NCP for Vomiting - 6 Nursing Diagnosis and Interventions

Nursing Care Plan for Vomiting

Definition

Vomiting is a complex reflex that is mediated by the vomiting center in the medulla oblongata of the brain.

Vomiting is spending gastric contents exclusively through the mouth with the help of contraction of the abdominal muscles. Necessary to distinguish between regurgitation, rumination, or gastroesophageal reflux.
Regurgitation is the food that was issued back-to-mouth due to esophageal peristaltic movement.
Rumination is perpetually conscious of food expenditure to be chewed and then swallowed back.
Gastroesophageal reflux is the return of stomach contents into the esophagus in a passive way that can be caused by hypotonia spingter lower esophagus, abnormal position of the esophagus connection with cardiac or slow emptying of the stomach contents.


Etiology

Discussion of the etiology of vomiting in infants and children by age is as follows:

Age: 0-2 months:

1. Allergic Colitis
Allergy to cow's milk or formula with a soy-based ingredients. Usually followed by diarrhea, rectal bleeding, and cranky.
2. Anatomic abnormalities of the gastrointestinal tract
Congenital anomalies, including stenosis or atresia. Manifestations of food intolerance in the first few days of life.
3. Esophageal Reflux
Regurgitation often occur immediately after feeding. Very often occur in neonates; Clinically important that this situation causes failure to thrive, apnea, or bronchospasm.
4. Increased intracranial pressure
Fussy or lethargy accompanied by abdominal distension, birth trauma and shaken baby syndrome.
5. Malrotation with volvulus
80% of these cases is found in the first month of life, mostly with biliary emesis.
6. Meconium ileus
Inspissated meconium in the distal colon; can be considered a diagnosis of cystic fibrosis.
7. Necrotizing enterocolitis
It often happens, especially in premature babies, especially if experiencing hypoxia at birth. Can be accompanied by irritability or fuss, abdominal distension and hematochezia.
8. Overfeeding
Regurgitation of milk that can not be digested, wet-burps often in infants with excess weight to excess breast milk given.
9. Stenosis pylorus
Peak at the age of 3-6 weeks of life. The ratio of men compared to women is 5: 1 and this situation often occurs in boys first. The clinical manifestations will progressively worsen, projectiles, and non biliary emesis.

Age: 2 months-5 years

1. Brain tumor
Think especially if it is found that the progressive headache, vomiting, ataxia, and no abdominal pain.
2. Diabetic ketoacidosis
Moderate to severe dehydration, a history of polydipsia, polyuria and polyphagia.
3. Corpus alienum
Associated with the incidence of recurrent choking, coughing occurs suddenly or saliva dripping.
4. gastroenteritis
Very often; often their history of contact with sick people, usually followed by diarrhea and fever.
5. Head trauma
Vomiting often or progressive signifies concussion or intracranial hemorrhage.
6. Incarcerated hernia
Onset of crying, anorexia and scrotal swelling that occurs suddenly.
7. Intussusception
The peak occurs at 6-18 months of life; patients rarely experience diarrhea or fever than children who are suffering from gastroenteritis.
8. Posttusive
Often, children will vomit after coughing or coughing repeatedly imposed.
9. pyelonephritis
High fever, looked ill, dysuria or polacisuria. Patients may have a history of urinary tract infections earlier.

Age: 6 years and older

1. Adhesion
Especially after abdominal surgery or peritonitis.
2. Appendicitis
Clinical manifestations and location of pain varies. Symptoms often include increasing pain, radiating to the right lower quadrant, vomiting preceded by pain, anorexia, fever subfebril, and constipation.
3. cholecystitis
More common in women, especially with hemolytic disease (eg, sickle cell anemia). Characterized by epigastric pain or right upper quadrant occurs suddenly after a meal.
4. Hepatitis
Mainly caused by a viral infection or drug-induced; the patient may have a history of bowel movements such as putty colored or tea-colored urine concentrated.
5. Inflammatory bowel disease
Associated with diarrhea, hematochezia, and abdominal pain. Stricture can cause obstruction.
6. Intoxication
More common in children who are learning to walk and adolescents. Suspected if a history of depression. Can also be accompanied by disturbances in mental status.
7. Migraine
Severe headache; often the presence of an aura before an attack such as scotoma. Patients may have a history of chronic headache or a family history of migraine.
8. Pancreatitis
Risk factors include upper abdominal trauma, history of previous infections or moderate infection, corticosteroid use, alcohol and cholelithiasis.
9. Peptic ulcer
In adolescents, the ratio of female: male = 4: 1. Chronic or recurrent epigastric pain, often worse at night time.


Complication

1. Metabolic Complications
Dehydration, metabolic alkalosis, electrolyte and acid-base disorders, depletion of potassium, sodium. Dehydration occurs as a result of fluid loss through vomiting or inputs that are less because of vomiting. Alkalosis as a result of the loss of stomach acid, it is exacerbated by the influx of hydrogen ions into the cell due to potassium deficiency and reduced extracellular sodium. Potassium can be lost along with the material vomit and out through the kidneys together bicarbonate. Sodium can be lost through vomiting and urine. In the state of severe alkalosis, the pH of urine can be 7 or 8, urine levels of sodium and potassium high despite the depletion of sodium and potassium.
2. Failure growth
Repeated vomiting and severe enough cause nutritional disorders due to intake be greatly reduced and when this happens long enough, there will be a failure of growth and development.
3. Aspiration of gastric contents
Material aspiration of vomit can cause asphyxia. Recurrent episodes of mild aspiration cause recurrent respiratory tract infections. This occurs as a consequence of GERD.
4. Mallory Weiss syndrome
A linear laceration on the border of the esophagus and gastric mucosa. Usually occurs in severe vomiting lasts longer. On endoscopic examination found redness of the lower esophageal mucosa LES area. In a short time will heal. When anemia occurs because of heavy bleeding need blood transfusions.
5. Peptic esophagitis
Due to prolonged reflux in chronic vomiting cause mucosal irritation of the esophagus by stomach acid.


Nursing diagnoses that may arise

Fluid volume deficit related to loss of active liquid.
Imbalanced Nutrition: less than body requirements related to absorption disorders.
Nausea related to gastric irritation.
Ineffective tissue perfusion related to hypovolemia.
Risk for Impaired skin integrity related to disruption of metabolic status.
Anxiety related to changes in health status.


Nursing Care Plan for Vomiting

Nursing Diagnosis 1. Fluid volume deficit related to loss of active liquid.
Goal: fluid and electrolyte deficit is resolved.
Expected outcomes:
signs of dehydration: none,
mucosa of the mouth and lips moist, fluid balance.

Intervention:

• Observation of vital signs.
• Observation for signs of dehydration.
• Measure the input and output of fluid (fluid balance).
• Provide and encourage the family to drink a lot more than 2000 - 2500 cc per day.
• Collaboration with physicians in fluid therapy, laboratory tests electrolyte.
• Collaboration with a team of nutrition in low-sodium fluid administration.

Nursing Diagnosis 2. Imbalanced Nutrition: less than body requirements related to absorption disorders.

Goal: nutrients are met.

Intervention:
1. Assess the extent to which the inadequate nutrition clients.
Rational: analyze the causes implement interventions.
2. Estimate / calculate the calorie intake, keep the comments about the appetite to a minimum.
Rationale: Identifying deficiencies / nutritional needs to focus on the problem and create a negative atmosphere affects the input.
3. Measure the weight as indicated.
Rational: Overseeing the effectiveness in diet.
4. Give eat little but often.
Rational: Do not let boredom and nutrient intake can be increased.
5. Encourage oral hygiene before eating.
Rationale: The mouth of the net increase appetite.
6. Offer a drink.
Rationale: It can reduce nausea and relieve gas.
7. consul of a / dislike of patients who cause distress.
Rational: Involve patients in planning, enables patients to have a sense of control and the drive to eat.
8. Provide a varied diet.
Rationale: The food was varied client can increase appetite.

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Fatigue related to Graves' Disease

Nursing Care Plan for Graves' Disease


Nursing Diagnosis : Fatigue related to hypermetabolic with increased energy needs; sensitive stimulation of nerves in connection with disorders of body chemistry.

Supporting Data: reveal very lack of energy to maintain the usual routine, decreased performance, lability / emotional stimuli sensitive, nervous, tense, agitated behavior, damage the ability to concentrate.

Goal: verbally disclose about an increase in energy levels, showed improvement in the ability to participate in the activity.

Nursing Intervention:

Independent:

1. Monitor vital signs and record pulse both at rest and during activity.
R /: pulse widely increased and even at rest, tachycardia (above 160 times / min) may be found.

2. Note the development of tachypnea, dyspnea, pallor and cyanosis.
R /: Needs and oxygen consumption will be increased on a hypermetabolic state, which is potentially hypoxia while doing the activity.

3. Provide / create a quiet environment, cold room, lower sensory stimulation, the colors are cool and relaxing music (calm).
R /: Lowering stimulation is likely to cause agitation, hyperactivity and insomnia.

4. Advise the patient to reduce the activity and increase bed rest as much as possible whenever possible.
R /: Helps combat the effects of increased metabolism.

5. Give the act of making the patient comfortable, such as: touch / massage, powder cool.
R /: Can lose energy in the nerves which further enhances relaxation.

6. Provide alternate activities fun and quiet, like reading, listening to the radio and watching television.
R /: Allows for the use of energy in a constructive way and probably will also reduce anxiety.

7. Avoid talking about a topic that is annoying or threatening the patient, discuss how to respond to these feelings.
R /: Increased sensitivity of the central nervous system can cause the patient easily aroused, agitation and excessive emotion.

8. Discuss with the people in a state of fatigue and emotional unstable.
R /: Understand that the physical behavior improve coping with the current state of encouragement and advice of people nearby to respond positively and provide support to the patient.

Collaboration:
9. Give the drug as indicated.
R /: To cope with the situation (nervous), hyperactivity and insomnia.

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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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Digestive System Neoplasm - Nursing Diagnosis and Interventions

Nursing Care Plan for Digestive System Neoplasm


Pre - Operation Nursing Diagnosis and Interventions

1. Pain (acute / chronic) related to the growth of cancer cells.

Goal : Pain is reduced until it disappears.

Interventions
1. Assess characteristics of pain, location, frequency.
R/ : Knowing the level of pain as the evaluation of interventions.

2. Assess the factors causing pain relief (fear, anger, anxiety).
R/ : By knowing the causes of pain, decisive action to reduce the pain.

3. Teach relaxation techniques take a deep breath.
R/ : Relaxation techniques can override the pain.

4. Collaboration with physicians for providing analgesic.
R/ : Analgesic effective for pain.



2. Anxiety related to planned surgery.

Goal : Anxiety can be minimized after the act of nursing.

Interventions :
1. Describe any actions to be performed on the patient .
R/ : The patient was cooperative in every action and reduce patient anxiety.

2. Allow the patient to express feelings of fear.
R/ : To reduce anxiety.

3. Evaluation of the level of understanding of the patient / significant others, on medical diagnosis.
R/ : Provide the information you need to select the appropriate interventions.

4. Acknowledge the fear / patient issues, and push express feelings.
R/ : Support enables the patient to start opening / accept the disease and treatment.



3. Imbalanced Nutrition : less than body requirements related to nausea, vomiting and no appetite.

Goal : The nutritional requirements can be met.

Expected Outcomes :
Nutrition met.
Nausea was reduced to disappear.

Interventions :
1. Serve food in small portions but often and warm.
R/ : warm food increases the appetite.

2. Assess the patient's eating habits.
R/ : Type of food that will help improve the patient's appetite.

3. Teach relaxation techniques that take a deep breath.
R/ : Helps to relax and reduce nausea.

4. Measure the weight whenever possible.
R/ : To determine the weight loss.

5. Collaboration with physicians for the provision of vitamins.
R/ : To prevent deficiency due to reduced absorption of fat-soluble vitamins.



4. Activity intolerance related to physical weakness .

Goal : Activity intolerance resolved.

Expected Outcomes :
Showed an increase in activity tolerance characterized by : do not complain of weakness, can move gradually.

Interventions :
1. Provide adequate rest periods.
R/ : Rest will provide enough energy and helps in the healing process.

2. Review of complaints during the move.
R/ : Identify abnormal activity.

3. Assess the ability to move.
R/ : Specifies the activities that can be done.

4. Help meet the needs.
R/ fulfillment needs.

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Liver Abscess - 7 Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis, Interventions and Evaluation for Liver Abscess

1. Breathing pattern, ineffective related to Neuromuscular, imbalance perceptual / cognitive.

Goal : normal breathing pattern / effective and free from signs of cyanosis or hypoxia .

Intervention :

• Maintain the patient's airway by tilting the head.
• Auscultation of breath sounds.
• Observation of the frequency and depth of breathing, the muscles use the respirator.
• Monitor vital signs continuously.
• Do the motion as soon as possible.
• Observation of the excess.
• Do suction mucus when necessary.
• Provide supplemental oxygen as needed.
• Give treatment as instructed.

2. Disturbed Sensory Perception : the process of thought related to chemical changes : the use of pharmaceutical drugs.

Goal : increasing the level of awareness

Intervention :

• Orient the patient back continuously after coming out of the influence of anesthesia.
• Talk with the patient in a clear voice and normal.
• Minimize negative discussion.
• Use the pads on the edge, do binding if necessary.
• Observations of the existence of hallucinations, depression and others.
• Maintain a calm and comfortable environment.

3. Fluid Volume Deficit, Risk for oral fluid intake restriction (process / medical procedure / nausea).

Goal : there is adequate fluid balance .

Intervention :

• Measure and record the input and output.
• Assess urinary spending, especially for the type of surgical procedure performed.
• Monitor vital signs.
• Note the emergence of nausea / vomiting, history of motion sickness.
• Check the pads, appliance drein at regular intervals , examine the wound for swelling.
• Give parenteral fluids, blood products and / or plasma expanders as directed. Level IV speed if necessary.
• Give back oral intake gradually as directed.
• Give antiemetics as needed.

4. Pain (acute) related to disorders of the skin, tissue, and muscle integrity.

Goal : pain has been controlled / eliminated, the client can rest and activity according to ability.

Intervention :

• Assess pain scale, intensity, and frequency.
• Evaluation of pain on a regular basis.
• Assess vital signs.
• Assess the cause of the discomfort that may be appropriate operating procedures.
• Put repositioning as directed.
• Encourage use of relaxation techniques.
• Give medicines as directed.

5. Impaired Skin Integrity related to the interrupt mechanism of the skin / tissue.

Goal : to improve the metabolic action shows.

Intervention :

• Review the functional capabilities and circumstances.
• Place the client in a particular position.
• Keep the body well-being functionally.
• Help or actions to perform range of motion exercises.
• Give skin care carefully.
• Monitor urine output.

6. Risk for infection related to an operating wounds and invasive procedures.

Goal : There are no signs and symptoms of infection

Intervention :

• Provide anti-septic and aseptic care, maintain good hand washing.
• Observations damaged skin area (stitches) attached regions invasive tool.
• Monitor the entire body on a regular basis, record the presence of fever, chills, and diaphoresis.
• Keep an eye or the number of visitors.
• Give antibiotics as indicated.

7. Disturbed Sleep Pattern related to the disease process, the effects of hospitalization, changes in the environment.

Goal : resting needs can be met

Intervention :

• Assess the client's ability and sleeping habits.
• Provide a comfortable bed with a few personal belongings. Example : pillows, bolsters.
• Suggest to light activity.
• Suggest to take action relaxation.
• Encourage the family to always accompany.
• Supervise and limit the number of visitors.

8. Knowledge deficit (learning need) regarding condition / situation, prognosis, treatment needs.

Goal : Declare, understanding of disease processes / pragnosis.

Intervention :

• Revisit surgery / special procedures performed and on future expectations.
• Discuss drug therapy , including the use of a prescription.
• Identification of specific activity limitations.
• Schedule an adequate period of rest.
• Emphasize the importance of further visits.
• Involve famous people in the teaching program. Provide written instructions / teaching materials.
• Repeat the importance of diet and fluid intake adequate nutrition.

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Ventricular Septal Defects - 7 Nursing Diagnosis and Interventions

Nursing Care Plan for VSD in Children

1. Decreased Cardiac Output related to cardiac malformations.

Goal: to improve cardiac output.

Outcomes: signs of improvement in cardiac output.

Intervention:

• Observe the quality and strength of the heartbeat, peripheral pulses, skin color and warmth.
• Assess the degree of cyanosis (mucous membranes, clubbing).
• Monitor signs of CHF (anxiety, tachycardia, tachipnea, shortness of breath, tired while drinking milk, periorbital edema, oliguria and hepatomegaly.
• Collaboration for the provision of drugs as indicated.

2. Impaired gas exchange related to pulmonary congestion.

Goal: improved gas exchange.

Outcomes: no signs of pulmonary vascular resistance.

Intervention:

• Monitor the quality and rhythm of breathing.
• Adjust the position of the child with Fowler position.
• Avoid child of an infected person.
• Give adequate rest.
• Give oxygen as indicated.

3. Activity intolerance related to imbalance between oxygen consumption by the body and oxygen supply to the cells.

Goal: client activity are met.

Outcomes: Children participate in activities according to ability.

Intervention:

• Allow the child frequent breaks and avoid disturbances during sleep.
• Suggest to do the game and light activity.
• Help children to choose activities appropriate to the age, condition and capacity of the child.
• Give the period of rest after activity.
• Avoid the ambient temperature is too hot or cold.
• Avoid things that cause fear / anxiety child.

4. Delayed Growth and Development related to an inadequate supply of oxygen and nutrients to tissues.

Goal: There is no change of growth and development.

Outcomes: Growth of children according to the growth curves of weight and height.

Intervention:

• Provide a balanced diet, high nutrients to achieve adequate growth.
• Monitor height and weight.
• Involve the family in providing nutrition to children.

5. Imbalanced Nutrition: less than body requirements related to fatigue at mealtime and increased caloric needs.

Goal: nutritional needs are met.

Outcomes: The child maintains food and beverage intake.

Intervention:

• Measure body weight each day with the same scales.
• Record intake and output correctly.
• Give small portions of food frequently.
• Give drink that much.

6. Risk for infection related to declining health status.

Goal: avoid infection.

Outcomes: no signs of infection.

Intervention:

• Monitor vital signs.
• Avoid contact with infected individuals.
• Give adequate rest.
• Provide optimal nutritional needs.

7. Parental Role Conflict related to hospitalization of children, fears of the disease.

Goal: There is a change in the role of parents.

Outcomes:

• Parents express their feelings.
• Parents are sure to have an important role in the success of the treatment.

Intervention:

• The motivation of parents to express their feelings in relation to the child.
• Discuss with parents about the treatment plan.
• Provide clear and accurate information.
• Involve parents in the care of the child while in hospital.
• The motivation to involve families in the care of other family members of children.

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Thyroid Cancer - 3 Nursing Diagnosis and Interventions

Nursing Care Plan for Thyroid Cancer

Thyroid cancer is a malignancy of the thyroid which has 4 types, namely: papillary, follicular, medullary and anaplastic. Thyroid cancer rarely causes enlargement of the gland, often causing small growth (nodule) in the glands. Most thyroid nodules are benign, thyroid cancer can usually be cured.

Thyroid cancer often limits the ability to absorb iodine and limit the ability to produce thyroid hormone, but sometimes produce enough thyroid hormone resulting in hyperthyroidism.

Thyroid cancer occurs in cells of the thyroid gland, which produces hormones serve to regulate the speed of the heart beat, blood pressure, body temperature and weight.

Nursing Diagnosis for Thyroid Cance

1. Ineffective airway clearance related to obstruction of the trachea by the pressure of the tumor mass.
2. Pain (acute / chronic) related to the presence of pressure / swelling of the tumor nodule.
3. Impaired verbal communication related to vocal cord injury.

Nursing Interventions and Rationale

1. Ineffective airway clearance related to obstruction of the trachea by the pressure of the tumor mass.

Goal: Effective airway.

Outcomes:

• There is no difficulty breathing.
• Easy exit discharge.
• Not complaining of shortness of breath.
• Respiration in the normal range (16-20).

Interventions :

• Monitor respiratory rate, depth and breath work.
• Auscultation of breath sounds, note the presence of crackles.
• Assess for dyspnea, stridor and cianosis.
• Note the quality of breathing.
• Collaboration of oxygen therapy if necessary.

Rationale :

• To determine the presence of early complications.
• To determine the presence of crackles or not.
• Knowing the client's breathing.
• Preventing the occurrence of dyspnea.
• Helping clients breathing.

2. Pain (acute / chronic) related to the presence of pressure / swelling of the tumor nodule.

Goal: reduced pain.

Outcomes:

• Pain reported lost / diminished.
• Pain scale: 0-2.
• Looks relax.
• There are no complaints to swallow.

Interventions :

• Observe for signs of pain both verbal and nonverbal.
• Teach and instruct the patient to use relaxation techniques.
• Collaboration of analgesics.

Rationale :

• Anticipate if there is pain.
• Provide comfort to the client.
• To reduce pain.

3. Impaired verbal communication related to vocal cord injury.

Goal: verbal communication breakdowns resolved.

Outcomes:

• Being able to create a method of communication in which needs can be understood.

Interventions :

• Assess speech function periodically.
• Keep communication simple.
• Provide appropriate alternative communication methods.

Rationale :

• To determine the condition of the client.
• In order not to force the client to speak.
• Adjust to the client's condition.

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Postpartum Hemorrhage - 5 Nursing Diagnosis and Interventions

Nursing Care Plan for Postpartum Hemorrhage

Nursing Diagnosis forPostpartum Hemorrhage

1. Fluid volume deficit related to vaginal bleeding.
2. Ineffective tissue perfusion related to vaginal bleeding.
3. Anxiety / fear related to changes in circumstances or the threat of death.
4. Risk for infection related to bleeding.
5. Risk for shock : hypovolemic related to bleeding.

Nursing Diagnosis 1. Fluid volume deficit related to vaginal bleeding.

Goal : Prevent dysfunctional bleeding and improve fluid volume.

Interventions and Rationale :
1. Advise patients to sleep with feet higher, while the body remained supine.
R / : With feet higher will increase the venous return , and allowing the blood to the brain and other organs.

2.Monitor vital signs.
R / : Changes in vital signs when bleeding occurs more intense.

3.Monitor intake and output every 5-10 minutes.
R / : Change the output is a sign of impaired renal function.

4. Evaluation of the urinary bladder.
R / : Full urinary bladder prevents uterine contractions.

5. Perform uterine massage with one hand and the other hand placed above the simpisis.
R / : Uterine massage stimulate uterine contractions and helps release the placenta, one hand above simpisis prevent inversion uterine.

6. Limit vaginal and rectal examination.
R / : Trauma that occurs in the vagina and rectum increases the incidence of bleeding was greater, in case of laceration of the cervix / perineal, or there is a hematoma.
When the blood pressure decreases, pulse became weak, small and fast, the patient feels sleepy, more intense bleeding, immediate collaboration.


Nursing Diagnosis 2. Ineffective tissue perfusion related to vaginal bleeding.

Goal : Vital signs and blood gases within normal limits.

Interventions and Rationael :
1. Monitor vital signs every 5-10 minutes.
R / : Changes in tissue perfusion causing changes in vital signs.

2. Note the discoloration of the nail, lip mucosa, gums and tongue, skin temperature.
R / : With vasoconstriction and relationship to vital organs, circulation in peripheral tissues is reduced, causing cyanosis and cold skin temperature.

3. collaboration :
Monitor blood gas levels and pH (changes in blood gases and pH levels are a sign of tissue hypoxia)
Give oxygen therapy (oxygen transport is needed to maximize circulation to tissue).


Nursing Diagnosis 3. Anxiety / Fear related to changes in circumstances or the threat of death.

Goal : The client can verbalize anxiety and said anxiety is reduced or lost.

Interventions and Rationael :
1. Assess the client's psychological response to the post- childbirth bleeding.
R / : Perceptions of client influence the intensity of anxiety.

2. Assess the client's physiological responses (tachycardia, tachypnea, shaking).
R / : Changes in vital signs lead to changes in the physiological responses.

3. Treat the patient calm, empathetic and supportive attitude.
R / : Provide emotional support.

4. Provide information about care and treatment.
R / : Accurate information can reduce the anxiety and fear of the unknown.

5. Help clients identify a sense of anxiety.
R / : The expression can reduce feelings of anxiety.

6. Assess the client's coping mechanisms used.
R / : Prolonged Anxiety can be prevented with proper coping mechanisms.


Nursing Diagnosis 4. Risk for infection related to bleeding.

Goal : Not an infection (lochia is no smell , and vital signs within normal limits)

Interventions and Rationale :
1. Note the changes in vital signs.
R / : Changes in vital signs (temperature) is indicative of infection.

2. Note the signs of fatigue, chills, anorexia, uterine contractions were flabby, and pelvic pain.
R / : The signs are an indication of the occurrence of bacteremia, shock is not detected.

3. Monitor uterine involution and lochia spending.
R / : Uterine infection, inhibit involution and lochia spending prolonged occurs.

4. Consider the possibility of infection in other places, such as respiratory infections, mastitis and urinary tract.
R / : Infection elsewhere worsen the situation.

5. Collaboration :
Give iron (anemia aggravate the situation).
Give antibiotics (antibiotics are necessary for the proper state of infection).

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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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Brain Tumor - 4 Nursing Diagnosis and Interventions

Nursing Care Plan for Brain Tumor

Tumor is a general term covering any benign growth in every part of the body. This growth was not intended, is growing at the expense of the parasite and the human host.

Brain tumor is a benign tumor on the lining of the brain or one of the brain.

Brain carcinoma (malignant) is a neoplasm that grows in the lining of the brain.

Neoplasm is a collection of abnormal cells formed by cells that grow continuously in a limited, uncoordinated with the surrounding tissue and not useful to the body.


Nursing Diagnosis and Nursing Interventions for Brain Tumor

I. Acute Pain / Chronic Pain related to the effects of surgery.

Goal: Pain is reduced until it disappears after the act of nursing.

Outcomes:

• Clients can perform activities without feeling pain.
• Relaxed facial expression.
• Clients demonstrate discomfort disappear.

Interventions:
1. Assess the level of pain (location, duration, intensity, quality) every 4-6 hours.
R /: As an early indicator in determining the next intervention.

2. Assess the patient's general condition and vital signs.
R /: As an early indicator in determining the next intervention.

3. Give a pleasant position for the patient.
R /: To assist patients in controlling pain.

4. Give a lot of time resting and less visitors as desired patient.
R /: Can reduce physical and emotional discomfort.

5. Collaboration with physicians in drug delivery.
R /: To assist in the healing of patients.



II. Low self-esteem related to dependency, role changes, changes in self-image.

Goal: Impaired self-resolved after the act of nursing.

Outcomes: Clients can be confident with the disease state.

Interventions:
1. Assess the response, and the patient's family's reaction to disease and treatment.
R /: To simplify the process approach.

2. Assess the relationship between patient and close family members.
R /: Support families helps in the healing process.

3. Involve everyone nearby in education and home care planning.
R /: Can ease the burden on the handling and adaptation at home.

4. Give time / listen to the things that become complaints.
R /: continuous support will facilitate the adaptation process.


III. Knowledge Deficit: about brain tumors related to ignorance about resources.

Goal: Information about self care and nutritional status is understood, after the act of nursing for 1 x 24 hours.

Outcomes:
The client expressed an understanding of the information provided.
Client states of consciousness and changes in patterns of self-care plan.

intervention:
1 Assess the patient's level of knowledge.
R /: To determine the level of knowledge in the receipt of information, so as to give correct information.

2 Discuss the relationship of the causative agent of the disease.
R /: To provide an understanding to the patient about the things that trigger the disease.

3 Explain the signs and symptoms of perforation.
R /: Symptoms of perforation is pain in the chest.

4 Explain the importance of the environment without stress.
R /: To prevent an increase in sympathetic stimulation.

5. Discuss implementation method of stress.
R /: How stress management: relaxation, exercise and medication.


IV. Anxiety related to chronic disease and an uncertain future.

Goal: Anxiety can be minimized after the act of nursing.

Outcomes: Anxiety is reduced.

Intervention:
1. Listen patiently client complaints.
R /: Facing issues of patients and need to be explained and opened the way to resolve it.

2. Answering questions from clients and families, with friendly.
R /: Make sure the patient and believe.

3. Encourage client and family confide.
R /: Creating trust and decrease misperceptions.

4. Using therapeutic communication techniques.
R /: Establishing a trust relationship the patients.

5. Give the physical comfort of the patient.
R /: It is difficult to accept with the issue when it experiences extreme emotional / physical discomfort persist.

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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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5 Diagnosis - NCP for Corneal Ulcer

Nursing Care Plan for Corneal Ulcer

Definition

Ulcerative keratitis better known as corneal ulceration, namely the presence of destruction (damage) on the corneal epithelium. (Darling, Vera H, 2000, p 112)


Causes

The reasons include:

• Abnormalities of the eyelashes (trichiasis) and systems tears (tears insufficiency, lacrimal duct blockage), and so on.
• External factors, namely: wounds in the cornea (corneal erosio), due to trauma, contact lens use, burns on the face.
• Corneal abnormalities caused by: chronic corneal edema, keratitis-exposure (on lagophtalmus, general anesthesia, coma); keratitis due to vitamin A deficiency, neuroparalytic keratitis, superficial keratitis virus.
• Systemic disorders; malnutrition, alcoholism, Stevens-Jhonson, acquired immune deficiency syndrome.
• Drugs that lower the immune mekaniseme, eg corticosteroids, IUD, local anesthetics and immunosuppressive group.

In etiologic corneal ulcers can be caused by:

• Bacteria: Germs that can cause corneal ulcers pure is streptokok pneumoniae, whereas other bacterial corneal ulcers caused by trigger factors above.
• Viruses: herpes simplex, zooster, vaccinia, variola.
• Fungi: Candida group, Fusarium, Aspergillus, Cephalosporium.
• Hipersensifitas reaction: The reaction to staphylococcus (marginal ulcers), tuberculosis (keratoconjunctivitis flikten), unknown allergens (ulcers ring). (Sidarta Ilyas, 1998, 57-60)

Pathophysiology

1. Progressive : In the process of progressive corneal be terihat, infiltration of leukocytes and lymphocytes cells that eat bacteria or necrotic tissue is formed.
2. Regressive
3. Establish scarring : In the formation of scar tissue there will be epithelial, new collagen tissue and fibroblasts.

Severity of illness was also determined by the physical state of the patient, a large inoculum and virulence.
Clinical symptoms:

1. Red eyes.
2. Mild to severe eye pain.
3. Photophobia.
4. Decreased vision.
5. White opacities in the cornea.

Symptoms that may accompany is the presence of corneal thinning, Descemet folds, corneal tissue reaction (due to interference iris vascularization), a flare, hypopyon, hyphema and posterior synechiae. In corneal ulcers caused by fungi and bacteria are surrounded PMN epithelial defect. When infections caused by viruses, will be seen surrounding hypersensitivity reaction. Usually gram-positive cocci, Staphylococcus aureus and Streptococcus pneumoniae would provide a limited picture of ulcer, round or oval, white gray suppurative ulcers in children. The area that is not exposed cornea will remain clear and no visible color inflammatory cell infiltration. If the peptic ulcer caused by Pseudomonas then be stretched quickly, green yellow purulent material seen attached to the surface of the ulcer.

When ulcers caused by fungi, it will infiltrate surrounded grayed infiltrates surrounding smooth (satellite phenomenon). When the dendrite-shaped ulcer there will be hypesthesia of the cornea. Ulcers can form a fast running descemetocele or corneal perforation which ended by making a form adherent leucoma. When the process of the ulcer is reduced it will show less pain, photophobia, reduced infiltration of ulcers and corneal epithelial defects become increasingly small.


Signs and Symptoms

In ulcers that destroy membranes and stromal bowman, will lead to corneal cicatrix.
Subjective symptoms such as corneal ulcers symptoms of keratitis. Objective symptoms such as ciliary injection, and partial loss of corneal tissue infiltrates. In more severe cases may occur iritis accompanied by hypopyon.
Photophobia.
Pain and lacrimation.

(Darling, Vera H, 2000, p 112)


Diagnostic Examination:

1. Cards eye / Snellen telebinocular (test visual acuity and central vision)
2. Tomography measurements: assessing IOP, normal 15-20 mmHg.
3. Ophthalmoscopy examination.
4. Blood examination, LED.
5. EKG.
6. Glucose tolerance test.

Assessment

1. Activity / rest: activity changes.
2. Neurosensory: blurred vision, glare.
3. Pain: discomfort, pain sudden / severe persistent / pressure in and around eyes.
4. Security: fear, anxiety.

(Doenges, 2000)


Nursing Diagnosis and Interventions for Corneal Ulcer

1. Fear or anxiety related to sensory impairment and lack of understanding of post-operative care, drug delivery.

Intervention:

• Assess the degree and duration of visual disturbance.
• Orient the patient to the new environment.
• Describe the perioperative routine.
• Suggest to run the day-to-day living habits when able.
• Encourage participation of family or people who mean to patient care.

2. Acute pain related to trauma, increased IOP, surgical intervention or administration inflammatory eye drops

Intervention:

• Give medication to control pain and IOP as prescribed.
• Give cold compress on demand for blunt trauma.
• Reduce lighting levels.
• Encourage the use of sunglasses in strong light.

3. Risk for Self-Care Deficit related to impaired vision.

Intervention:

• Give instructions to the patient or the person nearest the signs and symptoms, complications should be immediately reported to the doctor.
• Give oral and written instructions for the patient and the person who means the right techniques in delivering drugs.
• Evaluation of the need for assistance after discharge.
• Teach the patient and family guide vision techniques.

4. Disturbed Sensory Perception: Visual related to impaired vision.

Goal: Patient is able to adapt to changes.

Outcomes:

• Patients receive and resolve in accordance with the limits of vision.
• Using existing vision or other senses adequately.

Iintervention:

• Introduce the patient to the environment.
• Tell patient to optimize other sensing devices that are not impaired.
• Visit frequently to determine the needs and eliminate anxiety.
• Involve people in the care and activities nearby.
• Reduce noise and provide a balanced break.

5. Knowledge Deficit related to lack of information about self-care and disease processes.

Goal: Patients have enough knowledge about the disease.

Outcomes:

• Patients understand medication instructions.
• Patients using verbal communication to express the symptoms to be reported.

Intervention:

• Tell the patient about the disease.
• Teach self-care during illness.
• Teach hatching procedure eyedrops and replacement bandage on the patient and family.
• Discuss the symptoms of the rise in IOP and visual impairment.

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5 Nursing Diagnosis with Interventions for Chronic Kidney Disease

Nursing Diagnosis for Chronic Kidney Disease

According to Doenges (1999) and Lynda Juall (2000), nursing diagnoses that appear in patients with CKD are:

1. Decreased Cardiac Output.
2. Fluid and Electrolyte imbalances.
3. Imbalanced Nutrition.
4. Ineffective Breathing Pattern.
5. Impaired Skin Integrity.

Nursing Interventions for Chronic Kidney Disease

Decreased Cardiac Output related to increased cardiac load.

Goal:

• Decreased cardiac output does not occur with the outcome criteria:
• maintain cardiac output and blood pressure with evidence of cardiac frequency in the normal range, strong peripheral pulses, and the same with capillary refill time.

intervention:
1 Auscultation of heart and lung sounds.
R: The presence of tachycardia, irregular heart rate.

2 Assess for hypertension.
R: Hypertension may occur due to interference with the system of the renin-angiotensin-aldosterone system (caused by renal dysfunction).

3 Investigate complaints of chest pain, note the location, radiation, severity (0-10 scale).
R: HT and CRF can cause pain.

4 Assess activity level, response to activity.
R: Fatigue can also accompany CRF anemia.



Fluid and Electrolyte imbalances related to secondary edema (fluid volume unbalanced because of the retention of Na and H2O).

Goal: Maintain ideal body weight without excess fluid with outcome criteria: no edema, the balance between inputs and outputs.

intervention:
1 Assess fluid status with daily weigh, balance input and output, skin turgor, vital signs.

2 Limit your fluid intake.
R: fluid restriction akn determine ideal body weight, urine output, and response to therapy.

3 Explain to the patient and family about the liquid restrictions.
R: Understanding to increase cooperation of patients and families in the fluid restriction.

d. Instruct the patient / teach the patient to record the use of fluid intake and output mainly.
R: To determine the balance of inputs and outputs.



Imbalanced Nutrition, Less Than Body Requirements related to anorexia, nausea, vomiting.
Goal: Maintain adequate nutrient inputs to the outcome criteria: demonstrate stable weight.

intervention:
1 Monitor the consumption of foods / liquids.
R: Identifying nutritional deficiencies.

2 Notice of nausea and vomiting.
R: Symptoms that accompany the accumulation of endogenous toxins that can alter or lower income and require intervention.

3 Give food a little but often.
R: The portion of a smaller can increase food intake.

4 Increase visits by people nearby during meals.
R: Provides transfer and improve the social aspects.

5. Provide frequent mouth care.
R: Lowering stomatitis oral discomfort and unwelcome taste in the mouth that can affect food intake.



Ineffective Breathing Pattern related to hyperventilation secondary: compensation via respiratory alkalosis.

Goal: breathing pattern back to normal / stable.

intervention:
1 Auscultation of breath sounds, note the presence of crakles.
R: To declare the existence of the collection of secretions.

2 Teach patient effective coughing and deep breathing.
R: Cleaning the airway and facilitate the flow O2.

3 Adjust the position as comfortable as possible.
R: Preventing the occurrence of shortness of breath.

4 Limit to move.
R: Reduce workload and prevent tightness or hypoxia.


Impaired Skin Integrity related to pruritis

Goal: The integrity of the skin can be maintained with the outcome criteria: Maintain intact skin, Shows behaviors / techniques to prevent damage to the skin.

intervention:
1 Inspection of the skin to change color, turgor, vascular, note the presence of redness.
R: Indicates area of ​​poor circulation or damage that may lead to the formation of pressure sores / infections.

2 Monitor fluid intake and hydration of the skin and mucous membranes.
R: Detecting the presence of dehydration or overhydration affecting circulation and tissue integrity.

3 Inspection of the area depends on edema
R: Tissue edema is more likely to be damaged / torn.

4 Change positions as often as possible.
R: Reduce pressure on edema, poorly perfused tissue to reduce ischemia.

5. Give skin care.
R: Reduce drying, skin tears.

6 Maintain a dry linen.
R: Lowering dermal irritation and the risk of skin damage.

7 Instruct the patient to use a damp and cold compresses to put pressure on the area pruritis.
R: Eliminate the discomfort and reduce the risk of injury.

8 Encourage wear loose cotton clothes.
R: Preventing direct dermal irritation and improve skin moisture evaporation.


Nursing Management for Chronic Kidney Disease

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Nursing Care Plan for Emphysema - Assessment and Diagnosis

Definition of Emphysema

Emphysema is a condition in which the alveoli become stiff expands and continuously filled the air even after expiration. (Kus Irianto.2004.216)

Emphysema is a chronic obstructive disease due to lack of elasticity in the lungs and alveoli surface area. (Corwin.2000.435)


Classification

There are two major types of emphysema, which are classified based on the changes that occur in the lungs:

1. Panlobular (panacinar), ie damage to the respiratory bronchi, alveolar ducts and alveoli. All air space in the little lobes much enlarged, with little inflammatory disease. The characteristics that have chest hyperinflation, and is characterized by dyspnea on exertion, and weight loss.
2. Centrilobular (centroacinar), the pathological changes mainly occur in the center of the secondary lobes, and peripheral of acini remain good. Often there is chaos-ventilation perfusion ratio, which lead to hypoxia, hypercapnia (increased CO2 in the arterial blood), polycythemia and heart failure episodes right. The condition leads to cyanosis, peripheral edema, and respiratory failure.

Etiology

Some things that can lead to pulmonary emphysema, namely:
1. Cigarette
Smoking can lead to pathological disorders of the airway ciliary movement, inhibits the function of alveolar macrophages, causing hypertrophy and hyperplasia of bronchial mucous glands.

2. Pollution
Industry and air pollutants can also cause emphysema. The incidence and mortality rates of emphysema can be said to be always higher in areas with high concentrations of industrialization, air pollution as well as tobacco smoke, can cause interference with cilia inhibits the function of alveolar macrophages.

3. Infection
Respiratory tract infections will cause more severe lung damage. Diseases such as respiratory infections, pneumonia, acute bronchiolitis and bronchial asthma, can lead to airway obstruction, which in turn can lead to emphysema.

4. Genetic

5. Exposure to dust


Clinical Manifestations

• Dyspnea.
• On inspection: chest shape 'barrel chest'.
• Chest breathing, abnormal breathing is not effective, and the use of accessory muscles of respiration (sternocleidomastoid).
• On percussion: hyperresonance and decreased fremitus in all lung fields.
• On auscultation: audible breath sounds with crackles, and expiratory length.
• Anorexia, weight loss, and general weakness.
• Distended neck veins during expiration.

Pathophysiology

Pulmonary emphysema is a lung development, accompanied by tearing of the alveoli that can not be recovered, can be either global or localized, the majority know the whole lung.

Charging excessive air with obstruction, occurs as a result of partial obstruction of the bronchi or bronchioles where the output of the air in the alveoli become more difficult than the input. In such a situation occurs that increases the accumulation of air in the distal alveoli.

In emphysema the narrowing of the airways, it can lead to narrowing of the airway obstruction and tightness, constriction of the airways caused by reduced lung elasticity.


Complication

• Frequent infections of the respiratory tract.
• The immune system is less than perfect.
• The level of lung damage more severe.
• Chronic inflammatory process in the airways.
• Pneumonia.
• Atelaktasis.
• Pneumothorax.
• Increase the risk of respiratory failure in patients.

Nursing Assessment  for Emphysema

1. Activity / Rest
Symptoms: Exhaustion, fatigue, malaise, inability to perform daily activities because of difficulty breathing, inability to sleep, need to sleep sitting up high, dyspnea at rest or in response to activity or exercise.
Symptoms: Fatigue, anxiety, insomnia, general weakness / loss of muscle mass.

2. Circulation
Symptoms: Swelling of the lower extremities.
Signs: Increased blood pressure, increased heart rate / severe tachycardia, dysrhythmias, distended neck veins, edema dependent, not associated with heart disease, heart sounds dim (which is associated with increased AP diameter of the chest), color of skin / mucous membranes: normal or gray / cyanosis, pallor may indicate anemia.

3. Foods / Liquids
Symptoms: Nausea / vomiting, poor appetite / anorexia (emphysema), inability to eat due to respiratory distress, permanent weight loss (emphysema), weight gain showed edema (bronchitis).
Signs: poor skin turgor, dependent edema, sweating, drop in body weight, decrease in muscle mass / fat subcutaneously (emphysema), abdominal Palpitations can cause hepatomegaly (bronchitis).

4. Hygiene
Symptoms: Decreased ability / enhancement needs help doing everyday activities.
Signs: Health less, body odor.

5. Respiratory
Symptoms: Shortness of breath (dyspnea hidden emergence as the prominent symptom of emphysema), especially at work, the weather or the recurrence of episodes of difficult airway (asthma), sense of chest pressure, inability to breathe (asthma)
"Air Hunger" chronic.
Shape settled with sputum production every day (especially when awake) for a minimum of 3 consecutive months each year at least 2 years. Sputum production (green, white and yellow) can be a lot of (chronic bronchitis)
Intermittent episodes of cough is usually not productive at an early stage can occur despite earning (emphysema)
A history of recurrent pneumonia: exposure to chemical pollution / respiratory irritants in the long term (eg, cigarette smoke) or dust / smoke (eg, abscess, or coal dust, sawdust)
The use of oxygen at night or continuously.

Signs: Respiratory: usually fast, slow, use of accessory muscles
Chest: hyperinflation with the elevation of the AP diameter, minimal movement of the diaphragm.
Breath sounds: may dim with expiratory wheezing (emphysema); spreads, soft or crackles, wheezing lungs throughout the area.
Percussion: hyperresonant the lung area
Color: pale with cyanotic lips and nail beds.

6. Security
Symptoms History of allergic reaction or are sensitive to substances / environmental factors, presence / recurrence of infection, redness / sweating (asthma).

7. Sexuality
Symptoms: Decreased libido.

8. Social interaction
Symptoms: The relationship of dependence, lack of support systems, improved inability / long illnesses.
Symptoms: Inability to / make maintaining respiratory sounds, physical mobility limitations, abnormalities with the family members.

9. Counseling / Learning
Symptoms: The use / abuse of drugs breathing, difficulty stopping smoking, regular alcohol use, failure to improve.



Nursing Diagnosis  for Emphysema

1. Impaired gas exchange related to ventilation-perfusion abnormalities secondary to hypoventilation.

2. Excess fluid volume related pulmonary edema.

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Nursing Diagnosis : Impaired Physical Mobility, Anxiety and Knowledge Deficit

Nursing Care Plan for Guillain-Barre Syndrome


1. Impaired Physical Mobility related to neuromuscular damage.

Goal / Outcomes:
Maintain body function with no complications (contractures, pressure sores).

Nursing Intervention :

Independent

1. Assess the strength of the motor / functional abilities using a scale of 0-5.
R /: Specifies the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.

2. Provide patient positioning lead to a sense of comfort.
R /: Reduce fatigue, enhance relaxation, reduce the risk of ischemia / damage to the skin.

3. Chock extremities and joints with pillows.
R /: Maintaining the limb in a position fisilogis, prevent contractures and loss of joint function.

4. Perform passive range of motion exercises.
R /: Stimulates circulation, improve muscle tone and increase joint mobilization.

Collaboration

5. Confirm with / refer to the physical therapy / occupational therapy.



2. Anxiety related to situational crisis.

Goal / Outcomes:
Appear relaxed and report anxiety is reduced to the level can be overcome.

Nursing Interventions:

Independent

1. Place the patient near the nurses' station, check the patient regularly.
R /: To provide assurance that immediate assistance can be done if the patient suddenly becomes not have the ability.

2. Provide primary care / nurse relationships are consistent.
R /: Improve mutual trust of patients and help to reduce anxiety.

3. Provide alternative forms of communication if necessary.
R /: Reduce feelings of helplessness and feelings of isolation.

4. Discuss the change in self-image, fear of losing the ability to settle, loss of function, death, problems regarding the need penyebuhan / repair.

Collaboration

5. Provide a brief description of the treatment, the patient's treatment plan, including the closest.
R. /: A good understanding can increase the need for patient cooperation activities and the involvement of patients and also the closest in care planning will be able to maintain some sense of control over themselves for life which will further enhance the self-esteem.



3. Knowledge Deficit related to less remembering, cognitive limitations.

Goal / Outcomes:
Patients know and understand about the disease.

Nursing Interventions:

Independent
1. Determine the patient's knowledge and ability to participate in the rehabilitation process.
R /: Influencing choice of interventions that will be done.

2. Review the patient's knowledge about the disease and its prognosis.
R /: The knowledge base is an important thing to make informed choices and participate in rehabilitation efforts.

3. Suggest to reveal what is in the natural, social, and increase independence.
R /: Increasing returns to normal and the development of his feelings on the situation.

4. Identify safety measures to find defeswit sensory-motor individually.
R /: Reduce the risk of injury / lower the actual risk of complications can still be prevented.

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Care Plan and Nursing Diagnosis for Spina Bifida

Nursing Assessment for Spina Bifida

Subjective and objective data collection on the nervous system disorders, in connection with spina bifida complications depends on other vital organs. Nursing assessment of spina bifida include anamnesis, medical history, physical examination, diagnostic studies, and psychosocial assessment.

1. Anamnesis

The identity of clients includes name, age, gender, education, address, occupation, religion, nationality, date and time of hospital admission, registration number, health insurance, medical diagnostics.

The main complaint is often the reason for a client to ask for help health is the presence of signs and symptoms similar to spinal cord tumors and neurological deficits. Complaints of lumbosacral lipoma on an important sign of spina bifida.


2. History of the disease at this time

Complaints of neurological deficits can manifest as impaired motor (motor paralysis of the lower limbs) and the inferior extremity sensory and / or disorders of the bladder and the sphincter of the stomach. Complaints of unilateral foot deformity and leg muscle weakness is the most common defect. Small feet can occur trophic ulcers and pes cavus. This condition may be accompanied by sensory deficits, especially in the distribution of L3 and S1. Complaints bladder sphincter disorders are found in 25% of infants with neurological involvement, lead to urinary incontinence, urinary dripping, and recurrent urinary tract infections. Usually accompanied by the anal sphincter weakness and sensory disturbance perianal area. Neurological disorders can gradually deteriorate, especially during adolescence mass growth.


3. History of previous illness

Assessment that need to be asked include a history of the growth and development of children, history meningomyelocele ever experienced before, a history of infection subarachnoid space (sometimes chronic or recurrent meningitis), a history of spinal cord tumors, poliomyelitis, spinal developmental disabilities, such as diastematomyelia and foot deformities.


4. Assessment of psychosocial

Assessment of coping mechanisms used and the client's family (parents) to assess the response to illness and changing roles in the family and society as well as responses or influence in their daily lives either in the family or in society. Are there impacts on the client and the parents that raised fears of disability, anxiety, a sense of inability to perform activities optimally.


5. Physical examination

After making the history that led to the complaint the client physical examination is very useful to support the assessment of data from history. Physical examination should be performed by the system (B1-B6) with a focus on examining physical examination B3 (brain) directed and connected with complaints from clients.

a. The general state
In case of spina bifida generally experience loss of consciousness (GCS less than 15), especially if it occurs widely neurological deficits and changes in vital signs.

b. B1 (Breathing)
Changes in the respiratory system associated with inactivity weight. In some circumstances, the results of the physical examination found no abnormalities.

c. B 2 (Blood)
Bradycardia is a sign of changes in brain tissue perfusion. Looked pale skin indicates a decrease in hemoglobin levels in the blood. Hypotension indicates a change in tissue perfusion and early signs of a shock.

d. B3 (Brain)
Spina bifida causes a variety of neurological deficit was primarily due to the effect of increased intracranial pressure. Assessment of B3 (Brain) is a focus and a more complete examination than assessments on other systems.

e. B4 (Bladder)
In the advanced stages of spina bifida, a client may experience urinary incontinence due to confusion and inability to use the urinary system due to damage motor and postural control. Sometimes the external urinary sphincter control is lost or diminished. During this period, intermittent catheterization performed with sterile technique. Urinary incontinence that persists showed extensive neurological damage.

f. B5 (Bowel)
The presence of fecal incontinence that continues to show widespread neurological damage. Bowel examination to assess the presence or absence of bowel sounds and the quality should be assessed prior to abdominal palpation. Bowel sounds are decreased or lost may occur in paralytic ileus and peritonitis.

g. B6 (Bone)
The presence of foot deformity is one important sign of spina bifida. The most common motor dysfunction is the weakness of the lower extremities. To assess the integrity of the skin lesions and sores. Be difficult to move because of weakness, sensory loss or spastic paralysis and fatigue cause problems on the pattern of activity and rest.


6. Diagnostic tests

Spine x-rays to identify any defect in the spine, usually occurs in the posterior arch of the vertebra in the spine midline amount varies. The presence of spinal dyspropism or widening of the spine is a typical sign of radiology at the lumbar (Perkin, 1999).



Nursing Diagnosis for Spina Bifida

1. Urinary incontinence r / t paralysis visceral

2. Risk for injury r / t spastic paralysis

3. Impaired Physical Mobility r / t motor paralysis

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Nursing Diagnosis for Disseminated Intravascular Coagulation (DIC)

Disseminated Intravascular Coagulation (DIC) can occur in virtually all persons without distinction of race, sex, and age. The symptoms of DIC, generally strongly associated with the underlying disease, plus additional symptoms due to thrombosis, embolism, organ dysfunction, and bleeding. Disseminated Intravascular Coagulation (DIC) is a complex diagnosis that involves a component of blood clots as a result of other diseases that precede.



Definition of Disseminated Intravascular Coagulation

Disseminated Intravascular Coagulation is a syndrome characterized by bleeding / clotting disorders are caused by the formation of plasmin which is a specific plasma protein that is active as a fibrinolytic in getting the circulation (Healthy Cau's)

In general, disseminated intravascular coagulation (DIC) is defined as a complex disorder or blood clotting disorder due to excessive stimulation of procoagulant and anticoagulant mechanisms in response to injury (Yan Euphrates Sembiring, Paul Tahalele)


Etiology of Disseminated Intravascular Coagulation

Bleeding occurs due to the following matters:

• Hypofibrinogenemia.
• Thrombocytopenia (a common cause of abnormal bleeding, can occur due to insufficient production of platelets by the bone marrow, or due to increased destruction of platelets).
• Circulating anticoagulant in blood circulation.
• Excessive fibrinolysis.

Diseases that predispose to DIC is as follows:

• Infections (dengue hemorrhagic fever, sepsis, meningitis, severe pneumonia, tropical malaria, rickettsial infection by some types). Where bacteria release endotoxins (a substance that causes clotting activation).
• Pregnancy complications (placental abruption, intrauterine fetal death, amniotic fluid embolism).
• After surgery (lung surgery, bypass cardiopulmonal, lobectomy, gastrectomy, splenectomy).
• malignancies (prostate carcinoma, lung carcinoma, acute leukemia).
• Acute liver disease (acute liver failure, obstructive jaundice).
• Palepasan severe trauma occurs to the network with a large number of blood vessels. The release coincides with hemolysis and endothelial damage that would release blood clotting factors in large numbers then activates blood coagulation systemically.

Clinical Manifestations of Disseminated Intravascular Coagulation

1. Bleeding from puncture area, wounds and mucous membranes in patients with shock, obstetric complications, sepsis (widespread infection), or cancer. If bleeding occurs under the skin, vascular lesions will appear.
2. Changes in the level of consciousness.
3. Cyanosis and tachypnea (increased respiratory rate) due to poor tissue perfusion and oxygenation are common. Splotches on the skin indicates tissue ischemia.
4. Hematuria (blood in the urine) due to bleeding or oliguria (decreased urine output) due to poor perfusion.

Complication

• Clot which formed much will cause obstruction or hindrance of blood flow in all organs of the body. Organ failure can occur at large. The mortality rate of more than 50%.
• Shock.
• Acute tubular necrosis.
• Pulmonary edema.
• Chronic renal failure.
• Convoluted.
• Coma.

Assessment for Disseminated Intravascular Coagulation (DIC)

1. Predisposing factors:

• Septicemia (most common cause).
• Obstetric complications.
• Severe and extensive burns.
• Neoplasia.
• Liver disease.
• Trauma.

2. Patterns of health functions
a. Health Perception and Management

• nausea, vomiting
• minus liquid
• Ht (if that exit the plasma, hematocrit rise; wrote out all that blood, Ht down)

b. Nutritional metabolic

• Impaired elimination patterns, both bladder and bowel movements. In bowel constipation or diarrhea occurs. Melena
• Hematuri
• Hematemesis

c. Activity exercise

• Changes in vital signs, SaO2 (descending)
• The need for assistance to meet their daily needs.
• Weak muscle contraction.

d. Sleep rest

• Changes meet the needs sleep (quality and quantity).

e. Cognitive-perceptual

• abdominal pain; pain, coldness in the fingers accompanied by numbness and tigling.

f. Role relationship

• With the long treatment, there will be obstacles in carrying out its role as before.

g. Sexuality reproductive

• Decreased sexual function
• Changes in menstrual patterns

h. Value-Belief Pattern

• Religious or cultural beliefs influence the selection of treatment.

Nursing Diagnosis for for Disseminated Intravascular Coagulation (DIC)

1) Ineffective Tissue Perfusion r / t disruption of blood circulation.

2) Risk for fluid volume deficit r / t bleeding.

3) Acute pain r / t tissue trauma.

4) Anxiety r / t threat of death from chronic diseases suffered...

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Hemorrhagic Stroke - 2 Nursing Diagnosis and Interventions

Nursing Care Plan for Hemorrhagic Stroke

Stroke is a neurological disease that is common and must be dealt with quickly and appropriately. Stroke is a brain dysfunction arising due to sudden occurrence of circulatory disorders of the brain and can happen to anyone and at anytime.

Stroke is the most common disease-causing defects such as limb paralysis, impaired speech, memory and thought processes forms other disability as a result of brain dysfunction.

Around the world, the incidence of stroke average of about 180 per 100,000 per year (0.2%) with a prevalence rate of 500-600 per 100,000 (0.5%).

In fact, many patients who came to the hospital in a state of decreased consciousness (coma). Such circumstances require special handling and care are: general, special, rehabilitation and discharge planning clients.

Knowing the circumstances mentioned above, the role of the nurse in collaboration with other health care team is needed both acute period, or thereafter. That can be implemented include overall health care, ranging promotive, preventive, curative to rehabilitation.


Hemorrhagic Stroke

Definition

Acute neurological dysfunction caused aleh as circulatory disorders of the brain, where it suddenly (several seconds) or quickly (a few hours) symptoms and signs corresponding to the focal area of disturbed tampered. (Djunaedi W, 1992).

According to Hudak and Gallo in the critical care book launch hemorrhagic CVA sudden onset and lasts 24 hours as a result of cerebrovascular desease.



Nursing Diagnosis for Hemorrhagic Stroke

1. Risk for Ineffective airway clearance related to the decline cough reflex.

Goal: not an interruption in airway clearance

Outcomes:
regular respiration, no stridor, Ronchi, whezing, RR: 16-20 x / min, no cough reflex.

Interventions:

1. Observe the speed, depth and breath sounds.
R /: respiratory rate indicates the body's attempt to meet the needs of O2.

2. Perform suction with extra caution when audible stridor.
R /: decreased cough reflex, causing bottlenecks spending secretions.

3. Maintain a half-sitting position, not pressed to one side.
R /: Ventilation easier when the position of the head in a neutral position, causing the emphasis to one point increase in ICT.

4. Perform chest physiotherapy.
R /: claping and vibrating cilia stimulates bronchial secretions to issue

5. Explain to the family about the change position every 2 hours.


2. Imbalanced Nutrition Less Than Body Requirements related to muscle weakness swallow.

Goal: Nutritional needs of clients are met.

Outcomes: either turgor, the intake can be entered in accordance
needs, there is the ability to swallow, the sonde is removed, increased weight 1kg.

Intervention:
1. Observations texture, skin turgor.
R /: to know the client's nutritional status.

2. Perform oral hygiene.
R /: oral hygiene stimulate appetite.

3. Observation intake out put.
R /: to know the client's nutritional balance.

4. Observation position and the success of the sonde
R / menghundari risk for infection / irritation

5. Collaboration:
- Provision of diet / sonde on schedule
R / help meet the nutritional needs of the client because the client swallow reflex decrease.

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Activity Intolerance and Impaired Verbal Communication NCP for Myasthenia Gravis

Myasthenia gravis is characterized by weakness and rapid fatigue of any muscle out of control. The cause of myasthenia gravis is a breakdown in the normal communication between nerves and muscles. Myasthenia gravis can affect people of any age, but it often occurs in women younger than 40 and in men more than 60 years.

Myasthenia gravis can affect any muscle, but the most commonly affected are the muscles that control eye movements, eyelids, chewing, swallowing, coughing and facial expressions. Shoulders, hips, neck, muscles that control body movement and muscle that helps breathing can also attacked.

Myasthenia Gravis Patients are usually not the same from one person to another person. Based on the data, the disease is still relatively rare because the lack of knowledge about the symptoms of the disease.

The symptoms that arise are the some of the weaker muscles. The muscles most frequently attacked are the muscles that control eye movements, eyelids, speech, swallowing, chewing, and more severe respiratory muscles are attacked.

In 90% of patients with Myasthenia Gravis initial symptoms appear is the ocular muscles that cause the decrease eyelids and double vision. Clearly visible physically. Obviously the symptoms will appear and spread further attack other muscles. Until a more severe attack the respiratory muscles are usually visible from weakening cough. In fact there is shortness of breath and can be fatal.


Nursing Diagnosis for Myastenia Gravis

Activity intolerance related to muscle weakness

Characterized by:
Subjective Data:

• Patients say tired after doing the activity.
• Patients report muscle weakness.

Objective Data:

• Patient seems tired and listless.
• Patient was not able to take action to meet their daily needs.
• Increased pulse.
• Increased blood pressure.
• Breathing increases.
• Decreased muscle strength.

Outcomes:

• Full muscle strength.
• Atrophy does not occur.
• Good muscle tone.
• Patients can perform the activity gradually.
• Muscle weakness does not occur.

Intervention:
1. Assess the strength of muscles, ptosis, diplopia, eye movement, ability to chew, swallow, cough reflex, talk.
R /: The rate of muscle weakness may be different in other parts of the body.

2. Assess muscle strength before and after drug administration.
R /: Knowing the effects of drug administration.

3. Perform scheduled breaks, keep quiet surroundings.
R /: Period after the break, increased muscle strength.

4. Encourage participation in treatment.
R /: Train activity gradually.


Nursing Diagnosis for Myastenia Gravis

Impaired verbal communication related to muscle weakness.

Characterized by:
Subjective Data:

• Patients say difficulty speaking

Data Objective :

• Patients appear to difficulties in verbal expression.
• Changes in behavior are not willing to communicate.
• The use of sign language / body.

Outcomes:
Patients expressing themselves verbally or non-verbally.

Intervention:
1. Assess the patient's ability to speak with the examination of cranial nerves V, VII, IX, X, XII.
R /: knowing the patient's ability to speak.

2. Ask a closed question, yes or no or body movements.
R /: Facilitate patient easily answered.

3. Talk with slow motion.
R /: Can see the speaker's lip movements.

4. Use images, paper or other means.
R /: Using media allows patients to express desire.

5. Inform staff or family, about the limitations of the patient in communication.
R /: Communication patterns that one would add to the frustration of patients.

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Nursing Care Plan and 5 Diagnosis for Bronchitis

Acute bronchitis is an inflammation of the bronchi are usually the trachea and larynx, so often named by laringotracheobronchitis. This inflammation can arise as airway abnormalities alone or as part of a systemic disease, for example in morbili, pertussis, diphtheria, and typhoid abdominalis.

The term chronic bronchitis showed abnormalities in the bronchus that are chronic (long lasting) and is caused by various factors, including the factors that originate outside of the bronchus and bronchus itself. Chronic bronchitis is a condition associated with excessive tracheobronchial mucus production, causing a cough that occurs for at least three months in a year for more than two consecutive years.

There are three main factors that affect the incidence of bronchitis is smoking, infection and pollution.

1. Smoking
According to the Report of the WHO Expert Committee on Smoking Control, smoking is a major cause of bronchitis. There is a close relationship between smoking and decreased forced expiratory volume in 1 second. In pathological cigarettes associated with bronchial mucus gland hyperplasia and squamous metaplasia of respiratory epithelium can also cause acute bronchoconstriction.

2. Infection
Most often mistaken for bronchitis exacerbations preceded by a viral infection which then causes secondary bacterial infection. Bacteria isolated most is Hemophilus influenza and Streptococcus pneumoniae.

3. Pollution
Pollution is not so great influence as a causative factor, but when added to a higher risk of smoking. The chemicals can also cause bronchitis are reducing agents such as O2, oxidizing substances such as N2O, hydrocarbons, aldehydes, ozone.


Acute bronchitis can be a complication of pathologic abnormalities in several organs, namely:

• Chronic heart disease, which is caused by pathologic abnormalities in the valves and myocardium. Chronic congestion on the wall of the bronchus weaken resistance to bacterial infection easily occur.
• Paranasalis sinus infections and oral cavity, the area is a source of bacterial infections that can invade the wall of the bronchus.
• Dilatation of the bronchi (bronchiectasis), cause the composition and function of bacterial infection of the bronchial walls so easily happen.
• Smoking can cause paralysis of the bronchus mucous membranes vibrating bristles that impaired mucus drainage. The set of mucus is a good medium for bacterial growth.

5 Nursing Diagnosis for Bronchitis

1. Ineffective airway clearance r / t increased production of secretions.

2. Impaired gas exchange r / t obstruction of the airway by secretions, spasm of the bronchi.

3. Ineffective breathing pattern r / t bronchoconstriction, mucus.

4. Imbalanced Nutrition Less than Body Requirements r / t dyspnoea, anorexia, nausea, vomiting.

5. Risk for infection r / t secretions persistence, chronic disease processes.

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