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Nursing Diagnosis for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body, including skin, eyes, lungs, heart, nerves and blood. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present. Often, symptoms come on gradually over weeks to months. 

While the cause of rheumatoid arthritis is not clear, it is believed to involve a combination of genetic and environmental factors. The underlying mechanism involves the body's immune system attacking the joints. This results in inflammation and thickening of the joint capsule. It also affects the underlying bone and cartilage. The diagnosis is made mostly on the basis of a person's signs and symptoms. X-rays and laboratory testing may support a diagnosis or exclude other diseases with similar symptoms. Other diseases that may present similarly include systemic lupus erythematosus, psoriatic arthritis, and fibromyalgia among others. 

Nursing Diagnosis for Rheumatoid Arthritis


Nursing Diagnosis for Rheumatoid Arthritis


1. Pain (acute / chronic)

related to:

tissue distended by the accumulation of fluid / inflammation,

joint destruction.


2. Impaired physical mobility

related to:

skeletal deformity,

pain,

decreased muscle strength.


3. Disturbed Body Image

related to:

changes in the ability to carry out common tasks,

increased use of energy,

imbalance mobility.


4. Self-care deficit

related to:

musculoskeletal damage,

decreased strength and endurance,

pain when moving,

depression.


5. Knowledge Deficit: about the disease, prognosis, and treatment needs

related to:

lack of exposure / recall,

misinterpretation of information.


Source :


 

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Nursing Diagnosis for Cataract

A cataract is a clouding or opacification of the normally clear lens of the eye or its capsule (surrounding transparent membrane) that obscures the passage of light through the lens to the retina of the eye. This blinding disease can affect infants, adults, and older people, but it predominates the latter group. It can be bilateral and vary in severity. The disease process progresses gradually without affecting daily activities early on, but with time, especially after the fourth or fifth decade, the cataract will eventually mature, making the lens completely opaque to light interfering with routine activities. Cataracts are a significant cause of blindness worldwide. Treatment options include correction with refractive glasses only at earlier stages, and if cataract mature enough to interfere with routine activities, surgery may be advised, which is very fruitful.

Cataracts are a common part of the eye’s aging process. Eventually, they can cause:

  • Vision that’s cloudy, blurry, foggy or filmy.
  • Sensitivity to bright sunlight, lamps or headlights.
  • Glare (seeing a halo around lights), especially when you drive at night with oncoming headlights.
  • Prescription changes in glasses, including sudden nearsightedness.
  • Double vision.
  • Need for brighter light to read.
  • Difficulty seeing at night (poor night vision).
  • Changes in the way you see color.


Nursing Diagnosis for Pre and Post Cataract Surgery :


Pre Cataract Surgery :

1. Impaired sensory perception (vision): related to changes in sensory reception.

2. Anxiety related to lack of information about operating procedure.


Post Cataract Surgery :

1. Acute pain related to postoperative wounds.

2. Risk for infection related to increased susceptibility secondary, due to surgical interruption of the ocular surface.

 

Source : https://creativenurse.blogspot.com/2021/08/nursing-diagnosis-for-cataract.html

 

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5 Nursing Diagnosis for Pancreatitis

Pancreatitis is an inflammation of the pancreas gland, the occurrence of a sudden, there is light, there is also to lead to fatal consequences. Even the deaths occurred mostly in just over two weeks since the first symptoms of pancreatitis or the pain symptoms first appear.

Symptoms of pancreatitis is divided into two types, acute pancreatitis and chronic pancreatitis. The difference, acute pancreatitis damage to the pancreas by certain enzymes sudden and thorough, while chronic pancreatitis occur destructively, pancreatitis mild type that does not heal, ongoing and increasingly severe and repetitive.

The cause of pancreatitis is due to the blockage so that the enzymes produced by the pancreas will still accumulate in the pancreas and pancreatic cells digest themselves from there emerged inflammation. Besides inflammation of the pancreas can also be caused by excessive alcohol consumption, taking certain medications, high triglycerides, high levels of calcium in the blood, inveksi virus, pancreas damage due to trauma or surgery, a lack of blood flow to the pancreas, pancreatic cancer or the use of estrogen in ladies high triglyceride levels.

Symptoms of Pancreatitis :
  • Pain in the pit of the stomach that breaks down to the back.
  • While eating, pain in the gut will be even worse.
  • Ongoing pain felt and the longer the severity increases.
  • Pain will continue to be felt for days.
  • The pain will get worse if the patient coughs.
  • Nausea and vomiting.
  • Increased body temperature.
  • Yellow skin.
  • Heartbeat becomes rapid.
  • Patients appears uneasy.
  • Swelling in the upper abdomen.
  • Acute inflammation of the pancreas that has been accompanied by severe symptoms of dehydration and low blood pressure.
  • Chronic pancreatitis symptoms are accompanied by diarrhea, oily dirt and also weight loss.

5 Nursing Diagnosis for Pancreatitis
  1. Ineffective breathing pattern.
  2. Impaired tissue perfusion.
  3. Fluid volume deficit.
  4. Acute pain.
  5. Hyperthermia.


Source :

https://nandacareplan.blogspot.com/2021/06/4-nursing-diagnosis-for-pancreatitis.html
http://www.nurseskomar.com/2015/11/nursing-diagnosis-for-acute-and-chronic.html

 

 

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5 Nursing Diagnosis for Anaphylactic Shock

 Anaphylactic Shock

Definition

Anaphylactic is a collection of symptoms that result from an acute reaction to a foreign substance to a person who previously had the sensitization (immediate / hypersensitivity reactions indirect immunity).

Etiology

  • Because drugs indirect histamine reaction that usually follows the injection of the drug weight, serum, the x-ray contrast media.
  • Certain foods, insect bites.
  • The reaction can sometimes idiopathic / immunologic abnormalities manifestations.
Symptoms
  • Cardiovascular: tachycardia, hypotension, shock, arrhythmia, palpitations.
  • Respiratory tract: rhinitis, sneezing, itching of the nose, bronchospasm, hoarseness, shortness, apnea.
  • Gastrointestinal: nausea, vomiting, abdominal pain.
  • Skin: pruritus, urticaria, angioedema, skin pale and cold.



Nursing Diagnosis for Anaphylactic Shock

1. Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.

2. Altered tissue perfusion related to decreased blood flow secondary to vascular disorders due to anaphylactic reactions.
characterized by: palpitations, skin pale, cold acral, hypotension, angioedema, arrhythmias, ECG features horizontal and inverted T waves.

3. Ineffective breathing pattern related to the swelling of the nasal mucosa wall
characterized by: shortness of breath, breath with the lips, there rhinitis.

4. Acute pain related to gastric irritation
characterized by: abdominal pain, looked grimacing while holding stomach.

5. Impaired skin integrity related to changes in circulation
characterized by: swelling and itching of the skin and the nose, there are hives, urticaria, and runny nose. 

 Source : https://purba-java-indo.blogspot.com/2014/11/5-nursing-diagnosis-for-anaphylactic.html

 

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9 Nursing Diagnosis for Encephalitis

Encephalitis is an acute inflammation of the brain. Usually the cause is a viral infection, but bacteria can also cause it. It can be mild or severe. Most cases are mild. Examples of viral infections that can cause encephalitis include herpes simplex virus (the virus that causes cold sores and genital herpes), varicella zoster virus (the chickenpox virus), mumps virus, measles virus and flu viruses. In the UK, the most common virus to cause encephalitis is herpes simplex virus.





Most cases of encephalitis are caused by the virus directly infecting the brain. However, sometimes encephalitis can develop if your immune system tries to fight off a virus and, at the same time, attacks the nerves in your brain in error. This is known as post-infectious or autoimmune encephalitis. Rarely, this type of encephalitis can develop after an immunisation.


Adult patients with encephalitis present with acute onset of fever, headache, confusion, and sometimes seizures. Younger children or infants may present irritability, poor appetite and fever. Neurological examinations usually reveal a drowsy or confused patient. Stiff neck, due to the irritation of the meninges covering the brain, indicates that the patient has either meningitis or meningoencephalitis.

Vaccination is available against tick-borne and Japanese encephalitis and should be considered for at-risk individuals.

Post-infectious encephalomyelitis complicating small pox vaccination is totally avoidable now as small pox is now eradicated. Contraindication to Pertussis immunisation should be observed in patients with encephalitis. An immunodeficient patient who has had contact with chicken pox virus should be given prophylaxis with hyperimmune zoster immunoglobulin.


9 Nursing Diagnosis for Encephalitis
  1. Hyperthermia
  2. Acute Pain
  3. Impaired physical mobility
  4. Impaired gas exchange
  5. Disturbed thought processes
  6. Risk for impaired skin integrity
  7. Risk for deficient fluid volume
  8. Imbalanced nutrition: Less than body requirements
  9. Anxiety

Source : https://purba-java-indo.blogspot.com/2014/12/9-nursing-diagnosis-for-encephalitis.html

 

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Activity Intolerance - Nursing Care Plan for Hypoglycemia

Hypoglycemia, also known as low blood sugar or low blood glucose, is when blood sugar decreases to below normal.

The most common cause of hypoglycemia is medications used to treat diabetes mellitus such as insulin, sulfonylureas, and biguanides. Risk is greater in diabetics who have eaten less than usual, exercised more than usual, or drunk alcohol. Other causes of hypoglycemia include kidney failure, certain tumors, liver disease, hypothyroidism, starvation, inborn error of metabolism, severe infections, reactive hypoglycemia, and a number of drugs including alcohol.

This may result in a variety of symptoms including clumsiness, trouble talking, confusion, loss of consciousness, seizures, or death. A feeling of hunger, sweating, shakiness, and weakness may also be present. Symptoms typically come on quickly. (wikipedia)


Activity Intolerance - Nursing Care Plan for Hypoglycemia

Activity Intolerance related to imbalance of oxygen supply and demand, weakness.

Defining characteristics:

  • Fatigue and weakness.
  • The response to activity indicates abnormal pulse and blood pressure.
  • Changes in ECG showed arrhythmia / dysrhythmia.
  • Dyspnea and discomfort.
  • Agitated.
Goal: The client is able to achieve: activity tolerance,

with expected outcomes:

Activity Tolerance:

  • Oxygen saturation within normal limits when activity.
  • HR in the normal range when the activity.
  • Respiration in the normal range when the activity.
  • Systolic blood pressure in the normal range when the activity.
  • Diastolic blood pressure in the normal range when the activity.
  • ECG within normal limits.
  • Skin color.
  • Breathing efforts when the activity.
  • Walking in the room.
  • Walk away.
  • Climbing up the stairs.
  • ADL strength.
  • The ability to talk while exercising.
Interventions :

Therapeutic Activities:

  • Note the frequency of heart rhythm, changes in blood pressure before, during and after activity as indicated.
  • Increase rest, limit activity and provide leisure activities that are not heavy.
  • Limit visitors.
  • Monitor response to emotional, physical, social and spiritual.
  • Describe the pattern of a gradual increase in activity.
  • Help clients recognize a meaningful activity.
  • Help clients know the options for activity.
  • Determine the client's commitment to increase the frequency of the activity.
  • Collaboration related to the physical, recreational therapy, proper supervision activity program.
  • Help the client make a specific plan for the transfer of routine daily activity.
  • Help the client / family know all the quality of a shortage of activity.
  • Train the client / family about the role of physical, social, spiritual, sense activity in health care.
  • Help the client / family environment with a desire to adjust the activity.
  • Provide activities that increase attention in a certain period.
  • Facilitation replacement activity when the client has passed the deadline, energy and movement.
  • Provide an environment that is not harmful to walk as indicated.
  • Provide positive reinforcement for participation in the activity.
  • Help the client generates its own motivation.
  • Monitor the emotional, physical, social, and spiritual activities.
  • Help the client / family getting monitor progress toward achieving the goal.

Energy Management :
  • Observation of the client restrictions in activity.
  • Encourage to express feelings towards limitations.
  • Assess the factors that cause fatigue.
  • Monitor nutrition and adequate sources of energy.
  • Monitor the client for physical fatigue and emotional excess.
  • Monitor the cardiovascular response to activity.
  • Monitor patterns of sleep and duration of sleep / rest.

Dysrhythmia Management :
  • Knowing for certain clients and families who have a history of heart.
  • Monitor and check oxygenation deficiency, acid-base balance, electrolytes.
  • Record ECG.
  • Advise the client to break every attack.
  • Record the frequency and duration of the attack.
  • Monitor hemodynamic status.

 

Source :

https://nanda-health.blogspot.com/2015/10/nursing-care-plan-for-hypoglycemia.html

https://care-plan-nursing.blogspot.com/2015/11/activity-intolerance-nursing-care-plan.html 

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Disturbed Sleep Pattern - Insomnia related to Fear and Anxiety

Disturbed Sleep Pattern - Insomnia related to Fear and Anxiety
Do you often feel bad mood, not calm, and easily distracted after having nightmares or when your sleep disturbed? It has nothing to do with the feeling and can be explained scientifically. A research shows that lack of sleep or sleep disorders affect parts of the brain associated with emotions. This then triggers the emergence of a sense of worry and anxiety.

Researchers from the University of California, Berkeley found that when people lack of sleep or often feel disturbed while sleeping, the activity in the amygdala and insular cortex region of the brain will increase. The increased activity was then trigger anxiety and worry naturally.

"It is difficult to find if lack of sleep is a result of anxiety, or lack of sleep can actually cause the emergence of anxiety. However, this study helped us find a link causal more clearly," said researcher Andrea Goldstein, as reported by the Huffington Post (27/06).

These results were obtained after the researchers observed 18 adults. They were asked to sleep soundly and reduces sleep time. The participants then underwent brain scans and tests of emotion. Researchers found that participants who do not get enough sleep have higher activity in the amygdala compared with participants who get enough sleep.

Meanwhile, previous studies have also demonstrated the opposite relationship. A Finnish study in 2007 showed that anxiety and stress can interfere with sleep quality and make people less sleep. They found that people who had undergone events that create tension and anxiety often experience sleep problems.

Anxiety Disorders related to Acute and Chronic Bronchitis

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