Bathing / Hygiene Self-care Deficit

Bathing / Hygiene Self-care Deficit

Impaired ability to perform or complete bathing/hygiene activities for oneself

Defining Characteristics:

Inability to: wash body or body parts;
obtain or get to water source;
regulate temperature or flow of bath water;
get bath supplies;
dry body;
get in and out of bathroom


Impaired physical mobility-functional level classification:
0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person for assistance, supervision, or teaching
3 Requires help from another person and equipment or device
4 Dependent—does not participate in activity

Related Factors:

Decreased or lack of motivation;
weakness and tiredness;
severe anxiety;
inability to perceive body part or spatial relationship;
perceptual or cognitive impairment;
pain;
neuromuscular impairment;
musculoskeletal impairment;
environmental barriers


NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Self-Care: Activities of Daily Living (ADLs)
Self-Care: Bathing
Self-Care: Hygiene

Client Outcomes

Remains free of body odor and maintains intact skin
States satisfaction with ability to use adaptive devices to bathe
Bathes with assistance of caregiver as needed without anxiety
Explains and uses methods to bathe safely and with minimal difficulty

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Bathing
Self-Care Assistance: Bathing/Hygiene

Read More :

http://all-about-nanda.blogspot.com/2013/09/bathing-hygiene-self-care-deficit.html

Bowel Incontinence

Change in normal bowel habits characterized by involuntary passage of stool.

Defining Characteristics:

Constant dribbling of soft stool, fecal odor;
inability to delay defecation;
rectal urgency;
self-report of inability to feel rectal fullness or presence of stool in bowel;
fecal staining of underclothing;
recognizes rectal fullness but reports inability to expel formed stool;
inattention to urge to defecate;
inability to recognize urge to defecate, red perianal skin


Related Factors:

Change in stool consistency (diarrhea, constipation, fecal impaction);
abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance);
defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele);
sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles);
neurological disorders impacting gastrointestinal motility,
rectal vault function and sphincter function (cerebrovascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellitus, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis)


NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Bowel Continence
Bowel Elimination

Client Outcomes

Regular, complete evacuation of fecal contents from the rectal vault (pattern may vary from every day to every 3 to 5 days) (Roig et al, 1993)
Defecates soft-formed stool
Decreased or absence of bowel incontinence incidences
Intact skin in the perianal/perineal area
Demonstrates the ability to isolate, contract, and relax pelvic muscles (when incontinence related to sphincter incompetence, pseudodyssynergia) Increases pelvic muscle strength (when incontinence related to sphincter incompetence)


NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Bowel Incontinence Care
Bowel Training
Bowel Incontinence Care: Encopresis

Read More : http://all-about-nanda.blogspot.com/2013/09/bowel-incontinence.html

Nursing Management for Malignant Lymphoma

Lymphomas are a group of cancers in which cells of the lymphatic system become abnormal and start to grow uncontrollably. Because there is lymph tissue in many parts of the body, lymphomas can start in almost any organ of the body.

The two main types of lymphoma are Hodgkin and non-Hodgkin lymphoma (NHL).

The diagnosis of malignant lymphoma requires the presence of malignant lymphocytes in a biopsy of lymph node or extra-lymphatic tissue. An excisional lymph node biopsy is essential for complete diagnostic assessment. If a whole lymph node is not obtainable, sufficient incised tissue from an extra-lymphatic site can be diagnostic but is less desirable. Fine needle aspiration biopsy is not sufficient for the initial diagnosis of malignant lymphoma.

Malignant lymphoma is derived from lymphocytes. These tumors usually stems from lymph nodes, but can involve the lymphoid tissue in the spleen, gastrointestinal tract (eg, stomach wall), liver, or bone marrow. Lymphocytes in lymph nodes is also derived from multipotential stem cells in the bone marrow. Multipotential stem cells in the early stages of transformation into a lymphocyte progenitor cells that subsequently differentiate along two parallel paths.

Partial maturation in the thymus gland to become T lymphocytes, and partly to the lymph nodes or remain in the bone marrow and differentiate into B lymphocytes cells
If there is an appropriate antigen stimulation by the T and B lymphocytes will be transformed into an active form and proliferating. Activated T lymphocytes functioning cellular immune response. Whereas B lymphocytes are then activated to imunoblas into plasma cells that form the immunoglobulins. Changes in normal lymphocytes into cell lymphoma is caused by a gene mutation on one of the cells of a group of old cell lymphocytes are in the process of transformation into imunoblas (the result of the stimulation of immunogen). This occurs in the lymph nodes, where lymphocytes are outside centrum old germinativum while imunoblast be the most central part germinativum centrum. If the tumor enlarges, it can cause and if not treated early it causes malignant lymphoma.

Cause of these tumors is unknown, but there are some risk factors include: immunodeficiency, infectious agents, environmental and occupational exposures (such as forest workers, farmers and agriculture), ultraviolet exposure, smoking, and eating foods high in animal fat. Signs and symptoms include fatigue, malaise weight loss, increased temperature, infection susceptibility, dysphagia, anorexia, nausea, vomiting, constipation, anemia, edema arising anasarka, drop in blood pressure, shortness of breath when grown in the chest area and disorders / enlargement organ. If this condition is ongoing, it can cause complications of pleural effusion, bone fracture, paralysis and kematin certainly occur within 1 to 3 years if no treatment.

Nursing Management for Malignant Lymphoma

According to Brunner and Suddarth (2000), in providing care and client education. Clients often feel afraid to drugs that are radioactive and requires maintenance action and follow-up monitoring is special because it is the nurse should convey information about the therapeutic and soothing feelings of clients and families. For clients with postoperative laparotomy, clients are encouraged to rest and to avoid strain on the stitches. Gauze covering the wound should be reviewed periodically to determine the presence or not and do peradahan wound care according to the program every day, to observe signs of infection.

Source : http://nurseskomar.blogspot.com/2013/09/nursing-management-for-malignant.html

Nursing Diagnosis for Premature Rupture Membranes : Risk for Infection

Nursing Care  Plan for Premature Rupture of Membranes

Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins. If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of membranes (PPROM).

PROM occurs in about 8 to 10 percent of all pregnancies. PPROM (before 37 weeks) accounts for one fourth to one third of all preterm births.

The management of PPROM is among the most controversial issues in perinatal medicine. Points of contention include:

• Expectant management versus intervention
• Use of tocolytics
• Duration of administration of antibiotic prophylaxis
• Timing of administration of antenatal corticosteroids
• Methods of testing for maternal/fetal infection
• Timing of delivery.

Risk Factors and Causes:

Certain types of infections appear to be able to cause preterm PROM, and in rare cases procedures such as amniocentesis can cause PROM, but researchers do not believe there is a single cause of the condition. The following are some known risk factors:

• Lower socioeconomic status
• history of PPROM
• bleeding during pregnancy
• Smoking
• Prior preterm birth
• Sexually transmitted diseases
• Multiple pregnancy
• Polyhydramnios

The following are the most common symptoms of PROM. However, each woman may experience symptoms differently. Symptoms may include:

• Leaking or a gush of watery fluid from the vagina
• Constant wetness in underwear

If you notice any symptoms of PROM, be sure to call your doctor as soon as possible. The symptoms of PROM may resemble other medical conditions. Consult your doctor for a diagnosis.


Nursing Diagnosis for Premature Rupture of Membranes : Risk for Infection related to invasive procedures, recurrent vaginal examination, and amniotic membrane rupture.

Goal: maternal infection does not occur

Expected outcomes: Mother states / shows are free of any signs of infection.

Nursing Interventions for Premature Rupture of Membranes:

1. Perform initial vaginal examination, when the contraction pattern repeat, or maternal behavior indicates progress.
R /: Repeated vaginal examinations play a role in the incidence of ascending tract infections.

2. Monitor temperature, pulse, respiration, and white blood cells as indicated.
R /: Within 4 hours after membrane rupture, chorioamnionitis incidence increased progressively in accordance with the time indicated by vital signs.

3. Give prophylactic antibiotics when indicated.
R /: Antibiotic may protect against the development of chorioamnionitis in women at risk.

Source : http://nandahealth.blogspot.com/2013/09/risk-for-infection-related-to-premature.html

NCP Heart Failure - Risk for Impaired Skin Integrity

Nursing Diagnosis Risk for impaired skin integrity> related to pitting edema.

Expected outcomes:
clients can demonstrate behaviors / techniques to prevent skin damage.
Maintaining the integrity of the skin.

Interventions:

1. Change position often in bed / chair, assistive range of motion exercises passive / active.
2. Provide frequent skin care, minimizing the moisture / excretion.
3. Check narrow shoes / sandals and change as needed.
4. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
5. Massage the area red or white.

Rational:

1. Improving circulation / lowering an area that interfere with blood flow.
2. Too dry or moist skin damage and accelerating damage.
3. Dependent edema can cause the shoe is too narrow, increasing the risk of stress and damage to the skin on the feet.
4. Lowering the pressure on the skin, improve circulation.
5. Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status. Increase blood flow, minimizing tissue hypoxia.

Source :

http://list-nanda-nursing-diagnosis.blogspot.com/2013/01/risk-for-impaired-skin-integrity-ncp.html