Risk for Infection - Nursing Assessment and Nursing Diagnosis

Risk for Infection - Nursing Assessment and Nursing Diagnosis

Infection is an invasion of the body by pathogens or microorganisms capable of causing illness (Potter and Perry, 2005).

Some of the factors that trigger the risk of infection in patients by Potter and Perry (2005) are:

1) Agent
The agent causing the infection, the microorganism can enter because the agent itself or because the toxins are released.

2) Host
The hosts were infected, so even if there is an agent, if no one can be charged, there is no infection. Hosts are usually people or animals in accordance with the needs of the agent to survive or breed.

3) Environment
Environment, the environment around the agent and the host, such as temperature, humidity, sunlight, oxygen and so on. There are certain agents that can only survive or infect certain environmental conditions as well.


Signs and Symptoms

Signs and symptoms are common in infections (Smeltzer, 2002) as follows:

1. Rubor
Rubor or redness is first seen in areas that become inflamed. When inflammatory reactions arise, dilation of the arterioles that supply blood to areas of inflammation. So that more blood flows to local microcirculation and capillary stretch quickly filled with blood. This condition is called hyperemia or congestion, causing local red color because of acute inflammation.

2. Calor
Calor occur simultaneously with redness of acute inflammatory reactions. Calor is also caused by increased blood circulation. Because blood has a temperature of 37 degrees Celsius is channeled to the body surface inflamed to the area more than normal.

3. Dolor
Changes in local pH or local concentration of certain ions can stimulate nerve endings. Spending substances such as histamine or other bioactive can stimulate nerves. The pain is caused also by the pressure was rising due to swelling of inflamed tissue.

4. Tumor
Swelling partly due to hyperemia and mostly caused by the delivery of fluid and cells from the blood circulation into the interstitial tissues.

5. Functio Laesa
Functio laesa is a loss of function or a disturbance of function.


Diagnostic

Laboratory tests are directly related to the infection include a complete blood count that includes: hemoglobin, leukocytes, hematocrit, erythrocytes, platelets, MCH, MCHV, basophils, eosinophils, stem segments, lymphocytes, and monocytes, erythrocyte sedimentation rate (ESR), random blood glucose, and albumin.


Medical Management

1. Aseptic
Actions taken in health care. This term is used to describe all the work done to prevent the entry of microorganisms into the body that are likely to lead to infection. The end goal is to reduce or eliminate the number of microorganisms, both on the surface of animate objects and inanimate objects so that medical equipment can be safely used.

2. Antiseptic
Efforts to prevent infection by killing or inhibiting the growth of microorganisms on the skin and other body tissues.

3. Decontamination
Actions taken so that an inanimate object can be handled safely by health workers, particularly medical clearance officer before washing done. An example is the examination table, medical equipment and gloves contaminated with blood or body fluids when actions are performed.

4. Washing
The removal of all blood, body fluids, or any foreign objects such as dust and dirt.

5. Sterilization
The removal of all microorganisms (bacteria, fungi, parasites and viruses), including bacterial endospore of inanimate objects.

6. Disinfection
The removal of most (not all) of disease-causing microorganisms from inanimate objects. High-level disinfection is done by boiling or using chemical solutions. This action can eliminate all microorganisms except some bacterial endospore.


Nursing Assessment

1. Identity
Getting the patient identity data, including name, age, education, occupation, address, registration number, and medical diagnostics.

2. Health history

• The main complaints: Complaints are most felt by the patient to seek help.
• Health history now: What is being felt now.
• Past medical history : Is the possibility of patients had never had this disease or have ever been.
• Family health history: Covering hereditary diseases or non-communicable diseases.

3. The need for Bio-Psycho-Social-Spiritual.
Needs Bio-Psycho-Social-Spiritual include breathing, eating, drinking, elimination, motion and activity, rest - sleep, personal hygiene, temperature control, security and comfort, socialization and communication, achievement and productivity, knowledge, recreation and worship.

4. Physical Examination
a. General State
The general state include: general impression, awareness, posture, skin color, skin turgor, and personal hygiene.
b. Cardinal Symptoms
Cardinal symptoms include: temperature, pulse, blood pressure, and respiration.
c. Physical State
Includes examining the physical state of the head to the lower extremities.

• Inspection: examine the skin, mucous membrane color, general appearance, adequacy systemic circulation, breathing pattern, chest wall movement.
• Palpation: local tenderness, feeling a lump or axilla and breeast tissue, peripheral circulation, the peripheral pulse, skin temperature, color and capillary refill.
• Percussion: knowing abnormal fluid, the air in the lungs, or the working diaphragm.
• Auscultation: abnormal sounds, murmurs, as well as friction sound, or the sound of an extra breath.

Nursing Diagnoses

Risk for Infection

Definition: Having an increased risk of pathogenic organisms

Risk Factor:

Chronic Diseases

• Diabetes mellitus
• Obesity

Knowledge is not enough to avoid pathogen exposure.
Defence inadequate primary body.

• Impaired peristaltic
• Damage to skin integrity (intravenous catheterization, an invasive procedure)
• Changes in pH secretion
• Decrease in work ciliary
• Premature rupture of membranes
• Smoking
• Static body fluids
• Tissue trauma network (ie., trauma, tissue destruction)

Inadequate secondary defenses

• Decrease in hemoglobin
• Immunosuppression (ie., Immunity acquired is inadequate, pharmaceutical agents including immunosuppressants, steroids, monoclonal antibodies, immunomodulators)
• Leukopenia
• Suspension inflammatory response

Vaccination inadequate
Exposure to environmental pathogens which increased

• outbreak

Invasive procedures
Malnutrition

Nursing Assessment for Hypertensive Heart Disease

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.

Assessment and Nursing Diagnosis for Malignant Lymphoma

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.

Signs and Symptoms - Asthma Bronchiale Nursing Assessment

Signs and Symptoms - Asthma Bronchiale Nursing Assessment

Nursing Care in clients with Asthma Bronchiale implemented through the nursing process approach, consisting of: Assessing, Diagnosing, Planning, Implementing, and Evaluating.

Nursing Assessment for Asthma Bronchiale : Signs and Symptoms

Basic assessment data :

Activity / Rest

• Symptoms: fatigue, malaise, inability to perform daily activities because of shortness of breath. Inability to sleep, need to sleep sitting up high. Dyspnea at rest or in response to activity or exercise
• Signs: fatigue, anxiety, insomnia, general weakness / loss of muscle mass.

Circulation

• Symptoms: swelling of the lower extremities.
• Signs: increase in blood pressure. Increased heart rate / severe tachycardia, dysrhythmias. Distended neck veins (severe disease). Dependent edema, unrelated to heart disease. Faint heart sounds (which is associated with increased AP diameter of the chest). Color of skin / membrane glucose: normal or gray / cyanosis: Nail clubbing and peripheral cyanosis. Pallor may indicate anemia.

 Ego integrity

• Symptoms: increased risk factor. Changes in lifestyle.
• Signs: anxiety, fear, sensitive stimuli.

Food / fluid

• Symptoms: nausea / vomiting. Poor appetite / anorexia (emphysema). The inability to eat due to respiratory distress. Losing weight sedentary (emphysema), weight gain showed edema (bronchitis).
• Signs: poor skin turgor, dependent edema, sweating, weight loss, decreased muscle mass / fat subcutaneously (emphysema). Abdominal palpitation may declare hepatomegaly (bronchitis).

Hygiene

• Symptoms: decreased ability / enhancement needs doing daily activities.
• Signs: poor hygiene, body odor.

Breathing

• Symptoms: shortness of breath (onset hidden, with dyspnoea as a prominent symptom of emphysema), particularly in the workplace: the weather or recurrent episodes of difficult breathing (asthma): chest distress, inability to breathe (asthma). "Air Hunger 'chronic. Cough settled, with the production of sputum every day (especially when awake) for a minimum of 3 months in a row, every year at least 2 years, production of sputum (green, white, or yellow) can be a great deal (chronic bronchitis). Intermittent episodes of cough, usually is not productive at this early stage although it can be productive (emphysema). History of recurrent pneumonia, exposure to chemical pollution / fumes eg asbestos, coal dust, jute cotton, sawdust, family factors and oxygen at night or continuously.
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• Signs: fast breathing, can be slow: lengthening the expiratory phase, with snoring, mouth breathing (emphysema). Preference for the three-point (Tripot) to breathe (especially with acute exacerbation of chronic bronchitis). The use of accessory muscles, eg raising the shoulders, retraction of supraclavicular fossa, widen the nose. hyperinflation of the chest can be seen quietly raising AP (shape-barrel): minimal diaphragm movement. Breath sounds: may dim with expiratory wheezing (emphysema): diffuse, soft or coarse moist crackles (bronchitis): crackles, wheezing in all lung areas on expiration, and the possibility for the inspiration to continue to decline or absence of wheezing (asthma). Percussion: hyper-resonant on the lung area (eg, air trap with emphysema): sound deaf in the area (eg, consolidation, fluid, mucosa). Difficulty speaking a sentence or more than 4 or 5 at a time. Color: pale with cyanotic lips and nail: gray Overall: red (chronic bronchitis "inflated blue '). Patients with emphysema were often called "pink fuffer" because skin color was normal despite normal gas exchange and rapid breathing frequency. Clubbing in the fingers (emphysema).

Security

• Symptoms: history of an allergic reaction or are sensitive to substances / environmental factors. The presence / recurrent infections. Redness / sweating (asthma).

Sexuality

• Symptoms: Decreased libido

Social interaction

• Symptoms: dependency relationship, lack of support systems, failure of support from family or significant others, long illness or incapacity improves.
• Signs: inability to create / maintain a sound, because respiratory distress. Physical mobility, abnormal relationships with other family members.

Counseling / Learning

• Symptoms: The use / abuse of drugs breathing, difficulty stopping smoking, regular alcohol use, failure to improve, repatriation planning considerations: the need for dental nursing, home care / home duties to maintain, change treatment / therapeutic program.

Pain Assessment Method Based PQRST

Pain Assessment Method Based PQRST

Pain Assessment Method Based PQRST

P-Provocative, palliative factors

• What might cause pain ...?
• Is it because of an impact ..?
• Due incision ..? etc..

Q-Quality

• How severe pain felt ..?.
• How does it feel ..?.
• How often happen ..?
• Ex: As punctured, depressed / crushed by heavy objects, sliced ​​to pieces, etc..

R-Region

• Location where pain is felt / found ..?
• Is also spread to other areas / areas spread ..?

S-Severity

• The scale of gravity can be viewed using the GCS (Glasgow Coma Scale) for disorders of consciousness, pain scale / other size-related complaints.

T-Time

• When the pain started to find / feel ..?
• How often does the pain feel / going on ...?
• Are occurs suddenly or gradually ..?
• Acut or chronic ..?