Nanda Nursing Diagnosis

Fatigue Fatigue is a condition with signs of reduced capacity of a person, for work and reduced efficiency of accomplishment, and this is usually accompanied by a feeling tired and weak. Fatigue can be acute and come on suddenly or chronic and persist. According to other sources of fatigue is a condition of the human body naturally feel tired, which usually happens after physical exercise or mental harm. Fatigue can be acute and come on suddenly or chronic and persist. Usually after a long exercise, surely people will feel tired, because of all the moving limbs, limbs will be ill and do not want to continue the exercise. However, this fatigue will soon be replaced with good health and well-being. Just like a mix between fatigue and the sense of satisfaction that people feel after working hard in the office or study, this is a healthy and natural fatigue. Fatigue at the beginning and at the end of pregnancy is also a natural thing, the reason is the increase in the activity of the hormo

Nursing Diagnosis for Dehydration Fluid volume deficit related to excessive output, less intake. Risk for ineffective tissue perfusion related to decreased blood flow. Risk for impaired skin integrity related to decreased skin turgor. Activity intolerance related to physical weakness. Risk for Decreased cardiac output related to a decrease in systemic vascular resistance. Nursing Care Plan for Dehydration Nursing Interventions for Dehydration 1. Fluid volume deficit related to excessive output, less intake. Goal: adequate fluid volume so that fluid volume deficiency can be overcome. Expected outcomes: Maintain fluid balance. Vital signs (pulse = 80-100 beats / min, temperature = 36-37oC) Capillary refill less than 3 seconds. Akral warm. Urine output: 1-2 cc / kg body weight / hour. Intervention: Monitor vital signs, capillary refill, the status of the mucous membranes. Discuss strategies to stop vomiting and use of laxatives / diuretics. Identification of a plan to increase the optima

Dehydration Definition Dehydration is a condition in which a person who is not fasting experiencing or at risk of dehydration vascular, interstitial or intra-vascular (Sell Lynda Carpenito, 2000: 139). Classification Classification of dehydration by Donna D. Ignatavicus there are 3 types: a. Isotonic dehydration Isotonic dehydration is lost water followed by the electrolyte so that the density remained normal, then this type of dehydration is usually not result in ECF fluid move to the ICF. b. Hypotonic dehydration Hypotonic dehydration is the loss of solvent from the ECF exceeds fluid loss, resulting in blood vessels become more concentrated. ECF osmotic pressure decreases, resulting in fluid moves from the ECF to ICF. Vascular volume also decreased, as well as cell swelling occurs. c. Hypertonic dehydration Hypertonic dehydration is ECF fluid loss exceeds the solvent is non-osmotic dehydration ECF decreased, resulting in fluid moves from ICF to ECF. Etiology Various causes dehydratio

Risk for Infection related to the invasion of microorganisms in the body Goal : after the act of nursing for 3x24 hours of infection did not occur. Expected outcomes: Patients will show a careful hand-washing techniques. Patients will be free of the nosocomial infection during hospitalization. Patients will demonstrate knowledge of the risk factors associated with infection and appropriate precautions to prevent infection. Intervention - Risk for Infection : 1. Monitor for signs and symptoms of infection. R /: To determine whether there is an infectious process. 2. Monitor laboratory results, Monitor the patient's temperature. R /: Leukocyte increased and increased body temperature is not expected, a sign of infection. 3. Use antiseptic technique when taking action to clients. R /: Prevent cross-infection. 4. Emphasize the need to wash hands regularly / thoroughly before and when handling food, after toileting. R /: Many viruses such as cytomegalovirus (CMV) can be excreted in th

Risk for Activity Intolerance related to physical weakness Activity Intolerance is a decrease in physiological capacity to maintain activity to the level desired or required. Defining Characteristics: Major : Change the client's physiological response to the activity undertaken. Respiratory: dyspnea (breathing frequency increased exaggeration). Shortness of breath (decrease frequency). Pulse: weak, declining, excessive increase, the increase in the rhythm, failed to return to the level before the activity after 3 minutes. Blood pressure: failed to increase the activity, an increase in diastolic over 15 mmHg. Minor: fatigue ,  weakness,  cyanosis or pale,  mental chaotic,  vertigo Subjective Data: weakness fatigue dyspnea lack of sleep Objective Data : Assess the strength and balance, the evaluation of an individual's ability to: Changing positions himself on the bed. Ambulation. Doing ADL (activity daily living) or daily activities. Assess for the presence of: pale cyanosis m

Nursing Care Plan for Febrile Seizures According to Doengoes (1999: 259-261 and 871-872) includes: History of causative factors: Idiopathic no cause is known. Post-trauma, head injury, inflammation of the lining of the brain, high fever. History of seizures Since what age? How long seizures occur? How many times a seizure occurs within 1 hour? When was the last seizures experienced? Physical examination, by inspection, palpation, percussion and auscultation. a. Activity / rest. Symptoms: Fatigue, general weakness. Limitations in activities / work caused by self-/ significant other / nursing care giver or others. Signs: Change of tone / muscle strength. Involuntary movements / muscle contraction. b. Circulation Symptoms: Ictal: hypertension, increased pulse and cyanosis. Post-ictal: normal vital signs or depression with decreased pulse and respiration. Signs: Heart sound: disratmia and development can lead to myocardial dysfunction, effects of acidosis / electrolyte imbalance. The skin

Nursing Care Plan for Pediatric Febrile Seizures Definition of Febrile Seizures Febrile seizures are seizures that occur on the rise in body temperature (rectal temperature of more than 380C) which is caused by an extra-cranial process. Febrile seizures occur in 2-4% of children aged 6 months - 5 years. Children who have had seizures without fever, then re febrile seizures are not included in the febrile seizures. Febrile seizures in infants younger than 1 month are not included in the febrile seizures. When children aged less than 6 months or more than 5 years experience seizures preceded by fever, think of other possibilities, such as central nervous system infections, or epilepsy that happen to occur along a fever. Etiology Until now, the etiology of febrile seizures is not known with certainty. Fever is often caused by: upper respiratory tract infection, otitis media, pneumonia, gastroenteritis, and urinary tract infection. Seizures are not always arise at high temperatures. Someti

Nursing Diagnosis for Schizophrenia : Risk for Self or Other- Directed Violence Goal: The patient can control violent behavior, with the following criteria: Bright face, smiling. Want to get acquainted and there is eye contact. Willing to tell the feeling. Telling cause irritation / anger. Can identify signs of violent behavior. Can identify, form of violence that is done. Can be identified as a result of violent behavior. Able to practice taught how to control anger. Able to engage in group activity therapy. Can taking medication with minimal assistance. Clients can continue the relationship in accordance with the responsibilities of the role. Interventions Client Intervention Perform a trusting relationship. Identify the causes of violent behavior. Identify the signs and symptoms of violent behavior. Identification form of violence that is ever done. Identification due to violent behavior. Teach how to control violent behavior, among others: Physically (relaxation, activities and spo

Nursing Care Plan for Acute Lymphoblastic Leukemia Acute lymphoblastic leukemia is an acute form of leukemia, which are classified according to the cell that is more in the bone marrow, which is the form lymphoblasts. In case of leukemia occurred abnormal leukocyte cell proliferation, malignant, often accompanied by other forms of leukocytes than normal, excessive amounts, and can cause anemia, thrombocytopenia, and ends with death. Causes of Acute lymphoblastic leukemia is unknown, but it is possible because of the interaction of a number of factors: neoplasia infection radiation descent chemicals gene mutations Clinical manifestations Anemia: tiredness, lethargy, dizziness, tightness, chest pain. Anorexia. Bone and joint pain (bone marrow infiltration). Fever, sweating (hypermetabolism symptoms). Mouth infections, upper and lower respiratory tract, cellulitis, or sepsis. Skin bleeding (petechiae, ecchymosis atraumatic), bleeding gums, hematuria, gastrointestinal bleeding, brain hemor

Treatment of Schizophrenia Treatment should be as fast as possible, because the psychotic state in a long time lead to a greater likelihood of patients leading to mental deterioration. Even though the patient may not recover completely, but with treatment and good guidance, the patient can be helped to be able to function continuously, simple work at home or outside, and can raise and educate their children (Maramis, 2009). The type of treatment in patients with schizophrenia (Maramis, 2009), are as follows: 1. Pharmacotherapy An indication of antipsychotics in schizophrenia is to control the active symptoms and prevent relapse. Treatment strategy depends on the phase of the disease is acute or chronic. The acute phase is usually characterized by psychotic symptoms (experienced new or recurrent) that need to be addressed immediately. The aim here is to reduce the treatment of severe psychotic symptoms. With phenothiazines, delusions and hallucinations usually disappear within 2-3 weeks

Nursing Care Plan for Schizophrenia, Nursing Diagnosis : Disturbed Sensory Perception Schizophrenia is a disease that affects the brain and cause thoughts, perceptions, emotions, movement, strange and disturbed behavior (Videbeck, 2008). Nursing Diagnosis : Disturbed Sensory Perception hearing / vision related to: freaking out withdraw strss heavy, threatening the weak ego. Defining characteristics: talking and laughing themselves behave like listening to something (tilt the head to one side as if someone was listening to something). stop talking in the midst of a sentence to listen to something. disorientation low concentrations rapidly changing minds chaos groove mind response is not appropriate. Expected outcomes: Patients can be admitted that the hallucinations occur during extreme anxiety increased. Patients can say signs of increased anxiety and use certain techniques to break the anxiety. Planning: General purpose : Patients are able to define and examine the reality, reducing

Nursing Care Plan for Cataracts Cataract is the medical term for each state turbidity occurs in the eye lens that can occur as a result of hydration (adding liquid lens), the lens protein denaturation, or can also be a result of both. Usually on both eyes and walked progressive. Cataracts cause the patient can not see clearly because of the cloudy lens is difficult light reaches the retina and will produce a blurred shadow on the retina. The number and shape of the eye lens opacities in each may vary. Causes of Cataracts Aging (Senile Cataracts): Most cataracts occur due to degenerative process or the age of a person. The average age of a cataract is at age 60 years and older. Trauma: Eye injury can be informed of all ages such as a hard blow, puncture objects, clipped, high heat, and chemicals can damage the eye and the lens is called cataract traumatic circumstances. Other eye diseases (uveitis) Systemic disease (Diabetes Mellitus). Congenital defects. Cataract is diagnosed mainly b

Nursing Care Plan for Endocarditis NURSING DIAGNOSIS 1. Acute pain related to systemic effects of infection. Interventions : Independent Assess the complaint of chest pain. Pay attention to nonverbal cues of discomfort. Provide a quiet environment and comfort measures, such as: changes in position, back rub, use a warm compress / cold. Give proper entertainment activities. Collaboration Give medications as indicated. Give O2 supplementation as indicated. Rationale : Chest pain may and may not accompany the presence or absence of ischemia depends endocarditis. This action can reduce the patient's physical and emotional discomfort. Redirecting attention, provide distraction in the level of individual activities. Can relieve pain, decrease the inflammatory response. Maximize the availability of O2 to reduce the workload of the heart and prevent ischemia. 2. Risk for decreased cardiac output related to disorders of the heart valves and the endothelium. Interventions : Independent Mon

Nursing Care Plan for Rheumatoid Arthritis Rheumatoid arthritis is a chronic autoimmune disorder that causes inflammation of the joints (Lemone & Burke, 2001: 1248). Nursing Diagnosis for Rheumatoid Arthritis : Body image disturbance related to changes in the ability to perform common tasks, increased use of energy, mobility imbalance. Expected outcomes: Expressing increased confidence in the ability to cope with illness, changes in lifestyle, and possible limitations. Develop a realistic plan for the future. Nursing Interventions: Encourage disclosure about the problem of disease processes, hope for the future. Discuss the meaning of the loss / change in patient / significant other. Ascertain how the patient's personal views on the functioning of everyday lifestyle. Discuss the patient's perception of how the people closest to accept limitations. Acknowledge and accept the feelings of the bereaved, hostile, dependence Consider withdrawing behavior, or deny the use of too