Gastritis Assessment and Nursing Diagnosis

Gastritis is inflammation of the stomach lining. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. In some cases, the stomach lining may be "eaten away," leading to sores (peptic ulcers) in the stomach or first part of the small intestine. Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). In most cases, gastritis does not permanently damage the stomach lining.


In many cases, gastritis has no symptoms. Common symptoms can include:

• Loss of appetite
• Pain in the upper abdomen just under the ribs
• Nausea or indigestion
• Hiccups
• Vomiting
• Blood in the vomit
• Blood in the bowel actions, if the stomach lining has ulcerated (this turns stools black and is called melaena)
• Weight loss.

Diagnosis:

Several tests can be used to make a diagnosis. These include endoscopy of the stomach, where a thin tube with a light and a camera on the end is inserted down your throat into your stomach. This allows the doctor to see into your stomach and take samples (called a biopsy) from the lining if needed. The laboratory tests you may need will depend on the cause of your gastritis. A stool test may be used to check for the presence of blood, or a biopsy may be taken of the tissues of your esophagus or stomach. A breath test may detect H. pylori, or samples from your esophagus or stomach may be taken to look for this bacteria.


Nursing Assessment for Gastritis

• During the gathering health history, the nurse asked about the signs and symptoms in patients.
• Does the patient have heartburn, can not eat, nausea or vomiting?
• Does the patient have symptoms occur at any time, before or after meals, after ingesting spicy foods or irritants or after ingesting certain drugs or alcohol?
• Does the patient have symptoms associated with anxiety, stress, allergies, eating or drinking too much, or eating too fast? how the symptoms disappear?
• Is there a history of previous gastric or stomach surgery?
• Historical diet plus a new type of diet eaten for 72 hours, would help.
• Full history is essential in helping nurses to identify whether excess dietary frivolous known, associated with current symptoms, whether others in the same patient has symptoms, whether the patient vomited blood, and if the elements are known to have ingested causes.

Nursing Diagnosis for Gastritis

Based on all the data assessment, nursing diagnosis is the major include the following:

1. Anxiety related to treatment.
2. Imbalanced Nutrition, Less Than Body Requirements related to inadequate nutrient inputs.
3. Risk for Fluid Volume Deficit related to insufficient fluid intake and excessive fluid loss due to vomiting.
4. Knowledge Deficit: on the management of diet and disease processes.
5. Acute Pain related to gastric mucosal irritation.

7 Nursing Diagnosis for UTI

A urinary tract infection is an infection that can happen anywhere along the urinary tract. When it affects the lower urinary tract it is known as a simple cystitis (a bladder infection) and when it affects the upper urinary tract it is known as pyelonephritis (a kidney infection).

UTIs are diagnosed usually by isolating and identifying the urinary pathogen from the patient; there are some home tests available for presumptive diagnosis.

The most common cause of UTIs are bacteria from the bowel that live on the skin near the rectum or in the vagina, which can spread and enter the urinary tract through the urethra. Once these bacteria enter the urethra, they travel upward, causing infection in the bladder and sometimes other parts of the urinary tract.

Symptoms

May have an infection if have any of these symptoms:

• Feel pain or burning when urinate.
• Feel like have to urinate often, but not much urine comes out when do.
• Belly feels tender or heavy.
• Urine is cloudy or smells bad.
• Have pain on one side of the back under ribs. This is where kidneys are.
• Have fever and chills.
• Have nausea and vomiting.

7 Nursing Diagnosis for UTI

1. Acute pain
related to:
inflammation and infection of the urethra, bladder and other urinary tract structures.

2. Hyperthermia
related to:
inflammatory reaction

3. Impaired Urinary Elimination
related to:
frequent urination, urgency and hesistancy

4. Risk for Fluid Volume Deficit
related to:
excessive evaporation and vomiting

5. Disturbed Sleep Pattern
related to:
pain and nocturia

6. Imbalanced Nutrition, Less Than Body Requirements
related to:
anorexia

7. Anxiety
related to:
crisis situations, coping mechanisms are ineffective

8. Knowledge Deficit: about condition, prognosis, and treatment needs
related to:
lack of sources of information.

Gastritis - Nursing Diagnosis Interventions

Gastritis is an inflammation of the gastric mucosa, may be acute or chronic. Acute Gastritis, stomach disorders are the most common cause of gastric mucosal redness, edema, and erosion surfaces.

Chronic gastritis is common among the elderly and people with pernicious anemia. It is often present as chronic atrophic gastritis, gastric mucosal layer where all inflamed, with a reduced number of cells and parietal head. Acute or chronic gastritis can occur at any age.

Causes of Gastritis :

1. Consumption of unhealthy foods, such as chili (or allergic reactions) or alcohol.
2. Drugs such as aspirin and nonsteroidal anti-inflammatory agents, cytotoxic agents, caffeine, corticosteroids, anti-metabolites, phenylbutazone, and indomethacin.
3. Ingestion of toxins, especially dichlorodiphenyltrichloroethane, ammonia, mercury, carbon tetrachloride, or corrosive substances.
4. Endotoxin bacteria, such as staphylococci, Escherichia coli, and Salmonella.

Complications of Gastritis

1. Bleeding
2. Shock
3. Perforation
4. Peritonitis
5. Gastric cancer.

Signs and symptoms of patients with gastritis

Patients with acute gastritis usually feel discomfort in epigastrium, indigestion, cramps, anorexia, nausea, hematemesis, and vomiting. Patient's symptoms may last several hours to several days. Chronic gastritis may explain the same phenomenon, only experienced mild epigastric discomfort, or just a vague complaint. For example, patients may report spicy or fatty food intolerance or mild epigastric pain.

Patients with chronic atrophic gastritis is often asymptomatic.
On examination, the patient may appear normal or show signs of distress such as fatigue, grimacing, and anxious, depending on the severity of symptoms. If stomach bleeding has occurred, it may appear pale and vital signs may reveal tachycardia and hypotension. Inspection and palpation may reveal abdominal distention, tenderness, and guarding. Auscultation may reveal increased bowel sounds.

Gastritis Nursing Diagnosis

1. Acute Pain
2. Knowledge Deficit: (diagnosis and treatment)
3. Imbalanced Nutrition, Less Than Body Requirements
4. Ineffective Individual Coping
5. Risk for Fluid Volume Deficit

Expected outcomes:

1. Patients are able to express a feeling of comfort.
2. Patient expressed understanding about the disorder and treatment regimen.
3. Patients were able to maintain body weight.
4. Patients did not express concerns about the current conditions.
5. Patients were able to maintain normal fluid volume.

Gastritis Nursing Interventions:

1. Provide physical and emotional support.
2. Provide antiemetics and replace I.V. fluid appropriate order, as well as monitor fluid intake and output and electrolyte levels.
3. Give a soft diet food preferences into account.
4. Encourage eat little, but often to reduce the amount of gastric secretion resulting in pain.

Hyperthyroidism - Assessment and Nursing Diagnosis

Hyperthyroidism is a condition in which the thyroid gland makes too much thyroid hormone. The condition is often referred to as an "overactive thyroid."

Causes of Hyperthyroidism

• Hyperthyroidism occurs when the thyroid releases too much of its hormones over a short (acute) or long (chronic) period of time. Many diseases and conditions can cause this problem, including:
• Getting too much iodine
• Graves disease (accounts for most cases of hyperthyroidism)
• Inflammation (thyroiditis) of the thyroid due to viral infections or other causes
• Noncancerous growths of the thyroid gland or pituitary gland
• Some tumors of the testes or ovaries
• Taking large amounts of thyroid hormone

Symptoms of Hyperthyroidism

• Palpitations
• Heat intolerance
• Nervousness
• Insomnia
• Breathlessness
• Increased bowel movements
• Light or absent menstrual periods
• Fatigue
• Fast heart rate
• Trembling hands
• Weight loss
• Muscle weakness
• Warm moist skin
• Hair loss
• Staring gaze

Assessment for Hyperthyroidism

1. Health Perceptions
Knowledge of the disease and the side effects of drugs.

2. Metabolic Nutrition
Changes in food intake, such as appetite and increases food intake, body weight decreased.

3. Elimination
Changes in fecal elimination, increased frequency of bowel movements or many times. Every meal tend to defecate, urine in large quantities.

4. Activity and Exercise
Experiencing chest pain / angina, tachycardia despite the break, dysrhythmias, and murmur, dyspnea experienced during the activity / rest muscle weakness, severe accidents, muscle atrophy.

5. Rest and Sleep
Insomnia.

6. Cognitive Sensory
Complained of impaired vision rapid eye fatigue, blurred vision, orbital pain, exophthalmos.

7. Coping Mechanisms
Emotional instability, experiencing severe stress both emotional and physical, psychological conditions.

8. Sexual Relations
Decreased libido, hipomenorea, amenorrhoea and impotence.

9. Self-Concept
Less confident because of physical changes such as the eye.


Nursing Diagnosis for Hyperthyroidism

1. Decreased Cardiac Output
2. Fatigue
3. Disturbed Thought Processes
4. Imbalanced Nutrition
5. Anxiety
6. Impaired Tissue Integrity
7. Knowledge Deficit

Angina Pectoris - 4 Nursing Diagnosis

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand.

Angina pectoris is the medical term for chest pain or discomfort due to coronary heart disease. It occurs when the heart muscle doesn't get as much anginablood as it needs. This usually happens because one or more of the heart's arteries is narrowed or blocked, also called ischemia.

Angina often occurs when the heart muscle itself needs more blood than it is getting, for example, during times of physical activity or strong emotions.

There are many risk factors for coronary heart disease. Some include:

• Diabetes
• High blood pressure
• High LDL cholesterol and low HDL cholesterol
• Smoking

Other causes of angina include:

• Abnormal heart rhythms (usually ones that cause your heart to beat quickly)
• Anemia
• Coronary artery spasm (also called Prinzmetal's angina)
• Heart failure
• Heart valve disease
• Hyperthyroidism (overactive thyroid)

Angina is usually felt as:

• pressure,
• heaviness,
• tightening,
• squeezing, or
• aching across the chest, particularly behind the breastbone.

Patients may also suffer:

• indigestion,
• heartburn,
• weakness,
• sweating,
• nausea,
• cramping, and
• shortness of breath.

People with angina pectoris or sometimes referred to as stable angina have episodes of chest discomfort that are usually predictable and manageable. You might experience it while running or if you’re dealing with stress.

Normally this type of chest discomfort is relieved with rest, nitroglycerin or both. Nitroglycerin relaxes the coronary arteries and other blood vessels, reducing the amount of blood that returns to the heart and easing the heart's workload. By relaxing the coronary arteries, it increases the heart's blood supply.

If you experience chest discomfort, be sure and visit your doctor for a complete evaluation and, possibly, tests. If you have stable angina and start getting chest pain more easily and more often, see your doctor immediately as you may be experiencing early signs of unstable angina.

Angina Pectoris - 4 Nursing Diagnosis

1. Acute Pain

2. Activity Intolerance

3. Anxiety

4. Knowledge Deficit

Priority Nursing Diagnosis for Hepatitis

Nursing Care Plan for Hepatitis

Hepatitis is swelling and inflammation of the liver. It is not a condition, but is often used to refer to a viral infection of the liver. Characterized by the presence of inflammatory cells in the tissue of the organ.

Hepatitis may start and get better quickly (acute hepatitis), or cause long-term disease (chronic hepatitis). In some instances, it may lead to liver damage, liver failure, or even liver cancer.

How severe hepatitis is depends on many factors, including the cause of the liver damage and any illnesses you have. Hepatitis A, for example, is usually short-term and does not lead to chronic liver problems.

The symptoms of hepatitis include:

•     Abdominal pain or distention
•     Breast development in males
•     Dark urine and pale or clay-colored stools
•     Fatigue
•     Fever, usually low-grade
•     General itching
•     Jaundice (yellowing of the skin or eyes)
•     Loss of appetite
•     Nausea and vomiting
•     Weight loss

Many people with hepatitis B or C do not have symptoms when they are first infected. They can still develop liver failure later. If you have any risk factors for either type of hepatitis, you should be tested regularly.


Priority Nursing Diagnosis for Hepatitis

1. Imbalanced Nutrition, Less Than Body Requirements
relate to:
discomfort in the right upper quadrant
impaired absorption and digestion of food metabolism
input failure to meet the metabolic needs due to anorexia, nausea and vomiting.

2. Acute pain
related to:
swelling of the liver, the inflamed liver and portal vein dam.

3. Hyperthermia
related to:
invasion agent in blood circulation secondary to liver inflammation

4. Fatigue
related to:
chronic inflammatory process secondary to hepatitis

5. Risk for skin integrity and tissue damage
related to:
pruritus secondary to the accumulation of the pigment bilirubin in the bile salts

6. Risk for the transmission of infection
related to:
infectious nature of the virus agent

Nursing Diagnosis for Hydatidiform Mole

Definition of Hydatidiform Mole

A hydatidiform mole is a relatively rare condition in which tissue around a fertilized egg that normally would have developed into the placenta instead develops as an abnormal cluster of cells. A molar pregnancy is a gestational trophoblastic disease that grows into a mass in the uterus that has swollen chorionic villi. These villi grow in clusters that resemble grapes.

Causes of Hydatidiform Mole

The specific cause behind the occurrence of Hydatidiform mole still remains to be found out. Nevertheless, the doctors point at some reasons like abnormalities in the egg, nutritional deficiencies during pregnancy. If a woman follows a diet which is low in protein, carotene and folic acid she can also contract this malady.

Symptoms of Hydatidiform Mole

• Abnormal growth of the womb (uterus) ; Excessive growth in about half of cases, Smaller-than-expected growth in about a third of cases
• Nausea and vomiting that may be severe enough to require a hospital stay
• Vaginal bleeding in pregnancy during the first 3 months of pregnancy
• Symptoms of hyperthyroidism ; Heat intolerance, Loose stools, Rapid heart rate, Restlessness, nervousness, Skin warmer and more moist than usual, Trembling hands, Unexplained weight loss
• Symptoms similar to preeclampsia that occur in the 1st trimester or early 2nd trimester -- this is almost always a sign of a hydatidiform mole, because preeclampsia is extremely rare this early in a normal pregnancy ; High blood pressure, Swelling in feet, ankles, legs

Diagnosis of Hydatidiform Mole

The physician may not suspect a molar pregnancy until after the third month or later, when the absence of a fetal heartbeat together with bleeding and severe nausea and vomiting indicates something is amiss.
First, the physician will examine the woman's abdomen, feeling for any strange lumps or abnormalities in the uterus. A tubal pregnancy, which can be life threatening if not treated, will be ruled out. Then the physician will check the levels of human chorionic gonadotropin (hCG), a hormone that is normally produced by a placenta or a mole. Abnormally high levels of hCG together with the symptoms of vaginal bleeding, lack of fetal heartbeat, and an unusually large uterus all indicate a molar pregnancy. An ultrasound of the uterus to make sure there is no living fetus will confirm the diagnosis.

Treatment of Hydatidiform Mole

Hydatidiform moles should be treated by evacuating the uterus by uterine suction or by surgical curettage as soon as possible after diagnosis, in order to avoid the risks of choriocarcinoma.[19] Patients are followed up until their serum human chorionic gonadotrophin (hCG) level has fallen to an undetectable level. Invasive or metastatic moles (cancer) may require chemotherapy and often respond well to methotrexate. The response to treatment is nearly 100%. Patients are advised not to conceive for one year after a molar pregnancy. The chances of having another molar pregnancy are approximately 1%.

Management is more complicated when the mole occurs together with one or more normal fetuses.

Carboprost (PGF2α) medication may be used to contract the uterus.



Nursing Diagnosis for Hydatidiform Mole

1. Acute Pain

2. Activity Intolerance

3. Disturbed Sleep Pattern

4. Hyperthermia

5. Anxiety

Nursing Diagnosis for Depression Risk for Self-Harm

Nursing Diagnosis for Depression Risk for Self-Harm

General Purpose: Clients do not injure yourself.

Specific Purpose:

1. Clients can build a trusting relationship
Nursing Interventions:

• Introduce yourself to the client.
• Perform frequent interaction with patients with empathy.
• Listen to the patient's statement of patience and empathy to use more non-verbal language. For example: a touch, a nod.
• Note the patient talks and give responses according to her wishes.
• Speak with a low tone of voice, clear, concise, simple and easy to understand.
• Accept the patient is without comparing with others.

2. Clients can use adaptive coping
Nursing Interventions:

• Give encouragement to express his feelings and said that nurses understand what the patient feels.
• Ask the patient the usual way to overcome feeling sad / painful.
• Discuss with patients the benefits of coping used.
• With patients looking for alternatives coping.
• Encourage the patient to choose the most appropriate coping and acceptable.
• Encourage the patient to try to coping have been.
• Instruct the patient to try other alternatives in solving the problem.

3. Clients are protected from self injuring behavior
Nursing Interventions:

• Monitor carefully the risk of suicide / self-mutilation.
• Keep and store the tools that can be used for patients olch injure himself / others, in a safe and locked.
• Keep the tool material harm to the patient.
• Supervise and place the patient in a room that is easily monitored by peramat / officer.

4. Clients can increase self-esteem
Nursing Interventions:

• Help to understand that the client can overcome despair.
• Assess and internal sources mobilized individuals.
• Bantu identify sources of expectations (eg, interpersonal relationships, beliefs, things to be resolved).

5. Clients can use social support
Nursing Interventions:

• Assess and use individual external sources (those closest to the team of health care, support groups, religious affiliation).
• Assess support systems beliefs (values​​, past experiences, religious activities, religious beliefs).
• Make referrals as indicated (eg, counseling, religious leaders).

6. Clients can use the medication correctly and appropriately
Nursing Interventions:

• Discuss medications (name, frequency, effects and side effects of medication).
• Bantu using drugs with the principles of a true 5 (right patient, medication, method, time).
• Encourage talking about the effects and side effects are felt.
• Give positive reinforcement when using the drug properly.

Nursing Care Plan for Depression

Nursing Diagnosis for Decubitus Ulcer - 7 Nanda

Nursing Care Plan for Decubitus Ulcer

Decubitus ulcer: A bed sore, a skin ulcer that comes from lying in one position too long so that the circulation in the skin is compromised by the pressure, particularly over a bony prominence such as the sacrum (sacral decubitus).

The root cause of which is always pressure on a point of the body which isn't relieved, this causes an ulcer to develop. Bed sores are most prevalent on the bed bound or immobile as they cannot move their body to prevent these sores appearing.

If a patient is bed-ridden or immobile, proper monitoring is essential to prevent bed sores from becoming a real problem. The staff in hospitals, care homes etc. must make sure they are constantly vigilant of the signs that an decubitus ulcer is starting to form and try and relieve the pressure on the patient. This can be done by moving the patient into another comfortable position thus relieving the pressure on the part of the body.

The pressure on the skin must be reduced by turning the patient in bed every 2 hours and by the use of a pressure-reducing mattress. Pressure-reducing mattresses include low–air loss beds, air-fluidized beds, and Roho cushion mattress seats for wheelchairs. Furthermore, sitting patients should shift their body weight every 15 minutes.

A pressure ulcer starts as reddened skin that gets worse over time. It forms a blister, then an open sore, and finally a crater.

The most common places for pressure ulcers to form are over bones close to the skin, like the elbow, heels, hips, ankles, shoulders, back, and back of the head.

Pressure sores are categorized by how severe they are, from Stage I (earliest signs) to Stage IV (worst):

• Stage I: A reddened area on the skin that, when pressed, does not turn white. This indicates that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin breakdown now looks like a crater. There is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

7 Nursing Diagnosis for Decubitus Ulcer

1. Impaired Skin Integrity
related to:
mechanical damage of tissue secondary to stress,
shearing and friction.

2. Acute Pain
related to:
skin trauma,
infections of the skin
wound care.

3. Risk for Infection
related to:
display of decubitus ulcers to feces / urine drainage
personal hygiene is lacking.

4. Imbalanced Nutrition, Less Than Body Requirements
related to:
anorexia insufficiency secondary to oral input.

5. Impaired Physical Mobility
related to:
restriction of movement required,
status that is not conditioned,
loss of motor control or change in mental status.

6. Ineffective Individual Coping
related to:
chronic wounds,
changes in body image.

7. Disturbed Body Image
related to:
loss of skin layers.

12 Nursing Diagnosis for Myocardial Infarction

Myocardial infarction (MI) or acute myocardial infarction (AMI) is the death of heart muscle from the sudden blockage of a coronary artery by a blood clot. Myocardial infarction most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (cholesterol and fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and ensuing oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).

Chest pain or pressure is the most common symptom of a heart attack, Myocardial infarction (MI) or heart attack victims may experience a variety of symptoms including:

• Pain, fullness, and/or squeezing sensation of the chest
• Jaw pain, toothache, headache
• Shortness of breath
• Nausea, vomiting, and/or general epigastric (upper middle abdomen) discomfort
• Sweating
• Heartburn and/or indigestion
• Arm pain (more commonly the left arm, but may be either arm)
• Upper back pain
• General malaise (vague feeling of illness)
• No symptoms (Approximately one quarter of all heart attacks are silent, without chest pain or new symptoms. Silent heart attacks are especially common among patients with diabetes mellitus.)

An MI requires immediate medical attention. Treatment attempts to salvage as much myocardium as possible and to prevent further complications, hence the phrase "time is muscle". Oxygen, aspirin, and nitroglycerin may be administered. Morphine was classically used if nitroglycerin was not effective; however, it may increase mortality in the setting of NSTEMI. A 2009 and 2010 review of high flow oxygen in myocardial infarction found increased mortality and infarct size, calling into question the recommendation about its routine use. Other analgesics such as nitrous oxide are of unknown benefit. Percutaneous coronary intervention (PCI) or fibrinolysis are recommended in those with an STEMI. (wikipedia)


Nursing Care Plan for Myocardial Infarction

12 Nursing Diagnosis for Myocardial Infarction

1. Decreased Cardiac Output
related to:
changes in the frequency of heart rhythm.

2. Impaired Tissue Perfusion
related to:
decrease in cardiac output.

3. Ineffective Airway Clearance
related to:
accumulation of secretions.

4. Ineffective Breathing Pattern
related to:
lung development is not optimal.

5. Impaired Gas Exchange
related to:
pulmonary edema.

6. Acute Pain
relate to:
increase in lactic acid.

7. Fluid Volume Excess
related to:
retention of sodium and water.

8. Imbalanced Nutrition, Less Than Body Requirements
related to:
Inadequate intake.

9. Activity Intolerance
relate to:
imbalance between myocardial oxygen supply and needs.

10. Self-Care Deficit
related to:
physical weakness.

11. Anxiety
related to:
ncaman death.

12. Knowledge Deficit
related to:
lack of information.

Knowledge Deficit Hypertension Nursing Diagnosis Interventions

Nursing Diagnosis and Interventions for Hypertension

Knowledge Deficit related to lack of information about the disease process and self-care.

Purpose:

• Increased knowledge on the client

Expected outcomes:

• Clients understand the disease process and treatment.

Nursing Intervention:

1. Assess readiness and barriers to learning, including people nearby.

2. Apply and indicate normal blood pressure limits, explain about hypertension and its effect on the heart, blood vessels, kidneys and brain.

3. Avoid saying normal blood pressure and use the term "well-controlled" when describing the patient's blood pressure patient's blood pressure within normal limits.

Rational:

1. Misconceptions and disprove the diagnosis because of the feeling of well-being has long enjoyed affect the interests of patients and / significant other to study the disease, progression, and prognosis, if the patient does not accept the reality that requires treatment continue, then the behavior changes will not be retained.

2. Provide a basis for understanding the increase in blood pressure and clarify medical terms that are often used, understanding that high blood pressure can occur without symptoms is to allow patients to continue treatment even if you feel healthy.

3. Because treatment for hypertensive patients is through life, then by delivering the idea of ​​"control" will help patients to understand the need for continuing treatment / medication.

10 Nursing Diagnosis for Rheumatic Heart Disease - RHD

Nursing Care Plan for Rheumatic Heart Disease - Nanda Nursing Diagnosis for RHD

Rheumatic heart disease is a condition in which permanent damage to heart valves is caused by rheumatic fever. The heart valve is damaged by a disease process that generally begins with a strep throat caused by bacteria called Streptococcus, and may eventually cause rheumatic fever.

The symptoms of rheumatic fever usually start about one to five weeks after your child has been infected with Streptococcus bacteria. The following are the most common symptoms of rheumatic fever. However, each child may experience symptoms differently.

Symptoms may include:

• Joint inflammation - including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days.
• Small nodules or hard, round bumps under the skin.
• A change in your child's neuromuscular movements (this is usually noted by a change in your child's handwriting and may also include jerky movements).
• Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs).
• Fever.
• Weight loss.
• Fatigue.
• Stomach pains.

The symptoms of rheumatic fever may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

Rheumatic fever is uncommon in the US, except in children who have had strep infections that were untreated or inadequately treated. Children ages 5 to 15, particularly if they experience frequent strep throat infections, are most at risk for developing rheumatic fever.

To diagnose this condition, your doctor will ask about recent strep infections, examine your child and use a stethoscope to listen to their heart. In children with rheumatic heart disease, doctors can often hear a heart murmur — the sound of blood moving in the heart in a way that’s not normal.

During the exam, your child’s doctor will look for signs of inflammation in your child’s joints.

The doctor will ask for details about your child’s symptoms, their health history and your family health history. Your doctor may order a throat culture or a blood test to check for strep.

Your child will also need tests that provide information about how their heart looks and works. These may include a chest X-rays or MRI (magnetic resonance imaging) of the heart, echocardiography and electrocardiogram.

Nursing Care Plan for Rheumatic Heart Disease




10 Nursing Diagnosis for Rheumatic Heart Disease - RHD :


1) Decreased Cardiac Output

related to: a disturbance in the closure of the mitral valve (valve stenosis).

2) Ineffective Peripheral Tissue Perfusion

related to: decreased metabolism primarily due to vasoconstriction of peripheral blood vessels.

3) Acute Pain
related to: inflammation of the synovial membrane.

4) Hyperthermia

related to: inflammation of the synovial membrane, and inflammation of the heart valves.

5) Imbalanced Nutrition, Less Than Body Requirements
related to: an increase in stomach acid caused by the sympathetic nervous system compensation.

6) Activity intolerance

related to: muscle weakness, prolonged bed rest or immobilization.

7) Self-Care Deficit

related to: Musculoskeletal Disorders: polyarthritis / arthralgia and therapy bed rest.

8) Impaired Skin Integrity

related to: inflammation of the skin and tissue subcutan.

9) Risk for Impaired Gas Exchange

related to: the accumulation of blood in the lungs due to increased atrial filling.

10) Risk for Injury

related to: involuntary movements, irregular, rapid and muscle weakness / khorea.

Priority Nursing Diagnosis for Hypertension

Hypertension is among the world's famous disease. Hypertension is a condition of increased blood pressure on blood vessels. There are a lot of things that we need to know about the disease hypertension. This is mostly the complaints of every individual visiting clinics and hospitals all over the world and is among the complications too of other forms of diseases.

Normal blood pressure with respect to cardiovascular risk is less than 120/80 mm Hg, (however, unusually low readings should be evaluated for clinical significance as well).

Normal
Systolic, (top number) lower than 120, diastolic, (bottom number) lower than 80.

Prehypertension
Systolic 120-139, diastolic 80-99.

Stage 1 hypertension
Systolic 140-159, diastolic 90-99.

Stage 2 hypertension
Systolic equal to or more than 160, diastolic equal to or more than 100

Hypertension, also called high blood pressure, is categorized into two types - essential hypertension and secondary hypertension - on the basis of the underlying causes for its occurrence.

Taking your vital signs daily very often will let you determine if you have a high pressure in the blood or a low blood pressure. Having a blood pressure chart at home will let you see the average level that is recommended for your age and your weight. Also, the chart will let you compare the previous readings and thus make you alert once you notice that it is increasing or decreasing.

Examination Support

1. History and thorough physical examination.
2. Examination of the retina.
3. Laboratory tests to determine damage to organs such as the kidneys and heart.
4. ECG to determine left ventricular hypertrophy.
5. Urinalisa to determine protein in the urine, blood, glucose.
6. Examination; renogram, intravenous pielogram renal arteriogram, renal function tests and determination of urine separately.
7. Chest x-ray and CT scan.

Treatment of Hypertension

Treatment of hypertension all begins with doing lifestyle modifications. When you have seen in your blood pressure chart that your blood pressure reading is increasing, you should perform several lifestyle changes that way you can save yourself from having hypertension.

Natural treatment requires hypertension patients to implement certain lifestyle modifications. Exercise and relaxation therapies are an inevitable part of natural treatment. The excess calories have to be burnt off through regular exercises and it helps to induce oxygenation of blood. Relaxation therapies and meditation techniques such as yoga, breathing exercises, tai chi, biofeedback, and hypnotherapy help to avoid stress and other related psychiatric problems. Avoid alkaloid rich drinks such as coffee and fatty foods. Smoking has to be essentially quitted and dependency on alcohol has to be avoided.

Priority Nursing Diagnosis for Hypertension

1. Risk for Decreased Cardiac Output

2. Activity Intolerance

3. Acute Pain

4. Imbalanced Nutrition: More than Body Requirements

5. Knowledge Deficit

Nursing Plan for Pneumonia with Diagnosis and Interventions

What is Pneumonia ?

Pneumonia is an infection of the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake. Many different germs can cause pneumonia, including bacteria, viruses, and fungi.

Causes of Pneumonia

The most common are caused by viruses, including adenoviruses, rhinovirus, influenza virus (flu), respiratory syncytial virus (RSV), and parainfluenza virus (which causes croup).

Symptoms of Pneumonia

The symptoms of pneumonia include:

• rapid or difficult breathing
• cough
• fever
• chills
• loss of appetite
• wheezing (more common in viral infections).
• nasal congestion
• breathing with grunting or wheezing sounds
• vomiting
• chest pain
• abdominal pain
• decreased activity
• nausea
• diarrhea

Diagnosis of Pneumonia

Some of these tests may include:

•     sputum tests (lab tests done on the mucus or phlegm that you cough up from your lungs)
•     blood tests
•     chest X-rays

Treatment of Pneumonia

Pneumonia can be treated with antibiotics. These are usually prescribed at a health centre or hospital, but the vast majority of cases of childhood pneumonia can be administered managed effectively within the home. Hospitalization is recommended in infants aged two months and younger, and also in very severe cases.
 

Nursing Plan for Pneumonia
3 Nursing Diagnosis and Interventions for Pneumonia

1. Ineffective airway clearance related to inflammation, secret buildup.

Goal: Effective airway, pulmonary ventilation is adequate and there is no secret buildup.

Nursing Interventions:

1. Monitor respiratory status every 2 hours, assess the increase in respiratory status and abnormal breath sounds.
2. Perform percussion, vibration and postural drainage every 4-6 hours.
3. Give oxygen therapy according to the program.
4. Help patients cough up secretions / suctioning.
5. Give a comfortable position that allows the patient to breathe.
6. Create a comfortable environment so that patients can sleep.
7. Monitor blood gas analysis to assess respiratory status.
8. Give drink enough.
9. Provide sputum for culture / sensitivity test.
10. Collaboration of antibiotics and other drugs according to the program.

2. Impaired gas exchange related to changes in alveolar capillary membrane.

Goal: Patients showed improved ventilation, optimal gas exchange and tissue oxygenation adequately.

Nursing Interventions:

1. Observation of level of consciousness, respiratory status, cyanosis signs every 2 hours.
2. Give Fowler position / semi-Fowler.
3. Give oxygen according to the program.
4. Monitor blood gas analysis.
5. Create an environment that is quiet and patient comfort.
6. Prevent the occurrence of fatigue in patients.

3. Fluid Volume Deficit related to inadequate oral intake, fever, tachypnoea.

Goal: Patient will maintain normal body fluids.

Nursing Interventions:

1. Record intake and output of fluids. Encourage the mother to continue giving fluids orally and avoid the condensed milk / drink cold or cough inducing.
2. Monitor fluid balance in the mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs.
3. Keep drip infusion accuracy according to the program.
4. Perform oral hygiene.

Nursing Care Plan for Prostate Cancer - 3 Diagnosis and Interventions

The word "prostate" comes from Medieval Latin prostate and Medieval French prostate. The ancient Greek word prostates means "one standing in front", from proistanai meaning "set before".

The prostate is an exocrine gland of the male reproductive system, and exists directly under the bladder, in front of the rectum.

Prostate cancer generally affects men over 50 and is rare in younger men. It’s the most common type of cancer in men. Around 37,000 men in the UK are diagnosed with prostate cancer each year.

Prostate cancer is a disease which only affects men. Cancer begins to grow in the prostate - a gland in the male reproductive system. In the vast majority of cases, the prostate cancer starts in the gland cells - this is called adenocarcinoma. In this article, prostate cancer refers just to adenocarcinoma. Prostate cancer is mostly a very slow progressing disease. In fact, many men die of old age, without ever knowing they had prostate cancer - it is only when an autopsy is done that doctors know it was there.

The symptoms of both benign enlargement of the prostate gland and malignant tumours (cancer) are similar and can include any of the following:

•     difficulty passing urine
•     passing urine more frequently than usual, especially at night
•     pain when passing urine
•     blood in the urine (this is not common).

Nobody is really sure of what the specific causes are. There are so many possible factors, including :

• Age
• Genetics
• Diet
• Medication
• Obesity
• Sexually transmitted diseases (STDs)
• Agent Orange

3 Nursing Diagnosis and Nursing Interventions for Prostate Cancer


1. Impaired Urinary Elimination related to an enlarged prostate, and bladder distension.

Intervention:

•     Encourage the patient to urinate every 2-4 hours and when it suddenly felt.
•     Observation of the flow of urine, note the size and strength.
•     Percussion / palpation of the suprapubic area.
•     Encourage fluid intake to 3000 ml per day.
•     Monitor vital signs closely
•     Collaboration in the provision of drugs.

2. Resti for Infection related to invasive procedures (tools during surgery)

Intervention:

• Maintain a sterile catheter system, provide catheter care and give regular antibiotic ointment around the catheter.
• Perform ambulation with dependent drainage bag.
• Observation of wound drainage around suprapubic catheter.
• Replace dressings with frequent (supra incision / retropubic and perineal), cleaning and drying of the skin over time.
• Collaboration in the provision of antibiotics.

3. Imbalanced Nutrition, Less Than Body Requirements related to the nausea and weight loss

Intervention:

•      Assess the patient's nutritional status.
•      Encourage the patient to eat small amounts frequently.
•      Collaborate with a nutritionist.
•      Collaborate with the physician in the delivery of antiemetic drugs.

Diabetes Mellitus - 6 Nanda Nursing Diagnosis

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body.

Diabetes mellitus is a chronic disease that causes serious health complications including renal (kidney) failure, heart disease, stroke, and blindness.

Risk factors for type 2 diabetes mellitus are greater for some ethnicities, as mentioned before. Furthermore, those people who have a family history of type 2 diabetes, who are overweight or inactive also face a greater risk of type 2 diabetes mellitus.

Diabetes mellitus affects a variety of people of all races, ages and nations. It is unkown why some people develop type 1 diabetes.

It may be linked to environmental factors or a virus however it has been estabilished if there is a family history of type 1 diabetes then there is a higher risk of developing type 1 diabetes.

Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin.

Symptoms of diabetes can develop suddenly (over days or weeks) in previously healthy children or adolescents, or can develop gradually (over several years) in overweight adults over the age of 40. The classic symptoms include feeling tired and sick, frequent urination, excessive thirst, excessive hunger, and weight loss.

Diabetes is suspected based on symptoms. Urine tests and blood tests can be used to confirm a diagnose of diabetes based on the amount of glucose found. Urine can also detect ketones and protein in the urine that may help diagnose diabetes and assess how well the kidneys are functioning. These tests also can be used to monitor the disease once the patient is on a standardized diet, oral medications, or insulin.

Research continues on diabetes prevention and improved detection of those at risk for developing diabetes. While the onset of Type I diabetes is unpredictable, the risk of developing Type II diabetes can be reduced by maintaining ideal weight and exercising regularly. The physical and emotional stress of surgery, illness, pregnancy, and alcoholism can increase the risks of diabetes, so maintaining a healthy lifestyle is critical to preventing the onset of Type II diabetes and preventing further complications of the disease.

There is currently no cure for diabetes. The condition, however, can be managed so that patients can live a relatively normal life. Treatment of diabetes focuses on two goals: keeping blood glucose within normal range and preventing the development of long-term complications. Careful monitoring of diet, exercise, and blood glucose levels are as important as the use of insulin or oral medications in preventing complications of diabetes. In 2003, the American Diabetes Association updated its Standards of Care for the management of diabetes. These standards help manage health care providers in the most recent recommendations for diagnosis and treatment of the disease.

Diabetes Mellitus - 6 Nanda Nursing Diagnosis

1. Fluid Volume Deficit

related to:
osmotic diuresis (hyperglycemia).

2. Imbalanced Nutrition, Less Than Body Requirements

related to
poor nutrition intake.

3. Risk for Infection

related to:
high glucose levels
reduction in leukocyte function.

4. Knowledge Deficit: about the disease process

related tyo: lack of information.

5. Risk for Impaired Skin Integrity

related to:
immobilization
neuropathy.

6. Activity Intolerance

related to:
physical weakness.

9 Sample of Pulmonary Tuberculosis (PTB) Nursing Diagnosis - Nanda

Tuberculosis (TB) is an infectious disease that is caused by a bacterium called Mycobacterium tuberculosis.

Symptoms of TB in the lungs may include

• A bad cough that lasts 3 weeks or longer
• Weight loss
• Coughing up blood or mucus
• Weakness or fatigue
• Fever and chills
• Night sweats

Tuberculosis is ultimately caused by the Mycobacterium tuberculosis that is spread from person to person through airborne particles. It is not guaranteed, though, that you will become infected with TB if you inhale the infected particles. Some people have strong enough immune systems that quickly destroy the bacteria once they enter the body. Others will develop latent TB infection and will carry the bacteria but will not be contagious and will not present symptoms. Still others will become immediately sick and will also be contagious. 

9 Sample of Pulmonary Tuberculosis (PTB) Nursing Diagnosis - Nanda

1. Impaired Gas Exchange

related to:

• the exudate in alveo
• surface of the lung function decline.

2. Ineffective Airway Clearance

related to:

• increased sputum
• reduction effort to cough.

3. Ineffective Breathing Pattern

related to

• inflammation
• fatigue.

4. Hyperthermia

related to:

• the infection process.

5. Fluid Volume Deficit

related to:

• fever
• fatigue due to lack of fluid intake.

6. Imbalanced Nutrition, Less Than Body Requirements

related to:

• decreased appetite,
• fatigue
• dyspnea.

7. Risk for [spread] of Infection

related to:

• lower resistance of others who are around people.

8. Ineffective management Therapeutic regimen

related to:

• lack of knowledge about the disease process.

9. Activity Intolerance

related to:

• fatigue,
• changes in nutritional status
• fever.

Nursing Care Plan for Goiter - Assessment and Diagnosis

Nursing Assessment and Nursing Diagnosis for Goiter

Goiter (struma), is a swelling of the thyroid gland, which can lead to a swelling of the neck or larynx (voice box). Goitre is a term that refers to an enlargement of the thyroid (thyromegaly) and can be associated with a thyroid gland that is functioning properly or not.

A person with goiter can have normal levels of thyroid hormone (euthyroidism), excessive levels (hyperthyroidism) or levels that are too low (hypothyroidism).

A symptom is something the patient feels or reports, while a sign is something other people, including the doctor detects. For example, a headache may be a symptom while a rash may be a sign.

Some patients may have goiter and not know it because they have no symptoms.

The main symptom for a person with goiter is swelling of the thyroid gland. This may eventually become a noticeable lump in the throat. The patient may be more aware of it - a visible swelling at the base of the neck - when looking in the mirror and shaving or putting on makeup.

The following symptoms may also exist when a person has goiter:

• Hoarseness (voice)
• Coughing more frequently than usual
• A feeling of tightness in the throat
• Swallowing difficulties (less common)
• Breathing difficulties (less common)

Nursing Care Plan for Goiter - Assessment and Diagnosis

In implementing the nursing care, the authors use the guidelines as a basis for solving the nursing care of patient problems scientifically and systematically, which includes the step of assessment, nursing diagnosis, nursing Interventions and evaluation.


Assessment

Assessment is the first step in the nursing process as a whole in order to get the data or information needed to determine the health problems faced by patients through interviews, observation, and physical examination include:

a. Activity / rest
Subjective data: insomnia, muscle weakness, impaired coordination, severe fatigue.
Objective data: muscle atrophy.

b. Elimination
Subjective data: urine in large amounts, changes in the faeces, diarrhea.

c. Ego integrity
Subjective data: experiencing severe stress both emotionally and physically.
Objective data: emotional instability, depression.

d. Food / fluid
Subjective data: sudden weight loss, increased appetite, eat a lot, eat often, thirst, nausea and vomiting.
Objective data: thyroid enlargement, goiter.

e. The pain / comfort
Subjective data: orbital pain, photophobia.

f. Breathing
Subjective data: increased respiratory frequency, tachypnea, dyspnea, pulmonary edema (the crisis thyrotoxicosis).

g. Security
Subjective data: intolerance to heat, excessive sweating, allergic to iodine (may be used in the examination).
Objective data: the temperature rises above 37.40 C, diaphoresis, smooth skin, warm and reddish, thin hair, shiny and straight, eksoptamus: retraction, conjunctival irritation and watery, pruritus, erythema lesion (common in pretibial) is a very severe.

h. Sexuality
Data subyktif: decreased libido, bleeding slightly or not at all, impotence.


After all the data collected, further divided into two groups:

a. subjective data
Subjective data include: coordination disorder insomnia, changes in the pattern of elimination, the ability to handle the pressure (stress), weight loss, increased appetite, orbital pain, respiratory frequency increases, the power adjustment to heat and cold, decreased libido.

b. objective data
It is characterized by muscle atrophy, emotional instability, depression, thyroid enlargement, goiter, increased temperatures above 37.40 C, diaphoresis, nature and characteristics of the body, including hair quality situation and the state of the eye.


The next step is determining the nursing diagnosis is a statement and a real or potential problem, based on the data collected.


Nursing Diagnosis for Goiter

Nursing diagnosis in patients with goitre especially post surgery can be formulated as follows:

1. Risk for Ineffective Airway Clearance related to obstruction of the trachea, swelling, bleeding and laryngeal spasm,
characterized by:
Subjective data: pain swallowing, painful wound.
Objective data: breathing fast and deep, there are secretions / mucus.

2. Impaired Verbal Communication related to vocal cord injury / damage to the larynx, tissue edema, pain, discomfort,
characterized by:
Subjective data: swelling of the throat tissues, pain in the wound, the patient does not feel comfortable, pain swallowing.

3. Risk for Injury / tetany related to the surgery, stimulation of the central nervous system,
characterized by:
Subjective data: rapid breathing (tachypnea), wound pain.
Objective data: increased body temperature, tachycardia, cyanosis, convulsions, numbness, and infection of the surgical wound.

4. Acute Pain related to the surgery of the tissue / muscle and postoperative edema,
characterized by:
Subjective data: ask, ask for information, statements misconceptions.
Objective data: do not follow the instructions / complications that can be prevented.

Ineffective Breastfeeding Nursing Diagnosis

Nursing Diagnosis for Ineffective Breastfeeding

NANDA definition of an ineffective breastfeeding diagnosis is the "dissatisfaction or difficulty a mother, infant or child experiences with the breastfeeding process." This can include physical discomfort as well as lack of knowledge or skill for the mother and poor weight gain for the infant.

Defining Characteristics

• Actual or perceived inadequate milk supply (mother)
• Arching and crying when at the breast (infant)
• Evidence of inadequate intake (infant)
• Fussiness and crying within the first hour of feeding (infant)
• Inability to latch on to nipple correctly (infant)
• Insufficient emptying of each breast
• Unsatisfactory breastfeeding process (mother and infant)

Related Factors

• Basic breastfeeding knowledge
• Normal breast structure
• Normal infant oral structure
• Infant gestational age greater than 34 weeks
• Support sources [available]
• Maternal confidence

Expected Outcomes
The mother will

• Express physical and psychological comfort in breastfeeding practice and techniques.
• Show decreased anxiety and apprehension.
• State at least one resource for breastfeeding support.

The infant will

• Feed successfully on both breasts and appear satisfied for at least 2 hr after feeding.
• Grow and thrive.

Assessment Focus (Refer to comprehensive assessment parameters.)

• Communication
• Roles and relationships
• Values and beliefs

Nursing Interventions :

1. Initiate breastfeeding within first hour after birth.
2. Keep infant with mother
3. Monitor effectiveness of current breastfeeding efforts.
4. Determine support systems available to mother/family.
5. Identify cultural beliefs/practices regarding lactation, letdown techniques, maternal food preferences.
6. Assess mother’s knowledge and previous experience with breastfeeding.
7. Encourage mother to drink at least 2000 mL of fluid per day or 6 to 8 oz every hour.
8. Provide information as needed about early infant feeding cues (e.g., rooting, lip smacking, sucking fingers/hand) versus late cue of crying.
9. Discuss/demonstrate breastfeeding aids (e.g., infant sling, nursing footstool/pillows, breast pumps).
10. Encourage mother/other family members to express feelings/concerns, and Active-listen
11. Educate father/SO about benefits of breastfeeding and how to manage common lactation challenges.
12. Review techniques for expression (breast pumping) and storage of breast milk.
13. Recommend avoidance of specific medications or substances (e.g., estrogen-containing contraceptives, bromocriptine, nicotine, alcohol).

Depression - 9 Nursing Diagnosis Care Plan

Nanda Nursing Diagnosis for Depression

Depression is a state of low mood and aversion to activity that can have a negative effect on a person's thoughts, behavior, feelings, world view and physical well-being.

Symptoms

• Sadness
• Loss of interest or pleasure in activities you used to enjoy
• Change in weight
• Difficulty sleeping or oversleeping
• Energy loss
• Feelings of worthlessness
• Thoughts of death or suicide

Depressed people may lose interest in activities that once were pleasurable; experience loss of appetite or overeating; have problems concentrating, remembering details, or making decisions; and may contemplate or attempt suicide. Insomnia, excessive sleeping, fatigue, loss of energy, or aches, pains or digestive problems that are resistant to treatment may be present. They may feel sad, anxious, empty, hopeless, worried, helpless, worthless, guilty, irritable, hurt, or restless.

Depression in women

Rates of depression in women are twice as high as they are in men. This is due in part to hormonal factors, particularly when it comes to premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), postpartum depression, and perimenopausal depression. As for signs and symptoms, women are more likely than men to experience pronounced feelings of guilt, sleep excessively, overeat, and gain weight. Women are also more likely to suffer from seasonal affective disorder.

Depression in men

Depression is a loaded word in our culture. Many associate it, however wrongly, with a sign of weakness and excessive emotion. This is especially true with men. Depressed men are less likely than women to acknowledge feelings of self-loathing and hopelessness. Instead, they tend to complain about fatigue, irritability, sleep problems, and loss of interest in work and hobbies. Other signs and symptoms of depression in men include anger, aggression, violence, reckless behavior, and substance abuse. Even though depression rates for women are twice as high as those in men, men are a higher suicide risk, especially older men.


9 Nanda Nursing Diagnosis for Depression

1. Risk for self-directed violence / Risk for Suicide

2. Ineffective coping

3. Hopelessness

4. Social isolation

5. Imbalanced Nutrition, Less Than Body Requirements

6. Self-care deficit

7. Low self-esteem

8. Ineffective sexuality patterns

9. Spiritual distress