Nursing Assessment of Typhoid Fever by Doenges

Nursing Assessment According to Doenges (1999: 476-485) are:

a. Activity and Rest.
Symptoms: weakness, fatigue, malaise, feeling anxious and anxiety, restriction of activities / work in relation to the disease process.

b. circulation
Signs: Tachycardia (fever response, the inflammatory process and pain), relative bradycardia, hypotension including postural, skin / mucous membranes poor turgor, dry, dirty tongue.

c. Ego integrity
Symptoms: Anxiety, emotional, upset eg feelings of helplessness / no hope.
Signs: Refuse, narrowed attention.

d. elimination
Symptoms: Diarrhea / constipation.
Signs: Decreased bowel / no peristalsis increased in constipated / a peristaltic.

e. Food / fluid
Symptoms: Anorexia, nausea and vomiting.
Signs: Decreased subcutaneous fat, weakness, muscle tone and poor skin turgor, mucous membranes pale.

f. Hygiene
Signs: The inability to maintain self-care, body odor.

g. Pain / comfort
Symptoms: Hepatomegaly, Spenomegali, epigastric pain.
Symptoms: Tenderness in the right hipokondilium or epigastrium.

h. security
Symptoms: Increased body temperature of 38 C - 40 C, blurred vision, mental delirium / psychosis.

i. Social interaction
Symptoms: Decreased relationships with others, relating to conditions in nature.

j. Counseling / Learning
Symptoms: A family history of inflammatory bowel diseased.

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Gastritis Nursing Concepts - Assessment

Assessments were conducted in patients with gastritis include:

1. Activity / Rest
   
   • Signs: tachycardia, tachypnea / hyperventilation (in response to activity)
   • Symptoms: weakness, fatigue
   
   
2. Circulation
   
   • Symptoms:
     • hypotension (including postural)
     • tachycardia, dysrhythmias (hypovolemia / hypoxemia)
     • weakness / weak peripheral pulses
       capillary refill underlayer / slowly (vasoconstriction)
     • skin color: pale, cyanosis (depending on the amount of blood loss)
     • weakness of skin / mucous membranes = sweating (shows status of shock, acute pain, psychological responses)
   
   
3. Ego integrity
   
   • Signs: signs of anxiety, such as: anxiety, pallor, sweating, attention narrows, shaking, trembling voice.
     
   • Symptoms: acute or chronic stress factors (financial, labor relations), feeling helpless.
   
   
4. Elimination
   
   • Signs:
     • Abdominal tenderness, distention
       
     • Bowel sounds: often hyperactive during bleeding, hypoactive after bleeding.
       
     • Stool Characteristics : diarrhea, blood dark, brownish or sometimes bright red, frothy, foul smell (steatorrhoea). Constipation can occur (changes in diet, use of antacids).
       
     • Urine output: decreased, concentrated.
       
     
     
   • Symptoms: a history of previous hospitalization for gastro intestinal bleeding or GI related problems, eg wound peptic / gastric, gastritis, gastric surgery, gastric irradiation area. Changes in bowel habit / characteristic stool.
   
   
5. Food / fluid
   
   • Symptoms:
     • Vomiting: color: dark coffee or bright red, with or without blood clots.
     • Dry mucous membranes, decreased mucous production, poor skin turgor (chronic bleeding).
     
     
   • Symptoms:
     • Anorexia, nausea, vomiting (vomiting which extends suspected pyloric obstruction in relation to the outside of the duodenal injury).
     • Problems swallowing: hiccup
     • Heartburn, belching sour smell, nausea / vomiting


6. Neurosensory
   
   • Symptoms:
     • Feeling beat, dizziness / light headaches, weakness.
     • Mental status: level of consciousness can be disturbed, ranges from slightly inclined sleeping, disorientation / confusion, fainting and coma (depending on the volume of circulation / oxygenation).
   
   
7. Pain / Leisure
   
   • Signs: wrinkled face, be careful in the area of ​​pain, pallor, sweating, narrowed attention.
   • Symptoms: pain, described as sharp, shallow, burning, pain, sudden severe pain can be accompanied by perforation. Sense of discomfort / distress faint after eating a lot and lost a meal (acute gastritis). Pain epigastrum left till the middle / back or spreading to occur 1-2 hours after eating and lost with antacids (gastric ulcer). Pain epigastrum left until / or spread to the back occurred about 4 hours after eating when the stomach is empty and relieved by food or antacids (duodenal ulcer). There was no pain (esofegeal varices or gastritis).
     Trigger factors: food, cigarettes, alcohol, use of certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors.


8. Security
   
   • Signs: an increase in temperature, spider angioma, palmar erythema (indicating cirrhosis / portal hypertension)
   • Symptoms: allergies to medications / sensitive eg ASA


9. Counseling / Learning
   
   • Symptoms: the use of prescription / OTC containing ASA, alcohol, steroids. NSAIDs cause GI bleeding. Complaints can be accepted at this time due to (eg anemia) or diagnoses unrelated (eg, head trauma), intestinal flu, or episodes of severe vomiting. Long health problems eg cirrhosis, alcoholism, hepatitis, eating disorders (Doengoes, 1999, p: 455).
     

Gastritis Nursing Diagnosis and Nursing Interventions

Management of Acute Gastritis and Chronic Gastritis

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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.

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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

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Assessment Nursing Care Plan for Chest Pain

Common signs and symptoms that accompany chest pain are:

• Heartburn
• Headache
• Pain that is projected onto the arm, neck, back
• Diaphoresis / sweating
• Shortness of breath
• Tachycardia
• Pale
• Difficulty sleeping (insomnia)
• Nausea, vomiting, anorexia
• Anxiety, nervous, focus on yourself
• Weakness
• The face tense, m erintih, crying
• Changes in consciousness

Primary Assessment - Nursing Care Plan for Chest Pain

a. Airway
- How airway clearance?
- Is there any obstruction / accumulation of secretions in the airway?
- How to breath sounds, is there any additional breath sounds?

b. Breathing
- What is the pattern of breath? frequency? the depth and rhythm?
- What is the use of auxiliary respiratory muscles?
- Are there any additional breath sounds?

c. Circulation
- How does the peripheral arteries and carotid arteries? quality (content and voltage)
- How capillary refill, what there is akral cold, cyanosis or oliguria?
- Is there a decrease in consciousness?
- How vital signs? blood pressure, temperature, pulse, respiration?


2. Secondary Assessment - Nursing Care Plan for Chest Pain

Important things that need to be studied further in chest pain (coronary):

a. location of pain
Where to start, propagation (coronary chest pain: from the sternal border radiating to the neck, chin or shoulder to the left arm of the ulna)

b. The nature of pain
Feeling of fullness, heaviness such as seizures, squeezing, stabbing, choking / burning, etc..

c. Characteristics of pain
Degree of pain, duration, how many times arise in a given time period.

d. chronological pain
Beginning there is pain and progress in sequence

e. Circumstances at the time of the attack
Whether arising in times / circumstances

f. Factors that reinforce / relieve pain such as attitude / posture, movement, pressure, etc..

g. Other symptoms that may be present whether or not the relationship with chest pain.

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Nursing Assessment and Nursing Diagnosis for Headaches

Nursing Assessment for Headaches

Subjective and objective data is essential to determine the causes and nature of the headache.

1. Subjective Data

• Understanding the patient about headaches and possible causes.
• Aware of the existence of trigger factors, such as stress.
• Measures to reduce symptoms such as drugs.
• Place, frequency, pattern and nature of the place of pain including headache, duration and interval between headaches.
• Beginning of the headache attacks.
• There are symptoms or not prodomal
• There are accompanying symptoms.
• Family history of headaches (especially important when a migraine).
• The situation is made more severe headaches.
• There is an allergy or not.

2. Objective Data

• Behavior: showing symptoms of stress, anxiety or pain.
• Changes in the ability to perform daily activities.
• There is an abnormal assessment of the physical assessment of cranial nerve system.
• Body temperature
• Drainage of the sinus.

In the assessment of headache, a few important things to consider. Among them are:

• Localized headaches usually associated with migraine headaches or organic disorders.
• Headaches are usually caused by complete or psychological causes of increased intracranial pressure.
• Migraine headaches can move from one side to the other.
• Headaches are accompanied by an increase in intracranial pressure usually occurs during sleep or waking headaches wake patients from sleep.
• Type headache sinuses arise in the morning and the afternoon to get worse.
• A lot of headaches associated with stress conditions.
• The pain is dull, annoying, escalate and continue to exist, often occurs in the psikogenis headache.
• Organic materials that cause pain and its still growing steadily.
• Migraine headaches can accompany menstruation, headaches can be preceded by eating foods that contain monosodium glutamate, sodim nitrate, tyramine as well as alcohol.
• Sleeping too long, fast, inhaling the toxic odors in the workplace where insufficient ventilation can cause headaches.
• Oral contraceptive medications can aggravate migraines.
• Each found the secondary of a headache needs to be studied.

Nursing Diagnosis for Headaches

1. Acute pain r/t stess and tension, irritation / nerve pressure, vasospasm, increased intracranial pressures.

2. Ineffective individual coping r/t situations of crisis, personal vulnerability, not adequat support systems, work overload, inadequate relaxation, severe pain, excessive threat to himself.

3. Deficient knowledge : about the condition and treatment needs r/t lack of recall, did not know the information, cognitive limitations.

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