Assessment and Nursing Diagnosis for Malignant Lymphoma

Lymphomas are a group of cancers in which cells of the lymphatic system become abnormal and start to grow uncontrollably. Because there is lymph tissue in many parts of the body, lymphomas can start in almost any organ of the body.

Primary malignant lymphoma: The excessive proliferation of lymphocytes which forms part of the immune system. Primary cancers refer to the fact that the cancer originated in the lymph cells rather than having metastasized. More detailed information about the symptoms, causes, and treatments of Primary malignant lymphoma is available below.


Nursing Assessment for Malignant Lymphoma

Assessment at the client's malignant lymphoma by Doenges, (1999) obtained the following data:

1. Activity / rest
  • Symptoms: fatigue, weakness, or general malaise, loss of productivity and decreased exercise tolerance.
  • Signs: decreased strength, shoulders slumped, walking slowly, and other signs that show fatigue.

2. Circulation
  • Symptoms: palpitations, angina / chest pain.
  • Signs: tachycardia, dysrhythmias, cyanosis face and neck (venous drainage obstruction due to enlarged lymph nodes is a rare occurrence), scleral jaundice, and general jaundice, liver damage and in connection with bile duct obstruction by enlarged lymph nodes, pallor (anemia), diaphoresis , night sweats.

3. Ego integrity
  • Symptoms: stress factor, fear / anxiety in connection with the diagnosis and possible fear of death, diagnostic tests and treatment modalities (chemotherapy and radiation therapy).
  • Signs: various behaviors, such as angry, withdrawn, passive.

4. Elimination
  • Symptoms: changes in urine and stool characteristics, history of intussusception obstruction, or malabsorption syndrome (infiltration of retro-peritoneal lymph nodes)
  • Signs: tenderness in the right upper quadrant on palpation and enlargement (hepatomegaly), tenderness in the left upper quadrant on palpation and enlargement (splenomegaly), decreased urine output, dark urine, anuria (urethral obstruction / fail ginja), bowel dysfunction, and bladder.

5. Food / fluid
  • Symptoms: anorexia / loss of appetite, dysphagia (esophageal pressure) weight loss.
  • Signs: swelling of the face, neck, jaw, or right hand (secondary to superior vena cava compensated by enlarged lymph nodes), lower extremity edema in relation to the inferior vena cava obstruction of intra-abdominal lymph node enlargement (non-Hodgkin), ascites (obstruction in vena cava inferior with respect to intra-abdominal lymph node enlargement)

6. Neurosensory
  • Symptoms: nerve pain (neuralgia) indicates nerve root compression by enlarged lymph nodes in the brachial, lumbar, and sacral plexus, muscle weakness, paresthesias.
  • Signs: mental status; lethargy, withdrawal, lack of interest in the general vicinity, paraplegia (spinal stem compression from vertebral tubauh, discus involvement in compression / degeneration or compression of the blood supply to the spinal rod)

7. Pain / comfort
  • Symptoms: tenderness / pain on the affected lymph nodes, eg at about mediastinum, chest pain, back pain (vertebral compression) general bone pain (bone involvement limfomatus), pain in the affected area immediately after drinking alcohol.
  • Mark: a focus on self, cautious behavior.

8. Breathing
  • Symptoms: dyspnea at work or rest; chest pain
  • Symptoms: dyspnea; tachycardia, dry non-productive cough, respiratory distress signal; increased respiratory rate and depth, use of accessory muscles, stridor, cyanosis, husky / laryngeal paralysis (pressure of enlarged nodes in laryngeal nerve).

9. Security
  • Symptoms: a history of frequent / infection, mononukleus history, history of ulcer / perforation gastric bleeding, fever, night sweats without chills, redness / general pruritus
  • Symptoms: fever settled without any symptoms of infection, lymph node symmetric, no pain, swollen / enlarged, enlarged tonsils, general pruritus, most areas of melanin pigmentation loss (vitilago).


Nursing Diagnosis for Malignant Lymphoma

Once the data is collected, followed by analysis of the data to determine nursing diagnoses.

According Doenges (1999), nursing diagnoses in clients with postoperative laparotomy + biopsy, with an indication of malignant lymphomas as follows:

1. Risk for Infection related to invasive procedures, the surgical incision.

2. Risk for Fluid Volume Deficit related to excessive loss, ie: vomiting, bleeding, diarrhea.

3. Acute Pain related to the surgical incision.

4. Activity Intolerance related to general weakness, decreased energy reserves, increase the metabolic rate of the production of massive leukocytes.

5. Constipation or Diarrhea related to decreased dietary input, change the digestive process.

6. Risk for Impaired Skin Integrity related to decreased blood and nutrients to the tissues, secondary surgery.

7. Knowledge Deficit related to lack of accurate information about home care.

Powerlessness and Ineffective Therapeutic Regimen Management - NCP Diabetes Mellitus



Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the pancreas does not produce enough insulin, or because cells do not respond to the insulin that is produced.

Type 1 diabetes is a chronic illness characterized by the body’s inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas. It is most common in juveniles, but it can also develop in adults in their late 30s and early 40s.

The classic symptoms of type 1 diabetes are:
  • polyuria, 
  • polydipsia, 
  • polyphagia,
  • unexplained weight loss. 
Other symptoms may include:
  • fatigue, 
  • nausea, 
  • blurred vision.

Type 2 diabetes consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion.

Many patients with type 2 diabetes are asymptomatic. Clinical manifestations include the following:
  • Classic symptoms: Polyuria, polydipsia, polyphagia, and weight loss
  • Blurred vision
  • Lower-extremity paresthesias
  • Yeast infections (eg, balanitis in men)


Nursing Care Plan for Diabetes Mellitus

Nursing Diagnosis and Interventions for Diabetes Mellitus

Powerlessness related to long-term disease / progressive untreatable.

Goal: The feeling of powerlessness is reduced during treatment.

Expected Outcomes:
  • acknowledge feelings of hopelessness,
  • identify healthy ways to deal with feelings,
  • assist in planning their own care.

Intervention:

a) Instruct patient / family to express feelings about hospitalization and illness as a whole.

b) Provide opportunities for families to express concern and discuss how they can help the patient fully.

c) Determine goals / expectations of the patient / family.

d) Determine whether there are changes related to people nearby.

e) Provide support to patients to participate in self-care.


Ineffective Therapeutic Regimen Management related to insufficiency of knowledge about diabetes.

Goal: Client following diabetes education.

Expected Outcomes:
  • Clients can mention names, dosage, mode of action and time to drink regularly.

Interventions:

a) Explain to the client and family about the etiology and treatment of diabetes.

b) Encourage clients to frequently monitor blood sugar levels.

c) Explain the importance of adhering to a diet and exercise program is recommended.

d) Teach the client to use insulin (dose, timing, injection site).

e) Teach the importance of achieving and maintaining a normal body weight.

HHD Hypertensive Heart Disease - 5 Nursing Diagnosis Interventions

Hypertensive heart disease refers to heart problems that occur because of high blood pressure. These problems include:
  • Coronary artery disease and angina
  • Heart failure
  • Thickening of the heart muscle (called hypertrophy)

HHD can not only be caused by high blood pressure, but it can also lead to heart disease, stroke, thickened blood vessels, and heart attack. It can also cause sudden death.

Symptoms of HHD include:
  • Shortness of breath
  • Fatigue
  • Irregular pulse
  • Weight gain
  • Nausea
  • Bloating
  • Swelling of feet
  • Chest pain
  • Dizziness
  • Sweating


Nursing Diagnosis and Interventions for HHD Hypertensive Heart Disease

1. Acute Pain: Chest pain related to tissue ischemia due to decreased oxygen supply.

Goal:
  • Chest pain is gone.
  • Calm face expression.
  • Vital signs within normal limits.

Interventions :
  • Adjust the position of the patient semi-fowler
  • Collaboration with a physician for treatment
  • Give analgesics according to the medical program
  • Assess chest pain after a given action
  • Observation of vital signs


2. Ineffective Tissue Perfusion: cerebral related to decreased supply of oxygen and nutrients in the brain due to hypertension.

Goal:
  • The patient does not feel dizzy
  • The patient does not look uneasy
  • There is no sign of change in mental status are lacking.
  • Normal vital signs

Interventions :
  • Observation of vital signs
  • Assess history of hypertension
  • Observation of changes in sensory and motor
  • Instruct the patient to bedrest
  • Collaboration of anti-hypertensive therapy


3. Ineffective Breathing Pattern related to increased compensation body to increase oxygen supply to the tissues.

Goal:
  • Patient does not feel shortness of breath
  • Normal breathing frequency
  • Regular breathing rhythm
  • No increase in chest retraction

Interventions :
  • Assess the patient's level of anxiety
  • Observation of vital signs
  • Give oxygen as needed
  • Atue sitting with semi-Fowler position

4. Disturbed Sleep Pattern related to the feeling of dizziness.

Goal:
  • Patient can sleep as needed
  • Patient does not look lethargic
  • Normal vital signs
  • Normal blood pressure within 3 days of treatment

Interventions :
  • Assess the patient's ability to adapt to headache
  • Assess the patient's ability to rest and sleep needs
  • Teach relaxation techniques
  • Create a calm atmosphere
  • Limit visitors
  • Collaboration with physicians for the provision of medicines

5. Anxiety related to lack of knowledge about the disease, treatment program and maintenance actions to be performed and experienced.

Goal:
  • Patient look calm
  • Patients cooperative in care and treatment programs
  • Increase patients' knowledge about the disease, the signs and the conditions experienced, as well as the complications that may occur.

Interventions :
  • Assess the patient's anxiety
  • Provide an opportunity for patients to express anxiety
  • Provide a description of the information about: disease condition, food on abstinence and the reason, care and treatment programs will be carried out, break relations with the condition of the disease
  • Provide an opportunity for patients to explain the re-explanation.

Nursing Care Plan for Diabetes Mellitus - 5 Diagnosis Interventions

Assessment for Diabetes Mellitus

Assessment is the first step in the nursing process and basic overall.

Assessment of patients with diabetes mellitus (Doenges, 1999) include:

a. Activity / Rest
Symptoms: weakness, fatigue, difficulty moving / walking, muscle cramps, decreased muscle tone.
Signs: decreased muscle strength.

b. Circulation
Symptoms: ulcers on the legs, a long healing process, tingling / numbness in the extremities.
Signs: skin hot, dry and reddish.

c. Ego integrity
Symptoms: depend on others.
Signs: anxiety, sensitive stimuli.

d. Elimination
Symptoms: changes in the pattern of urination (polyuria), nocturia
Signs: dilute urine, pale dry, poliurine.

e. Food / fluid
Symptoms: loss of appetite, nausea / vomiting, do not follow the diet, weight loss.
Symptoms: dry skin / scaly, ugly turgor.

f. Pain / comfort
Symptoms: pain in the ulcer wound
Signs: face grimacing with palpitations, looks very carefully.

g. Security
Symptoms: dry skin, itching, skin ulcers.
Symptoms: fever, diaphoresis, damaged skin, lesion / ulceration

h. Counseling / learning
Symptoms: family risk factors diabetes, heart disease, stroke, hypertension, long healing. The use of drugs such as steroids, diuretics (thiazides): diantin and phenobarbital (may increase blood glucose levels).


Nursing Diagnosis for Diabetes Mellitus

Nursing diagnoses in patients with diabetes mellitus (Doenges, 1999) are:

  1. Fluid Volume Deficit related to osmotic diuresis, gastric loss, excessive diarrhea, nausea, vomiting, limited input, mental mess.
  2. Imbalanced Nutrition, Less Than Body Requirements related to insulin insufficiency, decreased oral input: anorexia, nausea, a full stomach, abdominal pain, change in consciousness: hypermetabolism status, the release of stress hormones.
  3. Risk for Infection related to inadequate peripheral defense, changes in circulation, high blood sugar levels, invasive procedures and skin damage.
  4. Fatigue related to decreased metabolic energy production, changes in blood chemistry, insulin insufficiency, increased energy demand, hypermetabolism status status / infection.
  5. Knowledge Deficit: about condition, prognosis and treatment needs related to misinterpretation of information / do not know the source of information.


Nursing Intervention and Implementation
for Diabetes Mellitus

Intervention is planning nursing actions that will be implemented to address the problem in accordance with the nursing diagnoses.

Implementation is the realization of management and nursing plans that had been developed at the planning stage.

Nursing Intervention and implementation in patients with diabetes mellitus (Doenges, 1999) include:

1). Fluid Volume Deficit

Expected outcomes:
Patients showed an improvement in fluid balance,
the criteria; spending adequate urine (normal range), vital signs stable, clear peripheral pulse pressure, good skin turgor, capillary refill well and mucous membranes moist or wet.

Intervention / Implementation:
1. Monitor vital signs, note the presence of orthostatic blood pressure.
R: Hypovolemia can be manifested by hypotension and tachycardia.

2. Assess breathing and breath patterns.
R: The lungs secrete carbonic acid is produced through respiration compensated respiratory alkalosis, the state of ketoacidosis.

3. Assess temperature, color and moisture.
R: Fever, chills, and diaphoresis is common in the infection process. Fever with skin redness, dry, maybe a picture of dehydration.

4. Assess peripheral pulses, capillary refill, skin turgor and mucous membranes.
R: Is an indicator of the level of dehydration or adequate circulating volume.

5. Monitor intake and output. Record the urine specific gravity.
R: Provide the estimated need for fluid replacement, renal function and the effectiveness of a given therapy.

6. Measure body weight every day.
R: Provide the best results of the assessment of the status of ongoing fluid and further in giving replacement fluids.

7. Collaboration fluid therapy as indicated
R: Type and amount of fluid depends on the degree of dehydration and individual patient response.


2). Imbalanced Nutrition, Less Than Body Requirements

Goal: weight can be increased with normal laboratory values ​​and no signs of malnutrition.

Expected outcomes:
Patients are able to express an understanding of substance abuse, decrease the amount of intake (diet on nutritional status).
Demonstrate behaviors, lifestyle changes to improve and maintain a proper weight.

Intervention / Implementation:

1. Measure body weight per day as indicated.
R: Knowing eating adequate income.

2. Determine the diet program and diet of patients compared with food that can be spent on the patient.
R: Identify deviations from the requirements.

3. Auscultation of bowel sounds, record the presence of abdominal pain / abdominal bloating, nausea, vomiting, keep fasting as indicated.
R: Influence of intervention options.

4. Observation of the signs of hypoglycemia, such as changes in level of consciousness, cold / humid, rapid pulse, hunger and dizziness.
R: Potentially life-threatening, which must be multiplied and handled appropriately.

5. Collaboration in the delivery of insulin, blood sugar tests and diet.
R: It is useful to control blood sugar levels.


3). Risk for Infection

Goal: Infection does not occur.

Expeected outcomes:
Identify individual risk factors and potential interventions to reduce infection.
Maintain a safe aseptic environment.

Intervention / Implementation

1. Observation for signs of infection and inflammation such as fever, redness, pus in the wound, purulent sputum, urine color cloudy and foggy.
R: incoming patients with infections that normally might have been able to trigger a state ketosidosis or nosocomial infections.

2. Increase prevention efforts by performing good hand washing, each contact on all items related to the patient, including his or her own patients.
R: prevention of nosocomial infections.

3. Maintain aseptic technique in invasive procedures (such as infusion, catheter folley, etc.).
R: Glucose levels in the blood will be the best medium for the growth of germs.

4. Attach catheter / perineal care do well.
R: Reduce the risk of urinary tract infection.

5. Give skin care with regular and earnest. Massage depressed bone area, keep skin dry, dry linen and tight (not wrinkled).
R: peripheral circulation can be impaired which puts patients at increased risk of damage to the skin / eye irritation and infection.

6. Position the patient in semi-Fowler position.
R: Makes it easy for the lung to expand, lowering the risk of hypoventilation.

7. Collaboration antibiotics as indicated.
R: penenganan early can help prevent the onset of sepsis.

4. Fatigue - NCP Diabetes Mellitus

5. Knowledge Deficit

Goal: patient expressed understanding of the conditions, procedures and effects of the treatment process.

Expected outcomes:
Perform the necessary procedures and explain the rationale of an action.
Initiate the necessary lifestyle changes and participate in treatment regimen.

Intervention / Implementation:
1. Assess the level of knowledge of the client and family about the disease.
R: Find out how much experience and knowledge of the client and family about the disease.

2. Give an explanation to the client about diseases and conditions now.
R: By knowing the diseases and conditions now, clients and their families will feel calm and reduce anxiety.

3. Encourage clients and families to pay attention to her diet.
R: Diet and proper diet helps the healing process.

4. Ask the client and reiterated family of materials that have been given.
R: Knowing how much understanding of clients and their families and assess the success of the action taken.

Activity Intolerance and Excess Fluid Volume related to CHF

Congestive heart failure (CHF) occurs when the heart isn't able to pump blood normally. As a result, there is not enough blood flow to provide the body's organs with oxygen and nutrients. The term "heart failure" does not mean that the heart stops beating completely, but that the heart is not working as efficiently.

There are two basic problems in congestive heart failure:
  • systolic dysfunction occurs when the heart can't pump enough blood to supply all the body's needs
  • diastolic dysfunction occurs when the heart cannot accept all the blood being sent to it


Nursng Diagnosis for CHF : Activity Intolerance related to
  • Imbalance between oxygen supply.
  • General weakness.
  • Prolonged bed rest / immobilization.
Characterized by:
  • weakness
  • fatigue
  • changes in vital signs
  • presence of dysrhythmias, dyspnea, pallor, sweating.
Goals / expected outcomes:

Client will:
  • participate in desired activities,
  • meet self-care,
  • achieve increased tolerance activity can be measured
evidenced by the decrease in weakness and fatigue.

Nursing Intervention

1. Check vital signs before and immediately after the activity, especially if the client is using vasodilators, diuretics and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), displacement fluid (diuretics) or influence cardiac function.

2. Note the cardiopulmonary response to activity, noted tachycardia, dysrhythmias, dyspnea, sweating and pale.
Rationale: Decrease / inability of the myocardium to increase the volume, as long as the activity can lead to an immediate increase in heart rate and oxygen demand is also increasing fatigue and weakness.

3. Evaluation of increased activity intolerance.
Rational: It can show an increase in cardiac decompensation rather than excess activity.

4. Implementation of cardiac rehabilitation programs / activities (collaboration).
Rational: gradual increase in activity, avoiding cardiac work / oxygen consumption is excessive. Strengthening and improvement of cardiac function under stress, when the heart is unable to function better again.


Nursng Diagnosis for CHF : Fluid Volume Excess related to
  • Decline in glomerular filtration rate (decreased cardiac output)
  • Increased ADH production and retention of sodium / water
characterized by: Orthopnea, S3 heart sound, oliguria, edema, weight gain, hypertension, respiratory distress, abnormal heart sounds.

Goals / expected outcomes:

Client will:
  • demonstrate stable fluid volume with the balance of inputs and outputs,
  • breath sounds clean / clear,
  • vital signs within acceptable range,
  • stable weight and no edema,
  • expressed an understanding of individual fluid restriction.
Nursing Intervention:

1. Monitor urine output, record the number and color of the time in which diuresis occurs.
Rational: urine output may be few and concentrated, due to decreased renal perfusion. Supine position so that helps diuresis of urine may be increased during bed rest.

2. Monitor / count balance input and output for 24 hours.
Rational: diuretic therapy may be caused by a sudden loss of fluid / redundant (hypovolemia) although edema / ascites is still there.

3. Keep sitting or bed rest with semifowler position during the acute phase.
Rational: The position is increasing kidney filtration and reduce the production of ADH to increase diuresis.

4. Monitor BP and CVP (if any)
Rationale: Hypertension and increased CVP showed excess fluid and may indicate an increase in pulmonary congestion, heart failure.

5. Assess bowel sounds. Record complaints anorexia, nausea, abdominal distension and constipation.
Rational: visceral congestion (occurring in chronic heart failure) can interfere with the function of gastric / intestinal.

6. Administration of drugs as indicated (collaboration)

7. Consult with a dietitian.
Rationale: The need to provide an acceptable diet that meets the client's needs calories in sodium restriction.

Nursing Interventions for Schizotypal Personality Disorder

Schizotypal personality disorder is a personality disorder with reduced ability to carry out the interpersonal relationship of cognitive distortion, resulting in disturbances in thought patterns, appearance, and behavior.

People with this disorder feel extreme discomfort with maintaining close relationships with people, and therefore they often do not. People who have this disorder may display peculiar manners of talking and dressing and often have difficulty in forming relationships. They typically have few, if any, close friends, and feel nervous around strangers although they may marry and maintain jobs.

Cause of schizotypal personality disorder is unknown. Genes are thought to be involved because this condition is more common in relatives of schizophrenics.

Common signs of schizotypal personality disorder include:
  • Discomfort in social situations
  • Inappropriate displays of feelings
  • No close friends
  • Odd behavior or appearance
  • Odd beliefs, fantasies, or preoccupations
  • Odd speech

Talk therapy is an important part of treatment. Social skills training can help some people cope with social situations. Medicines may also be a helpful addition.

The communications strategy for clients who have a personality disorder include:
  • Create a declaration affirming reality.
  • Limit discussions on concrete topics and are well known clients.
  • Do not try to give logical thinking as opposed to the client.
  • Discuss topics that are not controversial issue.
  • Acknowledge the fear and pain experienced by the client.
  • Give peace a gentle if these perceptions create fear.

Nursing Interventions for Schizotypal Personality Disorder :
  1. Help clients identify problems and areas of concern.
  2. Encourage clients to identify problems without labeling him know someone else is bad.
  3. Ask the client to discuss all the unmet needs and help clients to decide which is most important.
  4. Help clients identify behaviors that are useful to address the problem situation, eg to refrain from labeling others or ourselves a bad one.
  5. Teach the client and give the opportunity to practice the skills issue resolution, social skills and communication.
  6. Individualized therapy:
  • Work to build relationships with clients.
  • Establish a trusting relationship
  • Encourage clients to learn and practice decision-making
  • Provide support and strive to maintain the client run the function comfortably.