Nursing Process / Laboratory
Case Study
Example 1:
Sinusitis is inflammation of the paranasal sinuses, which may be due to infection,
allergy, or autoimmune issues. Most cases are due to a viral infection and resolve
over the course of 10 days. It is a common condition; for example, in the United
States more than 24 million cases occur annually.
Nursing Diagnosis for Sinusitis
1 Acute Pain: head, throat, sinus related to inflammation of the nose
Goal : Pain is reduced or lost
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Expected outcomes are:
Clients express the pain diminished or disappeared
Clients do not grimace in pain
Interventions:
1. Assess client's level of pain
R :/ Knowing the client's level of pain in determining further action
2. Explain the causes and effects of pain on the client and family
R :/ With the causes and consequences of pain the client is expected to participate in
treatment to reduce pain
3. Teach relaxation techniques and distractions
R :/ The client knows the distraction and relaxation techniques can be practiced so as
if in pain
4. Observation of vital signs and client complaints
R :/ Knowing the general state and development of the client's condition.
2. Anxiety related to lack of client knowledge about diseases and medical procedures
(sinus irrigation / operation)
Goal: Anxiety is reduced / lost
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Expected outcomes are:
Clients will describe the level of anxiety and coping patterns.
The client knows and understands about his illness and its treatment.
Interventions:
1. Assess client's level of anxiety
R :/ Determining the next action
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2. Give comfort and ketentaman on the client:
Show empathy (it comes with a touch client)
R :/ Facilitate client's receipt of the information provided
3. Give an explanation to clients about the illness slowly, quietly and use of clear
sentences, short easy to understand
R :/ Increase client understanding about the disease and therapies for the disease so
that the client more cooperative
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4. Get rid of excessive stimulation such as:
Place the room quieter client
Limit contact with others / other clients are likely to experience anxiety
R :/ By removing the stimulus that will enhance the peace of the client concerned.
3. Ineffective Airway Clearance related to the obstruction (nasal secret buildup)
secondary to inflammation of the sinuses
Goal: Effective airway, after a secret (seous, purulent) issued
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Expected outcomes are:
Clients no longer breathe through the mouth
Airway back to normal, especially the nose
Interventions:
1. Assess the existing build-secret
R :/ Knowing the severity and subsequent action
2. Observation of vital signs
R :/ Knowing the client's development prior to surgery
3. Collaboration with the medical team for cleaning discharge
R :/ cooperation to eliminate the buildup of secret / problem
Example 2:
Risk for Injury of Hemophilia
Nursing Diagnosis : Risk for Injury related to weakness of the defense secondary
to hemophilia
characterized by frequent injuries
Objectives / Expected outcomes: injury and complications can be avoided / did not
happen.
Nursing Interventions
1.
2.
3.
4.
Maintain security of client's bed, put a safety on the bed
Avoid injury, light - weight
Keep an eye on every move that allows the occurrence of injury
Encourage the parents to bring children to the hospital immediately in case of
injury
5. Explain to parents the importance of avoiding injury.
Rational
1. Fragile tissue and impaired clotting mechanisms boost the risk of bleeding
despite the injury / mild trauma
2. Patients with hemophilia are at risk of spontaneous bleeding was controlled so
that the required monitoring every move that allows the occurrence of injury
3. Early identification and treatment can limit the severity of complications
4. Parents can find out mamfaat of injury prevention / risk of bleeding and avoid
injury and complications.
5. Lower the risk of injury / trauma.
Example3:
Constipation / Diarrhea related to Anemia
Nursing Diagnosis: Constipation / Diarrhea related to a reduction in dietary
inputs, changes in digestion, the side effects of oral therapy.
Signs :
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frequency change
characteristics and the amount of feces
nausea / vomiting
anorexia
sudden abdominal pain
impaired bowel sounds.
Expected outcomes are:
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normal bowel function
behavioral changes necessary to live as the cause.
Nursing Intervention:
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Observation of color, consistency, frequency, amount.
Auscultation of bowel sounds
Supervise the input / output
Encourage input 2500-3000 ml
Consult with a nutritionist: high-fiber diet
Give an enema as indicated
Give anti-diarrheal medications as indicated.
Example4:
Appendicitis is known to be a surgical disease, as it commonly requires
removal of the inflamed vermiform appendix, a tubular prominence of the
cecum.
Causes of acute appendicitis:
The appendix contains a lumen in it. Anything that causes obstruction of the
lumen will cause appendicitis. In adults, the lumen is commonly obstructed by
fecaliths. Fecalith means hard fecal matter.
In teens and children, the lumen can be obstructed due to inflammation
(submucosal lymphoid hyperplasia).
Appendicitis symptoms present itself as a type of acute abdominal pain. It
usually spreads around the person's abdomen's lower right region. After some
time, the infection spreads and the intensity of pain will increase. You can
distinguish the pain because it seems sharper as compared to other typical
abdominal conditions.
Vomiting and anorexia can occur after the feeling of pain. Besides, an elevated
body temperature is a sign of an ongoing inflammation in the body.
Nursing Diagnosis
1. Risk for Infection
2. Acute pain
3. Risk for Fluid Volume
4. Anxiety
5. Knowledge Deficit
Exam:
Asthma is a very serious condition so everyone should be aware of the
symptoms. Asthma is a common respiratory disease that affects a person's
airways. Asthma affects the individual's ability to breathe normally and can
cause tightness in the chest, coughing and wheezing and shortness of breath, in
more serious cases it can trigger asthma attacks that can be life threatening to
the individual.
Numerate the Nursing Diagnosis for Asthma
Exam
Dengue Fever
Dengue fever is an acute febrile disease caused by dengue virus and
is spread through the medium of the Aedes aegypti mosquito, which had
been infected with the dengue virus. Dengue fever is divided into two,
namely: dengue fever and dengue hemorrhagic fever. Dengue hemorrhagic
fever is a more severe form of dengue fever, bleeding and shock, which
can sometimes occur that result in death.
What are the Nursing Diagnosis:
Exam
Tuberculosis is a common and very dangerous as well as a contagious
disease which can be caused by a range of strains of mycobacteria, The bacteria
causing tuberculosis can be spread from one person to the next via particles in the air
The important symptoms of Tuberculosis are chest pain, coughing up blood, and a
productive and lingering cough for more than three weeks. There are some of the
systematic symptoms of this disease too and these are continuous fever, chills,
frequently getting night sweats, immediate appetite loss, weight loss, whiteness, and
feeling exhausted in most of the time. The infected person has odorous mucus. Some
of the extra pulmonary infections can be included, like the pleura in tuberculosis
pleurisy for which the central nervous system gets affected.
What are the Nursing Diagnosis