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Nursing Intervention for Anemia

Nursing Intervention for Anemia

1. High risk of infection related to an inadequate secondary defenses (decreased hemoglobin leucopenia, or a decrease in granulocytes (inflammatory response depressed)).

Goal :
Infection does not occur.

Expected Outcomes :
  • Identify the behaviors to prevent / reduce the risk of infection.
  • Improving wound healing, free of purulent drainage or erythema, and fever.
Nursing Intervention :
  • Increase of good hand washing; by care givers and patients.
    Rational: to prevent cross-contamination / bacterial colonization. Note: patients with severe anemia / aplastic can be risky due to the normal flora of the skin.
  • Maintain strict aseptic technique in the procedure / treatment of injuries.
    Rational: reducing the risk of colonization / infection of bacteria.
  • Provide skin care, perianal and oral carefully.
    Rational: reducing the risk of damage to the skin / tissue and infection.
  • Motivation changes in position / ambulation frequently, coughing and breathing exercises that deep.
    Rational: to improve the ventilation of all lung segments, and help mobilize secretions to prevent pneumonia.
  • Increase adequate fluids.
    Rational: to assist in the dilution of respiratory secretions to facilitate the spending and prevent stasis of body fluids such as respiratory and kidney.
  • Monitor / limit visitors. Provide insulation if possible.
    Rational: to limit exposure to the bacteria / infection. Protection of insulation required in aplastic anemia, when the immune response is disrupted.
  • Monitor body temperature. Note the chills and tachycardia with or without fever.
    Rational: the process of inflammation / infection require evaluation / treatment.
  • Observe erythema / wound fluid.
    Rational: indicators of local infection. Note: the formation of pus may not exist when granulocytes depressed.
  • Take specimens for culture / sensitivity as indicated (collaboration)
    Rational: differentiate an infection, identify the specific pathogen and affect treatment options.
  • Give a topical antiseptic; systemic antibiotics (collaboration).
    Rational: propilaktik may be used to reduce colonization or for the treatment of local infection process.

2. Activity intolerance related to imbalance between oxygen supply (delivery) and demand.

Goal :
Able to maintain / improve ambulation / activity.

Expected Outcomes :
  • Reported an increase in activity tolerance (including daily activities).
  • Indicates decrease in physiological signs of intolerance, such as pulse, respiration, and blood pressure is still within the normal range.
Nursing Intervention :
  • Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity.
    Rational : Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues.
  • Assess patient ability to perform ADLs
    Rational : Influences choice of interventions and needed assistance.
  • Provide or recommend assistance with activities and ambulation as necessary, allowing client to be an active participant as much as possible.
    Rational : Although help may be necessary, self-esteem is enhanced when client does some things for self.
  • Suggest client change position slowly; monitor for dizziness.
    Rational : Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
  • Identify and implement energy-saving techniques
    Rational : Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.
  • Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.
    Rational : Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary strain and stress may lead to decompensation and failure.
Nursing Intervention for Anemia
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Nursing Diagnosis for Anemia

Nursing Diagnosis for Anemia

Nursing diagnoses that appear in patients with anemia (Doenges, 1999) include :
  1. High risk of infection related to an inadequate secondary defenses (decreased hemoglobin leucopenia, or a decrease in granulocytes (inflammatory response depressed)).
  2. Changes in nutrition less than body requirement related to failure to digest or inability to digest the food / nutrient absorption necessary for the formation of red blood cells.
  3. Activity intolerance related to imbalance between oxygen supply (delivery) and demand.
  4. Changes in tissue perfusion related to decreased cellular components required for the delivery of oxygen / nutrients to the cells.
  5. High risk of damage to skin integrity related to circulatory and neurological changes.
  6. Constipation or diarrhea related to decreased dietary inputs; changes in the digestive process; the side effects of drug therapy.
  7. Lack of knowledge in relation to the lack of exposure / recall; incorrect interpretation of information; do not know the source of information.

Read More : NANDA Nursing Doagnosis for Anemia
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Nursing Care Plan for Anemia

Nursing Care Plan for Anemia



Anemia (uh-NEE-me-uh) is a condition in which your blood has a lower than normal number of red blood cells.

Anemia also can occur if your red blood cells don't contain enough hemoglobin (HEE-muh-glow-bin). Hemoglobin is an iron-rich protein that gives blood its red color. This protein helps red blood cells carry oxygen from the lungs to the rest of the body.

If you have anemia, your body doesn't get enough oxygen-rich blood. As a result, you may feel tired and have other symptoms. Severe or long-lasting anemia can damage the heart, brain, and other organs of the body. Very severe anemia may even cause death.


Blood is made up of various parts, including red blood cells, white blood cells, platelets (PLATE-lets), and plasma (the fluid portion of blood).

Red blood cells are disc-shaped and look like doughnuts without holes in the center. They carry oxygen and remove carbon dioxide (a waste product) from your body. These cells are made in the bone marrow—a sponge-like tissue inside the bones.

White blood cells and platelets (PLATE-lets) also are made in the bone marrow. White blood cells help fight infection. Platelets stick together to seal small cuts or breaks on the blood vessel walls and stop bleeding. With some types of anemia, you may have low numbers of all three types of blood cells.

Anemia has three main causes: blood loss, lack of red blood cell production, or high rates of red blood cell destruction. These causes may be due to many diseases, conditions, or other factors.


Many types of anemia can be mild, short term, and easily treated. You can even prevent some types with a healthy diet. Other types can be treated with dietary supplements.

However, certain types of anemia may be severe, long lasting, and life threatening if not diagnosed and treated.

If you have signs and symptoms of anemia, see your doctor to find out whether you have the condition. Treatment will depend on the cause and severity of the anemia.
Source :

Nursing Care Plan for Anemia

Nursing Assessment for Anemia

Assessment of patients with anemia (Doenges, 1999) include :
  1. Activity / rest
    Symptoms :
    fatigue, weakness, general malaise. Lost productivity: a reduction in enthusiasm for work. Low exercise tolerance. The need for sleep and rest more.

    Signs :
    tachycardia / takipnae; dyspnea during work or rest. Lethargy, withdrawn, apathetic, lethargic, and less interested in its surroundings. Muscle weakness, and decreased strength. Ataxia, the body is not upright. Shoulders down, slumped posture, slow, and other signs that indicate fatigue.
  2. Circulation
    Symptoms :
    A history of chronic blood loss, such as chronic gastrointestinal bleeding, heavy menstruation, angina, CHF (due to excessive cardiac work). History of chronic infective endocarditis. Palpitations (tachycardia compensation).

    Signs :
    Blood pressure: systolic to diastolic steady improvement, and widening pulse pressure, postural hypotension. Dysrhythmias: ECG abnormality, ST segment depression and T wave leveling or depression; tachycardia. The sound of the heart: systolic murmur. Extremity (color): pale skin and mucous membranes (conjunctiva, mouth, pharynx, lips) and the base of the nail. (Note: in black patients, white may appear to be grayish). Leather like waxy, pale or bright lemon yellow. Sclera: blue or pearly white. Slow capillary filling (decreased blood flow to the capillary and vasoconstriction compensation) nails: easily broken, shaped like a spoon (koilonikia). Hair: dry, easily breaking, thinning, gray hair grow prematurely.
  3. Integrity ego
    Symptoms :
    Religious beliefs / cultural influence treatment options, such as refusal of blood transfusions.

    Signs :
  4. Elimination
    Symptoms :
    A history of pyelonephritis, kidney failure. Flatulen, malabsorption syndrome. Hematemesis, stool with fresh blood, melena. Diarrhea or constipation. Decrease in urine output.

    Signs :
    Abdominal distension.
  5. Food / fluid
    Symptoms :
    Decreased dietary input. Painful mouth or tongue, difficulty swallowing (pharyngeal ulcers). Nausea / vomiting, dyspepsia, anorexia. The presence of weight loss. Never satisfied to chew or sensitive to ice, dirt, corn flour, paint, clay, and so forth.

    Signs :
    Tongue looks red meat / subtle deficiency of folic acid and vitamin B12. Dry mucous membranes, pale. Skin turgor: ugly, dry, looks shriveled / lost elasticity. Stomatitis and glositis (deficiency status). Lips: selitis, such as inflammatory lips with the corner of his mouth cracked.
  6. Neurosensori
    Symptoms :
    Headache, throbbing, vertigo, tinnitus, inability to concentrate. Insomnia, decreased vision, and shadows on the eyes. Weakness, poor balance, unsteady legs, paresthesias hands / feet; klaudikasi. The sensation of being cold.

    Signs :
    Sensitive to stimuli, anxiety, depression tend to sleep, apathy. Mental: not able to respond, slow and shallow. Ophthalmic: hemoragis retina. Epitaksis: bleeding from the holes (aplastic). Impaired coordination, ataxia, decreased sense of vibration, and position, positive Romberg sign, paralysis.
  7. Pain / comfort
    Symptoms: abdominal pain, headache
  8. Breathing
    Symptoms :
    A history of tuberculosis, lung abscess. Short of breath at rest and activity.

    Signs :
    Tachypnoea, orthopnea, and dyspnea.
  9. Security
    Symptoms :
    A history of work exposure to chemicals,. History of exposure to radiation, either to treatment or accident. History of cancer, cancer therapy. Not tolerant of cold and heat. Previous blood transfusion. Impaired vision, poor wound healing, frequent infections.

    Signs :
    A low fever, chills, night sweats, general lymphadenopathy. Ptekie and ekimosis(aplastic).
  10. Sexuality
    Symptoms :
    Changes in menstrual flow, such as menorrhagia or amenorrhea. Lost libido (male and female). Imppoten.

    Signs :
    Pale vaginal walls.
Nursing Care Plan for Anemia

Nursing Intervention for Anemia
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Nursing Care Plan for Osteoarthritis

Nursing Care Plan for Osteoarthritis


Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion. A variety of causes—hereditary, developmental, metabolic, and mechanical—may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax.

Treatment generally involves a combination of exercise, lifestyle modification and analgesics. If pain becomes debilitating joint replacement surgery may be used to improve the quality of life. OA is the most common form of arthritis, and the leading cause of chronic disability in the United States. It affects about 8 million people in the United Kingdom and nearly 27 million people in the United States.


Exercise, including running in the absence of injury, has not been found to increase one's risk of developing osteoarthritis. Some investigators believe that mechanical stress on joints underlies all osteoarthritis, with many and varied sources of mechanical stress, including misalignments of bones caused by congenital or pathogenic causes; mechanical injury; overweight; loss of strength in muscles supporting joints; and impairment of peripheral nerves, leading to sudden or uncoordinated movements that overstress joints.

PrimaryPrimary osteoarthritis of the left knee. Note the osteophytes, narrowing of the joint space (arrow), and increased subchondral bone density (arrow).

This type of OA is a chronic degenerative disorder related to but not caused by aging, as there are people well into their nineties who have no clinical or functional signs of the disease. As a person ages, the water content of the cartilage decreases as a result of a reduced proteoglycan content, thus causing the cartilage to be less resilient. Without the protective effects of the proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration. Inflammation of the surrounding joint capsule can also occur, though often mild (compared to that which occurs in rheumatoid arthritis). This can happen as breakdown products from the cartilage are released into the synovial space, and the cells lining the joint attempt to remove them. New bone outgrowths, called "spurs" or osteophytes, can form on the margins of the joints, possibly in an attempt to improve the congruence of the articular cartilage surfaces. These bone changes, together with the inflammation, can be both painful and debilitating.

A number of studies have shown that there is a greater prevalence of the disease between siblings and especially identical twins, indicating a hereditary basis. Up to 60% of OA cases are thought to result from genetic factors.

Both primary generalized nodal OA and erosive OA (EOA. also called inflammatory OA) are sub-sets of primary OA. EOA is a much less common, and more aggressive inflammatory form of OA which often affects the DIPs and has characteristic changes on X-Ray.

SecondaryThis type of OA is caused by other factors but the resulting pathology is the same as for primary OA:

* Congenital disorders of joints
* Diabetes.
* Inflammatory diseases (such as Perthes' disease), (Lyme disease), and all chronic forms of arthritis (e.g. costochondritis, gout, and rheumatoid arthritis). In gout, uric acid crystals cause the cartilage to degenerate at a faster pace.
* Injury to joints, as a result of an accident or orthodontic operations.
* Septic arthritis (infection of a joint )
* Ligamentous deterioration or instability may be a factor.
* Marfan syndrome
* Obesity
* Alkaptonuria
* Hemochromatosis and Wilson's disease

Signs and symptoms

The main symptom is pain, causing loss of ability and often stiffness. "Pain" is generally described as a sharp ache, or a burning sensation in the associate muscles and tendons. OA can cause a crackling noise (called "crepitus") when the affected joint is moved or touched, and patients may experience muscle spasm and contractions in the tendons. Occasionally, the joints may also be filled with fluid. Humid and cold weather increases the pain in many patients.

OA commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel worse, the more they are used throughout the day, thus distinguishing it from rheumatoid arthritis.

In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen. Some people notice these physical changes before they experience any pain.

OA is the most common cause of joint effusion, sometimes called water on the knee in lay terms, an accumulation of excess fluid in or around the knee joint.
Source :

Nursing Care Plan for Osteoarthritis

Nursing Assessment for Osteoarthritis
  1. Activity / Rest
    • Joint pain due to movement, tenderness worsened by stress on the joints, stiffness in the morning, usually occurs bilaterally and symmetrically functional limitations that affect lifestyle, leisure, work, fatigue, malaise.
    • Limitation of movement, muscle atrophy, skin: contractor / abnormalities in the joints and muscles.
  2. Cardiovascular
    • Raynaud's phenomenon of the hand (eg litermiten pale, cyanosis and redness on the fingers before the color returned to normal.
  3. Ego Integrity
    • Stress factors of acute / chronic (eg, financial jobs, disability, relationship factors.
    • Hopelessness and helplessness (inability situation).
    • Threats to the self-concept, body image, personal identity, for example dependence on others.
  4. Food / Fluids
    • The inability to produce or consume food or liquids adequately nausea, anorexia.
    • Difficulty chewing, weight loss, dryness of mucous membranes.
  5. Hygiene
    • The difficulties to implement self-care activities, dependence on others.
  6. Neurosensory
    • Tingling in hands and feet, swollen joints
  7. Pain / comfort
    • The acute phase of pain (probably not accompanied by soft tissue swelling in the joints. chronic pain and stiffness (especially in the morning).
  8. Security
    • Skin shiny, taut, nodules sub mitaneus
    • Skin lesions, foot ulcers
    • The difficulty in handling the task / household maintenance
    • Mild fever settled
    • Dryness in the eyes and mucous membranes
  9. Social Interaction
    • Damage interaction with family or others, the changing role: isolation.
  10. Counseling / Learning
    • Family history of rheumatic
    • The use of health foods, vitamins, cure disease without testing
    • History pericarditis, valve lesion edge. Pulmonary fibrosis, pleuritis.

Nursing Diagnosis for Osteoarthritis
  1. Pain Acute / Chronic related to distention of tissue by the accumulation of fluid / inflammatory process, Liquor joints.
  2. Impaired Physical Mobility related to skeletal deformities, pain, discomfort, decreased muscle strength.

Nursing Diagnosis and Nursing Intervention for Osteoarthritis

1. Pain Acute / Chronic related to distention of tissue by the accumulation of fluid / inflammatory process, Liquor joints.

Expected Outcomes :
  • Showing pain is reduced or controlled
  • Looks relaxed, to rest, sleep and participate in activities based on ability.
  • Following the therapy program.
  • Using the skills of relaxation and entertainment activity in the pain control program.
Nursing Intervention :
  • Assess pain; note the location and intensity of pain (scale 0-10). Write down the factors that accelerate and signs of non-verbal pain.
  • Give the hard mattress, small pillow. Elevate bed when a client needs to rest / sleep.
  • Help the client take a comfortable position when sleeping or sitting in a chair. Depth of bed rest as indicated.
  • Monitor the use of a pillow.
  • Help clients to frequently change positions.
  • Help the client to a warm bath at the time of waking.
  • Help the client to a warm compress on the sore joints several times a day.
  • Monitor temperature compress.
  • Give a massage.Encourage the use of stress management techniques such as progressive relaxation bio-feedback therapeutic touch, visualization, self hypnosis guidelines imagination, and breath control.Engage in activities of entertainment that is suitable for individual situations.
  • Give the drug before activity / exercise that is planned as directed.
  • Assist clients with physical therapy.

2. Impaired Physical Mobility related to skeletal deformities, pain, discomfort, decreased muscle strength.

Expected Outcomes :

  • Maintain or improve strength and function of the compensation part of the body

  • Demonstrating techniques / behaviors that allow doing activities.

  • Nursing Intervention

    • Monitor the level of inflammation / pain in joints
    • Maintain bed rest / sit if necessary
    • Schedule of activities to provide a rest period of continuous and uninterrupted nighttime sleep.
    • Assist clients with range of motion active / passive and resistive exercise and isometric if possible.
    • Slide to maintain an upright position and sitting height, standing, and walking.
    • Provide a safe environment, for example, raise the chair / toilet, use a high grip and tub and toilet, the use of mobility aids / wheelchairs rescue.
    • Collaboration physical therapist / occupational and specialist vasional.
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    Various Types of Nursing Diagnosis


    It is a client problem that is present at the time of the nursing assessment. Examples are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms.


    It is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status.


    “Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.” Examples of wellness diagnosis would be Readiness for Enhanced spiritual Well Being or Readiness for Enhanced Family Coping.


    It is one in which evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it. For example, an elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. Until more data are collected, the nurse may write a nursing diagnosis of Possible Social Isolation related to unknown etiology.


    It is a diagnosis that is associated with a cluster of other diagnoses.

    Source :
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    Nursing Care Plan for Hypertension

    Nursing Care Plan for Hypertension

    Nursing Care Plan for Hypertension


    Hypertension (HTN) or high blood pressure is a chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. It is classified as either primary (essential) or secondary. About 90–95% of cases are termed "primary hypertension", which refers to high blood pressure for which no medical cause can be found. The remaining 5–10% of cases (Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart, or endocrine system.

    Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure. Moderate elevation of arterial blood pressure leads to shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment may prove necessary in patients for whom lifestyle changes prove ineffective or insufficient.


    Essential Hypertension

    Essential hypertension is the most prevalent hypertension type, affecting 90–95% of hypertensive patients. Although no direct cause has been identified, there are many factors such as sedentary lifestyle, smoking, stress, visceral obesity, potassium deficiency (hypokalemia), obesity (more than 85% of cases occur in those with a body mass index greater than 25), salt (sodium) sensitivity, alcohol intake, and vitamin D deficiency that increase the risk of developing hypertension. Risk also increases with aging, some inherited genetic mutations, and having a family history of hypertension. An elevated level of renin, a hormone secreted by the kidney, is another risk factor, as is sympathetic nervous system overactivity. Insulin resistance, which is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension. Recent studies have implicated low birth weight as a risk factor for adult essential hypertension.

    Secondary Hypertension

    Secondary hypertension by definition results from an identifiable cause. This type is important to recognize since it's treated differently to essential hypertension, by treating the underlying cause of the elevated blood pressure. Hypertension results in the compromise or imbalance of the pathophysiological mechanisms, such as the hormone-regulating endocrine system, that regulate blood plasma volume and heart function. Many conditions cause hypertension, some are common and well recognized secondary causes such as Cushing's syndrome, which is a condition where the adrenal glands overproduce the hormone cortisol. In addition, hypertension is caused by other conditions that cause hormone changes such as hyperthyroidism, hypothyroidism (citation needed), and certain tumors of the adrenal medulla (e.g., pheochromocytoma). Other common causes of secondary hypertension include kidney disease, obesity/metabolic disorder, pre-eclampsia during pregnancy, the congenital defect known as coarctation of the aorta, and certain prescription and illegal drugs.

    Nursing Care Plan for Hypertension

    NANDA Hypertension - Nursing Diagnosis for Hypertension

    Hypertension Nursing Interventions

    Nursing Diagnosis for Hypertension

    Nursing Diagnosis and Nursing Intervention for Hypertension
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    Nursing Care Plan for Urolithiasis

    Nursing Care Plan for Urolithiasis

    Nursing Care Plan for Urolithiasis


    Urolithiasis is the condition where urinary calculi are formed in the urinary tract.

    The term kidney stone (or "renal calculus") is sometimes used to refer to urolithiasis in any part of the urinary tract, however it is more properly reserved for stones that are actually in the collecting duct of the kidney itself.

    The term nephrolithiasis can be used to describe the condition of having kidney stones, and ureterolithiasis can be used to describe the condition of having stones in the ureter.

    Obstruction of the ureter by the kidney stones causes a renal colic attack which is why intense pain is felt in groin and back.

    The term bladder stone is more frequently associated with veterinary science.


    Bladder stones can occur if kidney(s), the bladder or urinal tracts get inflamed. Another reason is if a patient has frequent insertion of urinary catheters. Some people who are paralyzed and unable to pass urine require small plastic tubes (catheters) placed in the bladder. These tubes are prone to infection which irritates the bladder resulting in stone formation. Finally kidney stones can travel down the ureter into the bladder and grow in to bladder stones. There is some evidence indicating that chronic irritation of the bladder by retained stones may increase the chance of bladder cancer.


    Urinary stones may be composed of the following substances :

    * Calcium oxalate monohydrate (whewellite)
    * Calcium oxalate dihydrate (weddellite)
    * Calcium phosphate
    * Magnesium phosphate
    * Ammonium phosphate
    * Ammonium magnesium phosphate (struvite)
    * Calcium hydroxyphosphate (apatite)
    * Uric acid and its salts (urates)
    * Cystine
    * Xanthine
    * Indigotin (rare)
    * Urostealith (rare)
    * Sulphonamide (rare)

    Nursing Care Plan for Urolithiasis

    Nursing Assessment for Urolithiasis

    History of Nursing and Physical Assessment : based on the Doenges classification (2000), history of nursing that need to be assess are :
    1. Activity / rest :
      Symptoms :
      • History of work monotony, physical activity is low, more sedentary.
      • History of working in an environment of high temperature.
      • The limited physical mobility due to other systemic diseases (cerebrovascular injury, long bed rest).
    2. Circulation
      Signs :
      • Increased blood pressure (pain, anxiety, kidney failure)
      • Skin warm and reddish or pale.
    3. Elimination
      Symptoms :
      • History UTI chronic, History obstruksi
      • Decrease in urine volume
      • Burning, urge to urinate
      • Diarrhea
      Signs :
      • Oliguria, haematuria, piouria
      • Changes in urination pattern
    4. Food and liquids :
      Symptoms :
      • Nausea / vomiting, abdominal tenderness
      • History diet high-purine, calcium oxalate or phosphate
      • Hydration is not adequate, do not drink water with enough
      Signs :
      • Distension Abdominal, decline / no noisy intestine
      • Throw up
    5. Pain and comfort :
      Symptoms :
      • Pain is severe in the acute phase (colicky pain), location of pain depends on the location of stones (kidney stones cause pain shallow constant)
      Signs :
      • Behavior careful, behavioral distraction
      • Tenderness in the area of kidney pain
    6. Security :
      Symptoms :
      • The use of alcohol
      • Fever / chills
    7. Counseling / learning :
      Symptoms :
      • History of urinary tract stones in the family, kidney disease, hypertension, gout, UTI Chronic
      • History of disease small intestine, abdominal surgery before, hyperparathyroidism
      • The use of antibiotics, antihypertensives, sodium bicarbonate, alopurinul, phosphate, tiazid, excessive input of calcium or vitamin.

    Nursing Diagnosis for Urolithiasis
    • Impaired sense of comfort : pain related to an increased frequency / impulse ureteral contraction, tissue trauma, edema formation.
    • Changes in elimination of urine related to bladder stimulation by stones, kidney or ureteral irritation, mechanical obstruction, inflammatory.

    Nursing Intervention for Urolithiasis

    1. Impaired sense of comfort : pain related to an increased frequency / impulse ureteral contraction, tissue trauma, edema formation.

    Goal :
    The pain may be missing or less 

    Result Criteria :
    • Report the pain disappear
    • Relaxed, able to sleep / rest with the appropriate
    Intervention :
    • Record the location, duration of the intensity (scale 0-10) and deployment. Consider non-verbal signs, for example increased blood pressure, pulse, restless and whimpering.
    • Explain the cause of pain and the importance of reporting to the nurse to changing events / characteristics of pain.
    • Give the actions comfortable, eg, back massage patients, the environment a break.
    • Assist the use of breath focused, the guidance of imagination and the therapeutic activity.
    • Note the complaint improvement / establishment of abdominal pain.
    • Give appropriate therapy program.

    2. Changes in elimination of urine related to bladder stimulation by stones, kidney or ureteral irritation, mechanical obstruction, inflammatory.

    Goal :
    The elimination of urine in the normal amount

    Result Criteria :
    • voiding with a normal amount and the pattern usually
    • Not have any signs of obstruction
    • Monitor the income and expenditure and characteristics of urine
    • Determine the patient's normal micturition pattern and notice the variation
    • Encourage increased fluid intake
    • Check all the urine, note the output of stone and send to laboratory for analysis.
    • Observation of changes in mental status, behavior or level of consciousness
    • Supervise laboratory
    • Give appropriate therapy program

    Source :
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    Nursing Care Plan for Bronchial Asthma

    Nursing Care Plan for Bronchial Asthma

    Bronchial Asthma

    Bronchial asthma is a disease of the lungs in which an obstructive ventilation disturbance of the respiratory passages evokes a feeling of shortness of breath. The cause is a sharply elevated resistance to airflow in the airways. Despite its most strenuous efforts, the respiratory musculature is unable to provide sufficient gas exchange. The result is a characteristic asthma attack, with spasms of the bronchial musculature, edematous swelling of the bronchial wall and increased mucus secretion. In the initial stage, the patient can be totally symptom-free for long periods of time in the intervals between the attacks. As the disease progresses, increased mucus is secreted between attacks as well, which in part builds up in the airways and can then lead to secondary bacterial infections. Bronchial asthma is usually intrinsic (no cause can be demonstrated), but is occasionally caused by a specific allergy (such as allergy to mold, dander, dust). Although most individuals with asthma will have some positive allergy tests, the allergy is not necessarily the cause of the asthma symptoms.

    Symptoms can occur spontaneously or can be triggered by respiratory infections, exercise, cold air, tobacco smoke or other pollutants, stress or anxiety, or by food allergies or drug allergies. The muscles of the bronchial tree become tight and the lining of the air passages become swollen, reducing airflow and producing the wheezing sound. Mucus production is increased.

    Typically, the individual usually breathes relatively normally, and will have periodic attacks of wheezing. Asthma attacks can last minutes to days, and can become dangerous if the airflow becomes severely restricted. Asthma affects 1 in 20 of the overall population, but the incidence is 1 in 10 in children. Asthma can develop at any age, but some children seem to outgrow the illness. Risk factors include self or family history of eczema, allergies or family history of asthma. Bronchial asthma causes cough, shortness of breath, and wheezing. Bronchial asthma is an allergic condition, in which the airways (bronchi) are hyper-reactive and constrict abnormally when exposed to allergens, cold or exercise.

    Nursing Care Plan for Bronchial Asthma

    Nursing Assessment for Bronchial Asthma
    1. Past medical history :
      • Assess personal or family history of previous lung disease.
      • Review the history of allergic reaction or sensitivity to the substances / environmental factors.
      • Assess the patient's employment history.
    2. Activity
      • The inability to perform activities because of difficulty breathing.
      • The decline in the ability / improvement needs help doing daily activities.
      • Sleeping in a sitting position higher.
    3. Respiratory
      • Dipsnea at rest or in response to activity or exercise.
      • Breath worsened when the patient lay supine in bed.
      • Using the drug ventilator, for example: raising the shoulders, widen the nose.
      • The existence of wheezing breath sounds.
      • The recurrent coughing.
    4. Circulation
      • The increasing blood pressure.
      • There is an increasing frequency of heart.
      • The color of skin or mucous membranes normal / gray / cyanosis.
      • Redness or sweating.
    5. Ego integrity
      • Anxiety
      • Fear
      • Be sensitive to stimuli
      • Restlessness
    6. Nutrition
      • Inability to eat due to respiratory distress.
      • Weight loss due to anorexia.
    7. Sosal Relations
      • The limited physical mobility.
      • Difficult to talk or stammering.
      • The existence of dependence on others.
    8. Sexuality
      • Decrease in libido.

    Nursing Diagnosis for Bronchial Asthma
    1. Ineffective airway clearance related to the accumulation of mucus.
    2. Ineffective breathing pattern related to decreased lung expansion.
    3. Impaired nutrition less than body requirements related to inadequate intake.

    Nursing Intervention for for Bronchial Asthma

    1. Ineffective airway clearance related to the accumulation of mucus.

    Goal :
    The Way of breath effectively.

    Result Criteria :
    • Shortness reduced
    • Coughing reduced
    • Clients can issue a sputum
    • Wheezing is reduced / lost.
    • Vital signs within normal limits.
    Nursing Intervention :
    • Auscultation of breath sounds, record the sound of breath, for example: wheezing, erekeis, ronchi.
      Rational : Some degree of bronchial spasms occur with airway obstruction. Faint breath sounds with expiratory wheeze (empysema), no breathing function (severe asthma).
    • Review / monitor respiratory frequency, record the ratio of inspiration and expiration.
      Rational : Tachypnoea usually found in some degree and can be found at the reception during the stress / the process of acute infection. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.
    • Assess the patient to a safe position, for example: elevation of the head does not sit on the backrest.
      Rational : Elevation head is not easier for respiratory function by using gravity.
    • Observation of the characteristic cough, persistent, hacking cough, wet. Auxiliary actions to improve effectiveness cough efforts.
      Rational : The cough can be settled but is not effective, especially on elderly clients, acute pain / weakness.
    • Give warm water.
      Rational : use of warm fluids can decrease bronchial spasms.
    • Collaboration based drug Spiriva indikasi.Bronkodilator 1 × 1 (inhalation).
      Rational : Freeing airway spasm, wheezing and mucus production.

    2. Ineffective breathing pattern related to decreased lung expansion.

    Goal :
    The pattern of effective breathing.

    Result Criteria :
    • effective breathing pattern
    • The sound of normal breathing or net
    • Vital signs within normal limits
    • Coughing reduced.
    • Expansion of the lungs inflate.
    Nursing Intervention :
    • Assess respiratory frequency and depth of chest expansion. Record the respiratory effort including the use of auxiliary respiratory muscles / nasal dilation.
      R / velocity usually reaches a depth of respiration varies depending on the degree of respiratory failure. Limited chest expansion associated with atelectasis and / or chest pain.
    • Auscultation of breath sounds and record sounds like crekels breath, wheezing.
      R / rhonchi and wheezing accompanying airway obstruction / respiratory failure.
    • Elevate the head and help change the position.
      R/ Sitting high enable lung expansion and eases breathing.
    • Observation of the pattern of coughing and secretions character.
      R / alveolar congestion often result in cough / irritation.
    • Encourage / assist the patient in breathing and coughing exercises.
      R / Can increase / number of sputum where the interference plus the lack of comfortable ventilation and breathing effort.
    • Collaboration
      • Provide supplemental oxygen.
      • Provide additional humidifikasi eg nebulizer.
      R / Maximize breath breathe and reduce labor, provide moisture to the mucous membranes and helps thinning secretions.

    Source :
    READ MORE - Nursing Care Plan for Bronchial Asthma

    Nursing Diagnosis for Benign Postatic Hyperplasia (BPH)

    Here are examples of Nursing Diagnosis for Benign Postatic Hyperplasia (BPH) :
    1. Impaired sense of comfort : (pain) are associated with muscle spasm spincter.
    2. Changes in patterns of elimination: urinary retention associated with secondary obstruction.
    3. Sexual dysfunction associated with loss of body function.
    4. Potential occurrence of infection associated with port de entrée microorganisms through catheterization.
    5. Lack of knowledge related to the missing information about the disease and treatment.
    READ MORE - Nursing Diagnosis for Benign Postatic Hyperplasia (BPH)

    Nursing Diagnosis and Nursing Intervention for Typhoid Fever

    Nursing Diagnosis and Nursing Intervention for Typhoid Fever

    Nursing Diagnosis and Nursing Intervention for Typhoid Fever

    Nursing Diagnosis for Typhoid Fever
    1. The increase in body temperature related to salmonella typhi infection.
    2. Impaired nutritional needs, less than body requirements related to anorexia.
    3. Disorders of fluid balance (less than demand) are associated with excess fluid (diarrhea / vomiting)

    Nursing Intervention for Typhoid Fever

    1 The increase in body temperature related to salmonella typhi infection

    Goal :
    The normal body temperature

    Result Criteria :
    • Patients reported an increase in body temperature.
    • Seeking help to prevent increase in body temperature.
    • Improved skin turgor.
    Nursing Intervention :
    • Give an explanation to the patient and family about the increase in body temperature.
    • Tell the patient to wear thin and absorbs sweat.
    • Restrict visitors.
    • Observation of vital signs every 4 hours.
    • Tell the patient to drink a lot, drink a lot of fluid intake.
    • Collaboration with doctor in the provision of antibiotics and antipyretic therapy.

    2. Impaired nutritional needs, less than body requirements related to anorexia

    Goal :
    Patients are able to maintain adequate nutritional needs

    Reasult Criteria :
    • Increased appetite.
    • Patients able to spend a portion of food in accordance with the given.
    Nursing Intervention :
    • Explain to the client and family about the benefits of food / nutrition.
    • Weigh the client body weight every 2 days.
    • Give nutrition with soft diet, do not contain much fiber, not stimulate, or cause a lot of gas and serve while still warm.
    • Give small amounts of food and frequency often.
    • Collaboration with doctor for the administration of antacids and parenteral nutrition.

    3. Disorders of fluid balance (less than demand) are associated with excess fluid (diarrhea / vomiting)

    Goal :
    Fluid balance

    Results Criteria
    • Increased skin turgor
    • The face does not look pale
    Nursing Intervention :
    • Give an explanation of the importance of fluid requirements in patients and families.
    • Observation of input and output of fluid.
    • Instruct the patient to drink plenty of 2.5 liters / 24 hours.
    • Observation drip infusion.
    • Collaboration with physicians to fluid therapy (oral / parenteral).
    READ MORE - Nursing Diagnosis and Nursing Intervention for Typhoid Fever

    Nursing Diagnosis and Nursing Intervention for Diabetes Mellitus

    Nursing Diagnosis and Nursing Intervention for Diabetes Mellitus

    Nursing Diagnosis for Diabetes Mellitus
    1. Impaired tissue perfusion related to weakening / decreased blood flow to the area gangrene due to obstruction of blood vessels.
    2. Integrity of the tissue disorder related to gangrene in the extremities.

    Nursing Intervention for Diabetes Mellitus

    1. Impaired tissue perfusion related to weakening / decreased blood flow to the area gangrene due to obstruction of blood vessels.

    Goal :
    Peripheral Circulation remain normal.

    Result Criteria :
    • Palpable peripheral pulse strong and regular
    • The color of the skin around the wound was not pale / cyanotic
    • The skin around the wound felt hot.
    • Edema did not occur and injuries from getting worse.
    • Sensory and motor improvement.

    Nursing Intervention :
    • Teach the patient to mobilize
      Rational : the mobilization improves blood circulation.
    • Teach about the factors which can increase blood flow :
      Elevate feet slightly lower than the heart (the position of elevation at rest), avoid crossing legs, avoiding tight bandage, avoid the use of pillows, hamstrings and so forth.
      Rational : to increase blood flow through so that does not happen edema.
    • Teach about the modification of risk factors such as :
      Avoid a diet high in cholesterol, relaxation techniques, smoking cessation, and drug use vasoconstriction.
      Rational : high cholesterol can accelerate the occurrence of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.
    • Collaborate with other health team in giving vasodilators, checking blood sugar regularly and oxygen therapy (HBO).
      Rational : giving vasodilators will increase the dilation of blood vessels so that tissue perfusion can be improved, while checking blood sugar regularly to know the progress and state of the patient, to improve oxygenation HBO areas ulcer / gangrene.

    2. Integrity of the tissue disorder related to gangrene in the extremities.

    Goal : The achievement of the wound healing process.

    Result Criteria :
    • Decreased edema around the wound.
    • The presence of granulation tissue.
    • The stench of injury is reduced.
    Nursing Intervention :
    • Assess the wound area and state as well as the healing process.
      Rational : the right assessment of the wound and the healing process will assist in determining further action.
    • Treat wounds with good and true: clean wound abseptik use solution that is not irritating, lift the rest of the bandages that stick to the wound and nekrotomi dead tissue.
      Rational : treating wounds with aseptic technique, wound contamination and can maintain the solution will damage the granulation tissue irritating tyang arise, the remaining dressing to hamper the process of necrotic tissue granulation.
    • Collaboration with physicians for the administration of insulin, pus culture examination, examination of blood sugar, giving anti-biotic.
      Rational : the insulin will lower blood sugar, pus culture examination to determine the types of germs and antibiotics, are appropriate for the medication, checking blood sugar levels to determine the progression of the disease.

    3. Impaired sense of comfort (pain) related to ischemic tissue.

    Goal :
    No pain / reduced pain

    Result Criteria :
    • Patients say the pain verbally reduced / lost.
    • Patients can perform the methods or actions to overcome or reduce pain.
    • Expanding patient movement.
    • No cold sweat, vital signs within normal limits. (Temperature: 36 to 37.5 0C, Nadi 60 - 80 x / min, Blood Pressure: 100-130 mmHg, Respiratory: 18 - 20 x / min).
    Nursing Intervention :
    • Assess the level, frequency, and reaction to pain experienced by patients.
      Rational : to find out how severe pain experienced by patients.
    • Explain to the patient about the causes of pain.
      Rational : understanding the patient about the causes of pain that occurs will reduce the tension of patients and allows patients to be invited to cooperate in taking action.
    • Create a peaceful environment.
      Rational : excessive stimulation from the environment will aggravate the pain.
    • Teach a distraction and relaxation techniques.
      Rational : distraction and relaxation techniques can reduce pain felt by patients.
    • Adjust the position of the patient as pleasant as possible according to patient preference.
      Rational : a comfortable position to help provide opportunities for relaxation in the muscles optimally.
    • Collaboration with the doctor for giving analgesics.
      Rational : analgesic drugs may help reduce pain patients.
    Read More :
    Nursing Assessment for Diabetes Mellitus

    NANDA Diabetes

    12 Nursing Diagnosis for Diabetes MellitusNursing Interventions for Diabetes Mellitus

    Nursing Diagnosis and Interventions - Diabetes Mellitus with Gangrene
    READ MORE - Nursing Diagnosis and Nursing Intervention for Diabetes Mellitus

    Nursing Diagnosis and Nursing Intervention for CRF - Chronic Renal Failure

    Nursing Diagnosis and Nursing Intervention for CRF - Chronic Renal Failure

    Nursing Diagnosis and Nursing Intervention for Chronic Renal Failure - CRF

    Nursing Diagnosis for CRF
    1. Nutrition Disorders : Less than body requirements related to restriction intake (diet) and the effect of protein malnutrition resulting uremia - calori.
    2. Potential infections related to immune system suppression, due to uremia.
    3. Less able to care for themselves related to physical weakness.

    Nursing Intervention for CHF

    1. Nutrition Disorders: Less than body requirements related to restriction intake (diet) and the effect of protein malnutrition resulting uremia - calori.

    Goal :
    Balanced nutrition

    Result Criteria :
    Stable weight, eating out

    Nursing Intervention :
    • Assess for the presence of nausea, vomiting and anorexia.
    • Monitor food intake and body weight changes; Monitor laboratory data: serum proteins, fats, potassium and sodium.
    • Provide appropriate foods and dietary modification is recommended as Client favorite.
    • Assist or instruct the patient to perform oral hygiene before meals.
    • Give antiemetic and monitor responses.
    • Collaboration premises dietitian for granting the right diet for patients.

    2. Potential infections related to immune system suppression, due to uremia.

    Goal :
    No infection

    Nursing Intervention
    • Assess for the presence of signs of infection.
    • Monitor temperature every 4-6 hours: Monitor laboratory data: WBC: Blood, urine, sputum culture. Monitor serum potassium.
    • Keep antiseptic techniques during the treatment and always obey the universal precaution.
    • Maintain personal hygiene, adequate nutrition status and adequate rest.
      Healthy living habits that help prevent infection.

    3. Less able to care for themselves related to physical weakness.

    Goal :
    Personal hygiene is fulfilled

    Nursing Intervention :
    • Kaji weakness and fatigue, and provide an explanation about the need for self-care.
    • If the patient is not capable at all, Bantu do care to patients by involving the family.
    • Do breathing exercises in cough and ambulation in bed.
    READ MORE - Nursing Diagnosis and Nursing Intervention for CRF - Chronic Renal Failure

    Nursing Care Plan for Chronic Renal Failure - CRF

    Nursing Care Plan for Chronic Renal Failure - CRF

    Nursing Care Plan for Chronic Renal Failure - CRF

    Chronic Renal Failure - CRF

    Chronic renal failure (CRF) is the progressive loss of kidney function. The kidneys attempt to compensate for renal damage by hyperfiltration (excessive straining of the blood) within the remaining functional nephrons (filtering units that consist of a glomerulus and corresponding tubule). Over time, hyperfiltration causes further loss of function.

    Chronic loss of function causes generalized wasting (shrinking in size) and progressive scarring within all parts of the kidneys. In time, overall scarring obscures the site of the initial damage. Yet, it is not until over 70% of the normal combined function of both kidneys is lost that most patients begin to experience symptoms of kidney failure.

    Signs and Symptoms

    Chronic renal failure (CRF) usually produces symptoms when renal function — which is measured as the glomerular filtration rate (GFR) — falls below 30 milliliters per minute (< 30 mL/min). This is approximately 30% of the normal value. When the glomerular filtration rate (GFR) slows to below 30 mL/min, signs of uremia (high blood level of protein by-products, such as urea) may become noticeable. When the GFR falls below 15 mL/min most people become increasingly symptomatic.

    Nursing Care Plan for Chronic Renal Failure - CRF

    Nursing Assessment for Chronic Renal Failure - CRF

    1. Activity / rest

    Symptoms :
    • The weakness malaise
    • Sleep disturbance (insomnia / restless or somnolen)
    Signs :
    • Muscle weakness, loss of tone, decreased range of motion

    2. Circulation

    Symptoms :
    • History prolonged or severe hypertension
    • Palpitations, chest pain (angina)
    Signs :
    • Hypertension, strong pulse, general and light socket tissue edema in the feet, palms
    • The pulse is weak, smooth, orthostatic hypotension
    • Cardiac Dysrhythmias
    • Pale skin
    • Friction rub pericardial
    • The tendency of bleeding

    3. Ego integrity

    Symptoms :
    • Stress factors, such as financial problems, relationships with other people
    • Feeling helpless, hopeless
    Signs :
    • Reject, anxiety, fear, anger, personality changes, easily aroused

    4. Elimination

    Symptoms :
    • Decrease in urinary frequency, oliguria, anuria (failure stage)
    • Diarrhea, constipation, abdominal bloating
    Signs :
    • Change the color of urine, the sample thick yellow, brown, reddish, cloudy
    • Oliguria or anuria
    5. Food / fluid Symptoms :
    • Increased weight fast (edema), weight loss (malnutrition)
    • Anorexia, nausea / vomiting, heartburn, unpleasant metallic taste in the mouth (breathing ammonia)
    Signs :
    • abdominal distension / anxiety, liver enlargement (final stage)
    • Edema (general, depending)
    • Changes in skin turgor / humidity
    • Ulceration of gums, bleeding gums / tongue
    • Decrease in muscle, subcutaneous fat loss, no powerful appearance
    6. Neurosensori Symptoms :
    • Muscle cramps / spasms, restless leg syndrome, burning sensation in the head, blurred vision
    • soles of feet
    • numb / tingling and weakness of extremities especially the lower (peripheral neuropathy)
    Signs :
    • Impaired mental status, such as inability to concentrate, memory loss, confusion, decreased level of consciousness, decreased field of attention, stupor, coma
    • Seizures, muscle fasciculation, seizure activity
    • thin hair, thin and brittle nails.
    7. Pain / comfort Symptoms :
    • headache, muscle cramps / leg pain, pelvic pain
    Signs :
    • cautious behavior / distraction, anxiety
    8. Respiratory Symptoms :
    • dyspnea, shortness of breath, paroxysmal nocturnal, cough with or without sputum.
    Signs :
    • dyspnea, respiratory Tachypnoea kusmaul
    • productive cough with watery pink sputum (pulmonary edema)
    9. Security Symptoms :
    • Itchy skin, there is / recurrent infections
    Signs :
    • pruritus
    • Fever (sepsis, dehydration)
    10. Sexuality Symptoms :
    • amenorrhea, infertility, decreased libido
    11. Social interaction Symptoms :
    • Difficulty lowered condition, eg unable to work, maintain the function of roles in the family
    12. Counseling
    • History of diabetes mellitus in the family (Resti chronic renal failure), polycystic disease, hereditary nephritis, urinary calculus
    • History of exposure to toxins, drug samples, environmental toxins
    • The use of nephrotoxic antibiotics current / recurrent.

    Nursing Diagnosis and Nursing Intervention for Chronic Renal Failure - CRF

    1. Decrease in cardiac output related to an increased cardiac load

    Goal :
    Decrease in cardiac output does not occur with the

    Result Criteria :
    Maintain cardiac output with evidence of blood pressure and cardiac frequency in the normal range, strong peripheral pulse and equal to the capillary filling time.

    Nursing Intervention :
    • Auscultation of heart and lung sounds
      Rational : There is an irregular heart frequency tachycardia
    • Review of hypertension
      Rational : Hypertension may occur due to disturbances in the system renin-angiotensin-aldosterone system (caused by renal dysfunction)
    • Assess complaints of chest pain, perhatikanlokasi, rediasi, weight (scale 0-10)
      Rational : Hypertension and chronic renal failure can cause pain
    • Assess the level of activity, response activity
      Rational : Fatigue may accompany chronic renal failure

    2. Changes in nutrition: less than the needs associated with anorexia, nausea, vomiting

    Objective :
    Maintain adequate nutrition inputs

    Reasult Criteria :
    Shows stable weight

    Nursing Intervention :
    • Monitor the consumption of food / fluid
      Rational : Identifying nutritional deficiencies
    • Watch for nausea and vomiting
      Rational : Symptoms that accompany the accumulation of endogenous toxins that can alter or reduce revenue and require intervention.
    • Give the patient a little food but often.
    • Rational : a smaller portion to increase the input of food
    • Increase visits by people closest to during meal.
      Rational : Provide diversion and increase the social aspect.
    • Give frequent oral care
      Rational : Reducing the discomfort of oral stomatitis and feeling unwelcome in the mouth that can affect food inputs.
    READ MORE - Nursing Care Plan for Chronic Renal Failure - CRF

    Nursing Care Plan Acute Renal Failure - ARF

    Nursing Care Plan Acute Renal Failure - ARF

    Nursing Care Plan Acute Renal Failure

    Acute Renal Failure Definition

    Acute renal failure (ARF) is the rapid breakdown of renal (kidney) function that occurs when high levels of uremic toxins (waste products of the body's metabolism) accumulate in the blood. ARF occurs when the kidneys are unable to excrete (discharge) the daily load of toxins in the urine.

    Based on the amount of urine that is excreted over a 24-hour period, patients with ARF are separated into two groups :
    • Oliguric: patients who excrete less than 500 milliliters per day (< 16 oz/day)
    • Nonoliguric: patients who excrete more than 500 milliliters per day (> 16 oz/day)

    Acute Renal Failure Causes

    Causes of acute kidney failure fall into one of the following categories:
    • Prerenal: Problems affecting the flow of blood before it reaches the kidneys

    • Postrenal: Problems affecting the movement of urine out of the kidneys

    • Renal: Problems with the kidney itself that prevent proper filtration of blood or production of urine

    Acute Kidney Failure Symptoms

    The following symptoms may occur with acute kidney failure. Some people have no symptoms, at least in the early stages. The symptoms may be very subtle.
    • Decreased urine production

    • Body swelling

    • Problems concentrating

    • Confusion

    • Fatigue

    • Lethargy

    • Nausea, vomiting

    • Diarrhea

    • Abdominal pain

    • Metallic taste in the mouth
    Seizures and coma may occur in very severe acute kidney failure.

    Nursing Care Plan for ARF - Acute Renal Failure

    Acute Renal Failure Nursing Assessment
    1. Activity and Rest
      Fatigue, weakness, malaese

      Muscle weakness and loss of tonus
    2. Circulation

      Hypotension / hypertension (including malignant hypertension, eclampsia / hypertension due to pregnancy).
      Cardiac dysrhythmia.
      Pulse weak / soft orthostatic hypotension (hipovalemia).
      Strong pulse (hipervolemia).
      Edema public network (including the periorbital area of the sacrum ankle).
      Pale, bleeding tendency
    3. Elimination
      Changes in the pattern of urination, increased frequency, polyuria (early failure), or decrease the frequency / oliguria (final phase)
      Dysuria, doubt, encouragement, and retention (inflammation / obstruction, infection).
      Abdominal bloating, diarrhea or constipation.

      Change the color of dark yellow urine samples, red, brown, cloudy.
      Oliguric (usually 12-21 days), polyuria (2-6 liters / day).
    4. Food / Fluids
      Increased weight (edema), weight loss (dehydration).
      Nausea, vomiting, anorexia, heartburn
      Use of diuretics

      Changes in skin turgor / humidity.
      Edema (General, bottom).
    5. Neurosensori
      Headaches, blurred vision.
      Muscle cramps / spasms, syndrome "Restless legs".

      Impaired mental status, examples of decline in the field of attention, inability to concentrate, memory loss, confusion, decreased level of consciousness (azotemia, electrolyte imbalance / acid-base.
      Seizures, seizure activity.
    6. Pain / Leisure
      Body aches, headache

      Cautious behavior / distraction, anxiety
    7. Respiratory
      Shortness of breath

      Takipnoe, dispnoe, increased frequency, kusmaul, ammonia breath, productive cough with thick pink sputum (pulmonary edema).
    8. Comfort
      Transfusion reaction

      Fever, sepsis (dehydration), or skin ptekie ekimosis, pruritus, dry skin.
    9. Counseling / Learning
      Family history of polycystic disease, hereditary nephritis, urinary stones, malignancies., a history of exposure to toxins, (drugs, environmental toxins), nephrotic repeated use of drugs eg aminoglycosides, amphotericin, anesthetic vasodilator.

    Acute Renal Failure Nursing Diagnosis
    1. Excess fluid volume related to decreased Glomerular filtration rate and sodium retention.
    2. Imbalanced nutrition: less than body requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure.
    3. Risk for infection related to alterations in the immune system and host defenses.

    Acute Renal Failure Nursing Intervention

    1.Excess fluid volume related to decreased Glomerular filtration rate and sodium retention.

    Goal : Achieving fluid and electrolyte balance

    Nursing Intervention
    • Monitor urinary output and urine specific gravity; measure and record intake and output including urine, gastric suction, stools, wound drainage, perspiration (estimate).
    • Monitor serum and urine electrolyte concentrations.
    • Monitor for signs and symptoms of hypovolemia or hypervolemia because regulating capacity of kidneys is inadequate.
    • Inspect neck veins for engorgement and extremities, abdomen, sacrum, and eyelids for edema.
    • Evaluate for signs and symptoms of hyperkalemia, and monitor serum potassium levels.
    • Administer sodium bicarbonate or glucose and insulin to shift potassium into the cells.
    • Instruct patient about the importance of following prescribed diet, avoiding foods high in potassium.
    • Prepare for dialysis when rapid lowering of potassium is needed.
    2. Imbalanced nutrition: less than body requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure.

    Goal :
    Maintaining adequate nutrition

    Nursing Intervention
    • Monitor BUN, creatinine, electrolytes, serum albumin, prealbumin, total protein, and transferrin.
    • Be aware that food and fluids containing large amounts of sodium, potassium, and phosphorus may need to be restricted.
    • Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories.
    • Work collaboratively with dietitian to regulate protein intake according to impaired renal function because metabolites that accumulate in blood derive almost entirely from protein catabolism.
    • Prepare for hyperalimentation when adequate nutrition cannot be maintained through the GI tract.

    3. Risk for infection related to alterations in the immune system and host defenses.

    Goal :

    Nursing Intervention
    • Remove bladder catheter as soon as possible; monitor for UTI.
    • Use intensive pulmonary hygiene high incidence of lung edema and infection.
    • Monitor for all signs of infection. Be aware that renal failure patients do not always demonstrate fever and leukocytosis.
    • If antibiotics are administered, care must be taken to adjust the dosage for renal impairment.

    Source :
    READ MORE - Nursing Care Plan Acute Renal Failure - ARF

    Nursing Care Plan for Stevens Johnson Syndrome

    NCP - Nursing Care Plan for Stevens Johnson Syndrome

    Nursing Care Plan for Stevens Johnson Syndrome

    Stevens-Johnson syndrome (SJS) is an immune-complex–mediated hypersensitivity complex that is a severe expression of erythema multiforme. It is known by some as erythema multiforme major, but disagreement exists in the literature. Most authors and experts consider Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) different manifestations of the same disease. For that reason, many refer to the entity as SJS/TEN. SJS typically involves the skin and the mucous membranes. While minor presentations may occur, significant involvement of oral, nasal, eye, vaginal, urethral, GI, and lower respiratory tract mucous membranes may develop in the course of the illness. GI and respiratory involvement may progress to necrosis. SJS is a serious systemic disorder with the potential for severe morbidity and even death. Missed diagnosis is common.

    Although several classification schemes have been reported, the simplest breaks the disease down as follows :
    • Stevens-Johnson syndrome - A "minor form of TEN," with less than 10% body surface area (BSA) detachment
    • Overlapping Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) - Detachment of 10-30% BSA
    • Toxic epidermal necrolysis - Detachment of more than 30% BSA

    Causes of Stevens Johnson Syndrome

    Stevens Johnson Syndrome is thought to arise from a disorder of the immune system.


    It can be caused by infections (usually following infections such as herpes simplex virus, influenza, mumps, cat-scratch fever, histoplasmosis, Epstein-Barr virus, mycoplasma pneumoniae or similar).


    It can be caused by adverse effects of drugs (allopurinol, diclofenac, etravirine, Isotretinoin, aka Accutane, fluconazole, valdecoxib, sitagliptin, oseltamivir, penicillins, barbiturates, sulfonamides, phenytoin, azithromycin, oxcarbazepine, zonisamide, modafinil, lamotrigine, nevirapine, pyrimethamine, ibuprofen, ethosuximide, carbamazepine, nystatin, and gout medications).

    Although Stevens–Johnson Syndrome can be caused by viral infections, malignancies or severe allergic reactions to medication, the leading cause appears to be the use of antibiotics and sulfa drugs.

    Medications that have traditionally been known to lead to SJS, erythema multiforme and toxic epidermal necrolysis include sulfonamides (antibiotics), penicillins (antibiotics), barbiturates (sedatives), lamotrigine and phenytoin (e.g. Dilantin) (anticonvulsants). Combining lamotrigine with sodium valproate increases the risk of SJS.

    Non-steroidal anti-inflammatory drugs are a rare cause of SJS in adults; the risk is higher for older patients, women and those initiating treatment. Typically, the symptoms of drug-induced SJS arise within a week of starting the medication. People with systemic lupus erythematosus or HIV infections are more susceptible to drug-induced SJS.

    SJS has also been consistently reported as an uncommon side effect of herbal supplements containing ginseng. SJS may also be caused by cocaine usage.

    In some East Asian populations studied (Han Chinese and Thai), carbamazepine- and phenytoin-induced SJS is strongly associated with HLA-B*1502 (HLA-B75), an HLA-B serotype of the broader serotype HLA-B15. A study in Europe suggested that the gene marker is only relevant for East Asians. Based on the Asian findings, similar studies were performed in Europe which showed 61% of allopurinol-induced SJS/TEN patients carried the HLA-B58 (B*5801 allele - phenotype frequency in Europeans is typically 3%). One study concluded "even when HLA-B alleles behave as strong risk factors, as for allopurinol, they are neither sufficient nor necessary to explain the disease."

    Nursing Care Plan for Stevens Johnson Syndrome

    Nursing Care Plan : Assessment

    a. Subjective Data
    • Client said high fever, malaise, headache, cough, runny nose, and sore throat / difficulty in swallowing.

    b. Objective Data
    • Skin erythema, papules, vesicles, bull fragile so that erosion is a widespread, often obtained purpura.
    • Black and thick crust on the lips or mucous membranes, stomatitis and pseudomembrane in the pharynx.
    • Conjunctiva, corneal ulcer bleeding sembefalon, iritis and iridosiklitis.

    c. Supporting Data
    • Lab: leukocytosis or esosinefilia
    • Histopathology : mononuclear cell infiltrates, edema and extravasation of red blood cells, degeneration of the basal layer, epidermal cell necrosis, spongiosis and intracellular edema in the epidermis.
    • Immunology: deposis IgM and C3 and there is immune complex containing IgG, IgM, IgA.

    Nursing Care Plan : Nursing Diagnosis
    1. Impaired sense of comfort, fever, headache, throat related to a bull.
    2. Fulfillment of nutritional disorders: Less than body requirements related to the difficulty in swallowing.
    3. Impaired skin integrity related to the fragile bull.
    4. Lack of knowledge about the disease process associated with less information.
    5. Potential secondary infections associated with side effects and therapeutic steroid infusion installed.

    Nursing Intervention for Stevens Johnson Syndrome

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