Risk for Injury - Alzheimer's Disease Nursing Care Plan

Alzheimer's disease is a brain disease that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. People may have trouble remembering things that happened recently or names of people they know. Memory problems are one of the first signs of Alzheimer's. Over time, symptoms will most often get worse, and problems can include getting lost, repeating questions, and taking longer than normal to finish daily tasks. As the disease progresses, people may have trouble learning new things, recognizing family and friends, and communicating. Eventually, they need total care.

Alzheimer's disease is named after Dr. Alois Alzheimer, a German doctor. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness. He found many abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary tangles). Today, these plaques and tangles in the brain are considered the main signs of Alzheimer's disease.

People with Alzheimer's disease are at a serious disadvantage. Their impairments in memory and reasoning severely limit their ability to act appropriately in crises.
Specific home safety precautions may apply and environmental changes may be needed.

Prevention begins with a safety check of every room in your home. Use the following room-by-room checklist to alert you to potential hazards and to record any changes you need to make. You can buy products or gadgets necessary for home safety at stores carrying hardware, electronics, medical supplies, and children's items.

Nursing Care Plan for Alzheimer's Disease - Risk for Injury

Nursing Diagnosis : Risk for Injury
related to:

•     Unable to recognize / identify hazards in the environment.
•     Disorientation, confusion, impaired decision making.
•     Weakness, the muscles are not coordinated, the presence of seizure activity.

Nursing Interventions and Rational :

Nursing Intervention

1. Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in visual perception.
2. Help the people closest to identify the risk of hazards that may arise.
3. Eliminate / minimize sources of hazards in the environment
4. Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.

Rational:

1. Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.
2. An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.
3. Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.

10 NANDA COPD Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a general term which includes the conditions chronic bronchitis and emphysema. COPD is the preferred term, but you may still hear it called chronic obstructive airways disease (COAD).

•     Chronic means persistent.
•     Bronchitis is inflammation of the bronchi (the airways of the lungs).
•     Emphysema is damage to the smaller airways and air sacs (alveoli) of the lungs.
•     Pulmonary means 'affecting the lungs'.

The term COPD is used to describe airflow obstruction due to chronic bronchitis, emphysema, or both.

The sudden risk caused by COPD is due to the increase in people who smoke and the demographic changes in many countries. In the US, COPD is considered as the fourth leading cause of death. In economic terms the cost of the disease to the US economy in 2007 is pegged at $42.6 billion in terms of health care costs and loss in productivity.

The symptoms of COPD include: constant cough; excess sputum (mucus) production; shortness of breath while doing activities you used to be able to do; wheezing, or whistling sound when you breathe; and tightness in the chest.

The most common symptoms of COPD are breathlessness, or a 'need for air', excessive sputum production, and a chronic cough. However, COPD is not just simply a "smoker's cough", but a under-diagnosed, life threatening lung disease that may progressively lead to death.

The loss of lung function in COPD patients is so gradual that many patients do not realize that they have the condition until it is severe. By the time most patients seek medical attention, they may have lost 50% of their pulmonary function.

There is a need for greater awareness of COPD and early diagnosis and treatment can retard progression of disease and improve quality of life. A person who has COPD should adopt a number of strategies in order to manage and to combat this lung disease. Some of these important strategies include saying no to smoking, vaccinations, rehabilitation and drug therapy. Drug therapies can be done thru the use of inhalers.

The inhalers that are suggested help dilate the airways and the theophylline. Most of the time, the inhaled steroids can be used to contain lung inflammation and can suppress flare-ups. Usually antibiotics are also used during the flare-ups of the symptoms of COPD.

10 NANDA - Nursing Diagnosis for COPD Chronic Obstructive Pulmonary Disease 

1. Ineffective airway clearance 
2. Ineffective breathing pattern 
3. Impaired gas exchange 
4. Activity intolerance
5. Imbalanced Nutrition: less than body requirements
6. Disturbed sleep pattern
7. Bathing / Hygiene Self-care deficit 
8. Anxiety 
9. Ineffective individual coping 
10. Deficient Knowledge

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.

CVA - Stroke Definition and Nursing Diagnosis

A cerebral vascular accident is another name for a stroke. It is damage to the brain caused by a disruption of the blood supply to a part of the brain. This disruption of blood supply can be caused by a blood clot, or by a ruptured artery.

The symptoms of a cerebral vascular accident depend on which part of the brain is affected. Common symptoms may include paralysis of a part of the body, loss of all or part of the vision, or loss of the ability to speak or to understand speech.

A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. Risk factors for stroke include old age, high blood pressure, previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, tobacco smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke. It is the second leading cause of death worldwide.

Stroke symptoms typically start suddenly, over seconds to minutes, and in most cases do not progress further. The symptoms depend on the area of the brain affected. The more extensive the area of brain affected, the more functions that are likely to be lost. Some forms of stroke can cause additional symptoms. For example, in intracranial hemorrhage, the affected area may compress other structures. Most forms of stroke are not associated with headache, apart from subarachnoid hemorrhage and cerebral venous thrombosis and occasionally intracerebral hemorrhage.

Stroke is diagnosed through several techniques: a neurological examination (such as the Nihss), CT scans (most often without contrast enhancements) or MRI scans, Doppler ultrasound, and arteriography. The diagnosis of stroke itself is clinical, with assistance from the imaging techniques. Imaging techniques also assist in determining the subtypes and cause of stroke. There is yet no commonly used blood test for the stroke diagnosis itself, though blood tests may be of help in finding out the likely cause of stroke.

Nursing Diagnosis for CVA - Stroke:

1. Ineffective Cerebral Tissue Perfusion

2. Impaired Physical Mobility.

3. Imbalanced Nutrition, Less Than Body Requirements.

4. Impaired Skin Integrity.

5. Impaired Verbal Communication

6. Disturbed Sensory Perception

7. Self-Care Deficit

8. Knowledge Deficit