Nursing Diagnosis for Intestinal Obstruction

Intestinal Obstruction is complete or partial blockage in the intestines. This blockage prevents the solids, fluids and the gases from moving from the intestines normally. The obstruction may occur either in the small intestine or large intestine. Blockage of bowel may trouble you a lot if not taken care properly. A complete intestinal obstruction may cause complete absence of gas or stool. Partial blockage may cause diarrhea.

Symptoms of Intestinal Obstruction :

• Cramping and pain
• Abdominal fullness
• Bad breath
• Abdominal bloating
• Constipation
• Diarrhea
• Vomiting
  

Causes of Intestinal Obstruction :

• Fetal and neonatal blockages are caused by the intestinal atresia where there is an absence of a part of intestine or a narrowing.
• Non mechanical obstructions are caused due to inflammation or due to the side effects or infections of certain medicines.
• Other causes are hernias, cancer and Crohn's disease.
• Sometimes a change in the food habits and life styles also causes such issues. It may make the waste material get harder and it becomes difficult to be eliminated.
• It may be due to tumors.
• Narrowing or twisting of intestines or scar tissues may be one of the reasons. Such blockages are mechanical blockage.
• In addition to changed food habits, changes in the water intake as well as exercise changes may also lead to bowel obstruction sometimes.
• Bowel obstruction may sometimes be due to the changes within the walls of abdomen area, bowel lumen or external to the belly area.

Nursing Diagnosis for Intestinal Obstruction

1. Deficient Fluid Volume related to nausea, vomiting, fever or diaphoresis.

Goal:

• Fluid requirements are met

Expected outcomes are:

• Normal vital signs
• Balanced input and output
  

2. Acute Pain related to distention, rigidity.

Goal:

• The pain is resolved or controlled
  

Expected outcomes are:

• Patients revealed a decrease discomfort
• States pain level can be tolerated,
• Indicate relaxed.

3. Ineffective Breathing Pattern related to abdominal distension and or rigidity.

Goal:

• The pattern of breathing becomes effective.
  

Expected outcomes are:

• Patients showed the ability to do breathing exercises
• Breathing deeply and slowly.

4. Anxiety related to crisis situations and changes in health status.

Goal:

• Anxiety is resolved

Expected outcomes are:

• Patients expressed an understanding of current disease
• Demonstrating positive kooping skills in dealing with anxiety.

Nursing Interventions for Urinary Tract Infection (UTI)

Nursing Diagnosis for Urinary Tract Infection (UTI) :

1. Impaired Urinary Elimination
2. Knowledge Deficit

Nursing Interventions for Urinary Tract Infection (UTI) :

1. Impaired Urinary Elimination related to mechanical obstruction of the bladder or other urinary tract structures.

Expected outcomes are:

• Improved elimination pattern, not the signs urinary disorders (urgency, oliguri, dysuria)

Nursing Interventions Impaired Urinary Elimination of UTI :

a. Monitor input and output characteristics of the urine.
Rational: provides information about renal function and presence of complications

b. Determine the patient's voiding patterns
c. Encourage increased fluid intake
Rationale: increased hydration will flush the bacteria.

d. Review the full bladder complaints
Rational: urinary retention may occur causing tissue distension (bladder / kidney)

e. Observations of changes in mental status:, behavior or level of consciousness
Rational: the accumulation of residual uremic and electrolyte imbalance can be toxic to the central nervous system

f. Unless contraindicated: reposition the patient every two hours
Rational: To prevent static urine

g. Collaboration:
- Monitor laboratory tests: electrolytes, creatinine
Rational: control of renal dysfunction
- Take action to keep the urine acid: increase input berry juice and give medicines to increase urine aam.
Rational: aam urine inhibit the growth of germs. Increased input juice may affect the treatment of urinary tract infections.

2. Knowledge Deficit: about condition, prognosis, and treatment needs related to the lack of sources of information.

Expected outcomes are:

• Expressed understanding of the condition, diagnostic examination, treatment plan, self-care and preventive measures.

Nursing Interventions Knowledge Deficit of UTI :

a. The review process of the disease and hope that will come
Rational: provides basic knowledge which the patient can make an informed choice.

b. Provide information on: sources of infection, measures to prevent the spread, explain the administration of antibiotics, diagnostic examination: objectives, a brief overview, preparation required prior to inspection, examination after treatment.
Rational: knowledge of what is expected to reduce anxiety and help develop client adherence to therapeutic plan.

c. Make sure the patient, or the people closest to have written agreements for continued treatment and written instructions for care after the examination
Rational: verbal instructions can be easily forgotten.

d. Instruct patient to use a given drug, drink as much as approximately eight glasses a day, especially berry juices.
Rationale: Patients often discontinue their medication, if the signs of the disease subsided. Fluids to help flush the kidneys. Pyruvic acid from berry juice helps to maintain the state of the urine acid and prevent bacterial growth.

e. Provide the opportunity for patients to express feelings and concerns about the treatment plan.
Rational: To detect the signal indicative of the possibility of non-compliance and help to develop a therapeutic plan acceptance.

4 Nursing Diagnosis Interventions for Hypertension

Nursing Diagnosis for Hypertension - Nursing Care Plan for Hypertension

1. Risk for decreased cardiac output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy.

Purpose: afterload is not increased, there was no vasoconstriction, and myocardial ischemia does not occur.

Expected outcomes:

• Maintaining blood pressure within an acceptable range.
• Showed stable cardiac rhythm and frequency.
• Participate in activities that lower blood pressure.

Nursing interventions:

• Monitor and measure blood pressure in both hands, using a cuff and proper techniques in terms of measuring blood pressure.
• Auscultation of breath sounds and heart tone. Observe skin color, moisture, temperature and capillary refill time.
• Note the presence, quality of the central and peripheral pulses.
• Maintain restrictions on activities such as rest in bed or chair.
• Assist in performing self-care activities as needed.
• Provide a quiet environment, convenient, and therapeutic and reduce activity. Note the general edema.
• Monitor response to medication to control blood pressure. Give fluid and dietary sodium restriction as indicated.
• Medical collaboration in the provision of drugs as indicated.

2. Acute pain: headache related to increased cerebral vascular pressure.

Purpose: The pressure does not increase cerebral vascular

Expected Outcomes: Patients revealed the absence of headache and looked comfortable.

Nursing interventions:

• Maintain bed rest, quiet neighborhood, a little light.
• Limit of patients in the activity.
• Minimize disruption and environmental stimuli.
• Give a fun action according to indications such as ice packs, the position of comfort, relaxation techniques, counseling imagination, avoid constipation.
• Medical collaboration in providing analgesic and sedative drugs.

3. Ineffective Tissue Perfusion: cerebral, renal, cardiac related to impaired circulation.

Purpose: The circulation of the body is not impaired.

Expected outcomes :

• Patients demonstrating an improved tissue perfusion as indicated by: blood pressure within acceptable limits, no complaints of headache, dizziness, laboratory values ​​within normal limits.
• Stable vital signs.
• Urine output 30 ml / min.

Nursing interventions:

• Maintain bed rest, elevate the head position in bed patients.
• Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if it is available.
• Measure the input and discharge.
• Observe the sudden hypotension.
• Ambulation within your means and avoid fatigue in patients.
• Monitor electrolytes, creatinine according to medical advice.
• Maintain fluids and medications according to medical advice.

4. Knowledge deficit related to lack of information about the disease process and self-care.

Purpose : patients are met in terms of information about hypertension.

Expected outcomes :

• Patients can express their knowledge and skills of the management of early treatment of hypertension.
• Reported the use of drugs according to medical advice.

Nursing interventions:

• Describe the nature of the disease and the purpose of the procedure and the treatment of hypertension.
• Explain the importance of a peaceful environment and theraupetik, and management of stressors.
• Discuss the importance of maintaining a stable weight.
• Discuss the need for low-calorie diet, low in sodium to order.
• Discuss the importance of avoiding fatigue in the activity.
• Explain the need to avoid constipation in the bowel movement.
• Explain penetingnya maintain proper fluid intake, amount allowed, restrictions such as caffeinated coffee, tea and alcohol.
• Discuss the symptoms of relapse or progression of complications reported to the doctor: headache, dizziness, fainting, nausea and vomiting.
• Talk about drugs: the name, dosage, time of administration, purpose and side effects or toxic effects.
• Explain the need to avoid drug-free, without a doctor's examination.

Related Articles : Nursing Care Plan for Hypertension
Hypertension Diet
Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions
Nursing Management of Hypertension
Pathophysiology of Hypertension
Nanda Nursing Diagnosis for Hypertension

Nursing Assessment for Hallucinations

At this stage the nurse explore the factors that exist below, namely:

1. Predisposing Factors

Are risk factors that affect the type and number of sources that can be generated by individuals to cope with stress. Obtained either from patients or their families, the social development of cultural factors, biochemical, psychological and genetic risk factors that influence the type and number of sources that can be generated by individuals to cope with stress.

• Development factor
  If the task of development is congested, and disturbed interpersonal relationships then the individual will experience stress and anxiety.


• Sociocultural factors
  Various factors in the community can lead to a lonely feel excluded by the environment where the client was raised.


• Biochemical factors
  Have an influence on the occurrence of mental disorders. In the presence of excessive stress experienced by a person then in the body will produce a substance that can be hallucinogenic neurochemistry.


• Psychological factors
  Interpersonal relationships are not harmonious and the presence of conflicting multiple roles and are often accepted by the children will lead to high stress and anxiety disorders, and ended with reality orientation.


• Genetic factors
  What genes are affected in skizoprenia not yet known, but the findings suggest that family factors showing a highly influential in this disease.

2. Precipitation Factor

Stimulus that is perceived by the individual as the challenges, threats / demands that require extra energy for coping. Presence of environmental stimuli are often the client's participation in groups such as, for too long encouraged communication, there are objects in the environment is also the atmosphere of quiet / isolation is often a trigger hallucinations because it can increase stress and anxiety that stimulates the body to excrete hallucinogenic.

3. Behavior

Client response to the hallucinations may be a suspicion, fear, insecurity, anxiety and confusion, self-destructive behavior, lack of attention, not able to make decisions and can not distinguish between real and unreal circumstances. According to Rawlins, and Heacock, 1993 tried to solve the problem of the existence of hallucinations based upon the nature of an individual as a creature that was built on the basis of the elements of bio-psycho-socio-spiritual that hallucinations can be seen from the dimensions:

• Physical Dimensions
  Constructed by the human sensory system to respond to external stimuli provided by the environment. Hallucinations can be caused by some physical conditions such as fatigue, drug use, fever to delirium, alcohol intoxication and difficulty sleeping for a long time.


• Emotional Dimensions
  Excessive feelings of anxiety on the basis of problems that can not be overcome is the cause hallucinations occurred. The content of the hallucinations can be a force command and scary. Clients no longer able to oppose the order to the client's condition to do something to fear.


• Intellectual Dimensions
  In this intellectual dimension explained that individuals with hallucinations would show a decrease in ego functions. At first hallucination is a business of his own ego to fight the impulse to hit, but it is a matter that raises awareness that can take all the attention and often the client will control all client behavior.


• Social Dimensions
  Social dimension in individuals with hallucinations showed a tendency to be alone. Individuals are preoccupied with hallucinations, as if it is a place to meet the need for social interaction, self control and self-esteem is not found in the real world. Content of hallucinations made by the individual control system, so if the command hallucinations in the form of threats, the individual himself or others inclined to it. Therefore, an important aspect in implementing nursing interventions with clients seeking a process of interpersonal interactions that lead to a satisfying experience, and not alone mengusakan client so the client always interacts with its environment and hallucinations did not take place.


• Spiritual Dimensions
  God created human beings as social creatures, so that interaction with other human beings is a fundamental requirement. At the individual is likely to be alone until the above process does not occur, the individual is not aware of the existence and hallucination into the control system of the individual. Hallucinations when an individual loses control of life.

4. Coping Sources
An evaluation of one's choice of coping strategies. Individuals can cope with stress and anxiety with coping resources in the environment. Source of capital for coping such as problem solving, social support and cultural beliefs, can help a person integrate the stressful experience and adopt coping strategies that work.

5. Coping Mechanisms
Every effort is directed at the implementation of stress, including the immediate problem-solving efforts and the use of defense mechanisms to protect themselves.
the religious field.

Impaired Verbal Communication related to Stroke

Nursing Diagnosis for Stroke : Impaired Verbal Communication

A stroke is a medical emergency that occurs when the blood flow to the brain is interrupted. This typically occurs when a blood clot blocks the flow of blood, thereby preventing the brain from getting the oxygen that it needs. Without oxygen, the brain cannot function properly and could be permanently damaged.

Stroke are the third leading cause of death in the United States. Even if you don't die, strokes are one of the causes of brain damage.

Stroke may cause language and speech problems, abnormally slow and cautious behavior, problems judging distances, impaired judgment and behavior, short-term memory loss and other memory problems, balance problems, and more. Therefore, it is extremely important that everyone know about the symptoms of strokes. If caught early, brain damage treatment can take place and the stroke victim can live an ordinary life.

There are many different symptoms that a person may suddenly experience if he or she is having a stroke. Every person may experience slightly different symptoms, but what makes stroke signs stand out is that the symptoms occur suddenly and are easily spotted by others. If you notice a sudden onset of any of the following, be sure to seek emergency treatment as soon as possible:

Numbness or weakness, especially on one side of the body

• Slurring of speech
• Disorientation or confusion
• Loss of balance or trouble walking
• Severe headache

The Risk Factors

1. Age
Human aging is the biological process that is unavoidable but controllable. Starting at age 40, the cells in our body begin this process causing the deterioration of some functions of our body. Most people of this age group already have some form of cholesterol building up in their arteries and high blood pressure resulting in an increased risk of stroke.

2. Heredity
People with a family history of stroke have a greater chance of stroke than those do not have such a family history.

3. Race
Because of frequent high blood pressure in African Americans, they have a significantly higher risk of stroke than their Caucasian counterparts.

4. High blood pressure
High blood pressure causes hardening and thinning of arterial walls and makes our heart work harder to pump blood throughout our body resulting in heart diseases as well as increasing the risk of stroke.

5. Excessive alcohol consumption
Drinking one cup of wine for women and 2 cups of wine for men might help to increase the circulation of blood as well as providing more oxygen for cells. However, excessive drinking not only damages the normal function of liver but also raises high blood pressure, increasing the risk of stroke.

6. Diabetes
Diabetes with unhealthy diet causes high levels of glucose in the bloodstream. Diabetics have a greater risk of stroke, because high levels of glucose damage the arterial wall as well as clotting the arteries and blood vessels.

7. Gender
Males have a 20% greater risk of stroke than females.

8. Smoking
Smokers may be exposed to toxic cadmium, causing high blood pressure and heart diseases as well as contributing to a higher risk of stroke.

Nursing Diagnosis for Stroke: Impaired Verbal Communication related to damage to the cerebral circulation neuromuscular damage, loss of muscle tone / control muscle fascia / oral weakness / general fatigue.

Expected outcomes are:

• Indicate an understanding of communication problems.
• Creating a communication method which needs to be expressed.
• Using the resources appropriately.

Nursing Interventions for Stroke: Impaired Verbal Communication

1. Assess the functional type as the patient does not seem to understand the words or have difficulty speaking / making sense of their own.
Rational: To help determine the areas and degree of cerebral damage and the difficulty that occurs in several stages of the communication process.

2. Ask the patient to write a name or short sentences.
Rational: Assess the ability to write and correct deficiencies in reading, which is also part of the sensory aphasia and motor aphasia.

3. Provide alternative methods of communication. Ex: write on the board and give visual clues.
Rational: Provides communication of needs based on the state / the underlying deficit.

4. Anticipate and meet the needs of patients.
Rational: Beneficial reduce frustration.

5. Collaboration on a speech therapist.
Rational: Serves to identify needs therapy.

2 Nursing Care Plan for Rheumatic Heart Disease - Assessment, Diagnosis and Interventions

Nursing assessment is done in providing nursing care in rheumatic heart disease beginning to collect data on the following matters:

• About heart function.
• Nutritional status of patients.
• Tolerance to the activities and attitudes of patients toward limiting the activities undertaken.
• Disturbances in sleep patterns.
• Level of discomfort felt by rheumatic fever patients.
• Ability of the patient in terms of troubleshooting.
• Knowledge of patients and families will be suffered by rheumatic heart disease.

Assessment of the above are generally aware of what is known by the patient and the family of rheumatic heart disease. Now the next step in the assessment in terms of nursing as one of the nursing process. Next examined the nursing care in rheumatic heart disease are:

• History of rheumatic heart disease.
• Monitor cardiac complications in the event.
• Auscultation of heart sounds, usually typical in patients with rheumatic heart was weakened heart sounds with the rhythm of galloping diastole.
• Assessment of the patient's vital signs.
• Assessment of pain.
• Assessment of the presence of markers of inflammation in the joints.
• Assessment of the presence of lesions on the skin.

Nursing Care Plan for Rheumatic Heart Disease

Next is the nursing diagnosis of rheumatic heart disease. Some nursing diagnoses that may arise in providing nursing care in rheumatic heart disease, among which are:

1. Decreased cardiac output related to valvular stenosis

Goals to be achieved is to increase cardiac output.

Expected outcomes are:

• Patients showed reduced levels of dyspnoe experienced.
• Patients participating in participating in the activity and demonstrate increased tolerance.

Nursing interventions:

• Monitor vital signs such as: blood pressure, apical pulse and peripheral pulse.
• Monitor cardiac rhythm and frequency.
• Semifowler bed rest in a position that is 45 degrees.
• Encourage the patient to stress management techniques (quiet environment, meditation).
• Bantu patient activity as indicated when the patient is able.
• Medical collaboration in terms of oxygen delivery and therapy.

2. Activity intolerance related to decreased cardiac output, oxygen supply and demand imbalance.

Goals to be achieved is an optimal patient can tolerate the activity does.

Expected outcomes are:

• Verbal response to reduced fatigue
• Conducting activities within the limits of his ability (pulse activity should not be more than 90X/mnt, no chest pain).

Nursing interventions:

• Energy saving during the acute patients.
• Maintain bed rest until the results of laboratory and clinical status of patients improved.
• In line with the good general condition, monitor the gradual increase in the level of activity undertaken.
• Teach to participate in activities of daily necessities.
• Create a schedule of activities and also the breaks.

Deficient Knowledge related to COPD

Definition of Deficient Knowledge:

The absence or lack of cognitive information, with respect to the specific topic.

Defining characteristics:

• verbalization of the problem,
• follow the instructions inaccuracies,
• inappropriate behavior.

Related factors:

• cognitive limitations,
• interpretation of the information is wrong,
• lack of desire to seek information,
• do not know the sources of information.

NOC - Deficient Knowledge of COPD:

• Kowlwdge: Disease process
• Kowledge: Health behavior

Expected Result :

• Patients and families expressed an understanding of the disease, condition, prognosis and treatment programs
• Patients and families are able to carry out procedures correctly explained
• Patients and families are able to explain again what is described nurse / other health care team.

NIC - Deficient Knowledge related to COPD :

• Teaching: Disease Process

• Give an assessment of the patient's level of knowledge about specific disease processes
• Describe the pathophysiology of the disease and how this relates to the anatomy and physiology, in a proper way.
• Describe the signs and symptoms usually appear on the disease, in an appropriate manner
• Describe the disease process, in an appropriate manner
• Identification of possible causes, in a proper way
• Provide information to patients about the condition, in a proper way
• Avoid a hopeless
• Provide information to families about the progress of patients in an appropriate manner
• Discuss lifestyle changes that may be necessary to prevent complications in the future or control the disease
• Discuss the choice of therapy or treatment
• Support the patient to explore or get a second opinion in a proper way or the indicated
• Exploration of possible sources or support, in a proper way
• Refer patients to the group or agency in the local community, in an appropriate manner
• Instruct patients about the signs and symptoms to report on health care providers, in an appropriate manner.

Ineffective Airway Clearance of COPD

Ineffective Airway Clearance Definition: The inability to clear secretions or obstruction of the respiratory tract to maintain airway hygiene.

Limitation of Characteristics:

• Dyspnoea, decrease in breath sounds
• Orthopneu
• Cyanosis
• Abnormalities of breath sounds (rales, wheezing)
• Difficulty speaking
• Cough, ineffective or no
• Eyes widened
• Production of sputum
• Fidget
• Changes in frequency and rhythm of the breath

Related factors:

• Environment: smoking, tobacco smoke, passive smoking, infection
• Physiological: neuromuscular dysfunction, hyperplasia of the bronchial wall, airway allergy, asthma.
• Obstruction of the airway: airway spasm, secretion retention, the amount of mucus, the artificial airway, bronchial secretions, presence of exudate in the alveoli, the presence of foreign bodies in the airway.

NOC - Ineffective Airway Clearance of COPD:

• Respiratory status: Ventilation
• Respiratory status: Airway patency
• Aspiration control

Expected outcomes are:

• Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
• Showed a patent airway (the client does not feel suffocated, breath rhythm, respiratory frequency in the normal range, there is no abnormal breath sounds)
• Able to identify and prevent factors that can inhibit airway.

NIC - Ineffective Airway Clearance of COPD :

(1) Airway Suction

• Make sure the needs of oral / tracheal suctioning
• Auscultation of breath sounds before and after suctioning.
• Inform the client and family about suctioning
• Ask the client to do a deep breath before suction.
• Give oxygen using nasal to facilitate suksion nasotrakeal
• Use sterile tools that every action
• Instruct the patient to rest and breathe in after the catheter removed from nasotrakeal
• Monitor patient's oxygen status
• Teach the family how to perform suction
• Stop suksion and give oxygen if the patient showed bradycardia, increased oxygen saturation, etc..

(2) Airway Management

• Open the airway, chin lift technique guanakan or jaw thrust if necessary
• Position the patient to maximize ventilation
• Identify the patient's need for the installation of an artificial airway device
• Replace the mayo if needed
• Perform chest physiotherapy if necessary
• Remove secretions by coughing or suctioning
• Auscultation of breath sounds, note the presence of additional noise
• Apply suction to the mayo
• Give bronchodilators if necessary
• Provide NaCl humidifiers Damp wet gauze
• Adjust intake to optimize fluid balance.
• Monitor respiration and oxygen status

Nursing Management for Pneumonia

Nursing Management for Pneumonia

Assessment for Pneumonia

1. Activity / rest

• Symptoms: weakness, fatigue, insomnia
• Signs: lethargy, decreased activity tolerance.

2.Circulation

• Signs: tachycardia, the appearance of redness, or pale.

3. Food / fluid

• Symptoms: loss of appetite, nausea, vomiting, history of diabetes mellitus
• Symptoms: Abdominal consistency, dry skin with poor turgor, cachexia appearance
• (malnutrition).

4. Neuro-sensory

• Symptoms: headache frontal area (influenza)
• Symptoms: mental destruction (confused)
  

5. Pain / comfort

• Symptoms: headache, chest pain (increased by coughing), imralgia, arthralgia.
• Signs: protecting the sore area (sleeping on the affected side to restrict the movement)

6. Breathing

• Symptoms: a history of chronic UTI, tachypnoea (shortness of breath), dyspnea.

mark:

• o Sputum: pink, rusty
• o perfusion: a flat area of consolidation of deaf
• o premikus: taksil and vocals gradually increased with the consolidation
• o decreased breath sounds
• o Color: pale / cyanotic lips and nails

7. Security

• Symptoms: a history of immune system disorders such as: AIDS, steroid use, fever.
• Signs: sweating, chills over and over, shaking

8. Education / learning

• Symptoms: a history of surgery, chronic alcohol use
• Mark: indicates the average length DRG treated 6-8 days
• Repatriation plan: assistance with personal care, home maintenance tasks.

Nursing Management for Pneumonia


A. Effective airway, pulmonary ventilation is adequate and there is no secret buildup.

Plan of action:
1) Monitor respiratory status every 2 hours, examine an increase in respiratory status and abnormal breath sounds.
2) Perform percussion, vibration and postural drainage every 4-6 hours.
3) Give appropriate oxygen therapy program.
4) Help cough up secretions / suction lenders.
5) Give the comfortable position that allows the patient to breathe.
6) Create a comfortable environment so that patients can sleep in peace.
7) Monitor blood gas analysis to assess respiratory status.
8) Give drink.
9) Provide sputum for culture / sensitivity test.

B. Patients showed improvement of ventilation, gas exchange and the optimal oxygenation of tissues adequately.

Action Plan:
1) Observe level of consciousness, respiratory status, signs of cyanosis every 2 hours.
2) Give Fowler's position / semi-Fowler.
3) Give oxygen according to the program.
4) Monitor blood gas analysis.
5) Create a quiet environment and patient comfort.
6) Prevent the occurrence of fatigue in patients.

3. Patient will maintain normal body fluids.

Action Plan:
1) Record fluid intake and output. Encourage mothers to give fluids orally tetaap à avoid milk is thick / cold drinking à stimulate coughing.
2) Monitor fluid balance à mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs tyanda.
3) Maintain the accuracy of the droplet infusion according to the program.
4) Perform oral hygiene.

4. Patients can perform activities according to the conditions.

Action Plan:
1) Assess the patient's physical tolerance.
2) Assist patients in activities of daily activities.
3) Provide age-appropriate games with the activity of patients who did not spend much energy à adjust activities to the condition.
4) Give the O2 according to the program.
5) Give the energy needs.

Nursing Interventions for Pneumonia

Diarrhea related to Rectal Cancer / Colon Cancer

Nursing Diagnosis for Rectal Cancer / Colon Cancer : Diarrhea related to inflammation, Irritation, intestinal malabsorption or partial narrowing of the intestinal lumen, secondary to the process of intestinal malignancy.

Definition:
Diarrhea is a bowel movement (defecation) by the number of stools more than normal (normal 100-200 cc / hr feces). With the stool is liquid / solid half, may be accompanied by an Increased frequency.

According to WHO (1980), diarrhea is watery bowel movements more than 3 times a day.

Characterized by:

• Increased bowel sounds / peristaltic
• Improved liquid defecation
• Stool color changes
• Pain / cramping abdominal

Nursing Interventions for Diarrhea related to Rectal Cancer / Colon Cancer:

1. Assist clients in meeting the needs of defecation (if bed rest to prepare the necessary tools near the bed, put the curtains and immediately dispose of faeces after defecation).
Rational: defecation can occur suddenly without any signs, so it needs to anticipate client needs to prepare.

2. Increase / maintain oral fluid intake.
Rationale: Prevents dehydration.

3. Teach about food and drink that may exacerbate / trigger the diarrhea.
Rational: To help clients avoid the agent trigger diarrhea.

4. Observation and record the frequency of defecation, stool volume and characteristics.
Rational: Assessing the development of an issue.

5. Observation of fever, tachycardia, lethargy, leukocytosis, decreased serum protein, anxiety and lethargy.
Rational: Anticipating the danger signs of perforation and peritonitis requiring emergency action.

6. Collaboration of appropriate medication therapy program (antibiotics, anticholinergics, corticosteroids).
Rational: Antibiotics to kill / inhibit the growth of pathogenic biological agents, anticholinergic to reduce bowel peristalsis and decrease the secretion of digestive disorders, corticosteroids to reduce inflammation.

5 Nursing Diagnosis for Colon Cancer and Rectal Cancer - Care Plan

Nursing Diagnosis for Colon Cancer and Rectal Cancer

1. Diarrhea related to inflammation, irritation, intestinal malabsorption or partial narrowing of the intestinal lumen, secondary to the process of intestinal malignancy.

Characterized by:

• Increased bowel sounds / peristaltic
• Improved liquid defecation
• Stool color changes
• Pain / cramping abdominal

2. Imbalanced Nutrition Less Than Body Requirements related to impaired absorption of nutrients, hypermetabolic state, secondary to the process of intestinal malignancy.

Characterized by:

• Weight loss, decreased subcutaneous fat / muscle mass, poor muscle tone
• Increased bowel sounds
• Pale conjunctiva and mucous membranes
• Nausea, vomiting, diarrhea

3. Anxiety (describe level) related to psychological factors (the threat of changes in health status, socio-economic status, functions, roles, interaction patterns) and sympathetic stimulation (neoplastic process)

Characterized by:

• Acute phase of disease exacerbation
• Increased tension, distress, fear
• iritabel
• Narrows the focus of attention

4. Ineffective individual coping related to the intensity and repetition stesor adaptive threshold exceeded (chronic illness, death threats, the vulnerability of individuals, severe pain, no adequate support system)

Characterized by:

• Declare an inability to face problems, hopelessness, anxiety
• Declared worthless
• Depression and dependence

5. Knowledge Deficit: about condition, prognosis and treatment needs related to less exposure and or misinterpretation of information.

Characterized by:

• Ask questions, request information or a statement of the concept of fault
• Does not accurately follow the instructions
• Complications / exacerbations can be prevented.

Nursing Care Plan for Cardiac Arrhythmias

Heart rhythm disorder or arrhythmia is a frequent complication in myocardial infarction. Arrhythmias or dysrhythmias is the change in frequency and heart rhythm caused by abnormal conduction of the electrolyte or automatic (Doenges, 1999).

Arrhythmias arise from changes in myocardial cell electrophysiology. Electrophysiological changes are manifest as changes in the form of an action potential is a graph recording the electrical activity of cells (Price, 1994). Heart rhythm disorders are not just limited to heart rate irregularities, but also including the rate and conduction disturbances (Hanafi, 1996).


Etiology

Etiology of cardiac arrhythmias in the outline can be caused by:

1. Inflammation of the heart, such as rheumatic fever, myocardial inflammation (myocarditis due to infection)
2. Interruption of coronary circulation (coronary atherosclerosis or coronary artery spasm), such as myocardial ischemia, myocardial infarction.
3. Because the drug (intoxication), among others, by digitalis, quinidin and anti-arrhythmia drugs other.
4. Electrolyte imbalance (hyperkalemia, hypokalemia)
5. Disorders of the autonomic nervous system settings that affect the work and the rhythm of the heart.
6. Psychoneurotic disorders and central nervous system.
7. Metabolic disorders (acidosis, alkalosis)
8. Endocrine disorders (hyperthyroidism, hypothyroidism)
9. Arrhythmia due to cardiomyopathy or heart tumor
10. Heart rhythm disturbances due to degeneration disease (fibrosis of the cardiac conduction system)

Clinical Manifestations

1. Changes in BP (hypertension or hypotension); pulse may be irregular; pulse deficit; sounds irregular heart rhythm, extra sounds, beats down; pale skin, cyanosis, sweating; edema; decreased urine output when cardiac output decreased weight.
2. Syncope, dizziness, throbbing, headache, disorientation, confusion, lethargy, pupillary changes.
3. Mild to severe chest pain, may be lost or not with anti-angina drugs, anxiety
4. Shortness of breath, cough, change in velocity / depth of breathing; additional breath sounds (crackles, wheezing) may have showed respiratory complications such as left heart failure (pulmonary edema) or pulmonary tromboembolitik phenomenon; hemoptysis.
5. Fever; skin redness (drug reactions); inflammation, erythema, edema (siperfisial thrombosis); loss of muscle tone / strength

Physical Assessment

1. Activities: general fatigue
2. Circulation: changes in BP (hypertension or hypotension); pulse may be irregular; pulse deficit; sound of irregular heart rhythm, extra sounds, beats down; skin color and moisture changes such as pallor, cyanosis, sweating; edema; decreased urine output when cardiac output decreased weight.
3. Ego Integrity : feeling nervous, feeling threatened, anxious, frightened, refused, angry, anxious, crying.
4. Food / fluid: loss of appetite, anorexia, food intolerance, nausea, vomiting, weight peryubahan, changes in skin moisture
5. Neuro-sensory: dizziness, throbbing, headache, disorientation, confusion, lethargy, pupillary changes.
6. Pain / discomfort: mild to severe chest pain, may be lost or not with anti-angina drugs, anxiety
7. Respiratory: chronic lung disease, shortness of breath, cough, change in velocity / depth of breathing; additional breath sounds (krekels, crackles, wheezing) may have showed respiratory complications such as left heart failure (pulmonary edema) or pulmonary tromboembolitik phenomenon; hemoptysis.
8. Security: fever; skin redness (drug reactions); inflammation, erythema, edema (siperfisial thrombosis); loss of muscle tone / strength.

Assessment of Cardiovascular

Doing a good assessment, it is necessary to the understanding, practice and skills, recognize the signs and symptoms displayed by patients. This process is carried out through the interaction of client care, observation, and measurement.

The purpose of conducting the assessment:

1. Assessing cardiovascular function.
2. Know the early presence of real or potential problems.
3. Identifying the cause of disturbance.
4. Plan how to overcome existing problems and avoid the problems that will occur.

Assessment techniques:
Assessment can be done at least once, but can be done several times on a regular basis, eg every hour in critically ill patients. Assessment techniques include:

1. Assessment
2. Physical examination
3. Diagnostic tests / investigations

Interview:
1. The main complaint
Ask about the most important problems perceived by the client, so it needs help. Complaints that should be considered include shortness of breath, chest pain radiating to the arms, fatigue, cough, or bloody mucus, fainting, palpitations, and other according to the pathology of the disease.

2. History of present illness
Ask about the course of the disease, since the complaint until the client asks for help. For example:

• ask since when the complaint is felt,
• how many times the complaint occurred,
• how the nature of the complaint,
• when and what the cause of the complaint,
• circumstances which aggravate and mitigate the complaint,
• how to attempt to resolve complaints before asking for help,
• the success of action.

3. History of previous illness
Ask about the disease that never experienced before:

• ask whether the client had been treated previously
• with any disease,
• have you ever experienced severe pain

4. Additional history adapted to the pathology of the disease

• family history
• employment history
• history of geography
• history of allergy
• social habits
• smoking habits

Physical examination of the cardiovascular system

• In topographic heart is in the front cavity of the mediastinum
• The chest which is occupied by the projection of the heart as illustrated above is called the precordium

General considerations:

• Clothes for the patient should be prepared in an open state.
• The courtroom must be quiet to show adequate auscultation.
• Fixed always maintain patient privacy
• Prioritize and watch for signs of distress.

Inspection of the Heart
Signs were observed:
(1) form of the precordium
(2) at the apex of the heart rate
(3) The pulse of the chest
(4) venous pulse