Gastric Cancer - Assessment and 5 Nursing Diagnosis

Assessment for Gastric Cancer

Nurses get a history of the patient's diet that focuses on issues such as high food intake and input smoked or marinated fruits and vegetables are low. Is the patient experiencing weight loss, if so how much.

Does the patient smoke ? If yes how much a day and how long ? Is the patient complained of stomach discomfort during or after smoking ? Does the patient drink alcohol ? If so how much ? The nurse asks the patient if there is a family history of cancer. If such a close family member or immediate or distant relatives affected ? Is the patient's marital status ? Is there someone who can provide emotional support ?
During the physical examination is possible to palpate a mass. Nurses must observe the presence of anxiety. Organs examined for tenderness or masses. Pain is usually the symptoms are slow. (Brunner & Suddart, 2001).

1. Anamnesis (Hamsafir, 2010) :

• Pain.
• Weight loss.
• Vomiting.
• Anorexia.
• Dysphagia.
• Nausea.
• Weakness.
• Hematemesis.
• Regurgitation.
• Easily satisfied.
• Ascites (abdominal bloating).
• Abdominal cramps.
• Real or faint blood in the stool.
• The patient complained of discomfort in the stomach, especially after eating.

2. Physical Examination (Hamsafir, 2010) :

• Hemodynamic Status : blood pressure, pulse, acral and breathing.
• Less weight, cachexia, conjunctiva sometimes anemic.
• Abdominal examination may be palpable mass epigastric region, epigastric pain. In malignancy can be found hepatomegaly, ascites.
• If there are complaints of melena, do a digital rectal examination.
• Malignancy = search enlargement supraclavicular (Virchow's node), axillary nodes left (Irish 's node), to the umbilicus (Sister Mary Joseph's nodes), palpable tumors pelvic cul - de - sac on the digital rectal examination (Blumer's shelf), enlarged ovaries (Krukenberg's tumor).

Nursing Care Plan for Gastric Cancer

Nursing Diagnosis for Gastric Cancer

1. Pain ( acute / chronic ) related to the presence of abnormal epithelial cells , nerve impulse disorders of the stomach .

2. Imbalanced Nutrition : less than body requirements related to anorexia .

3. Anxiety related to malignancy advanced disease .

4. Risk for Infection related to the surgical incision .

5. Risk for ineffective airway clearance related to the buildup secret .

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Brain Tumor Assessment, Pre and Post Operative Nursing Diagnosis

Nursing Assessment for Brain Tumor

1. Health Perception and Health Management

• A family history of tumors.
• Exposed to excess radiation.
• A history of visual problems; lost visual acuity and diplopia.
• Alcohol Addiction, heavy smokers.
• There was a feeling abnormal.
• Personality disorder / hallucinations.

2. Nutritional Metabolic Pattern

• History of epilepsy.
• Loss of appetite
• The presence of nausea, vomiting during the acute phase.
• The loss of sensation on the tongue, cheeks and throat.
• Difficulty swallowing (interference on the palate and pharyngeal reflex).

3. Elimination Pattern

• Changes in the pattern of urination and bowel movements (incontinence).
• Bowel sounds; negative.

4. Activity and Exercise Pattern

• Disorders of muscle tone, the muscle weakness, impaired level of consciousness.
• Risk of trauma due to epilepsy.
• Hamiparese, ataxia.
• vision disorders.
• Feel tiredness, loss of sensation.

5. Sleep Rest Pattern

• Hard or easy to relax and fall asleep.

6. Cognitive-Perceptual Pattern

• Dizziness.
• Headache.
• weakness.
• Tinnitus.
• Motor aphasia.
• Loss of sensory stimuli contra-lateral.
• Impaired sense of taste, smell and sight.
• Decline in memory, problem solving.
• Lost the ability influx of visual stimuli.
• Impairment of consciousness up to coma.
• Not able to record images.
• Not able to distinguish right / left.

7. Self-Perception-Self-Concept Pattern

• The feeling of helplessness and despair.
• Emotions unstable and difficult to express.

8. Role-Relationship Pattern

• Speech problems.

9. Reproduction

• The existence of disturbances and irregularities.
• Influence / relationship to disease.

10. Coping-Stress Tolerance Pattern

• Existence of feelings of anxiety, fear, impatient or angry.
• Coping mechanism commonly used.
• Feelings of helplessness, hopelessness.
• Emotional response to the client's current status.
• People who help in solving the problem.
• Irritability.

11. Value-Belief Pattern

• The religion, whether religious activities interrupted.

Nursing Diagnosis for Brain Tumor Pre-Surgery

1. Imbalanced Nutrition Less than Body Requirements related to nausea, vomiting and loss of appetite / growth of cancer cells.
2. Acute Pain / Chronic Pain ; head related to the growth of cancer cells in the brain.
3. Impaired physical mobility related to movement disorders and weakness.
4. Impaired Verbal Communication related to damage to the cerebral circulation.
5. Low self-esteem related to dependency, role changes, changes in self-image.
6. Knowledge Deficit; about the condition and treatment of diseases related to lack of information.
7. Anxiety related to surgical plan.

Nursing Diagnosis for Brain Tumor Post-Surgery

1. Acute Pain related to the effects of surgery.
2. Low self-esteem related to dependency, role changes, changes in self-image.
3. Knowledge Deficit; about brain tumors related to ignorance about resources
4. Anxiety related to chronic disease and an uncertain future.

Brain Tumor - 4 Nursing Diagnosis and Interventions

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NCP for Febrile Convulsions : Assessment and Nursing Diagnosis

Nursing Care Plan for Febrile Convulsions


Definition

Febrile Seizures is an occurrence in infants or children who usually occurs between the ages of 3 months to 5 years was associated with fever but never proven the existence of intra-cranial infection or a particular cause . ( Consesnsus Statement On Febrile Siezures , 1980).



Classification

1. Simple febrile seizures :

• Age 6 months to four years.
• Long seizures are not more than 15 minutes.
• Seizures are common.
• Seizures occurred 16 hours after the onset of fever.
• EEG normal one week after the seizure.
• Neurological examination before and after abnormal spasm.
• Seizure frequency generation in a single year is not more than four times.

2. Complex febrile seizures :

• Seizure time more than 15 minutes.
• Seizure frequency more than once in 24 hours.
• Children have a neurological disorder or a history of febrile seizures before.
• Seizure frequency generation in one year more than four times.

3. Epilepsy provoked by fever.

• Is that not all febrile seizures above criteria.

Originator or Risk Factors :

• High fever caused by upper respiratory tract infection, pneumonia, gastroenteritis and urinary tract infections.
• History of febrile seizures in parents or siblings.
• Developmental delay.
• Problems in the newborn period.
• Children in special care.
• Children with low levels of Na.
• Family history of epilepsy.

Pathophysiology

In a state of fever 1oC temperature rise will lead to increased basal metabolism 10-15 % and oxygen demand increased by 20%, resulting in a change in the balance of cell membranes of neurons and in a short time, diffusion of sodium and potassium ions through the membrane before, with the result of off an electric charge. Remove the charge is so large that it can spread throughout the cell and surrounding cell membrane with the aid of the so-called "neurotransmitters" and there was a seizure.


Differential diagnosis

• Another cause febrile seizures should be removed, especially meningitis and encephalitis.
• Children with high heat can arise delirium, chills and fever, cyanosis so as to resemble seizures.

Prognosis
Dependent factors :

• A history of seizures without fever disease in the family.
• Families with neurological disorders.
• Prolonged seizures or convulsions locally.

If there are two of these three factors will then later on febrile seizures is approximately 13%.



Nursing Care Plan for Febrile Convulsions

Nursing Assessment

1. Client identity

• Age is usually six months to four years, male gender women with a ratio of 2 : 1 , the highest incidence in children aged two years.

2. The main complaint

• Seizures because of the fever.

3. History of present illness

• Time of occurrence of seizures less than five minutes.
• Seizures are general.
• Seizures occurred within 16 hours after the onset of fever.
• No neurological abnormalities both clinical and laboratory.

4. Past medical history

• The presence of predisposing factors of febrile seizures among other head trauma, infection, and reactions to immunization.

5. Family history of disease

• 25-50 % of febrile seizures have a heredity factor families affected by the presence of febrile seizures, neurological diseases or other diseases.

6. Previous history

• History of pregnancy : maternal illness, bleeding, and medications used.
• Labor History : spontaneous birth or by action, antepartum hemorrhage, premature rupture of membranes, Aspixia.

Activity Daily Live

1). Food or liquids

• Patients will complain sensitive to foods that stimulate seizure activity, tooth decay, the presence of gingival hyperplasia , as a result of side effects of drugs.

2). Activity and Rest

• Patients complain of fatigue, general weakness, limitation of activities and changes in muscle tone.

3). Elimination

• Incontinensia
• Ictal face : an increase in pressure and tone springter blader.
• Post- ictal : muscle relaxation.

4). Psycho - social history

• Psycho : anamnesis of the child's temperament, cognitive abilities, and the response of pain conditions as well as hospitalization.
• Social : anamnesis the source of economic status and family, and the family response patterns of daily childcare.

Test and Diagnosis

1). Vital signs

• Decreased awareness
• Ictal phase : Increased pulse, respiration, blood pressure and temperature.
• Post ictal : normal V5 sometimes depression.

2. Physical Examination

• Head : head shape disproportion, generalized seizures, tonic clonic seizures and headaches.
• Eyes : Dilated pupils, eye movements and rapid eyelid, and conjunctival reflexes down red light.
• Mouth : Excessive production of saliva, vomiting and Cyanosis oral mucosa.
• Nose : The existence nostril breathing, Cyanosis.
• Neck : the tetanus occurs stiff neck.
• Chest : Ictal phase : Cyanosis, decreased respiratory movement and the pull intercostae. Post ictal : Apnoe or breath deep and slow.
• Abdomen : Ictal phase : Improved muscle tone blader and spingter. Post ictal : relaxation and hyper peristaltic muscles.
• Extremities : Ictal phase : spasms in upper and lower extremities and cyanosis of the fingers and toes. Post ictal : muscle relaxation and pain and weakness in the muscles.

3. General examination

• Electrolytes : Electrolyte imbalance predispose to seizures.
• Glucose : Hypoglycemia predispose to seizures.
• BUN : Increased BUN is a potential seizure.
• CBC : Aplastic Anemia can occur as a side effect of drug administration.
• LP : to detect the presence of abnormal pressure and signs of infection.
• Skull X - ray : the existence of space and lesions persisted.
• EEG : The focus of seizure activity.
• CT scan : Local cerebral abscess detect tumor lesions with or without contrast.

Nursing Diagnosis for Febrile Convulsions

1. Increased body temperature relation : the presence of pyrogens which disrupt the thermostat, the average increase in metabolism and disease dehydration.
2. Risk for Ineffective airway clearance related to neuromuscular damage and obstruction tracheo - broncial.
3. Knowledge Deficit : family related to misinterpretation and lack of information.
4. Self-concept Disturbance (low self esteem) related to epilepsy and wrong perceptions and uncontrolled.

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Pleural Effusion - Assessment and Nursing Diagnosis

Pleural effusion is a medical condition where there is an excessive accumulation of fluid in the lungs, particularly in the pleural space. This fluid is responsible for lubricating the lungs so that they do not experience friction from rubbing against the ribs or other components of the thoracic cavity. Normally, the space around the lungs contains 10-15 milliliters of this fluid.

There are types of pleural effusion, depending on what is causing the issue. These include:

Hemothorax : This occurs when blood builds up in the chest cavity. It is most often due to injury
Hydrothorax : This is the general term for when any fluid accumulates in the chest cavity.
Pneumothorax : This condition arises when the entire lung collapses, which can be the result of pressure from fluid buildup.
Chylothorax : This happens when blood or pleural fluid remains in the thoracic cavity. While this can also be attributed to injury, it is most often related to lymphoma, or cancer of the lymph nodes.


Assessment for Pleural Effusion

1. Systemic Examination

a) Cardiovascular System
Hypotension, increased pulse, temperature sometimes rose.

b) Respiratory System
From this system, the assessment needs to be done related to pleural effusion is dyspnea, tachypnea, cough, fremitus focal weakness, chest wall is more convex on the side that contains fluid.

c) Digestive System
On the client with pleural effusion usually found loss of appetite, nausea, vomiting, hyperactive bowel sounds.

e) Musculoskeletal System
Physical weakness, prefer to lay on the direction that contains fluid.

f) Integumentary System
Dry skin, increased skin temperature, poor turgor.


2. Pattern of Daily Activities
That needs to be studied in daily activities are:

• Personal hygiene: Due to a decrease in the ability or increased need help doing everyday activities.
• Nutrition: There is a change and a problem in meeting the nutritional needs due to the tightness and lack of appetite.
• Elimination: No problem.
• Activities and sports: On the client with pleural effusion occurs fatigue, weakness, malaise, inability to perform daily activities because of difficulty breathing, fatigue or activity intolerance. Can not exercise because of pain due to tightness WSD installation actions.
• Rest and sleep: There was difficulty sleeping at night due to coughing, tightness, pain, fever and sweating.

3. Psychological Data

• Status of emotions: emotional instability can be found facing the disease.
• The concept of self: changes in self-concept for fear of disease, negative views of themselves, due to the changing role of dependence.
• Coping patterns: what is being done to overcome the problem client is maladaptive actions and to whom the client to ask for help or tell me if there is a problem.

4. Social Data
Behavior occurs withdraw from social interactions due to the inability to communicate.

5. Spirituality Data
Difficulty to perform the religious obligations because of illness and limited activity.


6. Diagnostic examination
According Doenges et al (2002) Diagnostic examination consists of:

• Chest X-ray: to declare lung hyperinflation, flattening of the diaphragm, increased retrosternal air area.
• Lung Function Tests: performed to determine the cause of dyspnea, to determine whether the abnormal function is obstruction or retraction.
• Blood gas analysis: estimating progression of chronic disease processes.
• Blood chemistry: to convince deficiency and emphysema primary diagnosis.
• Sputum cultures to determine the presence of infection, identify the pathogen, sitolitik examination to determine malignancy or allergic disorders.
• ECG right axis deviation, P wave elevation, atrial dysrhythmias, P wave elevation leads I, III, aVF, ventricular QRS axis.

7. Care and Treatment
Management of pulmonary tuberculosis disease is the provision of a high-calorie diet and high protein, WSD installation.


Nursing Diagnosis for Pleural Effusion

According Doenges et al (2002), nursing diagnoses that appear in patients with pleural effusion is:

1. Acute pain r / t surgical action (WSD).

2. Ineffective airway clearance r / t inflammatory process and secret accumulation in the respiratory tract.

3. Imbalanced Nutrition: Less Than Body Requirements r / t lack of food intake.

4. Activity intolerance r / t physical weakness

5. Knowledge Deficit: the conditions, rules and precautionary measures r / t the wrong interpretation of the cognitive limitations of the information, the information is inadequate / incomplete information.

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Physical Examination and Nursing Assessment for COPD

The assessment includes information about the symptoms and manifestations of the disease earlier. Here are some guidelines to get the data questions health history of the disease process:

1. How long has the patient had difficulty breathing?
2. Does activity increase dyspnea?
3. How much limits the patient's activity tolerance?
4. When patients complain most tired and short of breath?
5. Is eating and sleeping habits affected?
6. History of smoking?
7. The drugs used every day?
8. The drugs used in the acute attack?
9. What is known about the patient's condition and disease?

Additional data were collected through observation and examination as follows:

1. Patient's pulse rate and breathing?
2. Do the same breathing, without effort?
3. Is there a contraction of the abdominal muscles during inspiration?
4. Is there any use of accessory respiratory muscles during breathing?
5. Barrel chest?
6. Does it seem cyanosis?
7. Is there a cough?
8. Are there peripheral edema?
9. Is the neck veins appear enlarged?
10. What color, amount and consistency of sputum of patients?
11. What is the status of patients sensorium?
12. Is there an increase in stupor? Anxiety?
13. Results of diagnostic tests such as:

Chest X-Ray:
May indicate pulmonary hiperinflation, flattened diaphragm, increased retrosternal air space, decrease vascular signs / bullae (emphysema), an increase in the form of bronchovaskular (bronchitis), normally found during periods of remission (asthma)

Examination of Lung Function: Guide to determine the cause of dyspnea, determine whether the function abnormalities due to obstruction or restriction, to estimate the level of dysfunction and to evaluate the effects of therapy, eg bronchodilator.

TLC: Increase in severe bronchitis and usually on asthma, decreased in emphysema.

Capacity Inspiration: Decrease in emphysema

FEV1/FVC: Ratio of pressure expiratory volume (FEV) against the pressure of the vital capacity (FVC) decreased in bronchitis and asthma.

ABGs: Indicates a chronic disease process, often decreased PaO2 and PaCO2 normal or increased (chronic bronchitis and emphysema) but often decreased in asthma, the normal pH or acidosis, respiratory alkalosis secondary to hyperventilation light (moderate emphysema or asthma).

Bronchogram: Can show dilatation of the bronchi during inspiration, kollaps bronchial expiratory pressure (emphysema), enlargement of mucous glands (bronchitis)

Complete Blood: Increased hemoglobin (severe emphysema), an increase in eosinophils (asthma).

Blood Chemistry: Alpha 1-antitrypsin is made to the possibility of less on primary emphysema.

Sputum culture: To determine the presence of infection, identify the pathogen, cytologic examination to determine malignancy or allergic disease.

ECG: right axis deviation, tall P wave (severe asthma), atrial dysrhythmias (bronchitis), gel. P in Leads II, III, AVF length, height (bronchitis, emphysema), QRS axis vertical (emphysema)

Exercise ECG, Stress Test: Helping assess the level of respiratory dysfunction, evaluate the effectiveness of bronchodilator drugs, plan / program evaluation ..

Palpation:

1. Reduction in the development of breast palpation?
2. Is there decreased tactile fremitus?

Percussion:

1. Is there hiperesonansi on percussion?
2. The diaphragm moves just a little bit?

Auscultation:

1. Is there a loud wheezing sound?
2. Is there ronkhi sound?
3. Nomal or decreased vocal fremitus?

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