Impaired Physical Mobility - NCP for Cellulitis

Nursing Care Plan for Cellulitis

Cellulitis is an infection streptococcal, staphylococcal acute, of the skin and subcutaneous tissue is usually caused by bacterial invasion through a tear in the skin area, however this can occur without evidence of side entry and this usually occurs in the lower extremities. (Tucker, 1998: 633).

The aetiology is derived from the bacterium Streptococcus sp. Other negative anaerobic microorganisms such as Prevotella, Porphyromona, and Fusobacterium (Berini, et al, 1999). Odontogenic infections are generally a mixed infection of a variety of bacteria, both aerobic and anaerobic bacteria has a synergistic function. (Peterson, 2003).

According Mansjoer (2000: 82) the clinical manifestations of chronic cellulitis is damage to the skin venous and lymphatic systems at both extremities, skin disorders such as diffuse infiltrates subcutaneous, local erythema, pain quickly spread and infitratif to the underlying tissue, swelling, red and warm tenderness , suppuration and leukocytosis.


Nursing Diagnosis : Impaired Physical Mobility related to neuromuscular disorders, pain / discomfort, decreased strength and resistance.

Goal: The client is able to move to the purpose of free range of motion, increase control and / or muscle mass.

Expected outcomes:

• The client expressed and demonstrated a desire to participate in the activity.
• The client can maintain the position of the function, evidenced by the absence of contractures.
• The client can maintain or improve the strength function ill and / or compensation of the body.
• The client shows the techniques / behaviors enabling activity.

Intervention:

1. Maintain proper body position.
Rational: improving the functional position of the limb and prevent contractures.

2. Note the circulation, movement and sensation in the fingers often.
Rational: edema can affect circulation in the extremities, which is the potential for tissue necrosis.

3. Perform rehabilitation at the reception.
Rational: it will be easier to make participation if the patient is aware of healing.

4. Perform range of motion exercises consistently, starting with passive then active.
Rational: prevent progressively tighten the abdominal tissue and contraction, increasing the maintenance function of muscle / joints and decrease the loss of calcium from bone.

5. Give the medicine before the activity / exercise.
Rational: reducing muscle stiffness and tension enables the patient to be more active and help participation.

6. Schedule of treatment and care activities to provide uninterrupted rest period.
Rational: improving strength and tolerance of the patient to the activity.

7. Instruct and assist in mobility, for example sticks, walkers, as appropriate.
Rational: improve security ambulation.

8. Encourage the patient's participation in all activities corresponding individual abilities.
Rational: enabling families / people closest to active in patient care and provide more therapeutic constant / consistent

9. Clean and close the wound quickly.
Rational: early excision is known to lower the risk of scarring and infection, so it helps healing.

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.