Tampilkan postingan dengan label medical. Tampilkan semua postingan
Tampilkan postingan dengan label medical. Tampilkan semua postingan
A. Definition
Cholecystitis is inflammation of the gallbladder is an acute inflammatory gallbladder wall with upper right abdominal pain, tenderness and heatbody. Are two classifications namely acute and chronic ( Brooker , 2001).
Acute cholecystitis is inflammation of the gallbladder wall, usually is the result of the presence of gallstones in the cystic duct, which issudden attack causing tremendous pain.
Chronic cholecystitis is a chronic inflammation of the gallbladder wall, which is characterized by recurrent attacks of abdominal pain and severe sharp.
Cholesistektomy is the surgical removal of the gall bladder (usually forrelief of gallstone pain).
B. Etiology
Approximately 95 % of patients with acute gallbladder inflammation, have gallstones. Sometimes a bacterial infection causes inflammation. Acute cholecystitis without stones is a serious illness and tendarise after the occurrence of :
-injury
-surgery
-burn
-sepsis ( infection that spreads throughout the body
-severe diseases ( especially people who receive food throughinfusion in the long term ).
Before secsara suddenly felt a tremendous pain in the abdomenabove, patients usually do not show signs of gallbladder disease. Chronic cholecystitis caused by recurrent attacks of acute cholecystitis, that causes thickening of the gallbladder wall and shrinkageempedu. On bladder finally gallbladder bile is not able to accommodate. The disease is more common in women and increase the number of eventsat the age above 40 years. Risk factor is a history of chronic cholecystitisprevious acute cholecystitis.
C. Pathophysiology
The gall bladder has a function as a place to store bile andconcentrate the bile fluid in it by way of absorbing water andelectrolyte. Bile is a liquid produced by the cell electrolyteliver. In normal individuals, bile flows into the gallbladder at the time of Oddi valve closed. In the gallbladder, bile is concentrated by absorb water. Degrees shown by the increase in concentration solids. Stasis of bile in the gallbladder may lead to progressive supersaturation and precipitation changes in the chemical composition of these elements. Metabolic changes caused by changes in the composition of bile, stasisbile, can cause infection of the gallbladder.
D. Symptom
The onset of symptoms can be triggered by eating fatty foods.
Symptoms can include :
- Early signs of inflammation of the gallbladder is usually a pain in the right abdomen top.
- Pain is intensified when the patient breathe deeply and often spread to right shoulder
- Usually there is nausea and vomiting
- Abdominal tenderness
- In a few hours , the abdominal muscles become stiff right hand .
- At first, mild fever, which is the longer tends to rise .
- The attack reduced pain within 2-3 days and then disappear within 1 week .
- Chronic digestive disorders
- Abdominal pain is not clear ( vague )
- Belching .
E. Complication
High fever, chills, increased leukocyte count and cessation of movement intestine ( ileus ) may indicate the occurrence of abscesses, gangrene or perforation of the bladder bile. Attack with jaundice ( jaundice ) or backflow of bile into in the liver showed that the bile duct was blocked partially by stone bile or by inflammation. If blood tests show elevated levels of the enzyme amylase, may there has been inflammation of the pancreas ( pancreatitis ) caused by blockage bile duct stones in the pancreas ( pancreatic duct ).
F. Investigations
- CT scan of the abdomen
- Oral Kolesistogram
- Abdominal ultrasound .
- Blood tests ( looking for elevated white blood cells)
G. Medical Management
- The usual treatment is surgery .
- Cholecystectomy surgery can be done through the abdomen or throughlaparoscopy .
- Patients who have a high surgical risk due to other medical conditions, recommended for low-fat diet and lose weight.
- Can be given antacids and anticholinergic drugs.
H. Nursing Management
-Assessment Assessment is the first step in the process and basic nursing thorough ( Boedihartono , 1994).
Post operative patient assessment ( Doenges , 1999) are included:
1 ) . Circulation Symptoms : a history of heart problems, GJK, pulmonary edema, vascular disease peripheral or vascular stasis ( increased risk of formation thrombus ).
2 ) . ego integrity Symptoms : feelings of anxiety , fear , anger , apathy ; stress factor multiple , such as financial , relationship , lifestyle .Mark : can not break , increasing tension / sensitive excitatory ;sympathetic stimulation .
3 ) . Food / fluid Symptoms : pancreatic insufficiency / DM , ( predisposition to hypoglycemia /ketoacidosis ), malnutrition ( including obesity ) ; mucous membranedry ( restriction intake / preoperative fasting period
4 ) . breathing Symptoms : infection , chronic conditions / cough , smoking .
5 ) . security Symptoms : allergic / sensitive to medications , foods , plasters , and solutions ; Immune deficiency ( risk of systemic infection and delay shealing ) ; emergence of cancer / latest cancer therapies ; History family of malignant hyperthermia reaction / anesthesia ; Historyhepatic disease ( effect of detoxification of drugs and canchange coagulation ) ; history of blood transfusion / transfusion reactions .Signs : infection exhausting process ; fever.
6 ) . Counseling / Learning Symptoms : anticoagulation , steroids , antibiotics , antihypertensives ,cardiotonic glokosid , antidisritmia , bronchodilator , diuretic ,decongestants , analgesics , anti-inflammatory , anticonvulsant or tranquilizers and also the-counter medicines or drugs recreational. Alcohol use ( risk of kidney damage ,affecting coagulation and anesthesia options , and also potential for postoperative withdrawal ) .
I. Nursing Diagnoses
that appear in patients post Operative include :
1. Breathing pattern , ineffective related to neuromuscular , imbalanceperceptual / cognitive , increased lung expansion , tracheobronchial obstruction .
2. Changes in thought processes associated with chemical changes such as the use of pharmaceutical drugs , hypoxia ; limited therapeutic environment for example excessive sensory stimuli ; physiological stress.
3. Fluid volume deficiency , associated with a high risk of restrictions oral fluid intake , loss of body fluids is not normal , blood vessel integrity expenditures .4 . Acute pain associated with disorders of the skin , tissue and integrittas muscle , trauma muskuloskletal , appearance and hose lines ( Doenges , 1999) .
J. Intervention and Implementation
Intervention is planning nursing actions that will be implemented to tackle the problem in accordance with the nursing diagnoses ( Boedihartono ,1994). Implementation is the realization of the plan of management and nursing have been prepared at the planning stage ( Effendi , 1995). Nursing interventions in post- operative patients ( Doenges , 1999) include :
- DP 1 :Goals : establish a normal breathing pattern / effective and free of cyanosis or other signs of hypoxia. Expected outcomes : no change in the frequency and depth of breathing .
- Maintain patient's airway by tilting the head , jaw hyperextension ,oral pharyngeal airflow
R : prevent airway obstruction .
- Auscultation of breath sounds . Listen to the presence / absence of breath sounds .
R : lack of breath sounds is an indication of obstruction by mucus orthe tongue and can be addressed by changing the position or suction .
- Observation of the frequency and depth of breathing , use of auxiliary musclesbreathing , chest expansion , retraction or nostril breathing ,skin color , and the air flow
R : is done to ensure that the effectiveness of respiratory effortsegerra can be done to fix it
- Place the patient in the appropriate position , depending on the power of breathingand type of surgery
R : elevation head and tilted position will prevent the occurrence of aaspirasivomiting , the correct position will encourage ventilation on lung lobe sectionsdown and reduce pressure on the diaphragm
- motion exercises as soon as possible in patients with reactive and continuein the postoperative period
R : active ventilation opening in the alveoli , issued secretion ,increase oxygen transport , dispose of anesthetic gases ; cough assistissued secretion of the respiratory system
- Perform suctioning if necessary
R : airway obstruction may occur due to the presence of blood or mucus inthroat or trachea
- Collaboration , giving oxygen as needed
R : is done to improve or maximize the uptake of oxygenwill be bound by the hemoglobin in the place of anesthetic gases and encourageterssebut gas expenses substances through inhalation
- DP 2 :Goals : increasing the level of awareness. Outcomes: the patient is able to recognize one's limitations and seek sourcesassistance as needed.
- Orient the patient continuously back after being out of the influenceanesthesia ; stated that the operation had been completed
R : because patients have increased awareness , support and guarantee it willhelp eliminate anxiety
- Talk in patients with jelaas and normal voice without yelling , consciousfull of what was said
R : can not be determined when the patient fully conscious , but sensoryhearing is the first time the ability to recover
- Evaluation of sensation / movement of the extremities and the corresponding trachea
R : return of function after spinal nerve block or localdepends on the type or amount of drug used and the duration of the procedureperformed
- Use the pads on the edge of the bed, do binding if necessary
R : provide security for the patient during the emergency phase , preventinginjury to the head and extremities when patients take the fight forperiod of disorientation
- Test the infusion , endotracheal tube , catheter , when installed and make surekepatenannya
R : in patients who experienced disorientation may occur damthe infusion flow system and other expenses , regardless , or kinked
- Maintain a calm and comfortable environment
R : external stimulus may cause abrasion psychic when it occursdissociative anesthetic drugs that have been given
- DP 3 :Objectives : adequate fluid balance .Criteria results : no no signs of dehydration ( stable vital signs ,good pulse quality , normal skin turgor , mucous membranesmoist and corresponding expenditures urine )
- Measure and record income and expenditure . Review the operation of intra records .
R : Accurate documentation will help in identifying expenditureliquid / replacement requirements and the choices that affectintervention .
- Assess urinary spending , especially for the type of surgical procedure performed .
R : may be a decrease or elimination of the procedures setelahaor genitourinary system and adjacent structures indicatemalfunction or obstruction of the urinary system .
- Monitor vital signs .
R : hypotension , tachycardia , increased breathing indicates lacklack of fluids .
- Place the patient in the appropriate position , depending on the power of breathingand type of surgery .
R : elevation head and tilted position will prevent the occurrence of aaspirasivomiting , the correct position will encourage ventilation on lung lobe sectionsdown and reduce pressure on the diaphragm.
- Check pads , appliance drain at regular intervals . Assess the wound for theswelling .
R : excessive bleeding can refer to hypovolemia / hemorrhage .
- Monitor the temperature of the skin , palpation of peripheral pulses .
R : skin cold / damp , weak pulse indicates a decreaseperipheral circulation and extra fluid needed for replacement .
- Collaboration , give parenteral fluids , blood products and plasma expanders oras directed . Increase speed IV if large is .
R : replace fluid losses have been documented . Record timepenggangtian circulation volume potential for the reduction of complications ,such imbalances
Intervention
- Evaluation regular seccara pain , note the characteristics , location andintensiitas ( 0-10 ) .
R : provide information about the need / effectiveness of the intervention .
- Note the emergence of anxiety / fear and connect with the environment and preparationfor the procedure .
R : consider the things that are unknown and / or inadequate preparationapendikstomi eg emergency ) can worsen the patient's perception would tastesick .
- Assess vital signs , note tachycardia , hypertension and increasedbreathing , even if the patient denied any pain .
R : can indicate acute pain and discomfort .
- Provide information on the nature of discomfort , as needed .
R : understand the cause of discomfort , provide emotional security .
- Do repositioning as directed , such as semi - Fowler ; skewed .
R : may reduce pain and improve circulation . Position semi -Fowler can reduce abdominal muscle tension and muscle pungguungarthritis , while reducing pressure dorsal oblique .
- Observation of analgesic effect .
R : respiration may be decreased in the administration of narcotics , and may causesynergistic effects with anesthetic agents .
- Collaboration , IV administration of analgesics as needed .
R : IV analgesic with pain by immediately reach the center , raisesbusting drug is more effective in small doses .
R : Accurate documentation will help in identifying expenditureliquid / replacement requirements and the choices that affectintervention .
- Assess urinary spending , especially for the type of surgical procedure performed .
R : may be a decrease or elimination of the procedures setelahaor genitourinary system and adjacent structures indicatemalfunction or obstruction of the urinary system .
- Monitor vital signs .
R : hypotension , tachycardia , increased breathing indicates lacklack of fluids .
- Place the patient in the appropriate position , depending on the power of breathingand type of surgery .
R : elevation head and tilted position will prevent the occurrence of aaspirasivomiting , the correct position will encourage ventilation on lung lobe sectionsdown and reduce pressure on the diaphragm.
- Check pads , appliance drain at regular intervals . Assess the wound for theswelling .
R : excessive bleeding can refer to hypovolemia / hemorrhage .
- Monitor the temperature of the skin , palpation of peripheral pulses .
R : skin cold / damp , weak pulse indicates a decreaseperipheral circulation and extra fluid needed for replacement .
- Collaboration , give parenteral fluids , blood products and plasma expanders oras directed . Increase speed IV if large is .
R : replace fluid losses have been documented . Record timepenggangtian circulation volume potential for the reduction of complications ,such imbalances
- DP 4 :Purpose: The patient said that the pain has been controlled or missing .Outcomes: the patient seemed to relax , to rest / sleep and domovement which means the corresponding tolerance .
Intervention
- Evaluation regular seccara pain , note the characteristics , location andintensiitas ( 0-10 ) .
R : provide information about the need / effectiveness of the intervention .
- Note the emergence of anxiety / fear and connect with the environment and preparationfor the procedure .
R : consider the things that are unknown and / or inadequate preparationapendikstomi eg emergency ) can worsen the patient's perception would tastesick .
- Assess vital signs , note tachycardia , hypertension and increasedbreathing , even if the patient denied any pain .
R : can indicate acute pain and discomfort .
- Provide information on the nature of discomfort , as needed .
R : understand the cause of discomfort , provide emotional security .
- Do repositioning as directed , such as semi - Fowler ; skewed .
R : may reduce pain and improve circulation . Position semi -Fowler can reduce abdominal muscle tension and muscle pungguungarthritis , while reducing pressure dorsal oblique .
- Observation of analgesic effect .
R : respiration may be decreased in the administration of narcotics , and may causesynergistic effects with anesthetic agents .
- Collaboration , IV administration of analgesics as needed .
R : IV analgesic with pain by immediately reach the center , raisesbusting drug is more effective in small doses .
J. Evaluation Evaluation is the stage at which the level of success of the nursing process in achievement of nursing assessed and the need to modify the destination or a nursing intervention defined ( Brooker , 2001)
Evaluation of the expected post- operative patients included :
1 . Establish a normal breathing pattern / effective and free of cyanosis or other signs of hypoxia .
2 . Increase the level of awareness .
3 . Adequate body fluid balance .
4 . The patient said that the pain has been controlled or missing .
REFERENCES
Brooker, Christine. 2001. Kamus Saku Keperawatan. Jakarta : EGC.
http://arifs45.multiply.com/journal/item/8
http://kamus.landak.com/cari/cholecystectomy
http://www.mamashealth.com/stomach/cholecy.asp
http://www.medicastore.com/index.php?mod=penyakit&id=607
http://www.medicastore.com/index.php?mod=penyakit&id=608
Sloane, Ethel. 2004. Anatomi dan Fisiologi Untuk Pemula, Edisi I. Jakarta : EGC.
Syaifudin, H, B.Ac, Drs. 1997. Anatomi Fisiologi Untuk Siswa Perawat, Edisi 2.
Jakarta: EGC.
Evaluation of the expected post- operative patients included :
1 . Establish a normal breathing pattern / effective and free of cyanosis or other signs of hypoxia .
2 . Increase the level of awareness .
3 . Adequate body fluid balance .
4 . The patient said that the pain has been controlled or missing .
REFERENCES
Brooker, Christine. 2001. Kamus Saku Keperawatan. Jakarta : EGC.
http://arifs45.multiply.com/journal/item/8
http://kamus.landak.com/cari/cholecystectomy
http://www.mamashealth.com/stomach/cholecy.asp
http://www.medicastore.com/index.php?mod=penyakit&id=607
http://www.medicastore.com/index.php?mod=penyakit&id=608
Sloane, Ethel. 2004. Anatomi dan Fisiologi Untuk Pemula, Edisi I. Jakarta : EGC.
Syaifudin, H, B.Ac, Drs. 1997. Anatomi Fisiologi Untuk Siswa Perawat, Edisi 2.
Jakarta: EGC.
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.
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
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?
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.
B. Etiology 1 . Cerebral infarction ( 80 % )a. embolism1 ) cardiogenic embolisma) Atrial fibrillation or other arrhythmiasb ) left ventrikek mural thrombusc ) mitral or aortic valve diseased ) Endocarditis2 ) paradoxical embolism ( patent foramen ovale )3 . Aortic arch embolismb . Aterotrombotik ( blood vessel disease medium-high )1 ) Disease ekstrakarniala) the internal carotid arteryb ) the vertebral artery2 ) Disease intrakarniala) the internal carotid arteryb ) middle cerebral arteryc ) the basilar arteryd ) Lakuner ( perforans small artery occlusion )2 . Intracerebral hemorrhage ( 15 % )a. hypertensiveb . Arteriovenous malformationc . amyloid angiopathy3 . Subarachnoid hemorrhage ( 5 % )4 . Other causes ( can lead to infarction or hemorrhage )a. Thrombosis dinus durab . Carotid or vertebral artery dissectionc . Central nervous system vasculitisd . Moya - moya disease ( occlusion of a large intracranial arterial progressive )e . migrainef . hypercoagulable conditiong . Misuse of drugs ( cocaine or amphetamines )h . Haematological disorders ( sickle cell anemia , polycythemia , or leukemia )i . atrial myxoma
C. PathophysiologyThrombosis ( disease trombo - occlusive ) is the most frequent cause of stroke . Cerebral arteriosclerosis and cerebral circulation slowdown is the main cause of cerebral thrombosis , which is a common cause of stroke . Signs of cerebral thrombosis varies . Onset of the headache is not common . Some patients experience dizziness , seizures , and cognitive changes or some other common onset . In general, cerebral thrombosis did not occur suddenly , and temporary loss of speech , hemiplegia or paresthesias in half body weight may precede the onset of paralysis in a few hours or days .Thrombosis occurs usually has something to do with the local damage blood vessel walls due atrosklerosis . The process of atherosclerosis is characterized by fatty plaque in the intima layer of the artery . Sereberi artery intima part becomes thin and stringy , whereas cells - muscle cells disappeared . Lamina interna elastika torn and frayed , so the vessel lumen partially filled by the sclerotic material . Plaques tend to form at branching or places - places curved . Thrombi were also associated with a place - such a special place . Vessels - vascular risk in order to have less and less are as follows : internal carotid artery , vertebral and basilar part of the bottom . Intima loss will make connective tissue exposed . Platelets stick to the exposed surface so that the surface of the blood vessel walls become rough . Platelets will let go of the enzyme , adenosine diphosphate mechanisms that initiate coagulation . Fibrinotrombosit stopper can be detached and form emboli , or it can remain in place and eventually all that will be clogged artery perfectly .Embolism : embolism sereberi including second leading cause of many strokes . Embolism patients are usually younger than patients with thrombosis . Most sereberi emboli originating from a thrombus in the heart , so the real problem faced is the embodiment of heart disease . Although less common , embolus may also originate from atheromatous plaques karotikus sinus or internal carotid artery . Each part of the brain can suffer embolism , but usually embolus embolus will clog parts - small parts .. the most frequently affected artery embolus sereberi is sereberi media , especially the top .Cerebral hemorrhage : cerebral hemorrhage including third leading cause of all cases GPDO ( Brain Blood Vessel Disorders ) and a tenth of all cases of the disease . Intracranial hemorrhage is usually caused by the rupture of cerebral arteries . Extravasation of blood occurs in the brain and / or subarachnoid , so the networks are located nearby will be displaced and depressed . Blood is very irritating to the brain tissue , resulting in vasospasm in arteries around the bleeding . These spasms can spread throughout the brain and the circle wilisi hemisper . Blood clot that initially resemble soft red jam will eventually dissolve and shrink . In the light of histological brain located around the clot can swell and undergo necrosis . Because the action of the enzyme - enzyme liquefaction process will occur , thus forming a cavity . After several months of all necrotic tissue will be replaced by astrocytes and capillaries - new capillaries to form the fabric around the cavity earlier . Finally cavities filled by fibers - fibers that experienced astroglia proliferation . Subarachnoid hemorrhage is often associated with rupture of an aneurysm . Most aneurysms of the circle of wilisi . Hypertension or bleeding disorders facilitate the possibility of rupture . Often there is more than one aneurysm .
D. CLINICAL1 . sudden headache .2 . Paraesthesia , paresis , Plegia part of the way .3 . dysphagia4 . aphasia5 . Impaired vision6 . Changes in cognitive abilities
E. RISK FACTORSWhich can not be changed : age , male gender , race , family history , history of TIA or stroke , coronary heart disease , atrial fibrillation , and heterozygous or homozygous for homo cystinuria .That can be changed : hypertension , diabetes mellitus , smoking , alcohol and drug abuse , oral contraceptives , increased hematocrit , asymptomatic carotid bruit , hyperuricemia , and dispidemia .
F. ACUTE STROKE UNIT IN EMERGENCYTime is brain is an expression that shows the importance of stroke treatment as early as possible , because the ' therapeutic window ' of a stroke is only 3-6 hours . Management of rapid , precise , and accurate , emegang dasil major role in determining the end of treatment . Things that should be done is :1 . Stabilization of patients with ABC action2 . Consider intubation bil a kesadaranstupor tau respiratory failure or coma3 . Put an intravenous infusion line with normal saline solution 0.9 % in water and saline 0.45 % , due to brain edema memperhebar4 . Give oxygen 2-4 liters / minute via nasal cannula5 . Do not give food or drink by mouth6 . Create recording electrocardiogram (ECG ) and chest X-ray did Rongen photo7 . Take samples for blood tests : complete examination of peripheral blood with platelets , blood chemistry ( glucose , electrolytes , urea and creatinine ) . Asa prothrombin and partial thromboplastin time8 . If there is any indication, do the following tests : jadar alcohol , liver function , arterial blood gases , and toxicology screening9 . Enforce diagnosis based on history and physical examination10 . CT scans or magnetic resonance tool when available . If not, the Siriraj score to determine the type of stroke .G. Nursing care1 . ASSESSMENT1 . Changes in level of consciousness or responivitas as evidenced by the movement , refused to change its position and response to stimulation , oriented towards the time, place and person2 . Presence or absence of a volunteer or involuntary limb movements , muscle tone , posture and head position .3 . Flaksiditas stiffness or neck .4 . Eye opening , comparative pupil size , and pupil reaction to light and ocular position .5 . Color of the face and extremities , skin temperature and humidity .6 . Quality and frequency of pulse , respiration , arterial blood gases as indicated , body temperature and arterial pressure .7 . Ability to speak8 . The volume of fluid you drink and urine volume issued every 24 hours .2 . MANAGEMENTa. Acute phase :
Maintain vital functions : airway, breathing , oxygenation and circulation
Reperfusion with trombolityk or vasodilation : Nimotop
Prevention of increased ICP
Reduce cerebral edema with diureticsb . Post acute phase
Prevention spatik paralysis with antispasmodics
program Fisiotherapi
Handling psychosocial problemsc . First Aid In Stroke PatientsFirst Aid In Stroke ( By way of bleed on each end of the leaf tips of fingers and ears ) . There is one best way to provide first aid to people who had suffered a STROKE . This way can save lives in addition to the patient , also does not cause any side effects . The first aid is aid EMERGENCY guaranteed to work 100 % .As we know , people who had suffered a STROKE , whole blood in the body will drain very fast towards the blood vessels in the brain . If the activities of aid given terlambatsedikit course , the blood vessels in the brain will not withstand the flow of blood flowing profusely and will soon be broken little by little .In the face of such circumstances not to panic but to be quiet . Sipenderita should remain its original place where he fell ( eg in the bathroom , bedroom , or anywhere else ) . DO NOT MOVED ! ! ! because by moving the patient from the original will hasten rupture small blood vessels in the brain .Patients should be assisted take a good sitting position in order not to fall again , and at that time extravasation can be done . It is best to use a syringe , but if not there , then NEEDLE SEWING / pin / pin can be used to advance first sterilized by burning over the fire . As soon as sterile needles , do the stabbing on 10 END FINGER . Insertion point is approximately 1cm from the tip of the nail . Each finger is quite stabbed one time only in the hope of every finger dispense 1 drop of blood . Extravasation can also be assisted by the push of blood if it was not out of his fingertips . In a period of approximately 10 minutes , the patient will regain consciousness soon .When sipenderita looks lopsided mouth / not normal , then BOTH EARS sipenderita LEAF - DRAWN TO PULL until goldenReddish . After that do 2 TIMES stabbing at each END DOWN LEAF EAR so that 2 drops of blood out of each end of the ear . Thus in a few minutes form the mouth sipenderita will return to normal .After the state sipenderita recovered and no significant abnormalities , then take sipenderita carefully to the doctor or the nearest hospital to get further help .
4 . Nursing Diagnosisa. Damage to physical mobility bd decreased muscle strength , controlb . Ineffective tissue perfusion related to cerebral hemorrhage . brain edemac . B.d self care less physical weaknessd . Verbal communication b.d damage brain damagee . Risk of damage to skin integrity bd mechanical factorsf . Decrease the risk of infection b.d primary defense
5 . INTERVENTIONNo Diagnosis Goals / Interventions Rationale KH1 . Damage to physical mobility bd penuruna n NOC muscle strength : Ambulation / maintained normal ROM .After the act of nursing 5x24 hoursKH :o The joints are not stiffo No muscle atrophy occurs NIC :1.Terapi exercisejoint mobilityo Explain to the client & kelg purpose joint movement exercises .o Monitor the location and discomfort during exerciseo Use loose clothingo Assess client's ability to moveo Encourage active ROMo Teach ROM active / passive on the client / family .o Change the client's position every 2 hours .o Assess development / progress exercises2 . Self Care Assistanceo Monitor client independenceo assist the client in terms of self-care : eating , bathing , toileting .o Teach the family in meeting self-care clients .Movement of active / passive aims to maintain flexibility of jointsPhysical and psychological disabilities clients can reduce their daily self-care and can be fulfilled with the help of clients that personal hygiene can be maintained2 . Ineffective cerebral tissue perfusion bd brain hemorrhage , edema o NOC : cerebral tissue perfusion . After the act of nursing for 5 x 24 hours with adequate tissue perfusion indicator :o adequate tissue perfusion is based on peripheral pulse pressure , the warmth of the skin , urine output is adequate and there is no interference with respiration NIC : Nursing circulationIncrease in brain tissue perfusionactivity :1 . Monitor neurologic status2 . monitor the status of respitasi3 . monitor heart sounds4 . place the head with a slightly elevated position and in a neutral position5 . appropriate medication management order6 . Oxygen is given as indicated 1 . tk identify trends and potential increase ICT awareness and find out the location . Extensive CNS damage and progress2 . Respiratory irregularity can give you an idea location of damage / increase in ICT3 . Bradycardia could occur as a result of brain damage .4 . Lowers arterial pressure by improving drainage and improve circulation5 . Prevention / treatment decreased ICT6 . lowering hypoxia3 . Decrease the risk of infection bd primary defense NOC : Risk Control After nursing action for 3 x 24 hours the client does not have an infectionKH :o Clients are free of signs of infectiono The client is able to explain the signs and symptoms of infection NIC : Prevent infection1 . Observe and report signs and symptoms of infection , such as redness , warm , discharge and an increase in body temperature2 . assess client netropeni temperature every 4 hours , reported if the temperature is more than 380C3 . Using electronic or mercury thermometer to assess temperature4 . Record and report the value of laboratory5 . Assess skin color , skin moisture , texture and turgor do proper documentation on any changes6 . Support for the consumption of a balanced diet , the emphasis on protein for the formation of the immune system1 . Onset of infection with the immune system is activated and signs of infection appear2 . Clients with netropeni not produce enough heat inflammatory response because it is usually a sign and often the only sign of3 . Temperature values have important consequences for the proper treatment4 . Lab values correlated with client history and physical examination to give him a holistic view5 . Can prevent skin damage , skin intact is the first defense against microorganisms6 . Immune function is affected by protein intake4 . Self-care deficit bd physical weakness NOC : Self Care Assistance ( bathing , dressing , eating , toileting .After the act of nursing for 5 x 24 hour client can meet the needs of self-careKH :- The client is free from odor , can feed themselves , and dress himself
NIC : Self Care1 . Observation of the client's ability to bathe , dress and eat .2 . Assist the client in a sitting position , make sure the head and shoulders upright for eating and 1 hour after meals3 . Avoid exhaustion before eating , bathing and dressing4 . Encourage clients to continue to eat little but often1 . By using direct intervention to determine appropriate interventions for clients2 . Seated position helps prevent ingestion and aspiration3 . Improve energy conservation and activity tolerance improved self-care skills4 . To increase appetite5 . Risk of damage to the skin intagritas bd mechanical factors NOC : maintain skin integrityAfter a 5 x 24- hour care skin integrity remains adequate indicators:No significant damage to the skin characterized by redness , sores decubitus NIC : Give stress management1 . Perform replacement loom every day and place the appropriate mattress2 . Monitor the skin area kemerahan/pecah23 . monitor the depressed area4 . give masage on back / depressed area and provide moisturizing pad area pecah25 . monitor nutritional status1 . Improve comfort and reduce the risk of itchinglajutan damage kulità2 integrity . Indicates the initial symptoms3 . Depressed area usually less than optimal circulation allows for trigger blisters4 . facilitate the circulation of. 5. Good nutritional status can help prevent skin integrity keruakan .6 Lack of knowledge bd less access to health information NOC : Knowledge increased clientKH :- The client and family understanding of disease Stroke , care and treatment NIC : Health Education1 . Assess the client's readiness and ability to learn2 . Assess the knowledge and skills of previous clients about the disease and its effect on the desire to learn3 . Give the most important material on the client4 . Identify the main source of support and attention to the client's ability to learn and support the behavior change necessary5 . Assessing the family wishes to support changes in client behavior6 . Highly priced hasi evaluation pembelajarn through demonstrations and restates the material being taughtThe learning process depends on the particular situation , the interaction of social , cultural and environmental valuesNew information is absorbed meallui previous facts and assumptions and biases affect the process of transformationInformation will be more striking when explained from a simple concept to complexFamily support is needed to support behavior change.
Langganan:
Postingan (Atom)