Nanda Nursing Diagnosis

Hydrocephalus is a buildup of fluid inside the skull, leading to brain swelling. Hydrocephalus is caused by cerebrospinal fluid flow problems, the fluid that surrounds the brain and spinal cord. This fluid carries nutrients to the brain, eliminating waste from the brain, and acts as a cushion. CSF normally moves through the area of the brain called ventricles, around the outside of the brain and spinal cord. This fluid is then absorbed into the bloodstream. Fluid buildup can occur in the brain if the flow or absorption is blocked or if too much fluid is produced. Accumulation of fluid puts pressure on the brain, pushing the brain to the skull and damaging or destroying brain tissue. Hydrocephalus - Nursing Diagnosis and Interventions (NIC - NOC) 1. Ineffective cerebral tissue perfusion related to the increased volume of cerebrospinal fluid. NOC: Circulation status Expected outcomes (NOC): 1. Shows the status of circulation which is characterized by the following indicators: Systolic a...

Nursing Care Plan for Mastoiditis Mastoiditis is an inflammation of the mastoid bone, usually from the tympanic cavity. The expansion of middle ear infections repeatedly can cause changes in the mastoid, such as thickening of the mucosa and accumulation of exudate. Over time there is inflammation of the bone (osteitis) and collecting exudate / pus that more and more, eventually finding a way out. The weak areas are usually located behind the ear, causing an abscess superiosteum. According to George (1997: 106), the clinical manifestations in patients with mastoiditis include: The fever usually disappear and arise. Pain tends to settle and throbbing, located around and inside the ears, and experience tenderness in the mastoid. Hearing loss. Tympanic membrane bulging contain skin that has been damaged and discuss sebaceous (fat). Posterior canal wall hanging. Postauricular swelling. A large discharge through the ear canal and the odor. Nursing Diagnosis and Interventions for Mastoiditis ...

Nursing Diagnosis for Cesarean Section : Acute pain related to surgical trauma, anesthesia, hormonal effects, distended bladder / abdomen. Goal: Identify and use interventions to treat pain / discomfort appropriately. Reveal a reduction in pain. Relaxed able to sleep / rest. Intervention: 1. Determine the characteristics and location of discomfort. Pay attention to verbal and non-verbal cues such as grimacing, stiffness, and limited movement or protect. Rationale: The client may not be verbally reported pain and discomfort directly. Distinguish specific characteristics of pain and postoperative pain helps distinguish from complications. 2. Evaluation of blood pressure and pulse, note the change in behavior change. Rationale: Pain can cause restlessness and increased blood pressure and pulse. 3. Change the position of the client, reduce harmful stimuli, and give a back rub. Encourage the use of breathing techniques, relaxation and distraction. Rationale: muscle relaxes and distracts fr...

Nursing Care Plan for Pain Pain is the most common reason a person seek medical assistance. Pain occurs with the disease process, diagnostic examination and treatment process. Pain is very annoying and difficult many people. Nurses can not see and feel the pain experienced by the client, because pain is subjective (between one individual to another individual is different in addressing the pain). Nurses provide nursing care to clients in a variety of situations and circumstances, which provide interventions to improve comfort. According to some theories of nursing, comfort is a basic requirement that the client is the purpose of nursing care. The statement was supported by Kolcaba who said that comfort is a state of fulfillment of basic human needs have. Definition According to the International Association for the Study of Pain (IASP), pain is a subjective sensory and emotional obtained unpleasant associated with actual or potential tissue damage or described the condition of the occu...

Angina pectoris is a clinical syndrome of chest pain due to transient myocardial ischemia. Myocardial ischemia is a condition where the heart muscle is deprived of oxygen, but has not suffered damage and is reversible, which is the diagnostic tool ECG showed ST depression or T inversion. Based on clinical symptoms, Angina pectoris divided into two stable angina pectoris and unstable angina pectoris. Stable angina pectoris is a chest pain incident lasted no more than 15 minutes, the originators is a physical activity or trigger factors such as stress. Chest pain can be relieved by rest or medication (sublingual nitroglycerin). Unstable angina pectoris is chest pain incident lasted more than 15 minutes with intensity and increasing frequency whenever recurrence. Lighter trigger factors, can occur at rest. Were classified as unstable angina pectoris that patients with angina in the last 2 months felt increasingly burdensome with frequency quite often (can occur 3 times a day), patients wi...

Nursing Diagnosis : Acute Pain r / t Increase in intraocular pressure (IOP) Definition Glaucoma is a group of eye disorders characterized by increased intraocular pressure. (Long Barbara, 1996) Glaucoma often occurs in both eyes, but extra fluid pressure first begins to build up in one eye. If you don't seek treatment for glaucoma and can't control it, your peripheral vision will decrease by time and subsequent eye damage may easily lead to blindness. Etiology There are different types of glaucoma. Most occur when pressure in the eye (intraocular) increases, damaging the optic nerve but sometimes optic nerve damage can occur even when intraocular pressure is normal. Other types of glaucoma are rare and are caused by abnormal eye development, drugs, eye infections or inflammatory conditions, interruption of blood supply to the eye, systemic diseases and trauma. Symptoms: Headaches. Sensitivity to light. Blurred vision. Decreased peripheral vision- gradual loss. Nausea and vomit...

Nursing Diagnosis : Acute Pain - NCP Gastritis Gastritis is basically an erosion of the stomach lining, which can occur suddenly due to certain factors or happen gradually over a longer period of time. Inflammation or irritation of the lining of the stomach is also a form of gastritis. Gastritis can occur in adults and in children, which when left untreated can give rise to other gastrointestinal problems. There can be a number of different causes that give rise to gastritis. An infection caused by Helicobacter pylori (H. pylori) or other bacteria and viruses living in the mucous lining of the stomach could be one of the causes. A back flow of bile from the bile tract into the stomach, which is known as bile reflux could give rise to gastritis. Pernicious anemia, which is the stomach's inability to properly digest vitamin B12 could be another cause. Acute Pain Definition : Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in ter...

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, ...

Acute Pain Definition: An unpleasant sensory and emotional experience arising in an actual or potential tissue damage or describe the damage (International Association of Pain Study): a sudden attack or low in intensity from mild to severe which can be anticipated by the end of a predictable and with a duration less than 6 months . Defining Characteristics : Report of verbal or non verbal The fact of the observation Antalgic position to avoid pain Movement to protect Cautious behavior Face masks Sleep disturbances (eyes glazed, looking tired, difficult or chaotic motion, grinning) Focused on self- Focus narrowed (decreased perception of time, the damage is thought process, decreased interaction with people and the environment) Behavior distraction, for example: roads, meet other people and / or activities, repetitive activities) Autonomic Response (such as diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils) Changes in muscle tone, autonomic (probably...