Impaired Gas Exchange Nursing Diagnosis and Intervention for NCP Cardiac Decompensation

Cardiac Decompensation
Cardiac Decompensation is a condition of congestive heart failure in which the heart is unable to ensure adequate cellular perfusion in all parts of the body without assistance. Causes may include myocardial infarction, increased workload, infection, toxins, or defective heart valves.

Nursing Diagnosis Nursing Care Plan Cardiac Decompensation

Impaired Gas Exchange related to pulmonary congestion, secondary to changes in alveolar capillary membrane and interstitial fluid retention.

Definition : Impaired Gas Exchange

Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system.

Goal :
  • Maintain ventilation and oxygenation are adequate,
  • Normal blood pH,
  • PO 2 80-100 mmHg,
  • PCO2 35-45 mm Hg,
  • HCO3 -3 - 1.2

Nursing Interventions :
  • Assess the respiratory work (frequency, rhythm, sound and depth)
  • Provide additional oxygenation
  • Monitor saturation (oximetry) PH, BE, HCO3
  • Correction of acid-base balance
  • Give a position that allows clients improve lung expansion. (Semi-Fowler)
  • Prevent atelectasis with the train effective coughing and deep breathing
  • Perform fluid balance
  • Limit fluid intake
  • Eavluasi radiographic pulmonary congestion through

Acute Pain Nursing Diagnosis and Intervention for Nursing Care Plan Angina Pectoris

Angina Pectoris
Angina pectoris, commonly known as angina, is severe chest pain due to ischemia (a lack of blood, thus a lack of oxygen supply) of the heart muscle, generally due to obstruction or spasm of the coronary arteries (the heart's blood vessels). Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries.

Nursing Diagnosis for Nursing Care Plan Angina Pectoris

Acute pain related to myocardial ischemic

Acute Pain Definition :

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.

Nursing Interventions :
  • Assess the factors that aggravate the pain.
  • Complete rest during episodes of angina (the first 24-30 hours) with a semi-Fowler position.
  • Observation of vital signs every 5 minutes every attack of angina.
  • Create a calm environment, limit the visitor when necessary.
  • Give soft foods and let the client rest 1 hour after meals.
  • Stay with clients who are experiencing pain or anxious.
  • Teach distraction and relaxation techniques.
  • Collaboration treatment.

Nursing Diagnosis and Intervention Activity Intolerance Nursing Care Plan Hypertension

Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. Hypertension is classified as either primary (essential) hypertension or secondary hypertension; About 90–95% of cases are categorized as "primary hypertension," which means high blood pressure with no obvious medical cause. The remaining 5–10% of cases (Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart or endocrine system.



Nursing Diagnosis for Hypertension

Activity intolerance related to general weakness, imbalance between supply and demand oxygenation.

Activity Intolerance is used when a patient has insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications, or emotional states such as depression or lack of confidence to exert one’s self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.



Goal:

Activity patients fulfilled

Expected Result:

Clients can participate in activities at the desired / required, reported an increase in tolerance activity can be measured.

Nursing Intervention and Rational :
  1. Assess the patient's tolerance to activity by using the parameters: pulse frequency 20 per minute above the resting frequency, noted an increase in blood pressure, dipsnea, or chest pain, severe fatigue and weakness, sweating, dizziness or fainting.
    R: / Parameter patients showed physiological response to stress, activities and indicators of the degree of influence of the excess of work / heart.
  2. Assess readiness to increase the activity of an example: a decrease weakness / fatigue, unstable blood pressure, pulse frequency, increased attention to activity and self-care.
    R: / physiological stability at rest is important to advance the level of individual activity.
  3. Push to promote the activity / tolerance of self-care.
    R: / myocardial oxygen consumption during the various activities can increase the amount of oxygen available. Progress of activity gradually to prevent sudden increase in cardiac work.
  4. Provide assistance as needed and encourage the use of bath seats, brushing teeth / hair by sitting and so on.
    R: / energy-conservation techniques reduce energy use and thus help balance supply and oxygen demand.
  5. Encourage the patient to partisifasi in choosing the period of activity.
    R: / Like the schedule increases the tolerance to the progress of activities danmencegah weakness.

Activity Intolerance Nursing Diagnosis and Interventions for Nursing Care Plan Appendicitis

Appendicitis

Appendicitis a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".


Nursing Diagnosis for Nursing Care Plan Appendicitis

Activity intolerance related to limitation of motion secondary to pain.

Activity Intolerance is used when a patient has insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications, or emotional states such as depression or lack of confidence to exert one’s self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.


Goal:
Activity tolerance

Expected Result:
Clients can move without restriction

Nursing Intervention and Rational :
  1. Note the emotional response to mobility.
    R / immobilization imposed will increase anxiety.
  2. Provide activities in accordance with client's circumstances.
    R / Increasing organ kormolitas sesuiai expected.
  3. Give the client for passive motion exercises and active movements.
    R / Improve body mechanics.
  4. Assist clients in conducting activities that are burdensome.
    R / Avoiding things that can aggravate the situation.

Acute Pain Nursing Diagnosis and Intervention for NCP Urinary Tract Infection

Urinary Tract Infection
A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli. Although urine contains a variety of fluids, salts, and waste products, it does not usually have bacteria in it. When bacteria get into the bladder or kidney and multiply in the urine, they may cause a UTI.


Nursing Diagnosis for Urinary Tract Infections

Acute pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

Acute Pain Definition :

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.


Expected Result:
Pain is reduced / lost during and after micturition

Nursing Intervention and Rationale:
  • Monitor urine color change, monitor the pattern of urination, the input and output every 8 hours and monitor the results of urinalysis repeated. Rational: to identify indications of progress or deviations from the expected results

  • Record the location, duration of the intensity scale (1-10) pain. Rational: to help evaluate the place of obstruction and cause pain

  • Provide comfort measures, such as massage. Rational: increase relaxation, decrease muscle tension.

  • Provide perineal care. Rational: to prevent contamination of the urethra

  • If dipaang catheter, catheter treatment 2 times per day. Rational: The catheter provides a way for bacteria to enter the bladder and up into the urinary tract.

  • Divert attention to a pleasant thing. Rational: relaxation, avoiding too much pain.

Nursing Diagnosis and Nursing Intervention for Thyroidectomy

Nursing Diagnosis and Nursing Intervention for Thyroidectomy

Thyroidectomy

A thyroidectomy is an operation that involves the surgical removal of all or part of the thyroid gland. Surgeons often perform a thyroidectomy when a patient has thyroid cancer or some other condition of the thyroid gland (such as hyperthyroidism). Other indications for surgery include cosmetic (very enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing). One of the complications of "thyroidectomy" is voice change and patients are strongly advised to only be operated on by surgeons who protect the voice by using electronic nerve monitoring. Most thyroidectomies are now performed by minimally invasive surgery using a cut in the neck of no more than 2.5 cms(1 inch).

Thyroidectomy
Nursing Diagnosis

Impaired Verbal Communication

Related to
  • laryngeal nerve damage
  • vocal cord injury,
  • tissue edema; pain and discomfort

Can be evidenced by
  • impaired articulation,
  • does not or cannot speak; use of nonverbal cues such as gestures

Expected Result
  • Communication
  • Establish method of communication in which needs can be understood.

Nursing intervention and Rationale for Thyroidectomy
  1. Assess the client periodically talks
    R /: hoarse voice and sore throat is the second factor of odema / network as the effects of surgery.

  2. Perform a brief communication with the yes / no answer.
    R /: Reduced response to talk too much.

  3. Provide alternative methods of communication as Appropriate-slate board, letter and picture boards. Place intravenous (IV) line to minimize interference with written communication.
    R /: Facilitates expression of needs.

  4. Encourage speech assessed periodically and voice rest.
    R /: hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last Several days. Permanent nerve damage can occur (rare) That Causes paralysis of vocal cords and or compression of the trachea.

Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative

Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative

Cesarean Section

A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems happen during delivery. These include
  • Health problems in the mother
  • The position of the baby
  • Not enough room for the baby to go through the vagina
  • Signs of distress in the baby
C-sections are also more common among women carrying more than one baby.


Nursing Diagnosis and Nursing Intervention for Cesarean Section Postoperative

Nursing Diagnosis

Risk for infection

Related to :
  • bleeding,
  • postoperative wound

Goal :
There were no infections, bleeding and wounds, after surgery.

Nursing Intervention for Cesarean Section Postoperative
  1. Assess the condition of output / dischart out; number, color, and odor from the operation wound.
    R / recording the changes in output. The existence of a darker color with a bad smell may be a sign of infection.
  2. Tell the client the importance of wound care during the postoperative period.
    R / Infection can arise from lack of cleanliness of the wound.
  3. Have a general culture in the output.
    R / Various bacteria can be identified through the output.
  4. Perform wound care.
    R / Incubation germs in the wound area can cause infection.
  5. Tell the client how to identify signs of infection.
    R / Various clinical manifestations can be nonspecific sign of infection, fever and increased pain may be symptoms of infection.

Nursing Diagnosis

Acute Pain

Related to
  • postoperative wound
Goal :
Pain is reduced / no pain

Nursing Intervention for Cesarean Section Postoperative
  1. Assess the condition of pain experienced by the client.
    R / Measurement of the level of pain can be performed with pain scales.
  2. Tell the client suffered pain and its causes.
    R / Improving coping clients, in dealing with pain.>
  3. Teach relaxation techniques.
    R / Reduced perception of pain.
  4. Collaboration of analgesics.
    R / Reduced pain can be done by giving oral or systemic analgesics, in a broad spectrum / specific.

Useful Tips for Psychiatric Nurses for Assessment of Patients

Assessment of patients, or the understanding of the patient especially in connection with the disease or ailment, assumes special significance in psychiatric nursing, because the responsibility of a psychiatric nurse is not mere care and assistance for curing the disease, as in other cases, but the wholesome care of the patient and restoring normalcy to the patient. The patients requiring psychiatric treatment are generally insane or have some sort of mental disorder and restoring normalcy or near normalcy becomes the ultimate challenge for a psychiatric nurse.

Assessment of the patient, his or her feelings, behavior, attitude, characteristics, mental state and awareness and all such things, gain paramount importance in psychiatric nursing, as these details, though trivial as it may look, provide important clues for formulating the nursing process, diagnosis and evaluation of the course of treatment for the patient as a whole.

Active participation of the patient in the treatment process is essential in psychiatric nursing and invariably requires an extended stay of the patients at the hospital or specialty care centers.

As part of the assessment of the patient, the following details need to be recorded:

  1. The perception of the patient with regard to the facilities in the hospital, the services rendered and the general atmosphere available in the center needs to be ascertained and recorded
  2. General strength of the patient, as perceived by him or her and explained to the psychiatric nurse as part of the therapeutic communication should find place in the assessment. In addition, psychiatric nurse's view about patient's strength can also be included.
  3. The assessment record should include the perception of the disease from the patient's point of view and how he or she copes with the disease. In other words, the efforts put in by the patient to deal with the present ailment or disease needs to be recorded.
  4. Information about the patient's family, the background and historical patterns of behavior in the family members needs to be recorded by gathering information from the patient and his or her close relatives or family members interested in the cure of the patient
  5. Appearance, cultural background and the primary language of the patient
  6. Habits of the patient that include addictions, if any, for smoking, drinking or chewing tobacco or such other things
  7. Level of memory of the patient – such as recent memory and remote memories, as well as orientation of the patient – the place of residence and living
  8. Complete and comprehensive details of the patient's physical systems, as well as nutrition problems, allergies and such other medical issues, if any
  9. Details related to suicidal thoughts, perceptions of hallucinations or delusions, aggression or such other thoughts should also be noted as part of the assessment.
  10. Relationship with family members, present living conditions, communication skills, cognition levels, mood related issues should also find a place in the Assessment
  11. Present standard of living, income earning capability and remuneration, value systems in life, hobbies, interests and spiritual affinity should also be recorded in the assessment form.

Some of the details recorded by the psychiatric nurse might look trivial, but they are essential for further treatment and preparation of nursing plans and diagnosis in association and co-operation of the patient.


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Health Benefits of Bitter Gourd

Momordica charantia or karela or Bitter Gourd is a tropical vegetable. The vegetable skin is warty in nature like that of a crocodile. It is bitter to taste. The plant is slender and is a climber. It bears yellow flowers. The bitter gourd is available in many sizes. The fresh juice of the vegetable is used to treat various ailments like diabetes, colic, sores, fungal infections, etc., Young immature biter gourds are best to cook. The skin in dark green in colour and the flesh is white and the seeds are tender. Its also known as Karela, Balsam pear or Bitter melon.

Bitter gourd is rich in vitamin A, B1, B2 and c and contains minerals like calcium, phosphorous, iron, copper and potassium. It aids purify blood tissue, enhances digestion, and stimulates the liver. Pregnant women and nursing mothers should avoid eating bitter gourd. Since ancient times, the extracts of Bitter gourd have been used in natural medicine. Bitter gourd is a blood purifier, activates spleen and liver. It is a purgative, appetizer and digestive. All parts of the plant, the seeds, leaves and vines, are used for medicinal purposes. Like most bitter fruits and vegetables it promotes digestion. Primarily Asians used bitter gourd to treat malaria. Its is said to have a positive effect in controlling the blood sugar level and is termed as 'Plant Insulin'. Three active constituents in bitter melon know as steroidal saponins (charntin, insulin-like peptides, and alkaloids) are believed to be responsible for the blood-sugar lowering. Rich in iron, bitter melon has twice the beta carotene of broccoli, twice the calcium of spinach, twice the potassium of bananas. Its is used to treat blood disorders like blood boils, scabies, ring worm etc.,

The juice of the leaf is used to treat alcoholism and piles. The juice of the Bitter Gourd leaves are used to treat cholera. It is useful as an emtic, purgative. Excessive ingestion of bitter melon juice, much more than the amount recommended may lead to diarrhea and abdominal pain.

Bitter melon is seldom mixed with other vegetables due to its strong bitter flavour. The Chinese used the bitter melon in stir fry dishes and soups. Bitter melon capsules are also available in the market.


By: idea2cash

Nursing Care Plan for Diabetes Mellitus

Nursing Care Plan for Diabetes Mellitus

Assessment

  1. Family Health History
    Are there families who suffer from diseases such as patient ?
  2. Patient Medical History and Prior Treatment
    How long a client suffering from diabetes, how to handle, gets what type of insulin therapy, how to take medicines regularly do, what do the patients to cope with their illness.
  3. Activity / Rest :
    Tired, weak, Difficult Moves / walking, muscle cramps, decreased muscle tone.
  4. Circulation
    Is there a history of hypertension, AMI, numbness, tingling in the extremities, ulcers on the feet that long healing, tachycardia, changes in blood pressure.
  5. Ego Integrity
    Stress, anxiety
  6. Elimination
    Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea
  7. Food / Fluids
    Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, the use of diuretics.
  8. Neurosensory
    Dizziness, headache, tingling, numbness in muscle weakness, paresthesias, visual disturbances.
  9. Pain / Leisure
    Abdomen tense, pain (moderate / severe)
  10. Respiratory
    Cough with or without purulent sputum
  11. Security
    Dry skin, itching, skin ulcer.

Read More :

Nursing Care Plan for Diabetes Mellitus

Dementia Nursing Assessment

Nursing Assessment for Dementia


Nursing Assessment for Dementia

  1. Fostering a relationship of trust with patients
    To carry out a review of nursing in patients with dementia, first you must build a trusting relationship with patients.

    In order to foster a trusting relationship, things can be done as follows :
    • Always saying hello to the patient such as: good morning / afternoon / evening / night or according to the religious context of the patient.
    • Introduce your name (nickname), including a report that relatives are nurses who will care for patients.
    • Also ask the patient's name and his favorite nickname.
    • Explain your goals and patient care activities to be performed.
    • Explain when the activities will be implemented and how long the activity.
    • Be empathetic manner :
      • Sit with the patient, make eye contact, give a touch and show concern
      • Speak slowly, simply and give the patient time to think and respond
      • Nurses have the expectation that patients would be better
      • Be warm, simple to express hope in patients.
    • Use short sentences, clear, simple and easy to understand.
    • Speak slowly, say the word or phrase that is clear and wait for a response if asked patients
    • Ask one question each time and re-asked questions with the same words.
    • Volume increased if there is hearing loss, if the volume is increased, the tone should be subdued.
    • The attitude of non-verbal communication coupled with good verbal.
    • Attitudes have to communicate face to face, maintain eye contact, relax and open up.
    • Create a therapeutic environment when communicating with patients :
      • Very quiet
      • The room comfortable, light and ventilation adequate
      • The distance is adjusted, to minimize disruption.

Read More :

ECGs for Prehospital Emergency Care

ECGs for Prehospital Emergency Care


Product Description

Now that state of the art equipment can be carried in ambulances, prehospital emergency staff are able to perform an ECG soon after arrival on scene, enabling the EMS provider to gather important diagnostic information that can not only guide prehospital therapy but also direct hospital-based treatment. This book exclusively addresses ECGs for prehospital emergencies, ranging from basic rhythm diagnosis to critical care applications of the electrocardiogram and advanced 12-lead ECG interpretation in the ACS patient. It provides self testing traces covering all these conditions seen in prehospital and hospital- based environments. It includes 200 randomly presented cases mirroring real life situations, with the answers set out separately together with additional invaluable information. Written by highly experienced emergency physicians with EMS qualifications and experience, this text is an ideal learning tool for trainees and fully qualified staff alike, including ground EMS advanced life support providers, aeromedical staff, and inter-facility critical care transport personnel.

From the Back Cover

Now that state of the art equipment can be carried in ambulances, prehospital emergency staff are able to perform an ECG soon after arrival on scene, enabling the EMS provider to gather important diagnostic information that can not only guide prehospital therapy but also direct hospital-based treatment.

This book exclusively addresses ECGs for prehospital emergencies, ranging from basic rhythm diagnosis to critical care applications of the electrocardiogram and advanced 12-lead ECG interpretation in the ACS patient. It provides self testing traces covering all these conditions seen in prehospital and hospital- based environments. It includes 200 randomly presented cases mirroring real life situations, with the answers set out separately together with additional invaluable information.

Written by highly experienced emergency physicians with EMS qualifications and experience, this text is an ideal learning tool for trainees and fully qualified staff alike, including ground EMS advanced life support providers, aeromedical staff, and inter-facility critical care transport personnel.

Read More :

ECGs for Prehospital Emergency Care

Diabetes Mellitus Nursing Assessment

Nursing Assessment for Diabetes Mellitus


Nursing Assessment for Diabetes Mellitus
  1. Family Health History
    Are there families who suffer from diseases such as client ?
  2. Patient Medical History and Prior Treatment
    • How long a client suffering from diabetes ?
    • Gets what kind of insulin therapy ?
    • How to take medication regularly ?
    • What do the client to cope with illness ?
  3. Activity / Rest :
    Tired, weak, Difficult Moves / walking, muscle cramps, decreased muscle tone.
  4. Circulation
    Is there a history of hypertension, acute myocardial infarction, numbness, tingling in the extremities, ulcers on the feet that long healing, tachycardia, changes in blood pressure.
  5. Ego Integrity
    Stress, anxiety
  6. Elimination
    Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea.
  7. Food / Fluids
    Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, the use of diuretics.
  8. Neuro Sensory
    Dizziness, headache, tingling, numbness in muscle weakness, paresthesias, visual disturbances.
  9. Pain / Leisure
    Abdomen tense, pain (moderate / severe)
  10. Respiratory
    Cough with or without purulent sputum (depending on the presence of infection)
  11. Security
    Dry skin, itching, skin ulcer.


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Hypertension Nursing Assessment

Nursing Assessment for Hypertension



Nursing Assessment for Hypertension

Assessment is the main basis of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment - a careful collection of data about clients, their families, the data obtained through interviews, observation and examination.

The data collected can be divided into two (Kelliat, Budi Ana., 1995) :
  1. Data base
  2. Specific data relating to the current situation of the client which can be determined by the nurse, client or family.
The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).

Basic Nursing Assessment data by Doenges (1999) :
  1. Activity / Rest
    • Symptoms: weakness, fatigue, shortness of breath, monotonous lifestyle.
    • Signs: The frequency of the heart increases, changes in heart rhythm, tachypnoea.
  2. Circulation
    • Symptoms: History of hypertension, atherosclerosis, coronary heart disease / valve and cebrocaskuler disease, episodes of palpitations.
    • Signs: The increase in BP, pulse throbbing clear from the carotid, jugular, radial, tachycardia, valvular stenosis murmur, jugular venous distension, pale skin, cyanosis, cold temperature (peripheral vasoconstriction) filling the capillary may be slow / delayed.
  3. Ego Integrity
    • Symptoms: History personality changes, anxiety, multiple stress factors (relationship, financial, work related).
    • Signs: Explosion mood, anxiety, continue narrowing of attention, tears burst, face muscles tense, breathing heaved, increased speech patterns.
  4. Elimination
    • Symptoms: Impaired renal current or (such as obstruction or a history of kidney disease in the past).
  5. Food / fluid
    • Symptoms: The preferred food that includes foods high in salt, fat and cholesterol, nausea, vomiting and changes in body weight lately (up / down) Historical use of diuretics.
    • Signs: normal weight or obese, the presence of edema, glikosuria.
  6. Neuro Sensory
    • Genjala: Complaints of dizziness / headache, throbbing, headache, suboksipital (happens when you wake up and eliminate spontaneously after a few hours) Impaired vision (diplobia, blurred vision, epistaxis).
    • Signs: mental status, changes in waking, orientation, pattern / content of speech, effects, think the process, decreased hand grip strength.
  7. Pain / discomfort
    • Symptoms: Angina (coronary artery disease / heart involvement), headache.
  8. Respiratory
    • Symptoms: dyspnea related to the activities / work Tachypnoea, orthopnea, dyspnea, cough with or without the formation of sputum, history of smoking.
    • Signs: respiratory distress / respiratory accessory muscle use additional breath sounds (krakties / wheezing), cyanosis.
  9. Security
    • Symptoms: Impaired coordination / gait, postural hypotension.
Nursing Assessment for Hypertension


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Oral Cavity Assessment

Oral Cavity Assessment



History

  • Last dental exam
  • Missing, broken, or loose teeth
  • Pain in the mouth, teeth, gums
  • Bleeding gums
  • Dry mouth
    • Sores or lesions in mouth/tongue
    • Difficulty biting, chewing, swallowing
  • Presence of halitosis
  • Altered sense of taste
  • Dentures/partials
  • Sores under dentures
  • Stability during chewing
  • History of head or neck radiation
  • Usual dental/oral hygiene
  • Medications

Assessment

Lips and Mouth
  • Cracking, lesions, ulcers, swelling, discoloration, redness
Buccal Mucosa
  • Induration, tenderness, abrasions, redness/discoloration, hydration, hygiene
Tongue
  • Color, size, coating, tremor, lesions, deviation
Palate
  • Symmetry, lesions, discoloration
Oropharynx
  • Gag reflex, uvula position, masses, exudate, color, lesions
Gingiva
  • Color, bleeding, edema, exudates, hypertrophy, recession from teeth, food impaction
Teeth
  • Caries, root exposure, visible decay, missing or loose teeth, mobile and/or worn teeth

Black & Matassarin-Jacobs (1997); Forciea & Lavizzo-Mourey (1996); Jarvis (1992); Weber & Kelly (1998).


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