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Acute Pain and Risk for Impaired Skin Integrity related to Hemorrhoids

Nursing Diagnosis and Interventions for Hemorrhoids Acute Pain related to hemorrhoids or after surgical treatment and tissue injury. Goal: Patients will experience reduced pain. Intervention and Rationale: 1. Give the pain medication regularly after surgery 24-48 hours. Rationale: It reduces pain stimulation. 2. Instruct the patient to avoid stretching during bowel movements. Rationale: This prevents pressure on the perineal area or rectal tissue injury. The pressure will cause pain and may slow healing. 3. Instruct the patient to use an ointment, suppository, or other form. Rationale: Helps shrink swollen mucous membranes. 4. Instruct the patient about the prognosis: the perfect healing may take several weeks. The pain will disappear after a time. Rationale: Knowledge of the expected results will reduce fear and provide a reference for the progress towards the perfect cure. Risk for impaired skin integrity (bleeding) related to irritation by defecation (inte...

Kinds or Types of Anxiety Disorders

Phobias, Panic Disorder, Generalized Anxiety Disorders, Obsessive-Compulsive Disorder and Post-Traumatic Stress Disorder (PTSD) Anxiety produces both physical and psychological responses. People who suffer from anxiety disorders can be hard to relax and also difficult to feel comfortable in a variety of situations. Which includes anxiety disorders are as follows: Anxiety Disorders: Phobias Phobias Rejection by the fear of objects or situations encountered. Although actually harmless and phobia sufferers themselves acknowledge that fear is felt that there is no basis. Simple phobias Source of fear in the form of animals, heights, enclosed places, blood. Suffering from a simple phobia mostly women and starting from children. Agoraphobia Comes from the Greek. Agora means a place of assembly, or market. So agoraphobia is the fear that is centered on public places like shopping fear, fear of crowds, fear of traveling and a lot to ask for help. Many women who suffer ...

Clinical Symptoms of Hallucinations in Accordance with The Stages

Patients with hallucinations tend to withdraw, often found sitting with eyes fixated on one particular direction, smile or speak for themselves, suddenly angry or attacking others, anxiety, motion like he was enjoying something. Also a description of the patient's own hallucinations she experienced (what is seen, heard or felt). The following is based on clinical symptoms of hallucinations (Budi Anna Keliat, 1999): Stages of Hallucinations There are four stages of hallucinations, namely (Stuart and Laraia, 2001): 1. Comforting Clients experiencing deep feelings as moderate anxiety, loneliness, guilt and fear and try to focus on pleasant thoughts to relieve anxiety. Here clients smile or a laugh that does not fit, move the tongue without sound, rapid eye movement, silent and absorbed. 2. Condemning At severe anxiety, sensory experience disgusting and frightening. Clients started regardless of control and may try to distance himself with the source of the perceive...

Self-care Deficit related to Decreased Ability and Self-care Motivation

Nursing Diagnosis : Self-care deficit: personal hygiene and clothing / makeup r / t decreased ability and self-care motivation. General goals : The client can increase the interest or motivation and maintaining personal hygiene. Specific goals : 1. The client can build a trusting relationship. Outcomes : The client can express feelings and the current state: Friendly facial expression. Show pleasure. There is eye contact. Want to shake hands. Want to mention names. Want to answer greeting. Clients want to sit side by side with nurses. Want to express the problems encountered. Interventions : Create a trusting relationship by using therapeutic communication principles: Greetings to the client with a friendly verbal and non-verbal. Introduce yourself politely. Ask the client's full name and nickname that the client prefer. Explain the purpose of the interaction. Honest and keep promises. Show empathy. Pay attention to the basic needs of the client. ...

Cataract : Causes, Symptoms and Treatment in Elderly Through Operation Process

A cataract is a cloudy part in the normally clear lens of the eye and obscures vision. This is a very common disease. Eye lens is a transparent section in the back of the pupil (the black spot in the center of the eye) that serves to focus light on the retina. In the presence of a cataract, light entering the eye becomes blocked. Cataracts usually occur when a person enters old age. Eventually a cataract condition will be increased so as to obstruct vision. Many sufferers are eventually require surgery to replace the damaged lens with an artificial lens. Causes Cataracts in Elderly The cause of cataract is not known with certainty. Along with age, the proteins that make up the eye lens ever changing. This makes the lens of the eye that had been clear, changed into murky. Until now, not yet known how the aging process can lead to changes in proteins in the eye lens. Some other factors that will heighten your risk of developing cataracts: Eye exposure to sunlight for a lo...

Therapy Modalities in Psychiatric Nursing

Therapy Modalities in Psychiatric Nursing Mental disorder is a disease with multi-causal, a disease with many causes that vary widely. Causes of mental disorders has been identified include the movement in the area of organo-biological, psycho-educational areas, and socio-cultural areas. In the concept of stress-adaptation cause maladaptive behavior as the stage began the predisposing factors, precipitation factor in the form of a stressor originator, capability assessment of stressors, coping resources of the individual, and how the coping mechanisms chosen by an individual. From here and then determine whether an individual's behavior is adaptive or maladaptive. Many experts in mental health have a different perception of what is a mental disorder and how behavioral disorders occur. The divergent views embodied in the form of conceptual model of mental health. View psychoanalysis models in contrast with the view of social models, behavioral models, existential models, medica...

Definition of Amnesia and Types of Amnesia

Definition of Amnesia and Types of Amnesia Definition of Amnesia Amnesia is a sense memory loss diseases, which could take place in a short time and continues extension, especially it concerns the ideas should be expressed with words. Amnesia can also take place definitively (to be sure, not temporary), permanent and lost for ever. Amnesia can partially lost from memory, but can also be total and can not be recalled. Sometimes amnesia could take place periodically or regularly. In the event of a concussion (commotio cerebri) and injury to the brain, amnesia is often the case. Types of Amnesia 1. Retrograde Amnesia (Backward) Retrograde amnesia is loss of memory of the event and all the things of which precede an accident. All impression of the past before the accident, so missing. This usually lasts a short / brief. 2. Anterograde Amnesia Anterograde amnesia is loss of memory of events immediately after the accident occurred, which occurs after the shock, concussion or ...

Transcultural Nursing Process : Assessment, Nursing Diagnoses, Planning and Evaluation

The conceptual model developed by Leininger in explaining nursing care in a cultural context described in terms of sunrise (Sunrise Model) Assessment Assessment is designed based on 7 components in the "Sunrise Model" namely: Religious and philosophical factors. Kinship and social factors. Cultural values and life ways. Political and legal factors. Economical factors. Educational factors. Technological factors. Nursing Diagnoses There are three nursing diagnosis is often enforced in transcultural nursing care, namely: Impaired verbal communication related to cultural differences, Impaired social interaction related to socio-cultural disorientation, and Ineffective management of therapeutic regimen related to the value system believed. Nursing Planning Cultural care preservation / maintenance Identification of the difference between the client and the nurse concept of childbirth and infant care. Be calm and do not rush when interacting with clie...

Pediatric Care Plan - Nursing Diagnosis and Interventions for Coarctation of the Aorta (CoA)

Nursing Diagnosis and Interventions for Coarctation of the Aorta (CoA) 1. Decreased cardiac output r / t cardiac malformations. Goal : Maintain adequate cardiac output Interventions : Observation of the quality and strength of the heartbeat, peripheral pulse, skin color and warmth. Assess the degree of cyanosis (circumoral, mucous membranes, clubbing). Monitor signs of CHF (anxiety, tachycardia, tachypnea, tightness, fatigue, periorbital edema, oliguria, and hepatomegaly). Collaboration therapy in accordance with the order, using the toxicity hazard prevention techniques. Give treatment to reduce afterload. Give diuretic as indicated. 2. Impaired gas exchange r / t pulmonary congestion. Goal : Reduce the increased pulmonary vascular resistance Interventions : Monitor the quality and rhythm of breathing. Adjust the position of children with Fowler position. Avoid the child of an infected person. Provide adequate rest. Provide optimal nutrition. Give oxygen if...

NCP for Rhinitis - 4 Nursing Diagnosis and Interventions

Nursing Care Plan for for Rhinitis Rhinitis is an inflammation of the mucous membranes of the nose. (Dorland, 2002) Rhinitis is the term for inflammation of the mucosa. By their nature can be divided into two: Acute rhinitis (coryza, commond cold) is an inflammation of the mucous membrane of the nose and sinuses accessories caused by a virus and bacteria. This disease may affect almost every person at a time and often occurs in the winter with the highest incidence in the early rainy season and spring. Chronic rhinitis is a chronic inflammation of the mucous membranes caused by recurrent infections, due to allergies, or as vasomotor rhinitis. 1. Ineffective Airway Clearance related to obstruction / presence of thickened secretions. Purpose: The airway effective after the secret was issued. Expected outcomes: Clients no longer breathe through the mouth. Airway back to normal, especially the nose. Intervention Assess the existing accumulation of secretions. Obser...

Causes, Types and Some Tips To Prevent Osteoporosis

Osteoporosis is a disease characterized by decreased bone density, in which the bones become porous, so that people with osteoporosis are very fragile and susceptible to trauma, and also prone to fracture. The disease is common and usually affects the elderly, especially after menopause, and are dominated by women, or about 75%. Osteoporosis increases the risk of bone fractures, especially of the hip, wrist and spine. This happens due to the lack of new bone formation or resorption increase (re-absorption) long bones. Some of the causes of Osteoporosis: Hormone deficiency in the body (in women; estrogen deficiency, and in men; androgen deficiency). Calcium and vitamin D deficiency (lack of calcium and vitamin D in the body, can lead to osteoporosis and vitamin D can help the absorption of calcium in the bones). Some other causes such as bone cancer that can cause a reduction in bone density, lack of physical exercise or sports, heredity, duration of use of steroid drugs or be...

Know Knee Joint Pain due to Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that primarily affects the joints, causing inflammation, pain, swelling, stiffness, and eventual joint damage. It can also affect other organs and systems in the body. Here's a comprehensive overview of rheumatoid arthritis:   Causes and Risk Factors: Autoimmune Disorder: RA occurs when the immune system mistakenly attacks healthy tissues, particularly the synovium (the lining of the joints), leading to inflammation and joint damage. Genetics: Family history of RA increases the risk of developing the condition. Environmental Factors: Certain environmental factors, such as smoking, infections, and hormonal changes, may contribute to the development of RA. Gender: Women are more likely to develop RA than men. Age: Although RA can develop at any age, it most commonly begins between the ages of 30 and 60. Symptoms: Joint Symptoms: Pain, swelling, stiffness, and warmth in the affected joints, typically affecting multiple joints...

Nursing Care Plan for Risk for Violence related to Schizophrenia

Nursing Diagnosis : Risk for Violence: Self-Directed or Other-Directed related to: Less confidence: suspicion of others. Freaking Out. Stimulation catatonic. Angry reactions. Instruction from hallucinations. Delusional mind. Walking back and forth. Stiff jaw; clenched hands, rigid posture. Aggressive action: direct damage destination objects that are in the surrounding environment. Self-destructive behavior or active; aggressive suicide. Threatening words were hostile; action brag, to torment others psychologically. Increased motor activity, footsteps, arousal, irritability, restlessness. Environment perceives as a threat. Receive a "command" through hearing or vision as a threat. Planning: Goal / Purpose: General Purpose: The patient will not injure themselves, other people and the environment. Specific purpose: In 2 weeks the patient can recognize signs of increased anxiety and report to the nurse to be given intervention as needed. Expected o...

Home Care Management for Agitation (Anxiety and Restlessness)

Agitation (restlessness or anxiety) is a form of interference that show excessive motor activity and not intended or fatigue, usually associated with a state of tension and anxiety. In some literature says that the agitation is psychomotor disorders that are characterized by an increase in motor activity and psychology in patients (their irritability). Movement goes back and forth in the room for no reason, the movement of wringing hands, took off the shirt and wear it again in the reverse condition, and unwarranted actions and other motor. In severe circumstances, the movement generated could endanger others, such as tearing, biting fingernails and biting own lips that give rise to the potential for bleeding due to trauma. Psychomotor agitation is a typical symptom that can be found in major depressive disorder or abnormal obsession and sometimes found in bipolar disorder, although this disorder is the result of excess stimulus received. Middle age (decade to 2 and 3) and old age ...

8 Nursing Diagnosis related to Elimination

Here's 8 nursing diagnosis related to elimination: 1. Bowel incontinence or incontinence alvi / stool. Changes in bowel habit pattern. Can be caused by chronic diarrhea, diet, immobilization, stress, medication, lack of hygiene at the time toileting, etc. Differentiate with diagnosis of "Diarrhea". In this diagnosis, normal faeces, only patterns are changing. For example, once daily routine, because of factors relating, in two or three days. 2. Diarrhea. The main data is not shaped stool until the liquid. The main indicator is defecation (liquid) at least three times in one day. The results of abdominal auscultation, abdominal cramping and abdominal pain are signs of other symptoms. Factors related divided into three groups; physiological, psychological and situational. For example, because of anxiety, high stress levels, the process of inflammation, irritation, malabsorption, poisoning, long trips, alcohol consumption and the effect of radiation. 3. Impaired urina...

9 Factors That Influence the Process of Defecation

Defecation, commonly known as bowel movement or passing stool, is the process of eliminating waste products from the body through the anus. It's a vital function of the digestive system and involves coordinated actions of various muscles and nerves. Here's a detailed overview of defecation:   Process of Defecation: Rectal Filling: As waste products from digestion accumulate in the large intestine (colon), they are gradually pushed toward the rectum. Rectal Distension: The rectum serves as a temporary storage site for feces. As fecal matter accumulates, the walls of the rectum stretch, signaling the urge to defecate. Defecation Reflex: When the rectum becomes sufficiently distended, sensory nerves in the rectal walls send signals to the spinal cord, triggering the defecation reflex. Relaxation of Internal Anal Sphincter: Nerve impulses from the spinal cord cause the internal anal sphincter, a smooth muscle under involuntary control, to relax, allowing feces to enter the anal can...

6 Alteration in Bowel Elimination

Bowel elimination, also known as defecation, is the process by which waste products are removed from the body through the rectum and anus. It's a vital function of the digestive system. Here's an overview of bowel elimination:   Process of Bowel Elimination: Digestion: Food moves through the digestive system, where it's broken down and nutrients are absorbed in the small intestine. Formation of Feces: Waste products, including undigested food, water, bacteria, and dead cells, move into the large intestine (colon) where water and electrolytes are absorbed, and the waste material becomes more solid, forming feces. Rectal Storage: Feces are stored in the rectum until the rectal walls are stretched, signaling the need for a bowel movement. Defecation Reflex: When the rectum is sufficiently full, nerve impulses trigger the defecation reflex, leading to the relaxation of the internal anal sphincter (a smooth muscle) and the urge to defecate. Voluntary Control: The external anal s...

Assigning of Priority Nursing Diagnosis

Intervention phase is the third phase of the nursing process in which goals or outcomes and interventions selected. The most appropriate action plans to address the problems or needs of patients effectively. In the intervention phase steps that must be done is to prioritize problems, make goals or outcomes, determining the nursing interventions, and finally do documentation. Planning components Make the order of priority nursing diagnoses. Make outcomes. Writing nursing instruction. Documenting the nursing care plan. In the assessment phase will find a wide range of patient problems. Then determine nursing diagnosis statement to the patient's problem, then the nurse made a priority nursing diagnosis. The order of nursing diagnosis allows nurses, patients, families and significant others, to regulate the issue of patients with order of importance and urgency. Identification of priorities is the first step in planning. This step begins with choosing the order of priority ...

Concept / Model Theory of Nursing Home Care

Concept / Model Theory of Nursing Home Care 1. Environmental Theory (Florence Nightingale) Environment according to Nightingale refers to the external physical environment that influence the process of healing and health, which includes the five most important environmental component in maintaining the health of individuals that include: clean air, clean water, efficient maintenance hygiene, as well as lighting / lighting Nightingale more emphasis on the physical environment rather than the social and psychological environment that is explored in more detail in writing. The emphasis on the environment is very clear in a statement that if you want to predict health problems, then that should be done is to assess the state of the house, conditions and way of life of a person rather than a physical examine his / her body. 2. Theory of Unitary Human Beings (Martha Rogers) In understanding the concept of the model and the theory, Rogers assumes that the human is a unifi...

Nursing Care Plan for Anxiety related to Angina Pectoris

Manifestations of Myocardial Ischemia, usually due to a narrowing or blockage of the coronary arteries are the most frequent angina pectoris, acute myocardial infarction and sudden death, but sometimes it can also arise as heart failure or arrhythmias. William Heberden in 1768 has reported the clinical syndrome of angina pectoris and discussed this with the perfect introduction and management. Angina pectoris is pain or discomfort in the area of ​​the heart or substernal (chest discomfort), primarily due to physical activity or stress, will subside when the rest or sublingual nitrate meal. It can also spread to the neck and arm till left. Clinical manifestations include: Substernal or retrosternal chest pain radiating to the neck, throat area inter scapula or left arm. Quality of pain like a heavy pressure, squeezing, hot, sometimes just a bad feeling in the chest (chest discomfort). Duration of pain lasts 1 to 5 minutes, no more daari 30 minutes. Pain is lost (reduced) when...

Nursing Interventions for Colostomy

Colostomy Care is a nursing action in terms of cleaning the colostomy stoma, the skin around the stoma, and a colostomy bag periodically replace as needed. The purpose of this colostomy care are as follows : Maintain cleanliness of the patient 's own. Prevent infection. Prevent skin irritation around the stoma. Will maintain patient comfort and the environment. The patient can defecate regularly : Avoid eating foods laxative effect. Avoid eating foods that cause constipation (hard food). Collaboration with the nutritionist diet problem. Control of food brought from home. Provide sufficient drinking. A regular diet. Nursing Interventions for Colostomy The pain can be reduced : Record administration of medications at the time of intraoperative. Evaluation of pain and characteristics. Give an understanding of the client so that the pain is accepted as a reasonable within certain limits. Give analgesics as an act of collaboration. The patient may sleep / ...