Nursing Care Plan for Peritonitis : 5 Diagnosis and Interventions

Peritonitis Definition

Peritonitis is inflammation of the peritoneum - the serous membrane lining the abdominal cavity and covers the viscera is dangerous complications that can occur in acute or chronic form or set of signs and symptoms, including tenderness and pain on palpation loose, defans muscular, and general signs of inflammation. Patients with peritonitis may experience symptoms of acute, mild illness and limited, or severe and systemic disease with septic shock.

Infectious peritonitis, are divided over the causes perimer (spontaneous peritonitis), secondary (associated with pathological processes in visceral organs), or tertiary cause (recurrent or persistent infection after adequate initial therapy). Infection of the abdomen are grouped into pertitonitis infection (common) and abdominal abscesses (local peritonitis infection is relatively difficult to enforce and very dependent of the underlying disease. The cause of peritonitis is spontaneous bacterial peritonitis due to chronic liver disease.

Other causes of secondary peritonitis is perforated appendicitis, peptic and duodenal ulcer perforation, perforation of the colon due to diverdikulitis, volvulus and cancer, and ascending colon strangulation. The cause of iatrogenic trauma generally comes from the upper gastrointestinal tract including pancreas, bile ducts and colon sometimes also can occur from trauma endoscopy. Stitching operation that is leaking is a common cause of peritonitis.

After surgery, abdominal effective for non-infectious etiology, incidence of secondary peritonitis (due to rupture of suture surgery should be less than 2%. Surgery for inflammatory diseases (eg appendicitis, divetikulitis, cholecystitis) without risk of perforation is less than 10% of secondary peritonitis and peritoneal abscess. Risk occurrence of secondary peritonitis and abscess higher with the involvement of the duodenum, pancreatic colonic perforation, peritoneal contamination, perioperative shock, and the passive transfusion.

Peritonitis Clinical Manifestations

The presence of blood or fluid in the peritoneum cavity will provide signs of stimulation peritoneum. Peritoneum stimuli cause tenderness and muscular defans, liver dullness may disappear due to free air under the diaphragm. Decreased peristaltic lost due to temporary paralysis of the intestines.

In case of bacterial peritonitis, the patient's body temperature will rise and there is tachycardia, hypotension and the patient seemed lethargic and shock. This stimulation causes pain on any movement that causes the shift of peritoneum. Pain is a subjective form of pain when the patient moves such as roads, breathing, coughing, or straining. Pain is a pain if the objective is moved such as palpation, tenderness loose, psoas test, or other tests.

Clinical diagnosis of peritonitis enforced by the presence of abdominal pain (Acute abdomen) with a dull pain and obscure location (visceral peritoneum) that more and more obvious location (parietal peritoneum). Relative signs of peritonitis with severe infection is high fever or sepsis patients who could be hypothermia, tachycardia, dehydration to be hypotensive. Severe abdominal pain which usually has a punctum maximum specific place as a source of infection.

The walls of the stomach will feel tight because the mechanism of anticipation patient unconsciously to avoid palpation painful or tense because of irritation of the peritoneum.


5 Nursing Diagnosis Nursing Care Plan for Peritonitis

1. Acute Pain Nursing Care Plan for Peritonitis

2.Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

3. Risk for Infection Nursing Care Plan for Peritonitis

4. Deficient Fluid Volume Nursing Care Plan for Peritonitis

5.Ineffective Breathing Pattern Nursing Care Plan for Peritonitis

NANDA Chronic Pain

NANDA Chronic Pain


Chronic Pain Definition:

Feeling and an unpleasant emotional experience arising from tissue damage (actual and potential), or a picture of the damage. This can occur suddenly or slowly, the intensity of light or heavy. Constant or intermittent, with no prediction of healing time, and more than 6 months.

Limitation Carakteristik:

a. Changes in body weight
b. Reports verbally and non verbally, or report the behavior to protect, guard, face mask, irritability, focus on self, anxiety, depression)
c. On a bunch of muscle atrophy
d. Changes in sleep patterns
e. Fatigue
f. Fear of injury
g. Reduced interaction with others
h. Inability to resume previous activities
i. Sympathetic response (temperature, cold, changes in body position, hypersensitivity)
j. Anorexia

Explanation

Basically, the nurse divides pain into two criteria, namely acute and chronic. The basic difference is only in the aspect of prediction time and length of time heal heal.

Physiology of Pain:

The millions of pain receptors in the body, receiving sensations then taken to the spinal cord is the gray area continued to spinothalamicus tract, next to the cerebral cortex. The mechanism is as follows:
  1. The flow of the burning pain of the hands of a chemical release Bradykinin, prostaglandins then stimulate the end of the nerve receptors which then helps the transmission of pain from the hand that burned into the brain.
  2. Impulses delivered to the brain via nerve to the dorsal horn, the spinal cord.
  3. Messages received by the thalamus as a sensory center in the brain.
  4. The impulses are sent to corteks where the intensity and location of pain is felt.
  5. Decrease in pain begins as a signal from the brain, down through the spinal cord.
  6. In the dorsal horn of chemicals such as endorphins released to reduce pain.

COPD Nanda Nursing Diagnosis

NANDA Nursing Diagnosis for COPD

1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.

3. Impaired Gas Exchange related to ventilation perfusion inequality.

4. Activity Intolerance related to imbalance between supply with oxygen demand.

5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

6. Disturbed Sleep Pattern related to discomfort, the setting position.

7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.

8. Anxiety related to threat to self-concept, the threat of death, unmet needs.

9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.

10. Knowledge Deficit related to lack of information, do not know the source of information.

GC990 ZTE Specifications

GC990 ZTE Specifications

GC990 ZTE


Network: Dual On GSM (SIM 1) + CDMA (SIM 2) (GSM 900/1800 MHz and CDMA 800 MHz # (2 SIM provider lock Flexi)

Model: QWERY Phone

Screen: TFT 2.4-inch, 262k color (320 x 240 pixels)

Camera: 1.3 MP

Connection: GPRS

Memory: Micro SD external

Applications: SMS, MMS, Java, Shortcut Yahoo, Twitter, and Facebook

Browser: WAP

Color Options:
Battery: standby, talk time

Other features:
MP3/MP4 player, FM radio, Document viewer (word, excel, PDF)

Askep CHF

Askep CHF

CHF

Congestive heart failure, or simply heart failure, is a condition that occurs when the heart is unable to pump enough blood to meet the needs of the body's tissues. It generally occurs as a result of other forms of heart disease.

Symptoms of left-side heart failure may include:
  • Fatigue and shortness of breath (but unlike the breathlessness of angina, which feels like a heavy weight pressing on the chest)
  • Difficulty breathing at night, sometimes causing awakening
  • Asthma-like wheezing or a dry hacking cough that worsens with lying down, but improves with sitting up or standing.
  • Unintended weight loss

Symptoms of right-side heart failure may include:
  • Fatigue
  • Accumulation of fluid: first in the feet, next in the ankles and legs, and finally in the abdomen
  • Enlargement of the liver
  • Weight gain (although muscle mass is lost and appetite may be depressed, weight gain often occurs because salt and water are retained)
Download Askep Congestive heart failure (CHF) Click Here

Tips to Stabilize the Blackberry Bold Connection

Stabilize the Blackberry Bold Connection


Ever found it difficult to get a signal on your BlackBerry Bold ?
maybe it's because the signal switching between 3G and 2G.

Normally the default setting for the blackberry bold is "Automatic",
Means support "Switching" from 3G to 2G, or vice versa.

However, some operators have not stabilized between 2G and 3G networks it, This resulted in signal loss, and you must turn off the cellular phone or even remove the battery so that the signal back to normal.

But you can set this in the sense that we can to keep the connection settings in one network. Only 2G or 3G only.
How:
  1. Select Options
  2. Then select Mobile Networks
  3. Change setting Coverage Area to 2G, 3G or 2G & 3G (Automatic)
  4. Back, then save changes
With this set we can prevent the occurrence of "Signal Loss" or wasteful of the battery due to constant network switching from 2G and 3G.

Sinusitis - 2 Nursing Diagnosis and Interventions

Sinusitis - 2 Nursing Diagnosis and Interventions

1. Nursing Diagnosis: Pain (Acute / Chronic): (head, throat)
related to an increase in sinus pressure, secondary to inflammation of the paranasal sinuses.

Goal: Pain is felt the client is reduced, or disappear within 1x24 hours.

Expected outcomes:

a) The client reveals the pain diminished or disappeared
b) Respiratory Rate = 16-20 X / min, Pulse = 60-100x/menit, facial expressions client no longer grinning.
c) The scale of pain 2

Nursing Interventions and Rational:

collaboration:

Give analgesic drugs
Rational: analgesic drugs can reduce or eliminate pain.

independent:

Teach techniques of pain distraction or diversion and relaxation techniques
Rational: distraction technique is expected to reduce the scale of pain after treatment with analgesic drugs.

independent:

Observation of vital signs, client complaints and pain scale
Rational: Observation made ​​to ensure that pain is characterized by reduced respiratory rate in normal scale.


2. Nursing Diagnosis: Ineffective airway clearance related to the presence of thickened secretions.

Goal: Effective Way of breath again within 10-15 minutes.

Expected outcomes:

a) The client no longer uses the nostril breathing
b) The absence of additional breath sounds
c) Ronchi (-)
d) Respiratory Rate = 16-20 x / minute
e) The absence of chest wall retraction

Nursing Interventions and Rational:

collaboration:

Give nebulizer.
Rational: Nebulizer can thin the secretions and as bronchodilators to widen the airway.

independent:

Photo of thoracic chest and do clapping or vibration
Rational: Knowing the location of secret and secret accumulate in supsternal making it easy for the drainage.

collaboration:

Perform suctioning (in px. Who experienced loss of consciousness and unable to cough effectively).
Rational: Removing secretions from the lungs.

collaboration:

Perform suctioning (in px. Who experienced loss of consciousness and unable to cough effectively).
Rational: Removing secretions from the lungs.

independent:

Teach effective cough (in px. Who did not experience a decrease in consciousness and is able to cough effectively).
Rational: Removing secretions from the airway especially in patients who did not experience a decrease disturbance of consciousness and can perform an effective cough.

independent:

Observation of vital signs
Rational: To determine the health development of the client.

Sample of Nursing Care Plan for Sinusitis

3 Nursing Diagnosis for Parkinson's Disease with Interventions and Evaluation

Parkinson's Disease


Nursing Diagnosis 1.

Impaired physical mobility related to bradykinesia, muscle rigidity and tremors

characterized by:
Subjective data: the client said it was difficult to do activities
Objective data: tremors while on the move

Outcome: improve the mobility

Nursing Interventions:
  • Help clients make daily exercise such as walking, cycling, swimming, or gardening.
  • Encourage clients to stretch and exercise as directed postural therapist.
  • Bathe with warm water and the clients do sorting to help muscle relaxation.
  • Instruct the client to rest on a regular basis in order to avoid weakness and frustration.
  • Teach for postural exercise and walking techniques to reduce the stiffness when walking and the possibility of learning continues.
  • Instruct the client to walk with your legs open.
  • Create a client's hand with awareness raising, lifting the feet when walking, use the shoes for walking, and walking with step length.
  • Tell the client to walk to the rhythm of music to help improve the sensory.

Evaluation: client sessions of physical therapy, facial exercise 10 minutes 2 times a day.


Nursing Diagnosis 2.

Imbalanced Nutrition Less Than Body Requirements related to the difficulty: moving the food, chewing, and swallowing

characterized by:
Subjective data: the client said it was difficult to eat, weight loss
Objective data: thin, weighing less than 20% ideal body weight, pale conjunctiva, and mucous membranes pale.

Outcome : optimize the nutritional status

Nursing Interventions:
  • Teach the client to think while swallow-shut lips and teeth together, lifting the tongue with food on it, then move the tongue back and swallowing, lifting his head to the back.
  • Instruct the client to chewing and swallowing, using a second wall of the mouth.
  • Tell the client to consciously control the accumulation of saliva by holding the head and swallow periodically.
  • Provide a sense of security on the client, with a stable eating and using the equipment.
  • Encourage eating in small portions and add a snack (snack).
  • Monitor weight.
Evaluation: the client can eat 3 times in small portions and two snacks, no weight loss.


Nursing Diagnosis 3.

Impaired verbal communication related to the decline in speech and facial muscle stiffness

characterized by:
Subjective data: client / family says the difficulty in speaking
Objective data: the words difficult to understand, pelo, faces stiff.

Outcome : maximize the ability to communicate.

Nursing Interventions:
  • Keep the complications of treatment.
  • Refer to speech therapy.
  • Teach the client and facial exercises using breathing methods to improve the words, volume, and intonation.
  • Breath deeply before speaking to increase the volume and number of words in sentences every breathe.
  • Practice speaking in short sentences, reading aloud in front of the glass or into a voice recorder (tape recorder) to monitor progress.
Evaluation: the lack of difficulty in speaking, words can be understood.

Nursing Care Plan - Diagnosis and Interventions for Hallucinations

Nursing Diagnosis and Interventions for Hallucinations

1. Risk for hurting themselves and others

Hear hallucinations

Long-term goals:
  • Clients can control the hallucinations and not hurt themselves or others.

Interventions:

Psychotherapeutic:
  • Conduct frequent and brief contact
  • Observations of verbal and nonverbal behavior associated with hallucinations
  • Give clients the opportunity to express what is felt the client in accordance with client's verbal and nonverbal responses.
  • Hallucinations as the real thing for the client, and give the opinion that the hallucinations are not real to the nurse.
  • Ask open-ended questions that require extensive answers.
Daily activities (Actifity Daily Living)
  • Together with the client to schedule activities to avoid loneliness
  • With clients to discuss how to control the hallucinations Hear: like to join with others to talk, watch TV, take part in group activities.
  • Guided clients on preferred activities
Psikofarmaka
  • Discuss with the client and family about drug therapy and side effects arise.
  • Give drugs with five principles correctly.
  • Facilitate client's current medication
  • Make sure that the drug had been taken by the client.
  • Give positive reinforcement when clients take medication regularly.
  • Keep records after drug administration.
Therapeutic Environment
  • Provide tools as time: clock and calendar.
  • Give marks / names in the client room
  • Call client by name calling, which is preferred by the client
  • Nurses wore nameplate.
  • Recommend to interact with the name of each client
  • Facilitate clients in group activities gradually
  • Increase client response to reality by way of showing calendar, clock, name space.
Health Education:
  • Discussing with the client about trigger the onset of hallucinations.
  • Encourage clients to report to the nurse if there is a hallucination
  • Give information on the client where the client asked for assistance if it is difficult to control when hallucinations occur.
  • Explain to the client signs of hallucinations, how to cope, a situation that causes hallucinations and facilities that can be used when experiencing difficulties.

2. Social Isolation

Long-term goals:
  • Clients do not pull out and interacting with others

Interventions:

Psychotherapeutic
  • Construct a trusting relationship
  • Listen to what is disclosed by the client
  • Perform frequent contact and a brief
  • Support and encourage the client to communicate with the nurse if there is something they think.
  • Give positive reinforcement
  • Encourage clients to see the positive things about him.
Daily activities (ADL)
  • Limit the client to not daydream / outs by clients involved in routine activities in the room, such as preparing meals, sweeping, making beds, washing dishes.

Psikofarmaka
  • Discuss with the client and family about drug therapy and side effects arise.
  • Give drugs with five principles correctly.
  • Facilitate client's current medication
  • Make sure that the drug had been taken by the client.
  • Give positive reinforcement when clients take medication regularly.
  • Keep records after drug administration.
Therapeutic Environment
  • Encourage clients to get acquainted with other people, one time each day.
  • Discuss how to interact further.
  • Accompany clients to be in addition to clients ranging from silent to verbally communicate a simple, phased according to the capacity of the client.
  • Involve clients in interacting groups conducted in stages from small groups to large groups.
  • Involve clients in activities of group activity (TAK: socialization)
  • Provide a means of information and entertainment such as magazines, newspapers, TV.
Health Education
  • Involve the family to always to keep in contact with the client, such as family visiting clients at least one week.
  • Teach client how to meet the other clients.
  • Discuss with client events leading to withdrawal
  • Provide information to families about how to care for clients by withdrawing
  • Encourage the family mengikutisertakan clients in family and community environment.
  • Provide a description of the importance of taking medication regularly on clients and families.

Example Process of Hallucinations

Hallucinations may occur due to various factors, including organic mental disorders, low self esteem, withdrawal, sidrome drug withdrawal, drug toxicity, affective disorders and sleep disorders.

Client hallucinations arise because of changes of social relationships. Inadequate social development led to the failure of individuals to learn and maintain communication with others. As a result, clients tend to separate themselves and only get involved in their own mind which does not require the control of others. Thus the onset of loneliness, social isolation, shallow relationships and dependent (Haber, 1987).

As a result of enjoying the sounds that are heard, then the client is only involved in his own mind, so clients are lazy or lack of interest in performing daily activities such as personal hygiene, eating, and others.

Hallucinations occur on the client to hear, this is caused because the client had a history of a breakup with her boyfriend one time, then by the family of married clients. After being married for three months, his wife left him and the client was very disappointed, often alone, daydreaming, do not want to eat then the client admitted to a psychiatric hospital for 8 months.

This is consistent with the occurrence of hallucinations in the first phase described by Haber et al, 1982. In this phase, clients experiencing anxiety, stress, feeling separate, alone. Clients may be daydreaming or focusing the mind on a fun thing to relieve anxiety and stress. In this way a temporary help, the client still can control his consciousness and perception to know his mind, but the intensity increases.

After eight months of treatment, the client declared cured and allowed to go home. At home, the client had an accident while riding a motorcycle was later treated in hospital. After discharge from the hospital, a few days later, the client began to daydream and to hear voices that say or tell him to throw cups and plates. The symptoms of this client indicates that the client is experiencing symptoms of hallucinations into two phases, namely where the client is at the level of listening, thinking it stand out like a picture of the internal sounds and sensations.

A month ago, the client is hearing voices and asked the nurse whether the client should make friends with a spirit, because he is often invited to speak. In accordance with the stage of hallucination, the client is in the third phase, which is more prominent hallucinations, mastering, hallucinations give pleasure and sense of security while.

And then the client enters the fourth phase to the symptoms of hallucinations that are threatening the client's hearing voices "I'm not scared of you". Then the client said "I'm also not scared of you!"

With the existence of this hallucination, then the problems that arise on a potential client is on a rampage, potentially hurting themselves and others, impaired personal hygiene, impaired ADL. Clients tend to pull away, smiling and talking to herself.

As a result he was unable to provide adequate emotional response, the client looks bisar, does not fit (Fortinash, 1991; Benner, 1989; Hater, 1987). Potentially hurt themselves and others, potential amok may occur on the client, because the client heard voices threatening, mocking, the client was told by the spirits for slamming plates and glasses.


Example Process of Hallucinations


Example Process of Hallucinations

Of the problems it found a number of eleven pieces of nursing problems, namely:

1. Impaired reality orientation
2. Impaired interpersonal relationships: Pulling away
3. Impaired verbal and nonverbal communication
4. Ineffective individual coping
5. Impaired perception: Hear Hallucinations
6. Impaired self-care
7. Ineffective family coping
8. Risk for hurting themselves and others
9. Risk for rampage
10. Risk for impaired nutrition: less than body requirements
11. Risk for relapse