Wednesday, November 4, 2015

Bacteremia and Sepsis - Definition, Causes and Symptoms

Bacteremia and Sepsis


DEFINITIONS

  • Bacteremia is the presence of bacteria in the bloodstream.
  • Sepsis is an infection in the bloodstream.

CAUSES

Sepsis is the result of a bacterial infection in the human body.
Which is often the source of sepsis is an infection of the kidney, liver or gall bladder, intestines, skin (cellulitis) and the lungs (pneumonia due to bacteria).

Risk factors for sepsis:
  • Surgery on the infected part of the body or body parts which normally grow bacteria (eg intestine).
  • Insert foreign objects into the body, for example; intravenous catheter, urinary catheter or drainage hose.
  • Drug abuse by injection.
  • Patients with immune system disorders (eg, due to anti-cancer therapy).


SYMPTOMS

Transient bacteremia rarely cause symptoms because the body is usually able to eradicate a small number of bacteria immediately.

If someone sepsis, there will arise the following symptoms:
  • Fever or hypothermia (decreased body temperature).
  • Hyperventilation.
  • Chills.
  • The skin feels warm.
  • Skin rash.
  • Tachycardia (increased heart rate).
  • Delirious or dazed.
  • Decreased production of urine.
If not addressed, sepsis can lead to infection throughout the body (metastatic infection). Infections can occur in the lining of the brain (meningitis), in the pericardium (pericarditis), in the heart (endocarditis), in the bone (osteomyelitis) and in the large joints. An abscess (accumulation of pus) may develop in almost all parts of the body.

Friday, October 16, 2015

Signs and Symptoms of Hypoglycemia According to Experts

Hypoglycemia occurs due to an excess of insulin in the blood resulting in low blood sugar levels. Blood sugar levels can cause symptoms of hypoglycemia, varies between one another.

At first the body responds to low blood sugar levels by releasing epinephrine (adrenaline) from the adrenal glands and certain nerve endings. Epinephrine stimulates the release of sugar from body reserves but also causes symptoms that resemble anxiety attacks (sweating, restlessness, trembling, fainting, palpitations, and sometimes hunger). More severe hypoglycemia cause a reduction of glucose to the brain and cause dizziness, confusion, fatigue, weakness, headache, unusual behavior, inability to concentrate, impaired vision, convulsions and coma. Prolonged hypoglycemia can cause permanent brain damage. Symptoms that resemble anxiety and disruption of brain function can begin slowly or suddenly. It most often occurs in people who take insulin or oral hypoglycemic drugs. In patients with insulin-producing pancreatic tumor, symptoms occurred on the morning after an overnight fast, especially if the blood sugar stores are depleted by exercise before breakfast. At first only occasional episodes of hypoglycemia-time, but after a long time the attacks become more frequent and more severe.

Signs and symptoms of hypoglycemia consists of two phases include:
  • The first phase of the symptoms that arise as a result of activation of the autonomic centers in the hypothalamus so that the release of the hormone epinephrine. Symptoms include palpitations, out a lot of sweat, tremors, fear, hunger and nausea (glucose by 50 mg%).
  • The second phase is the symptoms that occur as a result of the start of the disruption of brain function, symptoms such as dizziness, blurred vision, decreased mental acuity, loss of fine motor skills, loss of consciousness, seizures and coma (blood glucose of 20 mg%).

The symptoms of hypoglycemia are not typical is the following:
  • Changes in behavior.
  • Syncope sudden attack.
  • Headache in the morning, which will disappear with the morning meal.
  • Excessive sweating bedtime.
  • Waking from sleep at night to eat.
  • Hemiplegia / aphasia passing.
  • Angina pectoris without coronary artery abnormalities.
Research on people who are not diabetic indicate a disturbance in brain function that is ahead of phase I and in the call subliminal brain dysfunction, in addition to symptoms that are not typical.
Sometimes symptoms do not appear adrenergic phase and direct patients away in the phase disruption of brain function, there are two types of loss of alertness, namely acute and chronic.
Acute example: in patients with type 1 diabetes mellitus with blood glucose control is very tight near normal, the neuropathy autonomic in a patient who had been suffering from diabetes, and use of beta-blockers are nonselective, loss of alertness that chronicles usually irreversible and is considered a complication of diabetes serious.
As a basic diagnosis of Whipple's triad can be used, ie hypoglycaemia with symptoms of central nervous, glucose levels less than 50 mg% and the symptoms will disappear with the administration of glucose.

Hypoglycemia in diabetes is more common than ketoacidosis, although most spread are those of insulin dependence. Onset of hypoglycemia is much faster and manifestations are more varied, often in ways that are not clear so as to deflect the attention of a person until the person does not realize what is actually happening and not being able to find a treatment that does not fit, so the reactions of hypoglycaemia due to insulin may occurred in the midst of everyday life of the patient. Although significant recovery, and hypoglycemia can be rapid and complete within a few minutes after an appropriate treatment, many patients are emotionally (psychologically possibility) remain shaken for several hours or even for several days after an insulin reaction. Finally, in conditions of extreme hypoglycemia, still has the possibility to cause permanent brain damage and even fatal. (Ester, 2000 :).


In the quotation from Karen Bruke 2005 there are few clinical signs and symptoms that include:
  • Hungry.
  • Nausea and vomiting.
  • Pale, cold skin.
  • Headache.
  • Rapid pulse.
  • Hypotension.
  • Irritability.
Manifestations cause changes in cerebral function:
  • Headache.
  • Coma.
  • Difficulty in thinking.
  • Inability to concentrate.
  • Changes in attitude emotion.

Nursing Care Plan for Hypoglycemia: Activity Intolerance


Nursing Care Plan for Hypoglycemia

Activity Intolerance related to imbalance of oxygen supply and demand, weakness.

Defining characteristics:
  • Fatigue and weakness.
  • The response to activity indicates abnormal pulse and blood pressure.
  • Changes in ECG showed arrhythmia / dysrhythmia.
  • Dyspnea and discomfort.
  • Agitated.
Goal: The client is able to achieve: activity tolerance,

with expected outcomes:

Activity Tolerance:
  • Oxygen saturation within normal limits when activity.
  • HR in the normal range when the activity.
  • Respiration in the normal range when the activity.
  • Systolic blood pressure in the normal range when the activity.
  • Diastolic blood pressure in the normal range when the activity.
  • ECG within normal limits.
  • Skin color.
  • Breathing efforts when the activity.
  • Walking in the room.
  • Walk away.
  • Climbing up the stairs.
  • ADL strength.
  • The ability to talk while exercising.

Interventions :

Therapeutic Activities:
  • Note the frequency of heart rhythm, changes in blood pressure before, during and after activity as indicated.
  • Increase rest, limit activity and provide leisure activities that are not heavy.
  • Limit visitors.
  • Monitor response to emotional, physical, social and spiritual.
  • Describe the pattern of a gradual increase in activity.
  • Help clients recognize a meaningful activity.
  • Help clients know the options for activity.
  • Determine the client's commitment to increase the frequency of the activity.
  • Collaboration related to the physical, recreational therapy, proper supervision activity program.
  • Help the client make a specific plan for the transfer of routine daily activity.
  • Help the client / family know all the quality of a shortage of activity.
  • Train the client / family about the role of physical, social, spiritual, sense activity in health care.
  • Help the client / family environment with a desire to adjust the activity.
  • Provide activities that increase attention in a certain period.
  • Facilitation replacement activity when the client has passed the deadline, energy and movement.
  • Provide an environment that is not harmful to walk as indicated.
  • Provide positive reinforcement for participation in the activity.
  • Help the client generates its own motivation.
  • Monitor the emotional, physical, social, and spiritual activities.
  • Help the client / family getting monitor progress toward achieving the goal.

Energy Management :
  • Observation of the client restrictions in activity.
  • Encourage to express feelings towards limitations.
  • Assess the factors that cause fatigue.
  • Monitor nutrition and adequate sources of energy.
  • Monitor the client for physical fatigue and emotional excess.
  • Monitor the cardiovascular response to activity.
  • Monitor patterns of sleep and duration of sleep / rest.
Dysrhythmia Management :
  • Knowing for certain clients and families who have a history of heart.
  • Monitor and check oxygenation deficiency, acid-base balance, electrolytes.
  • Record ECG.
  • Advise the client to break every attack.
  • Record the frequency and duration of the attack.
  • Monitor hemodynamic status.

Monday, October 12, 2015

More Complete About Symptoms of Stroke


Stroke is a condition when the blood supply to a part of the brain is suddenly interrupted. In brain tissue, in case of lack of blood flow will cause a series of biochemical reactions, which can be destructive and deadly nerve cells in the brain.

The death of brain tissue, may result in loss of function that is controlled by the tissue. Therefore, stroke, including diseases that cause death number 3 after the first HIV / AIDS, the second is a heart attack and the third is a stroke.

The most common symptoms of stroke known is suddenly paralyzed, the face looks down on one side, difficulty speaking, blindness, numbness, blurred vision, movement seemed unreal and difficult to balance until lost consciousness.

For more details about the symptoms of a stroke are as follows:

1. Paralysis in the limbs
Paralysis in the limbs of a sudden is a symptom of stroke. Could only right hand or left hand, can also be a weakness in the right hand and left hand. Weakness on the right foot or left foot. Or both legs.

2. Sensibility or impaired sense of touch half body
Impaired sense of numbness or tingling in the form of half body or a limb that occurs suddenly should be suspected as a symptom of stroke. If interference occurs, such as the loss or lack of sensation or tingling or shock sensation in the limbs half.

3. Facial nerve paralysis
Facial nerve paralysis is one of the symptoms of stroke were the most frequently reported. Which of these facial nerve paralysis caused a disturbance in cranial nerve number 7. The face of sudden asymmetry.

4. Aphasia or difficult to communicate
Losing the ability to communicate both verbally and non-verbally that occurs suddenly it also includes symptoms of a stroke. If someone is suddenly could not speak or do not understand the contents of the conversation, then that person should be suspected as a symptom of stroke.

5. Loss of speech or slurred speech
Loss of speech or slurred speech is one of the main symptoms of stroke.

6. Disorientation or sudden confusion
If a person experiences a sudden confused even experienced a loss of consciousness, then it should be suspected as a symptom of stroke. If someone lose their ability to recognize people, given the time and place that occurs suddenly, then this should be suspected as a symptom of stroke.


Stroke treatment is a race against time. If there are symptoms of a stroke immediately seek the right help quickly. With quick and precise handling will give good results.

Diagnosis pathology (stroke blockage or bleeding stroke) was determined with minimal CT scan of the head. Good handling at the beginning, the expected good results.

11 Symptoms of Type 2 Diabetes


Diabetes mellitus is a disorder of insulin system due to excess levels of glucose in the blood. There are two types of diabetes, namely; Type 1 diabetes and Type 2 diabetes . While both are still associated with excess blood sugar, there are fundamental differences are noteworthy, ranging from the causes, symptoms, and ways of prevention.

Type 2 diabetes affects more adults with prefix aged 35 and over. Over time, people with type 2 diabetes not only older people, but young people aged 25 and even 20 years or older are also many who suffer from diabetes. A common cause of type 2 diabetes is improper diet and irregular with infrequent exercise.

Symptoms of type 2 diabetes is difficult to recognize before exiting the diagnosis. The easiest way to find out is to do a blood sugar test. If positive diabetes, which is recognized as a way to treat diabetes usually begins with efforts taking oral medication or oral drug, changing lifestyle such as exercise more and eat a regular diet (reducing carbohydrate intake), and through weight reduction are also common.

Therefore it is difficult to know whether the body of a diabetic, you can see a list of the following symptoms of type 2 diabetes.

1. More frequent urination
Diabetics often said he had increased urge to urinate. If at any time you experience the same thing, try to consult a doctor as early as possible in order to get treatment faster and controlled.

2. Increased appetite
Increased sense of wanting to eat can be another sign of diabetes. Hunger can not be controlled, because the hunger signal sent by this body, must be met, so that all the cells into functioning properly due to get more glucose intake.
Hunger is not because the cells in the body is not getting glucose from food intake, but because the food has been ingested can not enter the cells to be used in the process of metabolism, causing the body's response was as hungry.

3. Body weight decreased
Be good news for people who have problems with overweight and obesity. But, look at the factors triggering the weight loss is due to diabetes, certainly makes you increasingly concerned. The weight loss is indeed closely related to the patient, because the body is unable to absorb glucose (the body's energy source) correctly.

4. Thirst
Increased urge to urinate affects fluid in the body, resulting in dehydration. The body is dehydrated will provide a response in the form of thirst with the aim to restore lost fluids.

5. Numbness
In many cases of diabetes that afflicts some people, almost entirely to experience symptoms such as numbness. As part of the body often feel numbness or tingling of the hands, feet, and his fingers. This early warning of diabetes occur due to increased blood sugar levels, making the nerve fibers damaged.

6. Vision Becomes blurred or unclear
Problems such as blurred vision is often a common complaint of patients with type 2 diabetes. Vision becomes blurred or unclear as ever, occurs due to increased glucose levels rise, damaging blood vessels and limiting fluid into the eye. This condition could change the shape of the lens and the eye.
The good news, these symptoms are reversible (can be back to normal) along with the reduced blood sugar levels to normal limits. However, if high blood sugar disorders of the eye can lead to permanent blindness.

7. Fatigue and quick emotion
Fatigue appears not without cause. When sleeping, diabetics would not be comfortable with his condition. Often wake up to urinate and drink water, so that the process of sleep disturbed and not qualified. The next day the body experience fatigue and often invited emotion.

8. Skin Problems
Diabetes affects blood circulation, and make the experience of dysfunctional sweat glands, making the skin becomes scaly, itchy, dry, and irritation. Symptoms of this one is quite difficult to detect as diabetes, because many other causes that make skin problems like this.

9. The process of wound healing is slow
The presence of injuries when the body is not in good condition, such as excess blood sugar makes the body's immune system becomes abnormal. This certainly affects the recovery rate cuts or bruises, will take longer than usual.

10. Fungal infections
Diabetes affects the immune system of patients. The body will be susceptible to attack by a variety of bacteria and fungi. So the more the number of bacteria or fungus enters the body during the immune system is not prepared to fortify the body.

11. Disorders of the gums
Of the events that had passed, people with diabetes are more susceptible to damage gums. Such as gums become red, swollen, and irritation. Some even feel the gums recede from the teeth and gum infections there.

Thursday, October 8, 2015

7 Nursing Diagnosis for GERD


Gastroesophageal Reflux Disease (GERD) is defined as a pathological state as a result of reflux of gastric contents into the esophagus causing a variety of symptoms that interfere in esophageal and extra-esophageal and or complications (Susanto,

The clinical manifestations of GERD may include typical symptoms (esophageal) and atypical symptoms (extra esophagus). GERD symptoms 70% are typical, namely:
  1. Heartburn, that burning sensation in the retrosternal area. Symptoms of heartburn is the most common symptom.
  2. Regurgitation, a condition in which stomach material was in the pharynx. Then sour and bitter taste in the mouth.
  3. Dysphagia. It usually occurs because of complications such as stricture (Joseph, 2009)
Atypical symptoms:
  • Chronic cough, and sometimes wheezing.
  • Hoarseness.
  • Pneumonia.
  • Pulmonary fibrosis.
  • Bronchiectasis.
  • Nonkardiak chest pain (Joseph, 2009).
Other symptoms:
  • Weight loss.
  • Anemia.
  • Haematemesis or melena.
  • Odynophagia (Bestari, 2011).

Complications of GERD include:
  • Barrett's Esophagus, which changes the squamous epithelium, becomes metaplastic columnar.
  • Ulcerative esophagitis.
  • Bleeding.
  • Stricture of the esophagus.
  • Aspirations. (Asroel, 2002).


Nursing Diagnosis for GERD
  1. Risk for aspiration related to barriers to swallow, decreased reflux larynx and glottis to liquid reflux.
  2. Deficient Fluid Volume related to nausea and vomiting / excessive spending.
  3. Imbalanced Nutrition: less than body requirements related to anorexia, nausea, vomiting.
  4. Acute pain related to inflammation of the esophagus lining.
  5. Ineffective airway clearance related to reflux of fluid into the larynx and throat.
  6. Impaired Swallowing related to narrowing / stricture of the esophagus due to gastroesophageal reflux disease.
  7. Anxiety related to the disease process.

Tuesday, October 6, 2015

Encephalitis Assessment and Nursing Diagnosis

Encephalitis is an infection of the central nervous system caused by viruses or other microorganisms, which cause strong lymphocytic infiltration in brain tissue and leptomeninges cause cerebral edema, brain ganglion cell degeneration and destruction of nerve cells diffusion (Anania, 2008). Encephalitis is an inflammation of the brain tissue that can be caused by bacteria, worms, protozoa, fungi, rickets, or viruses (Mansjoer, 2000)

Although the cause is different, the clinical symptoms of encephalitis is more or less the same and distinctive, so that it can be used as diagnostic criteria. Generally, the symptoms include fever, convulsions and decreased consciousness. (Mansjoer, 2000).

Signs and symptoms of encephalitis as follows:
  1. Sudden temperature rises, often found hyperpyrexia.
  2. Consciousness quickly dropped.
  3. gag.
  4. Seizures, which can be general, focal or twitching only.
  5. Other cerebral symptoms, which may occur individually or together, eg paresis or paralysis, aphasia, and so on.

Assessment

Data that needs to be examined include (Doenges, 1999):

1. Biodata.
Biodata is the identity of the clients includes: name, age, gender, religion, ethnicity, address, date of hospital admission, registration number, date of assessment and medical diagnostics. This identity is used to differentiate clients from one another.

2. Main complaint.
The main complaint is the need to encourage clients to enter the hospital. The main complaints in patients with encephalitis include headaches, neck stiffness, impaired consciousness, fever and seizures.

3. History of present illness.
A history of current clients which include complaints, the nature and great complaints, start or recurrence of disease ever experienced before. Usually the prodromal period lasts between 1-4 days, characterized by fever, headache, dizziness, vomiting, sore throat, malaise, pain in the extremities and pale. Followed by signs of encephalitis that the severity depends on the distribution and extent of the lesion in neurons. The symptoms such as anxiety, irritable, screaning attack, behavioral changes, impaired consciousness and convulsions sometimes with focal neurological signs such as aphasia, hemiparesis, hemiplegia, ataxia and paralysis of the nerves of the brain.

4. History of pregnancy and birth.
In this case studied, among others; a history of prenatal, natal and post natal. In prenatal history should note any disease ever suffered by the mother primarily infectious diseases. History of childbirth need to know whether the baby is born in the gestational age at term or not, because it affects the immune system against the disease in children. The trauma of childbirth also affect the incidence of diseases for example; amniotic fluid aspiration in children. History of post childbirth is necessary to know the state of the child after birth. Example: low birth weight, and Apgar score.

5. P6. revious medical history.
Contact or relationship with meningitis cases will increase the likelihood of inflammation or infection of the brain tissue. Immunizations need to be studied to determine how the child's immune system. Allergies in children need to know to be avoided because it may make things worse.

6. Family health history.
Is a picture of the health of the family, whether there is a relationship with the illness. In this situation the health status of families need to know, if there are family members who suffer from infectious diseases in connection with the disease experienced by the client (Soemarno marram, 1983).

7. Social history.
Environment and the child's family is very supportive to the growth and development of children. Traveling clinic of the disease so disturbing mental status, behavior and personality. Nurse charged assess the status of the client or family in order to prioritize the issue in treatment.

8. Basic Needs (daily activities).
In patients with encephalitis often disruption of daily habits, among others: the fulfillment of nutritional disorders because of nausea, vomiting, hypermetabolic due to infectious processes, and increased intracranial pressure. Rest patterns in patients with frequent seizures, it greatly affects the patient. Pattern personal hygiene should be practiced on the bed because the patient is weak or unconscious, and is likely to depend on others, play behavior is unknown if any changes need to know as a result of hospitalization in children.


Nursing Diagnosis for Encephalitis
  1. Hyperthermia r / t the disease: infection.
  2. Nausea r / t increased intracranial pressure, inflammation of the brain.
  3. Disturbed Sensory Perception (type: visual, auditory, kinesthetic, tactile, olfactory) r / t biochemical imbalances.
  4. Risk for trauma r / t reduction in muscle coordination.

Monday, October 5, 2015

Physiological and Psychological Responses to Anxiety


Autonomic nervous system responses to fear and anxiety cause involuntary activities in the body including the self-defense mechanism. Sympathetic nerve fibers "activate" vital signs at any sign of danger for preparing the body's defenses. The adrenal glands release adrenaline (epinephrine), which causes the body to take in more oxygen, dilates pupils, and increases arterial pressure and heart rate while making constricting peripheral blood vessels and makes shunting of blood from the gastrointestinal and reproductive system and increases glycogenolysis be free glucose to sustain heart , muscle, and central nervous system. When the danger has ended, parasympathetic nerve fibers reverse this process and restore the body to its normal state until the signs of the next threat to re-activate the sympathetic response (Videbeck, 2008).

Anxiety causes the response of cognitive, psychomotor and physiological uncomfortable, such as difficulty thinking logically, increased motor activity, agitation, and increased vital signs. To reduce discomfort, individuals try to reduce the discomfort level to perform adaptive behavior that is new or defense mechanisms. Adaptive behavior can be a positive thing and helps individuals adapt and learn, for example: using imagination techniques to refocus attention on the beautiful scenery, relaxation of the body sequentially from head to toe, and breathing slowly and regularly to reduce muscle tension and vital signs. Negative response to anxiety can lead to maladaptive behaviors, such as headache due to tension, pain syndromes and stress-related responses that lead to immune efficiency (Videbeck, 2008).

Anxiety can be passed from one individual to another individual through words, for example, heard a shout "fire" in a crowded room or hear the sound vibrating from the mother who can not find the child in a crowded mall. Anxiety may be communicated nonverbally through empathy, a sense of self-adjust the position of others for some time (Sullivan, in Videbeck, 2008).

When people become anxious, they use defense mechanisms to reduce anxiety. Defense mechanisms is the cognitive distortions used by a person to maintain a sense of control over stressful situations. This process includes self deception, limited awareness of the situation, or the emotional commitment is lacking. Most defense mechanisms arise from the subconscious so that individuals do not consciously use it. When the patient can not explain the accident that had just happened, his mind was using the mechanism of repression (forget the terrifying events that unconsciously).

Some individuals use excessive defense mechanisms and it stopped them learn a variety of appropriate methods to cope with situations that cause anxiety. Dependence on one or two defense mechanisms can also inhibit the growth of emotional, causing poor problem-solving skills, and cause trouble in a relationship.

2 Nursing Interventions for Pemphigus Vulgaris

Pemphigus vulgaris is a chronic blistering skin disease with skin lesions that are rarely pruritic, but which are often painful.

Pemphigus vulgaris is an autoimmune, intraepithelial, blistering disease affecting the skin and mucous membranes.

1. Acute Pain related to damage to the soft tissue, soft tissue erosion.

Goal: Pain is reduced / lost or adapted.

Expected outcomes:
  • Subjectively reported reduced pain or can be adapted. Pain scale: 0 -1.
  • Can identify activities that increase or decrease the pain.
  • The patient is not restless.
Interventions:

1. Assess PQRST approach (P = Provocation / Palliation, Q = Quality / Quantity, R = Region / Radiation, S = Severity Scale, T = Timing)
Rationale: Being a basic parameter to determine the extent of intervention required and as the evaluation of the success of the intervention pain management.

2. Explain and help the patient with pain relief action nonpharmacological and noninvasive.
Rationale: The approach by using relaxation and other nonpharmacological have shown effectiveness in reducing pain.

3. Perform nursing management of pain:

a. Set the physiological position.
Rationale: It would increase the intake of oxygen into the subcutaneous tissue inflammation. Setting ideal position is in the opposite direction to the lesion pemphigus.

b. Perform maintenance of oral hygiene.
Rationale: Overall patient's oral cavity can be eroded and exposed surfaces. Necrotic tissue can form in this area so that adds to the suffering of patients and interfere with food intake. Weight loss and hypoproteinemia may occur. Careful oral hygiene care is very important to keep the oral mucosa is kept clean and allow the regeneration of the epithelium. Rinse the mouth that often must be done to cleanse the mouth and reduces pain in the area of ​​ulceration. Be kept moist lips by applying a lip moisturizer.

c. Rest client
Rationale: Rest is needed during the acute phase. This condition will increase the supply of blood to the inflamed tissue.

d. If necessary premedication before performing wound care.
Rationale: wet and cool compresses or immersion therapy is protective measures that can reduce pain. Patients with extensive lesions and pain should receive premedication prior to the preparation of an analgesic before the skin care began.

e. Environmental management: calm environment and limit visitors.
Rationale: Tranquil environment will decrease the pain stimulus of external and visitor restrictions will help increase oxygen conditions of the room, which will be reduced if many visitors who were in the room.

d. Teach deep breathing relaxation techniques.
Rationale: Improve input oxygenation in patients, resulting in lower secondary pain from inflammation.

e. Teach technique of distraction during painful.
Rationale: Distraction can reduce internal stmulus.

f. Perform touch management.
Rationale: It can help reduce pain. Light massage can increase blood flow and automatically helps the blood supply and oxygen to the painful area, and reduce the sensation of pain.

4. Collaboration with physicians for providing analgesic.
Rationale: Analgesics block the path of pain so the pain will be reduced.


2. Impaired Skin Integrity related to local necrosis secondary to tissue accumulation of pus in the hair follicles.

Goal: Improved skin integrity optimally.

Expected outcomes:
  • Increased tissue growth, improved wound state, spending pus in the wound no longer exists, the wound closed.
Interventions:

1. Assess soft tissue damage that occurs on the client.
rationale:
Being the basic data to provide information about wound care interventions, what tools will be used, and the type of solution that will be used.

2. Perform maintenance bullae.
Rationale: The patient with bullae broad area, has a characteristic odor which will be reduced after secondary infection under control. The patient's skin after a bath, the skin is dried carefully and sprinkled with powder that is not irritating so that the patients can move more freely in bed. The amount of powder that is pretty much it may be necessary to keep the patient's skin is not sticky on the sheets. Hypothermia often happens and actions for keeping the patient warm and comfortable is a priority in nursing activity.
Increased tissue growth, improved wound state, spending pus in the wound no longer exists, the wound closed.

3. Increase the intake of nutrients in patients.
Rationale: Nutrition is necessary to increase the intake of the needs of the body's tissues.

4. Evaluation of tissue damage and the development of tissue growth.
Rationale: If still not reached of the evaluation criteria, then it needs to be re-examined factors that can inhibit the growth of the wound.

Thursday, October 1, 2015

6 Nursing Interventions for Glaucoma

Nursing Diagnosis and Interventions for Glaucoma


1. Acute Pain related to an increase in IOP

Goal: Pain is reduced and the client is on the comfort level.

Expected outcomes:
  • The Client do not complain of pain.
  • Normal intraocular pressure / down.
  • Calm facial expression.
Interventions:
  • Assess the type, intensity and location of pain. Use pain scale to determine the level of analgesic doses.
  • Keep the rest in bed in a quiet room and dark with the head elevated 30 ° or in a comfortable position.
  • Rest of clients in the room that does not dazzle with the head rather an extension or a comfortable position for the client.
  • Encourage relaxation techniques.
  • Avoid nausea, vomiting, give anti-emetic if necessary.
  • Collaboration with physicians in providing analgesic.

2. Disturbed Sensory Perception (visual) related to damage to the nerve fibers due to increased IOP.

Goal: Decrease of visual field can be reduced.

Expected outcomes:
  • The client can use the drug correctly.
  • Cooperative in every action.
  • Realized loss of eyesight permanently.
  • Vision did not decline further.

Interventions:
  • Assess and record the visual acuity.
  • Assess functional description of what can be seen / not.
  • Environment with the ability to adjust the vision.
  • Orient on the environment: Put the tools that are often used in client outreach vision, Provide adequate lighting, Put the tools in place which remains, Provide reading materials with great writing, avoid glare.
  • Use the clock sound.
  • Assess the amount and type of stimuli that can be accepted by the client.
  • Advise on alternative forms of stimulation such as radio, TV.


3. Risk for injury related to a decrease in the visual field.

Goal: The client was not injured.

Expected outcomes:
  • The client can explain how to prevent injury.
  • The is able to demonstrate on alertness anxiety.
  • The officer asked for help when the ends meet.
Interventions:
  • Orient the client to the environment when it arrives.
  • Explain the origin of a decrease in peripheral vision and do like bumping into objects.
  • Suggest to turn his head to look into each side.
  • Arrange the room in order to walk around freely.
  • Make modifications to the environment to move all the dangers: Get rid of the obstacles on a walk. Get rid of the foot rolls. Get rid of items that may injure the client. Help clients and families to evaluate the home environment against the dangers that may occur.

4. Risk for infection related to the surgical wound.

Goal: infection can be prevented / controlled.

Expected outcomes:
  • Free from signs and symptoms of infection.
Interventions:
  • Wash hands before and after nursing actions.
  • Improve sufficient nutrients (nutritious and contain vitamin A).
  • Monitor signs and symptoms of systemic and local infections.
  • Monitor susceptibility to infection.
  • Inspection condition of the wound / surgical incision.
  • Instrusikan clients to drink antibiotics as recommended.
  • Teach clients and families about the signs and symptoms of infection, and how to avoid infection.

5. Disturbed body image related to the lesions on the skin which affects its appearance.

Goal: The client can accept the situation.

Expected outcomes:
  • Discuss strategies to cope with changes in body image.
Interventions:
  • Assess the patient's knowledge of the existence of a potential disability associated with surgery or skin changes.
  • Monitor the patient's ability to see the changes against him.
  • Encourage the patient to discuss feelings about the changes in the appearance of the surgery.
  • Give support group for people nearby.

6. Anxiety related to loss of vision, lack of knowledge.

Goal: Anxiety is reduced.

Expected outcomes:
  • Reduced feeling nervous.
  • Reveals an understanding of the plan of action.
  • Relaxed body position.
Interventions:
  • Carefully deliver permanent loss of vision.
  • Give the client the opportunity to express about the condition.
  • Maintain a relaxed condition.
  • Explain the purpose of each action.
  • Prepare bell on the bed and instructed the client to indicate when asking for help.
  • Maintain effective pain control.

Sunday, September 27, 2015

Home Care - How to Relieve Severe Nausea in Pregnant Women

Home Care - How to Relieve Severe Nausea in Pregnant Women

Nausea is the sensation issued a strong food or want to vomit. Vomiting sensation is accompanied by signs of autonomic, such as hypersalivation (excessive saliva expenditure), diaphoresis, tachycardia, pallor, and tachypnea. Nausea is closely linked to the occurrence of anorexia and vomiting.

Nausea can also occur due to take medication, the effects that occur after surgery and radiation. Nausea often occurs during the first trimester to a pregnant woman.
Nausea can also be caused by extreme pain due to accidents or other issues, anxiety, alcohol poisoning (drunk) because of excessive consumption, or it can also be caused by food and beverages are not tasty.

Nausea during early pregnancy is often called morning sickness, because it generally occurs in the morning. Really just happened the morning ?, Not really, because there are some pregnant women can occur at any time throughout the day. Because the exact cause is unknown, treatment of this problem can have different effectiveness. But do not worry because there are some things you can do.

Increased estrogen and thyroxine become one of the causes of nausea in pregnant women. Sometimes in some women, the nausea lasts until severe. Therefore to avoid it, you can do some of the following home care.

Get plenty of rest
When you are pregnant, you are advised to have plenty of time to rest. Rest will make your body relax and minimize fluctuation of hormones that can cause nausea.

After sleep, get up slowly
When waking from sleep, get up slowly. If you wake up suddenly, then there is a jolt that will shock your body and can make you sick.

Eating healthy food
While pregnant, avoid foods that can trigger nausea. One of them is caffeine. Caffeine is a proven bad for your pregnancy because it can increase the acid in the stomach which would exacerbate nausea.

Increase your physical activity
Physical activity you do, can reduce severe nausea because physical activity will accelerate your body's metabolic system so that you avoid nausea.

Saturday, September 26, 2015

Nursing Diagnosis and Interventions for Cirrhosis of the Liver


Nursing Diagnosis 1.

Self-Care Deficit related to fatigue and the presence of ascites.

Goal: The client is able to care for themselves.
Expected outcomes: The client is able to show self-care activities.

Interventions :

1. Give the rest during the acute phase.
Rationale: Increased rest and tranquility providing the energy that is used for healing.

2. Give light activity during bed rest.
Rationale: Bed rest time, can reduce the ability, this is precisely the case due to the limited activities that disrupt the rest period.

3. If the client is tired, limit visits of family or friends.
Rationale: Increase rest and tranquility providing the energy that is used for healing.


Nursing Diagnosis 2.

Imbalanced Nutrition Less Than Body Requirements related to anorexia.

Goal: Nutrition clients are met.
Expected outcomes: The client is able to exhibit a lifestyle to improve or maintain an appropriate body weight, showed weight gain goals with laboratory values, and freely sign of malnutrition.

Interventions:

1. Observation vital signs.
Rationale: To determine the general state of the client.

2. Monitor dietary intake, or the number of calories and provide little in the frequency often.
Rationale: Eat a lot harder when the client anorexia. Anorexia is also the worst during the day, make food intake difficult in the afternoon.

3. Provide oral care before meals.
Rationale: Eliminate sense, it can not increase the appetite.

4. Monitor blood glucose.
Rationale: hyperglycemia or hypoglycemia can occur require changes in diet or insulin administration.

5. Collaboration: Consultation with a dietitian to provide a diet in accordance with the client's needs with the input of fat and protein as tolerated.
Rationale: Allows to create a diet program for individual needs. Protein restriction is indicated in severe diseases like hepatitis.


Nursing Diagnosis 3.

Risk for Impaired tissue integrity related to bed rest, ascites and edema.

Goal: Do not damage the integrity of the skin.

Expected outcomes: Identify the risk factors and shows the behavior or technique to prevent skin damage.

Interventions:

1. Elevate the lower extremities.
Rationale: Improves venous return and decrease edema in the extremities.

2. Keep the sheets dry and free of creases.
Rational: Humidity increase pruritus and improve skin damage.

3. Cut fingernails to short, and give the gloves if desired.
Rationale: Prevent clients from injury to the skin, especially at bedtime.

4. Give the massage at bedtime.
Rational: Beneficial to improve sleep by reducing skin irritation.

Nursing Diagnosis for Glaucoma (Pre and Post Operative)


Glaucoma is a group of eye diseases causing optic nerve damage. Glaucoma often affects both eyes, usually to varying degrees. One eye may develop glaucoma quicker than the other.Glaucoma is a condition which can affect sight, usually due to build up of pressure within the eye.

The exact causes of optic nerve damage from glaucoma is not fully understood, but involves mechanical compression and/or decreased blood flow of the optic nerve. Although high eye pressure sometimes leads to glaucoma, many people can also develop glaucoma with "normal" eye pressure.

There are four main types of glaucoma:
  • Acute angle-closure glaucoma – which often has severe symptoms
  • Chronic open-angle glaucoma – the most common type which often has few symptoms
  • Developmental glaucoma – a rare condition affecting young babies
  • Secondary glaucoma – caused by other conditions or eye treatments

Nursing Diagnosis for Glaucoma (Pre Operative)

1. Disturbed Sensory Perception (visual) related to the reception of sensory disturbances, impaired organ status.

2. Pain (acute / chronic) related to an increase in intra-ocular pressure (IOP)
characterized by nausea and vomiting.

3. Anxiety related to physiological factors, changes in health status, pain, possibility / reality vision loss.

4. Deficient Knowledge (learning needs) about the condition, prognosis, and treatment related to less exposed / do not know the source.



Nursing Diagnosis for Glaucoma (Post Operative)

1. Pain (acute / chronic) related to the surgical incision.

2. Risk for injury related to increased IOP, vitreous loss.

3. Risk for infection related to invasive procedures.

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