Fluid and Electrolyte Imbalance - Nursing Care Plan for Vomiting

Fluid and Electrolyte Imbalance - Nursing Care Plan for Vomiting

Vomiting   October 10, 2013

Nursing Care Plan for Vomiting - Nursing Diagnosis : Fluid and Electrolyte Imbalance : less than body requirements.

Vomiting is a symptom, not a disease. Symptoms of this form of discharge of the contents of the stomach and intestines through the mouth, with a force. Vomiting is the body's protective reflex, because it can protect against toxins accidentally ingested. In addition, an attempt vomiting removing toxins from the body and can reduce the pressure caused by the blockage or enlargement of the organ that puts pressure on the digestive tract. Generally vomiting consists of three phases, namely nausea (feeling sick), retching (initial maneuver to vomit) and regurgitation (evisceration stomach / intestine into the mouth).

Vomiting occurs through a mechanism that is very complex. The occurrence of vomiting is controlled by the vomiting center in the central nervous system (brain) us. Vomiting occurs when there are certain conditions that stimulate the vomiting center. Stimulation of the vomiting center and then proceed to the diaphragm (the partition between the chest and abdomen) and stomach muscles, resulting in decreased diaphragm and constricting (shrinking) the muscles of the stomach. That in turn resulted in increased pressure in the abdomen especially in the stomach and cause the release of stomach contents through the mouth. Some conditions that can stimulate the vomiting center in which various gastrointestinal disorders in both infections (including gastroenteritis) and non-infectious (such as obstruction of the digestive tract), toxins (poisons) in the digestive tract, balance disorders, and metabolic disorders.

Nursing Care Plan for Vomiting : Fluid and Electrolyte Imbalance : less than body requirements related to excessive fluid output.

Goal: fluid and electrolyte deficits resolved

Outcomes:

• There are no signs of dehydration,
• mucosa of the mouth and lips moist,
• fluid balance.

Intervention:

• Observation of vital signs.
• Observation for signs of dehydration.
• Measure the input and output of fluid (fluid balance).
• Provide and encourage the family to drink a lot more than 2000 - 2500 cc per day.
• Collaboration with physicians in fluid therapy, electrolyte laboratory examination.
• Collaboration with a team of nutrition in low-sodium fluids.

Factors Influencing Health Status of The Elderly

Factors Influencing Health Status of The Elderly

Geriatric Nursing   October 06, 2013

There are several factors that affect the mental health of the elderly. These factors shall be addressed wisely so that the elderly can enjoy their life happily. As for some of the factors facing the elderly are greatly affecting their mental health is as follows:

1. Decrease in Physical Condition

After someone entered the elderly, generally ranging seized their physical condition, which is pathological regression (multiple pathology), for example, reduced power, decreased energy, more wrinkled skin, the more teeth fall out, the more brittle bones, etc..

In general, the physical condition of a person who has entered a period of elderly decline exponentially. This all may cause interference or physical dysfunction, psychological and social, which in turn can lead to a state of dependence on others. In the lives of the elderly in order to maintain a healthy physical condition, it is necessary to align with the physical needs psychological and social conditions, so inevitably there must be efforts to reduce the activities of a physical memforsir. An elderly should be able to set a good way of life, such as eating, sleeping, rest and work in balance.



2. Decrease Function and Sexual Potency

Decrease function and sexual potency in the elderly is often associated with a variety of physical disorders such as:

1. Heart problems.
2. Metabolic disorders, eg, diabetes mellitus.
3. Vaginitis.
4. Recently completed operations: for example prostatectomy.
5. Malnutrition, due to imperfect digestion or appetite is very less.
6. The use of certain medications, such as antihypertensives, steroid group, tranquilier.
7. Psychological factors that accompany the elderly, among others:
   • Sense of taboo or embarrassment when maintaining sexual life of the elderly.
   • Attitudes families and communities that lack support and strengthened by tradition and culture.
   • Fatigue or boredom due to lack of variation in his life.
   • Spouse has died.
   • Sexual dysfunction due to hormonal changes or other mental health problems anxiety, depression, dementia, etc..

3. Changes in Psychosocial Aspects

In general, after entering the elderly then it decreased cognitive and psychomotor function. Cognitive function includes the process of learning, perception, comprehension, understanding, attention and others that cause reactions and behaviors of the elderly become increasingly slow. While psychomotor function (conative) covers matters relating to such will boost the movement, action, coordination, resulting in that the elderly become less nimble.
With the decrease in both functions, the elderly also experience changes in psychosocial aspects related to the state of kepabrikan elderly. Some of these changes can be differentiated based on 5 elderly personality types as follows:

1. Construction personality , usually this type is not a lot experienced turmoil , calm and steady until very old .
2. Independent personaliy , there is a tendency in this type of experience post power syndrome , especially if in the future be filled with the elderly are not activities that can provide autonomy on him .
3. Dependent personality , in this type usually greatly affected family life , family life always harmonious if the elderly are not volatile at times , but if the spouse dies, the spouse left behind will be miserable , especially if you do not get up from his position .
4. Hostility personality , in this type after entering the elderly are still not satisfied with his life , a lot of desire that is sometimes not in the carefully calculated , causing economic conditions to be messy .
5. Self Hate Personality , the elderly of this type generally looks miserable , because the behavior itself is difficult aided by others or themselves tend to be difficult .

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis and Interventions   October 06, 2013

Assessment

1. Physical examination:

• Musculoskeletal: decreased tone, strength, muscle size and endurance; range of motion of joints and skeletal strength.
• Cardiovascular: the formation of thrombosis, thrombophlebitis signs include: erythema, edema, tenderness and signs of positive Humans.
• Respiration: atelectasis and pneumonia symptoms, early signs include an increase in temperature and heart rate.
• Integument: ischemia injury against the first tissue is inflammatory, early changes seen on the surface of the skin as an irregular area of erythema.
• Urinary function: physical signs such as urinating a little and often, lower abdominal distension and bladder limits that can be touched.
• Gastrointestinal: constipation and faecal going small, hard and dry.
• Environment: bathroom without handles, loose rugs, lighting is not adequate, a high ladder, slippery floor and toilet seat that lowers the client mobility.

2. Assessing the skeletal body: The deformity and alignment. Abnormal bone growth due to bone tumors. Shortening of limb, amputation and body parts that are not in anatomical alignment. Abnormal angulation of the long bones or movement at a point other than the joints usually indicate the presence of fractures.

3. Assessing the spine:

• Scoliosis (curvature of the lateral deviation of the spine)
• Kyphosis (curvature of the spine increase the chest)
• Lordosis (quack, the curvature of the lumbar spine over)

4. Assessing joint system: Broad movement was evaluated both active and passive, deformity, stability, and the lumps, the joint stiffness.

5. Assessing muscle system: The ability to change the position, muscle strength and coordination, and the size of each muscle. Limb circumference to mementau or atropfi edema, muscle pain.

6. Assessing how patients walk: The irregular movements are not considered normal. If one limb shorter than the other. A variety of neurological conditions associated with abnormal gait (eg walking spastic hemiparesis way - stroke, patients go step by step - lower motor neuron disease, patients walked vibrate - Parkinson's disease).

7. Assessing the skin and the peripheral circulation: palpation of the skin can indicate a temperature hotter or colder than others and the edema. Peripheral circulation was evaluated by assessing peripheral pulses, color, temperature and capillary refill time.

8 . Assessment of functional status :

• Baths : Told independent when in client activity just need help to scrub or clean up a certain portion of the body member , said the dependent if the client requires assistance to more than one body part .
• Dress : Independent if unable to take his own clothes in a closet or drawer .
• To the toilet : Independent when the elderly can not afford to own a toilet , getting out of the toilet and hem itself . Dependent when it need a bed pan or pot .
• Transferring : Independent themselves when able to climb down from a bed or wheelchair . Dependent if always require assistance for activities above or unable to perform one or more activities of transferring .
• Continence : Independent shitting themselves when able ( urinary and defecation ) . When dependent on one or both of micturition or sefekasi require enema or catheter .
• Eating : Independent if it is able to bribe their own food , take away from the plate .

Nursing Diagnosis and Interventions of Activity Intolerance in Elderly

Nursing Diagnosis : Impaired Physical Mobility related to depression

Goal : Depression can be resolved and activities to do.

Outcomes:

Clients can perform daily activities , and depression disappeared .

Intervention :

1. The prevention of osteoporosis , either through medical intervention , nutrition , as well as lifestyle adjustments .
2. The prevention of falls in accordance with the results of the assessment of the environmental factors as well as risk factors does surgery on the risk of environmental factors .
3. Maintenance of strength and resilience of the musculoskeletal system , which includes daily exercise conditioning program both isometric and isotonic muscle contraction , strengthening and aerobic activity , nutrition and protein anabolism to increase bone formation and attitude of commitment to exercise .
4. Maintaining the flexibility of the joints involved in range of motion exercises , proper positioning and activities of daily living .
5. Maintenance of normal ventilation and hyperinflation include mobilization and eliminate secretions .
6. Maintenance of adequate circulation include supporting measures to maintain vascular tone , compression stockings to put external pressure on the limbs and adequate fluid intake to prevent dehydration effect on blood volume .
7. Maintenance of urinary and bowel function were normal relies on nutritional support and environmental structure and routines to facilitate elimination .