Nanda Nursing Diagnosis

Nursing Diagnosis for Knowledge Deficit Knowledge Deficit : About the Disease Process Knowledge Deficit Definition: The absence or lack of cognitive information in connection with a specific topic. Defining characteristics: verbalization of problems, inaccuracies follow instructions, inappropriate behavior. Knowledge Deficit Related Factors: cognitive limitations, interpretations of misinformation, lack of desire to seek information, not knowing the sources of information. NOC: Kowlwdge: disease process Kowledge: health behavior Results Criteria: Patients and families express an understanding of the disease, condition, prognosis and treatment programs Patients and families are able to perform the procedure correctly explained Patients and families are able to explain again what was described nurse / other health team NIC: Teaching: Disease Process Give your assessment of the level of knowledge about the patient's specific disease process Describe the pathophysiology of the disease

1. Relieves Pain To reduce pain nurses can encourage patients to bed rest and modification of the position is determined to improve lumbar flexion. Patients are taught to control and adjust the pains that go through the respiratory diaphragm and relaxation can help reduce muscle tension that contributes to lower back pain. Distract patients from pain with other activities such as reading books, watching TV and with imagination. Massage of the soft tissue, gently is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. When given the drug the nurse should assess the patient's response to each drug. 2. Improving physical mobility Physical mobility is monitored through continuous assessment. Nurses assess how patients move and stand. Once back pain is reduced, self-care activities may be performed with minimal strain on the injured structure. Change of position should be done slowly and assisted if necessary. Circular motion and sway shoul

The lower back is an intricate structure of interconnected and overlapping elements: Tendons and muscles and other soft tissues Highly sensitive nerves and nerve roots that travel from the lower back down into the legs and feet Small and complex joints Spinal discs with their gelatinous inner cores. An irritation or problem with any of these structures can cause lower back pain and/or pain that radiates or is referred to other parts of the body. Pain from resultant lower back muscle spasms can be severe, and pain from a number of syndromes can become chronic. These lower back pain symptoms include any combination of the following: Difficulty moving that can be severe enough to prevent walking or standing Pain that does not radiate down leg or pain that also moves around to the groin, buttock or upper thigh, but rarely travels below the knee; Pain that tends to be achy and dull Muscle spasms, which can be severe Local soreness upon touch Nursing Diagnosis of Low Back Pain 1. Acut

Definition : Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat. Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious pat

Nursing Diagnosis: Ineffective Airway Clearance NANDA Definition : Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA]

The main objective of Nursing Management program are as follows: To relieve pain and inflammation To maintain joint function and the maximum ability of the patient To prevent and or correct deformity that occurs in joints Maintaining independence so as not to depend on others. There are several ways the management to achieve the goals mentioned above, namely: Education The first step of this management program is to provide adequate education about the disease to patients, families and anyone associated with the patient. Education will include understanding the pathophysiology (disease course), the causes and estimated journey (prognosis) of the disease, all components of program management including complex drug regimens, sources of help to overcome this illness and effective method of management provided by health teams . This educational process must be done continuously. Rest It is important because rheumatic usually accompanied by severe fatigue. Although fatigue may ar

Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.3–0.7%. Diagnosis is based on observed behavior and the patient's reported experiences. Schizophrenia is associated with a wide variety of abnormal behaviors; therefore, assessment findings vary greatly, depending on both the type and phase of the illness. The individual may exhibit a decreased emotional expression, impaired concentration, and decreased social functioning, loss of function, or anhedonia. Individuals with these particular symptoms (present in one-third of the schizophrenic population) are associated with poor response to drug treatment a

Nursing Care Plan and Nursing Diagnosis for Tuberculosis (TB) Pulmonary tuberculosis Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs, but may spread to other organs. Symptoms The primary stage of TB usually doesn't cause symptoms. When symptoms of pulmonary TB occur, they may include: Cough (usually cough up mucus) Coughing up blood Excessive sweating, especially at night Fatigue Fever Unintentional weight loss Other symptoms that may occur with this disease: Breathing difficulty Chest pain Wheezing Prevention TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers. A positive skin test indicates TB exposure and an inactive infection. Discuss preventive therapy with your doctor. People who have been exposed to TB should be skin tested immediately and have a follow-up test a

  Nursing Diagnosis - Impaired Gas Exchange of Pulmonary Tuberculosis Tuberculosis, MTB, or TB (short for tubercle bacillus) is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis typically attacks the lungs but can also affect other parts of the body. It is spread through the air when people who have an active TB infection cough, sneeze, or otherwise transmit their saliva through the air. Most infections are asymptomatic and latent, but about one in ten latent infections eventually progresses to active disease which, if left untreated, kills more than 50% of those so infected. The classic symptoms of active TB infection are a chronic cough with blood-tinged sputum, fever, night sweats, and weight loss (the latter giving rise to the formerly prevalent term "consumption"). Infection of other organs causes a wide range of symptoms. Diagnosis of active TB relies on radiology (commonly

Nursing Care Plan for Heart Failure    Nursing Diagnosis : Decreased Cardiac Output  NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body Nursing Diagnosis : Decreased cardiac output related to Altered heart rate and rhythm AEB bradycardia characterized by: with pale conjunctiva, nail beds and buccal mucosa irregular rhythm of the pulse bradycardic pulse rate of 34 beats / min generalized weakness Short-Term Objectives: the patient Will Participate in activities That Reduced the workload of the heart. Long-Term Objectives: Will the patient be Able to display hemodynamic stability. Nursing Interventions Decreased Cardiac Output Congestive Heart Failure : 1. Auscultation apical pulse; examine the frequency, the heart rhythm. Rational: Usually tachycardia (even at rest) to compensate for the decrease in ventricular contractility. 2. Record the heart sounds. Rational: S1 and S2 may be weak due to decreased pumping action. Gallop rhythm common (S3

Nursing Diagnosis for Congestive Heart Failure (CHF) Activity Intolerance related to imbalance between oxygen supply. General weakness, long bedrest / immobilized. Characterized by: Weakness, fatigue, changes in vital signs, presence of dysrhythmias, dyspnea, pallor, sweating. Goals / evaluation criteria: Clients will participate in desired activities, meet self-care, achieve increased tolerance activity can be measured, evidenced by a decrease in weakness and fatigue. Nursing Interventions Activity Intolerance related to Congestive Heart Failure (CHF) : 1. Check vital signs before and immediately after activity, especially when the client is using vasodilators, diuretics and beta blockers. Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), the displacement of fluid (diuretics) or influence cardiac function. 2. Note the cardiopulmonary response to activity, note tachycardia, dysrhythmias, dyspnea sweaty and pale. Rationale: Decrease / in

Nursing Diagnosis for Leukemia - Acute pain  related to an agent of physical injury Purpose: pain is resolved Expected outcomes: The patient stated the pain disappeared or controlled Shows the behavior of pain management Looks relaxed and able to rest, sleep Nursing Intervention for Leukemia : Assess complaints of pain, notice changes in the degree of pain (using a scale of 0-10) Monitor vital signs, note the non-verbal clues such as muscle tension, anxiety Provide quiet environment and reduce stressful stimuli. Place the client in a comfortable position and prop joints, extremities with pillows. Change the position of periodic and soft assistive range of motion exercises. Provide comfort measures (massage, cold compresses and psychological support) The review / enhance client comfort interventions Evaluate and support the client's coping mechanisms Encourage the use of pain management techniques. Example: relaxation exercises / breathing in, touch. Auxiliary therapeutic activity,

Nursing Diagnosis for Leukemia Risk for Fluid Volume Deficit related to fluid intake and output, excessive loss: vomiting, bleeding, diarrhea decrease in fluid intake: nausea, anorexia increased need for fluids: fever, hypermetabolic. Purpose : the volume of fluid being met Expected outcomes: Adequate fluid volume The mucosa moist Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit Pulse palpated Urine output 30 ml / hour Capillaries and refill less than 2 seconds Nursing Intervention for Leukemia : Monitor fluid intake and output Monitor body weight Monitor BP and heart frequency Evaluation of skin turgor, capillary refill and mucous membrane conditions Give fluid intake 3-4 L / day Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive. Implement measures to prevent tissue injury / bleeding Limit oral care to wash mouth when indicated G

Nursing Care Plan for Obesity Nursing Assessment for Obesity Physical Examination 1. Activity / Rest symptoms: - Weakness, drowsiness trended - Inability / lack of desire to be active or exercise regularly - Dyspnea with work signs: - Increased heart rate / breathing with activity 2. circulation symptoms: - History of cultural factors / lifestyle affects food choices - Weight loss can / can not be accepted as a problem - Eating may relieve feelings of pleasure, such as loneliness, frustration, boredom - Prisoners of the closest people to lose weight 3. Food / fluid symptoms: - Digesting food with excess / normal - Experiment with different types of diet with little results - History repeated and decreased weight gain signs: - Weight loss is not right with height - Endormofik body type (soft / about) - Failed to determine the input of food to reduce demand (eg, changes in lifestyle from active to not exercise, aging) 4. Pain / Comfort Symptoms: Pain / discomfort in the joints that suppo

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation). Every year, several million people in North America are diagnosed with an AMI, and approximately one-third of these patients die during the acute phase. Health Canada has identified cardiovascular disease or heart diseases as the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national healthcare system. Clinical Manifestations of Myocardial Infarction Pain Chest pain that occurs suddenly and constantly not subside, usually above the sternal region and upper abdomen, this is the main symptom. The severity of pain can increase settled until unbear

Nursing Diagnosis : Risk for Injury related to weakness of the defense secondary to hemophilia characterized by frequent injuries Objectives / Expected outcomes: injury and complications can be avoided / did not happen. Nursing Interventions Maintain security of client's bed, put a safety on the bed Avoid injury, light - weight Keep an eye on every move that allows the occurrence of injury Encourage the parents to bring children to the hospital immediately in case of injury Explain to parents the importance of avoiding injury. Rational Fragile tissue and impaired clotting mechanisms boost the risk of bleeding despite the injury / mild trauma Patients with hemophilia are at risk of spontaneous bleeding was controlled so that the required monitoring every move that allows the occurrence of injury Early identification and treatment can limit the severity of complications Parents can find out mamfaat of injury prevention / risk of bleeding and avoid injury and complications. Lower t

Nursing Diagnosis: Ineffective Tissue Perfusio n related to active bleeding characterized by decreased consciousness, bleeding. Objectives / Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved Nursing Interventions Assess the cause of bleeding Assess skin color, hematoma, cyanosis Collaboration in the provision of adequate IVFD Collaboration in the provision of blood transfusion. Rational: By knowing the cause of bleeding it will assist in determining appropriate interventions for patients Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion. Source : http://careplannursing.blogspot.com/2012/03/3-nursing-diagnosis-interventions-for

Nursing Diagnosis for Parkinson's disease -  Self-care deficit Parkinson's disease is a common disorder that arises due to some imperfection that amends the normal functioning of the central nervous system. The disease results in the loss of the neurons or nerve cells that contain dopamine in the substantia niera, the part of the brain that controls movement. Parkinson's disease (Paralysis agitans) as described by James Parkinson in 1817 is characterized by degeneration of central nervous tissues, affecting the motor skills of a person, thereby impairing his (rarely her) movements and speech. The causes of the disease have not been proven, the following factors increase the risk of Parkinson's; Age Male Genetic link to a sufferer Stress Head trauma Environmental exposure to pesticides Rural living High fat diet There are also three factors that have been associated with a decreased risk of Parkinson's, these are cigarette smoking, anti-oxidants being present in die

A pheochromocytoma or phaeochromocytoma (PCC) is a neuroendocrine tumor of the medulla of the adrenal glands (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that failed to involute after birth and secretes excessive amounts of catecholamines, usually noradrenaline (norepinephrine), and adrenaline (epinephrine) to a lesser extent. Extra-adrenal paragangliomas (often described as extra-adrenal pheochromocytomas) are closely related, though less common, tumors that originate in the ganglia of the sympathetic nervous system and are named based upon the primary anatomical site of origin. Nursing Management of Pheochromocytoma Monitor vital signs, especially blood pressure changes--> severe hypertension can precipitate a cerebrovascular accident and/or sudden blindness Administer antihypertensive medications as ordered Promote rest and decrease stressful stimuli--> acute attacks may be precipitated by emotional stress, physical exertion, and change in positio

Acromegaly is the overgrowth of the bones and soft tissues due to excessive secretion of the growth hormone. Incidence Acromegaly is uncommon; only three to four cases are diagnosed per million people each year. It develops very gradually and may not be recognized until it has been present for many years. hyperpituitarism occurs equally among men and women. The mean age at diagnosis is about 40-60 years. It is caused by prolonged, excessive secretion of growth hormone (GH). The most common cause of acromegaly is a benign tumour (adenoma) of the somatotroph cells, which produce growth hormone. These cells are within the anterior pituitary gland, located in the middle of the head just below the brain. Nursing Diagnosis for Acromegaly / Gigantism 1. Disturbed body image related to enlargement of body parts as manifested by enlarged hands, feet and jaw. 2. Disturbed sensory perception related to enlarged pituitary gland as manifested by protrusion of eye balls . 3. Fluid volume de

Interventions 1. Fluid volume deficit related to excessive urinary output as manifested by increased thirst and weight loss. Ø Assess the fluid level of the patient Ø Monitor vital signs frequently Ø Restrict oral fluid intake. Ø Administer hypotonic saline intravenously. Ø Administer medications if ordered.   2. Disturbed sleeping pattern, insomnia related to nocturia as manifested by verbalization of patient about interrupted sleep. Ø Assess the sleeping pattern of the patient Ø Give psychological support. Ø Advice the patient to restrict oral fluids Ø Provide calm and quiet environment.   3. Activity intolerance related to fatigue and frequent urination as manifested by fatigue and weakness of the patient. Ø Assess the activity status of the patient Ø Give psychological support to the patient.   4. Anxiety related to course of disease and frequent urination as manifested by verbalization of anxious questions. Ø Assess the anxiety level of the patient. Ø Explain the patient about the

Nursing Diagnosis for Diabetes Insipidus Diabetes insipidus (DI) is a condition which causes frequent urination. The reduction in production or release of ADH results in fluid and electrolyte imbalance caused by increased urinary output. Depending on the cause, Diabetes insipidus may be transient or life long condition. In its clinically significant forms, diabetes insipidus is a rare disease. Clinical Manifestations Diabetes insipidus is characterized by increased thirst and increased urination. The primary character of DI is polyuria, excretion of large quantities of urine ( 5-20L per day)with a very low specific gravity(less than 1.005) and urine osmolality of < 100mmol/kg. In partial DI urine output may be lower(2-4L per day). Polydipsia (excessive intke of fluids) is also a characteristic feature of DI. Patient compensate for fluid loss by drinking great amount of water. The patient with central DI favours cold or iced drinks. Nocturia occurs due to frequent tendency to

Gastrostomy is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube, called a "g-tube," is used for feeding or drainage. Gastrostomy is performed because a patient temporarily or permanently needs to be fed directly through a tube in the stomach. Reasons for feeding by gastrostomy include birth defects of the mouth, esophagus, or stomach, and neuromuscular conditions that cause people to eat very slowly due to the shape of their mouths or a weakness affecting their chewing and swallowing muscles. Gastrostomy is also performed to provide drainage for the stomach when it is necessary to bypass a longstanding obstruction of the stomach outlet into the small intestine. Obstructions may be caused by peptic ulcer scarring or a tumor. Nursing Diagnosis for Gastrostomy Imbalanced nutrition, less than body requirements, related to enteral feeding problems Risk for infection related to pre

Colostomy surgery is often a frightening prospect for most people. But it can dramatically improve a person's quality-of-life, especially in cases of serious disease. Types of Colostomies There are several different types of colostomies including ascending, transverse, and descending. Ascending. This colostomy has an opening created from the ascending colon, and is found on the right abdomen. Because the stoma is created from the first section of the colon, stool is more liquid and contains digestive enzymes that irritate the skin. This type of colostomy surgery is the least common. Transverse. This surgery may have one or two openings in the upper abdomen, middle, or right side that are created from the transverse colon. If there are two openings in the stoma, (called a double–barrel colostomy) one is used to pass stool and the other, mucus. The stool has passed through the ascending colon, so it tends to be liquid to semi-formed. Descending or sigmoid. In this surgery, the desc

Parkinson's disease (also known as Parkinson disease, Parkinson's, idiopathic parkinsonism, primary parkinsonism, PD, or paralysis agitans) is a degenerative disorder of the central nervous system. The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain; the cause of this cell death is unknown. Early in the course of the disease, the most obvious symptoms are movement-related; these include shaking, rigidity, slowness of movement and difficulty with walking and gait. Later, cognitive and behavioural problems may arise, with dementia commonly occurring in the advanced stages of the disease. Other symptoms include sensory, sleep and emotional problems. PD is more common in the elderly, with most cases occurring after the age of 50. Nursing Diagnosis for Parkinson's Disease : Impaired physical mobility related to bradykinesia, muscle rigidity and tremors characterized by: Subjective da

Peritonitis is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Peritonitis may be localised or generalised, and may result from infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process. Treatment Depending on the severity of the patient's state, the management of peritonitis may include: General supportive measures such as vigorous intravenous rehydration and correction of electrolyte disturbances. Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum. The empiric choice of broad-spectrum antibiotics often consist of multiple drugs, and should be targeted against the most likely agents, depending on the cause of peritonitis (see above); once one or more agents are actually isolated, therapy will of course be targeted on them. Surgery (laparotomy) is needed to perform

Peritonitis Definition Peritonitis is inflammation of the peritoneum - the serous membrane lining the abdominal cavity and covers the viscera is dangerous complications that can occur in acute or chronic form or set of signs and symptoms, including tenderness and pain on palpation loose, defans muscular, and general signs of inflammation. Patients with peritonitis may experience symptoms of acute, mild illness and limited, or severe and systemic disease with septic shock. Infectious peritonitis, are divided over the causes perimer (spontaneous peritonitis), secondary (associated with pathological processes in visceral organs), or tertiary cause (recurrent or persistent infection after adequate initial therapy). Infection of the abdomen are grouped into pertitonitis infection (common) and abdominal abscesses (local peritonitis infection is relatively difficult to enforce and very dependent of the underlying disease. The cause of peritonitis is spontaneous bacterial peritoni

Nursing Diagnosis for Deficient Fluid Volume Hypovolemia; Dehydration Definition : Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal (GI) tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances. Deficient Fluid Volume re

Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation. Types of fluids Four types of fluids can accumulate in the pleural space: Serous fluid (hydrothorax) Blood (haemothorax) Chyle (chylothorax) Pus (pyothorax or empyema) Treatment Treatment depends on the underlying cause of the pleural effusion. Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain (either pigtail or surgical). When managing these chest tubes, it is important to make sure the chest tubes do not become occluded or clogged. A clogged chest tube in the setting of continued production of fluid will result in residual fluid left behind when the chest tube is removed. This fluid can lead to complications such as hypoxia due to lung collapse from the fluid, or fibrothorax, later, when

Hepatitis Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids (e.g. from blood transfusions or invasive medical procedures using contaminated equipment). Hepatitis B is also transmitted by sexual contact. The symptoms of hepatitis include jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.( who.int ) Nursing Interventions for Hepatitis Ineffective breathing pattern related to the collection of intra-abdominal fluid, ascites, decreased lung expansion and accumulation of secretions. Results : Adequate breathing pattern Intervention : Monitor the frequency, depth and respiratory effort Auscultation additional breath sounds Give the semi-F

Nursing Diagnosis and Interventions for Dengue Hemorrhagic Fever 1. Nursing Assessment Assess the patient’s medical history Assess the increase in body temperature, signs of bleeding, nausea, vomiting, no appetite, heartburn, muscle pain and signs of shock (rapid and weak pulse, hypotension, skin cold and moist, especially on the extremities, cyanosis, restlessness, decreased awareness). 2. Nursing Diagnosis for DHF – Dengue Hemorrhagic Fever Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting, and fever. Ineffective Peripheral Tissue Perfusion related to bleeding. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting, no appetite. Hyperthermia related to the process of viral infection. 3. Nursing Interventions for DHF – Dengue Hemorrhagic Fever Goal: Show signs of liquid fulfillment Shows signs of adequate peripheral tissue perfusion Showed vital signs within normal limits The family suggests that adaptive coping 1. Defi

Nursing Diagnosis for Hydrocephalus Ineffective Cerebral Tissue Perfusion related to increased volume of cerebrospinal fluid. NOC : circulation status NOC – Expected outcomes: 1. Indicate the status of the circulation is characterized by the following indicators: Systolic and diastolic blood pressure within normal range No major vein noisy 2. Demonstrated cognitive abilities, characterized by the indicator: Communicate clearly and in accordance with the age and ability Show attention, concentration and orientation Demonstrated long-term memory and the current Process information Make the right decision Hydrocephalus – Ineffective Cerebral Tissue Perfusion – NIC Interventions 1. Monitor the following matters: Vital signs Headache Level of awareness and orientation Inistagmus diplopia, blurred vision, visual acuity 2. Monitoring of ICT: ICT monitoring and neurological response of the patient care activities Monitor tissue perfusion pressure Note the change in the patient in response

Nursing Assessment for Hypertension Basic Nursing Assessment data by Doenges (1999) : Activity / Rest Symptoms: weakness, fatigue , shortness of breath, monotonous lifestyle. Signs: The frequency of the heart increases, changes in heart rhythm, tachypnoea. Circulation Symptoms: History of hypertension, atherosclerosis, coronary heart disease / valve and cebrocaskuler disease, episodes of palpitations. Signs: The increase in BP, pulse throbbing clear from the carotid, jugular, radial, tachycardia, valvular stenosis murmur, jugular venous distension, pale skin, cyanosis, cold temperature (peripheral vasoconstriction) filling the capillary may be slow / delayed. Ego Integrity Symptoms: History personality changes, anxiety, multiple stress factors (relationship, financial, work related). Signs: Explosion mood, anxiety, continue narrowing of attention, tears burst, face muscles tense, breathing heaved, increased speech patterns. Elimination Symptoms: Impaired renal current or (such

Anemia is a clinical condition in which total number of red blood cells or the quantity of hemoglobin in blood declines than the normal level so the oxygen binding ability of hemoglobin is decreased. Anemia is a relatively common disorder where one’s body does not produce enough red blood corpuscles (or cells) in the blood. As a result, the reduced number of cells does not have enough of the protein hemoglobin, which contains iron and transports oxygen around one’s bloodstream, thus the patient feels weak and looks pale – the most noticeable symptoms of anemia. Types of Anemia Iron deficiency anemia; Folate deficiency anemia; Sickle Cell Disease; and Thalassemia. Anemia in some individuals may remain hidden as the symptoms do not arise very frequently. The signs and symptoms may depend upon the underlying cause. Individuals suffering from anemia generally show non-specific symptoms like weakness, general malaise and poor concentration. They may also report shortness of br