Nursing Blog

Definition Low Birth Weight “as one whose birth weight is less than 2500gm irrespective of the gestational age”. Very low birth infants weight 1500gm or less and Extremely-low birth infant weight 1000gm or less. 1. Altered breathing pattern dyspnea related to poor lung maturity secondary to respiratory distress. Baby should be positioned with neck slightly extended. Tackling stimulation by sole flaring can be provided to stimulate respiratory effort Do gentle suctioning to remove the secretion, Concentration of oxygen to be maintained to have saO2 between 90 and 95% and paO2 between 60 and 80 mm of Hg. Baby’s respiration rate, rhythm, signs of distress, chest retraction, nasal flaring, apnea, cyanosis, oxygen, saturation, etc. to be monitored at frequent interval. Chest physiotherapy by percussion, vibration and postural drainage may be needed to loosen and remove respiratory secretion. 2. Altered body temperature hypothermia related to immature thermoregulation centre secondary to...

1. Nursing Diagnosis for Dysentery : Imbalanced Nutrition : less than body requirements related to: inadequate intake and output Goal: nutritional needs are met Expected outcomes: Increased appetite. Increased or normal weight according to age. Nursing Interventions for Dysentery : 1. Discuss and explain about the diet restrictions of patients (high fiber foods, fatty and water is too hot or cold) R / high fiber, fat, water is too hot / cold can stimulate irritate the stomach and intestinal tract. 2. Create a clean environment, away from the smell of the odor or litter, serve food in a warm state. R / situation comfortable, relaxed to stimulate appetite. 3. Provide hours of rest (sleep) and reduce excessive activity. R / Reducing energy consumption is excessive 4. Monitor intake and output within 24 hours. R / Knowing the amount of output can merencenakan amount of food. 5. Collaboration with other health care team: a. Nutritional therapy: A diet high in calories and high in protein, l...

Appendicitis is caused by blockage of the lumen of the appendix by fecalit, foreign objects, because there are previous inflammation. The obstruction causes mucus-producing mucosa, having the dam. However, the elasticity of the walls of the appendix has limitations that cause intra-luminal pressure. The increased pressure will inhibit the flow of lymph which will cause edema and ulceration of the mucosa, this occurs when the local acute appendicitis is characterized by the presence of pain. Appendix unknown function, is part of the cecum. Inflammation of the appendix may occur by the presence of mucosal ulceration or obstruction of the lumen wall (usually by fecalit / hardened feces). Penymbatan spending mucus resulting in adhesions, and inhibition of bloodstream infections. Of hypoxia, resulting gangreng or rupture within 24-36 hours. If this process continues around the walls of organs appendix adhesions will occur that will cause an abscess (chronic). If the infection ...

Nursing Diagnosis for Tetanus: Imbalanced Nutrition Less Than Body Requirements related to stiffness of muscles of mastication Characterized by: Intake less, eat and drink that came in through the mouth can come back again through the nose and body weight decreased with the results of protein or albumin less than 3.5 mg% Objectives: Nutritional needs are met Expected outcomes are: Optimal weight Adequate Intake The results of albumin from 3.5 to 5 mg% Tetanus Nursing Interventions and Rational: 1. Explain the factors that influence eating and kesuliatan the importance of food for the body. Rational: the effects of tetanus is a stiffness of the muscles of mastication so that clients experience kesuliatan swallowing reflex and sometimes behind or kesedak arise. With an adequate level of knowledge of the clients are expected to participate and cooperate in the diet. 2. Collaboration with a team of nutrition for the provision of a diet high in calories and high in protein,...

Pneumonia is an illness that affects one or both lungs and that used to be one of the main causes of death 2 centuries ago. It is caused by microorganisms that attack the tissue from the lungs, causing it to inflammate and leading to a severe condition if the infection is not treated in time. Some pneumonia is diagnosed only after an examination by a doctor reveals crackling sounds or coarse breathing in the chest. There may also be breathlessness, wheezing or the breathing sounds may be diminished in certain parts of the chest. A chest x-ray is the definitive way to diagnose the pneumonia, however sputum samples, blood tests and bronchoscopies can typically be ordered as well. The sputum samples can determine what the exact cause of the pneumonia is and determine the course of medical treatment. The blood work can help to determine how serious the infection is and may also provide a clue as to whether it is caused by a virus, bacteria or fungi. Nursing Diagnosis for Pneumonia Impaire...

Intussusception (Also Called 'Bowel Obstruction') Intussusception is when one segment of intestine "telescopes" inside of another causing an intestinal obstruction. Although it can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestine. The obstruction can cause swelling & inflammation that can lead to tearing of the intestines. Intussusception’s cause is unknown, but is usually preceded by a virus that produces swelling of the lining of the intestine, which then prolapses into the downstream intestine. In some children, it is caused by a congenital anomaly of the intestine such as a polyp or diverticulum. What are the symptoms of intussusception? The characteristic signs and symptoms of intussusception are episodic, severe, crampy abdominal pain alternating with periods of lethargy. Small children may draw their knees up to their chest. Other possible symptoms of intussusception include: Nausea and vomitin...

Nursing intervention with rationale 1. Continually assess motor function, as spinal shock and spinal cord edema resolves, by requesting client to perform certain actions, such as shrug shoulders, spread fingers, and squeeze and release examiner’s hands. Rationale: Continuous motor function assessment helps determine appropriate interventions for the specific motor impairment. 2. Provide means to summon help, such as special sensitive call light. Rationale: Promotes the client’s sense of control and reduces fear of being left alone. Note: Ventilator-dependent tetraplegic client may require continuous observation for timely interventions. 3. Perform or assist with full range of motion (ROM) exercises on all extremities using slow, smooth movements. Include periodic hip hyperextension. Rationale: ROM exercises enhance circulation, restore or maintain muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy. 4. Position arms at 90-degree angle at regular intervals...

Nursing Diagnosis for Cesarean Section Pain related to postoperative wound Definition for Acute Pain : Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months Subjective data: from patient usually Verbal report of pain Objective data: Observed evidence of pain, protective gestures avoid pain, Change in muscle tone, Expressive; restlessness, moaning, crying, vigilance, irritability, sighing. Definition for Chronic Pain : NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does, an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or r...

Nursing Diagnosis Imbalanced Nutrition less Than Body Requirements related to excessive nausea and vomiting . Nursing Interventions : Restrict oral intake until the vomiting stops. Rationale: Maintain fluid balance and elektfolit, and prevent further vomiting. Give the anti-emetic drugs are programmed with a low dose Rationale: Preventing vomiting and maintain fluid and electrolyte balance. Maintain fluid therapy can be saved. Rationale: Correction of hypovolemia and electrolyte balance Record intake and output. Rationale: Determining hydration fluids through vomiting and spending. Encourage to eat small meals but often Rational: Can adequate intake of nutrients your body needs Advise to avoid fatty foods Rational: to stimulate nausea and vomiting Encourage to eat a snack such as crackers, bread and the (hot) warm before waking up at noon and before bed Rational: snack can reduce or prevent nausea, vomiting, excessive excitatory Inspection of irritation or Iesi the mouth. Rational: To...

Heart failure (HF), often used to mean chronic heart failure (CHF), occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the needs of the body. The terms congestive heart failure (CHF) or congestive cardiac failure (CCF) are often used interchangeably with chronic heart failure. Symptoms commonly include shortness of breath, excessive tiredness, and leg swelling. The shortness of breath is usually worse with exercise, when lying down, and at night while sleeping. There is often a limitation on the amount of exercise people can perform, even when well treated. Nursing Intervention ForHeart Failure Assess cardiovascular status, vital sign and hemodynamic variable to detect signs of reduced cardiac output. Assess respiratory status to detect increasing fluid in the lungs and respiratory failure. Keep the client in semi-fowler's position to increase chest expansion and improve ventilation. Administer medication as prescribed, to enhance cardiac performanc...

Brain tumors include all tumors inside the skull or in the central spinal canal. They are created by an abnormal and Uncontrolled cell division, normally either in the brain Itself (neurons, glial cells (astrocytes, oligodendrocytes, ependymal cells, myelin-producing Schwann cells), lymphatic tissue, blood vessels), in the cranial nervous, in the brain envelopes (meninges), skull, pituitary and pineal gland, or spread from cancers primarily located in other organs (metastatic tumors). Impaired Gas Exchange related to neuromuscular dysfunction (loss of control of respiratory muscles) Characterized by: changes in depth of breath, dyspnea, airway obstruction, aspiration. Goal : Impaired gas exchange can be resolved Nursing Intervention for Brain Tumor Clear the airway Monitor vital signs Monitor the breathing pattern, breath sounds Monitor blood gases penururnan Blood gas analysis Collaboration Oxygenation Nursing Diagnosis for Brain Tumor Acute Pain : the head related to increased intra-...

Hypertension Degree of Severity Stage I (mild) – 140/90 to 159/99 mm Hg Stage II (moderate) – 160/100 mm Hg or greater Stage II (severe) – systolc pressure greater than 180 and diastolic pressure greater than 110 Stage IV (very severe) – systolic pressure greater than 210 or greater with diastolic pressure greater than 120 Etiology Primary (essential), which accounts for approximately 85% to 95% of all cases, has no identifiable cause Secondary, which occurs as a result of an identifiable, sometimes correctable,pathological condition, such as kidney disorders, adrenal gland tumors, or primary aldosteronism, medications, drugs, or other chemicals Statistics (NHLBI, 2006; Centers for Disease Control and Prevention [CDC], CDC, 2006b; 2007a) a. Morbidity: 72 million Americans are hypertensive (nearly 1 in 3). i. 23% of adults aged 20 to 75 are hypertensive. ii. 70% of adults over age 75 are hypertensive. iii. Approximately 20% are undiagnosed. iv. Prevalence: African Americans 32%, whites...

Actions/Interventions NURSING PRIORITY NO. 1. To identify causative/contributing factors: Review daily dietary regimen. Note oral/dental health that can impact intake. Determine fluid intake, to note deficits. Evaluate medication/drug usage and note interactions or side effects (e.g., narcotics, antacids, chemotherapy, iron, contrast media such as barium, steroids). Note energy/activity level and exercise pattern. Identify areas of stress (e.g., personal relationships, occupational factors, financial problems). Determine access to bathroom, privacy, and ability to perform self-care activities. Investigate reports of pain with defecation. Inspect perianal area for hemorrhoids, fissures, skin breakdown, or other abnormal findings. Discuss laxative/enema use. Note signs/reports of laxative abuse. Review medical/surgical history (e.g., metabolic or endocrine disorders, pregnancy, prior surgery, megacolon). Palpate abdomen for presence of distention, masses. Check for presence of fecal impa...

Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger Provision of a modified environment for the patient who is experiencing a confusional state Calming Technique: Reducing anxiety in patient experiencing acute distress Self-Care Assistance: Assisting another to perform activities of daily living Bathing: Cleaning of the body for the purpose of relaxation, cleanliness, and healing Hair/Nail Care: Promotion of neat, clean, attractive hair/nails and prevention of skin lesions related to improper care of nails Feeding: Providing nutritional intake for patient who is unable to feed self Bowel/Urinary Elimination Management: Establishment and maintenance of a regular pattern of bowel elimination/Maintenance of an optimum urinary elimination pattern Communication Enhancement: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision Nutrition Manage...

Nursing Interventions and Rational for Risk for Injury Monitor the client’s behavior for cues of rising anxiety. R: Behavioral cues signal increasing anxiety. Determine emotional and situational triggers. R: Knowledge of triggers is used in planning ways to prevent or manage outbursts. Intervene early with verbal comments or limits and/or removal from the situation. R: Potential outbursts can be defused through early recognition, verbal intervention, or removal. Give plenty of notice when having to change routines or rituals or end pleasurable activities. R: Children often react to change with catastrophic reactions and need time to adjust. Provide support for the recognition of feelings, reality testing, impulse control. R: These competencies are often underdeveloped in these children. If the client does not respond to verbal interventions, use therapeutic holding.Some might need special restraints (helmets, mittens, special padding) R: Therapeutic holding reassures the client that t...

NURSING INTERVENTIONS: ON GOING ASSESSMENT Assess characteristics of pain: location, severity on a scale of 1 – 10, type, frequency, precipitating factors, and relief factors using the pain assessment form. Observe or monitor signs and symptoms associated with pain, such as BP, HR, temperature, color & moisture of skin, restlessness and ability to focus. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain. Assess for probable cause of pain. Assess patient’s knowledge of or preference for the types of pain relief strategies available. Some patients may be unaware of the effectiveness of non-pharmacological methods and may be willing to try them. Often a combination (e.g., mild analgesics with distraction or heat) may be most effective. Evaluate the patient’s response to pain and medications or therapeutics aimed at abolishing or relieving pain. It is important to help the patients express as factually as pos...

A peptic ulcer is a distinct breach in the mucosal lining of the stomach (gastric ulcer) or the first part of the small intestine (duodenal ulcer), a result of caustic effects of acid and pepsin in the lumen. Histologically, peptic ulcer is identified as necrosis of the mucosa which produces lesions equal to or greater than 0.5 cm (1/5"). It is the most common ulcer of an area of the gastrointestinal tract that is usually acidic and thus extremely painful. Helicobacter pylori is one of the most common causes of peptic ulcer. Ulcers can also be caused or worsened by drugs such as aspirin, ibuprofen, and other NSAIDs. Symptoms of a peptic ulcer can be abdominal pain, classically epigastric strongly correlated to mealtimes. In case of duodenal ulcers the pain appears about three hours after taking a meal; bloating and abdominal fullness; waterbrash (rush of saliva after an episode of regurgitation to dilute the acid in esophagus - although this is more associated with gastroesophagea...

Nursing Diagnosis Risk for disturbed sensory perception related to withdrawal Outcomes: Fostering a trusting relationship. Mention the causes of withdrawal. Mention the advantages relate to others. Doing social relations gradually, the client - the nurse, the client - the group, the client - the family. Expressing feelings after dealing with others. Empowering support system. Using medications appropriately and correctly. Nursing Interventions : 1.1 Construct a trusting relationship: therapeutic greetings, introduce themselves, explain the purpose of interaction, create a peaceful environment, create a contract that clearly at every meeting (topic to be discussed, the place to talk, talk time). 1.2 Pay attention and awards: do not accompany the client time to answer, saying "I'll sit beside you, if you want to say something I am ready to listen". If a client looked at the nurse's face said "there would you say?". 1.3 Listen to clients with empathy: give a c...

Intestinal Obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency. The condition is often treated conservatively over a period of 2–5 days with the patient's progress regularly monitored by an assigned physician. Surgical procedures are performed on occasion however, in life-threatening cases, such as when the root cause is a fully lodged foreign object or malignant tumor. Nursing interventions Nursing Care Plans for Intestinal Obstruction Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Comfort Management Manipulation of the patient’s surroundings for promotion of optimal comfort Constipation/Impaction Management: Prevention and alleviation of con...

Nursing interventions Nursing care plans for Urinary tract infections (UTIs) Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Management Comfort Manipulation of the patient’s surroundings forpromotion of optimal comfort Teaching the patient of a teaching program about UTIs, how to prevent recurrent lower UTIs, and therapy. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information Sleep Enhancement to Facilitation of regular sleep/wake cycles. Simple Relaxation Therapy Use of techniques to encourage and elicit relaxation for the purpose of decreasing undesirable signs and symptoms such as pain, muscle tension, or anxiety. Environmental Management Manipulation of the patient’s surroundings for therapeutic benef...