Purba Java: Nursing Diagnosis

Nursing Diagnosis for Peritonitis

<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjffZpQ-liKR11ISAkM5aJzrpxN679ZvdDVAyxozPr1es8LJVoMojvF4WR_0GyPAdwiH5x7k0R5Vex37WvmB3mnGgjyx55MWasnOlriR2A2Ah-f2BWJ2E5Hl0BTni6-aoWJB-sgj-He6jBu0cAjdJAtSBz1HLpYZu1o2MQIYtklw_MXrxg0CdwnLG_abw=s728" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="NCP for Peritonitis" border="0" data-original-height="556" data-original-width="728" height="244" src="https://blogger.googleusercontent.com/img/a/AVvXsEjffZpQ-liKR11ISAkM5aJzrpxN679ZvdDVAyxozPr1es8LJVoMojvF4WR_0GyPAdwiH5x7k0R5Vex37WvmB3mnGgjyx55MWasnOlriR2A2Ah-f2BWJ2E5Hl0BTni6-aoWJB-sgj-He6jBu0cAjdJAtSBz1HLpYZu1o2MQIYtklw_MXrxg0CdwnLG_abw=w320-h244" title="NCP for Peritonitis" width="320" /></a></div>Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. Peritonitis is usually caused by infection from bacteria or fungi. Left untreated, peritonitis can rapidly spread into the blood (sepsis) and to other organs, resulting in multiple organ failure and death. So if you develop any of the symptoms of peritonitis -- the most common of which is severe abdominal pain -- it's essential to seek prompt medical evaluation and treatment that can prevent potentially fatal complications. Causes of Peritonitis The lining of the tummy (peritoneum) covers internal organs like the kidneys, liver and bowel. If the lining becomes infected, the internal organs it covers can also be damaged. This most often happens because of things like: <ul style="text-align: left;"><li>a burst stomach ulcer</li><li>a burst appendix</li><li>digestive problems, such as Crohn's disease or diverticulitis</li><li>pancreatitis</li><li>surgery</li><li>injury to the stomach</li><li>pelvic inflammatory disease</li><li>cirrhosis</li></ul>Rarely, if bacteria gets into peritoneal dialysis equipment used to treat people with kidney failure, this can cause infection. Symptoms of Peritonitis What are symptoms of peritonitis? Each person’s symptoms may vary. Symptoms may include: <ul style="text-align: left;"><li>Severe belly pain that gets worse with any motion</li><li>Nausea and vomiting</li><li>Fever</li><li>Sore or swollen belly</li><li>Fluid in the belly</li><li>Not being able to have a bowel movement or pass gas</li><li>Less urine than normal</li><li>Thirst</li><li>Trouble breathing</li><li>Low blood pressure and shock</li></ul>Peritonitis symptoms may look like other health problems. Always see your healthcare provider to be sure. Diagnosis of peritonitis Diagnosing peritonitis involves a number of tests, including:<ul style="text-align: left;"><li>Physical examination – the abdomen is hard and painful. There are no bowel movements or sounds.</li><li>Signs of shock – including low blood pressure, abnormal pulse rate and pale skin.</li><li>Blood tests – to check for which bacteria are responsible.</li><li>X-rays – of the abdomen.</li><li>Laparoscopy – a slender tube is inserted through an abdominal incision and the insides examined.</li><li>Peritoneal fluid culture – a sample of fluid is taken and examined for signs of infection.</li></ul> 6 Nursing Diagnosis for Peritonitis 
<ol><li><a href="http://nandanursingdiagnosis.blogspot.co.id/2011/07/nursing-diagnosis-for-acute-pain.html">Acute pain</a> related to inflammation, fever and tissue damage.</li><li><a href="http://nandanursingdiagnosis.blogspot.co.id/2011/07/nursing-diagnosis-risk-for-infection.html">Risk for infection</a> related to tissue trauma.</li><li>Imbalanced Nutrition : less than body requirements related to anorexia and vomiting.</li><li><a href="http://nandanursingdiagnosis.blogspot.co.id/2011/07/nursing-diagnosis-for-deficient-fluid.html">Deficient Fluid Volume</a> related to active fluid loss.</li><li><a href="http://nandanursingdiagnosis.blogspot.co.id/2011/06/nursing-diagnosis-for-ineffective.html">Ineffective breathing pattern</a> related to a decrease in the depth of breathing, abdominal distension secondary and avoid pain.</li><li>Anxiety related to changes in health status.</li></ol> Source : https://www.webmd.com/digestive-disorders/peritonitis-symptoms-causes-treatments https://www.nhs.uk/conditions/peritonitis/ https://www.hopkinsmedicine.org/health/conditions-and-diseases/peritonitis https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/peritonitis https://nandanursingdiagnosis.blogspot.com/2015/10/6-nursing-diagnosis-for-peritonitis.html

Nursing Diagnosis for Peritonitis

Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your a...

NCP for Combustion (Burning) - 5 Nursing Diagnosis and Interventions

A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals.Thermal (heat) burns occur when some or all of the cells in the skin or other tissues are destroyed by:<ul style="text-align: left;"><li>hot liquids (scalds)</li><li>hot solids (contact burns), or</li><li>flames (flame burns).(https://www.who.int)</li></ul><div>

Nursing Diagnosis :<ol style="text-align: left;"><li>Fluid volume deficit related to active fluid loss</li><li>Acute pain related to burn injury</li><li>Impaired skin integrity related to open wounds</li><li>Hyperthermia related to dehydration and infection</li><li>Anxiety related to changes in health status</li></ol>Nursing Interventions

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 No.
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 Nursing Diagnosis
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 Goal
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 Interventions
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 1.
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 Fluid volume deficit related to active fluid loss
 </td>
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 1. Fluid balance
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -14.2pt;">·     
 Blood pressure within expected range
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -14.2pt;">·     
 Balance intake and output in 24 hours
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -14.2pt;">·     
 No peripheral edema
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -14.2pt;">·     
 No abnormal thirst
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -14.2pt;">·     
 Skin hydration
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l0 level1 lfo1; text-indent: -14.2pt;">·     
 Hematocrit within normal limits
 <o:p> </o:p>
 2. Hydration
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l15 level1 lfo2; text-indent: -14.2pt;">·     
 Skin hydration
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l15 level1 lfo2; text-indent: -14.2pt;">·     
 No peripheral edema
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l15 level1 lfo2; text-indent: -14.2pt;">·     
 No abnormal thirst
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l15 level1 lfo2; text-indent: -14.2pt;">·     
 Blood pressure within normal limits
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l15 level1 lfo2; text-indent: -14.2pt;">·     
 Hematocrit within normal limits
 <o:p> </o:p>
 3. Nutritional status: food and fluid intake
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l2 level1 lfo3; text-indent: -14.2pt;">·     
 Oral food intake
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l2 level1 lfo3; text-indent: -14.2pt;">·     
 Oral fluid intake
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l2 level1 lfo3; text-indent: -14.2pt;">·     
 Total parenteral nutrition
 </td>
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 Fluid management:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l14 level1 lfo4; text-indent: -15.9pt;">1.    
 Maintain accurate intake and output records
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l14 level1 lfo4; text-indent: -15.9pt;">2.    
 Monitor hydration status (moisture of mucous
 membranes and adequate pulse), if necessary
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l14 level1 lfo4; text-indent: -15.9pt;">3.    
 Monitor vital signs every 15 minutes – 1 hour
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l14 level1 lfo4; text-indent: -15.9pt;">4.    
 Monitor food/fluid intake and calculate daily
 calorie intake
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l14 level1 lfo4; text-indent: -15.9pt;">5.    
 Collaboration IV fluid administration
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l14 level1 lfo4; text-indent: -15.9pt;">6.    
 Monitor nutritional status
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l14 level1 lfo4; text-indent: -15.9pt;">7.    
 Give oral fluids
 <o:p> </o:p>
 Hypovolemic management:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l20 level1 lfo5; text-indent: -15.9pt;">1.    
 Monitor fluid status including fluid intake
 and output
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l20 level1 lfo5; text-indent: -15.9pt;">2.    
 Monitor laboratory results in accordance with
 fluid retention (BUN, electrolytes, hematocrit, urine osmolality, albumin,
 and total protein)
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l20 level1 lfo5; text-indent: -15.9pt;">3.    
 Monitor the patient's response to fluid
 additions
 <o:p> </o:p>
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 2.
 </td>
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 Acute pain related to burn injury
 </td>
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 1. Pain level
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l17 level1 lfo6; text-indent: -15.85pt;">·      
 Reporting pain Duration of pain
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l17 level1 lfo6; text-indent: -15.85pt;">·      
 Facial expression when in pain
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l17 level1 lfo6; text-indent: -15.85pt;">·      
 Muscle tension
 <o:p> </o:p>
 2. Pain control
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l1 level1 lfo7; text-indent: -14.2pt;">·     
 Recognizing pain
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l1 level1 lfo7; text-indent: -14.2pt;">·     
 Shows the causal factor
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l1 level1 lfo7; text-indent: -14.2pt;">·     
 Report changes in pain
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l1 level1 lfo7; text-indent: -14.2pt;">·     
 Report pain control
 <o:p> </o:p>
 3. Degree of discomfort
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l19 level1 lfo8; text-indent: -14.2pt;">·     
 Pain, anxiety
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l19 level1 lfo8; text-indent: -14.2pt;">·     
 Moaning
 <o:p> </o:p>
 4. Vital signs
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l6 level1 lfo9; text-indent: -14.2pt;">·     
 Radial pulse
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l6 level1 lfo9; text-indent: -14.2pt;">·     
 Respiratory rate
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l6 level1 lfo9; text-indent: -14.2pt;">·     
 Systolic blood pressure, diastolic blood pressure
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 136.8pt;" valign="top" width="182">
 Pain Management:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l9 level1 lfo10; text-indent: -14.15pt;">1.   
 Perform a comprehensive pain assessment
 including location, characteristics, duration, frequency, quality, and
 precipitating factors
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l9 level1 lfo10; text-indent: -14.15pt;">2.   
 Observe nonverbal reactions and discomfort
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l9 level1 lfo10; text-indent: -14.15pt;">3.   
 Environmental controls that can affect pain
 such as room temperature, lighting, and noise
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l9 level1 lfo10; text-indent: -14.15pt;">4.   
 Teach about non-pharmacological techniques:
 deep breathing, relaxation, and distraction.
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l9 level1 lfo10; text-indent: -14.15pt;">5.   
 Collaborative administration of analgesics to
 reduce pain
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l9 level1 lfo10; text-indent: -14.15pt;">6.   
 Increase rest
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l9 level1 lfo10; text-indent: -14.15pt;">7.   
 Provide information about pain such as the
 cause of the pain, how long it will take for the pain to subside and
 anticipated discomfort from the procedure.
 <o:p> </o:p>
 Analgesic Administration:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo11; text-indent: -14.15pt;">1.   
 Determine the location, characteristics,
 quality and degree of pain before administering the drug
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo11; text-indent: -14.15pt;">2.   
 Check the doctor's instructions about the type
 of drug, dosage, and frequency
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo11; text-indent: -14.15pt;">3.   
 Check allergy history
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l21 level1 lfo11; text-indent: -14.15pt;">4.   
 Evaluation of analgesic effectiveness
 <o:p> </o:p>
 Environmental Management:
 convenience
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l23 level1 lfo12; text-indent: -15.85pt;">1.    
 Determining the source of discomfort
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l23 level1 lfo12; text-indent: -15.85pt;">2.    
 Provide a safe and clean environment
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l23 level1 lfo12; text-indent: -15.85pt;">3.    
 Facilitate a comfortable patient position
 <o:p> </o:p>
 </td>
 </tr>
 <tr style="mso-yfti-irow: 3;">
 <td style="border-top: none; border: 1pt solid black; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 19.4pt;" valign="top" width="26">
 3.
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 76.9pt;" valign="top" width="103">
 Impaired skin integrity related to open wounds
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 114.2pt;" valign="top" width="152">
 1. Tissue integrity: skin and mucous membranes
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l12 level1 lfo13; text-indent: -14.2pt;">·     
 Skin temperature
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l12 level1 lfo13; text-indent: -14.2pt;">·     
 Sensation
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l12 level1 lfo13; text-indent: -14.2pt;">·     
 Hydration
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l12 level1 lfo13; text-indent: -14.2pt;">·     
 Tissue perfusion
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l12 level1 lfo13; text-indent: -14.2pt;">·     
 Skin integrity
 <o:p> </o:p>
 2. Wound healing
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l5 level1 lfo14; text-indent: -14.2pt;">·     
 Scar formation
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l5 level1 lfo14; text-indent: -14.2pt;">·     
 The smell of rotten wounds
 <o:p> </o:p>
 3. Sensory function: skin
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l18 level1 lfo15; text-indent: -14.2pt;">·     
 Loss of sensation
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l18 level1 lfo15; text-indent: -14.2pt;">·     
 Paresthesia
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 <o:p> </o:p>
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 136.8pt;" valign="top" width="182">
 Pressure Management :
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l4 level1 lfo16; text-indent: -14.2pt;">1.   
 Instruct the patient to wear loose clothing
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l4 level1 lfo16; text-indent: -14.2pt;">2.   
 Avoid wrinkles on the bed
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l4 level1 lfo16; text-indent: -14.2pt;">3.   
 Keep skin clean to keep it clean and dry
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l4 level1 lfo16; text-indent: -14.2pt;">4.   
 Patient mobilization (change patient position)
 every 2 hours
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l4 level1 lfo16; text-indent: -14.2pt;">5.   
 Monitor patient activity and mobilization
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l4 level1 lfo16; text-indent: -14.2pt;">6.   
 Adjust the position to avoid pressure or
 tension on the wound
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l4 level1 lfo16; text-indent: -14.2pt;">7.   
 skin monitor
 <o:p> </o:p>
 Injury cure :
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l3 level1 lfo17; text-indent: -14.2pt;">1.   
 Burn treatment with hydrotherapy and
 debridement
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l3 level1 lfo17; text-indent: -14.2pt;">2.   
 Maintain sterile technique when performing
 wound care
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l3 level1 lfo17; text-indent: -14.2pt;">3.   
 Compare every change
 </td>
 </tr>
 <tr style="mso-yfti-irow: 4;">
 <td style="border-top: none; border: 1pt solid black; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 19.4pt;" valign="top" width="26">
 4.
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 76.9pt;" valign="top" width="103">
 Hyperthermia related to dehydration and infection
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 114.2pt;" valign="top" width="152">
 1. Thermoregulation
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l13 level1 lfo18; text-indent: -14.2pt;">·     
 Report temperature discomfort
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l13 level1 lfo18; text-indent: -14.2pt;">·     
 Decrease in skin temperature
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l13 level1 lfo18; text-indent: -14.2pt;">·     
 Skin discoloration, muscle twitching,
 dehydration
 <o:p> </o:p>
 2. Vital signs
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l16 level1 lfo19; text-indent: -14.2pt;">·     
 Body temperature, apical heart rate, apical
 heart rhythm
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l16 level1 lfo19; text-indent: -14.2pt;">·     
 Radial pulse. Respiratory rate, breathing
 rhythm, systolic blood pressure
 <o:p> </o:p>
 <o:p> </o:p>
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 136.8pt;" valign="top" width="182">
 Fever management:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l22 level1 lfo20; text-indent: -14.2pt;">1.   
 Monitor temperature as often as possible
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l22 level1 lfo20; text-indent: -14.2pt;">2.   
 Monitor skin color and temperature
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l22 level1 lfo20; text-indent: -14.2pt;">3.   
 Monitor BP, pulse, RR
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l22 level1 lfo20; text-indent: -14.2pt;">4.   
 Give treatment to overcome the cause of fever
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l22 level1 lfo20; text-indent: -14.2pt;">5.   
 Improve blood circulation
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l22 level1 lfo20; text-indent: -14.2pt;">6.   
 Increase fluid intake and nutrition
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l22 level1 lfo20; text-indent: -14.2pt;">7.   
 Leukocyte monitor
 <o:p> </o:p>
 Monitoring vital signs
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l8 level1 lfo21; text-indent: -14.2pt;">1.   
 Monitor presence and quality of pulse
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l8 level1 lfo21; text-indent: -14.2pt;">2.   
 Monitor skin tone, temperature and humidity
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l8 level1 lfo21; text-indent: -14.2pt;">3.   
 Identify possible causes of changes in vital
 signs
 </td>
 </tr>
 <tr style="mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
 <td style="border-top: none; border: 1pt solid black; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 19.4pt;" valign="top" width="26">
 5.
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 76.9pt;" valign="top" width="103">
 Anxiety related to changes in health status
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 114.2pt;" valign="top" width="152">
 1. Self-anxiety control
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l7 level1 lfo22; text-indent: -14.2pt;">·     
 Facial expressions
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l7 level1 lfo22; text-indent: -14.2pt;">·     
 Expression of anxiety symptoms
 <o:p> </o:p>
 2. Anxiety level
 Indicator:
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l10 level1 lfo23; text-indent: -14.2pt;">·     
 Facial expressions
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.9pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.9pt; mso-add-space: auto; mso-list: l10 level1 lfo23; text-indent: -14.2pt;">·     
 Body language
 <o:p> </o:p>
 3. Coping
 </td>
 <td style="border-bottom: 1pt solid black; border-left: none; border-right: 1pt solid black; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0cm 5.4pt; width: 136.8pt;" valign="top" width="182">
 Decreased anxiety
 <p class="MsoListParagraphCxSpFirst" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l11 level1 lfo24; text-indent: -14.2pt;">1.   
 Use a calming approach
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l11 level1 lfo24; text-indent: -14.2pt;">2.   
 Explain all procedures
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l11 level1 lfo24; text-indent: -14.2pt;">3.   
 Provide factual information about the
 diagnosis
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l11 level1 lfo24; text-indent: -14.2pt;">4.   
 Involve the family to accompany the patient
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l11 level1 lfo24; text-indent: -14.2pt;">5.   
 Instruct patient to use relaxation techniques
 <p class="MsoListParagraphCxSpMiddle" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l11 level1 lfo24; text-indent: -14.2pt;">6.   
 Identify anxiety levels
 <p class="MsoListParagraphCxSpLast" style="line-height: normal; margin-bottom: 0cm; margin-left: 15.85pt; margin-right: 0cm; margin-top: 0cm; margin: 0cm 0cm 0cm 15.85pt; mso-add-space: auto; mso-list: l11 level1 lfo24; text-indent: -14.2pt;">7.   
 Encourage patient to express feelings, fears,
 and perceptions
 </td>
 </tr>
</tbody></table>

<o:p> </o:p>

NCP for Combustion (Burning) - 5 Nursing Diagnosis and Interventions

A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction o...

4 Nursing Diagnosis for Parapharyngeal Abscess

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Parapharyngeal Abscess 
 
An abscess is a collection of pus (dead neutrophils) that accumulates in a cavity tissue because of the infectious process (usually due to bacteria or parasites) or due to foreign objects (eg splinters, needles). This process is a reaction of protection by the tissue to prevent the spread / extension of infection to other parts of the body. 
 
Parapharyngeal abscess is a collection of pus that forms in the parapharyngeal space. Parapharyngeal abscess occurs because parapharyngeal space infections. 
 
Parapharyngeal space can become infected by: 
<ol>
<li>Direct, which is due to needle puncture due to perform tonsillectomy analgesia. Inflammation occurs because the syringes are contaminated bacteria that penetrates the thin muscle layer (superior pharyngeal constrictor muscle) that separates the parapharyngeal space of the tonsillar fossa.</li>
<li>Suppurative process of neck lymph nodes, inside, teeth, tonsils, pharynx, nose, paranasal sinuses, mastoid and cerebral cervical be a source of infection for the parapharyngeal space abscess.</li>
<li>Explanation of peritonsillar space infection, retropharyngeal or submandibular.</li>
</ol>
 
The main signs and symptoms are trismus, induration or swelling in the area around the angle of the mandible, high fever and swelling of the lateral pharyngeal wall, so that the protruding towards medial. 
 
Nursing Diagnosis for Parapharyngeal Abscess 
<ol>
<li>Hyperthermia r / t infection process.</li>
<li>Imbalanced Nutrition: less than body requirements r / t intake is less, anorexia, difficulty swallowing.</li>
<li>Sleep pattern disturbance r / t pain, hyperthermia.</li>
<li>Knowledge deficit: about the disease process, diet, care and treatment r / t the lack of information.</li>
</ol>

4 Nursing Diagnosis for Parapharyngeal Abscess

Parapharyngeal Abscess An abscess is a collection of pus (dead neutrophils) that accumulates in a cavity tissue because of the infectiou...

5 Nursing Diagnosis for Pancreatitis

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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 : 
<ul>
<li>Pain in the pit of the stomach that breaks down to the back.</li>
<li>While eating, pain in the gut will be even worse.</li>
<li>Ongoing pain felt and the longer the severity increases.</li>
<li>Pain will continue to be felt for days.</li>
<li>The pain will get worse if the patient coughs.</li>
<li>Nausea and vomiting.</li>
<li>Increased body temperature.</li>
<li>Yellow skin.</li>
<li>Heartbeat becomes rapid.</li>
<li>Patients appears uneasy.</li>
<li>Swelling in the upper abdomen.</li>
<li>Acute inflammation of the pancreas that has been accompanied by severe symptoms of dehydration and low blood pressure.</li>
<li>Chronic pancreatitis symptoms are accompanied by diarrhea, oily dirt and also weight loss.</li>
</ul>
 
5 Nursing Diagnosis for Pancreatitis 
<ol>
<li>Ineffective breathing pattern.</li>
<li>Impaired tissue perfusion.</li>
<li>Fluid volume deficit.</li>
<li>Acute pain. </li>
<li>Hyperthermia.</li>
</ol>
 
Source : 
 <a href="https://nandacareplan.blogspot.com/2021/06/4-nursing-diagnosis-for-pancreatitis.html">https://nandacareplan.blogspot.com/2021/06/4-nursing-diagnosis-for-pancreatitis.html</a> 
<a href="http://www.nurseskomar.com/2015/11/nursing-diagnosis-for-acute-and-chronic.html" target="_blank">http://www.nurseskomar.com/2015/11/nursing-diagnosis-for-acute-and-chronic.html</a>

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 conseque...

6 Nursing Diagnosis for Pneumonia

<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCqBaK3NMQ1C_5kO7T_BFS6qsxNss-cRlEIFxYCmi-_adm9-ZPUX17uuRsJv_2h8Q6V61XY1EeULLPu2wb0YCrMjZwFTjmRvEqRMuD9-85QTdAWXxswJbM8uziRJygLFkttgFQSr9Esl0/s1600/6-nursing-diagnosis-for-pneumonia.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCqBaK3NMQ1C_5kO7T_BFS6qsxNss-cRlEIFxYCmi-_adm9-ZPUX17uuRsJv_2h8Q6V61XY1EeULLPu2wb0YCrMjZwFTjmRvEqRMuD9-85QTdAWXxswJbM8uziRJygLFkttgFQSr9Esl0/s1600/6-nursing-diagnosis-for-pneumonia.jpg" /></a></div>Pneumonia is one of the diseases of respiratory tract infection is the most established and often a cause of death in almost all the world. 
 
Most are caused by microorganisms, but also by others, so it is known: 
<ol><li>Lipoid pneumonia: therefore aspiration of mineral oil.</li>
<li>Chemical pneumonitis: inhalation of organic materials or chemical vapors such as beryllium.</li>
<li>Extrinsic allergic alveolitis: inhalation of material dust containing allergens, such as dust dare sugar mills containing dare actynomicetes thermophilic spores.</li>
<li>Drug induced pulmonary: nitrofurantoin, busulfan, methotrexate.</li>
<li>Pneumonia due to X-ray radiation.</li>
<li>Pneumonia with no clear cause: desquamative interstitial pneumonia, eosinophilic pneumonia.</li>
<li>Microorganisms.</li>
</ol> 
6 Nursing Diagnosis for Pneumonia 
<ol><li>Ineffective airway clearance related to tracheobronchial inflammation, edema formation, increased sputum production. (Doenges, 1999: 166)</li>
<li>Gas exchange disorders related to changes in the alveolar capillary membrane, the oxygen-carrying capacity disturbance, disruption to the delivery of oxygen. (Doenges, 1999: 166)</li>
<li>Ineffective breathing pattern related to the inflammatory process in the alveoli. (Doenges, 1999: 177)</li>
<li>Fluid and electrolyte imbalance related to excessive fluid loss, decreased oral input. (Doenges, 1999: 172)</li>
<li>Imbalanced Nutrition: less than body requirements related to the metabolic needs secondary to fever and infection process, anorexia associated with bacterial toxins smell and taste sputum, abdominal distention or gas. (Doenges, 1999: 171)</li>
<li>Activity intolerance related to insufficiency of oxygen for daily activities. (Doenges, 1999: 170)</li>
</ol> 
Source : 
<a href="http://nandanursingdiagnosis.blogspot.com/2011/09/nursing-diagnosis-for-pneumonia.html" target="_blank">http://nandanursingdiagnosis.blogspot.com/</a>

6 Nursing Diagnosis for Pneumonia

Pneumonia is one of the diseases of respiratory tract infection is the most established and often a cause of death in almost all the world. ...

Brain Cancer Symptoms and 7 Nursing Diagnosis

7 Nursing Diagnosis for Brain Cancer 
 
Brain cancer is a deadly and dangerous disease. Brain cancer attack on the outside of the brain, which is a three-part layers of the lining of the brain and parts of the skull. Basically cancer that attacks the cancer generally / benign tumor. But the attack was part of the brain, it is very dangerous. 
 
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Because it can damage and disrupt the function of the central nervous system structure that is located within the cranial cavity. With the development of these tumors, the brain tissue will be more depressed. And please note very limited volume of the cranial cavity, causing pain on the head or dizziness. If it is felt, then the possibility of an early symptom of brain cancer. 
 
Here are some symptoms of brain cancer we need to know: 
<ul>
<li>Headache accompanied by nausea and frequent vomiting.</li>
<li>Decreased vision capabilities.</li>
<li>Changes in behavior or loss of consciousness.</li>
<li>A disturbance at the time of speaking.</li>
<li>Disturbance in the hearing.</li>
<li>Body balance disorders.</li>
<li>Disorders of the nerves.</li>
<li>Weakened limbs or seizures.</li>
<li>The emergence fontanel prominent and large, in infants.</li>
</ul>
 
From the point above is a symptom of brain cancer, although these symptoms do not necessarily have ever experienced you are affected by brain cancer. But it would be a good idea to consult directly on the neurologist to determine whether you are really suffering from cancer of the brain or not. 
 
 
7 Nursing Diagnosis for Brain Cancer  
<ol>
<li>Altered cerebral tissue perfusion r / t increased intracranial pressure, tumor surgery, cerebral edema.</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2014/10/acute-pain-and-ineffective-breathing.html" target="_blank">Ineffective breathing pattern</a> r / t emphasis medulla oblongata.</li>
<li>Pain r / t increased intracranial pressure.</li>
<li><a href="http://nanda-nic-noc.blogspot.nl/2013/04/risk-for-injury-nursing-diagnosis.html" target="_blank">Risk for injury</a> r / t vertigo secondary to orthostatic hypotension.</li>
<li><a href="http://nanda-diagnosis.blogspot.com/2014/07/impaired-verbal-communication-nursing.html" target="_blank">Impaired verbal communication</a> r / t aphasia effect on the expression or interpretation.</li>
<li><a href="http://nanda-nic-noc.blogspot.nl/2013/03/disturbed-sensory-perception-nursing_22.html" target="_blank">Disturbed sensory</a> perception r / t sensory tract damage with changes in sensory reception, transmission, and integration.</li>
<li>Risk for <a href="http://nanda-nic-noc.blogspot.nl/2013/04/imbalanced-nutrition-less-than-body.html" target="_blank">Imbalanced Nutrition: less than body requirements</a> r / t the effects of chemotherapy and radiotherapy.</li>
</ol>

Brain Cancer Symptoms and 7 Nursing Diagnosis

7 Nursing Diagnosis for Brain Cancer Brain cancer is a deadly and dangerous disease. Brain cancer attack on the outside of the brain, whic...

Symptoms, Prevention and Nursing Diagnosis for Tuberculosis

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, the bacteria affect anyone, men and women regardless of age. And usually Tuberculosis often affects the average age of 15-35 years, arguably the productive age. 
 
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In general, tuberculosis is spread through the air, and usually Mycobacterium tuberculosis carried away when someone coughs and phlegm issued. The danger if the bacteria are always enter and accumulate in the lungs, the bacteria will multiply quickly let alone that have a low immune system. 
 
When it happens, the infection will spread easily through the blood vessels or lymph nodes. TB infection can affect other organs such as the brain, kidney, gastrointestinal tract, bone, lymph nodes, and usually the most commonly affected are the lungs. 
 
Here are the symptoms of TB in general: 
<ul>
<li>Often experience fever, which is not too high and long lasting.</li>
<li>Night sweats.</li>
<li>Susceptible to colds that are intermittent.</li>
<li>Weight loss and lack of appetite.</li>
<li>Coughing more than 3 weeks and sometimes also accompanied by blood.</li>
<li>The feeling was weak, lethargic, and not tasty.</li>
</ul>
 
Prior to happen to us that we should make prevention, so that we can avoid the TBC. As for how to prevent it are as follows: 
<ul>
<li>Not spit disembarang place, try to spit place exposed to direct sunlight or place trash.</li>
<li>When someone wants to cough or sneeze you should shut your mouth in order to avoid disease transmission.</li>
<li>Health agencies must often be on guard so that the immune system is always awake and powerful.</li>
<li>Do not stay up too often because of lack of rest will weaken the immune system.</li>
<li>Frequently exercise so that our body is always healthy.</li>
<li>Get immunizations for infants to prevent tuberculosis.</li>
<li>Drying beds for tuberculosis patients, because TB germs can die when exposed to sunlight.</li>
</ul>
 
<a href="http://nandanursingdiagnosis.blogspot.com/2011/07/nursing-diagnosis-for-tuberculosis.html" target="_blank">Nursing Diagnosis for Tuberculosis</a> 
<ol>
<li><a href="http://nandanursingdiagnosis.blogspot.com/2011/07/nursing-diagnosis-for-ineffective.html" target="_blank">Ineffective Airway Clearance</a></li>
<li>Risk for Impaired Gas Exchange</li>
<li><a href="http://blog-nursingcareplan.blogspot.com/2015/01/fluid-volume-deficit-and-imbalanced.html" target="_blank">Imbalanced Nutrition</a>: Less than Body Requirements</li>
<li><a href="http://ncp-blog.blogspot.com/2013/01/risk-for-infection-ncp-for-anemia.html" target="_blank">Risk for Infection</a></li>
<li>Fatigue</li>
<li>Ineffective Coping</li>
<li>Risk for Injury</li>
<li>Deficient Knowledge [Learning Need] regarding condition, treatment, prevention.</li>
</ol>

Symptoms, Prevention and Nursing Diagnosis for Tuberculosis

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, the bacteria affect anyone, men and women regardless of age. An...

Anemia - 9 Symptoms, 6 Causes, 4 Prevention and 11 Nursing Diagnosis

Anemia is a condition in which the number of red blood cells (hemoglobin) were below normal. Hemoglobin contained in red blood cells play a role in transporting oxygen from the lungs and deliver to all parts of the body. A patient is said to be anemic when the concentration of hemoglobin (Hb) in men less than 13.5 g / dL and hematocrit less than 41%, in women hemoglobin concentration of less than 11.5 g / dL or hematocrit less than 36%. 
 
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Symptoms of Anemia 
 
The most frequent symptoms of anemia among others, as follows: 
 
1. Pale color of the skin 
People with anemia usually clearly visible on the face and skin look pale. 
 
2. Eyelids pale 
In addition to the face, eyelids patients with anemia also look pale. This is one of the common symptoms of anemia. Examination is usually done by stretching the eyelids and see the lower eyelid color. 
 
3. Fingertip pale 
Inspection can be done by pressing the fingertip, normally when following in the press area will turn into red. However, in people with anemia, the fingertips will be white or pale. 
 
4. Too often and easily tired 
Too easily tired, but do not strenuous activity, if you feel easily tired all the time and lasts a long time you probably have anemia. This happens because the body's energy supply that is not optimal due to the shortage of red blood cells that serves as a natural means of transport in the body. 
 
5. Irregular heart beats 
Irregular heart beats, too strong and has a speed of heartbeat rhythm abnormalities. This occurs as a result of the body lacks oxygen. so irregularly beating heart. This check can only be done by a health worker. 
 
6. Often feel nauseous 
Usually patients with anemia often experience nausea in the morning. Almost the same as the signs of pregnancy. Nausea in the morning. 
 
7. Headache 
One of the effects of a shortage of red blood cells, the brain becomes oxygen deficiency. Causing pain in the head. Because of this anemia patients often complain of headaches. 
 
8. Immune decline 
Immune / defense system against disease anemia decreased and usually very susceptible to other diseases as a result of the weakening of the body's immune. 
 
9. Shortness of breath 
Patients with anemia often feel shortness of breath and feel breathless when doing activities, this happens due to lack of oxygen in the body, due to the lack of red blood cells. 
 
 
Causes of Anemia 
 
The most frequent cause of anemia is due to excessive bleeding, destruction of red blood cells to excess or often called hemolysis or red blood cell formation / ineffective hematopoiesis, iron deficiency, intestinal bleeding, lack of vitamin B12, folic acid deficiency, disorder bone marrow function, certain chronic diseases, such as cancer and HIV / AIDS. Can affect the production of red blood cells. 
 
AIn addition to the factors causing anemia, also influenced by also influenced by other risk factors, such as: 
<ol>
<li>Factor of heredity.</li>
<li>The lack of nutrient intake.</li>
<li>Disease and intestinal disorders as well as operations related to the small intestine.</li>
<li>Excessive menstrual bleeding.</li>
<li>Pregnancy.</li>
<li>Chronic diseases such as cancer, and kidney failure.</li>
</ol>
 
Prevention of Anemia 
 
For the prevention of anemia is actually very easy. As with eating foods that contain lots of iron, folic acid, vitamin b12, vitamin c. Here is an explanation on how to prevent anemia and the types of foods that can help prevent anemia, including: 
 
1. Consumption of foods that contain lots of iron 
Foods that contain lots of iron such as meat, beans, vegetables, green and others. Iron is also very important for women who are menstruating, pregnant women and children. 
 
2. Consumption of foods that contain lots of Folic Acid 
Consumption of foods that contain lots of folic acid such as bananas, dark green vegetables, nuts, oranges, cereals and others 
 
3. Foods that contain vitamin B 12. 
Can be obtained by eating meat and dairy. 
 
4. Food and drinks that contain Vitamin C 
There are so many benefits of Vitamin C, one of which can help the absorption of iron. the types of food that contain lots of vitamin C such as melon, citrus fruits, and berries. That's some way to prevent anemia naturally. 
 
 
<a href="http://nandanursingdiagnosis.blogspot.com/2011/05/nursing-diagnosis-for-anemia.html" target="_blank">Nursing Diagnosis for Anemia</a> 
<ol>
<li><a href="http://nurse-books.blogspot.com/2014/04/activity-intolerance-nursing.html" target="_blank">Activity Intolerance</a></li>
<li>Impaired oral mucous membrane</li>
<li><a href="http://nandanursingdiagnosis.blogspot.com/2011/06/nursing-diagnosis-for-imbalanced.html" target="_blank">Imbalanced Nutrition: Less than Body Requirements</a></li>
<li>Constipation/Diarrhea</li>
<li>Risk for Infection</li>
<li>Risk for <a href="http://nursing-nic-noc.blogspot.com/2013/10/deficient-fluid-volume.html" target="_blank">deficient fluid volume</a></li>
<li>Deficient Knowledge regarding condition, prognosis, treatment, self-care, prevention of crisis, and discharge needs,</li>
<li>Fatigue</li>
<li>Fear</li>
<li><a href="http://nandanursingdiagnosis.blogspot.com/2011/06/nursing-diagnosis-for-ineffective_24.html" target="_blank">Ineffective coping</a></li>
<li>Ineffective thermoregulation.</li>
</ol>

Anemia - 9 Symptoms, 6 Causes, 4 Prevention and 11 Nursing Diagnosis

Anemia is a condition in which the number of red blood cells (hemoglobin) were below normal. Hemoglobin contained in red blood cells play a...