Nanda Nursing Diagnosis

Meningitis is inflammation of the meninges, the covering of the brain and spinal cord. It is most often caused by infection (bacterial, viral, or fungal), but can also be produced by chemical irritation, subarachnoid haemorrhage, cancer and other conditions. who.int Signs of meningitis as follows : fever headache stiff neck photophobia and vomiting confused (possible) Septicemia patients usually do not show the existence of neurologic failure, but patients showed the existence of: circulatory changes decreased peripheral perfusion tachycardia tachypnoe hypotension ptechie as an indication of the patients had bacteremia by meningococcal Assessment Always use the ABCDE approach to assessment Airway Make sure the airway clearance Prepare tools to facilitate the airway if necessary If there is a decrease in respiratory function immediately contact an anesthesiologist and treated in the ICU Breathing Assess respiratory rate - less than 8 or over 30 is a significant sign. Assess oxygen satu...

COPD , or chronic obstructive pulmonary disease , is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time. COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms. Cigarette smoking is the leading cause of COPD . Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD . nhlbi.nih.gov Assessment Airway Assess and maintain airway Do the head tilt, chin lift if necessary Use the help of the airway if necessary Consider to be referring to the anesthesiologist Breathing Assess oxygen saturation using pulse oximeter Do inspection arterial blood gases to assess pH, PaCO2 and PaO2 If the arterial pH less than 7.2, more profitable patients using non-invasive ventilation (NIV) and references must be made in accordance with loca...

Nursing Care Plan for Empyema Empyema Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space). Symptoms Chest pain, which worsens when you breathe in deeply (pleurisy) Dry cough Excessive sweating, especially night sweats Fever and chills General discomfort, uneasiness, or ill feeling (malaise) Shortness of breath Weight loss (unintentional) Nursing Diagnosis of Empyema 1: Ineffective airway clearance related to bronchus spsame, increased production of secretions, weakness Nursing Intervention and Rational: Auscultation of breath sounds: note the presence of breath sounds, assess and monitor breathing sounds R /: To determine the presence of airway obstruction, the degree yan tachipneu found the process of acute infection. Assess the frequency of respiratory R /: The process of acute infection (tachipnea) Nursing diagnosis of empyema 2: Impaired Gas Exchange related to airway obstruction secondary to the buildup of secreti...

NCP - Nursing Care Plan for Perinatal Asphyxia Perinatal asphyxia or neonatal asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. Hypoxic damage can occur to most of the infant's organs (heart, lungs, liver, gut, kidneys), but brain damage is of most concern and perhaps the least likely to quickly or completely heal. In the more pronounced cases, an infant will survive, but with damage to the brain manifested as either mental, such as developmental delay or intellectual disability, or physical, such as spasticity — in fact, spastic diplegia and the other forms of cerebral palsy almost always feature asphyxiation during the birth process as a major, if not defining, factor. Nursing Assessment for Perinatal Asphyxia Physical Examination Respiratory system Low Apgar scores Breathing shallow, irregular, tachypnea Snoring, breathing nostrils, retracted s...

NCP - Nursing Care Plan for Cerebral Palsy (CP) Cerebral palsy (CP) is an umbrella term for a group of disorders affecting body movement, balance, and posture. Loosely translated, cerebral palsy means “brain paralysis.” Cerebral palsy is caused by abnormal development or damage in one or more parts of the brain that control muscle tone and motor activity (movement). The resulting impairments first appear early in life, usually in infancy or early childhood. Infants with cerebral palsy are usually slow to reach developmental milestones such as rolling over, sitting, crawling, and walking. Treatment Treatment for cerebral palsy is a lifelong multi-dimensional process focused on the maintenance of associated conditions. In order to be diagnosed with cerebral palsy the damage that occurred to the brain must be non-progressive and not disease like in nature. The manifestation of that damage will change as the brain and body develop, but the actual damage to the brain will not increase. Tre...

A peptic ulcer is a sore in the lining of your stomach or your duodenum, the first part of your small intestine. A burning stomach pain is the most common symptom. The pain : May come and go for a few days or weeks May bother you more when your stomach is empty Usually goes away after you eat Peptic ulcers happen when the acids that help you digest food damage the walls of the stomach or duodenum. The most common cause is infection with a bacterium called Helicobacter pylori. Another cause is the long-term use of nonsteroidal anti-inflammatory medicines (NSAIDs) such as aspirin and ibuprofen. Stress and spicy foods do not cause ulcers, but can make them worse. Nursing Assessment Nursing Care Plan for Peptic Ulcer Assess for chronic use of certain medications (such as aspirin, steroids). Collect information of complaints that brought client to the hospital. Obtain history of onset and progression of symptoms. Obtain information of diet, use of alcohol and tobacco, ingestion of irritat...

NCP For Delusional Disorders Delusional Disorder Delusional disorder is an illness characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms, according to the Diagnostic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). It defines delusions as false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary and these beliefs are not ordinarily accepted by other members of the person's culture or subculture. Nonbizarre refers to the fact that this type of delusion is about situations that could occur in real life, such as being followed, being loved, having an infection, and being deceived by one's spouse. Delusional disorder is on a spectrum between more severe psychosis and overvalued ideas. Bizarre delusions represent the manifestations of more severe types of psychotic illnesses (eg, schizophrenia) and "are clearly implausible, not understandable, and n...

Definition: Change in normal bowel habits characterized by involuntary passage of stool. Related Factors: Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele); sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles); neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (cerebrovascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural...

NANDA Definition : Absence or deficiency of cognitive information related to specific topic Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Teaching may take place in a hospital, ambulatory care, or home setting. The learner may be the patient, a family member, a significant other, or a caregiver unrelated to the patient. Learning may involve any of the three domains: cognitive domain (intellectual activities, problem solving, and others); affective domain (feelings, attitudes, beliefs); and psychomotor domain (physical skills or procedures). The nurse must decide with the learner what to teach, when to teach, and how to teach the mutually agreed-on content. Adult learning principles guide the teaching-learning process. Information should be made available when the patient wants and needs it, at the pace the patient determines, and using the teaching strategy the patient deems most effective. Man...

Gastroenteritis Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). Diarrhea, crampy abdominal pain, nausea, and vomiting are the most common symptoms. Viral infection is the most common cause of gastroenteritis but bacteria, parasites, and food-borne illness (such as shellfish) can be the offending agent. Many people who experience the vomiting and diarrhea that develop from these types of infections or irritations think they have "food poisoning," and they may indeed have a food-borne illness. Many people also refer to gastroenteritis as "stomach flu," although influenza has nothing to do with the condition. Travelers to foreign countries may experience "traveler's diarrhea" from contaminated food and unclean water. The severity of infectious gastroenteritis depends on the immune system's ability to resist the infection. Electrolytes (these include essential elements o...

NCP For Anorexia Nervosa Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600-800 calories per day, but there are extreme cases of complete self-starvation. It is a serious mental illness with a high incidence of comorbidity and the highest mortality rate of any psychiatric disorder. Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. However, it can affect men and women of any age, race, and socioeconomic and cultural background. Anorexia nervosa occurs in females 10 times more than...

NCP For Appendicitis Appendicitis Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis". Signs & Symptoms For the most part symptoms relate to disturbed function of bowels. Pain first, vomiting next and fever last has been described as classic presentation of acute appendicitis. Pain starts mid abdomen,and except in children below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various signs. Signs include localized findings in the right iliac ...

Psoriasis is a chronic immune-mediated disease that appears on the skin. It occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells. Psoriasis is not contagious. There are five types of psoriasis: plaque, guttate, inverse, pustular and erythrodermic. The most common form, plaque psoriasis, is commonly seen as red and white hues of scaly patches appearing on the top first layer of the epidermis (skin). Some patients, though, have no dermatological symptoms. In plaque psoriasis, skin rapidly accumulates at these sites, which gives it a silvery-white appearance. Plaques frequently occur on the skin of the elbows and knees, but can affect any area, including the scalp, palms of hands and soles of feet, and genitals. In contrast to eczema, psoriasis is more likely to be found on the outer side of the joint. The disorder is a chronic recurring condition that varies in severity from minor localized patches to complete body coverage. Fingernails and...

Tuberculosis (TB) is a bacterial infection caused by a germ called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they can also damage other parts of the body. TB spreads through the air when a person with TB of the lungs or throat coughs, sneezes or talks. If you have been exposed, you should go to your doctor for tests. You are more likely to get TB if you have a weak immune system. Symptoms of TB in the lungs may include A bad cough that lasts 3 weeks or longer Weight loss Coughing up blood or mucus Weakness or fatigue Fever and chills Night sweats If not treated properly, TB can be deadly. You can usually cure active TB by taking several medicines for a long period of time. People with latent TB can take medicine so that they do not develop active TB. nlm.nih.gov Centers for Disease Control and Prevention Nursing Care Plan for Pulmonary Tuberculosis Nursing Assessment IdentityThe assessment includes name, age, sex, religion, ethnicity, education, employmen...

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air. This can cause wheezing, coughing, chest tightness and trouble breathing, especially early in the morning or at night. When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks. Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms. NIH: National Heart, Lung, and Blood Institute Nursing Assessment for Asthma Assessment of nursing in asthma patient...