Nanda Nursing Diagnosis

Nursing Care Plan for Chronic Kidney Disease Chronic Kidney Disease (CKD) / CRF is a kidney disorder that is progressive and irreversible in which the ability of the body fails to maintain metabolism and fluid and electrolyte balance, causing uremia (retention of urea and other nitrogen garbage in the blood). Causes of Chronic Kidney Diseas CKD / CRF may be caused by systemic diseases are as follows: DM. Chronic Glomerulonefrtitis. Pyelonephritis. Toxic agents. Uncontrolled hypertension. Urinalysis tract obstruction. Vascular disorders. Infection. Clinical manifestations of Chronic Kidney Disease Cardiovascular system: includes hypertension (due to fluid retention and sodium from activation of the renin-angiotensin-aldosterone system), congestive heart failure and pulmonary edema (due to excess fluid) and pericarditis (due to irritation of the pericardial layers by uremic toxins). Integrumenurum system: severe itching (pruritus). Granules is a penunpukkan uremic urine crystals in the s...

Chronic kidney disease or end stage renal disease (ESRD) is a progressive disorder of renal function and the irreversible failure where the body's ability to maintain metabolism and fluid and electrolyte balance, causing uremia (retention of urea and other nitrogen garbage in the blood). (Brunner & Suddarth, 2001; 1448) Clinical Manifestations of Chronic Kidney Disease Clinical manifestations according Suyono (2001) is as follows: a. Cardiovascular disorders Hypertension, chest pain, and shortness of breath due to pericarditis, pericardial effusion and heart failure due to fluid retention, heart rhythm disturbances and edema. b. Pulmonary disorders Shallow breathing, Kussmaul breathing, cough with thick sputum and ripples, the sound crackles. c. Gastrointestinal disorders Anorexia, nausea, and fomitus associated with protein metabolism in the intestine, gastrointestinal tract bleeding, ulceration and bleeding mouth, ammonia breath odor. d. Musculoskeletal disorders Restless leg...

At this stage the nurse explore the factors that exist below, namely: 1. Predisposing Factors Are risk factors that affect the type and amount of resources that can be generated by individuals to cope with stress. Obtained either from the patient or his family, the cultural factors of social development, biochemical, psychological and genetic risk factors that affect the type and amount of resources that can be generated by individuals to cope with stress. Development factors: If the developmental tasks encountered resistance, and impaired interpersonal relationships then the individual will experience stress and anxiety . Sociocultural factors: A variety of factors can lead to a society ruled by a lonely feeling to the environment in which the client was raised. Biochemical factors: Having an influence on the occurrence of mental disorders. With the excessive stress experienced by a person inside the body will then produce a hallucinogenic substance that can be Neurochemistry. Psychol...

According May Thomas Durant (2004) hallucinations can generally be found in patients with psychiatric disorders such as: skizoprenia, depression, delirium and conditions associated with alcohol use, and environmental substances. Based on the assessment results of mental hospital patients found 85% of patients with hallucinations. So I feel compelled to write the case with the provision of nursing care ranging from assessment to evaluation. 1. Creating a therapeutic environment To reduce the level of anxiety, panic and fear in patients affected by hallucinations, preferably at the beginning of the approach, carried out on an individual basis and keep the eye contact occurs, if the patient can touch or hold. Patients not in isolation either physically or emotionally. Each nurse came into the room or close to the patient, talk with the patient. So also when it will leave the patient should be notified. The patient was told that action will be undertaken. In that room should provide a mean...

Definition of Low Self-Esteem Low Self-Esteem is a self-resisted as something precious and can not be responsible for their own lives. Process of Low Self-Esteem Self-concept is defined as all the thoughts, beliefs, and beliefs that make a person knows about themselves and affect relationships with others (Stuart & Sunden, 1995). The concept of self is not formed since birth but learned. One component is the concept of self-esteem, self-esteem which is about the attainment of individual self- assessment by analyzing how far the behavior in accordance with the ideal self (Keliat, 1999). While low self esteem is rejected him as something of value and not responsible for her own life. If an individual often fails then tend to low self esteem. Low self esteem if the loss of love and appreciation of others. Self-esteem derived from self and others, the main aspect was accepted and received the award from someone else. Low self esteem disorder described as feeling negative about themsel...

Constipation is a little defecation frequency, stool is not sufficient in number, in the form of hard and dry (Oenzil, 1995). Constipation is a decrease in frequency of defecation, stool followed by spending long or hard and dry. There was an effort straining during defecation is a sign associated with constipation. If the small intestine motility slowed, a longer period of exposure to feces on the intestinal wall and most of the absorbed water content in the feces. A small amount of water left out to soften and lubricate the stool. Spending dry and hard stools can cause pain in the rectum. (Potter & Perry, 2005). 1. Constipation related to irregular defecation pattern Goal : Patients can defecate regularly (every day) Outcomes: Defecation can be done once a day. Soft stool consistency. Faecal elimination without excessive straining. Nursing Interventions: Independent: 1. Determine the pattern of defecation and trained to do so. Rationale: To restore the regularity of defecation ...

Defecation as well on urination is a physiological process that includes working smooth muscles, and fiber latitude, central and peripheral innervation, coordination of the reflex system, good awareness and physical ability to reach a place of defecation. The difficulty of diagnosis and management of constipation is because of the many mechanisms involved in the normal process of defecation (urge to defecate normally stimulated by rectal distension through four stages, among others: the stimulus baffle recto-anal reflex, muscle relaxation of the internal sphincter, external sphincter muscle relaxation and muscles in the pelvic region, and an increase in intra-abdominal pressure). Disruption of one of these mechanisms can result in constipation . Defecation starting peristalsis of the large intestine to the rectum to deliver feces removed. Feces enter and stretch the ampulla of the rectum followed by relaxation of the internal anal sphincter. To avoid spontaneous spending stool, occurri...

The cause of the Colon cancer is unknown. Diet and reduction in circulation time in the large intestine (flow front feces) that includes the causative factor. Appropriate precautionary instructions recommended by the American Cancer Society, the National Cancer Institute, and other cancer organizations. Risk factors for colon cancer : Age over 40 years. Blood in the stool. History of rectal polyps or colon polyps. Adematosa polyps or adenomas villus. Family history of colon cancer or polyposis in the family. History of chronic inflammatory bowel disease. Diets high in fat, protein, meat and low in fiber. Some groups recommend a diet that had the little animal fat and high in vegetables and fruits (eg Mormons, Seventh Day Adventists). Foods to avoid: Red meat. Animal fats. Fatty foods. Meat and fish fried or grilled. Carbohydrates are filtered (example: the filtered juice) Foods should be consumed: Fruits and vegetables, especially Craciferous Vegetables from the cabbage group (such as...

Colon is a muscular, tube-shaped organ located at the lower part of your digestive system. The organ has a key role in helping the body taking in nutrients, water, and minerals. It also helps in removing waste of the body in the form of stool. Colon cancer is the growth of malignant tumor in the tissue of the colon (in the inner wall of the organ). Colon cancer symptoms aggravate as the malignancy heads toward the later stage. The asymptomatic illness suddenly becomes filled with disturbing manifestations, particularly abdominal pain that is present even during the earlier stage of Colon cancer. It is important to note that most of colon cancer cases start as small, noncancerous clumps of cells known as polyps. By time some of these polyps could become cancers. Signs and Symptoms Slimmer size of feces Feeling of abdominal fullness or incomplete bowel emptying Abrupt weight reduction Abdominal flatulence Feeling of incomplete elimination of fecal matter or stool Feeling of need to thro...

Definition of Adolescence The term adolescence is derived from the noun "adolescenta", which means teenagers, which means it grows into an adult (Hurlock, 2001). Adolescence means gradually toward physical maturity, intellect, mental, social and emotional. This suggests the general nature, namely that growth does not move from one phase to the other phase abruptly, but the growth was taking place step by step. Adolescent is a period of transition between childhood and adolescence, teens are often faced with a confusing situation, on the one hand we need to behave like an adult and the other side can not be said to be an adult. Changes of puberty in girls is occurring menarche (first menstruation). This suggests that the reproductive organs begin to mature. Categorization of Adolescence The World Health Organization set a limit on Adolescence in 2 parts: 1) The period of early adolescence This period ranges from age 10 to 12 years. The period of adolescence is a period of tran...

Appendectomy is the removal of the inflamed appendix with procedures or endoscopic approach. Complaints that often arise in post appendectomy is the verbal communication of pain that is felt, behavior too cautious, behavioral aberrations, (moaning, crying, restlessness), the face shows pain (eyes gloomy, sullen, restricting movement). Nursing Assessment for Appendicitis Assessment is the process whereby data relating to clients systematically collected. This process is dynamic and organized process that involves three basic activities, ie systematically collect, sort and organize the collected data and document data in a format that can be opened again. Assessment is used to recognize and identify health problems and needs of the client and the client's nursing physical, mental, social and environmental. This Assessment contains: 1) Identity. The identity of the client Appendicitis Post Operative on which to base the assessment, include: name, age, gender, education, occupation, r...

Measles is a highly contagious viral infection, which is characterized by fever, cough, conjunctivitis (inflammation of the lining of connective eye / conjunctiva) and skin rash. The disease is caused by infection of measles virus, Paramixovirus class. Transmission of the infection occurs because of inhaling spray saliva from patients with measles. Patients can transmit the infection within 2-4 days before the onset of skin rash and 4 days after the rash there. Before the widespread use of measles vaccination, measles outbreaks occur every 2-3 years, especially in children aged pre-school and elementary school children. If someone has had measles, then the rest of his life he normally would be immune to this disease. Symptoms begin to appear within 7-14 days after infection, which are: body heat, sore throat, runny nose, cough, muscle pain, red eyes (conjuctivitis). And 2-4 days later, small white spots appear on the inside of the mouth. Rash (redness of skin) that feels a bit itchy ap...