Nursing Blog

Assessment of the client with herniated nucleus pulposus by Marillyn E. Doenges , 2001: 1. Activity / rest Client has a history of work that needs to lift heavy objects, sitting for long periods of driving. Requires board or hard mattress during sleep, decreased range of motion of the extremity in one part of the body. Not being able to do activities that are usually performed. Atrophy of the muscles in the body are affected and disturbances in walking. 2. Elimination Constipation, experiencing pain in defecation, presence of incontinence / urinary retention 3. Neurosensory Tingling, stiffness, weakness of limbs, decreased deep tendon reflexes, muscle weakness, hypotonia, tenderness / paravertebralis muscle spasms and decrease the perception of pain. 4. Pain / discomfort Pain like a knife wound that will be worsened by coughing, sneezing, crouching, lifting, defecation, lifting legs or neck flexion. Pain that there is no ending or the presence of more severe episodes of pain is intermi...

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation). Primary Nursing Assessment Airways Blockage or accumulation of secretions Wheezing or crackles Breathing Shortness of breath with mild activity or rest Respiration more than 24 x / min, irregular rhythm shallow Ronchi, crackles The expansion of the chest is not full Use of auxiliary respiratory muscles Circulation Weak pulse, irregular Tachycardia Blood pressure increase / decrease Edema Nervous Acral cold Pale skin, cyanosis Decreased urine output http://nursing-assessment.blogspot.com/2011/05/nursing-assessment-for-acute-myocardial.html Secondary Nursing Assessment 1. Activities Symptoms: Weakness Fatigue Can not sleep Settled lifesty...

According Doenges (2000: 152-155) basic assessment of COPD include: 1. Activity / rest symptoms: a. Exhaustion, fatigue. b. The inability to perform daily activities because of difficulty breathing. c. Inability to sleep, need to sleep in a higher body position. d. Dyspnea at rest or in response to activity or exercise. Signs: a. Fatigue. b. Restlessness, insomnia. c. General fatigue or loss of muscle mass. 2. Circulation symptoms: a. Swelling of the lower extremities. Signs: a. The increase in blood pressure. b. Increased heart rate or severe tachycardia, dysrhythmias. c. Distended neck veins. d. Edema not associated with heart disease. e. Faint heart sounds. 3. Ego Integrity symptoms: a. Increased risk factors b. Changes in lifestyle Signs: a. Anxiety, fear, sensitive excitatory. 4. Food and fluids Symptoms: a. Nausea or vomiting. b. Anorexia. c. Weight loss. Signs: a. Poor skin turgor. b. Edema. c. Sweating. d. Decrease in muscle mass. 5. Hygiene Symptoms: a. Decreased ability or in...

Baseline assessment in patients with bronchitis: 1. Activity / rest Symptoms: Exhaustion, fatigue, malaise. The inability to perform daily activities. Inability to sleep. Dyspnoea at rest. Signs: Fatigue, anxiety, insomnia. General weakness / loss of muscle mass. 2. Circulation Symptoms: Swelling of the lower extremities. Signs: Increased blood pressure, increased heart rate / tachycardia weight. Distended neck veins. Dependent edema, heart sound dim. Color of skin / mucous membranes. normal / cyanosis. Pale, may indicate anemia. 3. Ego integrity Symptoms: Increased risk factors Changes in lifestyle Signs: Anxiety , fear, sensitive stimuli. 4. Food / fluid Symptoms: Nausea / vomiting . Poor appetite / anorexia inability to eat, losing weight, weight gain Signs: Poor skin turgor, dependent edema, sweating. Weight loss, abdominal palpitation 5. Hygiene Symptoms: Decreased ability / improvement needs Signs: Poor hygiene, body odor. 6. breathing Symptoms: Cough with sputum production settl...