Nursing Interventions Fluid Volume Deficit - NCP Diabetic Ulcer

Nursing Diagnosis for Diabetic Ulcer : Fluid Volume Deficit related to osmotic diuresis

Characterized by: decreased skin turgor and dry mucous membranes.

Goal: fluids or hydration needs are met.

With the expected outcomes:
Patients showed adequate hydration evidenced by stable vital signs, peripheral pulses can be palpated, skin turgor and capillary refill is good, proper urine output of individual and electrolyte levels within normal limits.
Nursing Interventions Fluid Volume Deficit - Nursing Care Plan for Diabetic Ulcer:

Independent:

1. Assess the client's history with respect to the duration or intensity of symptoms such as vomiting and excessive spending urine.
Rational:
Help estimate the total volume deficits. The process of infection resulting in fever and hypermetabolic conditions that increase water loss.

2. Monitor vital signs, note any changes in orthostatic blood pressure.
Rational:
Hypovolemia manifested by hypotension and tachycardia. Estimate the severity of hypovolemia as systolic blood pressure ≥ 10 mmHg fall from a lying position to a sitting or standing.

3. Monitor your breathing pattern as the Kussmaul breathing or breathing that smell ketones.
Rational:
Need to remove the carbonic acid produced by respiratory alkalosis respiratoris compensation to the state of ketoacidosis. Acetone breath odor caused asetoasetat acid solution and should be dropped when ketosis corrected.

4. Monitor the frequency and quality of breathing, use of accessory muscles breathing, periods of apnea and cyanosis.
Rational:
Hyperglycemia and acidosis causes normal breathing pattern and frequency. However, increased work of breathing, and rapid shallow breathing and cyanosis is indicative of respiratory fatigue or loss of capacity through compensation in acidosis. '

5. Monitor temperature, skin color, or moisture.
Rational:
Fever, chills, and diaphoresis are common in the infection process, fever with rash, dry is a sign of dehydration.

6. Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rational:
An indicator of the level of dehydration or adequate circulating volume.

7. Monitor input and output.
Rational:
Estimating the need for fluid replacement, renal function, and the effectiveness of a given therapy.

8. Measure weight every day.
Rational:
Provides the best assessment of the fluid status of ongoing and further in giving replacement fluids.

9. Maintain a minimum of 2500 ml of fluid / day.
Rational:
Maintaining hydration or circulating volume.

10. Improve the environment that cause a sense of comfort. Cover the client with a thin cloth.
Rational:
Avoid excessive heating of the client can further lead to loss of fluid.

11. Assess mental or sensory changes.
Rational:
Mental changes associated with hyperglycemia or hypoglycemia, electrolyte abnormalities, acidosis, decreased cerebral perfusion, and hypoxia. Cause untreated, the disorder predisposing to aspiration awareness on the client.

12. Observation nausea, abdominal pain, vomiting, and stomach distention.
Rational:
Lack of fluids and electrolytes alter gastrointestinal motility sehinnga often cause vomiting and potentially lead to lack of fluids and electrolytes.

13. Observation of an increased sense of fatigue, edema, weight gain, irregular pulse, and vascular distension.
Rational:
Fluid for rapid improvement potential fluid overload and chronic heart failure.

Collaboration

14. Give fluid therapy as indicated:
Rasiona:
The type and amount of liquids depends on the degree of lack of fluids and individual client response.

15. Normal saline or half normal saline with or without dextrose.
Rational:
Plasma expanders (replacement) is required if a life-threatening blood pressure was not able to return to normal with rehydration efforts that have been made.

16. Insert the catheter urine.
Rationale: Provides precise measurements of the expenditure urine, especially if autonomic neuropathy causing retention or incontinence.

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.

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.

Nursing Intervention for Preoperative Colorectal Cancer

Planning and Implementation

Objective

The main objective may include elimination of body waste products are adequate; reduction / elimination of pain; increased activity tolerance; obtain optimal levels of nutrients; maintain fluid and electrolyte balance; decreased anxiety; understand about the diagnosis, surgical procedures and self-care after discharge; maintain optimal tissue healing ; periostomal adequate skin protection; excavation and disclosure of feelings and problems of colostomy and its influence on the self.

1. Maintaining elimination
The frequency and consistency of bowel movements monitored.
Laxatives and enemas prescription.
Patients who show signs of progression toward total obstruction prepared for surgery.

2. Eliminate Pain
Analgesic prescription.
Environment is conducive to relaxation by dimming the lights, turning off the TV or radio, and limiting visitors and phone if desired by the patient.
Offer additional comfort measures: change of position, rubbing his back, and relaxation techniques.

3. Increasing Tolerance Activities
Assess the patient's level of tolerance activity.
Change and schedule activities to allow for an adequate period of bed rest in an attempt to reduce fatigue patients.
Komponendarah Therapy prescription when a patient suffering from severe anemia.
Improved postoperative activity and tolerance monitored.

4. Providing nutritional measures
If the patient's condition permits, a diet high in calories, protein, carbohydrates, and low preoperative residual given for several days to provide adequate nutrition and minimize peristaltic cramps by reducing excess.
Liquid Diet full 24 hours preoperatively, to replace nutrient depletion, vitamins and minerals.
Daily weighing is recorded, and the doctor notified when there is weight loss when receiving parenteral nutrition.

5. Maintaining Fluid and Electrolyte Balance
Record input and output, including vomiting, which will provide accurate data on fluid balance.
Limit entries oral food and fluids to prevent vomiting.
Give antiemetics as indicated.
Insert a nasogastric tube in the pre surgery to drain fluid and prevent the accumulation of abdominal distension.
Insert indwelling catheter to monitor urine output of every hour. Output of less than 30 ml / h was reported that intravenous fluid therapy can be adjusted.
Monitor and elktrolit IV fluids, especially serum to detect hypokalemia and hyponatremia, which occurs due to loss of gastrointestinal fluids.
Assess TTV to detect hypovolemia: tachycardia, hypotension and decreased number of beats.
Assess hydration status, decreased skin turgor, dry mucous membranes, concentrated urine, and urine specific gravity increased reported.

6. Lowers Anxiety
Assess the patient's level of anxiety and coping mechanisms used.
Efforts to provide support, including the provision of privacy when desired and instruct patients to practice relaxation.
Take time to listen to the phrase, sadness or questions raised by patients.
Set up a meeting with the pastor when the patient wants, the physician when the patient expects discussion of treatment or prognosis.
Another Stoma Patients may be asked to visit when the patient expressed an interest to talk to them.
To improve the comfort of patients, nurses must prioritize relaxation and behavioral empathy.

7. Prevent Infection
Give antibiotics such as kanamycin sulfate (Kantrex), erythromycin (erythromycin), and Neomycin Sulfate as prescribed, to reduce intestinal bacteria in preparation for bowel surgery.
Preparations given by mouth to reduce the bacterial content of the colon and soften and reduce the bulk of the contents of the colon.
Selian, the intestine can also be cleaned with enemas, or colonic irrigation.

8. Pre Operative
Assess the patient's level of need on diagnosis, prognosis, surgical procedures, and the desired level of function after surgery.
The required information about the patient's physical preparation for surgery, the appearance and maintenance of the expected post-op wound, colostomy care techniques, dietary restriction, pain control, and management of drug incorporated into the education material.