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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.