Nanda Nursing Diagnosis

Examination begins with inspection of the abdominal area is there any enlargement of the abdomen, stretch or bulge. Further palpation on the surface of the abdomen to assess the strength of the abdominal muscles. Palpation over the faecal mass can be felt in the colon, the presence of a tumor or aneurysm of the aorta. On percussion, among others sought excessive gas gathering, organ enlargement, asietes, or the presence of faecal mass. Auscultation, among others, to listen to the sound of bowel movements, normal or excessive intestinal example on the bridge. Examination of the anal region provide an important clue, for example, is there any hemorrhoids, prolapse, fissures, fistulas, and tumor mass in the anal area can interfere with the process of defecation. Digital rectal examination should be done, among others, to determine the size and condition of the rectum and the amount and consistency of stool. Digital rectal can provide information about: Rectal tone. Sphincter tone and stre...

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...

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...

Nursing Management of Diabetic Ulcers Diabetic ulcers are sores, or pain that occurs at the foot of the person who has suffered from diabetes mellitus. Meanwhile, according to Askandar (2001) Diabetic Ulcers are sores on the feet of red-black and foul smelling due to the blockage that occurred in medium or large vessels in the legs. The cause of diabetic ulcers Diabetic ulcers occur because of complications of diabetes mellitus called sensory neuropathy. People with diabetes also have poor blood circulation, thereby causing injury to the toe easily or toes which can lead to ulcer / gangrene. Diabetic ulcer wound care Dressing and wound control and help protect the wound from further damage. Keep the circulation in the legs with active passive movement. Control blood sugar levels. If necessary, collaboration with medical debridement for action. Prevention to avoid diabetic ulcers For patients with diabetes mellitus are at risk for diabetic ulcers should consult immediately to health car...

1. Relieves Pain To reduce pain nurses can encourage patients to bed rest and modification of the position is determined to improve lumbar flexion. Patients are taught to control and adjust the pains that go through the respiratory diaphragm and relaxation can help reduce muscle tension that contributes to lower back pain. Distract patients from pain with other activities such as reading books, watching TV and with imagination. Massage of the soft tissue, gently is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. When given the drug the nurse should assess the patient's response to each drug. 2. Improving physical mobility Physical mobility is monitored through continuous assessment. Nurses assess how patients move and stand. Once back pain is reduced, self-care activities may be performed with minimal strain on the injured structure. Change of position should be done slowly and assisted if necessary. Circular motion and sway shoul...

The main objective of Nursing Management program are as follows: To relieve pain and inflammation To maintain joint function and the maximum ability of the patient To prevent and or correct deformity that occurs in joints Maintaining independence so as not to depend on others. There are several ways the management to achieve the goals mentioned above, namely: Education The first step of this management program is to provide adequate education about the disease to patients, families and anyone associated with the patient. Education will include understanding the pathophysiology (disease course), the causes and estimated journey (prognosis) of the disease, all components of program management including complex drug regimens, sources of help to overcome this illness and effective method of management provided by health teams . This educational process must be done continuously. Rest It is important because rheumatic usually accompanied by severe fatigue. Although fatigue may ar...

A pheochromocytoma or phaeochromocytoma (PCC) is a neuroendocrine tumor of the medulla of the adrenal glands (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that failed to involute after birth and secretes excessive amounts of catecholamines, usually noradrenaline (norepinephrine), and adrenaline (epinephrine) to a lesser extent. Extra-adrenal paragangliomas (often described as extra-adrenal pheochromocytomas) are closely related, though less common, tumors that originate in the ganglia of the sympathetic nervous system and are named based upon the primary anatomical site of origin. Nursing Management of Pheochromocytoma Monitor vital signs, especially blood pressure changes--> severe hypertension can precipitate a cerebrovascular accident and/or sudden blindness Administer antihypertensive medications as ordered Promote rest and decrease stressful stimuli--> acute attacks may be precipitated by emotional stress, physical exertion, and change in positio...

Nursing Diagnosis for Hydrocephalus Ineffective Cerebral Tissue Perfusion related to increased volume of cerebrospinal fluid. NOC : circulation status NOC – Expected outcomes: 1. Indicate the status of the circulation is characterized by the following indicators: Systolic and diastolic blood pressure within normal range No major vein noisy 2. Demonstrated cognitive abilities, characterized by the indicator: Communicate clearly and in accordance with the age and ability Show attention, concentration and orientation Demonstrated long-term memory and the current Process information Make the right decision Hydrocephalus – Ineffective Cerebral Tissue Perfusion – NIC Interventions 1. Monitor the following matters: Vital signs Headache Level of awareness and orientation Inistagmus diplopia, blurred vision, visual acuity 2. Monitoring of ICT: ICT monitoring and neurological response of the patient care activities Monitor tissue perfusion pressure Note the change in the patient in response ...

Nursing Assessment for Hypertension Basic Nursing Assessment data by Doenges (1999) : Activity / Rest Symptoms: weakness, fatigue , shortness of breath, monotonous lifestyle. Signs: The frequency of the heart increases, changes in heart rhythm, tachypnoea. Circulation Symptoms: History of hypertension, atherosclerosis, coronary heart disease / valve and cebrocaskuler disease, episodes of palpitations. Signs: The increase in BP, pulse throbbing clear from the carotid, jugular, radial, tachycardia, valvular stenosis murmur, jugular venous distension, pale skin, cyanosis, cold temperature (peripheral vasoconstriction) filling the capillary may be slow / delayed. Ego Integrity Symptoms: History personality changes, anxiety, multiple stress factors (relationship, financial, work related). Signs: Explosion mood, anxiety, continue narrowing of attention, tears burst, face muscles tense, breathing heaved, increased speech patterns. Elimination Symptoms: Impaired renal current or (such ...

Hypospadias Definition Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed urinary meatus (the opening, or male external urethral orifice). Instead of opening at the tip of the glans of the penis, a hypospadic urethra opens anywhere along a line (the urethral groove) running from the tip along the underside (ventral aspect) of the shaft to the junction of the penis and scrotum or perineum. A distal hypospadias may be suspected even in an uncircumcised boy from an abnormally formed foreskin and downward tilt of the glans. Impaired Skin Integrity Definition Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis). Related Factors: External: Hyperthermia, hypothermia, chemical substance, mechanical factors (e.g. friction, shearing forces, pressure, restraint), physical immobilization, humidity, extremes in age, moisture, radiation, medications Internal: ...

Nursing management is about administration, organization and having the ability to control staff and the department that they are responsible for. It is about making correct decisions with regard to their staff and patient's welfare. Most nursing managers have worked their way through the ranks of nursing so to speak and by the very process of having hands on experience should be well qualified to do the job. After having acquired the clinical skills in a general nursing capacity they may well take on a leadership role which requires further nursing education to degree level and possibly higher. The transition to nursing management would not be all that intellectually challenging for someone who has experience in nursing leadership. A nurse manager would have to have the ability to communicate and interact with not only their own staff but other healthcare workers and other departments within the establishment. The manager would be involved with the creation of nursing plans for th...

COPD (Chronic Obstructive Pulmonary Disease) is one of the most common lung diseases. It generally defines the conditions which consist of regular difficulty in expelling or exhaling air from the lungs. The most common symptoms of COPD are a cough with mucus, shortness of breath (dyspnoea) which gets more severe with any mild activity, fatigue, frequently respiratory infections such as colds and influenza, and wheezing. The symptoms of COPD usually develop slowly. There are two major forms of COPD: chronic bronchitis and emphysema. Chronic bronchitis consists of a long term cough with mucus. Emphysema is a gradual destruction of the lungs. Most people who have COPD have a combination of these forms because smoking is a major cause of both of them. Some severe symptoms may require hospital treatment. People should seek medical attention if they are having a hard time catching their breath or taking, see their lips or fingernails turning blue or gray (which is a sign of low COPD oxygen ...