1. Activity / rest
Symptoms: joint pain due to movement, tenderness, worsened by stress on the joints; stiffness in the morning, usually occurs bilaterally and symmetrically.
Functional limitations that affect your lifestyle, leisure, work, fatigue.
Limitations of range of motion; atrophy of muscle, skin, contractors / joint disorders.
Symptoms: Raynaud's phenomenon of fingers / legs (eg intermittent pale, cyanosis, and redness on the finger before the color returned to normal).
3. Ego integrity
Symptoms: stress factors of acute / chronic: eg; financial, employment, disability, relationship factors.
Decision and impotence (the inability of the situation)
The threat to the concept of self, body image, personal identity (such as dependence on others).
4. Food / liquid
Symptoms; inability to produce / consume food / fluids adequate: nausea, anorexia
Tags: Weight loss
Drought in the mucous membranes.
Symptoms: Various difficulties to carry out personal care activities. Dependence
Symptoms: numbness, tingling in hands and feet, loss of sensation in fingers.
Symptoms: Swollen joints symmetrically
7. Pain / comfort
Symptoms: acute phase of pain (may not be accompanied by soft tissue swelling in the joints).
Symptoms: The skin shiny, taut, subcutaneous nodules, skin lesions, leg ulcers. Difficulty in handling light duty / household maintenance. Drought is a mild fever settled on the eyes and mucous membranes.
9. Social interaction
Symptoms: Damage of social interaction with family / others; changing role; isolation.
1. AAcute Pain / Chronic associated with: the network distension by fluid accumulation / inflammation, joint destruction.
2. Mobility Physical damage associated with: skeletal deformities,
Pain, discomfort, activity intolerance, decrease in muscle strength.
Nursing Diagnosis 1:
Acute Pain / Chronic associated with: the network distension by fluid accumulation / inflammation, joint destruction.
* Indicates missing pain / uncontrolled
* There was relaxed, able to sleep / rest and participate in activities according to ability.
* Following prescribed pharmacological programs
* Combining the skills of relaxation and entertainment activities in the pain control program.
* Note the location and intensity (0-10 scale). Write down the factors that accelerate and signs of non-verbal pain
R / Assisting in determining needs and the effectiveness of pain management programs
* Give the mattress / mattress hard, small pillow,. Elevate the bed linen as required
R / mattress soft / soft, big pillow that will prevent the maintenance of proper body alignment, placing stress on joints that hurt. Bed linen exaltation reduce pressure on joints terinflamasi / pain
* Place / monitor the use bantl, sandbags, rolls of trokhanter, bandage, brace.
R / rest his joints pain and maintain a neutral position. Use brace can reduce pain and can reduce damage to the joints
* Encourage to frequently change positions. Help to move in bed, prop a pain in the joints above and below, avoid the jerking movements.
R / general Preventing fatigue and joint stiffness. Stabilize joints, reduce the movement / pain in the joints
* Instruct the patient to a warm bath or shower at the time awake and / or at bedtime. Provide a warm washcloth to compress the joints are sick several times a day. Monitor the temperature of the water compresses, baths, and so on.
R / Heat enhance muscle relaxation, and mobility, reduce pain and release the stiffness in the morning. Sensitivity to heat can be removed and dermal wound can be healed.
* Give a gentle massage
R / enhance relaxation / reduce pain
* Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeed back, visualization, guidelines imagination, self hypnosis, and breathing control.
R / Increase relaxation, provide a sense of control and may improve the ability köping.
* Engage in activities appropriate entertainment for the individual situation.
R / Focusing attention again, stimulate, and improve self-confidence and feeling healthy.
* Give medications before activity / exercise is planned according to instructions.
R / Increase realaksasi, reduce muscle tension / spasm, making it easier to participate in therapy.
* Collaboration: Give medicines as directed (eg, acetyl salicylate)
R / as an anti-inflammatory and mild analgesic effect in reducing stiffness and increasing mobility.
* Give me an ice cold pack if needed
R / A chill can eliminate pain and swelling during the acute period
Nursing Diagnosis 2:
Mobility Physical damage associated with: skeletal deformities, pain, discomfort, activity intolerance, decrease in muscle strength.
* Maintaining a function of position with the absence / restrictions contractures.
* Maintain or increase the power and functionality of and / or compensation of the body.
* Demonstrates techniques / behaviors that allow an activity.
* Evaluation / continue monitoring the level of inflammation / pain in the joints
R / level of activity / exercise depends on the development / resolution of inflammation peoses.
* Maintain a break tirah lying / sitting if necessary schedule of activities to provide a rest period of continuous night and sleep undisturbed.
R / Rest of systemic recommended during acute exacerbations and all phases of the disease is important to maintain the strength to prevent fatigue.
* Help with range of motion active / passive, resistive exercise also demikiqan and isometris if possible.
R / Maintain / improve joint function, muscle strength and general stamina. Note: inadequate exercise lead to stiffness, so that excessive activity can damage the joints.
* Change positions with the number of personnel is often enough. Demonstrate / aids removal techniques and the use of mobility aid, eg, trapeze
R / Eliminate pressure on the network and improve circulation. Memepermudah self care and independence of patients. Proper transfer techniques can prevent skin abrasion tear.
* Position with pillows, sand bags, rolls trokanter, bandage, brace
R / Increasing stability (reduce the risk of injury) and memerptahankan required joint position and body alignment, reducing the contractor.
* Use a small pillow / thin below the neck.
R / Prevent flexion of the neck.
* Encourage patients to maintain upright posture and sitting height, standing, and running R / Maximize function and maintain joint mobility.
* Provide a safe environment, such as raising the chair, using the railings on the toilet, use a wheelchair.
R / Avoiding injury due to accident / fall.
* Collaboration: consul with fisoterapi.
R / Useful in formulating training programs / activities based on individual needs and in identifying tools.
* Collaboration: Provide a foam mattress / modifier pressure.
R / Reducing pressure on the fragile network to reduce the risk of immobility.
* Collaboration: provide appropriate medication indication (steroids).
R / Maybe the system needed to suppress acute inflammation.
All About Nursing
- Nursing Diagnoses: Definitions and Classification 2012-14 (Nanda International)
- Nursing Diagnoses 2009-2011: Definitions and Classification (NANDA NURSING DIAGNOSIS)
- NOC and NIC Linkages to NANDA-I and Clinical Conditions: Supporting Critical Reasoning and Quality Care, 3e (NANDA, NOC, and NIC Linkages)
- Nursing Diagnoses, Outcomes, and Interventions: NANDA, NOC and NIC Linkages
- Nursing Diagnoses, Outcomes, and Interventions : Nanda, Noc And Nic Linkages 2ND EDITION
- Nursing Care Plans: Nursing Diagnosis and Intervention (Nursing Care Plans: Nursing Diagnosis & Intervention)
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Activity Intolerance
- Acute Pain
- Chronic Pain
- Decreased Cardiac Output
- Deficient Fluid Volume
- Imbalanced Nutrition Less Than Body Requirements
- Imbalanced Nutrition More than Body Requirements
- Impaired Physical Mobility
- Impaired Skin Integrity
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Risk for Decreased Cardiac Output
- Knowledge Deficit
- Risk for Infection
- Risk for Increased Intracranial Pressure
- Risk for Injury
- Self-Care Deficit
Nursing Care Plan
- Nursing Care Plan Anxiety
- Nursing Care Plan for Anemia
- Nursing Care Plan for Appendicitis
- Nursing Care Plan for Asthma
- Nursing Care Plan for Bronchiectasis
- Nursing Care Plan for Bronchopneumonia
- Nursing Care Plan for Dengue Fever
- Nursing Care Plan for Diabetes Mellitus
- Nursing Care Plan for Diarrhea
- Nursing Care Plan for Hypertension
- Nursing Care Plan for Low Back Pain
- Nursing Care Plan for Meningitis
- Nursing Care Plan for Nephrotic Syndrome
- Nursing Care Plan for Pneumonia
- Nursing Care Plan for Tonsillitis
- Nursing Care Plan for Typhoid Fever
- Nursing Care Plan for Urethral Stricture
- ► 2012 (23)
- ► 2011 (110)
- ► 2010 (188)
- ▼ 2009 (8)
Nanda Nursing Interventions
Nursing Care Plan : Nursing Diagnosis - Interventions
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- Nursing Interventions for Impaired Physical Mobility related to Stroke
- Nursing Management of Low Back Pain
- Self-Care Requisites - Dorothea Orem
- Model and Theory of Nursing by JEAN WATSON
- Family Nursing Diagnosis - Nursing Care Plan for Tuberculosis
- Nursing Care Plan for Deficient Knowledge
- Nursing Care Plan for Deficient Knowledge
- Nursing Care Plan for Appendicitis Post Operative
- COPD - Acute Pain Nursing Interventions
- 12 Nursing Diagnosis for Diabetes Mellitus
- 6 Nursing Diagnosis and Interventions for Gastritis
- Pleural Effusion - Nursing Assessment, Diagnosis and Interventions
- Heart Failure - List of Nursing Diagnosis and Interventions
- Nursing Care Plan for Dengue Hemorrhagic Fever
- Risk for Injury related to Meniere’s Disease
- Nursing Diagnosis for Rectal Cancer
- Activity intolerance related to IHD
- Pleural Effusion Nursing Diagnosis – Ineffective Airway Clearance