Nanda Nursing Diagnosis

Nursing Care Plan for Glomerulonephritis Glomerulonephritis is a type of kidney disease in which the part of your kidneys that helps filter waste and fluids from the blood is damaged. Symptoms of Glomerulonephritis Common symptoms of glomerulonephritis are: Blood in the urine (dark, rust-colored, or brown urine) Foamy urine Swelling (edema) of the face, eyes, ankles, feet, legs, or abdomen Symptoms that may also appear include the following: Abdominal pain Cough Diarrhea General ill feeling Fever Joint aches Muscle aches Loss of appetite Shortness of breath nlm.nih.gov Nursing Assessment for Glomerulonephritis Genitourinary Turbid urine Proteinuria Decrease in urine output Haematuria Cardiovascular Hypertension Neurological Lethargy Irritability Seizures Gastrointestinal Anorexia Vomitus Diarrhea Hematology Anemia Azotemia Hyperkalaemia...

Nursing Care Plan for Nephrotic Syndrome Nephrotic Syndrome Nephrotic syndrome is a group of symptoms including protein in the urine (more than 3.5 grams per day), low blood protein levels, high cholesterol levels, high triglyceride levels, and swelling. Causes of Nephrotic Syndrome Nephrotic syndrome is caused by various disorders that damage the kidneys, particularly the basement membrane of the glomerulus. This immediately causes abnormal excretion of protein in the urine. The most common cause in children is minimal change disease, while membranous glomerulonephritis is the most common cause in adults. This condition can also occur as a result of infection (such as strep throat, hepatitis, or mononucleosis), use of certain drugs, cancer, genetic disorders, immune disorders, or diseases that affect multiple body systems including diabetes, systemic lupus erythematosus, multiple myeloma, and amyloidosis. It can accompany kidney disorders such as glomerulonephritis, focal and segmenta...

Nursing Care Plan for Myocardial Infarction A heart attack (also known as a myocardial infarction ) is the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Coronary arteries are blood vessels that supply the heart muscle with blood and oxygen. Blockage of a coronary artery deprives the heart muscle of blood and oxygen,causing injury to the heart muscle. Injury to the heart muscle causes chest pain and chest pressure sensation. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur. Muscle continues to die for six to eight hours at which time the heart attack usually is "complete." The dead heart muscle is eventually replaced by scar tissue. Approximately one million Americans suffer a heart attack each year. Four hundred thousand of them die as a result of their heart attack. Symptoms of a heart attack Although chest pain or pressure is the most common symptom o...

Nursing Care Plan for Alzheimer's Disease Alzheimer's disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects a person's ability to carry out daily activities. AD begins slowly. It first involves the parts of the brain that control thought, memory and language. People with AD may have trouble remembering things that happened recently or names of people they know. A related problem, mild cognitive impairment(MCI), causes more memory problems than normal for people of the same age. Many, but not all, people with MCI will develop AD. In AD, over time, symptoms get worse. People may not recognize family members or have trouble speaking, reading or writing. They may forget how to brush their teeth or comb their hair. Later on, they may become anxious or aggressive, or wander away from home. Eventually, they need total care. This can cause great stress for family members who must care for them. AD us...

Nursing Care Plan for 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. www.who.int Nursing Assessment for Hepatitis 1. Main complaint No appetite, malaise, fever (more frequent in hepatitis A). Taste stiff, and headache on Hepatitis B. 2. Health Assessment a. Activity * Weakness * Fatigue * Depression b. Circulation * Bradycardia (hiperbilirubin weight) * Jaundice in the sclera of skin, mucous mem...

COMMON DYSRHYTHMIAS Tachycardias I. Sinus Tachycardia a. Sinus node creates rate that is faster than normal (greater than 100) b. Associated with physiological or psychological stress; medications, such as catecholamines, aminophylline, atropine, stimulants, and illicit drugs; enhanced automaticity; and autonomic dysfunction II. Atrial Flutter a. Occurs in the atrium and creates regular atrial

Alteration in Bowel Elimination: Constipation Definition: A situation where an individual experience or a higher risk of static in the large intestine, resulting in a rare bowel movements, hard, dry stools. Related Factors: Pathophysiology Related to innervation disorders, pelvic floor muscles are weak, and immobilization: Spinal cord lesions Spinal cord injury Dementia Cerebrovascular injury (CSV, stroke) Neurological Disease Related to a reduced metabolic rate: Obesity Diabetic neuropathic Uremia Hypothyroidism Hyperparathyroidism Related to decreased peristalsis: Hypoxia (cardiac, pulmonary) Action Related to side effects (specific): Aluminum antacids Aspirin anesthetic Iron Fenotiasine Barium Calcium Anticholinergics Diuretics Narcotics Agents antiparkinson Situational Related to decreased peristaltis Immobilization Gestation Stress Lack of exercise Related to elimination pattern ketitakteraturan Dealing with fear of pain Related to fluid intake takadekuat Major Data Frequency decr...

MYOCARDIAL INFARCTION I. Pathophysiology a. Marked reduction or loss of blood flow through one or more of the coronary arteries, resulting in cardiac muscle ischemia, and over a finite period, resulting in necrosis b. Occurs most often due to coronary artery disease (CAD) c. Cellular ischemia and necrosis can affect the heart’s rhythm, pumping action, and blood circulation. d. Other problems may

Nursing Care Plan for Imbalanced Nutrition Less than Body Requirements Definition A situation where individuals who are at risk of weight loss associated with inadequate input, or metabolism of nutrients is not adequate for metabolic needs. Related Factors: Pathophysiology Related to an increased calorie needs and difficulty in digesting sufficient calories Burn Infection Dependence of chemicals Cancer Trauma Related to dysphagia Cerebrovascular injury Amiotrofik lateral sclerosis Cerebral palsy Parkinson's Abnormalities neurovaskuler Muscular dystrophy Related to decreased absorption of nutrients Crohn's Disease Cystic Fibrosis Lactose Intolerance Related to decreased desire to eat Decreased level of consciousness Related to vomiting is stimulated alone, refusing to eat Anorexia nervosa Related to a reluctance to eat for fear of poisoning Paranoid behavior Related to anorexia, excessive physical agitation Bipolar disorder Related to anorexia and diarrhea Protozoan infection Re...

Nursing Care Plan for Imbalanced Nutrition More than Body Requirements Definition : A situation where an individual experiencing or at risk of weight gain associated with the input that exceeds the metabolic needs. Related Factors: Pathophysiology Related to changes in the pattern of satisfaction Drugs (corticosteroids, antihistamines) Radiation (decreased sense of taste and smell) Situational (Personal, environmental) Related to the risk of weight gain more than 25-39 pounds during pregnancy Related to lack of basic nutrition knowledge Maturisional (The adult / elderly) Related to the decline in activity patterns and a decrease in metabolic demand. Major Data Being overweight (10% higher than the ideal body standards) Obesity (20% higher than the ideal body standards) Triceps skinfolds greater than 15 mm in men, and 25 mm in women Minor Data Reported a diet of unwanted Input exceeds the metabolic needs Monotonous activity pattern Expected Outcomes Nursing Care Plan for Imbalanced Nutr...

ANGINA (CORONARY ARTERY DISEASE, ACUTE CORONARY SYNDROME) I. Pathophysiology a. The disorder is characterized by a narrowing of coronary arteries due to atherosclerosis, spasm or, rarely, embolism. b. Atherosclerotic changes in coronary arteries results in damage to the inner layers of the coronary arteries with stiffening of vessels and diminished dilatory response. c. Accumulation of fatty

PULMONARY TUBERCULOSIS (TB) I. Pathophysiology a. Bacterial infection by Mycobacterium tuberculosis bacilli (TB) i. Primarily affects the lungs (70% per Centers for Disease Control and Prevention [CDC], 2004) although it can invade other body systems ii. Airborne droplets are inhaled, with the droplet nuclei deposited within the alveoli of the lung. b. Primary infection followed by a latent or

VENTILATORY ASSISTANCE (MECHANICAL) I. Pathophysiology—impairment of respiratory function affecting O2 uptake and CO2 elimination, requiring mechanical assist to support or replace spontaneous breathing a. Inability to maintain adequate oxygenation (hypoxemia) b. Inability to maintain adequate ventilation due to apnea or alveolar hypoventilation causing a rise in PaCO2 and a fall in serum pH (

Ineffective Thermoregulation Definition: Circumstances where an individual experiencing or at risk of inability to maintain normal body temperature effectively with any discrepancies or changes in external factors. Related Factors: Situational (Personal, environmental) Related to fluctuations in environmental temperature Related to objects that are wet and cold (clothing, bedding) Related to a wet body surface Related to clothing that is not compliant with the weather Related to limited regulation of metabolic compensation Elderly Newborns Expected Outcomes Nursing Care Plan for Ineffective Thermoregulation Babies will Having a temperature between 36.4 to 37.5 º C. Parents will Explain the techniques to avoid heat loss at home. Nursng Intervention Nursing Care Plan for Ineffective Thermoregulation Reduce or eliminate the sources of heat loss in infants Evaporation When a shower, prepare a warm environment. Wash and dry each section to reduce evaporation Limit the time of contact with c...

Hyperthermia Definition: Circumstances where an individual experiencing or at risk of increased body temperature continuously above 37.8 per oral or per-rectal 38.8 ° C because of the increased vulnerability to external factors. Nursing Care Plan for Hyperthermia Related Factors: Related to decrease the ability to sweat : (Special Treatment) Situational Exposure to heat (sun) Clothing that does not comply with the climate Related to a decrease in circulation: Extreme weight loss Dehydration Insufficiency hydration for heavy activity Maturisional Related to temperature regulation is not effective: Newborns Premature Babies Elderly Major Data: Higher temperature 37.8 orally or 38.8 º C per rectal Minor Data: Skin redness Warm to the touch Respiratory frequency increased Tachycardia Goosebumps Dehydration Pain or illness-specific or general (eg, headache, fatigue) Malaise / fatigue / weakness Loss of appetite Expected Outcomes Individuals will: Identifying risk factors to hyperthermia ....

Hypothermia Hypothermia is a condition in which core temperature drops below the required temperature for normal metabolism and body functions which is defined as 35.0 °C (95.0 °F). Body temperature is usually maintained near a constant level of 36.5–37.5 °C (98–100 °F) through biologic homeostasis or thermoregulation. If exposed to cold and the internal mechanisms are unable to replenish the heat that is being lost, a drop in core temperature occurs. As body temperature decreases, characteristic symptoms occur such as shivering and mental confusion. Nursing Care Plan for Hypothermia Related Factors: Situational (Personal, environmental) Heat, rain, wind Clothing that does not comply with the climate Decrease in circulation: Extreme weight loss Consuming alcohol Dehydration Inactivity Maturisional Ineffective temperature regulation: Newborns Elderly Major Data: Temperatures below 35.5 º C per rectal Cold skin Pallor (medium) Shivering (mild) Minor Data: Mental disorder / sleepy / rest...

HEART FAILURE: CHRONIC I. Pathophysiology a. Remodeling of the myocardium (as a structural response to injury) changes the heart from an efficient football shape to an inefficient basketball shape, making coordinated contractility difficult. i. Ventricular dilation (systolic dysfunction) results in poor contractility and inadequate emptying of chamber. ii. Ventricular stiffening (diastolic

HYPERTENSION: SEVERE I.Pathophysiology—malignant or cancerous tumor, starting from the cells of the breast tissue and occurring primarily in women, although men may also be affected. b. Types (NCCN, 2007) i. This is cout3. This is cout3. This is cout3. This is cout3.This is cout3. A. Pathophysiology—malignant or cancerous tumor, starting from the cells of the breast tissue and occurring

Definition : Impaired Gas Exchange Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system. Related Factors: Altered oxygen supply Alveolar-capillary membrane changes Altered blood flow Altered oxygen-carrying capacity of blood Nursing Care Plan for Impaired Gas Exchange Major Data Dyspnea when performing activities Minor data Confusion / agitation. The tendency to take a three-point position (sitting, one hand on each knee, leaning forward). Breathing with the lips with a long expiratory phase. Lethargy and fatigue . Increased pulmonary vascular resistance. Decrease in gastric motility. Decrease in oxygen content, decreased O2 saturation, PCO2 decreased as shown by the results of blood gas analysis. Cyanosis. Nursing Care Plan for Impaired Gas Exchange Nursing Care Plan for Hypothermia

RADICAL NECK SURGERY: LARYNGECTOMY (POSTOPERATIVE CARE) I. Pathophysiology a. Malignancy lies above the clavicle, for instance lip, mouth, nasal cavity, paranasal sinuses, pharynx, larynx, but excludes the brain, spinal cord, axial skeleton, and vertebrae. b. Cancers limited to the vocal cords (intrinsic) tend to spread slowly, whereas cancers involving the epiglottis (extrinsic) are more likely

PNEUMOTHORAX/HEMOTHORAX I. Pathophysiology a. Partial or complete collapse of lung due to accumulation of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) in the pleural space b. Intrathoracic pressure changes induced by increased pleural space volumes and reduced lung capacity, causing respiratory distress and gas exchange problems and producing tension on mediastinal

LUNG CANCER: POSTOPERATIVE CARE I. Pathophysiology a. Usually develops within the wall or epithelium of the bronchial tree b. Prolonged exposure to cancer-promoting agents causes damage to ciliated cells and mucus-producing cells, leading to genetic mutations and development of dysplastic cells. II. Classification (Memorial Sloan-Kettering Cancer Center, 2008; National Cancer Institute, 2008) a.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND ASTHMA I. Pathophysiology a. Chronic obstructive pulmonary disease (COPD): chronic obstructive bronchitis and emphysema i. Chronic airflow limitations (CAL): caused by a mixture of small airway disease (obstructive bonchiolitis) and parenchymal destruction (emphysema) ii. Airway inflammation: causes structural changes, narrowing of lumina, and

PNEUMONIA I. Pathophysiology a. Inflammation of the lung parenchyma associated with alveolar edema and congestion that impairs gas exchange b. Common pathogens i. Viruses 1. Common causative organisms include respiratory syncytial virus (RSV) and influenza 2. Accounts for approximately half of all cases of community-acquired pneumonia (CAP) ii. Bacteria 1. Divided into typical and atypical types