Anemia - Nursing Care Plan

Anemia Definition

Anemia is characterized by levels of hemoglobin (Hb) and red blood cells (erythrocytes) is lower than normal. If the hemoglobin level is less than 14 g / dl and erythrocyte less than 41 % in men, then a man is said to be anemic. Similarly in women, women with hemoglobin levels less than 12 g / dl and erythrocyte less than 37 %, then the woman was said to be anemic. Anemia is not a disease, but rather a reflection of the state of a disease or disorder caused by the body's functions. Physiologically anemia occurs when there is a shortage of hemoglobin to carry oxygen to the tissues.

Anemia was defined as a decrease in the volume of red blood cells or hemoglobin level to below the range of accepted values ​​for healthy people. Anemia is a symptom of an underlying condition, such as loss of blood components, elements inadequate or lack of nutrients needed for the formation of blood cells, resulting in decreased oxygen-carrying capacity of the blood, and there are many types of anemia with different causes.

Etiology
  1. Hemolysis (erythrocytes easily broken).
  2. Bleeding.
  3. Bone marrow suppression (eg by cancer).
  4. Nutrient deficiency (nutritional anemia), including iron deficiency, folic acid, pyridoxine, vitamin C and copper.

According to various sources the causes of anemia include:
  1. Less consumption of foods containing iron, vitamin B12, folic acid, vitamin C, and the elements necessary for the formation of red blood cells.
  2. Excessive menstrual blood. Women who are menstruating prone to iron deficiency anemia when much menstrual blood and not enough iron stores.
  3. Pregnancy. Pregnant women are prone to anemia because the fetus to absorb iron and vitamins for growth.
  4. Certain diseases. Diseases that cause continuous bleeding in the digestive tract such as gastritis and appendicitis can lead to anemia.
  5. Certain drugs. Several types of medications can cause stomach bleeding (aspirin, anti- inflammatory, etc.). Other drugs can cause problems in the absorption of iron and vitamins (antacids, birth control pills, antiarthritis, etc.).
  6. Retrieval operation of part or all of the stomach (gastrectomy). It can cause anemia because the body absorbs less iron and vitamin B12.
  7. Chronic inflammatory diseases such as lupus, rheumatoid arthritis, kidney disease, thyroid gland problems, some types of cancer and other diseases can cause anemia because they affect the process of the formation of red blood cells.
  8. In children, anemia can occur due to hookworm infection, malaria, or dysentery that caused a severe shortage of blood.

Pathophysiology

The presence of an anemia marrow reflects the existence of a failure or loss of red blood cells or both. Marrow failure (for example, reduced erythropoiesis) can occur as a result of nutritional deficiencies, toxic exposure , tumor invasion or other unknown causes.

Red blood cells can be lost through bleeding or hemolysis (destruction).
Red blood cell lysis (dissolution) occurs primarily in phagocytic cells or in the reticuloendothelial system, mainly in the liver and spleen. Byproducts of this process is bilirubin that would enter the bloodstream. Any increase in red blood cell destruction (hemolysis) immediately reflected by an increase in plasma bilirubin (normal concentration of ≤ 1 mg / dl, levels above 1.5 mg / dl result in jaundice in the sclera).

If the destruction of red blood cells in the circulation experience, (in hemolytic disorders) then it will appear in the plasma hemoglobin (hemoglobinemia). If the plasma concentration exceeds the capacity of plasma haptoglobin ( protein binding to free hemoglobin ) to bind everything, hemoglobin diffuses in the renal glomerulus and into the urine (hemoglobinuria).

Conclusions about whether an anemia in patients caused by destruction of red blood cells or red blood cell production is not sufficient usually be obtained on the basis of : 1 . reticulocyte count in the blood circulation ; 2 degree of the proliferation of young red blood cells in the bone marrow and maturation ways, as seen in the biopsy ; and presence or absence of hyperbilirubinemia and hemoglobinemia.


Signs and Symptoms
  1. Weak, tired, lethargic and tired.
  2. Often complain of headache and dizziness.
  3. Further symptoms such as eyelids, lips, tongue, skin and palms became pale. Pale because of lack of blood volume and hemoglobin, vasoconstriction.
  4. Tachycardia and heart murmur (an increase in blood flow velocity) Angina (chest pain).
  5. Dyspnea, shortness of breath, tired quickly when activity (reduced O2 delivery).
  6. Headache, weakness, tinnitus (ringing in the ears) illustrates the reduced oxygenation of the CNS
  7. Severe anemia GI disorders, and CHF (anorexia, nausea, constipation or diarrhea).

Complication 
  • Heart failure.
  • Seizures.
  • Poor muscle development (long-term).
  • Concentration decreases.
  • The ability to process information that is heard decrease.

Test
  • Hemoglobin concentration, hematocrit, red blood cell indices, white blood cell studies, the levels of Fe, iron binding capacity measurement, folate, vitamin B12, platelet count, bleeding time, prothrombin time, and partial thromboplastin time.
  • Bone marrow aspiration and biopsy. Unsaturated iron - binding capacity of serum.
  • Diagnostic assay to determine the presence of acute and chronic diseases as well as the source of chronic blood loss.

Nursing Care Plan for Anemia

Nursing Diagnosis for Anemia
  1. Ineffective Cerebral Tissue Perfusion related to changes in the oxygen bond with hemoglobin, decrease in hemoglobin concentration in the blood.
  2. Imbalance nutrition less than body requirements related to inadequate food intake .
  3. Self-care deficit related to weakness
  4. Risk for infection related to inadequate secondary defenses (decreased hemoglobin )
  5. Activity intolerance related to imbalance between supply and demand of oxygen .
  6. Impaired gas exchange related to ventilation perfusion .
  7. Ineffectivene breathing pattern related to fatigue .
  8. Fatigue related to anemia .

Disturbed Sleep Pattern - NCP for Lower Back Pain

Nursing Care Plan for Lower Back Pain (LBP)


Low Back Pain is chronic pain in the lumbar, usually caused by a recessive the vertebral muscles, herniation and regeneration of the nucleus pulposus, osteoarthritis of the lumbar sacral spine (Brunner, 1999).

Causes
  • Changes in posture usually because primary and secondary trauma. Primary trauma such as : Trauma spontaneously, for example accidents. Secondary trauma such as : HNP, osteoporosis, spondylitis, spinal stenosis, spondylitis, osteoarthritis.
  • Lumbosacral ligament instability and muscle weakness.
  • Procedures degeneration in elderly patients.
  • The use of heels that are too high.
  • Obesity.
  • Lifting weights the wrong way.
  • Sprain.
  • Prolonged exposure to vibration.
  • Gait.
  • Smoking.
  • Sitting too long.
  • Less exercise (by sport).
  • Depression / stress.
  • Sports (golp, tennis, soccer).

Risk Factors of Low Back Pain

Physiological risk factors.
  • Age ( 20-50 years ).
  • Lack of physical exercise.
  • Less anatomical postures.
  • Obesity.
  • Severe scoliosis.
  • HNP.
  • Spondylitis.
  • Spinal stenosis (narrowing of the spine).
  • Osteoporosis.
  • Smoking.
Environment risk factors .
  • Sitting too long.
  • Prolonged exposure to vibration.
  • Sprains or twisted.
  • Sports ( golf, tennis, gymnastic, and football).
  • Vibration old.

Psychosocial risk factors.
  • Inconvenience of work.
  • Depression.
  • Stress.

Clinical Manifestations

Changes in gait.
  • Walking stiff.
  • No bias play back.
  • Lame.
Innervation
  • When tested with a light and a touch of the pin, the patient felt a sensation on both limbs, but having a stronger sensation in areas that are not stimulated.
  • Uncontrolled defecation and urination.

Pain.
  • Acute and chronic back pain for more than two months.
  • Pain when walking with the heel.
  • Pain in the muscles.
  • Lower back pain gets spread legs.
  • Painful heat on the back of the thigh or calf.
  • Severe pain in the feet increases.

Nursing Care Plan for Lower Back Pain

Nursing Diagnosis : Disturbed Sleep Pattern related to pain, discomfort

Defining characteristics :
  • Patients appear to endure pain ( moaning, grinning )
  • Patients express can not sleep because of pain .

Goal : sleep needs can be met.

Outcomes :

Sleep
  • The amount of time to sleep enough.
  • Normal sleep patterns.
  • Enough quality sleep.
  • Sleep on a regular basis.
  • Not often awakened.
  • Vital signs within normal limits.
Rest
  • Adequate rest.
  • The quality of a good rest.
  • Enough physical rest.
  • Enough psychic rest.
Anxiety control
  • Adequate sleep.
  • There is no physical manifestation.
  • No behavioral manifestations.
  • Seeking information to reduce anxiety.
  • Using relaxation techniques to reduce anxiety.
  • Interact socially.

Interventions for Lower Back Pain

Improved sleep / Sleep Enhancement
  1. Assess patterns of sleep / activity patterns.
  2. Encourage clients to sleep on a regular basis.
  3. Explain the importance of adequate sleep during illness and treatment.
  4. Monitor sleep patterns and note the physical, psychosocial disrupt sleep.
  5. Discuss on the client and family about the technical improvement of sleep patterns.

Environmental management
  1. Limit visitors.
  2. Take care of the noisy environment.
  3. No nursing action when clients sleep.

Anxiety Reduction
  1. Explain all procedures including the feelings that may be experienced while undergoing the procedure.
  2. Give the object that can provide a sense of security.
  3. Speaking slowly and calmly.
  4. Build a trusting relationship.
  5. Listen attentively clients.
  6. Create an atmosphere of mutual trust.
  7. Encourage parents to express feelings, perceptions and anxiety verbally.
  8. Provide equipment / entertaining activities to reduce tension.
  9. Suggest to use relaxation techniques.
  10. Provide a quiet environment.
  11. Limit visitors.

Impaired Gas Exchange - Asthma Nursing Diagnosis and Interventions

Nursing Care Plan for Asthma

Nursing Diagnosis : Impaired Gas Exchange related to changes in capillary membrane - alveolar

Goal :
Clients are able to :
  • Respiratory Status: Ventilation.
  • Respiratory status : Airway patency.
  • Vital sign status.

Outcomes :
  • Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips)
  • Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
  • Vital signs within normal range (blood pressure, pulse, respiration).


NIC :

Airway Management
  • Open the airway , use techniques jaw thrust or chin lift if necessary.
  • Position the patient to maximize ventilation.
  • Identification of the patient's need for installation of an artificial airway.
  • Attach mayo if necessary.
  • Perform chest physiotherapy if necessary.
  • Remove secretions by coughing or suctioning.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Perform suction on orofaringeal airway.
  • Give a humidifier.
  • Set intake to optimize fluid balance.
  • Monitor respiration and O2 status.

Oxygen Therapy
  • Clean the mouth, nose and trachea.
  • Maintain a patent airway.
  • Set oxygenation equipment.
  • Monitor the flow of oxygen.
  • Maintain the position of the patient.
  • Observe for signs of hypoventilation.
  • Monitor the presence of the oxygenation of the patient's anxiety.


Monitoring vital signs
  • 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 respiratory rate and rhythm .
  • Monitor lung sounds .
  • Monitor abnormal breathing pattern .
  • 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

7 Nursing Diagnosis for Dementia

The most frequent cause of dementia is Alzheimer's disease. The cause of Alzheimer's disease is unknown , but is thought to involve genetic factors, because the disease seems to be found in some families and is caused or influenced by some specific gene abnormality. In Alzheimer's disease, some parts of the brain decline, resulting in cell damage and reduced response to a chemical that transmits signals in the brain.

By: Silvia (2006 ) , dementia associated with some types of diseases as follows :
  • Diseases associated with medical syndromes : These include hypothyroidism, Cushing's disease, nutritional deficiencies, AIDS dementia complex, and so on.
  • Diseases associated with neurological syndromes : This group includes Huntington's chorea, Schilder's disease, and other demyelinating processes ; Creutzfeldt- Jakob disease ; brain tumors ; brain trauma ; the brain and meningeal infection ; and others.
  • Disease with dementia as the only sign of conspicuous : Alzheimer's disease and Pick's disease are included in this category.
  • Dementia in terms of anatomy to distinguish between cortical dementia and subcortical dementia. Of the etiology and course of the disease to distinguish between reversible and irreversible dementia.

According to (Silvia , 2006) In general, signs and symptoms of dementia are as follows :
  • Decline in memory that continues to happen. In patients with dementia , " forget " become a part of daily life that can not be separated.
  • Impaired orientation time and place, for example : forget the day, week, month, year, place of people with dementia are.
  • The decline and inability to arrange words into a correct sentence, using words that are not appropriate for a condition, repeat the word or the same story many times.
  • Excessive expression, such as excessive crying when she saw a television drama, furious at small mistakes committed by others, fear and nervousness unwarranted. People with dementia often do not understand why these feelings arise.
  • A change in behavior, such as : indifferent, withdrawn and anxious.

At first the disease is damaging the nerves cells in the brain that regulate memory, particularly in the hypothalamus and related structures. When the nerve cells of the hypothalamus stops functioning properly, there is a failure of short -term memory, followed by a failure of the ability to perform actions and tasks as usual. The disease is also on the cerebral cortex, particularly the areas responsible for language and thought. A loss of language skills, lower the person's ability to make decisions, and the resulting changes in personality. Explosive emotions and behavioral disorders, such as walking without purpose and agitation began to arise, and the more slowly over the course of the disease (Sylvia, 2005). Finally, many areas are involved, the atrophy and the patient is usually unable to interact with others, and very dependent on other people to do the most basic personal tasks, such as eating, drinking, defecation urination, and defecation. Macroscopically, the brain changes in this disease involves severe damage to cortical and hypothalamic neurons, and amyloid accumulation in the intracranial vessels. Morphological changes consist of two characteristic lesions that eventually evolved into soma degeneration, axons and dendrites of neurons (Wiwik, 2005). One sign of lesion is neurofibrillary tangles, the intracellular structures containing fibers tangled, twisted, which is composed mostly of proteins. In the central nervous system, most of these proteins have been studied as inhibitors structurally related shaper in stabilizing microtubules and is an important component of the cytoskeleton of neuronal cells (Muttaqin, 2008).

According Silvia, (2006), a complication that will arise are as follows :
  • Acute or chronic disease, such as congestive heart failure, pneumonia, kidney and liver disease, cancer and stroke.
  • Hormonal and nutritional factors, diabetes, adrenal imbalance, or thyroid, malnutrition and dehydration.
  • Sensory damage associated with loss of vision and hearing as well as sleep deprivation.
  • Treatment, including taking a variety of medications, prescription (especially the drug combinations that are anticholinergic).
  • Drugs that interfere with the cholinergic system, and the neurotransmitter acetylcholine can affect memory, learning ability.

7 Nursing Diagnosis for Dementia

1. Relocation stress syndrome
related to changes in the activities of daily life
Characterized by :
confusion, concern, anxiety, looking anxious, irritable, defensive behavior, mental confusion, suspicious behavior, and aggressive behavior.

2. Disturbed Thought Process related to physiological changes (irreversible neuronal degeneration)
Characterized by :
memory loss or memory, loss of concentration, not able to interpret the stimulation and assess reality accurately.

3. Disturbed Sensory perception related to changes in perception, transmission or sensory integration (neurological disease, unable to communicate, sleep disorders, pain)
Characterized by :
anxiety, apathy, anxiety, hallucinations.

4. Distrubed Sleeping Pattern related to changes in the environment
Characterized by : a verbal complaint about difficulty sleeping, constantly awake, not able to determine the needs / sleep time.

5. Self-care Deficit related to activity intolerance, decreased endurance and strength
Characterized by :
decreased ability to perform activities of daily living.

6. Risk for injury related to the difficulty of balance, weakness, uncoordinated muscle, seizure activity.

7. Risk for Imbalanced Nutrition Less Than Body Requirements related to forgetfulness , setbacks hobby , sensory changes .

Disturbed Thought Process - NCP for Dementia

Nursing Care Plan for Dementia

One of the degenerative disease is dementia, ie which have insidious onset and progressive in general, be getting worse. Overview of various aspects of specialty include loss of intellectual abilities such as memory, judgment, abstract thought, and other higher cortical functions , as well as changes in keperibadian and behavior (Townsend , 2000) .

Dementia is a clinical syndrome that includes loss of intellectual function and memory were so serious that it causes dysfunction of everyday life. Dementia is a condition when a person experiences memory loss and other thinking power which significantly interfere with daily activities (Arif muttaqin, 2008) .

Nursing Diagnosis : Disturbed Thought Process related to physiological changes (irreversible neuronal degeneration).

Characterized by :
  • memory loss,
  • loss of concentration,
  • not able to interpret the stimulation,
  • not able to assess reality accurately.
Goal : expected to be able to recognize a change in thinking.

Outcomes :
  • Able to demonstrate the ability to undergo cognitive consequences of stressful events on the emotions and thoughts of self.
  • Able to develop strategies for overcoming negative self- perception.
  • Be able to identify the behavior and the causes.


Interventions :
  • Develop a supportive environment and nurse - client relationship is therapeutic.
  • Maintain a pleasant and quiet environment.
  • Face-to- face when talking to clients.
  • Call client by name.
  • Use a rather low voice and speak slowly to the client.

Rationale :
  • Reduce anxiety and emotional.
  • Noise is excessive sensory neurons that increase interference.
  • Raises concern , especially in clients with perceptual disorders.
  • The name is a form of self-identity and lead to the introduction of reality and the client.
  • Increase understanding. High Speech and hard cause stress and confrontation that sparked an angry response.

Nursing Interventions for Imbalanced Nutrition Less Than Body Requirements


Imbalanced Nutrition Less Than Body Requirements
related to :
  • Decreased oral intake, discomfort in the mouth, nausea, vomiting.
  • Decreased absorption of nutrients.
  • Vomiting, anorexia, impaired digestion.
  • Depression, stress, social isolation.
Outcomes : The client will :
consume the daily nutritional needs in accordance with the level of activity and metabolic demand.

Indicator :
  • Explaining the importance of adequate nutrition.
  • Identify gaps or deficiencies in the daily intake.
  • Mention the methods to increase appetite.

Intervention


1. Explaining the need for the consumption of carbohydrates, fats, proteins, vitamins, minerals and adequate fluid.
2. Consult with a nutritionist to establish a daily calorie needs and the type of food that is in accordance with the client.
3. Discuss with the client the possible causes of loss of appetite.
4. Encourage clients to rest before eating.
5. Instruct food in small amounts but often .
6. On the condition of decreased appetite, limit fluid intake during meals and avoid consuming fluids one hour before and after meals.
7. Encourage and assist clients to maintain good oral hygiene.
8. Set the position of foods high in calories and high in protein are presented when the client is usually the most hungry.
9. Perform the following steps to increase appetite :
  • Determine the client's food preferences and set it to the food presented whenever possible.
  • Eliminate odors and unpleasant sight of the dining area.
  • Control pain and nausea before eating.
  • Instruct the nearest person is allowed to bring food from home if possible.
  • Create a relaxing environment while eating.
10. Give the client a list of diet nutrient material , which consists of :
  • High intake of complex carbohydrates and fiber .
  • Reduction of the intake of sugar , salt , cholesterol , total fat and saturated fat .
  • The use of alcohol only in moderation .
  • Appropriate caloric intake to maintain ideal weight .

Constipation Causes Symptoms and Treatment


Constipation is a common digestive problem. Usually characterized by constipation bear or irregular bowel movements. In addition to people who suffer from constipation often experience bowel movement, and a knotted stomach ache. People who experience constipation defecate normally only 3 times a week or even less.

Usually constipation is only temporary. Lifestyle changes along with a proper diet, which contains lots of fiber and nutrients are able to overcome this.

To learn more about the constipation, please read the following description, from the symptoms, causes and ways of treatment.


Symptoms of Constipation

Signs and symptoms of constipation include:
  • A bowel movement fewer than three times a week.
  • Difficult defecation.
  • Excruciating abdominal pressure when the movement of the intestine.
  • Feeling of blockage in the rectum.
  • The feeling was not finished after a bowel movement.

Causes and Risk Factors

Normally feces in the intestine is driven by the contraction of the intestinal muscles. In the large intestine the water and salt absorbed back because it is important for the body. But when the colon absorbs too much water, or colon muscle contractions slowly then the stool will be hard and dry so that the movement of the large intestine becomes too slow.

You may also experience constipation if the muscles are used to move the intestines do not function properly. This problem is called anismus.


A number of factors which led to, among others :
  • Lack of fluids or dehydration.
  • Lack of fiber in the diet.
  • Lack of physical activity (especially in the elderly).
  • Irritable bowel syndrome.
  • Changes in lifestyle or routine, including pregnancy, aging and travel.
  • Pain ('re having a disease).
  • Frequent use or misuse of laxatives.
  • Certain diseases, such as stroke, diabetes, thyroid disease, and Parkinson's disease.
  • Problems in the colon and rectum, such as bowel obstruction or diverticulosis.
  • Certain drugs.
  • Hormonal disorders, such as thyroid gland is not active.
  • Damage to the anal skin and hemorrhoid.
  • The loss of salt levels in the body due to vomiting or diarrhea.
  • Injury to the spinal cord, which can have an effect on the intestine.


In rare cases, constipation can be a sign that you are experiencing a serious medical condition, such as colon cancer, hormone disruption or interference with the autoimmune. In children, constipation may indicate Hirschsprung disease - nerve cells lost condition inborn.


Prevention

There is a saying that prevention is better than cure . And here's how to prevent constipation or constipation :
  • Eating foods rich in fiber .
  • Limit foods low in fiber .
  • Drinking enough.
  • Regular exercise .
  • Do not delay when you want to defecate .
  • Try fiber supplements .
  • Be careful in choosing a laxative .

NANDA Nursing