ARDS Care Plan - Diagnosis Nanda

Nursing Diagnosis for ARDS

Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood.

ARDS also known as respiratory distress syndrome (RDS) or adult respiratory distress syndrome is a serious reaction to various forms of injuries or acute infection to the lung.

It is characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure.

ARDS can be caused by any major injury to the lung. Some common causes include:
  • Breathing vomit into the lungs (aspiration)
  • Inhaling chemicals
  • Lung transplant
  • Pneumonia
  • Septic shock (infection throughout the body)
  • Trauma

Symptoms
  • Difficulty breathing
  • Low blood pressure and organ failure
  • Rapid breathing
  • Shortness of breath

Symptoms usually develop within 24 to 48 hours of the injury or illness. Often, people with ARDS are so sick they cannot complain of symptoms.

There is no specific treatment for ARDS. A person with ARDS is treated in the intensive care unit at the hospital. Often a person with ARDS will need a machine's help to breathe (called mechanical ventilation) and oxygen therapy.

Treatments may include:
  • Oxygen through tubes in your nose or through a mask
  • Oxygen through a breathing tube. The tube is flexible and goes through your mouth or nose into your windpipe. The tube is connected to a ventilator, a machine that helps you breathe.
  • Fluids through an IV line to improve your blood flow and to provide nutrition
  • Medicine to prevent and treat infections and to relieve pain


Nanda Nursing Diagnosis for ARDS

1. Ineffective Airway Clearance

2. Ineffective Breathing Pattern

3. Impaired Gas Exchange

4. Decreased Cardiac Output

5. Risk for Injury

6. Excess Fluid Volume

7. Impaired Physical Mobility

8. Impaired Skin Integrity

9. Impaired Verbal Communication

10. Ineffective Coping

11. Sleep Pattern Disturbance

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Risk for Injury related to Meniere's Disease - NCP


Nursing Care Plan for Meniere's Disease- Risk for Injury

The exact cause of Meniere's disease is unknown. It may occur when the pressure of the fluid in part of the inner ear gets too high.

In some cases, Meniere's disease may be related to:
  • Head injury
  • Middle or inner ear infection

Other risk factors include:
  • Allergies
  • Alcohol use
  • Family history
  • Fatigue
  • Recent viral illness
  • Respiratory infection
  • Smoking
  • Stress
  • Use of certain medications

Risk for Injury : At risk of injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources


Nursing Diagnosis : Risk for Injury related to altered mobility because of gait disturbance and vertigo

Goal: Keep free from injuries related to an imbalance and / falls

Expected outcomes:
  • Not to fall due to impaired balance.
  • Fear and anxiety is reduced.
  • Conduct training in accordance with the provisions.
  • Identify the nature of feeling full or feeling pressure in the ear that happens before the attack.
  • Immediately perform a horizontal position when dizzy.
  • Keep the head remained silent when dizzy.
  • Use prescription drugs as well.
  • Report an effort to reduce vertigo.

Intervention and Rational:

1. Assess vertigo which includes history, onset, description of the attack, duration, frequency, and the presence of symptoms related ear hearing loss, tinnitus, a feeling of fullness in the ear.
Rationale: History provide the basis for further intervention.

2. Assess the extent of disability in connection with the activities of daily living.
Rationale: The extent of disability lowers the risk of falling.

3. Teach vestibular therapy or stress / balance in accordance with the provisions.
Rationale: This exercise can speed up the compensation maze reduce vertigo and impaired way street.

4. Give or teach how anti-drug or vertigo and vestibular sedatives and give instructions to patients about the side effects.
Rationale: Eliminate the symptoms of acute vertigo.

5. Encourage the patient to lie down if feeling dizzy, with fence bed is raised.
Rationale: Reduces the possibility of falls and injuries.

6. Put a pillow on both sides to limit motion fist.
Rationale: Move will aggravate vertigo.

7. Help patients locate and determine the aura (the aural symptoms) that precedes the occurrence of any attack.
Rationale: The introduction of the aura can help determine when the need for drugs before the attack so as to minimize the severity of the effects.

8. Instruct the patient to keep open his eyes and looked straight ahead while lying down and experiencing vertigo.
Rationale: The feeling of vertigo and reduced eye movement when experiencing decelerations remained on guard in a fixed position.

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Management of Dengue Hemorrhagic Fever - Nursing Care


Dengue Hemorrhagic Fever - Nursing Care

Assessment

1. Identity
Dengue Hemorrhagic Fever is a tropical disease that often leads to the death of children, adolescents and adults (Effendy, 1995).

2. Main complaint
Patients complain of heat, headache, weakness, heartburn, nausea and decreased appetite.

3. History of present illness
Medical history showed headache, muscle aches, the whole body aches, pain on swallowing, weakness, heat, nausea, and decreased appetite.

4. History of previous illness
There is no a specific illness.

5. Family history of disease
History of Dengue Hemorrhagic Fever disease in other family members is crucial, due to Dengue Hemorrhagic Fever disease is a disease that can be transmitted through mosquito bites aigepty aides.

6. Environmental Health History
Usually less than clean environment, many puddles of water like tin cans, old tires, a water bird that rarely changed the water, the tub is rarely cleaned.

7. Developmental History


Nursing Management of Dengue Hemorrhagic Fever

1. Hyperthermia related to the dengue virus infection

Goal: Normal body temperature
Expected outcomes: The body temperature between 36-37 0C, muscle pain disappeared.

Intervention:
1. Assess the patient's body temperature
Rational: find an increase in body temperature, facilitate intervention.
2. Give warm compresses
Rational: reduce heat to heat transfer by conduction. Warm water is slowly control the heat removal without causing hypothermia or shivering.
3. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated).
Rationale: To replace fluids lost due to evaporation.
4. Instruct patient to wear clothes that are thin and easy to absorb sweat.
Rationale: To provide a sense of comfort and wear thin easily absorbs sweat and does not stimulate an increase in body temperature.
5. Observation intake and output, vital signs (temperature, pulse, blood pressure) once every 3 hours or as indicated.
Rationale: Early Detect hydrated and knowing fluid and electrolyte balance in the body. Vital Signs is a reference to determine the patient's general condition.
6. Collaboration: intravenous fluid and drug delivery according to the program.
Rationale: Proper hydration is very important for patients with a high body temperature. Particular drug to lower a patient's body heat.

2. Risk for fluid volume deficit related to intravascular fluid into the extravascular migration.

Goal: Not voume fluid deficit
Expected outcomes: Input and output balanced, vital sign within normal limits, no sign of pre-shock.

Intervention:
1. Monitor vital sign every 3 hours / as indicated.
Rationale: Vital sign helps identify fluctuations in intravascular fluid.
2. Observation of capillary refill.
Rational: Indications adequacy of peripheral circulation.
3. Observation intake and output. Note the color of urine / concentration
Rationale: Decreased urine output with increased density concentrated suspected dehydration.
4. Encourage to drink 1500-2000 ml / day (as tolerated)
Rationale: To meet the needs of the body fluids peroral
5. Collaboration: Intravenous Fluid
Rational: It can increase the amount of body fluid, to prevent hipovolemic shock.

3. Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid into the extravascular migration.

Goal: Not happening hypovolemic shock.
Expected outcomes: Vital signs within normal limits.

Intervention:
1. Monitor the patient's general condition
Rationale: To monitor the condition of the patient during treatment, especially when paused bleeding. Nurses immediately know the signs of pre-shock / shock.
2. Observation of vital sign every 3 hours or more
Rationale: Nurses need to continue to observe the vital sign to ensure it does not happen pre-shock / shock.
3. Explain to the patient and family sign of bleeding, and immediately report if bleeding occurs
Rationale: By involving the patient and family the signs of bleeding can be quickly identified and appropriate action is fast and can be immediately given.
4. Collaboration: Intravenous Fluid
Rationale: Intravenous fluids needed to overcome a severe loss of body fluids.
5. Collaboration: checks: HB, PCV, platelet
Rationale: To determine the level of blood vessel leakage experienced by patients and to take further action reference.

4. Risk for imbalanced Nutrition, Less Than Body Requirements related to inadequate nutritional intake due to nausea and decreased appetite.

Goal: No disruption nutritional needs.
Expected outcomes: There are no signs of malnutrition, indicating a balanced weight.

Intervention:
1. Review the history of nutrition, including food preferences
Rationale: Identify deficiencies, suspect the possibility of intervention.
2. Observation and record the patient's food intake
Rational: Supervise caloric intake / lack of quality food consumption.
3. Measure body weight each day (if possible)
Rational: Supervise weight loss / oversee the effectiveness of interventions.
4. Give food a little but often and or eating between meals
Rational: little food can reduce vulnerabilities and increase input also prevent gastric distention.
5. Give and oral hygiene aids.
Rationale: Increased appetite and input peroral
6. Avoid foods that stimulate and gassy.
Rationale: Reducing distention and gastric irritation.

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5 Gonorrhea Nursing Diagnosis and Interventions

Nursing Care Plan for Gonorrhea

Nursing Care Plan for Gonorrhea

Gonorrhea is an infectious disease caused by Neisseria gonorrhea are transmitted through sexual intercourse either with genito-genital, oro-genital, ano-genital. This disease infects the inner lining of the urethra, cervix, rectum, throat, and conjunctiva.

Gonorrhea can spread through the bloodstream to other parts of the body, especially the skin and joints. In women, gonorrhea can spread to infect the genital tract and mucous in the pelvis, causing pelvic pain and reproductive problems.

The exact cause of gonorrhea is a bacterial disease that are pathogenic Neisseria gonorrhea.
The most easily infected mucosa is an area with a layer of flattened epithelial kuboid or undeveloped in female puberty yet.

In men:
  • The early symptoms of gonorrhea usually appear within 2-7 days after infection
  • Symptoms begin as malaise followed by pain in the urethra when urinating.
  • Dysuria that arise suddenly, feeling urination accompanied by mucoid discharge from the urethra.
  • Urinary retention caused by prostate inflammation.
  • Discharge of pus from the penis.

In women:
  • Early symptoms usually appear within 7-21 days after infection.
  • Patients often experience symptoms for several weeks or months (asymptomatic).
  • If symptoms develop, usually mild. However, some patients showed severe symptoms such as urgency to urinate.
  • Pain when urinating.
  • Discharge from the vagina.
  • Fever.
  • The infection can affect the cervix, uterus, ovaries, urethra, and rectum and cause pain in the hip when having sex.

5 Gonorrhea Nursing Diagnosis and Interventions

1. Acute pain related to the reaction of infection

Purpose:
  • After nursing actions, the client will:
  • Identifying the causes
  • Using the methods of prevention of non-analgesic to relieve pain
  • Using analgesics as needed
  • Reported pain was controlled

Intervention:
  1. Examine in a comprehensive pain include location, characteristics, and onset, duration, frequency, quality, intensity / severity of pain, and precipitation factors.
  2. Observation of non-verbal cues of discomfort, especially the inability to communicate effectively.
  3. Use therapeutic communication so that the client can express pain.
  4. Provide support to clients and families.
  5. Control of environmental factors that can affect the client's response to discomfort (ex.: room temperature, irradiation, etc.)
  6. Teach the use of non-pharmacologic techniques (ex.: relaxation, guided imagery, music therapy, distraction, application of heat and cold, massage, hypnosis, therapeutic activity)
  7. Give analgesics as directed.
  8. Increase sleep or rest.
  9. Evaluate the effectiveness of the measures that have been used to control pain.

2. Hyperthermia related to inflammatory reactions

Purpose:
  • After nursing actions, the client will:
  • The temperature in the normal range
  • Pulse and respiration within the normal range
  • No skin discoloration and no headache

Intervention:
  • Monitor vital sign.
  • Monitor the temperature at least 2 hours.
  • Monitor color.
  • Increase intake of fluids and nutrients.
  • Cover the client to prevent loss of body heat.
  • Compress clients in the groin and axilla.
  • Give antipyretics as needed.

3 Impaired Urinary Elimination related to the inflammatory process

Purpose:
  • After nursing actions, the client will:
  • Urine will be a continent
  • Elimination of urine would not be disturbed: the smell, the number, color of urine within expected ranges and urine output without pain.

Intervention:
  • Monitor urine elimination include: frequency, consistency, odor, volume, and color appropriately.
  • Refer to urologist if the cause of acute discovered.

4 Anxiety related to the disease

Purpose:
  • After nursing actions, the client will:
  • No signs of anxiety
  • Reported a decrease in the duration and episodes of anxiety
  • Reporting needs adequate sleep
  • Demonstrate flexibility role

Intervention:
  • Assess the level of anxiety and physical reactions to high levels of anxiety (tachycardia, takipneu, non-verbal expressions of anxiety).
  • Accompany clients to support the anxiety and fear.
  • Instruct client to use relaxation techniques.
  • Give medication to reduce anxiety in a proper way.
  • Provide current information on the diagnosis, treatment, and prognosis.

5 Low self-esteem related to disease

Purpose:
  • After nursing actions, the client will express a positive outlook for the future and resume previous level of functioning, with indicators:
  • Identifying the positive aspects of self.
  • Analyze own behavior and its consequences.
  • Identify ways to use and control affect the results.

Intervention:
  • Assist individuals in identifying and expressing feelings.
  • Encourage clients to envision the future and the positive outcomes of life.
  • Strengthen skills and positive character traits (eg, hobbies, skills, appearance, occupation).
  • Help clients receive positive and negative feelings.
  • Assist in identifying their own responsibility and control of the situation.

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