NANDA 2011

Nursing Diagnosis : Bowel Incontinence Mikel Gray 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 (obste...

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 ...

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...

Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States. Signs and Symptoms Symptoms vary depending on the age of the child and the cause of the pneumonia, but common ones include: fever chills cough nasal congestion unusually rapid breathing (in some cases, this is the only symptom) breathing with grunting or wheezing sounds labored breathing that makes the rib muscles retract (when muscles under the ribcage or between ribs draw inward with each breath) and causes nasal flaring vomiting chest pai...