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Showing posts from November, 2014

Nursing Interventions for Impaired Gas Exchange related to Bronchopneumonia

Nursing Diagnosis : Impaired Gas Exchange related to Pneumonia factors. Intervention and implementation : 1. Monitor respiratory status every 8 hours, vital signs every 4 hours and the results of blood gas analysis , x-rays and pulmonary function tests. Rationale: To identify the progress or deviations from expected results. 2. Give an expectorant in accordance with the recommendation, review of all drugs given and avoid the side effects of drug interactions between each other and schedule delivery of drugs to each other as well as to schedule the delivery of drugs. Rational : expectorant helps thin the secretions so that secretions can exit when coughing. 3. Encourage parents to give breast milk. Rationale: To help remove secretions can also help drain the drugs in the body. 4. Provide supplemental oxygen as recommended, if using an oxygen mask to grow agitated patients consult respiratory therapists. Rationale: The provision of supplemental oxygen can reduce the wor...

Bronchopneumonia - Data Analysis and Nursing Diagnosis

Bronchopneumonia , also known as lobular pneumonia, is a type of pneumonia characterized by inflammation and infection of the bronchioles (small airways) and surrounding lung tissue. It is typically caused by bacteria, viruses, fungi, or other microorganisms that infect the lower respiratory tract and spread to the smaller airways and alveoli (air sacs) of the lungs. Bronchopneumonia often affects multiple areas or lobes of the lungs and can lead to symptoms ranging from mild to severe.   Causes: Bacterial Infections: Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and Klebsiella pneumoniae are common bacterial pathogens associated with bronchopneumonia. Viral Infections: Influenza viruses, respiratory syncytial virus (RSV), adenovirus, and parainfluenza virus can cause viral bronchopneumonia. Fungal Infections: Fungal pathogens such as Candida species, Aspergillus species, and Pneumocystis jirovecii can cause fungal bronchopneumonia, particularly in immuno...

Ocular Pressure Measurement (IOP)

Tonometry is a technique for measuring the intra-ocular pressure (IOP). Tonometry Schiozt wear hand-held metal instrument (tonometer) is placed on the surface of the anesthetized cornea. The results vary, but good enough to estimate the IOP. Other pressure measuring devices, applanation tonometry of Goldman, associated with the slit lamp to measure IOP. Considered a form of IOP measurement tool most accurate. Provision of fluorescent dyes and topical anesthesia is required before applanation tonometry. IOP can also be measured by pneumotonometer, which gives a small air spray into the eye to measure the pressure. This method is especially useful when unwanted contact with the cornea. Assessing IOP is a regular component in a comprehensive eye examination and pressure should be measured frequently in patients with glaucoma or are at risk of intra-ocular hypertension. Determination general IOP can be done by providing a light finger pressure on the sclera eyes closed. The two middl...

Nursing Care Plan for Eye Disorders

Nursing Interventions for Eye Disorders The main target patients include pain relief, control anxiety, visual deterioration prevention, understanding and acceptance of handling, fulfillment of self-care activities, including drug treatment, prevention of social isolation and without complications. Nursing Interventions for Eye Disorders 1. Relieves pain. Pain can be caused by trauma, such as corneal scratches or increased pressure in the eye. Wrap the eye can help limit the movement of the eyes and reduce the pain they cause. The eyes are not closed also should be rested for the eyes to move in sync. Because light can cause pain in a variety of eye conditions, and because the eyes rested can facilitate healing after eye surgery, it is necessary to use lighting that is darker than necessary. If the patient requires light to do an activity, it can be used artificial lights dim. Patients were given instructions to avoid reading for some time after surgery or eye disease. Anal...

Information Displayed on Each Nursing Diagnosis

Information displayed on each nursing diagnosis include the following: Definition. Referring to the definition used in the NANDA nursing diagnoses predetermined. Etiology possibility ("related to"). This section states the possible causes for the problems that have been identified. Which is not expressed by NANDA, given the brackets [...]. Related factors / risk is given to high-risk diagnoses. Defining characteristics ("evidenced by"). This section covers the signs and symptoms are clear enough to indicate the existence of a problem. Again as in the definition and etiology. Which is not expressed by NANDA, bracketed. Goals / Objectives. These statements are written in accordance with the client's objective behavior. Goals / objectives must be measurable, is the long and short term goals, to be used in evaluating the effectiveness of nursing interventions to address the problems that have been identified. Maybe there will be more than a short-term goals, an...

3 Types of NANDA Nursing Diagnosis and 5 Nursing Process

NANDA Nursing Diagnosis and Nursing Process A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems / life processes. Nursing diagnoses provide the basic for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 1992 p.5) So the nursing diagnosis is a clinical decision about the response of individuals, families and communities about the actual or potential health problems, which is based on education and experience, nurses can identify and provide accountability for certain interventions to maintain, decrease, limit, preventive and change the client's health status (Carpenito, 2000; Gordon, 1976 & NANDA). Nursing diagnosis is an integral part of the nursing process. This is a component of the analysis steps, where nurses identify individual responses to the problems of the actual and potential health. Some countries diagnose identified in nursing practi...

Nursing Assessment for Attention Deficit Hyperactivity Disorder

According Videbeck (2008) Assessment for children who have Attention Deficit Hyperactivity Disorder (ADHD), among others: 1. Assessment of disease history. Parents may report that the child is fussy and having problems during infancy or hyperactive behavior disappear unnoticed until the child is old toddler or go to school or daycare. Children may have difficulty in all major areas of life, such as school or play and showed overactivity or even dangerous behavior at home. Being out of control and they find it impossible to face the child's behavior. Parents may report their efforts to discipline a child or change the behavior of children and all of it was largely unsuccessful. 2. The general appearance and behavior of the motor. Children can not sit quietly in a chair and wriggled and jiggled when trying to do so. Children may run around the room from one object to another with little purpose or without a clear purpose. Disturbed child's ability to speak, but can ...

Nursing Assessment - Data Collection Techniques - Interview

Data Collection Techniques - Interview (Nursing Assessment) So that data can be collected with a good and purposeful, the data classification should be done, based on the identity of the client, the main complaints, medical history, physical, psychological, social, spiritual, intelligence, test results and other special circumstances. Method used to collect data on clients include: interviews, observation, physical examination (pshysical assessment) and study documentation. Interview The interview is to ask or make a question and answer related to the problems faced by the client, also called anamnesis. The interview lasted for queries relating to issues facing clients and a planned communication. The purpose of the interviews was to obtain data on health issues and problems nursing clients, as well as to establish the relationship between nurses and clients. In addition, the interview also aims to help clients obtain information and participate in the identification of prob...

Nursing Assessment - Stages of Interview / Communication

Stages of Interview / Communication There are four stages in the interview / communication, as follows : 1. Preparation. Prior to communicate with the client, the nurse must make arrangements with the client to read status. Nurses are expected to have no prejudice to the client, because it would interfere with the relationship of trust with clients. If the client is not willing to communicate, nurses should not be forced or give an opportunity to the client, when the client is able. Rearranging the seating and techniques that will be used in the interviews should be structured in such a way as to facilitate the interview. 2. Opening or Introduction. The first step taken by a nurse, in initiating the interview is to introduce ourselves nurse : name, status, purpose of the interview, the time required and the factors that becomes a moot point. Nurses need to provide information to clients on the data collected and will be stored where, how to store it, and anyone who may kno...

Nursing Management of Osteomyelitis

Nursing Management of Osteomyelitis The affected area should be immobilized to reduce discomfort and prevent fractures. Can do warm saline baths for 20 minutes several times a day to increase the flow area. Initial target of therapy is to control and stop the process of infection, blood and swab cultures and abscess cultures performed to identify the organism and choose the best antibiotic. Sometimes, infections caused by more than one pathogen. Once the culture specimens were obtained, starting intravenous antibiotic therapy, assuming that the staphylococcus infection-sensitive semi-synthetic penicillin or cephalosporins. The goal is to control the infection before the blood flow to the area declined due to the occurrence of thrombosis. Continuous dosing of antibiotics appropriate time is crucial to achieve the levels of antibiotics in the blood are constantly high. Antibiotics are the most sensitive to the causative organism is given when known for culture and sensitivity. If ...

Pathophysiology of Osteomyelitis

Pathophysiology of Osteomyelitis Staphylococcus aureus is the cause of 70% to 80% of bone infection. Other pathogenic organisms often found in osteomyelitis include Proteus, Pseudomonas and Ecerichia coli . There is an increased incidence of penicillin-resistant infections, nosocomial gram-negative and anaerobic. The onset of osteomyelitis after orthopedic surgery can occur within the first 3 months (acute fulminant stage I) and is often associated with the accumulation of superficial hematoma or infection. Late-onset infections (stage 2) occurs between 4 and 24 months after surgery. Osteomyelitis onset time (stage 3) is usually due to hematogenous spread and occurred 2 years or more after surgery. Initial response to infection is one of the inflammation, increased vascularity and edema. After 2 or 3 days, in the vein thrombosis occurred in the area, resulting in ischemia with bone necrosis due to the increase and can spread to soft tissue or joints around it, unless the infecti...

NCP for Elderly with Disturbed Sensory Perception (Visual)

Nursing Care Plan Impaired visual acuity caused by : Presbiop. Abnormalities of the eye lens (eye lens reflections less). Cloudiness in the lens (cataract). Elevated pressure in the eye (glaucoma). Inflammation of the optic nerve. Vision Changes in Elderly Morphological changes : Decrease in fat tissue around the eyes. Decreased tissue elasticity and tone. The decline in the strength of the eye muscles. Decreased sharpness of the cornea. Degeneration in the sclera, pupil and iris. Increased frequency of occurrence of the disease process. Increased density and rigidity of the lens. Slowing the process information from the central nervous system. Physiological changes : Decreased vision at close range. Decreased eye movement coordination. Distortion shadow. View of blue and red. Compromised night vision. Decreased sharpness recognize green, blue and purple. Difficulty recognizing moving objects. Assessment Pupil size decreases. The use of glasses. ...