Nanda - Ineffective Individual Coping - NIC NOC

Defining characteristics:

• Sleep disorders
• Chemical abuse
• Decline in the use of social support
• Poor concentration
• Fatigue
• Complained about the inability of coping
• Destructive behavior toward self / others
• The inability to meet the expectations of the role

Related factors:

• Gender differences in coping strategies
• Confidence level is inadequate
• Uncertainty
• Ineffective social support
• Situational crisis / maturasional
• The degree of high-level treatment

NOC Labels: Coping

Expected outcomes:

• Shows the flexibility of the role
• Shows the flexibility of the role of family members
• Conflict issues
• Can set the value of family issues
• Manage the problem
• Involving family members in making decisions
• Express feelings and emotional freedom
• Shows a strategy to manage the problem
• Using stress reduction strategies
• Care for the needs of family members
• Determine priorities
• Determine the timetable for the routine, and family activities
• Schedule for respite care
• Have a plan on the condition of gravity
• Maintain financial stability
• Seeking help when needed
• Using social support

NOC assessment information:

1 = not done at all

2 = rarely done

3 = sometimes done

4 = often

5 = always done


NIC: Improved coping

• Respect the patient's understanding of the disease process and self-concept
• Appreciate and discuss the substitute response to the situation
• Respect the client's attitude toward the changing roles and relationships
• Support the use of spiritual resources upon request
• Use a calm approach and provide assurance
• Provide information about the actual diagnosis, and prognosis handlers
• Provide a realistic option at this aspect of care
• Support the use of appropriate defensive mechanism
• Encourage family involvement in an appropriate manner
• Help patients to identify positive strategies to overcome these limitations and to manage lifestyle and role changes
• Help clients to adapt and anticipate changes in client
• Help clients identify the possibilities that can occur.

Pathophysiology of Space Occupying Lesion (SOL)

A space occupying lesion is any abnormal tissue found on or in an organism, usually damaged by disease or trauma.

A space occupying lesion of the brain is usually due to malignancy but it can be caused by other pathology such as an abscess or a haematoma. Almost half of intracerebral tumours are primary but the rest have originated outside the CNS and are metastases.

The symptoms are also dependent on the area of the brain affected:

• Temporal lobe – dysphasia, contralateral homonymous hemianopia, amnesia
• Frontal lobe – Hemiparaesis, personality change, executive dysfunction
• Parietal lobe – Hemisensory loss, astereogenesis (can’t recognise objects by touch alone), reduced 2-point discrimination
• Occipital lobe – contralateral visual field defects, palinopsia (see things again once stimulus has left field of vision)
• Cerebellum – DASHING: Dysdiadochokinesis, Ataxia, Slurred speech, Hypotonia, Intention tremor, Nystagmus, Gait abnormalities
• Personality change – irritability, lack of concentration, socially inappropriate behaviour.

Pathophysiology of Space Occupying Lesion (SOL)

Brain tumors cause neurological disorders. Symptoms occur sequentially. This emphasizes the importance of history in the examination of the client. The symptoms should be addressed in a time perspective.

Neurologic symptoms in brain tumors typically considered to be caused by two factors focal disorder, caused by the tumor and intracranial pressure. Focal disruption occurs when an emphasis on brain tissue and infiltration / invasion of the brain parenchyma by direct tissue damage neurons. Of course the greatest dysfunction occurs in tumors that grew most rapidly.

Changes in blood supply due to the pressure caused by the growing tumor causing brain tissue necrosis. Impaired arterial blood supply is generally manifest as an acute loss of function and may be confused with primary cerebrovascular disorders. Seizures as a manifestation of neuro sensitivity changes associated with compression of the invasion and changes in blood supply to the brain tissue. Some tumors form cysts that also suppress the surrounding brain parenchyma so that aggravate focal neurological disorders.

Increased intra-cranial pressure can be caused by several factors: the increase of the mass in the skull, the formation of edema around the tumor and cerebrospinal circulation changes. Tumor growth causes increasing mass, because the tumor will take a relatively from the rigid skull. Malignant tumors cause edema in brain tissue. The mechanisms are not entirely understood, but due to the difference in osmotic allegedly causing bleeding. Venous obstruction and edema caused by damage to the blood brain barrier, all lead to an increase in intracranial volume. Observation of the circulation of cerebrospinal fluid from the ventricle into the sub-arachnoid laseral cause hidrocepalus.

Increased intracranial pressure would endanger the life, when it occurs rapidly due to a cause that has been discussed previously. Compensation mechanism takes many days / months to be effective and therefore not useful when intracranial pressure arise quickly. This compensation mechanism among other works lowering intra-cranial blood volume, cerebrospinal fluid volume, intracellular fluid content and reduce parenchymal cells. The increase in pressure resulting in untreated ulcer or serebulum herniation. Herniation occurs when the medial lobe gyrus temporals shifted to inferior through territorial notch by the masses in the cerebral hemispheres. Herniation pressing metencephalon cause loss of consciousness and hit the third nerve. In the cerebellar herniation, tonsillar before shifting down through the foramen magnum by a posterior mass. Compression of the medulla oblongata and stop breathing occur quickly. Intracranial fast is progressive bradycardia, systemic hypertension (widening pulse pressure and respiratory problems).

Atelectasis - Symptoms, Prevention and Treatment

Atelectasis is the collapse of part or (much less commonly) all of a lung.

The primary cause of atelectasis is obstruction of the bronchus serving the affected area. This condition may be caused by obstruction of the major airways and bronchioles, by pressure on the lung from fluid or air in the pleural space, or by pressure from a tumor outside of the lung.

Symptoms of Atelectasis : Breathing difficulty, Chest pain, Cough, Fever, low-grade, usually after surgery.

Atelectasis is diagnosed by clinical exam, close monitoring of a post-operative clinical course, and x-ray.

Prevention of Atelectasis

• Encourage movement and deep breathing in anyone who is bedridden for long periods.
• Keep small objects out of the reach of young children.
• Maintain deep breathing after anesthesia.

Treatment of Atelectasis

If atelectasis is due to obstruction of the airway, the first step in treatment is to remove the cause of the blockage. This may be done by coughing, suctioning, or bronchoscopy. If a tumor is the cause of atelectasis, surgery may be necessary to remove it. Antibiotics are commonly used to fight the infection that often accompanies atelectasis. In cases where recurrent or long-lasting infection is disabling or where significant bleeding occurs, the affected section of the lung may be surgically removed.

Anxiety - NCP for Pulmonary Edema

Pulmonary edema is an abnormal buildup of fluid in the air sacs of the lungs, which leads to shortness of breath.

Early symptoms of pulmonary edema include:

• shortness of breath upon exertion
• sudden respiratory distress after sleep
• difficulty breathing, except when sitting upright
• coughing

In cases of severe pulmonary edema, these symptoms will worsen to:

• labored and rapid breathing
• frothy, bloody fluid containing pus coughed from the lungs (sputum)
• a fast pulse and possibly serious disturbances in the heart's rhythm (atrial fibrillation, for example)
• cold, clammy, sweaty, and bluish skin
• a drop in blood pressure resulting in a thready pulse

The health care provider will perform a physical exam and use a stethoscope to listen to your lungs and heart. The following may be detected:

• Abnormal heart sounds
• Crackles in your lungs, called rales
• Increased heart rate (tachycardia)
• Pale or blue skin color (pallor or cyanosis)
• Rapid breathing (tachypnea)

Nursing Diagnosis : Anxiety related to Threat / Change in Health Status

Goal: Anxiety can be overcome

Expected outcomes:

• Reported fear / anxiety disappear or decrease to the level that can be handled, looks relaxed and resting / sleeping properly.

Nursing Intervention :

1) Record the degree of anxiety and fear. Inform the patient / person close to the patient, the normal feelings and push expressing feelings.
Rational:
Understanding that feelings (which are based plus oxygen imbalances that threaten) normal can help patients improve some sense of emotional control.

2) Explain the disease process and procedures in the level of the patient's ability to understand and handle information. Assess the current situation and the measures taken to address the problem.
Rational:
Eliminate anxiety as insecurity and reduce fear about personal safety. In the early phase of explanation needs to be repeated with frequent and short because the patient has decreased the scope of attention.

3) Provide comfort measures, ie, back massage, change of positions.
Rational:
Tool to reduce stress and indirect care to enhance relaxation and coping skills.

4) Help patients to identify behavioral help, eg a comfortable position, focus on breathing, relaxation techniques.
Rational:
Giving patients control measures to reduce anxiety and muscle tension.

5) Support the patient / significant other in accepting the reality of the situation, especially the plan for a long period of recuperation. Involve patients in planning and participation in care.
Rational:
Coping mechanisms and participation in treatment programs may improve learning patients to receive the expected result of the disease and improve some sense of control.

6) Watch out for out of control behavior or increased cardiopulmonary dysfunction, eg worsening dyspnea and tachycardia.
Rational:
Developing the capacity of anxiety requires further evaluation and possible intervention with anti-anxiety medication.

Hyperthyroidism - Assessment and Nursing Diagnosis

Hyperthyroidism is a condition in which the thyroid gland makes too much thyroid hormone. The condition is often referred to as an "overactive thyroid."

Causes of Hyperthyroidism

• Hyperthyroidism occurs when the thyroid releases too much of its hormones over a short (acute) or long (chronic) period of time. Many diseases and conditions can cause this problem, including:
• Getting too much iodine
• Graves disease (accounts for most cases of hyperthyroidism)
• Inflammation (thyroiditis) of the thyroid due to viral infections or other causes
• Noncancerous growths of the thyroid gland or pituitary gland
• Some tumors of the testes or ovaries
• Taking large amounts of thyroid hormone

Symptoms of Hyperthyroidism

• Palpitations
• Heat intolerance
• Nervousness
• Insomnia
• Breathlessness
• Increased bowel movements
• Light or absent menstrual periods
• Fatigue
• Fast heart rate
• Trembling hands
• Weight loss
• Muscle weakness
• Warm moist skin
• Hair loss
• Staring gaze

Assessment for Hyperthyroidism

1. Health Perceptions
Knowledge of the disease and the side effects of drugs.

2. Metabolic Nutrition
Changes in food intake, such as appetite and increases food intake, body weight decreased.

3. Elimination
Changes in fecal elimination, increased frequency of bowel movements or many times. Every meal tend to defecate, urine in large quantities.

4. Activity and Exercise
Experiencing chest pain / angina, tachycardia despite the break, dysrhythmias, and murmur, dyspnea experienced during the activity / rest muscle weakness, severe accidents, muscle atrophy.

5. Rest and Sleep
Insomnia.

6. Cognitive Sensory
Complained of impaired vision rapid eye fatigue, blurred vision, orbital pain, exophthalmos.

7. Coping Mechanisms
Emotional instability, experiencing severe stress both emotional and physical, psychological conditions.

8. Sexual Relations
Decreased libido, hipomenorea, amenorrhoea and impotence.

9. Self-Concept
Less confident because of physical changes such as the eye.


Nursing Diagnosis for Hyperthyroidism

1. Decreased Cardiac Output
2. Fatigue
3. Disturbed Thought Processes
4. Imbalanced Nutrition
5. Anxiety
6. Impaired Tissue Integrity
7. Knowledge Deficit

NCP Edema - Fluid Volume Excess NIC NOC

Definition: increased isotonic fluid retention

Defining characteristics:

• Body weight increased in a short time
• Excessive intake than output
• Altered blood pressure, pulmonary artery pressure changes, increased CVP
• Jugular venous distention
• Changes in breathing pattern, dyspnoe / shortness of breath, orthopnoe, abnormal breath sounds (Rales or crackles), pulmonary congestion, pleural effusion
• Decreased hemoglobin and hematocrit, electrolyte changes, particularly changes in density
• Heart sound SIII
• Reflex positive hepatojugular
• Oliguria, azotemia
• Mental position changes, nervousness, anxiety

Related Factor:

• Weak regulatory mechanisms
• Excessive fluid intake
• Excessive sodium intake

NOC Labels:

• Electrolit and acid base balance
• Fluid balance
• Hydration

Expected outcomes:

• Free from edema, effusion, anasarca
• The sound of breathing clean, no dyspnea / orthopnea
• Free from jugular venous distention, reflexes hepatojugular (+)
• Maintaining central venous pressure, pulmonary capillary wedge pressure, cardiac output and vital sign within normal limits
• Free from fatigue, anxiety or confusion
• Explaining the excess fluid indicator

NIC:


Fluid management

• Weigh diapers / pads if needed
• Maintain a record of intake and output accurately
• Insert urinary catheter if necessary
• Monitor lab results that correspond to fluid retention (BUN, Hmt, urine osmolality)
• Hemodynamic Monitor position including CVP, MAP, PAP, and PCWP
• Monitor vital sign
• Monitor indications retention / excess fluid (cracles, CVP, edema, distended neck veins, ascites)
• Assess the location and size of edema
• Monitor the input of food / liquid and count daily calorie intake
• Monitor portion of nutrients
• Give diuretics as instructed
• Limit fluid intake on the state of dilution hyponatremia with serum Na less than 130 mEq / l
• Collaboration doctor if signs of excess fluid appears to deteriorate.

Fluid Monitoring

• Determine history of the number and type of fluid intake and elimination
• Determine the possible risk factors of fluid imbalance (Hyperthermia, diuretic therapy, renal disorders, heart failure, diaphoresis, liver dysfunction, etc.)
• Monitor weight
• Monitor serum and urine electrolytes
• Monitor serum and urine osmilalitas
• Monitor BP, HR, and RR
• Monitor blood pressure and orthostatic changes in heart rhythm
• Monitor invasive hemodynamic parameters
• Record intake and output accurately
• Monitor the neck distention, peripheral eodem and weight gain
• Give drugs that can increase urine output
• Monitor signs and symptoms of edema.

The Benefits Of Iron Tablets for Pregnant Women

Iron supplements are dietary supplements containing iron that can be prescribed by a doctor for a medical reason, or purchased from a vitamin shop, drug store etc. They are primarily used to treat anemia or other iron deficiencies. There are three ways that an iron supplement can be delivered: orally, intravenously or intramuscularly.

This tablet is needed by pregnant women. Many women have an inadequate level of iron in their system to begin with, and the lack becomes more pronounced during pregnancy.

Iron is very vital for the fetus; it is the only nutrient which the fetus depends totally on the mother for the supply. The average woman cannot depend on diet alone. The demand doubles during pregnancy and so iron supplements are added to compensate for the insufficiency.

Iron-deficiency anemia during pregnancy is linked to an increased risk of preterm delivery and low birth weight. It's also associated with a higher risk of stillbirth or newborn death, so it's something to take seriously.

There are two types of iron, heme and nonheme iron, categorized this way because the former is derived from meat and the other from non-meat sources. Heme iron is more readily absorbed than nonheme iron.

Signs and symptoms of iron deficiency may include brittle nails, swelling or soreness of the tongue, cracks in the sides of the mouth, an enlarged spleen, and frequent infections.

People who have iron-deficiency anemia may have an unusual craving for nonfood items, such as ice, dirt, paint, or starch. This craving is called pica (PI-ka or PE-ka).

Some people who have iron-deficiency anemia develop restless legs syndrome (RLS). RLS is a disorder that causes a strong urge to move the legs. This urge to move often occurs with strange and unpleasant feelings in the legs. People who have RLS often have a hard time sleeping.

Within a week or so after starting treatment, you should be producing a lot of new red blood cells and your hemoglobin level will begin to rise. It usually takes just a couple of months for the anemia to resolve, but your caregiver will likely advise you to continue taking iron supplements for several more months so you can replenish your iron stores.

One more important thing to note: Be vigilant about keeping any pills containing iron in childproof containers and away from children. More kids die from iron overdose each year than from any other kind of accidental drug poisoning. In fact, a single adult dose can poison a small child.

Take your prenatal vitamin and eat a healthy diet that includes plenty of iron-rich foods. Red meat is your best bet, although poultry (dark meat), other meats, and shellfish are good sources, too. Non-animal iron-rich foods include beans, lentils, tofu, raisins, dates, prunes, figs, apricots, potatoes (leave the skin on), broccoli, beets, leafy green vegetables, whole grain breads, nuts and seeds, blackstrap molasses, oatmeal, and iron-fortified cereals. Keep in mind that your body absorbs the iron from animal sources (heme iron) much more readily than the iron from non-animal sources (non-heme iron).