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Nursing Care Plan for Cesarean Section (C-section)

A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems happen during delivery. These include
  • Health problems in the mother
  • The position of the baby
  • Not enough room for the baby to go through the vagina
  • Signs of distress in the baby
C-sections are also more common among women carrying more than one baby.

The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. However, more than half of women who have a C-section can give vaginal birth later.


Nursing Assessment for Cesarean Section


Assessment is the systematic process of gathering, verification, and communication of client data (Potter & Perry, 2005).

The assessment results are found on the client by cesarean section on nursing care plan maternal / infant (Doenges & Moorhouse, 2001) namely:
  1. Assessment of client data base
    Review the record of prenatal and intraoperative and indications for cesarean birth.

  2. Circulation
    Blood loss during surgical procedures of approximately 600-800 ml.

  3. Ego integrity
    Can show emotional labilitas of excitement to fear, anger or withdrawn. Client / partner may have questions or wrongly accept a role in the birth experience. Perhaps expressing inability to deal with new situations.

  4. Elimination
    Urinary catheter may be inserted, clear urine and pale bowel sounds absent, vague or unclear.

  5. Food / fluid
    Abdomen soft with no distension at baseline.

  6. Neoro sensory
    Damage to the movement and sensation below the level of spinal epidural anesthesia.

  7. Pain
    Discomfort may complain of a variety of sources such as surgical trauma, incision and accompanying pain, distended bladder-abdominal, the effects of anesthesia. The mouth may be dry.

  8. Respiratory
    The sound is clear and vesicular lung.

  9. Security
    Abdominal bandage may seem a little stain or dry and intact. Line parenteral, when used patent-free and hand erythema, swelling and tenderness.

  10. Sexuality
    Fundus contractions stronger and located at the umbilicus. Lochea is free flow and excessive clot / lot.

  11. Diagnostic tests
    Complete blood count, hemoglobin / hematocrit (Hb / Ht): assessing the change from preoperative levels and evaluate the effects of blood loss in surgery. Urinalysis: urine culture, blood, vaginal, and lochea.

Nursing Diagnosis for Cesarean section (C-section)
1. Acute pain related to postoperative wound

2. Risk for infection related to invasive procedures, skin damage, decrease in Hb

3. Risk for injury (mother) related to tissue trauma

4. Risk for impaired gas exchange (the fetus)

5. Deficient Knowledge : up to surgery

6. Anxiety

Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative
Nursing Diagnosis

Risk for infection

Related to :
  • bleeding,
  • postoperative wound

Goal :
There were no infections, bleeding and wounds, after surgery.

Nursing Intervention for Cesarean Section Postoperative
  1. Assess the condition of output / dischart out; number, color, and odor from the operation wound.
    R / recording the changes in output. The existence of a darker color with a bad smell may be a sign of infection.

  2. Tell the client the importance of wound care during the postoperative period.
    R / Infection can arise from lack of cleanliness of the wound.

  3. Have a general culture in the output.
    R / Various bacteria can be identified through the output.

  4. Perform wound care.
    R / Incubation germs in the wound area can cause infection.

  5. Tell the client how to identify signs of infection.
    R / Various clinical manifestations can be nonspecific sign of infection, fever and increased pain may be symptoms of infection.

Nursing Diagnosis

Acute Pain

Related to
  • postoperative wound
Goal :
Pain is reduced / no pain

Nursing Intervention for Cesarean Section Postoperative
  1. Assess the condition of pain experienced by the client.
    R / Measurement of the level of pain can be performed with pain scales.

  2. Tell the client suffered pain and its causes.
    R / Improving coping clients, in dealing with pain.

  3. Teach relaxation techniques.
    R / Reduced perception of pain.

  4. Collaboration of analgesics.
    R / Reduced pain can be done by giving oral or systemic analgesics, in a broad spectrum / specific.
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List of Pulmonary Tuberculosis Nursing Diagnosis NANDA

Pulmonary tuberculosis (TB) is a highly contagious disease caused by a bacteria known as Mycobacterium tuberculosis. TB generally affects the lungs, but it also can invade other organs of the body, like the brain, kidneys and lymphatic system.

TB is spread through coughing, sneezing, and spitting. Only a small amount of inhaled germs are needed to become infected, however prolonged exposure to someone else who has TB is the easiest way to get the disease. Those who have a weakened immune system are even more at risk.

Many people who are infected with TB have few or no symptoms at all, at least in the beginning. Some people develop symptoms slowly, over time, and pay little attention to them until the disease has reached the advanced stages. When symptoms do appear, they generally include:
  • fatigue
  • loss of appetite and weight loss
  • cough with purulent and/or bloody sputum
  • night sweats
  • low-grade fever that occurs mostly in the afternoon
  • lethargy

a. Ineffective airway clearance

related to viscous secretions or blood secretions, weakness, poor cough effort, edema, tracheal / pharyngeal.

b. Impaired Gas Exchange

related to the reduced effectiveness of the surface of the lung, atelectasis, alveolar capillary membrane damage, thick secretions, bronchial edema.

c. Imbalanced Nutrition: Less Than Body Requirements

related to fatigue, frequent coughing, the sputum production, dyspnea, anorexia, decreased financial capabilities.

d. Acute pain

related to lung inflammation, persistent cough.

e. Hyperthermia

related to active inflammatory process.

f. Intolerance Activity

related to the imbalance between supply and oxygen demand.

g. Knowledge Deficit: about conditions, treatments, prevention

associated with no one to explain, the interpretation is wrong, the information obtained is incomplete / inaccurate, lack of knowledge / cognitive

h. Risk for the spread of infection / re-infection activity related to inadequate primary defenses, decreased ciliary function / static secretions, tissue damage caused by the spread of infection, malnutrition, environmental contamination, lack of information about the bacterial infection.
READ MORE - List of Pulmonary Tuberculosis Nursing Diagnosis NANDA

Nursing Home / Home Care Mattresses

Nursing Home / Home Care Mattresses Size: 75" x 35"

Product Description

GF1500-175-1633 Size: 75" x 35" Features: -Economical, innerspring mattress. -Designed specifically for nursing homes and home care use. -Vented and reversible. -Mattress dimensions: 35'' width, 7'' height. -Easy to maintain, comfortable. -One year limited manufacturer warranty. Specifications: -Meets 16 CFR 1633 requirements. -Weight capacity: 350 lbs. -Overall dimensions: 7'' H x 35'' W x 75''-84'' D.


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3M Littmann Cardiology III Stethoscope

3M Littmann Cardiology III Stethoscope

Product Description

Littmann Cardiology III Stethoscope, Adult Ideal use for Cardiology or other High Performance adult and pediatric applications.

Features two tunable diaphragms (adult and pediatric) for listening to both low and high frequency sounds. Two-tubes-in-one design helps eliminate tube rubbing noise. The pediatric side of the chestpiece easily converts to a traditional bell by simply replacing the diaphragm with the nonchill bell sleeve included with each stethoscope.

Offers a solid stainless steel chestpiece, nonchill rims, and an adjustable doubleleaf binaural spring. 3M Littmann Snap Tight Soft-Sealing eartips provide an excellent acoustic seal and comfortable fit.



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Nursing Diagnosis for Tuberculosis

Tuberculosis, a bacterial infection, most commonly affects the lungs. Tuberculosis can also affect the central nervous system, lymphatic system, circulatory system, genitourinary system, bones and joints. Often Called TB for short, tuberculosis is the most common major infectious disease today. With that title the virus is infecting two billion people which is approximately one-third of the world's population. Nine million new cases of active disease annually, resulting in two million deaths. Most of these cases and deaths are in developing countries.

The disease tuberculosis is caused by the bacteria Mycobacterium tuberculosis. Tuberculosis can affect any part of the body but usually infects the lungs. Tuberculosis is spread through airborne droplets occurring when an infected individual sneezes, talks, or coughs. However, prolonged exposure to the infected individual must occur before you may become infected. The body may harbor the bacteria while the immune system prevents sickness. For this reason, there are two forms of TB: latent tuberculosis and active tuberculosis.

In many patients the infection of Tuberculosis waxes and wanes. Treatment with appropriate antibiotics kills bacteria and allows healing to take place. Areas where Tuberculosis has affected will eventually be replaced by scar tissue. A complete medical evaluation for Tuberculosis includes a medical history, a physical examination, a tuberculin skin test, a serological test, a chest X-ray, and microbiologic smears and cultures. This is quite an extensive procedure as you can see, but if you look at the numbers above it is a necessary process.

Active tuberculosis simply means that the tuberculosis bacteria are growing within the body causing an active infection. Signs and symptoms of active tuberculosis include fatigue, slight fever, chills, night sweats, loss of appetite, unintended weight loss, a cough that lasts three or more weeks producing discolored or bloody sputum, and pain with coughing or breathing. Active tuberculosis is highly contagious.

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Nursing Diagnosis for Tuberculosis
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Key Terms of Nursing Diagnosis

Key Terms of Nursing Diagnosis

Key Terms of Nursing Diagnosis

NANDA, North American Nursing Diagnosis Association—Formed in 1973, this group is responsible for developing a classification system of nursing diagnoses.Expected outcome—A measurable individual, family, or community state, behavior, or perception that is measured along a continuum and is responsive to nursing interventions.

Medical diagnosis—A medical determination of disease or syndrome performed by a physician. The focus is on the disease process and the physical, genetic, or environmental cause of that process.

NIC, Nursing Interventions ClassificationDeveloped by the Iowa Intervention Project, this is a collection of nursing interventions linked to the NANDA diagnoses. The 2000 publication includes approximately 500 interventions.

NOC, Nursing Outcomes Classification— Developed by the Iowa Outcome Project, this is a comprehensive, standardized classification of patient outcomes developed to evaluate the effects of nursing interventions. The outcomes may be linked to the NANDA diagnoses and other diagnoses systems. The 2000 publication includes 260 outcomes.

Nursing assessment—The way in which a nurse gathers and evaluates data about a client (individual, family, or community). The assessment includes a physical examination, interviewing, and observations. Assessment is also the first step in the nursing process.

Nursing diagnostic statement—The formal, written documentation of a nursing diagnosis. It includes the label or diagnosis, the etiology, and the indicators. In the statement, the etiology is preceeded by the phrase "related to." The indicators are the assessment data that led to the diagnosis. They are preceeded by the phrase, "as evidenced by."

Nursing intervention—Any treatment that a nurse performs on a patient in response to a nursing diagnosis to reach a projected outcome.

Risk diagnosis—A nursing diagnosis that recognizes a potential problem not an existing problem. The indicators for risk diagnoses are risk factors that are identified through assessment.

Source : http://nandadiagnosis.blogspot.com/2011/05/key-terms-of-nursing-diagnosis.html

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Family Nursing Care Plan for Tuberculosis

Family Nursing Diagnosis - Nursing Care Plan for Tuberculosis

Nursing Diagnosis that may arise in families with tuberculosis disease are:

a. Nutrition less than body requirements related to anorexia
b. Risk for Infection related to the secret is out
c. Ineffective airway clearance related to the accumulation of excessive secretions.
d. Disruption of gas exchange related to the decreased oxygen supply

In formulating nursing diagnoses in the family need to be a priority issue and a matter of priority criteria.

Priority issues

Things that need to be considered in the priority issues are as follows:
a. Not possible, the problems of health and nursing are found in the family can be addressed simultaneously.
b. Need to consider the problems that can threaten the lives of families like the problem of disease.
c. Need to consider the response and attention to family nursing care to be provided.
d. Family involvement in solving problems they face.
e. Family resources that can support problem solving health / family nursing.
f. Family and cultural knowledge.

Criteria for priority problems

Some of the criteria in priority setting problems:
1. Nature of the problem, are grouped into: health threats, is ill or unwell and crisis situations.

2. Possible problems can be changed, is the likelihood of success to reduce the problem or prevent a problem when it's done nursing and medical interventions.
Factors that may affect the problem of TB can be changed are:
a. Knowledge and action for the problem of tuberculosis.
b. Family resources, such as finance, personnel, facilities and infrastructure.
c. Care resources, including the knowledge and skills in handling the problem of tuberculosis.
d. Community resources, can be in the form of facilities, organization.

3. Potential problems of tuberculosis, to prevent, is the nature and severity of problems that will arise and TB can be reduced or prevented through nursing and health measures.
Things that need to be considered in view of the potential problem of prevention of tuberculosis are:
a. Severity / difficulty of the problem, this is related to severity of disease or tuberculosis that showed the prognosis and severity of tuberculosis suffered by family members.
b. Action has been and is being run, is an act to prevent and treat tuberculosis in order to improve the health status of the family.
c. The duration of the problem, severity of problems associated with tuberculosis in the family and the potential problems to be prevented.
d. The existence of high-risk groups within the family or a group of highly sensitive adds to the potential to prevent problems.

4. Prominence of the tuberculosis problem, is how families see and assess the tuberculosis problem in terms of severity and urgency to be addressed through nursing and medical interventions.

Nursing Care Plan for Tuberculosis

Tuberculosis Nursing Care Plan includes general and specific objectives based on problems that come with the criteria and standards that refer to the cause. Furthermore formulate action-oriented nursing criteria and standards.

There are several levels of objectives in the planning of nursing according to Friedman (1998: 64). Short-term goals that are measurable, immediate and specific. And long-term goal which is the final level of the broad purposes stated expected by nurses and families to be reached.

The purpose of nursing care in a family with tuberculosis:

A. Short term goals include:
Once the information is given to the families of tuberculosis, the family is able to recognize the problem of tuberculosis, is able to take decisions and be able to care for family members suffering from tuberculosis.

Evaluation criteria:
a. Verbal response, the family is able to mention the understanding, the signs and symptoms, causes, treatment and prevention of transmission of tuberculosis.
b. Effective response, the family able to care for family members suffering from tuberculosis.
c. Psychomotor response, the family is able to modify the environment for people with tuberculosis.

Evaluation standards:
Definition, signs and symptoms, causes, prevention of tuberculosis, prevention of transmission and ways of treatment of tuberculosis.

2. Long-term goals
Problem of TB in the family can be resolved / reduced after nursing actions.

Intervention phase begins with the completion of treatment planning. Like the opinion of Friedman (1998: 67). During the implementation of nursing interventions, new data is continuously flowing into. Because this information (the response from the client, the situation changes, etc.) were collected, nurses need to be quite flexible and can adapt to review the family situation by making modifications to the plan without a plan. In choosing nursing actions depending on the nature of the problem and the resources available for solving.

Read More : http://nanda-nursing-care-plan.blogspot.com/2012/03/family-nursing-diagnosis-nursing-care.html
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Nursing Diagnosis for Pain (Acute / Chronic)

There are many things that can cause a person pain and different people have different tolerances for types of pain. Someone with a low tolerance may find many things very painful. Someone with a higher tolerance may be able to withstand these things.

There is the pain of a headache and there are many kinds of headaches that produce vaious degrees and quality of pain. There is organ pain when something is wrong inside and muscle pain when they are pushed beyond the norm either by exercise or emergency. Pain can be mild and a mere annoyance, or brutal and debilitating.

Acute pain is a pain that is recent, a sudden onset of pain, something that has been caused by an accident, a fall, an injury, or something of that nature. Acute pain is usually quite strong and ranges from a sharp nerve pain or shooting pain, to a very strong ache. It can be made worse by certain movements and may restrict you from doing things.

These are some of the obvious things that cause instant pain but sometimes acute pain seems to appear out of nowhere. For example, the sudden onset of lower back pain or neck spasms.

Generally the majority of acute pain conditions are caused by muscle spasms. Sure they may feel like they are incredibly painful because when muscles spasm they can also entrap and irritate nerves. Acute pain conditions are generally easy to treat and do not leave any residual problems. Massage therapy is the treatment used to alleviate muscular problems. Remedial massage acts by stimulating the muscles that are in spasm so they release. By stimulating the right muscles the body will then correct itself, releasing the muscle spasms and bringing your body back to normal.

Nursing Diagnosis for Pain – Acute

Acute Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

Nursing Diagnosis for Pain – Chronic

Chronic Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.

Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult.

Nursing Diagnosisi Nursing Care Plan for Pain

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Nursing Diagnosis and Nursing Interventions for Hallucinations

Hallucinations are sensory experiences in the absence of stimulation (stimulus) such as patients hear voices, whispering in his ear when there is no source of the voice that whisper (Hawari, 2001).

Hallucinations - The person can touch, feel, hear, smell and see imaginary things, which do not exist in reality. Such symptoms are because of the deterioration in the brain's reception, as a result brain responds to fake sensory input.

Hallucinations can be further classified as:

Tactile Hallucination: A person experiencing this can feel imaginary hands touching him or can feel insects moving all over his body.

Auditory Hallucination: The person who suffer from such hallucination can hear and communicate with a person that is non-existent in real life. Sometimes, he can also hear someone constantly talking to him. He might even hear an inner voice to tell him about impending danger.

Olfactory Hallucination: The person can smell things that no one can.

Visual Hallucination: The person who experiences this type of hallucination can see objects and people that do not exist in real life. He is able to share thoughts with his imaginary friends and spend time with them.

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Nursing Interventions for Hallucinations
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Health - Beta Glucan Lowers Blood Lipids

Beta glucan Lowers Blood Lipids

BERLIN—Barley beta-glucan reduces serum lipid levels, according to research presented in April at the First International Congress on Pre-Diabetes and Metabolic Syndrome.

In the six-week study, 76 men and 79 women with hypercholesterolemia, aged

25 to 73, completed a four-week lowfat diet prior to baseline. At the beginning of the trial, test subjects were randomly allocated to one of four treatment groups or a control group and assayed for blood lipids and other cardiovascular disease (CVD) biomarkers. During the course of the study, test groups were administered 3 g and 5 g doses of low molecular weight (LMW) or high molecular weight (HMW) barley beta-glucan (from Cargill) twice daily, in cereal and juice.

Posttreatment assessment of blood lipids and other CVD biomarkers revealed improvements in low-density lipoprotein (LDL) cholesterol, triglycerides, markers of glycemic control

(glycosylated hemoglobin, HOMA model) and a key marker of inflammation

(hs-CRP).

The researchers concluded both doses of LMW and HMW barley beta-glucan improved blood lipids over a six-week treatment period. More Visit : here
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Breast Enlargement Implant Dangers

Breast Enlargement Implant Dangers

3% suffer leakage within three years causing a deflated implant

Occasionally, breast implants may break or leak. The saline fill is salt water and will be absorbed by the body without ill effects. Older implants with silicone gel can leak also. If this occurs, one of two things may occur. If breakage of the implant shell that has a contracture scar around it, then it may not feel like anything has happed. If the shell breaks and there is not a contracture scar, then leakage into the surrounding tissue results in a sensation that the implant is deflating. The leaking gel may collect in the breast and a new scar may form around it. In other cases gel can migrate through the lymphatic system to another area of the body. Breaks may require a second operation and replacement of the leaking implant. If the gel has migrated it may not be possible to remove all of the silicone gel. This silicone gel is the what some say is related to the initiation of connective tissue disorders.

One study they reviewed showed that 63.6% of breast implants which had been in place for between one and 25 years had ruptured or were leaking. (http://news.bbc.co.uk/1/hi/sci/tech/33450.stm)

For silicone gel and saline-filled implants, some causes of rupture or deflation include : damage by surgical instruments during surgery, overfilling or underfilling of the implant with saline solution (specific only to saline-filled breast implants), capsular contracture ,closed capsulotomy , stresses such as trauma or intense physical manipulation ,excessive compression during mammographic imaging, placement through umbilical incision ,site injury to the breast, normal aging of the implant ,unknown/unexplained reasons.

For more information visit: here
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Nursing Diagnosis for Dementia

Dementia is a medical condition that affects the brain. It is more common in older people, starting at about the age of sixty years and over.

Ageing is one cause of this condition, but there are other causes such as a stroke, Alzheimer's disease, or an injury to the brain from head trauma. Someone with Dementia may forget simple things that should be familiar to them.

People generally go through Dementia in three stages. During the first stage, a person will have trouble remembering things that they would typically know otherwise. Things such as phone numbers, how to get home, where they parked their car, and other common daily tasks are some of the things that will not be remembered by a person affected by Dementia. The next stage of Dementia is more serious and noticeable by people that know the person. In this stage the individual often does not know how to complete tasks around their own home such as cooking, getting dressed properly and washing themselves. Sometimes in this stage, the person affected also has trouble with their speech. The last stage begins to affect the body as well as the mind. The person may have weakness in certain parts of their body. It may cause them to not be able to move their arms and legs. Their ability to speak may worsen to the point of not making any sense when they talk.

Nursing Diagnosis for Dementia NANDA

Read More : Nursing Interventions for Dementia

http://nursing-care-plan.blogspot.com/2012/01/nursing-diagnosis-for-dementia-nanda.html
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8 Nursing Diagnosis for Pneumonia

DEFINITION OF PNEUMONIA

Pneumonia is an acute inflammation of the lung parenchyma are usually derived from an infection. (Price, 1995)
Pneumonia is an inflammation of the lung parenchyma, distal to the terminal bronchioles including respiratory bronchioles, alveoli, and cause consolidation of lung tissue and cause local disruption of gas exchange. (Zul, 2001)
Bronchopneumonia is used to describe pneumonia that has spread pattern mottled, irregular in one or more localized areas within the bronchi and extends into the adjacent lung parenchyma in the vicinity. In bronchopneumonia occurred consolidation stained area. (Smeltzer, 2001).

ETIOLOGY OF PNEUMONIA
bacterium
Bacterial pneumonia is usually found in old age. Organisms such as gram posifif: Steptococcus pneumonia, S. aerous, and streptococcus pyogenesis. Gram-negative bacteria such as Haemophilus influenza, Klebsiella pneumonia and P. Aeruginosa.
virus
Caused by influenza viruses that spread through droplet transmission. Cytomegalovirus in this case known as the leading cause of viral pneumonia.
mushrooms
Infections caused by fungi such as histoplasmosis spread through inhalation of air containing spores and are commonly found in bird feces, soil and compost.
protozoa
Cause the occurrence of Pneumocystis carinii pneumonia (CPC). Usually affects patients who have immunosupresi. (Reeves, 2001)

CLINICAL MANIFESTATION OF PNEUMONIA
Clinical manifestations of bronchopneumonia are among others:
1. Difficulty and pain when breathing
  • pleuritic pain
  • Shallow breathing and snoring
  • Tachypnea
2. Breath sounds over the area that had a late consolidation
  • Decreases, then disappears
  • Cracels, rhonchi, egofoni
3. Chest movement is not symmetrical
4. Chills and fever 38.8 ° C to 41.1 ° C, delirium
5. Diaphoresis
6. Anorexia
7. Malaise
8. Thick cough, productive
  • Greenish yellow sputum then turns into a reddish or rusty
9. Restless
10. Cyanosis
  • Area sirkumoral
  • Bluish nail beds
11. Psychosocial problems: disorientation, anxiety, fear of dying
Read More :

8 Nursing Diagnosis for Pneumonia
  1. Ineffective Airway Clearance
  2. Impaired Gas Exchange
  3. Ineffective Breathing Pattern
  4. Increased Body Temperature
  5. Risk for Infection
  6. Activity Intolerance
  7. Pain
  8. Imbalanced Nutrition Less Than Body Requirements
READ MORE - 8 Nursing Diagnosis for Pneumonia

Nursing Care Plan for Mental Retardation

Pediatric Nursing Care Plan - Mental Retardation Nursing Assessment

Assessment can be done through:
  1. Neuroradiology can find abnormalities in the structure of the cranium, such as classification or increased intracranial pressure.
  2. Echoencephalography can show the tumor and hematoma.
  3. A brain biopsy is only useful on a small number of children retardasii mentally. Not easy for parents to accept the role in brain tissue making even small amounts because they add to the brain damage is inadequate.
  4. Bio-chemical research to determine the metabolic rates of various materials which are known to affect brain tissue if not found in large quantities or small, such as hyperglycemia in preterm neonates, accumulation of glycogen in muscles and neurons, fat deposits in the brain and high levels of phenylalanine.

Or can perform the following assessments:
  • Assessment of physical
  • Assessment for growing up
  • Family history assessment, especially regarding mental retardation and hereditary disorders in which mental retardation is one of the main species.
  • Medical history to obtain evidence of trauma to prenatal, perinatal, postnatal, or physical injury.
  • Prenatal maternal infection (eg, rubella), alcoholism, drug consumption.
  • Inadequate nutrition.
  • Environmental deviations.
  • Psychiatric disorders (eg, Autism).
  • Infections, particularly those involving the brain (eg, meningitis, encephalitis, measles) or high body temperature.
  • Chromosome abnormalities.
  • Assist with diagnostic tests such as: analysts chromosomes, metabolic dysfunction, radiography, tomography, electro ensephalography.
  • Perform or assist with intelligence tests. Stanford Binet, Wechsler intellence, Scale, American Assiciation of Mental Retardation Adaptive Behavior Scale.
  • Observation of an early manifestation of mental retardation:
    • Not responsive to contact.
    • Poor eye contact during breastfeeding.
    • Decrease in spontaneous activity.
    • Decreased awareness of sound vibrations.
    • Sensitive stimuli.
    • Breast-feeding is slow.

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Nursing Care Plan Mental Retardation Nursing Diagnosis and Interventions
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Physical Examination for Congestive Heart Failure (CHF)

Congestive heart failureor Heart failure is inability of the heart to pump an adequate amount of blood to the systemic circulation to meet the body's metabolic demands.

In most cases, heart failure is a process that occurs over time, when an underlying condition damages the heart or makes it work too hard, weakening the organ. Heart failure is characterized by shortness of breath (dyspnea) and abnormal fluid retention, which usually results in swelling (edema) in the feet and legs.

Common symptoms of congestive heart failure include:
  • Shortness of breath with exertion or when lying down
  • Cough
  • Swelling in legs, feet and ankles (pooling of blood)
  • Swelling of the abdomen
  • Weight gain
  • Loss of appetite, indigestion
  • Irregular or rapid pulse
  • Low blood pressure
  • Weakness and fatigue
  • Heart palpitations (feeling the heart beat)
  • Difficulty sleeping
  • Other symptoms may include:
  • Decreased in alertness or ability to concentrate
  • Decreased urine production
  • Nighttime urination (the need to get out of bed to go to the bathroom)
  • Nausea and vomiting

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Physical Examination for Congestive Heart Failure (CHF)
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