Tuesday, September 25, 2012

Risk for impaired skin integrity related to pruritus, edema and ascites

Tuesday, September 25, 2012

Nursing Diagnosis and Interventions for Liver Cancer
  • Identify appropriate interventions for fiction specially condition.
  • Participate in techniques to prevent complications / enhance healing
  • Assess the skin of the side effects of cancer therapy. Notice of damage or slowing healing.
  • Wash with warm water and soap.
  • Encourage the patient to avoid scratching and patting dry skin from the scratching.
  • Invert / change positions often.
  • Instruct patient to avoid any skin creams, ointments and powders unless permission from a doctor.
  • Redness or radiation reaction effects can occur in the area of radiation can occur in the area of radiation. Dry desquamation and dry desquamation, ulceration.
  • Maintaining cleanliness without irritating the skin.
  • Helps prevent friction or trauma.
  • To improve circulation and prevent pressure on the skin / tissue unnecessarily.
  • Irritation or reaction can increase significantly.


Friday, August 31, 2012

Risk for Infection

Friday, August 31, 2012

Nursing Care Plan : Risk for Infection

Definition of Risk for Infection

The state in which an individual is susceptible to the pathogenic and opportunistic agents (viruses, fungi, bacteria, protozoa, or other parasites) from external sources, sources of exogenous and endogenous.

Related Factors

Related to the weakening of the immune host
Chronic disease
Renal failure
Hematological disorders
Diabetes mellitus
Hepatic disorders
Respiratory disorders
Collagen diseases
Changes or insufficiency leukocytes
Blood dyscrasias
Integumentary system changes
Periodontal Disease
Related to the weakening of the circulation
Peripheral vascular disease
Related to the entry of the organism
Total parenteral nutrition
The presence of invasive duct
Enteral feeding
Related to the weakening of host resistance
Radiation therapy
Organ transplants
Drug therapy (eg, chemotherapy, immunosuppressants)
Situational (Personal, environmental)
Related to the weakening of host resistance
Prolonged immobilization
His stay in hospital increased
History of infection
Related to the organism
Postpartum period
Bite (animals, humans, insects)
Thermal injury
Environment warm, moist, dark (skin folds, splint)
Related to contact infectious agents (nosocomial or acquired from the community)
Related to increased vulnerability of infants
Lack of maternal antibodies
Lack of normal flora
Open wounds (umbilicus, circumcision)
(Baby / child)
Related to vulnerability
Less immunization
Related to vulnerability of the elderly
Conditions that weaken
Decrease the immune response
Multiple chronic diseases

Expected outcomes

Individuals will:
1. Techniques showed a very careful hand washing.
2. Free from the nosocomial infection during hospitalization
3. Demonstrate the ability of the risk factors associated with infection and to take appropriate precautions to prevent infection


1. Identification of individuals at risk of nosocomial infection
a. Assess the predictor
- Infection (preoperative)
- Abdominal or thoracic surgery
- Operating more than 2 hours
- Procedure genitouranius
- Instrumentation (ventilator, suction, catheter, nebulizer, tracheostomy, noninvasive monitoring tool)
- Aestesia
b. Assess the factors that confound
- Age younger than 1 year old, or older than 65 years
- Obesity
- The conditions of the underlying disease (COPD, diabetes, cardiovascular disease)
- Drug abuse
- Nutritional Status
- Smokers
2. Reduce organisms that enter the body
a. Wash hands carefully
b. Antiseptic techniques
c. Isolation
d. Necessary diagnostic or therapeutic procedures
e. Reduction of microorganisms that can be transmitted through the air
3. Protect individuals from infection immune deficit
a. Instruct individuals to request to all visitors and personnel to wash their hands before approaching individual.
b. Limit visitors when possible
c. Limit invasive tools (IV, laboratory specimens) to really need it.
d. Teach individuals and family members signs and symptoms of infection
4. Reduce individual susceptibility to infection
a. Push and hold the input of calories and protein in the diet (see Changes in nutrition).
b. Monitor the use or overuse of antimicrobial therapy.
c. Give antimicrobial therapy was prescribed in 15 minutes of the scheduled time
d. Minimize the length of stay in hospital
5. Observe the clinical manifestations of infection (eg, fever, cloudy urine, purulent drainage)
6. Instruct individuals and families to know the causes, risks and the strength of transmission of infection.
7. Report infectious diseases.


Wednesday, August 22, 2012

Risk for Decreased Cardiac Output related to Uncontrolled Hyperthyroidism

Wednesday, August 22, 2012

Nursing Diagnosis for Hyperthyroidism : Risk for Decreased Cardiac Output
Nursing Diagnosis for Hyperthyroidism : Risk for Decreased Cardiac Output related to Uncontrolled Hyperthyroidism

The client will maintain adequate cardiac output in accordance with the needs of the body, with the following criteria:
  • Peripheral pulse can be felt normal.
  • Vital sign within normal limits.
  • Normal capillary refill
  • Good mental status
  • No dysrhythmias

Nursing Interventions :
1. Monitor your blood pressure at the position of lying, sitting and standing if possible. Note the magnitude of the pressure pulse.
2. Check for chest pain or angina patient complained.
3. Auscultation breath sounds. Note the presence of abnormal noise.
4. Observation of signs and symptoms of severe thirst, dry mucous membranes, pulse
weakness, decreased urine output, and hypotension.
5. Record input and output.

1. Orthostatic hypotension or general can occur as a result of excessive peripheral vasodilatation and a decrease in circulating volume.
2. A sign of increased oxygen demand by the heart muscle or ischemia.
3. S1 and prominent murmur associated with cardiac output increased in hypermetabolic state.
4. Rapid dehydration can occur which will reduce the volume of circulation and decrease cardiac output.
5. Losing too much fluid can cause severe dehydration.


Tuesday, August 21, 2012

Risk for Social Isolation related to Communication Barriers - Tinnitus

Tuesday, August 21, 2012

Nursing Diagnosis for Tinnitus
Nursing Diagnosis for Tinnitus :
Risk for Social Isolation related to communication barriers

Tinnitus is a hearing loss, with complaints of feeling heard no sound from external stimuli. Complaint may be a sound buzzing, roaring, hissing, or a variety of other sounds. Symptoms can appear continuous or intermittent.

The causes of tinnitus are very diverse, some of the causes include:

Dirt in the ear canal, which, if already in the clear ringing flavor will be lost.
Infections of the middle ear and the inner ear.
Blood disorders.
Blood pressure is high or low, where it stimulates the auditory nerve.
The disease Meniere's syndrome, in which the pressure of fluid in the cochlea increases, causing decreased hearing, vertigo, and tinnitus.
Drug toxicity.
The use of drugs known as aspirin, etc..

Risk for Social Isolation related to communication barriers

Goals / Criteria results:

Risk for Social Isolation can minimize

  • Assess difficulty hearing
  • Assess how severe the hearing loss in the client experience
  • If possible, help clients understand nonverbal communication
  • Encourage clients with hearing aids every in need if available.