Hyperthermia and Ineffective Airway Clearance related to Bronchitis

Nursing Diagnosis and Interventions for Bronchitis:

1. Ineffective airway clearance related to increased production of secretions.

Goal: The client does not feel shortness of breath and no sputum.

Expected outcomes:
  • Maintain a patent airway with breath sounds clean or clear.
  • Shows behavior to improve airway clearance, for example: an effective cough.
Interventions:
  • Assess the respiratory function, breath sounds, the speed of the rhythm.
  • Assess a comfortable position for a client.
  • Suggest to cough effectively.
  • Collaboration: Provision mukolitik, Give the drug as an indication.
Rationale:
  • Assist the breathing pattern changes.
  • Breathing can facilitate the circulation in the body.
  • Cough teach effectively so patients independently.
  • To lower airway spasm.
  • Lowering the mucosal edema and smooth muscle spasm.

2. Hyperthermia related to the inflammatory process.

Goal: The client can reach the normal temperature.

Expected outcomes:
  • Normal body temperature (36.5 to 37.5 0C-0C)
Interventions:
  • Give a warm compress or cold pack in accordance with the client's approval.
  • Encourage clients to use clothing that is thin and absorbs perspiration.
  • Dressing damp or wet with sweat that much.
  • Give a thin blanket.
  • Collaboration: Give antipyretics.
Rationale:
  • Warm compresses help dilate the pores of the skin surface so as to accelerate heat dissipation.
  • Clothing that is thin, does not hinder the body's heat loss.
  • Clothes are damp / wet will cause inconvenience to the client.
  • Thick blanket that will hinder the body's heat loss.
  • Can help you lose body heat.

Acute and Chronic Bronchitis - Causes, Risk Factors, Symptoms and Prevention


There are two types of bronchitis is acute bronchitis and chronic bronchitis.

General conditions of acute bronchitis often develops from a cold or other respiratory infection. Acute bronchitis usually improves within a few days without leaving the effect, although you can continue to cough within weeks.

While chronic bronchitis is a more serious condition, this condition is irritation or inflammation constantly on bronchial pipes and is often caused by smoking. However if you have recurrent bronchitis condition, you may be experiencing chronic bronchitis. Chronic bronchitis is one of the conditions associated with chronic obstructive pulmonary disease (COPD).

Causes of of Acute and Chronic Bronchitis

Acute Bronchitis
Cold viruses often cause acute bronchitis. But you can also experience non-infectious bronchitis because of exposure to cigarette smoke and other pollutants such as dust.

Bronchitis can also occur when stomach acid rises into the esophagus, a condition known as gastroesophageal reflux disease (GERD). And workers exposed to dust or fumes can suffer bronchitis particular. Acute bronchitis generally disappear when no longer exposed to the irritant.


Chronic Bronchitis
Sometimes the inflammation and bronchial wall thickening pipe becomes permanent, a condition known as chronic bronchitis. You generally consider that you have chronic bronchitis if you cough every day lost after three months of the year in two consecutive years.

Unlike acute bronchitis, chronic bronchitis persists and is a serious illness. Smoking is the biggest cause, but air pollution and dust or toxic gases in the environment or workplace also can contribute to this disease.


Risk Factors of Bronchitis

Factors that increase the risk of bronchitis, among others:
  • Smoking. Smoking was the source of various diseases. Therefore, stop smoking because it is very detrimental to health.
  • Weak immune system, may be due to recovering from illness or other conditions that make the immune system becomes weak.
  • The condition in which stomach acid up into the esophagus (gastroesophageal reflux disease).
  • Exposed to irritants, such as pollution, smoke or dust.


Symptoms of Acute and Chronic Bronchitis

Here are some of the symptoms of acute and chronic bronchitis need to know:
  • Cough.
  • The presence of mucus, either colorless, white or yellow-green.
  • Shortness of breath, worsening even while exerting little effort.
  • Tired.
  • Mild fever and chills.
  • Discomfort in the chest.

If you have acute bronchitis, you may have a cough that persists in a few weeks after recovering from bronchitis. However bronchitis symptoms can be confusing. You can not have mucus when you have bronchitis, and children often swallow the mucus so that parents may not know it. There can experience chronic bronchitis without acute bronchitis beforehand. As well as many smokers who have to clean up the mucus in the throat in the morning when waking from sleep, which, if it continues for more than three months, may have chronic bronchitis.

If you have chronic bronchitis, the inflammation in the long term lead pipe bronchila injured and produce too much mucus. Eventually the pipe wall will bronchial airways thicken and you may be injured. Signs and symptoms of chronic bronchitis also can be:

Cough which worsened in the morning and in the humid weather.
Frequent respiratory infections (such as colds and flu) with a worsening cough up phlegm.

If you have chronic bronchitis, you may have a period in which signs and symptoms will worsen. At that time you can have a well-padded acute bronchitis due to bacterial or viral in addition to your chronic bronchitis.


Prevention of Bronchitis

Measures that can help reduce the risk of bronchitis and protect your lungs in general are:
  • Avoid smoking or exposure to cigarette smoke.
  • Avoid those who are sick colds or flu.
  • Wash your hands regularly.
  • Use a mask to reduce the risk of infection.

Common Causes that Make a Person Loss of Appetite for Days

Everyone must have experienced the condition appetite decreased or disappeared at a time. In medical terms, decreased appetite termed anorexia.

In many cases, loss of appetite caused by the disease, which means that the condition is just a symptom of a disease. Appetite will return to normal once the disease is gone. The condition was not too worried unless lasted for more than one or two days.

Other circumstances such as stress, sadness and anxiety-whichever common nowadays, - can also affect the normal appetite. It often occurs in adolescents and adults.

What happens to the body so that appetite decreased?

Basically, the appetite is an internal regulatory system that aims to meet the energy and nutritional needs of the body. The loss of your normal appetite would be a problem if the condition persists. It could be a symptom of a more serious disease. If these conditions persist, a person at risk of malnutrition or lack of nutrients.


Causes of lost appetite or decreased

Apart from the pain, appetite can also be reduced because of the effects of medical drugs that are being consumed by a person, or as well as weight loss diet program that is being executed.

Decreased appetite also almost always occur in the elderly, for no apparent reason could be found. However, factors such as sadness, depression, and excessive anxiety is a common cause of these conditions, and decrease the weight, especially in the elderly.

Cancer can also cause a decrease in appetite drastically. Cancers that make appetite disappeared, among others:
  • colon cancer
  • ovarian cancer
  • pancreatic cancer
  • stomach cancer
In addition, below are some other common causes that make a person lose appetite for days:
  • Infection, for example; pneumonia, hepatitis, HIV, influenza, or kidney infection called pyelonephritis.
  • Heart disease, kidney, and liver were serious. For example is chronic renal failure, cirrhosis, or congestive heart failure can cause loss of appetite.
  • Blockage in the stomach, known as intestinal obstruction.
  • Inflammation of the stomach or intestine, as occurs in patients with pancreatitis, inflammation of the pancreas, irritable bowel, or appendix.
  • Endocrine problems, such as diabetes mellitus, or a condition that causes low thyroid hormone levels (hypothyroidism).
  • An autoimmune disorder, a condition in which a person's immune system attacks the body itself. Examples include rheumatoid arthritis and scleroderma.
  • Psychiatric conditions, such as depression, schizophrenia, or an eating disorder called anorexia nervosa.
  • Pregnancy.
  • Dementia, such as Alzheimer's disease, a condition that causes decreased memory and other brain function decline.

What long-term effects of a loss of appetite?

Malnutrition, lack of food and nutrients your body needs, is a major serious problem of loss of appetite if it lasts for more than a few weeks. Other long-term effects associated with the cause. For example, diabetes can cause damage to various organs in the body, including the kidneys, eyes and nerves. Because of a lack of appetite, the body lacks essential nutrients to control diabetes.

Other effects related to the cause was cancer, which can cause death.


How to Overcome Decreased Appetite

The main thing is to find the cause of the loss of appetite. If caused by common ailments such as colds and fever, the appetite will improve after the disease is cured.

Consuming a multivitamin appetite enhancer may be necessary as a first step to restore the lost appetite. You can also try your favorite dish to cope with the declining appetite.

But if you can not detect a cause, and the condition lasts for several days, immediately consult a doctor for further diagnosis.

Tetanus - Causes, Symptoms, Complications, Diagnosis and Preventions

Tetanus

Tetanus is a serious infectious disease that attacks the nervous system and is characterized severe muscle contractions (seizures). This disease usually occurs as a result of stab wounds in the body of contaminated dust, manure, soil and animal or human feces.


Causes of Tetanus

The cause is the bacteria Clostridium tetani, a type of bacteria that can only grow and thrive in situations that are less oxygen environment (anaerobic).


Symptoms of Tetanus

Incubation period between injury until symptoms occur, generally lasts approximately 8 days (5-21 days), starting with stiffness in the jaw so that the mouth becomes locked (lockjaw) followed by:
  • Muscle stiffness in: the face, neck, chest, stomach, back up the spine arched (epistotonus), hands and legs
  • Difficulty in swallowing
  • Fever
  • Excessive sweating
  • High blood pressure
  • Rapid heart rate
  • Disturbance defecating and urinating


Neonatal Tetanus

Neonatal tetanus is the tetanus which attack newborns (neonates). This disease generally occurs due care less hygienic umbilical cord so contaminated by tetanus germs, and is characterized by fussy baby, stiff muscles, difficulty eating / drinking and death.


Complications of Tetanus

Severe tetanus can lead to complications such as:
  • A torn muscle
  • Vertebral fractures
  • Respiratory failure, until death due to respiratory muscle spasm
  • In infants will occur serious brain damage


Diagnosing Tetanus

Until now there is no specific laboratory tests to make sure someone is suffering from tetanus, so doctors rely on their history of injuries and the typical symptoms are found.

Examination can be done to support the diagnosis is testing a spatula that is touching the wall of the throat with a spatula (a kind of scoop), tetanus response is biting the spatula and close the mouth while a normal person would react nausea.


Preventing Tetanus

Several steps can be taken to prevent this disease are:
  • Hygienic wound care
  • Tetanus vaccine (tetanus toxoid), both primary immunization in infants and children and repeated vaccination every 10 years or in the event of a serious injury.

The Characteristics of Patients with Bulimia Nervosa You Should Know


Bulimia Nervosa is a disorder of eating, which is visible from the habit of overeating that occurs continuously. Bulimia is an eating disorder that often occurs in women. The disorder usually is a form of self-torture. The most frequently performed by more than 75% of people with bulimia nervosa is making herself vomit, sometimes called cleaning; fasting, and use of laxatives, enemas, diuretics, and excessive exercise are also a common feature.

Bulimia is a disease caused by the psychology of the patient, resulting in eating disorders. Bulimia is a condition where a patient overeating repeatedly and then back out. Issued food eaten can be through vomiting usually induced by laxatives, but it is also by removing it through urination by using diuretics.

Moreover, in addition to overeating, bulimia sufferers also tend to be very strict diet and excessive exercise. Characteristics of bulimia disease is certainly a habit of issuing food eaten very quickly, so it is very strange to ordinary people when back regurgitate after eating food.

Cleaning or vomit estimated as action to reduce hatred or guilt because they binge. Patients obsessed to rid themselves of the food, so food intake did not get absorbed by the body.

Cleaning action usually takes place immediately, but in some people with bulimia do cleaning at some period thereafter.

As with anorexia, bulimia is always associated with a control diet or weight loss. People with bulimia are usually paid much attention to weight, always feel less confident with the weight that tend to excessive dieting. The difference with patients with anorexia, people with bulimia have more stable body weight so that the disease is rarely known by the general public.

To detect the symptoms of bulimia in everyday life is hard. Process sometimes overeating is a common thing in society. Eating is a fun activity, can relieve stress or depression. In addition, each person also has a different appetite, so eat with the number of lots that sometimes is normal.

In addition, people with bulimia are not always thin. Could have had a normal weight or even overweight. But there are some signs that can be considered as a symptom of bulimia, namely:
  • Always to the bathroom after meals to throw up (of course done many times).
  • Excessive exercise.
  • There is a change such as swollen cheeks or jaw, broken blood vessels in the eye, damage to the tooth enamel so that it is obvious.
  • Too shackled with heavy affairs or body shape.

Ineffective Individual Coping related to Bulimia Nervosa


Nursing Care Plan for Bulimia Nervosa

Bulimia nervosa is a disorder in eating habits. Eating disorders are a psychiatric syndrome that is characterized by eating patterns associated with aberrant psychological characteristics associated with eating, body shape and weight. eating disorders occur due to several reasons in eating behavior, such as consumption of less healthy foods or eating too much.

Bulimia nervosa is a feast of food, followed by washing stomach or vomiting. Eating disorders usually occur together with other diseases such as depression, being part of a violent, and anxiety disorders. In this case, people who suffer from eating disorders can experience physical health complications further, including the problem of the working conditions of liver and kidney failure, which can lead to death. Many people with bulimia have a normal weight and seem to be no significant problems in life. Their regular people who look healthy, successful in his field, and tend ferfeksionis. However, behind it, have low self-esteem and often depressed.


Nursing Diagnosis : Ineffective individual coping

Goal: ineffectiveness of individual coping can be met.

Expected outcomes:
  • Identify methods that are not associated with less food in the face of stress or crisis.
  • Expressed feelings of guilt, anxiety, anger, or excessive need for control.
  • Shows a more satisfying interpersonal relationships.
  • Revealed more realistic body image.
  • Addressing an alternative method of dealing with stress or crisis.
  • Revealed an increase in self-esteem and confidence.

Interventions :
  • Assess client's eating habits.
  • Encourage clients to eat with other clients or their families, if tolerated.
  • Encourage clients to express their feelings (anxiety and guilt about eating).
  • Encourage clients to keep a diary to write down the type and amount of food eaten, identify feelings experienced before and after eating, especially about excessive eating behavior and depletion.
  • Discuss the client's preferred food and reduce anxiety.
  • Help clients explore ways to overcome the emotions (anger, anxiety, and frustration).
  • Give positive feedback to the client.
  • Teach client about the use of problem-solving process.
  • Exploration with the client about personal power.
  • Discuss with the client about the idea of receiving underweight "ideal".
  • Encourage clients to express their feelings, about the family members and those closest, role and relationship with them.

Rationale :
  • Preventing overeating behavior that includes eating secretly and swallow food, helps clients quickly and return to normal diet (three times daily).
  • Prevent secrecy about eating, though at first anxiety, the client may be too high to join the meal together.
  • Helps reduce feelings verbally can reduce anxiety and reducing the depletion of food behaviors.
  • Helping clients examine food intake and feelings they experienced.
  • Helping clients looking at using food to cope with feelings or make it comfortable.
  • Helping clients to separate emotional issues of food and eating behavior.
  • Increase efforts to clients in the face of anxiety, anger, and other emotions honestly and openly.
  • Helps clients improve self-esteem and confidence of clients.
  • Helping clients find strength.
  • Change the client's perception of ideal body weight may be unrealistic and unhealthy.
  • Helping clients identify, accept, and cope with their feelings in a proper way.

Pathophysiology and Early Symptoms of Dementia

Pathophysiology and Early Symptoms of Dementia
Dementia is not a specific disease. Dementia is a term used to describe a collection of symptoms that can be caused by a variety of disorders that affect the brain. A person with dementia have impaired intellectual functioning and causes disruption in daily activities or relationships with people around. People with dementia also lose the ability to solve problems, control emotions, and can even experience personality changes and behavioral problems such as irritability and hallucinations. A person diagnosed with dementia when two or more brain functions, such as memory and language skills, decreased significantly without loss of consciousness.

Pathophysiology of dementia usually begins gradually and increasingly worse, so that this situation did not at first realize. A decline in memory, the ability to remember the time and the ability to recognize people, places and objects. Patients have difficulty in finding and using the right words and the abstract thinking (eg in the use of numbers). Frequent changes in personality and behavior disorders.

Early symptoms usually are oblivious to what just happened but it could also begin as depression, fear, anxiety, decreased emotion, or other personality changes. There is a change in the pattern of speaking lightly so people use words more simple, using words that are not appropriate or not being able to find the right words. Inability to interpret the signs could pose difficulties in driving. In the end, patients are unable to perform their social functions.

Some people can hide their deficiencies well. They avoid complex activities (such as reading or working). Patients who do not succeed in changing his life may experience frustration because of inability to perform everyday tasks. Patients forget to perform the essential duties or wrong in doing the task.

Dementia is quite common in the elderly, afflicts about 16% of the age group above 65 years of age and 32-50% in the age group above 85 years. In about 10-20% of cases of dementia are reversible or treatable. The most frequent cause of dementia is Alzheimer's disease. Causes of Alzheimer's disease is unknown, but is thought to involve genetic factors, because the disease seems to be found in some families and are caused or influenced by several specific gene abnormalities. In Alzheimer's disease, some parts of the brain decline, resulting in cell damage and reduced response to a chemical that transmits signals in the brain. In the brain found abnormal tissue (called senile plaques and irregular nerve fibers) and abnormal proteins, which can be seen at autopsy. Lewy Body dementia closely resembles Alzheimer's disease, but have differences in microscopic changes that occur in the brain.

Prompts for Patients with Hordeolum (Stye)

Hordeolum can affect anyone, from children to the elderly. Stated that the incidence in adults more than children. There is no difference in the incidence (incidence rate) between men and women. Sometimes a person is really experiencing hordeolum (recurring). Supposing, just recovered that one, then reappear somewhere else.

Hordeolum is an infection or inflammation of the gland at the edge of the upper eyelid and the lower part caused by bacteria, usually by staphylococcus bacteria (Staphylococcus aureus).

Hordeolum may arise in one or more of the eyelid glands. Eyelid glands include Meibomian glands, the glands of Zeis and Moll.
Based on the place, hordeolum is divided into 2 types:

Internal hordeolum, occurred on Meibomian glands. At this internal hordeolum bump leads to the conjunctiva (the inner lining of the eyelid).
External hordeolum, occurred at Zeis glands and Moll glands. Lump visible from the outside on the outside of the eyelid skin.


Symptoms of Hordeolum
  • Signs hordeolum is easily recognized, namely visible lump on the eyelid the top or bottom, reddish. Sometimes appear whitish or yellowish spots accompanied by swelling of the eyelids.
  • On the internal hordeolum, the lump will appear more clearly with open eyelid.
  • Complaints are often felt by people hordeolum, including lump on the eyelid flavor, tenderness and increasing pain when bent. Sometimes watery eyes and sensitive to light.
  • Hordeolum can form an abscess in the eyelid and broken by removing the pus.


Prompts for Patients with Hordeolum (Stye)
  • Avoid scratching or tapping hordeolum.
  • Do not squeeze the hordeolum. Let hordeolum broke by itself, then wipe with a sterile gauze when out pus or fluid from the hordeolum.
  • Close your eyes while cleaning hordeolum.
  • To temporarily stop using makeup on the eyes.
  • Remove contact lenses during the treatment period.

Causes and How to Prevent LBP (Low Back Pain)

Causes and How to Prevent LBP Low Back Pain
Low Back Pain (LBP) is pain that occurs in the lower back and can spread to the foot, especially the rear and outer side. These complaints can be so severe that patients have difficulty in every movement and the patient should rest and hospitalized.

LBP complaint turned out ranks the second most common after headache. From the data on patients who went to the clinic of Neurology shows that the number of patients over the age of 40 years who present with low back pain turned out to be quite a lot.

Given that low back pain is actually just a symptom, then the most important thing is to find the causes, so that appropriate treatment can be given.

Causes of LBP

Basically the onset of pain is due to pressure on the nervous edge of the lumbar region (pinched nerve). Pinching the nerves can occur due to disturbances in muscle and surrounding tissue, nerve disorders in themselves, spinal abnormalities and abnormalities in other places, such as an infection or kidney stones and others.

Muscle spasms (muscle tension) is the most common cause of LBP. This spasm can occur due to movement of the waist is too sudden or excessive beyond the power of the muscle. For example during exercise with no we realize we move too sudden, and excessive time chasing or hitting the ball (badminton, tennis, golf, etc.). Likewise, when we lift things a bit heavy with the wrong position, such as moving a table, a chair, lifting luggage, pushing the car, even when we are very excited lift our children or grandchildren will be able to happen LBP. Calcification of the spine around the waist that can result in pinching of the nerves that lead to severe back pain.

HNP (spinal disc herniation). This happens because the involuntary (trauma / accident) and the pain may spread to either the right or left foot (ischialgia). The other reason we need to consider are: tumors, infections, kidney stones, and others. All of which can lead to pressure on the nerve fibers.

Should not be forgotten for mental stress, namely: a mental state that causes the patient to feel very depressed. The clinical symptoms of psychological stress transferred into LBP, although previously had no vulnerability factors of the composition of the organs in the back.


How To Prevent LBP

Here's how to prevent LBP:

1. Regular exercise where the frequency / number and intensity should be enough, do not overdo it. For those who usually LBP, recommended for swimming, and should not be jumping up and down.

2. Set the food by avoiding foods that contain a lot of fat, uric acid, etc., in order to slow down the calcification of the spine. Besides, try not to happen overweight.

3. Living in a healthy environment with clean air and avoid excessive pollution.

Nursing Care Plan for Kawasaki Disease


Kawasaki disease (mucocutaneous lymph node syndrome) is a form of vasculitis identified by an acute febrile illness with multiple systems affected. Kawasaki fever is a fever in children is associated with vasculitis especially coronary blood vessels and other systemic complaints.

Kawasaki disease, also known as Kawasaki syndrome, lymph node syndrome, and mucocutaneous lymph node syndrome.

Kawasaki disease was described by and named after Japanese pediatrician Tomisaku Kawasaki in 1967. It is also called mucocutaneous lymph node syndrome or Kawasaki syndrome.

Kawasaki disease is largely seen in children under five years of age. Kawasaki disease affects many organ systems, mainly those including the blood vessels, skin, mucous membranes, and lymph nodes. Its rarest but most serious effect is on the heart, where it can cause fatal coronary artery aneurysms in untreated children.

The exact cause of Kawasaki disease is still unknown. Some studies suggest that it may be caused by the immune system’s reaction to an infectious agent, such as a virus. The condition itself is not contagious.

Early symptoms may include:
  • High fever
  • Bloodshot eyes (also known as “conjunctivitis without discharge”)
  • Rash
  • Swollen lymph nodes
  • Swollen, bright red tongue
  • Swollen hands and feet
  • Red palms and soles of the feet

Later symptoms may include:
  • Diarrhea
  • Peeling skin on the hands and feet
  • Vomiting
  • Pain in the joints

Nursing Diagnosis for Kawasaki Disease :

1. Chronic pain related to inflammation of the myocardium or pericardium.
2. Risk for decreased cardiac output related to accumulation of fluid in the pericardial sac.
3. Activity intolerance related to inflammation and degeneration of myocardial muscle cells.

Hyperthermia related to Urinary Tract Infections


Nursing Care Plan for Urinary Tract Infections

Hyperthermia related to Urinary Tract Infections
A urinary tract infection (UTI) is an infection that affects part of the urinary tract. A urinary tract infection (UTI) (also known as acute cystitis or bladder infection). Urinary tract infections (UTIs) are very common – particularly in women, babies and the elderly. Around one in two women and one in 20 men will get a UTI in their lifetime.

The infection can occur at different points in the urinary tract, including:
  • Urethra. An infection of the tube that empties urine from the bladder to the outside is called urethritis.
  • Kidneys. An infection of one or both kidneys is called pyelonephritis or a kidney infection.
  • Ureters. The tubes that take urine from each kidney to the bladder are rarely the only site of infection.
  • Bladder. An infection in the bladder is also called cystitis or a bladder infection.
Some of the symptoms include:
  • Burning pain or a ‘scalding’ sensation when urinating
  • Pain above the pubic bone
  • Wanting to urinate more often and urgently, if only a few drops
  • A feeling that the bladder is still full after urinating
  • Blood in the urine.

Most urinary tract infections are caused by bacteria that live in the digestive system. Bacteria that enter the urethra and then the bladder. Women tend to get them more often because their urethra is shorter and closer to the anus than in men.
The most common culprit is a bacterium common to the digestive tract called Escherichia coli (E. coli).
Other micro-organisms, such as mycoplasma and chlamydia, can cause urethritis in both men and women.


Nursing Care Plan for Urinary Tract Infections

Hyperthermia related to infection.
Goal: the patient's body temperature to normal.

Expected outcomes:
  • The patient's body temperature is normal.
  • Acral feel warm.
  • Patients calm / relaxed.

Interventions and Rationale :

Independent

1. Assess increase in body temperature through laboratory tests.
R /: To determine the factors causing an increase in body temperature and to establish further therapy program.

2. Perform a cold or warm compresses on the body.
R /: Warm compresses can enhance vasodilation of blood vessels while cold compress increase vasoconstriction of blood vessels.

Collaboration

3. Implement treatment programs: Management of antipyretics as indicated.
R /: Antipyretics reduce fever.

Observation

4. Monitoring of vital signs.
R /: To know the state of the patient.

5. Monitor fluid intake and output.
R /: Intake and output were less able to stimulate the growth of bacteria in the urinary vesica.

Nursing Assessment for Hypertensive Heart Disease

Hypertensive heart disease is heart disease caused by hypertension. Hypertension that is not controlled for a long time causing the left ventricle hypertrophy (LVH).

The main causes of hypertensive heart disease is chronic hypertension. Hypertension in adults is caused by several things including:
Essential hypertension occurred in 90% of cases of hypertension in adults.
Secondary hypertension 10% of cases of hypertension in adults is caused by abnormalities in the kidneys, endocrine disorders, increased ICT, etc.

In the early stages of hypertension, will appear the signs as a result of chronic sympathetic stimulation. Heart beat faster and stronger. Occurred hyper circulation that may result from increased activity and neurohumoral system accompanied by hipervolumia. At an advanced stage, there will be a compensation mechanism in the form of heart muscle hypertrophy of the left ventricle and increased peripheral vascular resistance. Will appear shortness of breath in patients by the presence of diastolic interference.

The assessment focused on the physical and psychological disorders caused by HHD. The existence of a long history of hypertension and a history of hypertension and heart disease in the family.

Data base assessment:

1. Activity / rest
Symptoms: There is weakness, fatigue, shortness of breath.
Signs: Heart rate increases, changes in heart rhythm, tachypnea.

2. Circulation
Symptoms: A history of hypertension, atherosclerosis, coronary heart disease and cerebrovascular disease.
Symptoms: Increased blood pressure, pulse clear the area of the carotid, jugular and radial. Femoral pulse slowed, while the pulse popliteal, tibial and dorsalis pedis becoming weaker.
Arising tachycardia and dysrhythmias, audible voice S4 atrial gallop.
Skin discoloration occurs in the extremities, cold temperatures, pale skin, cyanosis.

3. Ego integrity
Symptoms: The change of personality, anxiety, depression, anger, multiple stress factors.
Symptoms: Restlessness, narrowing the field of attention, crying, facial muscle tension, increased speech patterns, often sighed.

4. Elimination
Symptoms: The presence of disorders of the kidneys.

5. Food / liquids
Symptoms: The habit of eating foods high in salt, fat and cholesterol. Feelings of nausea and vomiting, weight changes, use of diuretics.
Signs: Normal weight or obese. Arising edema (general or specific).

6. Neuro sensory
Symptoms: The existence of complaints of dizziness, throbbing head, sub-occipital headache, weakness on one side of the body, impairments, and epistaxis may occur.

7. Pain / discomfort
Symptoms: There angina, intermittent pain in the legs as indications of arteriosclerosis, severe occipital headache, abdominal pain.

8. Breathing
Symptoms: dyspnoea associated with the activity, tachypnea, orthopnea, cough with or without sputum, a history of smoking.
Signs: The use of accessory respiratory muscles, the additional breath sounds, cyanosis.

9. Learning
Symptoms: Risk factors family history of hypertension, atherosclerosis, heart disease, diabetes, cerebrovascular disease / kidney. Race factor, the use of drugs / alcohol.