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Showing posts from February, 2015

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...