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Functional Health Patterns and 8 Nursing Diagnosis for Asthma

Nursing Care Plan for Asthma : Functional Health Patterns - Nursing Diagnosis

1. Health Perception – Health Management Pattern
  • Clients complain of shortness of breath, coughing, mucus difficult out.
  • Complain easily tired and dizzy.
  • Drug usage data.
  • Clients know / do not know the cause of the attack.
2. Nutritional – Metabolic Pattern
  • Nausea, vomiting, no appetite.
  • Shows signs of dehydration, dry mucous membranes.
  • Cyanosis, a lot of sweat.
3. Elimination Pattern

4. Activity – Exercise Pattern
  • Activity is limited because of wheezing and shortness of breath.
  • Smoking habits.
  • Cough and mucus that is difficult to remove.
  • Use of accessory muscles during inspiration.
5. Cognitive – Perceptual Pattern
  • The extent to which the client's knowledge about the disease.
  • The ability to overcome the problem.
  • The weakening process of thinking.
6. Sleep – Rest Pattern
  • Lack of sleep complaints.
  • Tired from the attack of shortness of breath and cough.
7. Self-perception – Self-concept Pattern
  • Clients likely to reveal the strategy to overcome the attack, but was unable to cope if the attack comes.
8. Role – Relationship Pattern
  • Disruption role in the attack.
  • Feel embarrassed if there is an attack.
9. Seuality – Reproductive Pattern

10. Coping – Stress Tolerance Pattern
  • Deny.
  • Angry.
  • Desperate.
11. Value – Belief Pattern






Nursing Diagnosis for Asthma

  1. Ineffective Airway Clearance r / t increased production of secretions.
  2. Impaired gas exchange r / t O2 supply disruption.
  3. Activity intolerance (in performing self-care) r / t shortness of breath, and physical weakness.
  4. Risk for imbalanced Nutrition: less than body requirements r / t input inadequate: nausea, vomiting and loss of appetite.
  5. Anxiety r / t shortness of breath and scared.
  6. Ineffective breathing pattern r / t decline in lung expansion during acute attacks.
  7. Risk for infection r / t inadequate primary defense (cilia work and persistence decrease secretions).
  8. Knowledge deficit r / t lack of information.

Pulmonary Tuberculosis (TB) - 3 Nursing Diagnosis, Interventions and Rational

Nursing Diagnosis for Plan Tuberculosis (TB) : Ineffective airway clearance related to the accumulation of purulent secretions in the airway.

Goal: Airway clearance back effectively.

Nursing Interventions:
  • Assess respiratory function, for example; breath sounds, speed and rhythm.
  • Give the patient semi-Fowler's position or high Fowler effectively assist the patient to cough and deep breathing exercises.
  • Maintain fluid intake at least 2500 ml / day, except, contra indications.
  • Collaboration for the administration of drugs according to indications, mucolytic drugs.

Rational:
  • Decreased breath sounds may indicate atelectasis, crackles, wheezing showed accumulation of secretions inability to clean the airway.
  • The position helps maximize lung expansion and lower respiratory effort.
  • High input of fluids helps to thin the secretions, making it easily removed.
  • Mucolytic agents decrease the viscosity and adhesion of lung secretions for easy cleaning.

Nursing Diagnosis for Plan Tuberculosis (TB) : Imbalanced Nutrition Less than Body Requirements related to the production of sputum, anorexia.

Goal: Demonstrate increased weight.

Nursing Interventions:
  • Record the patient's nutritional status, record of skin turgor, weight and degree of underweight, ability / inability to swallow, a history of nausea-vomiting.
  • Supervise the input or output and weight periodically.
  • Provide oral care before and after the act of breathing.
  • Encourage eating little and often with foods high in calories and high in protein.
  • Collaboration with a nutritionist to determine the composition of the diet.

Rational:
  • Useful in defining the degree / problems in determining appropriate intervention options.
  • Useful in measuring the effectiveness of nutrition and fluid support.
  • Lowering bad taste because the rest of the sputum or leftover medicines.
  • Maximize nutrient inputs as energy needs and decrease gastric irritation.
  • Provide assistance in planning a diet with adequate nutrients for metabolic and dietary needs.


Nursing Diagnosis for Plan Tuberculosis (TB) : Knowledge Deficit: on the conditions, rules of action and displacement.

Goal: To declare understanding of disease processes / prognosis and treatment needs.

Nursing Interventions:
  • Assess the patient's ability to learn. Example: the problem of weakness, the level of participation and the best environment.
  • Emphasize the importance of maintaining a high protein and carbohydrate diet and adequate fluid intake.
  • Explain the drug dose, frequency, expected work and long treatment reasons
  • Emphasize to not drink alcohol and do not smoke.
Rational:
  • Learning depends on the emotional and physical readiness improved in individual stages.
  • Meet the metabolic needs, help minimize the weaknesses and improve healing.
  • Increase cooperation in the treatment program and prevent withdrawal of the drug.

Risk for Injury - NCP for Cesarean Section


Nursing Care Plan for Cesarean Section

Nursing Diagnosis : Risk for Injury related to biochemical function or regulation, the effects of anesthesia, tissue trauma.

Goal:
  • Demonstrate behaviors to reduce risk factors and / or self-protection.
  • Free from complications.

Itervention:

1. Review the prenatal and intra prenatal record, the factors of clients in complications.
Rationale: The presence of risk factors such as fatigue miometrial, excessive uterine distension, slow oxytocin stimulation, or thrombophlebitis a prenatal, allowing clients more susceptible to post-operative complications.

2. Monitor blood pressure, pulse and temperature. Note the skin is cold, wet, weak pulse and subtle, changes in behavior, delayed capillary refill, or cyanosis.
Rationale: High blood pressure can indicate the occurrence or continuation of hypertension. Hypotension and tachycardia may indicate dehydration and hypovolemia but may not occur until the circulating blood volume has been decreased to 35% - 50%, pyrexia may indicate infection.

3. Inspection bandage against excessive bleeding.
Rationale: Surgical wounds with drain, can dampen the bandage, but seepage is usually not visible and can indicate the occurrence of complications.

4. Note the catheter and amount of lochia flow and consistency of the fundus.
Rationale: The flow of lochia should not be much or contains clots. Fundus must remain contracted, firmly on the umbilicus. Protrusion of the uterus resulting in increased blood flow and loss.

5. Encourage exercise foot / ankle and early ambulation.
Rationale: Increased venous return, preventing ataxia / buildup on the lower extremities, lower the risk of phlebitis.

5. Inspection incision regularly, note the slowdown, or a change in healing.
Rationale: Excessive Stretching the incision, slowing the healing can cause clients tend to tissue separation and possible hemorrhage.

6. Replace lost fluids intravenously, according to the program.
Rationale: Average blood loss typically 600-800 ml, but prenatal physiological edema, increasing the need for replacement of large fluid volumes.

7. Monitor hemoglobin / hematocrit Post-surgery, compared with preoperative levels.
Rationale: Clients with a hematocrit of 33% or greater and an increase in the plasma with respect to pregnancy can tolerate the actual blood loss.

8. Increase the oxytocin infusion if uterine relaxation and / or heavy lochia.
Rationale: Stimulate miometrial contractility and decrease blood loss.

Acute Pain - Nursing Care Plan for Cesarean Section


Nursing Diagnosis for Cesarean Section : Acute pain related to surgical trauma, anesthesia, hormonal effects, distended bladder / abdomen.

Goal:
  • Identify and use interventions to treat pain / discomfort appropriately.
  • Reveal a reduction in pain.
  • Relaxed able to sleep / rest.

Intervention:

1. Determine the characteristics and location of discomfort. Pay attention to verbal and non-verbal cues such as grimacing, stiffness, and limited movement or protect.
Rationale: The client may not be verbally reported pain and discomfort directly. Distinguish specific characteristics of pain and postoperative pain helps distinguish from complications.

2. Evaluation of blood pressure and pulse, note the change in behavior change.
Rationale: Pain can cause restlessness and increased blood pressure and pulse.

3. Change the position of the client, reduce harmful stimuli, and give a back rub. Encourage the use of breathing techniques, relaxation and distraction.
Rationale: muscle relaxes and distracts from the pain sensors.

4. Encourage early ambulation, Instruct to avoid gas-forming foods or liquids.
Rationale: Lower gas formation and increase the peristaltic to relieve discomfort due to gas accumulation.

5. Encourage the use of the left lateral recumbent position.
Rationale: Allows the gas increases from descending colon to the sigmoid, ease spending.

6. Palpate bladder, note the presence of the pain.
Rationale: Restore normal bladder function requires 4-7 days and overdistention of the bladder, creating a feeling of encouragement and discomfort.

7. Provide information for breastfeeding patients, the increased frequency of feeding, giving the exact position of the baby and mother's milk issued manually.
Rationale: This action can help the client lactation, stimulates milk flow and eliminates static and tension. Pillow helps support and protect the incision baby in a sitting position or tilted.

8. Encourage clients starting breastfeeding.
Rationale: The first strong sucking response and possible pain. Start breastfeeding may reduce pain and promote healing.

9. Collaboration of analgetic every 3-4 hours, continuing from the IV / intramuscular to the oral route. Give the drugs to clients who breastfeed 48-60 minutes before feeding.
Rationale: Improves comfort and correct the psychological status and improve mobility. Wise use of the drug, allowing the mother to enjoy the benefits of breastfeeding with no side effects in infants.

Down's Syndrome - Assessment, Nursing Diagnosis, Interventions and Evaluation


Nursing Care Plan for Down's Syndrome

Assessment

1. During the neonatal period, which needs to be studied:
  • The state of the body temperature, especially the neonatal period.
  • Nutritional needs / food.
  • The state of hearing and sight.
  • Assessment of cognitive abilities and mental development of children.
  • Children's ability to communicate and socialize.
  • Motor skills.
  • The ability of the family in caring for down syndrome premises, especially on the progress of the child's mental development.
2. Assessment of motor skills.
3. Assessment of cognitive abilities and mental development.
4. Assessment of the child's ability to communicate.
5. A hearing test, vision and bone abnormalities.
6. How family adjustment to diagnosis and progress of mental development.


Nursing Diagnosis for Down's Syndrome

1. Imbalanced nutrition less than body requirements related to difficulty feeding due to tongue far and high palate.

2. Risk for injury related to reduced hearing ability.

3. Ineffective Family Coping related to financial factors required in maintenance.

4. Lack of social interaction related to physical and mental limitations that they have.

5. Knowledge deficit (parents) related to down syndrome child care.


Interventions

1. Provide adequate nutrition.
  • See the child's ability to swallow.
  • Give parents information on the proper way / correct in giving good food.
  • Provide good nutrition in children with good nutrition.
2. Encourage parents to check their hearing and vision regularly.

3. Assess understanding parents about down syndrome.
  • Give an explanation to parents about the child's condition.
  • Give information to parents about the care of children with down syndrome.
4. Motivation of parents to:
  • Provide opportunities for children to play with the same age child to easily socialize.
  • Provide flexibility / freedom to children fatherly expression.
5. Give the motivation in the elderly in order to provide an adequate environment for children.
  • Encourage the participation of parents in giving motor exercises and instructions so that children are able to speak.
  • Encourage the parents to give children practice in their daily activities.


Evaluation
1. There is no difficulty in feeding the child. Child so that the child gets adequate nutrition and adequate.
2. Hearing and vision of the child can be detected early and can be evaluated on a regular basis.
3. Families participate actively in the care of children with down syndrome either.
4. Children are able to socialize and interact well so that children can build relationships with other people do not feel insecure.

Bronchopneumonia - Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis and Interventions for Bronchopneumonia -

1. Ineffective airway clearance related to accumulation of secretions.

Goal: Airway clearance back effectively.

Outcomes: secretions can come out.

Interventions:
  • Monitor respiratory status every 2 hours, assess the increase in respiratory and abnormal breath sounds.
  • Do suction as indicated.
  • Give oxygen therapy every 6 hours.
  • Create an environment / convenient so patients can sleep.
  • Give a comfortable position for the patient.
  • Monitor blood gas analysis to assess respiratory status.
  • Perform chest percussion.
  • Provide sputum for culture / sensitivity test.


2. Impaired gas exchange related to changes in alveolar capillaries.

Goal: back to normal gas exchange.

Outcomes: The client showed improved ventilation, gas exchange and oxygenation optimally adequately.

Interventions:
  • Observation of level of consciousness, respiratory status, signs cianosis.
  • Give appropriate sleeping position fowler / semi-Fowler.
  • Give oxygen according to the program.
  • Monitor blood gas analysis.
  • Ciprtakan comfortable environment.
  • Help prevent fatigue.


3. Fluid volume deficit related to excessive output.

Goal: Client will maintain normal body fluid.

Outcomes: no sign of dehydration.

Interventions:
  • Record intake and output of fluids (fluid balance).
  • Encourage the mother to continue to provide oral fluid.
  • Monitor fluid balance, mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs.
  • Maintain a drip infusion accuracy.
  • Observation of vital signs (pulse, temperature, respiration).


4. Risk for Imbalanced nutrition less than body requirements related to inadequate nutritional intake.

Goal: The nutritional requirements are met.

Outcomes: The client can maintain / improve nutritional intake.

Intervetions:
  • Assess the client's nutritional status.
  • Perform a physical examination of the abdomen (auscultation, percussion, palpation, and inspection).
  • Measure the client's body weight every day.
  • Assess for nausea and vomiting.
  • Give the diet a little but often.
  • Provide food in a warm state.
  • Collaboration with the nutrition team.


5. Increased body temperature related to the infection process.

Goal: There is an increase in body temperature.

Outcomes: Hyperthermia / increase in temperature can be resolved with no infection process.

Interventions:
  • Observation of vital signs.
  • Provide and encourage families to provide water compress on the forehead area and armpits.
  • Involve the family in every action.
  • Give drink orally.
  • Replace wet clothing with sweat.
  • Collaboration with doctors in febrifuge.


6. Knowledge Deficit : parents, about the care of clients related to a lack of information.

Goal: Knowledge parents about the child's illness increased after the act of nursing.

Outcomes: Parents know about the child's illness.

Interventions:
  • Assess the level of parental knowledge about the child's illness.
  • Assess the client's level of parental education.
  • Help parents to develop a plan of nursing care in the hospital such as: diet, rest and activity accordingly.
  • Emphasize the need to protect children ..
  • Explain to the client's family about the definition, causes, signs and symptoms, treatment, and prevention of complications by providing health education.
  • Give parents the opportunity to ask clients about things not yet understood.


7. Anxiety children related to the effects of hospitalization.

Goal: Anxious children is reduced / lost.

Outcomes: The client can be quiet, anxious lost, comfortable feeling fulfilled after the act of nursing.

Interventions:
  • Assess the client's level of anxiety.
  • Encourage the mother / family to give suport to the child by way of the mother is always near to the client.
  • Facilitating a sense of comfort by way of participating mothers caring for their children.
  • Make a visit, contact with clients.
  • Encourage other family visiting clients.
  • Give A toy according client's home.


Evaluation

The evaluation is expected in patients with Brochopneumonia are:
  1. Normal gas exchange.
  2. Effective airway clearance.
  3. Intake and output balance.
  4. Adequate nutritional intake.
  5. Body temperature within normal limits.
  6. Increase family knowledge.
  7. Anxiety resolved.

NCP for Bronchopneumonia with 7 Nursing Diagnosis

Nursing Care Plan for Bronchopneumonia

Definition

Bronchopneumonia is an inflammation of the lungs that affects one or more lobes of the lungs characterized by patches of infiltrates (Whalley and Wong, 1996).

Bronchopneumonia is the frequency of pulmonary complications, long productive cough, signs and symptoms usually increased temperature, increased pulse rate, increased respiration (Suzanne G. Bare, 1993).

Bronchopneumonia also called lobularis pneumonia, is inflammation of the lungs caused by bacteria, viruses, mold and foreign objects (Sylvia Anderson, 1994).


Etiology
  • Bacteria : Diplococcus Pneumoniae, Pneumococcus, Streptococcus Haemolyticus Aureus, Haemophilus Influenzae, Bacillus Friedlander, Mycobacterium Tuberculosis.
  • Virus : Respiratory syncytial virus, influenza virus, citomegalic virus.
  • Fungi : Histoplasma capsulatum, Cryptococcus Nepromas, Blastomyces Dermatitidis, Coccidioides Immitis, Aspergillus Sp, Candida Albicans, Mycoplasma Pneumonia.
  • Foreign body aspiration: Factors that influence the incidence of bronchopneumonia was decreased endurance for example due to protein energy malnutrition (MEP), chronic disease, antibiotic treatment is not perfect.


Clinical Manifestations

Usually preceded by upper respiratory tract infection. This disease usually occurs suddenly, rising temperatures 39-40 OC with shaking chills, shortness of breath and rapid coughing non productive "breath sound" percussion dim when the lung examination, auscultation of breath sounds smooth wet crackles and loud.

Cough and cold which may weigh up to respiratory insufficiency begins with upper tract infection, patients with a dry cough, headache, muscle pain, anorexia, and difficulty swallowing.


Complication

Complications of bronchopneumonia are:
  • Atelectasis is the development of the lungs that are not perfect or lung collapse is due to a lack of mobilization or cough reflex is lost.
  • Emphysema is a condition in which the accumulation of pus in the pleural space are in one place or the entire pleural cavity.
  • Lung abscess is a collection of pus in the inflamed lung tissue.
  • Systemic infection.
  • Endocarditis is an inflammation of the endocardial each valve.
  • Meningitis is an infection that attacks the lining of the brain.

Assessment for Bronchopneumonia

1. Health history
  • A history of previous respiratory tract infection: cough, runny nose, fever.
  • Anorexia, difficulty swallowing, nausea and vomiting.
  • History of immune-related diseases such as malnutrition.
  • Other family members were experiencing respiratory illness.
  • Productive cough, breathing nostrils, rapid and shallow breathing, anxiety, cyanosis.
2. Physical examination
  • Fever, tachypnea, cyanosis, respiratory nostril.
  • Auscultation of pulmonary crackles wet.
  • Laboratory leukocytosis, increased erythrocyte sedimentation rate or normal.
  • Abnormal chest x-ray (spotting, scattered consolidation in both lungs).
3. Psychological factors / developments to understand actions.
  • Age level of development.
  • Tolerance / ability to understand actions.
  • Coping.
  • Separate experiences of family / parents.
  • Previous experience respiratory infections.
4. Knowledge families / parents
  • The level of knowledge of respiratory disease families.
  • Family experience of respiratory disease.
  • Readiness / willingness to learn to take care of her family.

Nursing Diagnosis for Bronchopneumonia
  1. Ineffective airway clearance related to accumulation of secretions.
  2. Impaired gas exchange related to changes in alveolar capillaries.
  3. Fluid volume deficit related to excessive output.
  4. Risk for Imbalanced nutrition less than body requirements related to inadequate nutritional intake.
  5. Increased body temperature related to the infection process
  6. Knowledge Deficit : parents, about the care of clients related to a lack of information.
  7. Anxiety children related to the effects of hospitalization.

Nursing Care Plan for Personal Hygiene


Definition of Personal Hygiene
  • Personal hygiene is derived from the Greek language which means individual personal hygiene and healthy means. Personal hygiene is an action to maintain the cleanliness and health of a person's physical well-being.
  • Personal hygiene is an individual effort in maintaining personal hygiene which includes cleanliness of hair, teeth and mouth, eyes, ears, nails, skin, and dressed in improving hygiene in optimal health (Effendi, 1997).
  • Personal Hygiene is an act of maintaining the cleanliness and health of a person's physical and psychological well-being. The size of a person's cleanliness or appearance in fulfilling the needs of Personal Hygiene Personal differences in pain due to an interruption fulfillment.

Purposes of Personal Hygiene
  • Improve the health of a person.
  • Illness and disability can affect immabolisasi.
  • Maintaining the cleanliness of a person.
  • Fixing personl hygiene is lacking.
  • Prevent disease.
  • Improving one's self-confidence.
  • Creating beauty (tarwoto, 2004).


Factors affecting the Personal Hygiene
  • Body image. Image individuals against themselves strongly influence personal hygiene, for example due to a physical change that is never an individual concerned about hygiene
  • Social practices. In the children are always spoiled in personal hygiene, may lead to a change in personal hygiene.
  • Socioeconomic status. Changes in hygiene requires tools and materials such as soap, toothpaste, shampoo, bath equipment, all of which require a fee to provide it.
  • Knowledge. Knowledge of personal hygiene is very important because of his extensive knowledge to improve health.
  • Culture. Most of the people if a certain sick individuals, it must not be bathed.
  • The habit of a person. There is a custom of someone who uses pruduk tertuntu in self-care such as the use of soap, etc. sampoh.
  • Physical state. In particular illness, diminished ability to care for themselves and perlumembantu to do so.

Various of Personal Hygiene

Maintenance of personal hygiene means maintaining cleanliness and hygiene measures a person's physical and psychological well-being. A person is said to have good personal hygiene when, the person can have good personal hygiene which includes cleanliness of the skin, teeth and mouth, hair, eyes, nose, and ears, feet and nails, genitalia, as well as the cleanliness and tidiness pakaiannya.Menurut Potter and Perry (2005 ) assorted personal hygiene and the aim is:

1 Skin Care

The skin is an active organ that serves as a protector of various germs or trauma, secretion, excretion, temperature regulator, and sensation, so that adequate care is needed in maintaining its function. The skin has three main layers of the epidermis, dermis, and subcutaneous. When patients are not able or do personal skin care the nurses provide help or teach families how to carry out personal hygiene. A patient who is unable to move freely due to illness will be at risk of skin damage. Body parts hanging and exposed to pressure from the bottom surface of the body (eg matrasi body casts or wrinkled linen lining), will reduce circulation to the affected part of the body that can lead to pressure sores. Moisture on the surface of the skin is a bacterial growth medium and cause local irritation, smoothes the epidermis cells, and can cause skin maceration. Sweat, urine, watery fecal material and wound drainage may accumulate on the surface of the skin and will cause skin damage and infection. Patients who use some kind of external devices such as a cast skin, clothes fastener, bandages, dressings, and orthopedic jacket can exert pressure or friction on the skin surface so as causing skin damage. The purpose of skin care is the patient will have the skin intact, free of body odor, the patient can maintain range of motion, feel comfortable and prosperous, and can berpartisifasi and understand methods of skin care.

2 Bath

Bathing the patient is a total hygienic care. Bath, can be categorized as a cleansing or therapeutic. Bath, in bed complete necessary for patients with total dependence and requires total personal hygiene. Breadth bathing patients and methods used for bathing is based on the patient's physical abilities and needs of the required level of hygiene. Patients who rely in meeting personal hygiene needs, lying in bed and not being able to reach all members of the body can obtain most of the bath in bed. The purpose of bathing patients in bed is to maintain the cleanliness of the body, reduce infections caused by dirty skin, improving blood circulation system, and increase patient comfort. Bath can eliminate microorganisms from the skin and body secretions, eliminates bad odor, improve blood circulation to the skin, and make the patient feel more relaxed and refreshed. Patients can be bathed every day in the hospital. However, if the patient's skin dry, the bath may be limited once or twice a week so it will not add to the skin to become dry. Nurses or family members may need to help the patient to walk to the bathroom or the back of the bathroom. Nurse or family member must be there to help the patient flushed or dry out if necessary clean or replace clothes after bathing. Sometimes patients can bathe themselves in bed or they need the assistance of a nurse or family member to bathe the back or legs. Sometimes patients can not bathe themselves and the nurse or family member to bathe the patient in bed.

3. Oral hygiene

Patient immobilization is too weak to perform oral care, as a result, the mouth becomes too dry or irritated and cause unpleasant odors. These problems can be increased due to disease or medication used by the patient. Oral care should be done every day and depend on the state of the patient's mouth. Teeth and mouth is an important part of cleanliness must be maintained through this organ for a variety of germs can enter. Oral hygiene helps maintain the health status of the mouth, teeth, gums, and lips, scrub clean the teeth of food particles, plaque, bacteria, memasase gums, and reduce discomfort resulting from the smell and taste that is uncomfortable. Some diseases that may arise as a result of dental care and poor oral is caries, gingivitis (gum inflammation), and thrush. Good oral hygiene provide a sense of sound and further stimulate appetite. The purpose of oral hygiene care patient is a patient will have an intact oral mucosa are well hydrated and to prevent the spread of diseases that are transmitted through the mouth (eg typhoid, hepatitis), diseases of the mouth and teeth prevent, increase endurance, achieve a sense of comfort, understanding oral hygiene practices and able to perform their own oral hygiene care properly.

4. Eye, nose, and ears care

Special attention is given to cleaning the eyes, nose, and ears during bathing patients. Normally there is no special care needed for the eye because it is continuously cleaned by water eyes, eyelids and eyelashes to prevent the entry of foreign particles into the eye. Normally, the ears do not actually need cleaning. However, patients with too much wax, ears need to be cleaned either independently or performed by nurses and family. Ear hygiene has implications for auditory acuity. If the foreign body assembled on the outer ear canal, it will interfere with the conduction of sound. The nose serves as the sense of smell, monitor the temperature and humidity of inhaled air, and prevent the entry of foreign particles into the respiratory system. Patients who have limited mobilization need help nurses or family members for treatment of eyes, nose, and ears. Treatment goals eyes, nose, and ears are the patient will have a normal functioning of sensory organs, eyes, nose, and ears of the patient will be free from infection, and the patient will be able to make eye care, nose, and ears everyday.

5. Hair Care

Appearance and well-being often depends on the way the look and feel of the hair. Illness or disability prevents a person to maintain day-to-day hair care. Brush, comb and shampoo are basic hygienic ways of hair care, hair distribution pattern can be an indicator of general health status, hormonal changes, emotional and physical stress, aging, infections and certain diseases or drugs can affect the characteristics of the hair. Hair is part of the body which have a function as protection and temperature control, through hair changes in health status itself can be identified. Illness or disability makes the patient can not maintain the daily hair care. Patient immobilization hair tends to look wrinkled. Brushing, combing, and shampoo the hair higyene basis for all patients. Patients should also be allowed to shave when conditions permit. Patients who are able to perform self-care should be motivated to maintain their daily hair care. Whereas in patients who have limited mobilization need help nurse or the patient's family in doing higyene hair. The purpose of hair care is the patient will have the hair and scalp clean and healthy, the patient will achieve a sense of comfort and self-esteem, and the patient can berpartisifasi in hair care practices.

6. Foot and nail care

Feet and nails often need special attention to prevent infection, odor, and injury to the tissue. But often people are not aware of foot problems and nail until there is pain or discomfort. Maintain cleanliness of nails is important in maintaining personal hygiene due to a variety of germs can enter the body through the nail. Therefore, the nail should remain healthy and clean. Treatments can be combined for a shower or at separate times. The purpose of the foot and nail care is the patient will have the intact skin and soft surface of the skin, the patient feels comfortable and clean, the patient will understand and perform foot and nail care methods correctly.

7 Genital care

Genitalia care is part of a complete bath. Patients who need care the most rigorous genitalia is the biggest risk patients acquired the infection. Patients who are able to perform self-care can be allowed to do their own. Nurses may be embarrassed to provide care genitalia, especially in patients of the opposite sex. Can be helpful to have a nurse of the same sex with the patient in the room at the time of treatment genitalia. The goal of treatment is to prevent the occurrence of genital infections, genital hygiene maintaining, improving comfort and maintaining personal hygiene.

Nursing Care Plan for Encephalitis - Assessment, Diagnosis and Interventions


Nursing Care Plan for Encephalitis

Definition
  • Encephalitis is an infection of the CNS caused by a virus or other microorganism that non-purulent.
  • Encephalitis is an infection of the brain tissue by a variety of microorganisms. Encefalopati terminology that was used for the same symptoms, no signs of infection are now no longer in use. (Abdoerrachman, et al, 1985).


Etiology

A wide variety of organisms can cause encephalitis, such as bacteria, protozoa, worms, fungi, spirokaeta, and viruses. The most common cause is a virus. Infection can occur due to virus attacks the brain directly or acute inflammatory reaction due to systemic infection or previous vaccination. Encephalitis can also be caused by the direct invasion of the cerebrospinal fluid during a lumbar puncture. Various types of viruses can cause encephalitis, despite similar clinical symptoms. According to the type of virus and its epidemiology, known to a wide variety of viral encephalitis.


Signs and Symptoms
  • The clinical symptoms of encephalitis is not specific, depending on the cause and extent of the areas affected by the infection. Generally obtained sudden temperature rise, before consciousness decreased, often complain of headache, vomiting frequently found, lethargi, photofobi, sometimes a stiff neck desertai if infection of the meninges.
  • Children appear irritable, agitated sometimes accompanied by changes in behavior. May be accompanied by impaired vision, hearing, speech, and seizures. Seizures may be general or focal or just twitching alone. Seizures can last for hours, diverse cerebral symptoms may occur individually or together, such as paresis or paralysis, aphasia, and so on.
  • Cerebrospinal liquor often within normal limits, sometimes found little elevation cell count, protein or glucose levels.
  • Cerebrospinal fluid examination: Colors are clear pleocytosis ranges from 50 to 2000 cells. Where lymphocyte cells are the dominant cell, the protein rather increased, whereas glucose within normal limits.
  • EEG: Shows a diffuse inflammatory process "Bilateral" with low activity.
  • Other signs and symptoms that often arise are: Nuchal rigidity, Kernig's signs, Ataxia, Muscle weakness, Diplopia, Confusion, Irritability, Coma.


Complications
  • Encephalitis can also occur as a complication of measles, mumps or chickenpox.
  • Complications include encephalitis beginning of the cardiovascular system, respiratory and neurologic usually the brain stem.
  • Encephalitis can cause residual neurologic defects after recovery.


Assessment for Encephalitis

Symptoms may occur gradually, but may also occur in acute
  • Headaches.
  • High temperature.
  • Ridgiditas nuchal.
  • Kernig's signs.
  • Ataxia.
  • Muscle weakness.
  • Paralysis.
  • Diplopia.
  • Confusion.
  • Irritability.
  • Lethargy.
  • Coma.


Nursing Diagnosis and Interventions for Encephalitis

1. Ineffective Cerebral Tissue Perfusion related to inflammatory processes, increased ICP.

Intervention:
  • Observation level of consciousness.
  • Check the status of neurology every 1-2 hours and if necessary until a stable state.
  • Monitor the signs of the rise of ICT (elevated BP, peurunan pulse, irregular breath, anxiety, changes in pupil).
  • Elevate head of bed 30 °.
  • Keep the neck and head straight to improve venous return.
  • Teach children to avoid the Valsalva manuever (coughing, sneezing).
  • Monitor signs / symptoms of septic shock (hypotension, increased temperature, increased RR, confusion, disorientation, peripheral vasoconstriction).

2. Risk for injury related to disorientation, seizures, and the unfamiliar environment.

Intervention:
  • Observation level of consciousness.
  • Check the status of neurology every 1-2 hours and if necessary until a stable state.
  • Maintain a calm and comfortable environment.
  • Limit the number of visitors.
  • Teach ROM exercises (passive, active) as recommended and regularly.
  • Collaboration of anticonvulsants.

3. Altered thought processes related to changes in the level of consciousness

Intervention:
  • Observation level of consciousness.
  • Check the status of neurology every 1-2 hours and if necessary until a stable state.
  • Monitor the signs of the rise of ICT.
  • Speak slowly and clearly.
  • Maintain a calm and comfortable environment.
  • Limit the number of visitors.

4. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, fatigue, nausea, and vomiting

Intervention:
  • Ask the patient's favorite food.
  • Provide the recommended diet.
  • Serve food in small portions but frequently.
  • Encourage to eat slowly.
  • Allow families to provide food for children.
  • Monitor body weight per day.
  • Create a pleasant environment.
  • Encourage family members to accompany the child during meals.
  • Limit fluid intake during meals.
  • Give good oral care.

5. Acute pain related to irritation encephalon

Intervention:
  • Assess the level of pain.
  • Evaluation indicators of pain (facial expression, crying), location, duration, spread, intensity, and precipitating factors.
  • Take action to support comfort (change position, imagination, distraction, massage, cold compresses).
  • Instruct child to menghindarigerakan that can improve ICT (coughing, sneezing, bending, straining).
  • Limit visitors.
  • Collaboration of analgesics.

Nursing Care Plan for Impaired Sense of Comfort : Pain

Nursing Care Plan for Pain

Pain is the most common reason a person seek medical assistance. Pain occurs with the disease process, diagnostic examination and treatment process. Pain is very annoying and difficult many people. Nurses can not see and feel the pain experienced by the client, because pain is subjective (between one individual to another individual is different in addressing the pain). Nurses provide nursing care to clients in a variety of situations and circumstances, which provide interventions to improve comfort. According to some theories of nursing, comfort is a basic requirement that the client is the purpose of nursing care. The statement was supported by Kolcaba who said that comfort is a state of fulfillment of basic human needs have.


Definition
  • According to the International Association for the Study of Pain (IASP), pain is a subjective sensory and emotional obtained unpleasant associated with actual or potential tissue damage or described the condition of the occurrence of the damage.
  • Specificity theory "suggest" states that pain is a specific sensory arise because of the injury and the information obtained through the peripheral and central nervous system through the pain receptors in the peripheral nerves and specific pain in the spinal cord.
  • Coffery mc (1979): a condition that affects a person, its existence is known only to the folks if they'd ever experienced.
  • Feurst W. Wolf (1974): a feeling of physical and mental suffering or feelings that cause tension.
  • Arthur C. Emilion (1983): a mechanism for the production of the body, arises when tissue is damaged and causes the individual to react to relieve pain.

Etiology

1. Trauma. Trauma is also divided into several kinds. The cause of the trauma is divided into:
  • Mechanics. The pain caused by this mechanical arising from free nerve endings were damaged. Examples of this pain is due to mechanical trauma due to impact, friction, and other injuries.
  • Thermal. Painful as this arises because the nerve endings gets receptor stimulation caused by heat, cold, such as fire and water.
  • Chemist. Pain caused by contact with chemicals that are strong acids or bases.
  • Electric. Pain is caused by the influence of a strong electric current on the pain receptors that cause muscle spasms and burns.
2. Neoplasms. This neoplasm is also divided into two, namely:
  • Benign neoplasms.
  • Malignant neoplasm.
3. Disorders of blood circulation, and blood vessel abnormalities. This can be exemplified in patients with acute myocardial infarction or angina pectoris that is felt is the typical chest pain.
4. Inflammation. Pain is caused due to damage to nerve endings receptor due to inflammation or pinched by swelling. An example is the pain due to abscess.
5. Psychological trauma.


Signs and Symptoms

Behavioral responses to pain may include:
  • Verbal statements (moan, cry, Shortness of Breath, Snoring).
  • Facial expressions (Wince, gritted teeth, biting lip).
  • Body movements (Restless, immobilization, muscle tension, increase finger and hand movements.
  • Contact with other people / social interaction (conversational Avoiding, Avoiding social contact.
  • Decreased attention span, focus on pain-relieving activity.
  • Individuals who experience a sudden onset of pain may react very differently to pain that lasts for a few minutes or become chronic. Pain can cause fatigue and make people too tired to moan or cry. Patients can sleep, even with severe pain. Patients may seem to relax and engage in the activity because it becomes adept at diverting attention to pain.


Physiological Respon to Pain

A. Sympathetic stimulation (mild pain, moderate, and superficial)
  • Bronchial tract dilatation and increased respiration rate.
  • The increase in heart rate.
  • Peripheral vasoconstriction, increased BP.
  • Increased blood sugar values​​.
  • Diaphoresis.
  • Increased muscle strength.
  • Dilated pupils.
  • Decreased GI motility.
B. Stimulus parasympathetic (severe pain and in)
  • Pallor.
  • Hardened muscles.
  • Decreased HR and BP.
  • Rapid breathing and irregular.
  • Nausea and vomiting.
  • Fatigue and exhaustion.

Meinhart & McCaffery describe the 3 phases of the experience of pain:

Anticipation phase: occurs before pain received
This phase may not be the most important phase, because this phase can affect the other two phases. In this phase allows one to learn about the pain and the effort to relieve pain. The role of the nurse in this phase is very important, especially in providing information to the client.
Example: prior to surgery, the nurse describes the pain that will be experienced by the client after the surgery, so the client will be better prepared with the pain that will be encountered.

Sensation Phase : occurs when the pain feels.
This phase occurs when the client feel the pain, because the pain is subjective, then each person in dealing with the pain also varies. Tolerance to pain will also vary from one person to another person. People who have a high level of tolerance to pain will not complain of pain with a small stimulus, whereas people low tolerance to pain will be easier to feel pain with small painful stimulus. Clients with a high level of tolerance to pain is able to withstand the pain without help, otherwise people who have a low tolerance to pain is to find ways to prevent pain before the pain came.
The presence of enkephalins and endorphins help explain how different people feel the pain level of the same stimulus. Endorphin levels differ for each individual, individual with a little high endorphins pain endorphins and individuals with slightly greater pain.
Clients can express the pain in various ways, ranging from facial expressions, vocalizations and body movements. Expression of clients indicated that nurses used to identify patterns of behavior that indicate pain. Nurses should review carefully when clients express a bit of pain, not necessarily because people who do not express the pain was not experiencing pain. Such cases it would require the help of a nurse to help clients effectively communicate pain.

Aftermath phase: occurs when the pain is reduced or stopped
This phase occurs when the pain is reduced or lost. In this phase, the client still needs the control of the nurse, because pain is a crisis, thus allowing clients to experience residual symptoms after pain. If the client is experiencing recurrent episodes of pain, then the response due to the (aftermath) can be a serious health problem. Nurses play a role in helping to gain self control to minimize the fear of the possibility of recurring pain.


Classification of pain can be divided into:

1. According to the location of pain
  • Peripheral Pain. Peripheral pain is pain that is divided into 3 surface (superficial pain), pain in the (deep pain), pain appropriation (reffered pain). This appropriation means pain is pain felt in an area that is not a source of pain.
  • Central Pain. This pain occurs because of stimulation of the central nervous system, spinal cord, brain stem.
  • Psychogenic Pain. This pain is felt in the absence of an organic cause, but the result of psychological trauma.
  • Phantom Pain. Phantom Pain is a feeling on the part of the body that no longer exists, for example in amputation. Phantom pain arising from severe dendrite stimulation compared to stimulation of receptors normally. Therefore, the person will feel pain at the areas that have been raised.
  • Pain radiating. Pain is felt at the source which extends into the surrounding tissue.

2 According to the nature of pain.
  • Incidental. That is the nature of pain which arise from time to time and then disappear.
  • Steady. That is the nature of pain arising settled and felt in a long time.
  • Paroxysmal. That is the pain of high intensity and very strong and usually persists for 10-15 minutes, then disappears and then comes back.
  • Pain intractable. That is the nature of pain resistant to treatment or reduced. Example in arthritis, administration of narcotic analgesics is contraindicated due to the length of the disease that can lead to addiction.

3 According to the severity of pain.
  • Mild pain is pain that is located in a low intensity.
  • Moderate pain is pain that causes a physiological reaction and psychological reactions.
  • Heavy pain is pain that is located in a high intensity.
4 According to the time of the attack.
  • Acute Pain. Acute pain is usually short-lived, such as pain at the fracture. Clients who experience acute pain will generally show symptoms include: increased respiration, heart rate and increased blood pressure, and pallor.
  • Chronic Pain. Chronic pain develops more slowly and occurs in a longer time and in general, people are often hard to remember since when the pain began to be felt.



Nursing Care Plan for Pain

Assessment

Accurate assessment of pain is important for effective pain management efforts.
Pain is a subjective experience and perceived differently in each individual, the nurse needs to assess all the factors that affect pain, such as psychological factors, physiological, behavioral, emotional, and sociocultural. Assessment of pain consists of two main components, namely:

Nursing care of clients experiencing pain:

History of pain to get the data from the client
Direct observations on the behavioral and physiological responses of clients. The purpose of the assessment is to obtain objective understanding of the subjective experience.


Characteristics of pain (PQRST)
  • P (Provocative): factors that affect the severity of distress and pain.
  • Q (Quality): What kind; sharp, blunt, or broken.
  • R (Region): the journey of pain.
  • S (Severity / pain scale): severity / intensity of pain.
  • T (Time): long / time or frequency of pain attacks.


The things that need to be assessed:

1 Location
To determine the specific location of pain ask the client to indicate the area of pain, can with the help of images. Clients can mark parts of the body that is experiencing pain.

2 Intensity of pain
Use of pain intensity scale is an easy and reliable method to determine the patient's pain intensity.

3 Quality of pain
Sometimes the pain can feel like a pounded or tingling. Nurses need to record the words used to describe pain clients. For information have a big impact on the diagnosis and etiology of pain.

4 Patterns
The pattern of pain include the time of onset, duration, and recurrence intervals or pain. Therefore, nurses need to assess when the pain started, how long the pain lasts, whether recurrent pain, and pain at last appeared.

5. Factor precipitation
Sometimes, certain activities can trigger pain as an example, physical activity can cause severe chest pain. In addition, environmental factors (environment very cold or very hot), and emosionaljuga physical stressors can trigger pain.


Quality of pain

Sometimes the pain can feel like a pounded or tingling. Nurses need to record the words used to describe pain clients. For information have a big impact on the diagnosis and etiology of pain.

Pattern
The pattern of pain include the time of onset, duration, and recurrence intervals or pain. Therefore, nurses need to assess when the pain started, how long the pain lasts, whether recurrent pain, and pain at last appeared.

Symptoms that accompany
Symptoms include nausea, vomiting, dizziness, and diarrhea. These symptoms may be caused by the onset of pain or pain itself.

Influence on daily activities
By knowing the extent to which pain affects the client's daily activities will help nurses understand the client's perspective on pain. Some aspects of life that need to be examined in regard to pain is sleep, appetite, concentration, work, interpersonal relationships, marriage relationships, activities at home, at a time when leisure activity and emotional status.

Sources coping
Each individual has a different coping strategies in the face of pain. The strategy can be influenced by the experience of previous pain or influence of religion or culture.

Affective response
Client affective response to pain varies, depending on the situation, degree, and duration of pain, the interpretation of pain, and many other factors. Nurses need to assess the feelings of anxiety, fear, fatigue, depression, or feelings of failure on the client.


Observation of behavioral and physiological responses

Non-verbal responses that can be used as indicators of pain. One of the most important is the facial expression.
Behavior such as eyes tightly shut or wide open, biting the lower lip, and sneer face may indicate pain.

In addition to facial expressions, other behavioral responses that are indicative of pain is the vocalization (eg moans, crying, screaming), immobilization of the body that are experiencing pain, body movement without purpose (eg, kicking, flipping the mattress over the body reversal), etc..

While the physiological response to pain varies, depending on the source and duration of pain.
In the early onset of acute pain, the physiological response may include increased blood pressure, pulse, and breathing, diaphoresis, dilated pupils due srta terstimulasinya the sympathetic nervous system.
However, if the pain lasts longer, and the sympathetic nerve has been adapted, the physiological response may be reduced or even non-existent. Therefore, it is important for nurses to assess more than one response could be fisiolodis because the response is a poor indicator for pain.


Determination of Diagnosis
According to NANDA (2009-2011), nursing diagnosis for clients who are experiencing pain:
Acute Pain
Chronic pain


Nursing Diagnosis
  1. Acute Pain related to physical injury, reduction of blood supply, process of giving birth.
  2. Chronic pain related to the process of malignancy.
  3. Anxiety related to pain that is felt.
  4. Ineffective individual coping related to chronic pain.
  5. Impaired physical mobility related to musculoskeletal pain.
  6. Risk for injury related to lack of perception to pain.
  7. Disturbed sleep pattern related to low back pain.

Interventions:
Nurses develop a plan of nursing diagnoses that have been made​​. Nurses and clients together to discuss realistic expectations of action to overcome the pain, the degree of pain relief that is expected, and the effects are to be anticipated in lifestyle and client functions. Expected outcomes and objectives of nursing and nursing diagnoses are selected based on the client's condition. In general, the purpose of nursing care clients with pain are as follows:
  • Clients feel healthy and comfortable.
  • Clients retain the ability to perform self-care.
  • Clients maintain physical and psychological function held today.
  • Clients describe factors that cause pain.
  • Clients using the therapy given safely at home.
Nursing Diagnosis : Acute pain r / t physical injury (surgery)

Goal:
Pain level, pain control and comfort level with the expected outcomes:
  • Using a pain scale to identify the perceived pain.
  • Describing how to manage pain.
  • Expressing ability to sleep and rest.
  • Describing nonpharmacological therapy to control pain.
  • Vital signs within normal limits.
Interventions:
Pain management:
  • Assess pain experienced by clients (including PQRST).
  • Observation of nonverbal discomfort to pain.
  • Assess the client's experience of the past to pain.
  • Create a comfortable environment for clients.
  • Collaboration of analgesics.
  • Teach nonpharmacological techniques to cope with pain.
  • Etc. (see more fully in the NIC).
Intervention

Pain management consists of:
a. Pharmacological (collaboration); analgesic use.
Interfere with the reception / pain stimuli and its interpretation by pressing a function of the thalamus and cerebral cortex.
b. Non-pharmacological (standalone)
Therapeutic touch. This theory says that individuals who have a healthy balance between the body's energy with the outside environment. Sick people means there is an imbalance of energy, with a touch on the client, there is expected to transfer energy from the nurse to the client.
Acupressure. Giving emphasis on pain centers.
Guided imagery. Ask the client to imagine imagining things fun, this action requires an atmosphere and a quiet room and the concentration of clients. If the client is experiencing anxiety, action must be stopped. This action is done when the client feel comfortable and not in acute pain.
Distraction. Turning his attention to pain, effective for mild to moderate pain. Visual distraction (see TV or a football game), audio distraction (listening to music), touch distraction (massase, holding a toy), intellectual distraction (assembling puzzles, play chess)

Anticipatory guidence. Directly modify anxiety associated with pain. Examples of actions: the client before undergoing a surgical procedure, the nurse gives an explanation / information to the client about the surgery, so the client has no idea and will be better prepared for pain.
Hypnotize. Help change the perception of pain by affecting positive suggestions.

Biofeedback. Behavioral therapy is done by providing individual information about the physiological response to pain and how to train the voluntary control of the response. This therapy is effective for migraine and muscle tension, by placing electrodes on the temples.
Cutaneous stimulation. The workings of this system is still unclear, one is thinking this way can release endorphins, which can block pain stimulation. Could do with massase, warm baths, compresses with ice bags and transcutaneous electrical nerve stimulation (TENS / transcutaneus electrical nerve stimulation). TENS is a stimulation of the skin using a mild electrical current is delivered through the outer electrode.

The role of nurses in pain management:
  1. Identifying the cause of pain.
  2. Collaboration with other KES team for the treatment of pain.
  3. Provide pain relief intervention.
  4. Evaluating the effectiveness of pain relief.
  5. Acting as an advocate if pain relief is not effective.
  6. As educators keluarga§ and patients about pain management.

Nursing Care Plan for Tuberculous Spondylitis

Tuberculous spondylitis is a chronic granulomatous inflammation, destructive by mycobacterium tuberculosis. Tuberculous spondylitis is always a secondary infection from a focus elsewhere in the body. Percivall (1973) was the first author of this disease and states that there is a relationship between this disease with spinal deformity that occurs, so the disease is referred to as Pott's Disease. (Rasjad, 1998).

Clinically, tuberculous spondylitis symptoms similar to symptoms of tuberculosis in general, the weakness / lethargy, decreased appetite, weight loss, slightly increased temperature (sub-febrile), especially at night as well as back pain. In children, often accompanied by crying at night. (Rasjad. 1998).

At the beginning of radicular pain that can be found around the chest or abdomen, followed by paraparesis which was advancing more slowly, spasticity, clonus, hyperreflexia and bilateral Babinski's reflex. At this early stage of vertebral deformity has not been found, so there has been no word of pain in the spine. Persistent spinal pain, limited movement of the spinal and neurological complications are a sign of further destruction. Neurologic abnormalities occur in approximately 50% of cases, including the spinal cord due to the emphasis that causes paraplegia, paraparesis, or radix nerve pain. Signs are commonly found among them is the presence of kyphosis (gibbus), swelling in the paravertebral region, and signs of neurological deficits, as already mentioned above.

In tuberculous cervical vertebrae can be found in the back of the head pain, problems swallowing and breathing problems due to retropharyngeal abscess. It must be remembered in the beginning the emphasis from the anterior part so that clinical symptoms arise primarily motor disorders. Sensory disturbances in the early stages rarely found except when the posterior part of the bone is also involved.

Complications of tuberculous spondylitis of the most serious is Pott's paraplegia when appearing at an early stage due to the pressure extradural by pus or Sequester, or invasion of granulation tissue in the spinal cord and when they appear at an advanced stage due to the formation of fibrosis of granulation tissue or adhesions spine (ankylosing) above the spinal canal.

Myelography and MRI is helpful to distinguish the cause of this paraplegia. Paraplegic caused by extradural pressure by pus or Sequester require operative measures by way of decompressing the spinal cord and nerves.

Another possible complication is rupture of the thoracic paravertebral abscess into the pleural empyema causing tuberculosis, whereas in the lumbar spine, the pus will come down to form the iliopsoas muscle psoas abscess which is a cold abscess.


Nursing Diagnosis  for Tuberculous Spondylitis

1. Impaired physical mobility

2. Acute pain: joints and muscles.

3. Disturbed body image

4. Knowledge deficit: about home care.

(Susan Martin Tucker, 1998: 445)

Home Care : Basic Needs of the Elderly

Plans were made based on the problems faced by the elderly in order for the elderly, families, and health care workers, especially nurses, who perform either at home or in care homes, can help the elderly and the elderly themselves can function optimally in accordance with the abilities and physical condition, psychological, social and not depend on others.

The purpose of planning nursing actions on the elderly aimed at meeting basic needs such as:

1. Meeting the nutritional needs

The role of nutrition in the elderly is to maintain health and fitness, and slow the onset of degenerative diseases such as osteoporosis and defect common in the elderly, so that the elderly can achieve a healthy old age and remain active.

Nutritional deficiencies that may occur in the elderly can be caused by physical factors, psychological and social. Decreased olfactory and tasting tool, chewing less perfect and less comfortable when eating due to lack of complete dentition or worse, a full stomach and a sense of difficult defecation due to weakening of the muscles of the stomach and intestine will cause a decreased appetite elderly.

Changes in roles and situations in the elderly can lead to the onset of anxiety and despair that can lead to elderly refuse to eat or eat to excess.

Nutritional problems that often occur in the elderly is overnutrition (obesity, malnutrition), malnutrition (anorexia, weight loss), vitamin deficiency, and excess vitamin.


2. Improve safety and security

Accidents often occur in the elderly such as falls, traffic accidents, and fires. This is related to the aging process in which the flexibility of rigid began to decrease, characterized by the onset of mobilization problems due to pain in the joints. The situation is causing elderly are not able to refute her properly. In addition, a decrease in physical conditions such as vision and hearing to make the elderly less able to observe the surrounding situation so that they are prone to accidents.


3. Maintaining personal hygiene

As a result of the aging process, decline or motivation to perform self-care on a regular basis. It could also be a lack of self-care is caused because of memory loss in the elderly and therefore can not perform personal hygiene activities on a regular basis. It also deals with the elderly habits at a young age. If at a young age they are neat and clean, then usually they will continue to do self-care activities as well (if there are no physical limitations).


4. Maintaining the balance of sleep and rest
In general, age experience sleep disturbances due to the aging process. Efforts that can be done include:
  • Provide or allow time / comfortable bed.
  • Set the conducive environment (ventilation, sound).
  • Training the elderly to do light physical exercise for blood circulation and relaxes the muscles.
  • Provide a warm drink before bed.

5. Improving interpersonal relationships through communication

A common problem found in the elderly; memory loss, dementia, depression, irritability, irritable, and suspicious. This is caused by a decline in physical function in the elderly, and also because of inadequate interpersonal relationships.
Efforts that can be done include:
  • Communicating with the elderly by maintaining eye contact.
  • Provide stimulus or remind elderly to the activities undertaken.
  • Provide time to chat with old age.
  • Giving the elderly a chance to express feelings and respond to verbal and non-verbal responses elderly.
  • Involving the elderly in particular needs according to his ability.
  • Respect the opinion of old age.

NCP Hirschsprung's Disease : Assessment, Nursing Diagnosis and Interventions

Nursing Care Plan for Hirschsprung's Disease

Assessment of Hirschsprung's Disease

1. Activity / rest
  • Symptoms: Malaise, changing patterns of rest / sleep associated with pain, limitations.
2. Ego Integrity
  • Symptoms: Anxiety, fear, feelings of helplessness parents.
3. Elimination
  • Symptoms: Constipation can be accompanied by diarrhea.
  • Symptoms: Abdominal distension progressively, until the thin abdominal wall veins visible, peristaltic activity can be observed.
4. Food / fluid
  • Symptoms: Anorexia, nausea, vomiting, weight loss.
  • Signs: Decrease subcutan fat / muscle mass, weakness, a sign of malnutrition and growth failure.
5. Pain / comfort
  • Symptoms: Abdominal pain.
  • Signs: Facial expressions grimacing, moaning / crying, behavioral distraction, abdominal tenderness / distension.
6. Extension / learning
  • Parent questions related to the disease, care and treatment of children.
  • Patient's discharge plan: Requires assistance / demonstration how irrigation and colostomy care, the ability to assess the incidence of abdominal distension and obstruction.


Nursing Diagnosis and Interventions for Hirschsprung's Disease - Preoperative

1. Altered Bowel Elimination: observations related to hypertrophy and distention of the proximal colon.

Goal: Observation does not happen.

Outcomes:
  • Clients say can defecate.
  • Normal intestinal peristalsis.

Interventions:
1 Assess the client's pattern of elimination.
R /: Identify custom client to facilitate further action.

2 Encourage clients to drink water from 1500 to 2000 cc / day.
R /: Adequate fluid intake can improve the balance between absorption in the colon and fluid intake, thereby preventing the formation of a hard feeces.


2. Imbalanced Nutrition: Less Than Body Requirements related to intake less.

Goal: Fulfillment of nutrients can be resolved.

Outcomes:
  • Clients no nausea and vomiting.
  • Inkate adequate.
  • Clients are not weak.
Interventions:
1 Monitor food intake.
R /: Adequate intake affect the healing process.

2 Provision of adequate calories and balanced meals.
R /: Caloric intake helps the body to maintain homeostasis.

3 Encourage clients to spend a portion of their food.
R /: Adequate intake can assist in improving the general state of the client.


3. Anxiety related to ineffective coping.

Goal: Anxiety is resolved.
Outcomes:
  • Cheerful facial expressions.
  • Clients and their families are not asked again about his illness.
  • Clients and their families have hope of recovery.
Interventions:
1 Assess the level of anxiety.
R /: Make it easy for the next action.

2 Give the opportunity to the clients and their families to express his feelings.
R /: Thus the client and his family was relieved to express feelings.



Nursing Diagnosis and Interventions for Hirschsprung's Disease - Postoperative

1. Acute Pain related to the continuity of body tissues.

Goal: The client expresses a sense of comfort pain reduced / lost.
Outcomes:
  • Clients complained of pain at the surgical wound.
  • Cheerful facial expressions.
  • Vital signs within normal limits.
  • Relationships within normal limits.

Interventions:
1 Assess and record the location and duration of pain.
R /: Knowing the client's perception and reaction to pain as an effective basis for further intervention.

2 Give a fun position.
R /: Reduce emphasis on muscle and prevent muscle spasms that can cause pain.

3 Observation of vital signs every 2 hours.
R /: Practice deep breathing slowly and regularly will help to relax the muscles so that the supply of O2 to the tissue smoothly, thus reducing pain.

4 Implementation of appropriate analgesic drug administration programs.
R /: Analgesic serves to inhibit stimuli that are not perceived pain, so that pain is reduced / lost.


2. Disturbed Sleep Pattern related to postoperative wound pain.

Goal: Sleep patterns resolved.
Outcomes:
  • Clients sleep 7-8 hours.
  • Clients seem cheerful.
Interventions:
1 Assess sleep patterns and intirahat clients.
R /: Knowing the disturbance of rest / sleep clients to determine further intervention.

2 Create a pleasant environment.
R /: A quiet environment can provide peace to rest and sleep.

3 Encourage clients to a lot of rest and enough sleep.
R /: Adequate sleep can give a fresh taste to the clients and accelerate the healing process.

NCP for Abdominal Tumor - Nursing Diagnosis and Interventions


Nursing Care Plan for Abdominal Tumor

DEFINITIONS

Abdominal tumor is a solid mass with different thickness, which may wrap around large blood vessels and ureter. In the pathology of this disorder is easy to peel and can extend to retroperitonium, ureteral obstruction may occur or the inferior vena cava. Mass of fibrotic tissue that surround and define the structure in the wrapper but not invaded.

CAUSES

The immediate cause of the tumor is actually not known, but there are some results of the study showed that:
  • Excess nutrients, especially fat.
  • The end result of metabolic and bacterial.
  • Constipation.
  • Infections, trauma, hypersensitivity to the drug.

SIGNS AND SYMPTOMS
  • Pain
  • Anorexia, nausea, lethargy
  • Weight loss
  • Bleeding
  • Enlargement of the existing organ tumors

DIAGNOSTIC TEST
  • Digital rectal test
  • X - ray
  • Sigmoidoscope
  • Fiber optic scope plexible
  • Ultra sonography


Nursing Diagnosis and Interventions for Abdominal Tumor

1. Chronic Pain related to an emphasis on retroperitoneal organs,

Characterized by:
Subjective Data:
  • Clients say pain in the abdominal area.

Objective Data:
  • Grimacing facial expressions.
  • Tenderness in the abdomen.
Goal: Clients express pain diminished or disappeared.
Outcomes :
  • Clients do not complain of pain.
  • Cheerful facial expressions.
  • Vital signs within normal limits.

Interventions:
1. Assess and record the location and duration of pain.
R /: Knowing the client's perception and reaction to pain as an effective basis for further intervention.

2. Adjust the position of the fun.
R /: Reduce emphasis that can cause pain.

3. Observation of vital signs.
R /: Can be changed by pain and an indicator to assess the state of development of the disease.

4. Encourage clients to relax deep breath.
R /: It can help to relax the muscles so that the supply of O2 to the tissue smoothly so as to reduce pain.

5. Encourage clients perform massage around the painful area.
R /: Helps block pain stimuli that are not perceptible to the brain.

6. Management of analgesic drug administration according to the program so that the pain can be reduced / lost.


2 Risk for Imbalanced Nutrition: Less Than Body Requirements related to the intake of less

Characterized by:
Subjective Data:
  • Clients complains of nausea.
  • Clients say lack of appetite.

Objective Data:
  • Intake less
  • Vomiting
  • Appears weak
Goal: Nutritional needs can be met.

Outcomes:
  • Clients no nausea and vomiting.
  • Adequate Intake.
  • Clients are not weak.

Interventions:
1 Monitor food intake.
R /: Adequate intake affect the healing process.

2 Provision of adequate calories and balanced meals.
R /: Caloric intake helps the body in maintaining hemostasis.

3 Encourage clients to spend a portion of their food.
R /: adequate intake can assist in the process of wound healing and helps in improving the general state of the client.

4 Encourage clients to eat small meals but often.
R /: The food is more easily digested and can help intake is adequate.

5. Serve food in the form of interest and varies according to the client's nutritional needs.
R /: Increase appetite to fulfill the nutritional needs of the client.


3. Disturbed Sleep Pattern related to postoperative wound pain.

Goal: Sleep patterns resolved.

Outcomes:
  • Clients sleep 7-8 hours.
  • Clients seem cheerful.
Interventions:
1 Assess the client's pattern of sleep and rest.
R /: Knowing the disturbance of rest / sleep clients to determine further intervention.

2 Create a pleasant environment.
R /: A quiet environment can provide time for sleep.

3 Encourage clients to a lot of rest and enough sleep.
R /: Adequate sleep can give a fresh taste to the clients and accelerate the healing process.


4. Self-care deficit related to activity limitations.

Goal: The client indicates the requirement for self care.

Outcomes:
  • Clients can be dressed, bathing, bowel movement, bladder itself.
  • Clients seem fresh.
Interventions:
1 Assess the patient's ability in ADL.
R /: To determine the extent of assistance required to meet the client's ADL.

2 Assist clients in meeting the needs of bathing and dressing.
R /: Allows the requirement for a shower and get dressed so that the client can provide a fresh and comfortable sense.

3 Do activities ROM execise.
R /: To train all muscle movement and prevent muscle atrophy.

4 Encourage clients to practice sitting and walking.
R /: To train the muscle movement and the client does not feel bored to be in bed.

5. Encourage clients to perform self-care gradually.
R /: Self-care can gradually foster client independence in personal hygiene needs.


5. Anxiety related to ineffective coping

Goal: Anxiety is resolved

Outcomes:
  • Cheerful facial expressions.
  • Clients are not asked again about his illness.
  • Clients have the hope of recovery.

Interventions:
1 Assess the level of anxiety.
R /: Facilitate the further action ..

2 Assist clients in meeting the needs of bathing and dressing.
R /: Thus, the client was relieved to express his feelings to the nurse.

Nursing Management of Constipation

Examination begins with inspection of the abdominal area is there any enlargement of the abdomen, stretch or bulge. Further palpation on the surface of the abdomen to assess the strength of the abdominal muscles. Palpation over the faecal mass can be felt in the colon, the presence of a tumor or aneurysm of the aorta. On percussion, among others sought excessive gas gathering, organ enlargement, asietes, or the presence of faecal mass. Auscultation, among others, to listen to the sound of bowel movements, normal or excessive intestinal example on the bridge. Examination of the anal region provide an important clue, for example, is there any hemorrhoids, prolapse, fissures, fistulas, and tumor mass in the anal area can interfere with the process of defecation.

Digital rectal examination should be done, among others, to determine the size and condition of the rectum and the amount and consistency of stool.

Digital rectal can provide information about:
  • Rectal tone.
  • Sphincter tone and strength.
  • Pubo-rectal muscle strength and pelvic floor muscles.
  • Is there a mass pile of feces ?
  • Is there another mass (eg haemorrhoids) ?
  • Is there blood ?
  • Are there injury in the anus ?
Physical examination of constipation, most of the abnormalities found are not clear. However, careful examination and thorough needed to find abnormalities that could potentially affect the function of the colon in particular. Beginning with an examination of the oral cavity include gears, oral mucous membrane lesions and tumors that can disrupt a sense of taste and ingestion.

Laboratory tests associated with efforts to detect risk factors cause constipation, such as blood glucose, thyroid hormone levels, electrolytes, anemia associated with bleeding from the rectum, and so on. Other procedures such as anoscopy done routinely recommended in all patients with constipation to find there any fissures, ulcers, haemorrhoids and malignancy.

Abdominal plain radiography should be performed in patients with constipation, especially the occurrence of acute. This examination can detect there a fecal impaction and hard fecal masses that can cause blockage and perforation of the colon. If there were an estimated colonic obstruction, can be followed by barium enema to ensure a place and nature of the obstruction. Intensive examination is done selectively after 3-6 months of treatment of constipation is less successful and performed only at centers managing certain constipation.

Many kinds of drugs that are marketed for constipation, stimulating efforts to provide symptomatic treatment. Meanwhile, when possible, treatment should be directed at the cause of constipation. Long-term use of laxatives that are primarily stimulates intestinal peristalsis, should be limited. Treatment strategy is divided into:

1. Non-pharmacological treatment

Exercise colon: colon train is a suggested form of exercise behavior in patients with otherwise unexplained constipation. Patients are encouraged to hold a regular time each day to take advantage of large bowel movement. The recommended time is 5-10 minutes after eating, so it can take advantage of the gastro-colonic reflex to defecate. It is expected that this habit can cause sufferers to respond to the signs and induce bowel movements, and do not resist or postpone the urge to defecate.

Diet: The role of diet is important for constipation, especially in the elderly group. Epidemiological data indicate that a diet containing plenty of fiber reduces the incidence of constipation and various other gastrointestinal diseases, such as colorectal cancer and diverticular. Fiber increases stool weight and mass and shorten transit time in the gut. To support the benefits of fiber, adequate fluid intake is expected around 6-8 glasses a day, if there are no contraindications for fluid intake.

Sports: Pretty in activities or mobility and exercise help overcome constipation, walk or jog conducted in accordance with the age and ability of the patient, will invigorate the circulation and to strengthen the abdominal muscles of the abdominal wall, especially in patients with atony on the abdominal muscles .


2 Pharmacologic Treatment

If less successful behavior modification, pharmacological therapy is added, and is usually used class of laxative drugs. There are 4 types of laxative drug classes:

Enlarge and soften the stool mass.
Soften and lubricate the stool, this medicine works by lowering the surface tension of the stool, making it easier for water absorption.
Osmotic classes that are not absorbed, so it is quite safe to use, for example in patients with renal failure.
Stimulates peristalsis, thereby increasing the motility of the colon. This group is widely used. It should be noted that this class of laxatives can be used for long-term, can result in plexus mesentericus damage and colonic dysmotility.

When encountered severe chronic constipation and can not be solved by means of the above, surgery may be needed. Pasa generally, if not found a blockage due to the presence of a mass or volvulus, surgery was not performed.

Risk for Decreased Cardiac Output - NCP Acute Myocardial Infarction (STEMI)

Nursing Care Plan for AMI with ST elevation (STEMI)

Definition

Acute myocardial infarction is the destruction of tissue due to inadequate blood supply so that coronary blood flow is reduced. (Brunner & Suddath, 2002)

Acute myocardial infarction is the death of myocardial tissue caused by myocardial coronary blood damage, due to the inadequate blood flow. (Carpenito, 2000)

Acute myocardial infarction is ischemia or necrosis of the heart muscle caused by decreased blood flow through one or more coronary arteries. (Doengos, 2000)


Etiology

According to Noer, 1999; 103 caused by

a. Causal factors:

1. Oxygen supply to the heart is reduced due to:
a. Vascular factors: Atherosclerosis, spasm, arteritis.
b. Circulation Factor: hypotension, aortic stenosis, insufficiency.
c. Blood factors: anemia, hypoxemia, polycythemia.

2 Cardiac output increased
For example: Activity, emotional, eating too much, anemia, hyperthyroidism.

3. Increased myocardial oxygen demand at:
Myocardial damage, myocardial hypertrophy, diastolic hypertension.


b. Predisposing factors
1 Biological factors that can not be changed:
a. Age over 40 years.
b. Gender. The incidence is higher in men, whereas in women increases after menopause.
c. Heredity.
d. Race.

2 Risk factors that can be changed
a. Major; Hyperlipidemia, hypertension, heavy smoking, diabetes, obesity, a diet high in saturated fat.
b. Minor; physical activity, pattern type A personality (emotional, aggressive, ambitious, competitive).


Clinical Manifestations

Acute myocardial infarction usually occurs in men over 40 years and having artheriosklerosis. In the coronary vessels and is often accompanied by arterial hypertension. The attack also occurs in women and young men, early 30s or even 20s. Women who use the contraceptive pill and smoke have a very high risk. However, the overall incidence of myocardial infarction in men is higher than women at all ages.

Chest pain that lasted all of a sudden and continuous, located at the bottom of the sternum and upper abdomen is the main symptom that usually appears. Pain will be felt increasingly heavy can spread to the shoulder and arm, usually the left arm. Unlike the pain of angina pain arises spontaneously (not after heavy work or emotional disorders) and persist for several hours to several days and will not go away with rest or nitroglycerin. In some cases the pain may spread to the chin and neck, pain is often accompanied by shortness of breath, pallor, cold sweats, dizziness, light-headedness, nausea, vomiting (Brunner & Suddarth, 2002)


Pathogenesis

AMI with ST elevation (STEMI) usually occurs when coronary blood flow decreased abruptly after occlusion of thrombus on atherosclerotic plaque that already exists. STEMI occurs when a coronary artery thrombus occurs rapidly at the site of vascular injury, where the injury is triggered by factors such as smoking, hypertension, and lipid accumulation. In STEMI classical pathological picture consists of rich red fibrin thrombus, which is believed to be the basis of so STEMI respond to thrombolytic therapy. Furthermore, the location of plaque rupture, various agonists (collagen, ADP, epinephrine, serotonin) triggers platelet activity, which in turn will produce and release thromboxane A2 (potent vasoconstrictor local). In addition, platelet activation triggers a conformational change in the receptor glycoprotein IIb / IIIa. After experiencing a conversion function, the receptor has a high affinity for the amino acid sequence in soluble adhesion proteins (integrins) such as von Willebrand factor (vWF) and fibrinogen, both of which are multivalent molecules that can bind to two different platelets simultaneously, resulting in crosslinking of platelets and aggregation.

Coagulation cascade is activated by exposure of tissue factor on endothelial cells are damaged. Factor VII and X are activated, resulting in the conversion of prothrombin into thrombin, which then converts fibrinogen into fibrin. The coronary arteries are involved then will experience the occlusion by thrombus composed of platelets and fibrin aggregates. On rare occasions, STEMI may also be caused by occlusion of the coronary arteries caused by coronary embolism, congenital abnormalities, coronary spasm and systemic inflammatory diseases.



Nursing Care Plan for Acute Myocardial Infarction with ST Elevation (STEMI)

Nursing Diagnosis : Risk for Decreased Cardiac Output related to decreased constriction ventricular function, cardiac muscle degeneration.

Outcomes:
  • Lowering episodes of dyspnea, angina, and dysrhythmias.
  • Identify the behavior to decrease the heart's workload.

Nursing Interventions:

Independent

1. Monitor cardiac rhythm and frequency.
R /: Tachycardia and cardiac dysrhythmias may occur when attempting to increase cardiac output responds to fever. Hypoxia and acidosis due to ischemia.

2 Auscultation of heart sounds. Note the distance / tone heart, murmurs, S3 and S4 gallops.
R /: To provide early detection of complications such as CHF, cardiac tamponade.

3 Encourage bed rest in a semi-Fowler's position.
R /: Lowering cardiac workload, maximize cardiac output.

4 Provide comfort measures such as changes in position and back rub, and entertainment activity in cardiac tolerance.
R /: Improve relaxation and redirect the attention.

5. Encourage use of stress management techniques such as breathing exercises and guided imagery.
R /: This behavior can control anxiety, increase relaxation and decrease the work of the heart.

6 Evaluation of complaint fatigue, dyspnea, palpitations, chest pain continuously. Note the presence of breath sounds adventisius, fever.
R /: The clinical manifestations of CHF that can accompany endocarditis or myocarditis.


Collaborative

1 Give oxygen complement.
R /: Increase the availability of oxygen to myocardial function and decrease the effects of anaerobic metabolism, which occurs as a result of hypoxia and acidosis.

2 Give drugs in accordance with indications such as digitalis, diuretics.
R /: Can be given to increase myocardial contractility and decrease the workload of the heart in the presence of CHF (miocarditis).

3 Give Antibiotic / anti-microbial.
R /: Given to address the identified pathogens, prevent further heart damage.

4 Assist in emergency pericardiocentesis.
R /: The procedure was done in a bed can to lower the pressure in the fluid around the heart.

5. Prepare patients for surgery if indicated.
R /: Replacement valves may be required to improve cardiac output.

COPD - Gordon's Functional Health Patterns


Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease that is progressive, meaning that the disease lasts a lifetime and is slowly getting worse from year to year. In the course of this disease are the phases of acute exacerbation. Various factors play a role in the course of the disease, among other risk factors are factors that cause or aggravate diseases such as smoking, air pollution, environmental pollution, infections, genetics and climate change.

The degree of airway obstruction occurs, and the identification of components that allow for reversibility. Phase course of the disease outside the lung and other diseases such as sinusitis and chronic pharyngitis. That ultimately these factors make further deterioration occurs sooner. To undertake the management of COPD should be considered these factors, so that the better treatment of COPD. Chronic obstructive pulmonary disease is a broad classification of disorders that includes chronic bronchitis, bronchiectasis, emphysema and asthma, which is an irreversible condition associated with dyspnea on exertion and a decrease in the flow of air in and out of the lungs.

Lately the disease is more interesting to talk about because of the prevalence and mortality rate continues to increase. The increasing age of human life and to overcome other degenerative diseases, COPD is very disturbing quality of life of advanced age. Industry that can not be separated by air pollution and the environment as well as the habit of smoking is a major cause.



COPD - Gordon's Functional Health Patterns

Health Perception-Health Function
1) Past medical history, history of productive cough more than 2 weeks.
2) Smokers, examine shelter, ventilation, sunlight, pollution sources around the home, contact with smokers.
3) Difficulty mobilization and expenditure sputum, presence haemoptoe.
4) inadequate treatment.


Nutritional Metabolic Pattern
1) Anorexia
2) Nausea
3) Weight loss
4) Difficulty in eating or digestion


Activity Exercise Pattern
1) Weakness
2) Muscle cramps
3) Shortness of breath, cough


Sleep-Rest Pattern
1) Disruption of sleep patterns
2) Shortness of breath at night


Cognitive-Perceptual Pattern
1) Headache


Role-Relationship Pattern
1) Changes in the role.
2) Depression


Sexuality-Reproductive Pattern
1) Decrease in sexual activity because of shortness of breath


Coping-Areas Management Pattern
1) Sometimes the negative emotions that arise because of shortness of breath
2) Manipulation.
3) Isolation
4) Increased dependency