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Dengue Fever

Nanda Nursing Diagnosis for Dengue FeverDengue Fever

Dengue fever is an acute febrile disease caused by dengue virus and is spread through the medium of the Aedes aegypti mosquito, which had been infected with the dengue virus. Dengue fever is divided into two, namely: dengue fever and dengue hemorrhagic fever. Dengue hemorrhagic fever is a more severe form of dengue fever, bleeding and shock, which can sometimes occur that result in death.

Here are the Symptoms of Dengue Fever:
  • Sudden high fever continuously.
  • Headache especially in the forehead.
  • Pain in the back of the eyeball.
  • Pain in the body or joints.
  • Nausea / vomiting.
  • Reddish face.
  • Acute fever for 2-7 days, accompanied by headache, sore muscles and joints.
  • Be accompanied by a decrease of platelets.
  • The heat will go down in the third or fourth day.
  • Better cure rates.
Dengue Haemorrhagic Fever:
  • Sudden high fever, accompanied by headache, pain in the back of the eyeball, sometimes abdominal pain.
  • There are signs of a rash or red spots on the skin.
  • Not accompanied by a cough or sore throat.
  • Platelets and leukocytes down (less than 100,000)
  • An increase in hematocrit (up 20 percent of normal).
  • Bleeding in the soft tissues (nose, mouth, or gums).
  • Plasma leakage occurs. The more leaks can cause shock.
  • Pain in the gut are continuous.
  • Bleeding at the nose, mouth, gums or skin bruising.
  • Persistent vomiting, sometimes accompanied by blood.
  • Fecal droppings are blackish in color, due to the occurrence of bleeding in internal organs.
  • Excessive thirst.
  • The skin is pale and cold.
  • Decreased consciousness and somnolence.
Measures that can be done

Currently, the main methods used to control and prevent the occurrence of dengue hemorrhagic fever is to make the eradication of the mosquito Aedes aegypti as a dengue virus spreaders.

Mosquito Aedes aegypti can be indoors or outdoors. Inside the house are usually mosquitoes like to hide in dark places like closets, coat hanger, under beds, etc.. While outside the home when the mosquito Aedes aegypti is like the shade and moist. The female mosquito will usually put their eggs in water containers around homes, schools, offices, etc., where the eggs can hatch within 10 days.
Therefore, measures to drain the water bath, cover the places that contain water and bury the discarded items can be a puddle of water is very important to do, not just by governments alone but by all members of society so that the mosquito Aedes aegypti can be restricted existence.

Nursing Diagnosis for Dengue Fever
  1. Deficient Fluid Volume
  2. Ineffective Peripheral Tissue Perfusion
  3. Imbalanced Nutrition Less Than Body Requirements
  4. Hyperthermia

Risk for Infection - Nursing Care Plan for Tuberculosis

Risk for Infection - Nursing Care Plan for TuberculosisNursing Diagnosis for Tuberculosis : Risk for Infection related to inadequate primary defenses, decreased ciliary function / static discharge, malnutrition, environmental contamination, lack of information about the bacterial infection.

Expected outcomes are:
  • Identify interventions to prevent / reduce the risk of spreading infection.
  • Show / lifestyle changes to promote a safe environment.
Nursing Interventions: Risk for Infection - Nursing Care Plan for Tuberculosis:

1. Review of pathology of the disease phase (active / inactive) the spread of infection, through the bronchi of the surrounding tissues or the bloodstream or lymph system and the risk of infection through coughing, sneezing, spitting, laughing, kissing, or singing.
Rational: Helping the patient to want to understand and accept the therapy given to prevent complications.

2. Identification of persons at risk for infections such as family members, friends, people in one assembly.
Rational: People who are at risk to drug treatment programs to prevent the spread of infection.

3. Instruct the patient to close mouth and remove phlegm in an enclosed shelter if the cough.
Rational: This habit is to prevent transmission of infection.

4. Use a mask every action.
Rational: Reduce the risk of spreading infection.

5. Monitor the temperature.
Rational: febrile, an indication of infection.

6. Identification of individuals at high risk for pulmonary tuberculosis re-infection, such as: alcoholism, malnutrition, intestinal bypass surgery, using immune-suppressing drugs / corticosteroids, presence of diabetes mellitus, cancer.
Rationale: Knowledge of these factors help the patient to change lifestyle and avoiding / reducing conditions worse.

7. Emphasize not to discontinue therapy undertaken.
Rational: contagious period can occur only 2-3 days after onset of chemotherapy if it happens cavity, the risk, the spread of infection can continue for 3 months.

Collaboration:

8. Monitor sputum smear
Rational: To monitor the effectiveness of drugs and their effects as well as patient response to therapy.

Sample of Nursing Diagnosis - Interventions for Gastritis

Nursing Diagnosis for GastritisNursing Care Plan for Gastritis : Sample of Nursing Diagnosis and Nursing Interventions


1. Nursing Diagnosis: Risk for Fluid Volume Deficit related to inadequate intake and excessive fluid output (nausea and vomiting)

Goal:
After nursing actions, adequate fluid intake.

Expected outcomes are:
  • The mucosa of the lips moist
  • Good skin turgor
  • Good capillary refill
  • Input and output balanced
Nursing Interventions:
  • Fill your individual needs. Encourage clients to drink.
  • Provide additional IV fluids as indicated.
  • Monitor vital signs, evaluation of skin turgor, capillary refill and mucous membranes.
  • Collaboration: the provision of drugs.
Rational:
  • Adequate fluid intake will reduce the risk of patient dehydration.
  • Replacing lost fluids and improve fluid balance in the immediate phase.
  • Indicate the status of dehydration or the possibility of the need to increase fluid replacement.
  • Provision of drugs serves to inhibit gastric acid secretion.
2. Nursing Diagnosis: Acute pain related to irritation of the gastric mucosa secondary to psychological stress.

Goal:
After the act of nursing, pain can be reduced, patients can rest and generally good condition.

Expected outcomes are:
  • Clients express the pain diminished or disappeared.
  • The client does not grimace in pain.
  • Vital signs are within normal limits.
  • The pain intensity was reduced (reduced pain scale 1-10).
  • Demonstrate relax, rest, sleep, increased activity quickly.
Nursing Interventions:
  • Investigate complaints of pain, note the location, intensity of pain, and pain scale.
  • Instruct patient to report pain as soon as it began.
  • Monitor vital signs.
  • Explain the causes and effects of pain on the client and his family.
  • Encourage rest during the acute phase.
  • Encourage relaxation techniques.
  • Provide an environment conducive situation.
  • Collaboration with the medical team in the delivery of the action.
Rationale:
  • To find out where the pain and facilitate interventions to be performed.
  • Early intervention to facilitate recovery of muscle control pain by decreasing muscle tension.
  • Autonomic responses include, changes in blood pressure, pulse, respiration, associated with pain relief.
  • With the causes and consequences of pain the client is expected to participate in treatment to reduce pain.
  • Reduce pain that was exacerbated by movement.
  • Decrease muscle tension, increase relaxation, and increased sense of control and coping abilities.
  • Provide support (physical, emotional, increased sense of control, and coping skills).
  • Eliminate or reduce the client's complaints of pain.

3. Nursing Diagnosis : Imbalanced Nutrition: Less Than Body Requirements related to the lack of food intake.

Goal:
After the patient's nutritional needs of nursing actions are met.

Expected outcomes are:
  • General condition is quite
  • Good skin turgor
  • Increased weight
  • Difficulty swallowing is reduced
Nursing Interventions :
  • Instruct patient to eat small meals but frequently.
  • Give soft foods.
  • Perform oral hygiene.
  • Measure weight basis.
  • Texture observation, the patient's skin turgor.
  • Observations of nutritional intake and output.
Rationale:
  • Keeping the patient remained stable nutritional prevent nausea and vomiting.
  • To facilitate the patient to swallow.
  • Oral hygiene can stimulate the appetite of the patient.
  • Knowing the development of nutritional status of patients.
  • Knowing a patient's nutritional status.
  • Knowing a patient's nutritional balance.

Sample of Assessment - Nursing Care Plan Gastritis

Sample of Nursing Care Plan for Gastritis

Nursing Assessment
  1. Anamnese include:
    • Name :
    • Age :
    • Gender :
    • Type of work :
    • Address :
    • Tribe / Nation :
    • Religion :
    • The level of education: for those with low education level / low gain knowledge of gastritis, it will underestimate the disease, even just think of gastritis as upset stomach and will eat regular foods that can cause and exacerbate the disease.
    • History of illness and health
      • The main complaint: Pain in the pit of the stomach and lower right abdomen.
      • History of the disease at this time: Covers the journey of illness, initial symptoms are felt from the client, complaints arise suddenly or gradually felt, trigger factors, efforts to resolve the issue.
      • Past history of disease: Includes diseases associated with the disease now, history of the hospital, and a history of drug use.


  2. Physical examination, the Review of systems (ROS)

    General condition: there was pain on physical examination there is tenderness in the epigastric quadrants.
    • B1 (breath): tachypnea
    • B2 (blood): tachycardia, hypotension, dysrhythmias, weak peripheral pulses, peripheral charging slow, pale skin color.
    • B3 (brain): headache, weakness, level of consciousness can be disturbed, disorientation, pain epigastrum.
    • B4 (bladder): oliguria, fluid balance disorders.
    • B5 (bowel): anemia, anorexia, nausea, vomiting, heartburn, intolerance to spicy foods.
    • B6 (bone): fatigue, weakness


  3. Assessment Focus
    1. Activity / Rest
      Symptoms: weakness, fatigue
      Signs: tachycardia, tachypnea / hyperventilation (in response to activity)

    2. Circulation
      Symptoms: weakness, sweating
      Signs:
      • Hypotension (including postural)
      • Tachycardia, dysrhythmias (hypovolemia / hypoxemia)
      • Weak peripheral pulse
      • Slow capillary refill (vasoconstriction)
      • Skin color pale, sianosis (depending on the number of blood loss)
      • Weakness of skin / mucous membranes, sweating (shows status of shock, acute pain, psychological responses)

    3. Ego integrity
      Symptoms: acute or chronic stress factors (financial, labor relations), feelings of helplessness.
      Sign: a sign of anxiety, such as anxiety, pallor, sweating, narrowing of attention, shaking, trembling voice.

    4. Elimination
      Symptoms: a history of previous hospitalization due to bleeding gastroenteritis (GE) or problems associated with GE, such as injury or gastric ulcer, gastritis, gastric surgery, gastric irradiation area. Changes in bowel habit / characteristic stool.
      Signs:
      • Abdominal tenderness, distention
      • Bowel sounds: often hyperactive during hemorrhage, hypo-active after the bleeding.
      • The characteristics feses: diarrhea, blood color of dark, brownish or sometimes red bright, foamed, odor rotten (steatorrhoea), constipation can occur (a change diet, the use of antacids).
      • Urinary output: decreased, concentrated.

    5. Food / fluid
      Symptoms:
      • Anorexia, nausea, vomiting (throwing up that extends beyond the pyloric obstruction suspected in connection with a duodenal injury),
      • Swallowing problems: hiccups
      • Heartburn, sour belching, nausea or vomiting
      Symptoms: vomiting with a dark coffee color or bright red, with or without blood clots, dry mucous membranes, decreased mucus production, poor skin turgor (chronic bleeding).

    6. Neurosensory
      Symptoms: flavor pulsed, dizziness / sick heads because of rays, weakness.
      Sign: the level of consciousness can be impaired, the range of slightly inclined to sleep, disorientation / confusion, fainting and coma (depending on the volume of circulation / oxygenation).

    7. Pain / Comfort
      Symptoms:
      • Pain, described as a sharp, shallow, burning, stinging, sudden severe pain may be accompanied by perforation. Sense of discomfort / distress faint after eating a lot and lost with a meal (acute gastritis).
      • Pain epigastrum left until the middle / back or spread to occur 1-2 hours after eating and relieved by antacids (gastric ulcers).
      • Pain left to epigastrum / or spread to his back occurred approximately 4 hours after eating when the stomach is empty and relieved by food or antacids (duodenal ulcer).
      • No pain (esofegeal varices or gastritis).
      • Trigger factors: food, cigarettes, alcohol, the use of certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors.
      Signs: wrinkled face, be careful in the area of ​​pain, pallor, sweating, narrowing attention.

    8. Security
      Symptoms: allergy to the drug / sensitive
      Sign: an increase in temperature, spider angioma, palmar erythema (showing cirrhosis / portal hypertension)

    9. Guidance / Learning
      Symptoms: the use of prescription drugs

Nursing Interventions for Acute Pain - BPH Benign Prostatic Hyperplasia

BPH Nursing Diagnosis Acute PainNursing Diagnosis: Acute Pain - BPH Benign Prostatic Hyperplasia

Acute Pain Definition: Sensory and unpleasant emotional experience arising from actual or potential tissue damage, appear suddenly or slowly with mild to severe intensity with which the end can be anticipated or expected and lasted less than 6 months.

Related factors: Agents injury (biological, chemical, physical, psychological)

Acute pain - Limitation of Characteristics:
  • Reports of verbal or non verbal pain
  • The fact of the observation
  • The position to avoid pain
  • The movement to protect
  • Cautious behavior
  • Face masks
  • Sleep disturbance (glazed eyes, looking tired, it is difficult or chaotic motion, grinning)
  • Focused on self-
  • The focus narrows (decreasing the perception of time, damage to the thought process, decreased interaction with people and the environment)
  • Distraction behavior, eg roads, meet other people and / or activities, repetitive activities)
  • Autonomic responses (such as diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils)
  • Changes in muscle tone, autonomic (probably in the range from weak to stiff)
  • Expressive behavior (eg, restlessness, moaning, crying, alert, iritabel, breath / sigh)
  • Changes in appetite and drinking.

Goal :

1. Control Pain
Definition: a person's actions to control pain
Indicators:
  • Know the factors that cause
  • Know the onset / timing of pain
  • Non-analgesic relief measures
  • Using the analgesic
  • Reported the symptoms to the health care team (doctors, nurses)
  • Pain can be controlled
Description:
1 = not done
2 = rarely done
3 = sometimes done
4 = often done
5 = always done

2. Shows the level of pain
Definition: the severity of pain reported or indicated
Indicators:
  • Reported pain
  • Frequency of pain
  • The duration of pain episodes
  • The expression of pain: facial
  • The position of protecting the body
  • Anxiety
  • Changes in respiration rate
  • Changes in Heart Rate
  • Changes in blood pressure
  • Changes in pupil size
  • Perspiration
  • Loss of appetite
Description:
1: weight
2: a little heavy
3: medium
4: a little
5: no


Nursing Interventions for Acute Pain - BPH Benign Prostatic Hyperplasia

1. Pain Management
Definitions: change or reduction of pain to an acceptable level of patient comfort.

Intervention:
  • Assess thoroughly about pain, including: location, characteristics, time of occurrence, duration, frequency, quality, intensity / severity of pain, and trigger factors.
  • Observation of non-verbal cues of discomfort, especially in the inability to communicate effectively.
  • Give analgesics in accordance with the recommendation.
  • Use a personal communication that the client can express therapeutic pain.
  • Assess the client's cultural background.
  • Determine the impact of the expression of pain on quality of life: sleep patterns, appetite, activities, mood, relationships, work, responsibility roles.
  • Assess the individual's experience of pain, a family with chronic pain.
  • Evaluation of the effectiveness of the actions that have been used to control pain.
  • Provide support to clients and families.
  • Provide information about pain, such as: the causes, how long the case, and precautions.
  • Control of environmental factors that may affect the client's response to discomfort (eg, room temperature, irradiation, etc.).
  • Encourage clients to monitor their own pain.
  • Teach the use of non-pharmacological techniques. (Ex: relaxation, guided imagery, music therapy, distraction, application of heat and cold, massase).
  • Evaluate the effectiveness of measures to control the pain.
  • Modification of pain control measures based on client responses.
  • Increase the sleep / rest.
  • Encourage clients to discuss precisely the experience of pain.
  • Tell your doctor if action is not successful or event of a complaint.
  • Inform other healthcare team / family members when action nonfarmakologi done, to a preventive approach.
  • Monitor the comfort of the client to pain management.
2. Provision of Analgesic
Definition: the use of pharmacological agents to reduce or eliminate pain.

Intervention:
  • Determine the location of pain, characteristics, quality, and severity before treatment.
  • Give the drug to the principle of "5 right".
  • Check the history of drug allergy.
  • Involve the client in the electoral analgesics to be used.
  • Select the appropriate analgesic / analgesic combination of more than one if it has been prescribed.
  • Monitor vital signs before and after administration of analgesics.
  • Monitor adverse drug reactions and medication.
  • Document the response of the effects of analgesic and unwanted.
  • Perform actions to reduce analgesic effects (constipation / stomach irritation).
3. Environmental management: comfort
Definition: manipulate the environment for therapeutic benefit.

Intervention:
  • Choose a room with the right environment.
  • Limit visitors.
  • Determine the things that cause discomfort such as damp clothing.
  • Provide a comfortable bed and clean.
  • Determine the most comfortable room temperature.
  • Provide a quiet environment.
  • Pay attention to hygiene to maintain patient comfort.
  • Adjust the position of the patient made ​​comfortable.

Source : http://nursesnanda.blogspot.com/2012/07/nursing-interventions-for-acute-pain.html

Example of Nursing Diagnosis - Benign Prostatic Hyperplasia (BPH)

Nursing Diagnosis for BPHNursing Care Plan for Benign Prostatic Hyperplasia

BPH - Example of Nursing Diagnosis



Nursing Assessment of benign prostatic hyperplasia (BPH)

1. Before Operation

a. Subjective Data :
  • The client told pain while urinating.
  • Difficult urination.
  • Increased frequency of urination.
  • Frequent waking at night for micturition.
  • The desire to urinate can not be postponed.
  • Pain or feel hot at the time of micturition.
  • Jets of urine fell.
  • Not satisfied after micturition, the bladder does not empty properly.
  • If you want to have to wait long micturition.
  • The amount of urine decreased and should straining during urination.
  • The flow of urine is not smooth / disjointed.
  • Urine continue dripping after urination.
  • Feeling tired, no appetite, nausea and vomiting.
  • The client was concerned with the treatment to be performed.
b. Objective Data
  • Facial expressions seem to hold the pain.
  • Posted catheter.
2. After Surgery

a. Subjective Data
  • The client told pain in postoperative wound
  • The client says do not know about diet and medication after operation
b. Objective Data
  • Expression of pain appears to hold
  • There is a closed postoperative wound dressing
  • Looks Weak
  • Installed irrigation hoses, catheters, infusion

Medical History

Past medical history, history of present illness, family history of disease, BPH impact on patient's lifestyle, whether the patient experienced urinary problems.


Physical Assessment

1) Disturbances in urination, such as:
  • Frequent urination
  • Waking at night to urinate
  • Feeling like a very urgent micturition
  • Pain during micturition, weak urinary jet
  • Not satisfied after micturition
  • The amount of urine decreased and should straining during urination
  • The flow of urine is not smooth / broken, urine continues to drip after urination.
  • Pain when urinating
  • There was blood in the urine
  • The bladder feels full
  • Pain in the waist, back, stomach discomfort.
  • Urine is retained in the bladder, bladder distention occurs
2) Common symptoms such as fatigue, no appetite, nausea, vomiting, and epigastric discomfort
3) Assess the status of emotions: anxiety, fear
4) Examine the urine: the number, color, clarity, odor
5) Assess vital signs

Diagnostic examination
  • Radiographic Examination
  • Urinalysis
  • Lab such as blood chemistry, complete blood, urine
Assess the level of understanding and knowledge of the client and family about the situation and the disease process, treatment and care on the way home.

BPH Benign Prostatic HyperplasiaNursing Diagnosis for Benign Prostatic Hyperplasia

a. BPH - Pre Surgery :
  1. Acute Pain
  2. Anxiety
  3. Imbalanced Nutrition Less Than Body Requirements
  4. Impaired Urinary Elimination

b. BPH - Post Surgery :
  1. Acute pain
  2. Risk for Infection
  3. Knowledge Deficit: about the disease, diit, and treatment
  4. Self care deficit

Source : http://nursesnanda.blogspot.com/2012/07/example-of-nursing-diagnosis-benign.html