Altered Peripheral Tissue Perfusion - Nanda Nursing Diagnosis


Circumstances where an individual experiencing or at risk of a decline in nutrition and respiration at the cellular level, a decrease in peripheral capillary blood supply.

Related Factor:
Related to the weakening of blood flow
(Vascular disorders)
Arterial thrombosis
Of deep venous thrombosis
Collagen vascular disease
Rheumatoid arthritis
Diabetes mellitus
Diskariasis blood (platelet disorders)
Renal failure
Cancer / tumor
Varicose veins
Burger's Disease
Sickle cell crisis
Cirrhosis alcoholism
Related to immobilization
Related to the flow of invasive
Related to the pressure on place / constriction (bandages, stockings)
Related to vascular trauma
Situational (Personal, environmental)
Related to the pressure of the enlarged uterus on the peripheral circulation
Related to the pressure of the enlarged abdomen in the pelvic and peripheral circulation
Related to the collection hanging venosa
Related to hypothermia
Related to vasoconstriction effects of tobacco
Related to a decrease in circulating volume: dehydration

Major Data

Decrease or absence of a pulse
Changes in skin color
Pale (arterial)
Cyanosis (Vena)
Reactive hyperemia (arterial)
Changes in skin temperature
Cooler (arterial)
Warmer (venous)

Expected outcomes

Individuals will:
1. Identifying factors that increase peripheral circulation faktro
2. Identify the necessary lifestyle changes
3. Identify how medical, diet, medication, activity increases vasodilation
4. Reported a decrease in pain
5. Describes when to call the doctor / health


1. Teach individuals to
a. Maintain the limb in a dependent position
b. Maintaining extremities warm (do not use heating pads or hot botolair, because individuals with peripheral vascular disease may experience disturbances of sensation and not be able to determine if heat damage tissue, the use of external heating can also increase the metabolic needs of the tissues through its capacity limit.
c. Reduce the risk of trauma
- Change position at least every hour
- Avoid crossing legs
- Reduce the external pressure (eg, narrow shoes)
- Avoid skin pelundung of Tumut
- Encourage range of motion exercises
2. Plan a program runs every day
a. Instruct individuals in the reasons for the program
b. Teach individuals to avoid fatigue
c. Instruct to avoid an increase in the exercise to be assessed by a doctor for heart problems
d. Make sure the running back does not hurt individual vein or muscle.
3. Teach the factors that increase the flow of venous blood
a. Elevate the extremity above the heart, unless there are contraindications eg, heart disease, respiratory disorders.
b. Avoid standing or sitting with feet hanging for a long time.
c. Consider the use of bandages or elastic stockings below the knee to prevent static vein.
d. Reduce or remove the external vein compression disrupting the flow of the vein.
- Avoid pillows behind the knee or knee brace bed.
- Avoid crossing of the lower leg
- Change the position, move the limb or finger shaking legs every hour
- Avoid the use of garter and stocking thin above the knee.
4. Measure the base circle of the calves and thighs, if the individual risk of deep venous thrombosis or if it is suspected
5. Teach individuals to
a. Avoid long trips by car or plane, when the inevitable up and running at least every hour.
b. Keep the skin dry lubricated (broken skin eliminating physical barriers to infection)
c. Use warm clothing during cold weather
d. Use cotton or wool socks
e. Avoid dehydration in hot weather
f. Give special attention to the feet and toes.
- Wash and dry feet thoroughly every day
- Not merandam both feet
- Avoid harsh soaps or chemicals including iodine on foot
- Keep your nails cut and refined in a state
g. Observe the feet and lower legs against injury and suppression
h. Use clean socks
i. Use shoes that support, fit and comfortable
j. Observe the inside of shoes every day for rough lines.
6. Teach about the modification of risk factors
a. Diet:
- Avoid foods high in cholesterol
- Modify the input of sodium to control hypertension
- Refer to a dietitian
b. Relaxation techniques to reduce the effects of strs
c. Stop smoking
d. Exercise program

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Fluid Volume Deficit - Nanda Nursing Diagnosis

Nursing Care Plan Fluid Volume Deficit

The state in which an individual who did not undergo a period of fasting or at risk of dehydration vascular, interstitial, or intravascular.

Related Factor:

Dealing with excessive urine output
Uncontrolled diabetes.
Related to increased capillary permeability and evaporative loss to the road because it burns
Related to increased fluid loss
Drainage abnormal
Related to nausea / vomiting
Related to decreased motivation to drink fluids
Related to this diet
Related to food through a tube with a high dissolved
Related to difficulty swallowing or eating alone
Mouth pain, sore throat
Related to heat / excessive sunlight, drought.
Related to lose through:
Indwelling catheter
Related to insufficient fluid for the efforts sport or weather conditions.
Related to the excessive use of:
Laxative or enema
Diuretics or alcohol.
(Baby / child)
Related to increased vulnerability of the body
The decline acceptance fluid
Decrease in urine concentration
Related to increased vulnerability of the body
The decline acceptance fluid
Decrease in thirst sensation

Major data
  • Insufficient oral fluid intake
  • Negative balance between input and output
  • Weight loss
  • Skin / mucous membranes dry
Minor data
  • Increased serum natriun
  • Decreased urine output or the output of redundant
  • Concentrated urine or frequent urination
  • Decreased skin turgor
  • thirst / nausea / anokresia
Expected outcomes

Individuals will:
1. Increasing fluid intake at least 2000 ml / day (unless contraindicated)
2. Telling the need to increase fluid intake during heat stress or
3. Retaining urine specific gravity within normal limits
4. Show no signs and symptoms of dehydration


1. Assess the likes and dislikes; give a favorite drink within the diet
2. Plan your fluid intake goals for each turn (eg, 1000 ml during the morning, afternoon 800 ml, and 200 ml of the evening)
3. Assess the individual's understanding of the reasons to maintain adequate hydration and methods for achieving goals fluid intake.
4. For children, offering:
a. Liquid forms an interesting (popsicle, chilled juices, ice cone)
b. Unusual Containers (colored cups, straws)
c. A game or activity (tell kids to drink when the time came for the child)
5. Encourage the individual to maintain a written report of fluid intake and urine output, if necessary.
6. Monitor input; make sure at least 1500 ml orally every 24 hours.
7. Monitor the output of; make sure at least 1000-1500 ml per 24 hours.
8. Monitor urine specific gravity
9. Measure your weight every day with the same kind of clothes, weight loss of 2% -4% indicates mild dehydration, 5% -9% moderate dehydration.
10. Teach that coffee, tea, and juice grapes cause diuresis and can increase fluid loss.
11. Consider additional fluid loss associated with vomiting, diarrhea, fever, drein hose.
12. Monitor blood electrolyte levels, blood urea nitrogen, urine and serum osmolality, creatinine, hematocrit, and hemoglobin.
13. For wound drainage:
a. Maintain accurate records on the number and type of drainage.
b. Weigh bandage, if necessary, to estimate fluid loss.
c. Dressing the wound to minimize fluid loss.

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Clean Water Management

  • Drinking water is water quality, qualified health and can be drunk immediately.
  • Clean water is the water that is used day-to-day quality, qualified health and can be taken when it is cooked.
Benefits of Water
In human life the water used for all activities. Some kinds of various water use as follows:
  • Domestic consumption such as bathing, washing, eating, drinking, rinsing the mouth, etc..
  • The use of industry
  • Transport / shipping
  • Medical power source
  • Farm / agriculture / irrigation
  • recreation
  • Decomposition of dirt
  • Research, science
  • Spiritual, cultural

For everyday purposes, the water can be obtained from a number of sources including:

1. Rainwater
Rainwater is a sublimation of cloud / water vapor into pure water when it comes down and through the air will dissolve objects contained in the air. Objects are dissolved from the air are:
  • Gases (O2, CO2, N2, etc.)
  • Microscopic bodies
  • Dust
2. Surface Water
Surface water is one source that can be used for raw water.
Were included into the surface water is water that comes from:
  • river
  • gutter
  • swamp
  • trench
  • dam
  • lake
  • sea
3. Ground water
Most of the rain that reaches the earth surface will absorb into the soil and groundwater will be. Before reaching the ground water layer where rain water would penetrate several layers of soil while changing its nature.
  • Topsoil
  • Subsoil
  • Limestone

Terms Healthy Drinking

Drinking water does not cause the disease, then the water should strive to fulfill the health requirements. Healthy water must have the following requirements:

1. Physical Terms
Physical requirements for safe drinking water is clear (colorless), no taste, temperature under air outside it so that in everyday life, how to recognize water that meets the physical requirements is not difficult.

2. Bacteriology Terms 
Water for drinking purposes should be free of any bacteria. Especially bacterial pathogens. How to know if drinking water contaminated by pathogenic bacteria is by examining a sample (eg water).

3. Chemical Terms
Safe drinking water should contain specific substances within a certain amount anyway. Deficiency or excess of any chemicals in the water that causes fisioogis disorders in humans.


There are several ways through the water treatment process is as follows:

1. Disposal of objects that float, drift and settle
This thing needs to be removed first in order not to further disrupt water purification process. To use the filter process trellis.
Trellis filter is composed of iron rods as trellis window. Water flowed through the iron trellis. In this filter object stuck in the trellis transported and disposed of in an iron rake like claws. The water is still murky mud flowed into the deposition bath.

2. Deposition of silt.

In the siltation basin water flows slowly. The goal then the tub is wide and deep enough so that the mud settles and the water had become somewhat clear. When the water is suspected to contain bacteria too much then frequent disinfection at this stage is known as the initial chlorination.

3. Screening

The water then filtered using a rapid sand filter. In this filter objects floating detained mechanically by sand pores. Filtered water will flow by itself down through the pores between the sand grains due to the force of gravity.

4. Disinfection by chlorination
The application of water with chlorine disinfection of water is a great way in order that the water is free of pathogenic germs. By chlorination is not intended to obtain sterile water in water.

5. Storage
Once filtered water is stored in a large reservoir, to prevent any pathogens surviving in the water then the water will be disinfected before being distributed to residents.

6. Distribution
       The water was crystal clear and safe will be streamed through the pipes to the houses. In this distribution to note the time of day in which water use peaked and declined, hot or cold weather will affect fluctuations in water consumption.

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Stress and Various Body Reaction

Stress is often defined briefly as the pressures often faced everyday. At issue come off, people often define themselves easily in these circumstances.

In fact, if you want in terms of a complete medical, stress covers a very wide aspect included in the reactions they cause the body's systems, in other words, stress is not only related to the mind forever.

The complete, stress can be defined as a physical and spiritual burden that cross the threshold of one's body, and indeed, in terms of the most common, many stress triggers associated with emotional factors including thoughts, though besides that contributes to physical factors As with the trigger.

There are many physical factors that are meant here, including air pollution, temperature, heat, noise exceeds the threshold, and so on, in other words, the environment is very easy to come up as these stressors.

Stress and Various Body Reaction

People often do not realize that stress factors closely related to the body's reaction to adverse health. The cause of most diseases today, from a lot of research done by the experts, find stress plays an important role in causing serious illness and even play a role in cell mutation causing periodic cancer cases.

The background is actually the main trigger for the reaction that resulted in a set of circumstances where the body ended up losing a lot of important aspects in the working process so that one can be drastically lowered immune system, as the main factors that play a role in fighting the disease. When we deal with stress, the body will hold in an integrated response to deal with stressors (things that act as triggers stress) is.

There are several mechanisms that have now proven, and some are associated with hormonal systems, which stress will automatically cause the brain to enable the system to trigger the secretion of hormones.

And experts say this hormonal mechanism may explain the lower resistance of the state of stress is induced, at least as one of the most relevant factors to find the relationship significantly.

Stress and Hormonal Factors

From some research, most trigger secretion of stress hormone cortisol, which this hormone will then work to coordinate all systems in the body including the heart, lungs, circulation, metabolism and immune system in the reaction it causes.

The secretion of this hormone explains why when faced with stress in blood pressure and heart rate increases rapidly. The increase in the respiratory system is the lungs will cause extra work to pick up more oxygen to increase blood circulation also in all parts of the body from the muscles to the brain, and the increase mentioned some research can go up to 300% beyond normal limits.

As a result, not only can feel the heart pounding, but the whole body including the transpiration system will also increase rapidly.

In addition to the hormone cortisol, there are other hormones that play a role in this reaction, including catecholamine hormones composed of active substance dopamine, norepinephrine and epinephrine are more commonly known as adrenaline. Besides increasing the secretion of hormones that closely related to the increase in the body's systems work, catecholamines was also turns on a system of long-term memory will recall the same stressor on subsequent events and suppress parts of the brain that play a role in short-term memory.

In one study, short-term memory suppression is considered the experts as the main factors that cause people no longer can easily think rationally when they are affected by stress.

Immune System and Body Metabolism

From setting up the center was hormonal, immune system will enable multiple tracks on the skin, bone marrow and lymph nodes to be more attentive to the stress resistance.

Blood flow in the skin will usually be reduced to be diverted to other organs is more important that people who face stress usually easy to sweat, which in layman's terms is often called a cold sweat.

The flow of fluid in the mouth is also reduced so that will be easy to feel dry mouth and the muscles will tighten around the throat making it difficult to perform activities including speech and swallowing.

Against the body's metabolic system as a whole, the experts had to explain the effect of the stress response process various vitamins and minerals lost due to excessive secretion of adrenal hormones, because the production of this hormone is closely related to the role of various vitamins and minerals such as vitamin B and C, iron, potassium and calcium.

Consequently, not only the loss of vitamins and minerals was the problem, but also the effect continued to the immune defense and that was one of the essential role of vitamins and minerals in the body is an important factor constituent, such as vitamin C plays a role in the body's defenses and B vitamins play a role in the regulation of the nervous system.

Furthermore, the decline in all of these systems will affect the normal intake of the body where the sufferer is usually a little rest, insomnia, lack of appetite while they have to expend excessive energy to cope with the stress they experience, so the loss of nutrients becomes important benchmark here.

Psychological processes that occur too easily can lead to various diseases known
as psychosomatic ranging from dizziness, diarrhea, mualmuntah, muscle and joint pain, and many other functions impaired as a result of disruption of the body's various systems mentioned above.

Of the many mechanisms by which they are discovered, the experts who conducted the research in this field mention again that the magnitude of the role of stress in triggering various diseases unnoticed by the sufferer would even by medical personnel themselves, it is important to trace the causes of stress events affecting patients in a system integrated treatment, and according to them again, it also explains why some diseases can find a good healing progression after the stress factor is involved is handled.

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Causes and Symptoms of Diabetes Insipidus

What is Diabetes Insipidus?

Diabetes insipidus is a disorder in which there is a lack of antidiuretic hormone which causes excessive thirst (polidipsi) and spending large amounts of very dilute urine (polyuria).

There are two types of diabetes insipidus, namely:
  1. Central diabetes insipidus, where a decline in production of antidiuretic hormone or vasopressin.
  2. Nephrogenic diabetes insipidus, which antidiuretic hormone levels are normal but whose kidneys do not respond normally to the hormone.
Causes, among others:
  1. Tumors of the hypothalamus.
  2. Tumors of the pituitary and hypothalamic nuclei smash.
  3. Head trauma.
  4. Injury to surgery in the hypothalamus.
  5. Aneurysm or blockage of arteries leading to the brain.
  6. Granulomatous diseases.
Causes of nephrogenic diabetes insipidus include:
  1. Chronic kidney disease (polycystic kidney disease, medullary cystic disease, pielonefretis, obstruction / occlusion ureteral, renal failure continued.
  2. Electrolyte disorders (hypokalemia, hypercalcemia).
  3. Drugs (lithium, demoksiklin, asetoheksamid, tolazamid, glikurid, propoksifen).
  4. Sickle cell disease.
  5. Dietary disorders.
What are symptoms ?

Thirst and excessive urine spending and too often. And often it is the only symptom. Diabetes insipidus can occur gradually or suddenly at any age.

As compensation for the loss of fluid through the urine, the patient can drink large amounts of fluids (3.8 to 38 L / day). If compensation is not met, it soon will be dehydration that causes low blood pressure and shock. Patients continue to urinate in very much, especially at night.

If the symptoms described above, see your doctor. And the doctor will perform further tests. To get rid of diabetes mellitus (diabetes) examined the sugar in the urine.

Examination of the simplest and most reliable for diabetes insipidus is a water deprivation test. During the examination of these patients should not drink and severe dehydration can occur. Therefore, this examination should be performed in a hospital or doctor's office. Formation of urine, blood electrolyte levels (sodium) and weight were measured on a regular basis for a few hours. As soon as the drop in blood pressure or heart rate or weight loss of more than 5%, the test was terminated and given an injection of antidiuretic hormone.

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Nutritional Management for patients with Coronary Heart Disease

Nutritional Management for patients with Coronary Heart Disease
Nutrition is the process of making essential food substances  (Nancy Nuwer Konstantinides).
Nutrition is the sum of all interactions between organisms and the food consumed. (Cristian and Gregar 1985).
In other words, nutrition is what humans eat, and how the body uses. Communities get food or essential nutrients for growth and defense of all body tissues and normalize the functioning of all body processes. Nutrients are organic and inorganic chemicals found in food and obtained for the use of body functions.

The various sources of nutrients that need to be considered by patients with heart disease

1. Snacks and desserts

Fruits and fruit ices can be made snacks and desserts are good. Fried chips and crackers are high in fat should be avoided. Exchangers are appropriate include melba toast, Ry Krips, graham crackers, bagels, English muufins and vegetables. Sherbert, angel food cake, fruit flavored gelatin, cookies like ginger snaps low-fat, newton cookies and sometimes frozen yogurt or low-fat ice milk is acceptable. Cakes, pies, cakes made ​​from egg whites, egg substitute, skim milk, and unsaturated oils can be used at all times.

2. Food in the restaurant

Avoid fried food, fried food, the fast food restaurant, choose from the salad bar or food is burned. Order a meal without a sauce, butter and sour cream. Use margarine instead of butter and use only small amounts. Ask for salad dressing is served in addition to and used in limited quantities. Avoid high-fat toppings such as bacon, egg slices, and cheese, eat a few sunflower seeds and olives.

3. Comfort foods

Comfort foods generally high in saturated fat or cholesterol. One way around this is to provide early casseroles, breads and desserts low fat, low cholesterol composition and freeze for an event when a short preparation time. Currently some manufacturers are making low-fat frozen foods, low in calories.

4. Foods high in fiber.

Soluble fibers include pectin, gum and some hemicellulose are hypocholesterolemic agents. It's found in oat bran, bar ley, legumes and many fruits and vegetables. Soluble fiber that'' no'' as cellulose, found in wheat bran, has no such effect. Inclusion of dietary fiber is about 25-30g/hari desired. Appendix C provides a list of dietary fiber found in food.

Nutritional management for patients with coronary heart disease

1. Dietary management
  •      Recognize the need for permanent change and lifestyle to reduce risk.
  •      Reduce fat and cholesterol in the diet.
  •      Increase high-fiber input.
  •      Take steps to lower triglycerides (if possible).
  •      Achieve and maintain ideal weight.
  •      Perform aerobic exercise regularly.
2. Purpose of the diet
  •      Provide enough food without increasing cardiac work.
  •      Lose weight if the person is too fat.
  •      Prevent / eliminate the accumulation of salt / water
  •      Lowering LDL cholesterol levels below 130 mg / dl and total cholesterol levels below 200 mg / dl.
  •      Changing the type and dietary fat intake.
  •      Lowering the intake of dietary cholesterol.
  •      Increase intake of complex carbohydrates and lower intake of simple carbohydrates.

Characteristic of the diet of patients with heart disease
1. Sodium Restriction

Sources of sodium in the diet:
  • Sodium is a natural element found in all foodstuffs. Meat, fish, milk and eggs contain more sodium than fruits, cereals and vegetables mayor.
  • Sodium is a constituent in salt (sodium chloride) are commonly used for cooking and the kitchen table is provided as a flavor enhancer. Sodium is also a component of several food flavoring and additives such as spices (monosodium glutamate), baking soda (sodium bicarbonate). This element is also present in the food preservatives such as sodium benzoate and sodium sulphite (saltpeter).
  • The content of sodium in the diet increased with the application of various preservation method such as adding salt in the manufacture of fish sauce, dried shrimp, ham, tongue and smoked cheese. Similarly, fruits and pickled vegetables, pickles and vegetables stored in bottles or cans, various types such as taoco sauce, ketchup, chili sauce and others.
  • Breads and cakes that are developed with baking soda or sodium bicarbonate also increase sodium intake for those who have the habit of eating bread or cake as a snack.
2. Low-salt diet
  • In most cases, a moderate degree of restriction as illustrated by the examples outlined below low-salt diet is sufficient. This diet can be used to cope with primary hypertension, particularly mild hypertension. In some people, hypertension occur together with high salt intake.
  • Most of the preparations will encourage the excretion of potassium diuretic in addition to sodium excretion. To prevent depletion klasium during treatment with diuretic preparations necessary element supplementation.

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Non-pharmacological treatment of Constipation

Non-pharmacological treatment of Constipation

Many kinds of drugs that are marketed for constipation, stimulating efforts to provide symptomatic treatment. Meanwhile, when possible, treatment should be directed to the cause of constipation. Long-term use of laxatives, especially stimulating intestinal peristalsis, should be limited. Treatment strategies are divided into:

1. Exercises colon: colon practice is a recommended form of exercise behavior in patients with constipation is not clear why. Patients are encouraged to hold a regular time each day to take advantage of bowel movements. Recommended time is 5-10 minutes after eating, so it can take advantage of the gastro-colonic reflex to defecate. It is hoped this practice can cause sufferers respond to the signs and induce bowel movements, and do not withhold or delay the urge to defecate.

2. Diet: the role of diet is important to overcome constipation, especially in the elderly group. Epidemiological data indicate that a diet containing plenty of fiber, reducing the incidence of constipation and a variety of other gastrointestinal diseases, such as diverticular and colorectal cancer. Fiber increases stool mass and weight, and to shorten intestinal transit time. To support the benefits of fiber, it is hoped sufficient fluid intake of about 6-8 glasses a day, when there is no contraindication for fluid intake.

3. Exercise: adequate mobility and activity or exercise to help overcome constipation walk or jog is done according to age and ability of the patient, will invigorate the circulation and the stomach for memeperkuat abdominal wall muscles, especially in patients with abdominal muscle atonia.

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Parkinson's Disease Nanda Nursing Care Plan

NCP for Parkinson's Disease

Definition of Parkinson's Disease

Parkinson's Disease is a progressive neurological disease that affects the response mesensefalon and movement regulation. This is inherently slow disease that strikes middle age or old age, with onset at age 50 to 60 years. Not found a clear genetic cause and no treatment that can cure it.

Parkinson's Disease is a progressive neurodegenerative disease that is closely related to age. This disease has a characteristic degeneration of dopaminergic neurons of substantia nigra pars compacta, plus the presence of inclusions intraplasma consisting of a protein called Lewy Bodies. Neurodegenerative Parkinson's disease also occurs in other brain regions including the locus ceruleus, raphe nucleus, nucleus basalis of Meynert, hypothalamus, cortex cerebri, the motor nucleus.

Etiology of Parkinson's Disease

Parkinson's is caused by damage to brain cells, specifically in the substance nigra. A group of cells that regulate the movements that are not desired (involuntary). As a result, the patient can not control / restrain the movements unconsciously. Mechanisms of how the damage was unclear.

Parkinson disease is often associated with abnormalities of neurotransmitters in the brain of other factors such as:
  1. Deficiency of dopamine in the substantia nigra in the brain respond to the symptoms of Parkinson's disease,
  2. The underlying etiology may be associated with the virus, genetic toxicity, or other unknown causes.
Pathophysiology of Parkinson's Disease

Two hypotheses are referred to as a mechanism of neuronal degeneration in Parkinson's disease are: the free radical hypothesis and the hypothesis of neurotoxins.

1. Free Radical Hypothesis
Alleged that the enzymatic oxidation of dopamine can damage nigrostriatal neurons, because this process generates hydrogen peroxide and other oxygen radicals. Although there is a protective mechanism to prevent damage from oxidative stress, but at the advanced age of this mechanism may fail.

2. Neurotoxin Hypothesis
Presumably one or more kinds of neurotoxic substances play a role in the process of neurodegeneration in Parkinson's disease.
Current view emphasizes the importance of the basal ganglia, in neurophysiology plan required in movement, and the part played by the cerebellum is to evaluate the information received as feedback on the implementation of the motion. Basal ganglia is a primary task of collecting program for the movement, while the cerebellum monitor and rectification of errors that occur seaktu movement program is implemented. One picture of extrapyramidal disorders are involuntary movements.

Signs and Symptoms of Parkinson's Disease

Parkinson's disease had clinical symptoms as follows:
  1. Bradykinesia (slow movement), disappears spontaneously,
  2. Tremor is settled,
  3. Actions and movements are not controlled,
  4. The autonomic nervous disorders (insomnia, sweating, orthostatic hypotension,
  5. Depression, dementia,
  6. Face like a mask.

Parkinson's Disease Nanda Nursing Care Plan

  1. Assess cranial nerves, cerebral function (coordination) and motor function.
  2. Observation of gait and while performing the activity.
  3. Assess history of symptoms and their effects on body functions.
  4. Assess the clarity and speed of speech.
  5. Assess signs of depression.

Nanda Nursing Diagnosis of Parkinson's Disease
  1. Impaired physical mobility related to the stiffness and muscle weakness.
  2. Self-care deficit related to neuromuscular weakness, decline in strength, loss of muscle control / coordination.
  3. Impaired verbal communication related to the decline in speech and facial muscle stiffness.

Nursing Interventions of Parkinson's Disease

1. Impaired physical mobility related to the stiffness and muscle weakness.
Purpose: the client is able to perform physical activity according to ability.
Criteria: the client can participate in training programs, joint contractures did not occur, increased muscle strength and the client indicates an act to meninktkan mobility.
Intervention :
  • Assess existing mobility and the observation of increased damage.
  • Conduct training program increases muscle strength.
  • Encourage warm bath and massage the muscle.
  • Help clients to perform ROM exercises, self-care as tolerated.
  • Collaboration physiotherapists for physical exercise.
2. Self-care deficit related to neuromuscular weakness, decline in strength, loss of muscle control / coordination.
Purpose: self-care are met.
Criteria: the client may indicate a change of life for the needs of self-care, client is able to perform self-care activities in accordance with the level of ability, and identify personal / community that can help.
  • Assess the ability and the rate of decline and the scale of 0-4 to perform ADL.
  • Avoid anything that can not be done and help the client if necessary.
  • Collaboration of laxatives and consult a doctor of occupational therapy.
  • Teach and support the client during the client's activities.
  • Environmental modifications.
3. Impaired verbal communication related to the decline in speech and facial muscle stiffness.
Purpose: to maximize the ability to communicate.
  • Keep the complications of treatment.
  • Refer to speech therapy.
  • Teach clients to use facial exercises and breathing methods to correct the words, volume, and intonation.
  • Deep breath before speaking to increase the volume and number of words in sentences of each breath.
  • Practice your talk in short sentences, reading aloud in front of the glass or into a voice recorder (tape recorder) to monitor progress.

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Nursing Management of Appendicitis Pre Surgery and Post-Surgery

Basic Concepts of Appendicitis

A. Definiton 

Acute appendicitis is the most common cause of acute inflammation in the lower right quadrant abdominal cavity, the most common cause for emergency abdominal surgery.

Appendicitis is a condition where the infection occurs in the appendix. In mild cases may recover without treatment, but many cases require laparotomy with removal of an infected appendix. If untreated, the mortality rate is high, due to peritonitis and shock when the infected appendix is destroyed.

Appendicitis is an inflammation caused by infection of the appendix. This infection can cause pus. If the infection gets worse, the appendix can rupture. Usu clogged intestinal tract is clogged and the protruding ends of the lower colon or cecum. Appendix about the little hand size and is located in the lower right abdomen. Other structure such as the intestine,. However, many of which always contain mucus glands.

B. Etiology

The occurrence of acute appendicitis is usually caused by bacterial infection. However, there are many factors trigger the disease. Among obstruction that occurs in the lumen of the appendix. Obstruction in the lumen of the appendix is usually caused due to an accumulation of hard stools, hyperplasia of lymphoid tissue, worm disease, a foreign object in the body, the primary cancer and stricture. However, the most frequent cause obstruction of the lumen of the appendix is fecalith and hyperplasia of lymphoid tissue.

C. Pathophysiology

Appendix inflamed and edematous as a result of the possibility of bent or clogged by fecalith or foreign objects. Inflammatory process increased intraluminal pressure, causing upper abdominal pain or severe spread progressively, be some hours in localized in the lower right quadrant of the abdomen. Finally, the appendix becomes inflamed pus.

D. Clinical Manifestations
Appendicitis has a unique combination of symptoms, which include: nausea, vomiting and severe pain in the lower right abdomen. Pain may be sudden starts in the upper abdomen or around the navel, then nausea and vomiting. After several hours, the nausea disappeared and the pain shifts to the lower right abdomen. If the doctor presses on this area, the patient felt a dull pain and if the pressure is released, the pain may increase sharply. Fever could reach 37.8 to 38.8 oC.

In infants and children, the pain was comprehensive, in all parts of the stomach. On parents and pregnant women, the pain is not too heavy and dulling of pain in this area is not too pronounced. If the appendix ruptures, pain and fever can be severe. Worsening of infections can cause shock.

Nursing Management of Appendicitis Pre Surgery and  Post-Surgery

Pre Surgery
  • Installation of nasogastric tube to decompress.
  • Catheters to control urine production.
  • Rehydration.
  • Giving antibiotics with broad-spectrum, high doses given intravenously.
  • Medicines for fever.
  • If fever, must be lowered before anesthesia.
  • Appendectomy.
  • Appendix removed, if the appendix is perforated freely, then the abdomen was washed with physiological saline and antibiotics.
  • Appendix abscess treated with IV antibiotics, its mass may shrink, or abscess may require drainage within a period of several days. Appendectomy performed elective surgery if the abscess is done after 6 weeks to 3 months.
  • Observation of vital signs.
  • Lift the nasogastric tube, if the patient had been aware of that aspiration of gastric fluid can be prevented.
  • Put the patient in a semi-Fowler position.
  • Patients are said to be good when in the last 12 hours without any disturbance, while the patient fasted.
  • When the surgery is greater, for example on the perforation, fasting was continued until bowel function returned to normal.
  • Give the drink began to 15ml / h for 4-5 hours and then raised it to 30 ml / hour. The next day strain and give food the next day given soft foods.
  • One day after surgery patients are encouraged to sit up in bed for 2 × 30 minutes.
  • On the second day the patient can stand and sit outside the room.
  • Day-to-7 stitches can be removed and the patient allowed to go home.

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NANDA Nursing Care Plan for Pain

Nursing Care Plan for Pain - NANDA

The Casic Concept of Pain

1. Definition of Pain

Pain is a subjective sensory and emotional experience unpleasant tissue damage associated with actual or potential or perceived in the events where the damage occurred.

Another definition of pain is a subjective experience, greatly influenced by private educational, cultural, and cognitive meaning of the situation.

2. Type of pain based on the duration and length

Pain is usually divided into two major types are acute and chronic pain. Both can be distinguished from the onset, duration and cause pain.

a) Acute pain

Acute pain occurs after an acute injury, illness or surgical intervention and has a rapid onset, with varying intensity (mild to severe) and lasts for a short time (Meinhart and Mc Caffery, 1983, NIH 1986 in Potter and Perry, 1997).

By Bonica in 1987, acute pain as a collection of unpleasant experiences associated with sensory, perceptual and emotional responses related to the autonomic, emotional and behavioral.

Acute pain is usually a new event, a sudden and short duration. It is associated with acute illness, surgery or medical procedures or trauma and pain can help to determine its location. Another characteristic is the sense of pain can usually be identified, the pain was quickly reduced / lost, are clear and likely to end up / missing.

b) Chronic Pain

Chronic pain is pain that lasts a long, varied in intensity and usually lasts more than six months (Mc Caffery, 1986 in Potter and Perry, 1997). On clients with chronic pain often experience periods of remission (partial or complete loss of symptoms) and exacerbation (increased severity). The nature of this chronic pain can not be predicted which makes the client often leads to frustration and psychological depression.

Chronic pain is a situation or circumstance that experience persistent pain / continuously for several months / years after the healing phase of an acute illness / injury. Characteristics of chronic pain is not easily identifiable area of ​​pain, reduced pain intensity difficult, the pain usually increases, its nature is less obvious and less likely to heal / disappear.

Chronic pain can be categorized into two: chronic pain of malignant and non malignant. Malignant chronic pain can be described as pain associated with cancer or other progressive diseases. Non-malignant chronic pain is usually associated with pain due to non-progressive tissue damage, or have experienced healing.

3. Type of pain based on the intensity

The intensity of pain a person can be known from the assessment tools used. In the verbal descriptions of pain, the individual is the best assessor of the pain they experienced and should therefore be asked to describe and make level. Obtained pain intensity was measured using a scale of them; simple descriptive pain intensity scale, a scale of 0-10 numerical pain intensity and visual analogue scale (VAS). Scale used to describe the intensity / severity of pain.

a. Simple descriptive pain intensity scale
Pain intensity scale of this simple descriptive pain using six images of different facial expressions, showing a happy face to sad face, which is used to express pain. This scale can be used from children age 3 (three) years.

NANDA Nursing Care Plan for Pain

b. Numeric pain intensity scale: 0 -10
Severity of pain or pain made ​​into measurable with subjective pain make objective opinion. Numerical scale, was used from 0 to 10, zero (0) is a state with no or a pain-free, while ten (10), a very great pain.

c. Visual analog scale (VAS)
Similar scale is a straight line, without figures. Be free to express pain, to the left to no pain, unbearable pain in the right direction, with the center about which pain is. Clients asked to indicate the position of pain on the line between these two extreme values.

Pain Definition - Nanda

Feeling and an unpleasant emotional experience arising from tissue damage or a description of actual and potential damage. It can occur suddenly or slowly, the intensity of light or heavy. With predictions of healing time is approximately less than 6 months.

Defining characteristics:
  • Reports of verbal and nonverbal
  • Observation reports
  • Position the patient to be careful to avoid the pain
  • Movement to protect themselves
  • Cautious behavior
  • Face mask
  • Sleep disturbances (glazed eyes, looked tired, which is difficult or chaotic movement, smirk)
  • Focus on self-
  • The focus narrows (decreasing the perception of time, damage fikir process, decreasing the interaction with people and the environment)
  • Distracting activity (a walk, meet other people or activities, repetitive activities)
  • Response autonomy (diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils).
  • Autonomy in response to changes in muscle tone (visible from the weak to stiff)
  • Expressive behavior (restlessness, moaning, crying, alert, iritabel, deep breath, sigh)
  • Changes in appetite, drinking

Related factors:

a. Injury agents (biological, chemical, physical, psychological)
  • Not performed at all
  • Rarely do
  • Sometimes done
  • Often do
  • Always do

  • Pain Management

Interventions and Rational:
  • Perform a comprehensive assessment
  • Observation of nonverbal reactions and discomfort
  • Use therapeutic communication to know the experience of pain
  • Assess the culture that affect the pain response
  • Evaluation of past experience of pain
  • Assist patients and families to seek and find support
  • Environmental control
  • Reduce the Pain of precipitation factor
  • Select and doing pain management (pharmacologic, non-pharmacological and interpersonal)
  • Assess the source and type of pain to determine intervention
  • Teach about non-pharmacological techniques
  • Give analgesics for pain relief
  • Increase breaks
  • Collaboration with a physician if there are complaints of pain and the action does not work
  • Monitor the patient acceptance of pain management.

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Nursing Care of Patients with Respiratory System Disorders

Respiratory System Disorders

A. Medical History

Medical history that were examined include current data and past issues. The nurse examines the client or family and focus on the clinical manifestations of the main complaints, events that make the current situation, past treatment history, family history and psychosocial history.

Medical history starting from the biography of the client, in which aspects of the biography of a very close relationship with oxygenation disorders include age, sex, occupation (especially those related to working conditions) and shelter. State of residence includes living conditions and whether the client lives alone or with others which will be useful for discharge planning ("Discharge Planning").
  1. The main complaint

    The main complaint will determine the priority interventions and assess the client's knowledge of his condition at this time. The main complaint that usually appears on the client's need for oxygen and carbon dioxide interference include: cough, increased sputum production, dyspnea, hemoptysis, wheezing, chest pain and Stridor.

    • Cough
      Cough is the main symptom in clients with respiratory system diseases. Ask how long the client cough (eg 1 week, 3 months). Ask also how it was incurred by a specific time (eg at night, when I wake up) or its relationship with physical activity. Determine whether the cough is productive or non productive, congestion, dry.

    • Increased sputum production
      Sputum is a substance that comes out along with a cough or throat clearance. Tracheobronchial tree normally produces about 3 ounces of mucus a day as part of normal cleaning mechanism. But the production of sputum due to coughing is not normal. Ask and record the color, consistency, odor and amount of sputum because these things can indicate a state of pathological processes. If infections develop sputum, can be yellow or green, Sputum may be clear, white or gray. In case of pulmonary edema will be colored pink sputum, and blood contains large amounts.

    • Dyspnea
      Dyspnea is a perception of difficulty in breathing / shortness of breath and a subjective feeling of the client. Nurses learn about the client's ability to perform activities. Instances when the client is running if she experienced dyspnea?. also examine the possibility of paroxysmal nocturnal dyspnea and orthopnea, which is associated with chronic lung disease and heart failure left.

    • Hemoptysis
      Hemoptysis is blood coming out of the mouth coughed. Nurses assess whether the blood is coming from the lungs, nose or stomach bleeding. Blood from the lungs is usually bright red because of blood in the lung are stimulated by a reflex cough immediately. Diseases that cause hemoptysis include: Chronic bronchitis, bronchiectasis, pulmonary tuberculosis, cystic fibrosis, Upper airway necrotizing granulomas, pulmonary embolism, pneumonia, lung cancer and lung abscess.

    • Chest Pain
      Chest pain may be associated with heart and lung problems. Complete picture of chest pain can help nurses to differentiate pleural pain, musculoskeletal, cardiac and gastrointestinal. The lungs do not have the nerves that are sensitive to pain, but the ribs, muscles, parietal pleura and tracheobronchial tree have it. Due to the subjective feeling of pure pain, nurses must analyze the pain associated with painful problems that arise.

  2. Past Medical History

    The nurse asks about the client's history of respiratory disease. In general, the nurse asked about:

    • History of smoking: cigarette smoking is an important cause of lung cancer, emphysema and chronic bronchitis. All the circumstances it is very rarely happen to non-smokers. Anamnesis should include the:
      • Age of onset of smoking on a regular basis.
      • The average number of cigarettes smoked per day.
      • Removing age smoking.
    • Treatment of current and past
    • Allergy
    • Place of residence

    • Family Health History

      Purpose to ask family and social history of lung disease patients are at least three, namely:
      1) certain infectious diseases: tuberculosis, especially, is transmitted through one individual to another, so by asking for a history of contact with infected people can know the source of transmission.
      2) allergic disorders, such as bronchial asthma, suggesting a predisposition certain breeds, and also the asthma attacks may be triggered by the conflict of family or close acquaintances.
      3) Patients with chronic bronchitis may be living in areas of high air pollution. But air pollution does not cause chronic bronchitis, only aggravate the disease.
    2. Review System (Head to Toe)
    • Inspection

      1. Examination of the chest starts from the posterior thorax, the client in a seated position.
      2. Chest observed by comparing one side to another.
      3. Actions done from the top (apex) to bottom.
      4. Inspection of the thorax poterior skin color and condition, scars, lesions, masses, spinal problems such as kyphosis, scoliosis and lordosis.
      5. Record the number, rhythm, depth of breathing, chest movement and symmetry.
      6. Observation of the respiratory type, such as: nasal breathing or diaphragmatic breathing, and the use of auxiliary respiratory muscles.
      7. When observing respiration, record the duration of the phase of inspiration (I) and expiratory phase (E). ratio in this phase of the normal 1: 2. Prolonged expiratory phase showed the presence of airway obstruction and is often found on client Chronic Airflow Limitation (CAL) / COPD
      8. Assess and compare the configuration of the chest anteroposterior diameter (AP) and lateral diameter / tranversal (T). This ratio normally ranges from 1: 2 to 5: 7, depending on the client's body fluids.
      9. Abnormalities in the form of the chest:
        • Barrel Chest
          Barrel chest describes a rounded, bulging, almost barrel-like appearance of the chest that occurs as a result of long-term overinflation of the lungs. Because the lungs are overinflated with air, the rib cage stays partially expanded, giving the characteristic appearance of a barrel chest.
          Barrel chest can be due to a variety of reasons, including osteoarthritis and aging, but is also a common finding in the later stages of emphysema. Barrel chest is quite obvious, and can be detected by your healthcare provider during a physical examination.

        • Funnel chest (Pectus Excavatum)
          Depression of the breast bone - sunken chest appearance. The condition is usually a congenital deformity but may occur in association with conditions such as rickets, Marfan syndrome and Poland syndrome. Severe cases may result in breathing problems or may affect heart function.

        • Pigeon Chest (pectus carinatum)
          Pectus carinatum also called pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs. It is the opposite of pectus excavatum.

        • Kyphoscoliosis
          Kyphoscoliosis describes an abnormal curvature of the spine in both a coronal and sagittal plane. It is a combination of kyphosis and scoliosis. Kyphoscoliosis is a musculoskeletal disorder causing chronic underventilation of the lungs and may be one of the major causes of pulmonary hypertension.
          Kyphosis also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae (upper back). It can be either the result of degenerative diseases (such as arthritis), developmental problems (the most common example being Scheuermann's disease), osteoporosis with compression fractures of the vertebrae, or trauma.
          Scoliosis: is a medical condition in which a person's spine is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis may look more like an "S" or a "C", rather than a straight line.
      10. Observation of chest movement symmetry. Movement disorders or inadequate chest expansion indicated in the lung or pleural disease.
      11. Observation of abnormal retraction of the intercostal spaces during inspiration, which may indicate airway obstruction.

    • Palpation

      Conducted to assess the symmetry and observe chest movement abnormalities, identify the state of the skin and knowing vocals / premitus tactile (vibration).
      Palpation of the thorax to find out when inspections terkaji abnormality such as masses, lesions, swelling.
      Assess the softness of the skin, especially if a client complains of pain.
      Vocal premitus: chest wall vibration generated when speaking.

    • Percussion

      Nurses to assess the resonance pulmonary percussion, organ and development around it (excursion) of the diaphragm.
      • Resonant : normal: resonant, low tones. Generated in normal lung tissue.
      • Dullness: normal: upper parts produced in the heart or lungs.
      • Tympany: normal: the musical, produced in the stomach is filled with air.
    • Percussion sounds Abnormal:
      • Hyperresonant: Louder sound heard over lungs upon percussion. Longer sound heard over lungs upon percussion. Higher pitched sound heard over lungs upon percussion.
      • Flatness: very dullness and therefore a higher tone. Percussion can be heard on the thigh area, which contains the whole area network.

    • Auscultation

      Is a very meaningful assessment, including listening to breath sounds normal, additional sound (abnormal), and sound.
      Normal breath sounds from the vibrations produced when the air through the airway from the larynx to the alveoli, with the clear.
    3. Psychosoial Assessment

    The review of aspects of the habits of the clients that significantly affect the function of respiration. Some respiratory conditions resulting from stress.

    Chronic respiratory disease may cause changes in family roles and relationships with others, social isolation, financial problems, work or disability.

    By discussing coping mechanisms, the nurse can assess the client's reaction to the problem of psychosocial stress and find a way out.


    Nursing diagnosis related to disorders of oxygenation that includes ventilation, diffusion and transport, according to the classification of NANDA (2005) and the development of writers, among others:

    1. Ineffective airway clearance (Damage to the physiology of ventilation)

    Is a condition where an individual is unable to cough effectively.

    2. Impaireed gas exchange (damage to the physiology of diffusion)

    Condition in which the decline in gas intake between alveoli and the vascular system.

    3. Ineffective breathing pattern (damage to the physiology of transport)

    A condition is inadequate ventilation related to changes in breathing pattern. Hiperpnea or hyperventilation will cause a decrease in PCO2...

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    10 Factors that Affect the Response and Perception of Pain

    Not everyone exposed to the same stimulus had the same intensity of pain. A stimulus can lead to pain at some time, but not at other times. These factors can increase or decrease the sensitivity of the different components of the nociceptive system. As for the things that can affect pain perception and response are:

    1) Age

    In the younger children have difficulty understanding the procedures that cause pain measures. Children who have not been able to say these words too difficult to express verbally express their pain and to parents or health workers. Children cognitively toddler and pre school age are not able to remember the description of the pain or to associate the pain as an experience that can occur in various situations.

    The elderly have the ability to interpret the pain and may develop complications in the presence of various diseases with vague symptoms that may be of the same body part. Not all older adults experience cognitive impairment. However, when an elderly person has puzzled, then he will have difficulty remembering the experience of pain and give a detailed explanation.

    2) Gender
    In general, men and women did not differ significantly in response to pain (Gil, 1990 in Potter and Perry, 1997).

    3) Culture
    Some cultures believe that showing pain is natural. Other cultures tend to practice behaviors that are closed. Clancy and Mc Vicar (1992), states that cultural socialization determine a person's psychological behavior.

    4) The meaning of pain
    Meaning a person who is associated with pain affect a person's experience of pain and how to adapt to pain. Individuals will perceive pain in different ways, if the pain is to give the impression of a threat, a loss, penalties and challenges. The degree and quality of client perceived pain associated with the meaning of pain.

    5) Attention
    The level of a client to focus attention on the pain can affect the perception of pain. Increased attention associated with increased pain, while the transfer of effort associated with a decreased response to pain (Gil, 1990 in Potter and Perry, 1997).

    6) Anxiety
    The relationship between pain and anxiety is complex. Anxiety often increases the perception of pain, but pain can also cause a feeling of anxiety. Autonomic arousal pattern is the same in pain and anxiety (Gil, 1990 in Potter and Perry, 1997).

    7) Fatigue
    Fatigue increases the perception of pain. Fatigue causes the sensation of pain has intensified and lower coping abilities. This can be a common problem in individuals who suffer from the disease for a long time.

    8) The experience of previous
    Each individual learns from the experience of pain. Previous experience of pain does not necessarily mean that the individual will receive pain more easily in the future. If the individual has long had a series of frequent episodes of pain without ever recovering or suffering from severe pain, the anxiety or fear may arise. If individuals do not ever feel the pain, the first perception of pain can interfere with coping with pain.

    9) coping style
    Individuals who have a focus on internal control perceive themselves as individuals can control their environment and the end result of an event, such as pain (Gil, 1990 in Potter and Perry, 1997). In contrast, individuals who have an external locus of control, perception of other factors in their environment.

    10) Support of family and social
    Individuals who experience pain is often dependent on family members or close friends for support, assistance and protection. Although still felt pain, the presence of a loved one will minimize the loneliness and fear.

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    NCP Ventricular Septal Defect - Pre-surgical Care and Post-surgical Care

    Nursing Care Plan Ventricular Septal Defect - Nanda

    Definition of Ventricular Septal Defect

    Ventricular septal defect (VSD, Defek Septum Ventrikel) is a hole in the ventricular septum. Ventricular septum is the wall that separates the bottom of the heart (left ventricle and separates the right ventricle).

    Ventricular septal defect (DSV) is a SPA, the most frequently found, ie 30% of all types of CHD. In most cases, the diagnosis of this disorder is being established after passing the newborn period, because in the first weeks of significant noise usually has not been heard since resistensis still high pulmonary vascular decreased after 8-10 weeks.

    Etiology of Ventricular Septal Defect

    The cause is unknown. VSD is more common in children and is often a congenital heart defect.

    In children, the hole is very small, cause no symptoms and often shuts itself off before the child turned 18 years old.

    In the more severe cases, can occur ventricular dysfunction and heart failure. VSD can be found along with other cardiac abnormalities. Prenatal factors that may be associated with VSD:
    • Rubella or other viral infections in pregnant women.
    • Poor nutrition of pregnant women.
    • An alcoholic mother.
    • Maternal age over 40 years.
    • Mother had diabetes.

    Clinical Manifestations of Ventricular septal defect

    In both these disorders, the blood from the lungs into the heart, return flows to the lungs. As a result the amount of blood in the pulmonary blood vessels increases and causes:
    • Hurry tired
    • Cough
    • Shortness of breath when resting
    • Slow weight gain and weight did not increase
    • Baby has difficulty when feeding
    • Excessive sweating.

    Test Laboratory Diagnosis
    • Cardiac catheterization showed an abnormal relationship between the ventricles.
    • Electrocardiogram (ECG) and chest radiograph showed left ventricular hypertrophy
    • A complete blood count is a test routine pre-surgery.
    • Mass test prothrombin (PT) and partial thromboplastin mass (ICM) is performed before surgery can reveal bleeding tendency (usually normal).

    Nursing Care Plan for Ventricular Septal Defect

    A. Assessment

    a. Pulse
    • Apical pulse - rate, rhythm and quality
    • Peripheral pulse - there or not, if there is a review of frequency, rhythm, quality, and symmetry; the difference between the extremities
    • Blood pressure - all extremities

    b. Examination of the thorax and auscultation
    • Circumference of the chest (thoracic)
    • Presence of thoracic deformity
    • Heart sounds - murmurs
    • The point of maximum impulse

    c. General appearance
    • The level of activity
    • Height and weight
    • Anxiety and fear behavior
    • Clubbing (clubbing) of the hands and feet

    d. Skin
    • Pale
    • Cyanosis of mucous membranes, the extremities, the nail bed
    • Diaphoresis
    • Temperature

    e. Edema
    • Periorbital
    • Extremity

    f. Assess the presence of complications
    • Diastolic murmur, showed aortic insufficiency
    • Wide pulse pressure, suggesting insifisiensi aorta
    • Arrhythmias
    • Chronic heart failure
    • Bleeding
    • Low cardiac output, especially during the first 24 hours after surgery

    Nursing Diagnosis
    1. Anxiety
    2. Activity intolerance
    3. Decreased cardiac output
    4. Changes in tissue perfusion
    5. Excess fluid volume
    6. Risk for infection
    7. Risk for injury
    8. Changes in the family


    a. Pre-surgical Care

    Explain to the child with age-appropriate manner, before surgery

    1. Monitor the child's basic status:
    • Vital signs
    • The color of mucous membranes
    • The quality and intensity of the peripheral arteries
    • When the capillary
    • The temperature of the extremities
    2. Help and support children during the performance of laboratory tests and diagnostic tests
    • A complete blood count, urinalysis, serum glucose, and blood urea nitrogen
    • Serum Electrolytes - Na, K, and Cl
    • Blood type and cross-examination
    • Radiographic examinations
    • ECG

    b. Post-surgical Care

    1. Monitor the child's postoperative status every 15 minutes during the first 24 to 48 hours.
    • Vital signs
    • The color of mucous membranes
    • The quality and intensity of the peripheral arteries
    • When the capillary
    • Edema periorbital
    • Pleural effusions
    • Pulsus paradoxus or a decrease in pulse pressure
    • Arterial pressure
    • Heart rhythm

    2. Monitor the bleeding
    • Measure the chest tube output per hour
    • Assess the presence of a clot in the chest tube
    • Assess the presence of lesions and ecchymoses petekia
    • Assess the bleeding from somewhere else
    • Record the output of blood for diagnostic studies
    • Monitor intake and output strictly
    • Give fluids as much as 50% to 75% volume maintenance during the first 24 hours
    • Provide the necessary blood products
    3. Monitor the child's hydration status
    • Skin turgor
    • Humidity mucous membranes
    • Density
    • Weight daily
    • The output of urine

    »

    Nanda Care Plan for Anxiety

    Nanda Anxiety

    Anxiety is a signal to awaken; warned of the danger and allows one to take action and tackle the threat.

    Anxiety related to feeling uncertain / helplessness, emotional state does not have a specific object.

    Panic disorder experienced by approximately 1.7% of the adult population. Lifetime incidence of panic disorder was reported 1.5% to 5%, while the panic attacks as much as 3% to 5.6%.

    Panic disorder is often chronic occurred, vary widely among individuals. In the long term, 30% - 40% of patients no longer have panic attacks, 50% experience mild symptoms that do not affect his life, while the rest are still experiencing significant symptoms (Elvira, 2008).

    Definition According to the Experts

    1.Sigmound Freud declared that tension or anxiety that happens to an individual without a purpose or object, is not recognized and are associated with loss of self image.

    2. Sullivan stated that the concern arises because of the threat to self esteem by people nearby. Anxiety in adults occurs when pretige and self dignity are threatened by others.

    3. Pepleu states that anxiety can affect interpersonal relationships. Besides that anxiety is a response to the dangers of the unknown and occurs when there are obstacles to the implementation requirements.

    Anxiety is different from Fear

    Fear is the man dreams of a clear source, or where the person is the object which can identify and explain the object. Involves the interpretation of intellectual fear of the threatening stimulus, whereas anxiety involves the emotional response to the interpretation.

    Criteria for panic attacks, obsessions and compulsions

    • Palpitations, heart beating hard
    • Sweat
    • Shaky or unsteady
    • Feeling choked
    • Chest pain
    • Nausea
    • Feeling dizzy
    • Thoughts, impulses or images over and over and settle
    • Thoughts, impulses with excessive worries
    • Individuals attempt to suppress the irrational thoughts
    • Individuals recognize the mind's obsession
    • Repetitive behavior (such as hand washing) or mental acts (eg praying, counting, muttering words without sound) so that individuals feel compelled to do in response to an obsession.

    Signs and symptoms of anxiety

    Patients come to the health or psychiatric services typically complain of triad-anxiety, namely;
    • the anxiety of uncertain future,
    • over the activity, and
    • a feeling of tension and fear.

    Nanda Nursing Diagnosis for Anxiety
    1. Breathing pattern, ineffective
    2. Individual coping, ineffective
    3. Verbal communication, Impaired
    4. Anxiety
    5. Powerlessness
    6. Fear

    Nursing Interventions, Implementation and Evaluation :

    Severe anxiety / panic

    Objectives are expected to:
    Clients are protected from harm
    Clients can adjust to his new environment
    Clients can follow the activities scheduled
    Clients can experience healing by decreasing the signs of symptoms

    Interventions :

    1. Protect clients from harm
    Construct the therapeutic relationship: first thank his will and give clients the support of the fight.
    Recommend the reality of pain-related coping mechanisms Do not focus on phobias, rituals or physical complaints.
    Feedback on: the behavior of stress, assessment of stressors and coping resources
    Reinforce the idea that physical health Dealing with emotional health.
    Then begin to limit maladaptive behavior by supporting clients.

    2. Environmental modifications that can reduce anxiety
    Perform a calm manner to the client.
    Reduce the environmental stimulation.
    Limit patient interaction with others, to minimize the spread of anxiety in others.
    Identification and modification of situations that affect anxiety.
    Provide measures to support the physical, such as a warm bath, massage.

    3. Encourage clients to do the activities that have been scheduled
    Support clients to share their activities with activities such as cleaning the room, then take care garden reinforcement given socially productive behavior.
    Give some kind of physical exercise such as gymnastics, relaxation.
    Together with the client to create a schedule of activities.
    Involve the family or other support systems that allow.

    4. Collaboration for the administration of antianxiety drugs to reduce the symptoms of severe anxiety.
    Collaboration of antianxiety drugs,
    Observe the side effects of drugs.


    Implementation, tailored to the plan of nursing actions.


    1. Subjective evaluation
    a) The client feels comfortable in treatment.
    b) The client can gradually accept himself.

    2. Objective evaluation
    Clients change their behavior, there does not seem angry or aggressive symptoms
    Clients can start a conversation.

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