevent the trauma (eg, use a soft toothbrush, blow slowly, avoid knock and drop, avoid straining during defecation).
- Did not experience the side effects of drug delivery.
- Use all medications as prescribed.
- Recognizing rational to perform maintenance actions using all drugs.
Definition
Infection is associated with the proliferation of microorganisms in the human body, along with the body’s reaction to it.
Postpartum infections (puerperal sepsis or fever after childbirth) is a clinical infection in the genital tract that occurs within 28 days after abortion or childbirth (Bobak, 2004).
Etiology
This infection occurs after childbirth, the bacteria enter the body at the time of the birth process. Among them, when membranes rupture before, or during labor is to become a bridge entry of germs in the body through the uterus.
Infection can occur due to bacteria that are often found in the vagina (endogenous) or due to exposure to pathogenic agents from outside the vagina (exogenous) (Bobak, 2004). However, this infection usually does not cause disease in labor, birth or postpartum. Nearly 30 bacteria have been identified under the canals genital (vulva, vagina and cervix) at any time (Faro 1990). While some of it, including some of the fungus, are considered non pathogenic under most environments, and are at least 20, including E. coli, Staphylococcus aureus, Proteus mirabilis and Klebsiella pneumoniae, are pathogenic (Tietjen, L; Bossemeyer, D, & McIntosh, N , 2004).
Clinical Manifestations
Rubor (redness), calor (local fever) caused vasodilation and tumor (swelling) due to exudation. Nerve endings will feel stimulated by inflammation so that there are pain (dolor). Pain and swelling will lead to physiological disorders, and common reactions include headache, fever and increased heart rate (Sjamsuhidajat, R. 1997).
Pathophysiology
The reaction of the body can be a local reaction and may also be the general reaction. In infections with common reaction would involve neurological and metabolic reactions occur at that light-reticular limpo throughout the body, such as the proliferation of phagocytic cells and antibody producing cell (B lymphocyte). Then the local reaction is called an acute inflammatory reaction was continued during a process of tissue destruction by trauma. When the cause of destruction of tissue can be eradicated, then the rest of the damaged tissue called debris, will be in phagocytosis and removed by the body until there is a resolution and healing. When excessive trauma, corrections phagocytic cells sometimes excessively so excessive debris collects in a cavity or abscess formation gathered in other body tissues form flegman (extensive inflammation of connective tissue).
Prevention and Treatment
Reduce or prevent the predisposing factors such as anemia, malnutrition and weakness and treat the illnesses suffered by the mother.
Coitus in late pregnancy should be avoided or minimized and do be careful as it can cause rupture of the membranes. If this happens infection will easily fit in the birth canal. Avoid too long parturition and rupture length / take care that no protracted labor.
Resolving labor with little trauma as possible.
Injury to the vaginal birth for both action and periabdominal, cleaned, stitched as well as possible and maintain sterility.
Prevent bleeding a lot, if there is blood loss should be replaced by a blood transfusion.
All officers in the delivery room should cover the nose and mouth with a mask; suffering from respiratory infections are not allowed into the delivery room.
These tools and fabrics used in childbirth, should be disinfected.
Avoid repeated examination, do when there is a good indication to sterilization, especially if the membranes have ruptured.
Nursing Diagnosis for Postpartum Infections
1. Acute comfortable related to the inflammatory process.
2. Altered Body Temperature related to an increase in the metabolic rate.
3. Anxiety related to change in health status.
General purpose:
Clients do not injure themselves, others, and the environment.
Specific purpose:
1. Clients can build a trusting relationship with the nurse.
Rationale: The relationship of trust is fundamental to facilitate the interaction.
Nursing Interventions:
- Construct a trusting relationship: therapeutic greetings, introduce yourself, explain the purpose of the interaction, create a quiet environment, create a clear contract (subject, time, place).
- Do not argue and support the client’s delusions: tell the nurse receives client confidence “I accept your beliefs” with expressions received, say nurses do not support, accompanied by expressions of doubt and empathy, did not discuss the content of delusions clients.
- Ensure clients are safe and secure: tell the nurse will accompany the client and the client is in a safe place, use the openness and honesty do not leave the client alone.
- Observation is delusional disrupt daily activities and self-care.
Rationale: By knowing the capabilities of the client, it will allow nurses to direct the activities that are beneficial to the client rather than just thinking about it.
Nursing Interventions:
- Give compliments on the appearance and capabilities of clients are realistic.
- Discuss with clients the capabilities of past and present realistic.
- Ask the client, what is usually done, and encourage clients to do it now (linked with daily activities and self-care).
- If the client is always talking about delusions, listen to the needs of suspicion does not exist. Show the client that the client is essential.
Rationale: By knowing the needs of clients who have not met the nurse, can plan to meet them and pay more attention to the needs of the client, so the client feels comfortable and safe.
Nursing Interventions:
- Observation of daily client needs.
- Discuss the client’s needs are not being met, either for at home or in the hospital (pain, anxiety, anger).
- Connect the unmet needs and the emergence of delusions.
- Increase activities that can meet the needs of clients and require time and effort (for the schedule if possible).
- Set the circumstances that the client does not have time to use the delusions.
Rationale: In reality, the client can open his mind, that the reality is more true, than on what he thinks the client, so the client can eliminate the existing delusions.
Nursing Interventions:
- Speaking with clients in the context of reality (self, other people, places and times).
- Include the client in group activity therapy: reality orientation.
- Give praise to the positive activities undertaken by the client.
Rationale: The use of medications regularly and properly, will affect the healing process and the effects and side effects of drugs.
Nursing Interventions:
- Discuss with the client about drug name, dosage, frequency, effects and side effects of medication.
- Help clients use the drug with the principle of true 5 (patient name, drugs, dose, method and time).
- Encourage clients to talk about the effects and side effects of the drug are felt.
- Give reinforcement when the client is taking the correct medication.
Rationale: Support and care of the family in caring for clients will be helping with the healing process of clients.
Nursing Interventions:
- Discuss with the client’s family, through family meetings about: symptoms of delusions, how to care for the client, the family and follow-up drug.
- Give reinforcement on family involvement.
Definition
Chest pain comes in many varieties, ranging from a sharp stab to a
dull ache. Some types of chest pain can be described as crushing or
burning. In certain cases, the pain travels up the neck, pierces through
to the back or radiates down one or both arms.
Deciding the cause of chest pain is sometimes very difficult and may
require blood tests, X-rays, CT scans and other tests to sort out the
diagnosis. Often though, a careful history taken by the health care
professional may be all that is needed to find the answer.
Assessment conducted in nursing care of chest pain include two things, namely the primary assessment and secondary assessment.
In the primary assessment as well as on the stage that the CPR would
ABC is Airway, Breathing, Circulation. Although cardiopulmonary
resuscitation phase is different when we examine a patient with chest
pain. ABC is also included in assessment of primary studies are:
Airway
That we examine as a nurse, at this stage how the airway is among the
sufferers airway clearance, if there is a blockage / buildup of
secretions in the airway of patients, and how to breath sounds. Are
there additional breath sounds, in these patients.
Breathing
That we examine in this case is: how breathing pattern of the patient,
the frequency of respiratory rhythm as well as the depth and breath of
the patient. Do people also use a respirator muscles, is there an
additional breath sounds anyway?
Circulation
Which we examine in the circulation of patients with chest pain such as:
vital signs which will include blood pressure, temperature, pulse,
respiration, heart rate. Moreover studied were peripheral arteries and
the carotid arteries of the quality (content and voltage), Then we also
examine capillary refill, if there acral Coldness, cyanosis or oliguria.
And also we examine whether there is a decrease in consciousness
happens.
Secondary assessment on nursing care of chest pain. In this secondary assessment that we need to examine such as:
Chest Pain Location
Assessment of the location of pain may help in the diagnosis of chest
pain whether it comes from the heart whether from other organs. Where to
start, spreading (typical coronary chest pain: Chest pain started from
sternal spread to the neck, chin or shoulder to left ulna).
Typical of Chest Pain
Typical chest pain from the heart such as: a feeling of fullness,
heaviness such as seizures, squeezing, stabbing, choking / burning
sensation. The sensation of chest pain will be felt differently in each
patient’s coronary chest pain.
Characteristics of Chest Pain
Assessment in this section is the degree of pain, duration of pain, how
often arise within a certain timeframe. This will help in the diagnosis
of coronary heart disease.
Chronology of Chest Pain
The beginning there is pain, and the development sequence. The emergence of the current activity or whether at rest or sleeping.
The situation at the time of the attack
Are arise at times / conditions. Almost the same as mentioned above
about the conditions at the time of chest pain attacks occurred.
Factors that reinforce / relieve pain such as posture / body
position, movement, pressure. Is chest pain relieved with rest or not?
DEFINITION
Bladder cancer is a cancer that starts in the bladder. The bladder is the body part that holds and releases urine. It is in the center of the lower belly area.
The World Health Organization, In 2004, developed a new grading system for bladder cancer. This system divides bladder cancers into the following groups.
1. Risk for injury related to radiation therapy and chemotherapy.
Expected outcomes:
Intervention:
Expected outcomes:
Intervention:
Expected outcomes:
Expected outcomes:
Intervention:
Bladder cancer is a cancer that starts in the bladder. The bladder is the body part that holds and releases urine. It is in the center of the lower belly area.
The World Health Organization, In 2004, developed a new grading system for bladder cancer. This system divides bladder cancers into the following groups.
- Urothelial papilloma – noncancerous (benign) tumor
- Papillary urothelial neoplasm of low malignant potential (PUNLMP) – slow growing and unlikely to spread
- Low-grade papillary urothelial carcinoma – slow growing and unlikely to spread
- High-grade papillary urothelial carcinoma – more quickly growing and more likely to spread
- Blood in your urine
- A frequent urge to urinate
- Pain when you urinate
- Low back pain
- Ask clients about changes in urination, note the color change, the frequency and amount of urine.
- Hematuria with pain is the first sign of cancer blader, usually intermittent which often leads to barriers in the search for diagnostic services.
- Due to disease progression, clients experience iritable bladder, with dysuria. Finally gross hematuria, obstruction or vistula encourage clients to seek treatment.
1. Risk for injury related to radiation therapy and chemotherapy.
Expected outcomes:
- Clients do not develop problems associated with radiation therapy and chemotherapy
Intervention:
- Giving anti-spasmodic.
- Increased fluid intake.
- Provision for cystitis urinary tract antiseptic.
- Clients with proctitis, requires a low-fiber diet and agents to reduce intestinal motility.
Expected outcomes:
- Clients understand the diagnostic, surgical and treatment of urinary diversion.
Intervention:
- Prepare preoperatively, clients who experience urinary diversion.
- Education about urinary diversion.
- Encourage acceptance of the facts and results of urinary elimination through the skin of the rectum or stoma special.
- Prepare general physical and emotional.
- Note the gastrointestinal tract: non residue diet for a few days, intestinal sterilization, enema.
- Advise clients to prevent skin contact with urine, to prevent skin irritation due to urinary diversion.
- Clean the stoma with soap and water and then dried at any urine bag replacement.
Expected outcomes:
- Clients will be diagnosed early to eliminate dysuria.
- Installation of indwelling catheters.
- CBI to prevent blood clot
- Intervention in TUR – P (input fluids, analgesics and antispasmodics as needed)
Expected outcomes:
- Clients will not thrive on disruption of skin integrity, or peristomal irritation.
Intervention:
- Check the pH of the urine
- Check the bag of urine to leak and whether the skin sensitive to the material.
- Change bags for not leaking (too often replaced cause irritation).
- During replaced bags allow contact with air as possible.
- Give nystatin at around stoma.
Nasopharyngeal angiofibroma or juvenile nasopharyngeal
angiofibroma is a histologically benign but locally aggressive vascular
tumor that grows in the back of the nasal cavity, usually found in
adolescent boys.
Diagnosis
If nasopharyngeal angiofibroma is suspected based on physical exam (a smooth submucosal mass in the posterior nasal cavity), imaging studies such as CT or MRI should be performed. Biopsy can lead to extensive bleeding since the tumor is composed of blood vessels without a muscular coat.
Nursing Assessment
1. Hereditary factors or a history of cancer in the family eg mother or grandmother with a history of breast cancer.
2. Spheres of influence, such as chemical irritants, smoke a certain kind of wood.
3. The habit of cooking with certain ingredients or spices and eating foods that are too hot and preserved foods (meat and fish).
4. Low socioeconomic classes will also be related to the environment and living habits. (Efiaty & Nurbaiti, 2001 case 146)
5. Signs and symptoms:
Activity
Weakness or fatigue. Changes in the patterns of rest; presence of factors that affect sleep such as pain, anxiety.
Circulation
As a result of tumor metastases are palpitations, chest pain, decreased blood pressure, epistaxis / nose bleeding.
Ego integrity
Stress factors, concerns about appearance changes, deny the diagnosis, feelings of helplessness, loss of control, depression, withdrawal, anger.
Elimination
Changes in bowel habit constipation or diarrhea, urinary elimination alteration, change of bowel sounds, abdominal distension.
Food / fluid
Poor dietary habits (low fiber, additives, preservatives), anorexia, nausea / vomiting, mouth dryness, food intolerance, weight changes, cachexia, changes in humidity / skin turgor.
Neuro-sensory
Headache, tinnitus, deafness, diplopia, squint, exophthalmos.
Pain / comfort
Discomfort in the ear to ear pain (otalgia), stiffness in the neck area due to tissue fibrosis
Breathing
Smoking (tobacco, marijuana, living with someone who smokes)
Security
Exposure to toxic chemicals, carcinogens, exposure to the sun old / redundant, fever, skin rash.
Social interaction
Inadequate / support system weaknesses
(Doenges, 2000)
Diagnosis
If nasopharyngeal angiofibroma is suspected based on physical exam (a smooth submucosal mass in the posterior nasal cavity), imaging studies such as CT or MRI should be performed. Biopsy can lead to extensive bleeding since the tumor is composed of blood vessels without a muscular coat.
Nursing Assessment
1. Hereditary factors or a history of cancer in the family eg mother or grandmother with a history of breast cancer.
2. Spheres of influence, such as chemical irritants, smoke a certain kind of wood.
3. The habit of cooking with certain ingredients or spices and eating foods that are too hot and preserved foods (meat and fish).
4. Low socioeconomic classes will also be related to the environment and living habits. (Efiaty & Nurbaiti, 2001 case 146)
5. Signs and symptoms:
Activity
Weakness or fatigue. Changes in the patterns of rest; presence of factors that affect sleep such as pain, anxiety.
Circulation
As a result of tumor metastases are palpitations, chest pain, decreased blood pressure, epistaxis / nose bleeding.
Ego integrity
Stress factors, concerns about appearance changes, deny the diagnosis, feelings of helplessness, loss of control, depression, withdrawal, anger.
Elimination
Changes in bowel habit constipation or diarrhea, urinary elimination alteration, change of bowel sounds, abdominal distension.
Food / fluid
Poor dietary habits (low fiber, additives, preservatives), anorexia, nausea / vomiting, mouth dryness, food intolerance, weight changes, cachexia, changes in humidity / skin turgor.
Neuro-sensory
Headache, tinnitus, deafness, diplopia, squint, exophthalmos.
Pain / comfort
Discomfort in the ear to ear pain (otalgia), stiffness in the neck area due to tissue fibrosis
Breathing
Smoking (tobacco, marijuana, living with someone who smokes)
Security
Exposure to toxic chemicals, carcinogens, exposure to the sun old / redundant, fever, skin rash.
Social interaction
Inadequate / support system weaknesses
(Doenges, 2000)
Assessment for Peptic Ulcer
Patient history acts as an important basis for diagnosis. Patients were asked to describe the pain and the methods used to eliminate them. Peptic ulcer pain is usually described as a burning or gnawing and occurs approximately occurs after 2 hours after meals. This pain often awakens the patient hours of midnight and 3 am. The patient stated that the pain is only removed by antacids, eating or vomiting.
Patients were asked when vomiting occurs. If so, how much? Is vomit bright red or coffee color. Does the patient have a bowel movement with bloody stool? During the history taking, the nurse asked the patient to write the input of food, usually a period of 72 hours and include all eating habits (eating speed, regular meals, a fondness for spicy food, use herbs, use of beverages containing caffeine).
The level of tension and nervousness of patients studied. Does the patient smoke? If yes, how much? How patients express anger, especially in the context of work and family life? Is there or is there job stress with family problems? Is there a family history of ulcer disease?
Vital signs assessed for indicators of anemia (tachycardia, hypotension), fecal occult blood checked against. Physical examination and abdominal palpation performed to localize tenderness.
4 Nursing Diagnosis and Interventions for Peptic Ulcer
1. Acute pain related to irritation of the mucosa and muscle spasms.
Goal: Client expressed pain diminished or disappeared.
Intervention:
1. Give drug therapy according to the program:
2. Instruct to avoid drugs are sold freely, especially those containing salicylates.
R /: Medicines containing salicylates may irritate the gastric mucosa.
3. Encourage clients to avoid foods / drinks that irritate the gastric mucosa: caffeine and alcohol.
R /: to stimulate the secretion of hydrochloric acid.
4. Encourage clients to use the meals and snacks at regular intervals.
R /: Schedule regular eating helps retain food particles in the stomach that helps neutralize the acidity of gastric secretions.
5. Instruct patient to stop smoking
R /: Smoking can stimulate ulcer recurrence.
2. Anxiety related to the nature of the disease and long-term management.
Goal: Decrease anxiety.
Intervention:
1. Encourage clients to express their problems and fears and ask questions as needed.
R /: Open communication helps clients develop trusting relationships that help reduce anxiety and stress.
2. Explain the reasons for the planned treatment schedule obey, such as pharmacotherapy, dietary restrictions, modification of activity levels, reduce or stop smoking.
R /: Knowledge reduce anxiety appears to be a sense of fear due to ignorance. Knowledge can have a positive effect on behavior change.
3. Assist clients to identify situations that cause anxiety.
R /: stressors need to be identified before it can be overcome.
4. Teach stress management strategies: eg drugs, distraction, and imagination.
R /: decrease anxiety decrease the secretion of hydrochloric acid.
3. Imbalanced Nutrition, Less Than Body Requirements related to pain, which is related to food.
Goal: Getting optimal nutrition.
Intervention:
1. Encourage eating foods and drinks that do not irritate.
R /: Food and drinks are not irritating to help reduce epigastric pain.
2. Encourage eating on a regular schedule, avoid snacks before bedtime.
R /: Eating regularly helps neutralize gastric acid secretion; snack before bedtime increases the secretion of gastric acid.
3. Encourage eating food in a relaxed environment
R /: less relaxed environment cause anxiety. Decreased anxiety helps reduce the secretion of hydrochloric acid.
4. Knowledge Deficit: the prevention and treatment of symptoms related to the condition of inadequate information.
Goal: Clients gain knowledge about prevention and management.
Intervention:
1. Assess the level of knowledge and readiness to learn from clients.
R /: Desire to learn depends on the physical condition of the client, the level of anxiety and mental readiness.
2. Teach the required information: Use words that correspond with the level of knowledge of the client. Choose a time when most convenient and interested clients. Limit counseling sessions to 30 minutes or less.
R /: Individualization counseling improve learning.
3. Assure the client that the disease can be overcome.
R /: Gives confidence can have a positive influence on behavior change.
Patient history acts as an important basis for diagnosis. Patients were asked to describe the pain and the methods used to eliminate them. Peptic ulcer pain is usually described as a burning or gnawing and occurs approximately occurs after 2 hours after meals. This pain often awakens the patient hours of midnight and 3 am. The patient stated that the pain is only removed by antacids, eating or vomiting.
Patients were asked when vomiting occurs. If so, how much? Is vomit bright red or coffee color. Does the patient have a bowel movement with bloody stool? During the history taking, the nurse asked the patient to write the input of food, usually a period of 72 hours and include all eating habits (eating speed, regular meals, a fondness for spicy food, use herbs, use of beverages containing caffeine).
The level of tension and nervousness of patients studied. Does the patient smoke? If yes, how much? How patients express anger, especially in the context of work and family life? Is there or is there job stress with family problems? Is there a family history of ulcer disease?
Vital signs assessed for indicators of anemia (tachycardia, hypotension), fecal occult blood checked against. Physical examination and abdominal palpation performed to localize tenderness.
4 Nursing Diagnosis and Interventions for Peptic Ulcer
1. Acute pain related to irritation of the mucosa and muscle spasms.
Goal: Client expressed pain diminished or disappeared.
Intervention:
1. Give drug therapy according to the program:
2. Instruct to avoid drugs are sold freely, especially those containing salicylates.
R /: Medicines containing salicylates may irritate the gastric mucosa.
3. Encourage clients to avoid foods / drinks that irritate the gastric mucosa: caffeine and alcohol.
R /: to stimulate the secretion of hydrochloric acid.
4. Encourage clients to use the meals and snacks at regular intervals.
R /: Schedule regular eating helps retain food particles in the stomach that helps neutralize the acidity of gastric secretions.
5. Instruct patient to stop smoking
R /: Smoking can stimulate ulcer recurrence.
2. Anxiety related to the nature of the disease and long-term management.
Goal: Decrease anxiety.
Intervention:
1. Encourage clients to express their problems and fears and ask questions as needed.
R /: Open communication helps clients develop trusting relationships that help reduce anxiety and stress.
2. Explain the reasons for the planned treatment schedule obey, such as pharmacotherapy, dietary restrictions, modification of activity levels, reduce or stop smoking.
R /: Knowledge reduce anxiety appears to be a sense of fear due to ignorance. Knowledge can have a positive effect on behavior change.
3. Assist clients to identify situations that cause anxiety.
R /: stressors need to be identified before it can be overcome.
4. Teach stress management strategies: eg drugs, distraction, and imagination.
R /: decrease anxiety decrease the secretion of hydrochloric acid.
3. Imbalanced Nutrition, Less Than Body Requirements related to pain, which is related to food.
Goal: Getting optimal nutrition.
Intervention:
1. Encourage eating foods and drinks that do not irritate.
R /: Food and drinks are not irritating to help reduce epigastric pain.
2. Encourage eating on a regular schedule, avoid snacks before bedtime.
R /: Eating regularly helps neutralize gastric acid secretion; snack before bedtime increases the secretion of gastric acid.
3. Encourage eating food in a relaxed environment
R /: less relaxed environment cause anxiety. Decreased anxiety helps reduce the secretion of hydrochloric acid.
4. Knowledge Deficit: the prevention and treatment of symptoms related to the condition of inadequate information.
Goal: Clients gain knowledge about prevention and management.
Intervention:
1. Assess the level of knowledge and readiness to learn from clients.
R /: Desire to learn depends on the physical condition of the client, the level of anxiety and mental readiness.
2. Teach the required information: Use words that correspond with the level of knowledge of the client. Choose a time when most convenient and interested clients. Limit counseling sessions to 30 minutes or less.
R /: Individualization counseling improve learning.
3. Assure the client that the disease can be overcome.
R /: Gives confidence can have a positive influence on behavior change.
Hepatitis B is an infectious inflammatory illness of the liver caused by the hepatitis B virus (HBV) that affects hominoidea, including humans. Originally known as “serum hepatitis”, the disease has caused epidemics in parts of Asia and Africa, and it is endemic in China. About a third of the world population has been infected at one point in their lives, including 350 million who are chronic carriers.
Hepatitis C is an infectious disease affecting primarily the liver, caused by the hepatitis C virus (HCV). The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years. In some cases, those with cirrhosis will go on to develop liver failure, liver cancer or life-threatening esophageal and gastric varices.
Activity Intolerance Definition : Insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., -blockers), or emotional states such as depression or lack of confidence to exert one’s self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.
Nursing Care Plan for Hepatitis
Nursing Diagnosis : Activity Intolerance related to decreased energy
characterized by:
Subjective data:
- client complained of weakness, can not do the activity of as normal.
- client looks limp.
- client looks assisted families in their daily activities.
- Activities are met.
- client can perform the activity even though no oversight from family and caregivers.
- Assess client activity.
- Assist client activity.
- Increase bed rest / seat.
- Reposition the client every 2 hours once.
- Provide training on passive motion.
- Knowing the needs of client activity.
- For the fulfillment of client activity.
- Increase rest and tranquility to provide energy and blood circulation.
- Avoiding the risk of tissue damage
- Prolonged bed rest will reduce the ability.
A small PDA may not cause any symptoms. However, some infants may have symptoms such as: fast breathing, poor feeding habits, rapid pulse, shortness of breath, sweating while feeding, tiring very easily, poor growth.
Nursing Diagnosis for Patent Ductus Arteriosus (PDA)
- Decreased Cardiac Output related to malformations of the heart.
- Impaired Gas Exchange related to pulmonary congestion.
- Activity Intolerance related to imbalance between oxygen consumption by the body and oxygen supply to the cells.
- Delayed Growth and Development related to an inadequate supply of oxygen and nutrients to the tissues.
- Imbalanced Nutrition Less than Body related to fatigue at mealtime and increased caloric needs.
- Risk for Infection related to decreased health status.
Nursing Interventions for Patent Ductus Arteriosus (PDA)
1. Maintain adequate cardiac output:
- Observation of the quality and strength of heart rate, peripheral pulses, skin color and warmth.
- Enforce the degree of cyanosis (circumoral, mucous membranes, clubbing).
- Monitor signs of CHF (restlessness, tachycardia, tachypnea, spasms, fatigue, periorbital edema, oliguria, and hepatomegaly).
- Collaboration of drugs in accordance with the order, using toxicity hazard prevention techniques.
- Provide treatment to reduce afterload.
- Give diuretics as indicated.
- Monitor the quality and rhythm of breathing.
- Adjust the position of the child with Fowler position.
- Avoid children from an infected person.
- Give adequate rest.
- Provide optimal nutrition.
- Give oxygen if indicated.
- Allow the child to rest frequently, and avoid disturbances during sleep.
- Encourage to engage in play and light activity.
- Help child to choose activities appropriate to the age, condition and abilities.
- Avoid the ambient temperature is too hot or too cold.
- Avoid the things that cause fear / anxiety in children.
- Assess the level of development of the child.
- Give the stimulation of growth and development, play activities, gaming, watching TV, puzzles, drawing, and others according to the condition and age of the child.
- Involve the family in order to continue to provide stimulation during care.
- Provide a balanced diet, high nutrients for adequate growth.
- Monitor height and weight, documented in the form of graphs to determine the trend of growing children.
- Measure weight every day with the same weight and the same time.
- Record intake and output correctly.
- Provide food with small portions but often to avoid fatigue during meals.
- Children who receive diuretics are usually very thirsty, and therefore not restricted fluid.
- Avoid contact with infected individuals.
- Give adequate rest.
- Provide optimal nutritional needs.
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