NURSING DIAGNOSIS: September 2014

Scoliosis - 5 Nursing Diagnosis and Interventions

Scoliosis is a curvature, or lateral curvature of the spine due to the rotation and vertebral deformity.

Three forms of structural scoliosis are:

Idiopathic scoliosis is the most common form and classified into 3 groups: infantile, which arise from birth to age 3 years; children, who emerged from the age of 3 years to 10 years; and adolescents, which appears after the age of 10 years (the age of the most common).
Congenital scoliosis is scoliosis that causes malformation of one or more vertebral bodies.
Neuromuscular scoliosis, children who suffer from neuromuscular diseases (such as brain paralysis, spina bifida, or muscular dystrophy) which directly causes the deformity.

(Nettina, Sandra M.)

Clinical Symptoms

Spine curves abnormally to the side.
Shoulder or hip and the left and right are not the same height.
Back pain.
Fatigue in the spine after sitting or standing for long.
Severe scoliosis (curvature greater than 60) can cause respiratory problems.

Nursing Diagnosis and Interventions for Scoliosis

1. Ineffective Breathing Pattern related to emphasis the lung.
Goal: effective breathing pattern.
Intervention:

Assess respiratory status every 4 hours.
Help and teach the patient to do deep breaths every 1 hour.
Set the semi-Fowler position bed to improve lung expansion.
Auscultation of the chest to listen for breath sounds every 2 hours.
Monitor vital signs every 4 hours.

2. Acute pain: back related to body position tilted laterally.
Goal: pain is reduced / lost.
Intervention:

Assess the type, intensity, and location of pain.
Adjust the position of which can increase the sense of comfort.
Maintain a quiet environment to improve comfort.
Teach relaxation and distraction techniques to divert attention, thus reducing pain.
Encourage regular postural exercises to improve posture.
Teach and encourage use of the brace to reduce pain during activity.
Collaboration in providing analgesic to relieve pain.

3. Impaired physical mobility related to an unbalanced posture.
Objective: To improve physical mobility.
Intervention:

Assess the level of physical mobility.
Increase activity if pain is reduced.
Teaching aids and active joint range of motion exercises.
Involve the family in performing self-care.
Increase return to normal activity.

4. Disturbed Body Image or Self-concept disturbance related to kelateral tilted posture.
Objective: To enhance the image of the body.
Intervention:

Instruct to express feelings and problems.
Give supportive environment.
Help the patient to identify positive coping styles.
Give realistic expectations and goals for the short term to facilitate the achievement.
Give rewards for tasks performed.
Encourage communication with people nearby and need socialization with family and friends.
Give encouragement to care for themselves as tolerated.

5. Knowledge Deficit related to lack of information about the disease.
Goal: understanding of the treatment program.
Intervention:

Explain about the state of the disease.
Emphasize the importance and benefits of maintaining the recommended exercise program.
Tell us about the treatment of: name, schedule, purpose, dosage, and side effects.
Demonstrate the installation and maintenance brace or corset.

Decreased Cardiac Output - NCP for Angina Pectoris

Nursing Diagnosis for Angina Pectoris : Decreased cardiac output related to contraction disorders

NOC :

Cardiac Pump Effectiveness
Circulation Status
Vital Sign Status

Outcomes :

Vital Signs within the normal range (blood pressure, pulse, respiration).
Can tolerate the activity, there is no fatigue.
No pulmonary edema, peripheral and no ascites.
There is no loss of consciousness.

NIC

Cardiac Care

Evaluation of chest pain (intensity, location, duration).
Note the presence of cardiac dysrhythmias.
Note the reduction in signs and symptoms of cardiac putput.
Monitor cardiovascular status.
Monitor respiratory status that indicates heart failure.
Monitor the abdomen as an indicator of decreased perfusion.
Monitor fluid balance.
Monitor any changes in blood pressure.
Monitor the patient's response to the effects of antiarrhythmic treatment.
Set exercise and rest periods to avoid fatigue.
Monitor the patient's activity tolerance.
Monitor the presence of dyspnea, fatigue, tachypnea and orthopnoea.
Suggest to reduce stress.

Vital Sign Monitoring

Monitor BP, pulse, temperature, and RR.
Note the fluctuations in blood pressure.
Monitor VS when the patient is lying down, sitting, or standing.
Auscultation of blood pressure in both arms and compare.
Monitor BP, pulse, RR, before, during, and after activity.
Monitor the quality of the pulse.
Monitor the presence of pulsus paradoxus and pulsus alterans.
Monitor the number and monitors the heart rhythm and heart sounds.
Monitor respiratory rate and rhythm.
Monitor lung sounds, abnormal breathing patterns.
Monitor temperature, color, and moisture.
Monitor peripheral cyanosis.
Monitor the presence of Cushing's triad (widened pulse pressure, bradycardia, increased systolic).
Identify the cause of vital sign changes.

Ineffective Airway Clearance related to Bronchiectasis

Nursing Diagnosis for Bronchiectasis : Ineffective Airway Clearance related to increased mucus production and decreased ability to cough effectively.

Goal: Effective airway, eliminating the quantity of sputum viscosity to improve pulmonary ventilation and gas exchange.

Outcomes:

can demonstrate effective coughing,
can mention the ways to lower the viscosity of secretions,
no additional breath sounds,
normal breathing (16-20 x / min) without the use of auxiliary breathing muscles.

Nursing Interventions:

1. Assess color, consistency, and amount of sputum.
R /: Characteristics of sputum may indicate the severity of the obstruction.

2. Adjust the position semifowler.
R /: Enhance chest expansion.

3. Teach cough effectively.
R /: Cough is controlled and can effectively facilitate the embedding secret spending airway.

4. Help clients practice a deep breath.
R /: maximum ventilation opening the airway lumen and increase the secret movement into the large airway to be issued.

5. Maintain fluid intake at least 2500 ml / day unless indicated.
R /: Adequate hydration helps thin the secret and effective airway clearance.
In addition, to increase the client's fluid intake is a tendency to breathe through the mouth which increases water loss. Inhalation of evaporated water vapor is also helpful because it can moisturize the bronchial branching.

6. Perform chest physiotherapy with postural drainage techniques, percussion, and vibration chest.
R /: Postural drainage with percussion and vibration using the help of gravity to help increase the secretion that can be easily removed or inhaled. Therapies that can dilate the bronchi as aerosol therapy, bronchodilator aerosolization, or intermittent positive pressure breathing action (IPPB), must be given before postural drainage due to the secretion will flow more easily after tracheo-bronchial branching dilated. The client is instructed to breathe and cough effectively to help remove secretions. Postural drainage is usually performed when the client wakes up, to get rid of secretions that have accumulated throughout the night, and before the break, to improve the quality and quantity of sleep.

7. Collaboration of bronchodilators.
R /: Provision of bronchodilators via inhalation will go directly to the area that experienced the bronchus spasm resulting in faster dilated.

Ineffective Airway Clearance related to Bronchiectasis

Ineffective Airway Clearance related to Sinusitis - Nursing Diagnosis and Interventions

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Nursing Assessment for Social Isolation : Withdrawal

Social Isolation : Withdrawal

1. Identity
Often found at an early age or first appear at puberty.

2 Main Complaint
The main complaint is usually a result of the decline will and emotional shallowness.

3 Factors Predisposing
Predisposing factors are closely associated with etiological factors that heredity, endocrine, metabolic, central nervous system, the weakness of the ego.

4 Psychosocial
a. Genogram
Schizophrenic parents, one son 7-16% possibility of schizophrenia, when both suffered 40-68%, from 0.9 to 1.8% stepsister possibility, the twin brother of 2-15%, 7-15% sibling.

b. Self-Concept
Setbacks will and shallowness of the patient's emotions will affect the patient's self-concept.

c. Social Relations
Clients tend to withdraw from social environment, starry-eyed, silent.

d. Spiritual
Spiritual activity declines with the decline of the will.

5. Mental Status
a. Appearance
The patient appeared lethargic, lackluster, hair disheveled, shirt buttons are not right, not locked zipper, clothes not replaced, clothes upside as a manifestation of the willingness of the patient's deterioration.

b. Talks
Tone was low, slow, less talk, apathetic.

c. Activity of Motor
Activities undertaken are not varied, the tendency to defend one of its own position (catalepsy).

d. Emotions
Shallow emotions.

e. Afec
Superficially, there is no facial expression.

d. Interaction During Interview
Tend not cooperative, less eye contact, do not want to stare at the speaker, silent.

e. Perception
There were no hallucinations or delusions.

d. Thinking process
Impaired thought processes are rarely found.

e. Awareness
Altered consciousness, and the ability to make contact with the outside world and the restriction itself is disturbed at the level does not correspond to reality (qualitative).

f. Memory
Not found specific disorders, the orientation, time, good people.

g. Capability assessment
Can not make decisions, can not act in a situation, always giving reasons although the reasons are unclear or imprecise.

6. Everyday Needs

At the beginning people pay less attention to himself and his family, the more backward the job due to setbacks will. Interest to meet their own needs greatly decreased in terms of eating, urination / defecation, bathing, dressing, sleeping intirahat.

Mobilization and Immobilization Definition

Mobilization Definition

Mobility is the movement that gave freedom and independence for a person. (Ansari, 2011).
Mobilization is a condition where the body can perform activities freely. (Kosier, 1989 cit Ida 2009)
Mobilization is the ability to move freely, easily and regularly which aims to meet the needs of a healthy life. Mobilization is necessary for enhancing the health, slow the disease process, especially degenerative diseases and to actualization. Mobilization led to improved circulation, creating a deep breath and stimulate gastrointestinal function returns to normal, thrust to move the foot and lower leg as soon as possible, usually within 12 hours. (Mubarak, 2008).
Mobility or mobilization of an individual's ability to move freely, easily and regularly with the aim to meet the needs of the activity in order to maintain health. (AA Aziz, 2006)
Mobililis / Mobilisation is effortless motion / move. (Christine Brooker, 2001)
Physical mobility is a state when a person experiences or even at risk of physical limitations and is not immobile. (Doenges, M.E, 2000)
Mobility or mobilization is the ability of individuals to move freely, easy, and organized with the aim to meet the needs of the activity in order to maintain health.

Immobilization Definition

Immobility is broadly defined as the level of activity that is less than optimal mobility. (Ansari, 2011).
Immobilization is a condition in which the patient must rest in bed, do not move actively due to a variety of diseases or disorders of the organs of a physical or mental. Can also be interpreted as a state do not move / bedrest constant for 5 days or more due to changes in physiological function (Bimoariotejo, 2009).
Immobility (immobilization) is a state of not moving / bed rest (bed rest) for 3 days or more (Adi, 2005). A state of physical movement limited ability to independently experienced by a person (Pusva, 2009).
Immobilization is a relative condition, where individuals not only lose the ability to move in total, but also decreased the activity of the normal habits. (Mubarak, 2008).
Impaired physical mobility (immobilization) is defined by the North American Nursing Diagnosis Association (NANDA) as a situation where an individual is experiencing or at risk of physical movement limitations. Individuals who are experiencing or at risk of physical movement limitations, among others: the elderly, individuals with the disease who experienced a loss of consciousness of more than 3 days or more, the individual who lost the use of anatomic result in physiological changes (loss of motor function, a client with a stroke, a wheelchair user client) , the use of external tools (such as a cast or traction), and restriction of movement of volunteers (Potter, 2005).
Immobilization is the inability of a person to move his own body. Immobilization is said to be a major risk factor in the emergence of decubitus wounds both in hospitals and in the community. This condition can increase the time an emphasis on skin tissue, and subsequently lead to lower circulation decubitus sores. Immobilization in addition to directly affect the skin, also affects several organs. For example, in the cardiovascular system, peripheral blood circulation disorders, respiratory system, lower lungs to pick up oxygen movement of air (lung expansion) and result in decreased oxygen intake to the body Lindgren et al, 2004)