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Nursing Care Plan for Deficient Knowledge

Knowledge, deficient regarding condition, treatment program, self-care, and discharge needs related to lack of exposure and information, misinterpretation of information and unfamiliarity with information resources.

Deficient Knowledge Definition: Absence or deficiency of cognitive information related to a specific topic
Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Related Factors:
  • Lack of exposure
  • lack of recall
  • information misinterpretation
  • cognitive limitation
  • lack of interest in learning
  • unfamiliarity with information resources
Nursing Interventions Nursing Care Plan for Deficient Knowledge

1. Assess ability to learn or perform desired health-related care.
Rational : Cognitive impairments need to be identified so an appropriate teaching plan can be designed.

2. Determine client’s learning style especially if client had learned and retained new information in the past.
Rational: Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method facilitates success in mastery of knowledge.

3. Assess motivation and willingness of client.
Rational : Some clients are ready to learn soon after they are diagnosed.

4. Instruct client/ family in disease process, progression, what to expect, and answer all questions honestly.
Rational : Promotes optimal learning environment when client show willingness to learn. Family members may assist with helping the client to make informed choices regarding the treatment. Anxiety or large volumes of instruction may impede comprehension and limit learning.

5. Explain purpose of activity restrictions and need for balance between activity/rest.
Rational : Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion.

Nursing Care Plan for Appendicitis Post Operative

Nursing Care Plan for Appendicitis Post Operative

Definition of Appendicitis

a. Appendicitis is a minor surgical diseases most often occur. Although appendicitis can occur at any age, but most often in young adults. Before the antibiotic era, the high mortality of this disease (Sylvia A. Price, 1994).

b. Acute appendicitis is the inflammation spreads to the surface of the parietal peritoneum the pain persists, more powerful and gain weight when moving. (Barbara C. Long, 1996)

c. Acute appendicitis is the most common cause of acute inflammation in the lower right quadrant abdominal cavity, the most common cause for emergency abdominal surgery (Brunner and Suddarth, 2001).

Clinical Manifestations of Appendicitis


a. The main complaint of appendicitis: pain. Abdominal pain lasting more than 6 hours must be taken into consideration. The pain is caused by the blockage of the appendix and its the same as the pain caused by intestinal obstruction. At first intermittent pain such as colic, because the innervation of the appendix and small intestine together. People feel when flatus or bowel movement will relieve the pain.

Manifestations of pain:
  • The beginning of the pain felt in the epigastrium, or around the umbilicus.
  • Incurred local pain at the Mc. Burney. This inflammation will penetrate through the serosa and serous inflammation will spread to the peritoneum local parietale.
  • Any movement will cause pain, severe pain and the pain turned into a sharp and continuous.
  • In the event of perforation of the pain suddenly disappeared, but only briefly and then followed by intense pain throughout the abdomen due to peritonitis.
b. Anorexia is almost always the case.
c. Vomiting is a characteristic, vomiting occurs after pain.
d. Usually constipation.
e. Frequent diarrhea especially in children, and especially on the client that the appendix is ​​located in the nearby rectum.


Nursing Care Plan for Appendicitis Post Operative


Nursing Care Plan for Appendicitis Post Operative, as follows:

1. Assessment of post-operative data

The data on the client might get appendicitis authors include:
a. The identity of the client
  • Name, tribe / nation, age, education, employment, income, address and Registration number.

b. Medical history
  • History of the main complaints: Client: There is usually nausea, vomiting, rapid pulse, pain in the operated area.
  • Incidence of complaints:Quarter of an hour after surgery.
  • Nature of complaints: Since becoming aware of the client to feel the pain that persisted in the operated area.
  • Another complaint came: Clients feel nausea, vomiting, and headache / dizziness.

c. Past medical history
  • Lower right abdominal pain.

d. Physical examination
  • The general situation: Client appears ill.
  • Circulation: It may indicate respiratory bradycardia.
  • Respiration: It may seem tachipnea clients because there is a sense of nausea and vomiting.
  • Abdomen: abdominal distension may be tenderness in the area of ​​incision.
  • Extremities: There may be cyanosis.

e. Patterns of daily life
  • Nutrition: There is a sense of nausea and vomiting, the client can not eat, maybe a bad skin turgor.
  • Elimination :Bowel movements: The client has not / does not defecate, may not flatus. Urinating: There may be disorders of urination
  • Hygiene: Regional visible incision closed operations (wound was sterile).
  • Convenience: Clients seem grimace.

f. Psychological data
  • Clients seem restless.

NANDA Appendicitis

1. Risk for Infection

2. Acute pain

3. Risk for Fluid Volume

4. Anxiety

5. Knowledge Deficit 

Signs and Symptoms of UTI (urethritis, cystitis, and pyelonephritis)

Urethritis, Cystitis, and Acute Pyelonephritis

Acute pyelonephritis usually results from ascending bladder infection. Acute pyelonephritis can also occur through hematogenous infection. Infection can occur in one or both kidneys. Chronic pyelonephritis may occur due to repeated infections, and are usually found in individuals who develop stones, obstruction, or vesicoureteric reflux.

Cystitis (bladder inflammation) are most commonly caused by the spread of infection from the urethra. This can be caused by the backflow of urine from the urethra into the bladder (reflux urtrovesikal), fecal contamination, the use of catheters.

Urethritis an inflammation usually is an infection that spreads up to be classified as general or mongonoreal. Gonococcal urethritis caused by niesseria gonorhoeae and is transmitted through sexual contact. Nongonoreal urethritis; urethritis is not related to niesseria gonorhoeae usually caused by chlamydia urelytikum frakomatik or plasma urea. Pyelonephritis (upper urinary tract infection) is a bacterial infection of the kidney cup, and tissue tobulus intertisial of one or both kidneys. The bacteria reach the bladder through the urethra and ascend kmih to renal kidney although 20% to 25% in cardiac output; bacteria rarely reach the kidneys via the bloodstream; cases of hematogenous spread of less than 3%.

Signs and symptoms of UTI (urethritis, cystitis, and pyelonephritis)

1. Signs and symptoms of urethritis:




Signs and symptoms of urethritis

  • Reddened mucosa and edema
  • There is a purulent exudate fluid
  • There is ulceration of the urethra
  • The existence of a tingling itch
  • Good morning sign
  • Pus early micturition
  • Pain during micturition
  • Difficulty to initiate micturition
  • Pain in the lower abdomen.

2. Signs and Symptoms of Cystitis:



Signs and Symptoms of Cystitis

  • Dysuria (pain on urination)
  • Increased frequency of urination
  • Feeling of wanting to urinate
  • The presence of white blood cells in urine
  • Lower back pain or suprapubic
  • Fever is accompanied by the presence of blood in the urine in severe cases.

3. Signs and symptoms of acute pyelonephritis:



Signs and symptoms of acute pyelonephritis

  • Fever
  • Shiver
  • Low back pain
  • Dysuria

Chronic pyelonephritis may show a picture similar to acute pyelonephritis, but it can also cause hypertension and may eventually lead to kidney failure.

Anemia - Ineffective Tissue Perfusion Nursing Diagnosis and Interventions

Anemia - Ineffective Tissue Perfusion Nursing Diagnosis and Interventions


Nursing Diagnosis for Anemia: Ineffective Tissue Perfusion related to the decrease in the cellular components required for the delivery of oxygen / nutrients to the cells.

Objectives: increased tissue perfusion.

Expected outcomes are: - indicates inadequate perfusion, such as stable vital signs.

Ineffective Tissue Perfusion Nursing Interventions for Anemia

Independent

1. Monitor vital signs assess capillary refill, color of skin / mucous membranes, nail beds.
Rational: provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention.

2. Elevate head of bed as tolerated.
Rational: increase lung expansion and maximize oxygenation for cellular needs. Note: if there is hypotension contraindicated.

3. Monitor respiratory effort; auscultation of breath sounds adventisius note sounds.
Rational: dyspnea, gurgling menununjukkan heart problems due to strain the old heart / cardiac output increased compensation.

4. Investigate complaints of chest pain / palpitations.
Rational: influence cellular network myocardial ischemia / infarction risk potential.

5. Avoid using a bottle warmer or hot water bottle. Measure the temperature of bath water with a thermometer.
Rational: termoreseptor superficial dermal tissue due to disruption of oxygen.

Collaboration

1. Keep an eye on the results of laboratory examination. Give a complete red blood cell / blood product packed as indicated.
Rational: identify deficiencies and needs treatment / response to therapy.

2. Provide supplemental oxygen as indicated.
Rational: to maximize the transport of oxygen to the tissues.

Nursing Assessment for Appendicitis (NCP for Appendicitis)

Nursing Assessment for Appendicitis - Nursing Care Plan (NCP) for Appendicitis



Nursing Assessment for Appendicitis


Assessment according to Wong (2003), Doenges (1999), Catzel (1995), Betz (2002), among others:

A. Interview
  • Get a thorough medical history, especially regarding:
  • The main complaint: the client will get a pain around the epigastrium radiating to the lower right abdomen. Complaints arising under the right abdominal pain may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. Nature of the complaints of persistent pain is felt, may be lost or there is pain in a long time. Complaints which usually accompanies a client complaining of nausea and vomiting, loss of heat.
  • Past medical history: usually associated with health problems the client is now asked of the parents.
  • Diet, eating foods low in fiber.
  • Elimination habits.

2. Physical examination
  • General condition: the client looks sick mild / moderate / severe.
  • Circulation: tachycardia.
  • Respiratory: Tachypnea, shallow breathing.
  • Activity / rest: Malaise.
  • Elimination: Constipation in early onset, sometimes diarrhea.
  • Abdominal distension, tenderness / pain off, stiffness, decreased or absent bowel sounds.
  • Pain / comfort, epigastric and abdominal pain around the umbilicus, the increased severe and localized to the point Mc. Burney, an increase of walking, sneezing, coughing or breathing deeply. Pain in the lower right quadrant because the position of the right leg extension / seated upright position.
  • Fever over 38 0C.
  • Psychological data seem anxious clients.
  • There are changes in pulse rate and breathing.
  • Weight as an indicator to determine the drug.

3. Examination Support
  • Signs of peritonitis, lower right quadrant. Line drawings of air fluid level in the cecum or ileum.
  • Erythrocyte sedimentation rate (ESR) is increased in the state of appendicitis infiltrates.
  • Routine urinalysis is important to see what there is infection in the kidney.
  • The increase of leukocytes, Neutrophilia, without eosinophils.
  • Appendix on barium enema is not filled.
  • Ultrasound: fekalit non-calcified, non-perforated appendix, appendix abscess.

10 Nursing Diagnosis for Anemia

Nursing Diagnosis for Anemia

Anemia is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin deficiency.

Causes of Anemia
Except for the acute form, anemia is a result of systemic toxemia and acidosis-a condition of poisons, toxins and accumulated waste products floating in the blood - and lymph-streams, and of enervation or lowered nerve-tone. There is either an accumulation of these injurious substances due to failure of eliminative organs to handle a normal amount of such products, or they are produced in such considerable quantities that even normal organs, eliminating a normal amount or more than a normal amount of eliminations can not remove them rapidly enough. They have the effect of poisoning the organs that make the blood cells, which produce a deficient amount of blood cells or altered blood cells.
The signs and symptoms of this disease are:
1. Paleness
2. Headache
3. Irritability
Symptoms of more severe iron deficiency anaemia include:
1. Dyspnea
2. Rapid heartbeat
3. Brittle hair and nails

Clinical Manifestations of Anemia

Clinical symptoms that appear to reflect impaired function of the various systems in the body including decreased physical performance, neurological (nerve) which is manifested in changes in behavior, anorexia (loss emaciated), and abnormal cognitive development in children. Growth abnormalities often occur, epithelial dysfunction, and reduced gastric acidity.

Anemia can cause fatigue, weakness, lack of energy and the head was floating. If the anemia gets worse, can lead to stroke or heart attack (Sjaifoellah, 1998).

Here is  11 Nursing Diagnosis for Anemia - Nursing Care Plan for Anemia

  1. Activity Intolerance
  2. Impaired oral mucous membrane
  3. Imbalanced Nutrition: Less than Body Requirements
  4. Constipation/Diarrhea
  5. Risk for Infection
  6. Risk for deficient fluid volume
  7. Deficient Knowledge regarding condition, prognosis, treatment, self-care, prevention of crisis, and discharge needs,
  8. Fatigue
  9. Fear
  10. Ineffective coping

Nursing Care Plan for Peritonitis Nursing Diagnosis Risk for Infection

Nursing Diagnosis Risk for Infection Nursing Care Plan

Definition: At increased risk for being invaded by pathogenic organisms
Related Factors: See Risk Factors.

Risk Factors:

Invasive procedures; insufficient knowledge regarding avoidance of exposure to pathogens; trauma; tissue destruction and increased environmental exposure; rupture of amniotic membranes; pharmaceutical agents (e.g., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Immune Status
Knowledge: Infection Control
Risk Control
Risk Detection

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Infection Control
Infection Protection

Client Outcomes

Remains free from symptoms of infection
States symptoms of infection of which to be aware
Demonstrates appropriate care of infection-prone site
Maintains white blood cell count and differential within normal limits
Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.


Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

 Reference : http://careplannursing.blogspot.com/2011/12/risk-for-infection-nursing-care-plan.html

Sample Nursing Care Plan (ncp) for COPD

Chronic obstructive pulmonary disease (COPD) is one of the most common lung diseases. It generally defines the conditions which consist of regular difficulty in expelling or exhaling air from the lungs. There are two major forms of COPD: chronic bronchitis and emphysema. Chronic bronchitis consists of a long term cough with mucus. Emphysema is a gradual destruction of the lungs. Most people who have COPD have a combination of these forms because smoking is a major cause of both of them.

There are a few signs of COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are :
  • tachypnea, a rapid breathing rate
  • wheezing sounds or crackles in the lungs heard through a stethoscope
  • breathing out taking a longer time than breathing in
  • enlargement of the chest, particularly the front-to-back distance (hyperaeration)
  • active use of muscles in the neck to help with breathing
  • breathing through pursed lips
  • increased anteroposterior to lateral ratio of the chest (i.e. barrel chest).
Sample Nursing Care Plan (ncp) for COPD

NANDA Chronic Obstructive Pulmonary Disease

1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.

3. Impaired Gas Exchange related to ventilation perfusion inequality.

4. Activity Intolerance related to imbalance between supply with oxygen demand.

5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

6. Disturbed Sleep Pattern related to discomfort, the setting position.

7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.

8. Anxiety related to threat to self-concept, the threat of death, unmet needs.

9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.

10. Knowledge Deficit related to lack of information, do not know the source of information.


Sample Nursing Diagnosis and Nursing Intervention for COPD

Ineffective airway clearance related to the disruption of production increased secretions, retained secretions

Goal : Ventilation / oxygenation to the needs of clients.

Outcome : Maintain a patent airway and breath sounds clean

Intervention
  • Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
  • Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
  • Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
  • Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress
  • Help the abdominal breathing exercises or lip.
  • Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
  • Increase fluid intake to 3000 ml / day according to tolerance of the heart.
  • Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).

Pneumonia and Nursing Interventions

Nursing Care Plan for Pneumonia
Nursing Diagnosis for Pneumonia 
Nursing Interventions for Pneumonia

Pneumonia is an illness that affects one or both lungs and that used to be one of the main causes of death 2 centuries ago. It is caused by microorganisms that attack the tissue from the lungs, causing it to inflammate and leading to a severe condition if the infection is not treated in time.

Viral pneumonia is very common form of pneumonia affecting children, teenagers and the elderly. It can sometimes be mistaken for either the flu or a cold. Viral pneumonia presents the following symptoms: inflammation of the throat, productive or non-productive cough, a swelling in the lymph nodes, chest discomfort during breathing, mild to severe headache and a generalized feeling of fatigue. The cough may or may not produce varying amounts of mucus. You may also experience a mild fever and chills.

Pneumonia

1. Impaired Gas Exchange

2. Ineffective Breathing Pattern

3. Risk for Infection related

4. Ineffective airway clearance

5. Activity Intolerance


Nursng Interventions - Impaired Gas Exchange for Pneumonia:

- Assess the frequency / depth and ease of breathing
Rational: the manifestation of respiratory distress depends on the indication of the degree of lung involvement and general health status.

- Observe the color of skin, mucous membranes and nails. Note the presence of peripheral cyanosis (nail) or central cyanosis.
Rational: nails showed cyanosis vasoconstriction body's response to fever / chills, but cyanosis on the ears, mucous membranes and skin around the mouth indicate systemic hypoxemia.

- Assess mental status.
Rational: nervous irritability, confusion and somnolence may indicate cerebral hypoxia or decreased oxygen.

- Elevate the head and thrust frequently change position, breathe deeply and cough effectively.
Rationale: This action increases the maximum inspiration, increased spending secretions to improve ventilation ineffective.

- Collaboration
Give oxygen therapy correctly.
Rational: to maintain PaO2 above 60 mmHg. Oxygenation provided with a method that provides precise delivery.

Nursing Interventions - Ineffective Breathing Pattern for Pneumonia :

    Assess the frequency, depth of breathing and chest expansion
    Auscultation of breath sounds
    Elevate the head and help change the position
    Observation of cough pattern and character of secretions
    Encourage / help the patient breathe deeply and cough effectively exercise
    Give additional oxygen
    Watch the Blood Gas Analysis


Nursing Interventions - Ineffective Airway Clearance for Pneumonia :

- Assess the frequency / depth of breathing and chest movement
Rational: tachypnea, shallow breathing and chest movement was symmetrical often occurs because of discomfort.

- Auscultation of lung area, record the time there's an area of ​​decreased airflow and breath sounds
Rational: decrease in blood flow occurred in the area of ​​consolidation with fluid.

- Teach effective cough techniques
Rational: cough is a natural airway clearance mechanisms for maintaining a patent airway.

- Sucking as indicated
Rational: stimulate coughing or clearing the airway of mechanical noise on the factors that are not able to perform effectively because of a cough or a decreased level of consciousness.

- Give fluids at least
Rational: liquid (especially warm) mobilizing and removing secretions.

- Collaboration with physicians for drug delivery as indicated: mukolitik, ex.
Rational: a tool to reduce bronchial spasms with mobilization of secretions, analgesic given to improve the cough by decreasing the discomfort but should be used carefully, because it can reduce cough effort / suppress breathing.