NANDA 2011

NANDA Definition: The inability to identify, manage, or seek out help to maintain health Defining Characteristics: History of lack of health-seeking behavior;  reported or observed lack of equipment, financial, and/or other resources;  reported or observed impairment of personal support systems;  expressed interest in improving health behaviors;  demonstrated lack of knowledge regarding basic health practices;  demonstrated lack of adaptive behaviors to internal and external environmental changes;  reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas Related Factors: Disabled family coping, perceptual-cognitive impairment (complete or partial lack of gross or fine motor skills);  lack of or significant alteration in communication skills (written, verbal, or gestural);  unachieved developmental tasks;  lack of material resources;  dysfunctional grieving;  disabling spiritual distress;  inabi

NANDA Definition : 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

Many factors are thought to play a role in getting Graves' disease. These might include: Genes. Some people are prone to Graves' disease because of their genes. Researchers are working to find the gene or genes involved. Gender. Sex hormones might play a role, and might explain why Graves' disease affects more women than men. Stress. Severe emotional stress or trauma might trigger the onset of Graves' disease in people who are prone to getting it. Pregnancy. Pregnancy affects the thyroid. As many as 30 percent of young women who get Graves' disease have been pregnant in the 12 months prior to the onset of symptoms. This suggests that pregnancy might trigger Graves' disease in some women. Infection. Infection might play a role in the onset of Graves' disease, but no studies have shown infection to directly cause Graves' disease. Graves disease is an autoimmune disorder that leads to overactivity of the thyroid gland (hyperthyroidism). The

Risk for Impaired Gas Exchange related to the accumulation of blood in the lungs due to increased atrial filling Goal: risk for impaired gas does not occur Expected outcomes: Demonstrating adequate ventilation and oxygenation of the tissue, indicated by blood gas analysis / oximetry in the normal range and free of symptoms of respiratory distress. Participate in a treatment program within the ability / situation. Intervention and rationale: 1. Auscultation of breath sounds, note: crackles, mengii. 2. Instruct the patient to cough effectively, breathing deeply. 3. Maintain a semi-Fowler position, chock the hand with a pillow if possible 4. Collaboration in the provision of supplemental oxygen as indicated. 5. Collaboration for the examination of blood gas analysis. 6. Collaboration for the administration of diuretics. 7. Collaboration for the administration of bronchodilator drugs. Rational: 1. Stating pulmonary congestion / collecting secretions indicate the need

Nursing Diagnosis for Anema : Risk for Infection related to decreased immunity, invasive procedures Goal: There are no risk factors for infection Expected outcomes: free of symptoms of infection, normal leukocyte numbers (4-11000) vital signs within normal limits. Nursing Interventions: Control of infection: Clean up the environment after use for other patients. Limit visitor when necessary and recommended for adequate rest. Instruct patient’s family to wash their hands before and after contact with the client. Use anti-microbe soap for hand washing. Make hand washing before and after nursing actions. Use clothes and gloves as a protective device. Maintain aseptic environment during the installation of equipment. Perform wound care, and dresing infusion, catheter every day if any. Increase intake of nutrients, and adequate fluid. Give antibiotics according to the program. Protection of infection: Monitor signs and symptoms of systemic and local infections.

Assessment for Brain Tumor (Intracranial Tumor) Focal neurological disorders. In the frontal lobe, occurred personality disorders, affective disorders, the motor system dysfunction, seizures, aphasia. Precentral gyrus can be found on Jacksonian seizures. In the occipital lobe, visual disturbances, and headache. Temporal lobe can occur auditory hallucinations, visual or gustatory and psychomotor seizures, aphasia. In the parietal lobe can be found the inability to distinguish left – right, sensory deficit (contralateral). Increased ICT: lethargy, decreased HR, decreased level of consciousness, papilledema, projectile vomiting, seizures, changes in breathing patterns, changes in vital signs. Mental. Personality changes, depression, decreased memory and ability to make decisions. Pituitary dysfunction. Cushing’s syndrome, acromegaly, giantisme, hypopituitarism. Pain. Persistent headache. Seizure activity. Fluid status. Nausea and vomiting, decreased urine output, dry muc