Custom Search

Nursing Diagnosis for Postoperative Laminectomy

Nursing Care Plan for Laminectomy
Laminectomy is an orthopaedic spine operation to remove the portion of the vertebral bone called the lamina. There are many variations of laminectomy. In the most minimal form small skin incisions are made, back muscles are pushed aside rather than cut, and the parts of the vertebra adjacent to the lamina are left intact. The traditional form of laminectomy (conventional laminectomy) excises much more than just the lamina; the entire posterior backbone is removed, along with overlying ligaments and muscles. The usual recovery period is very different depending on which type of laminectomy has been performed: days in the minimal procedure, and weeks to months with conventional open surgery.

Nursing Diagnosis for Postoperative Laminectomy, according to Doenges (1999), Tucker (1998).

1. Anxiety related to a crisis situation, continuous pain disorder.

2. Ineffective tissue perfusion related to decreased blood flow secondary to edema surgery.

3. Ineffective airway clearance related to decreased lung expansion secondary to pain.

4. Pain (acute / chronic) related to physical injuries agent; compression of nerve, muscle spasm, the incision surgery.

5. Impaired physical mobility related to pain and discomfort, muscle spasm, neuromuscular damage.

6. Constipation related to immobility, decreased physical activity.

7. Knowledge deficit: the condition, prognosis and actions related to lack of knowledge or information.
List of Nursing Schools in California

List of Nursing Schools in California

List of Nursing Schools in California
  • Azusa Pacific University School of Nursing, Azusa
  • California State University, Bakersfield Department of Nursing, Bakersfield
  • California State University, Chico
  • California State University, Dominguez Hills School of Nursing, Carson
  • California State University, East Bay
  • California State University, Fresno
  • California State University, Fullerton School of Nursing, Fullerton
  • California State University, Long Beach School of Nursing, Long Beach
  • California State University, Los Angeles School of Nursing, Los Angeles
  • California State University, Northridge
  • California State University, Sacramento
  • California State University, San Bernardino Department of Nursing, San Bernardino
  • California State University, Stanislaus
  • Chaffey College Nursing Program, Rancho Cucamonga
  • Humboldt State University, Arcata
  • Loma Linda University School of Nursing, Loma Linda
  • Mount St. Mary's College Department of Nursing, Los Angeles
  • Mount San Antonio College, Walnut
  • Samuel Merritt University, Oakland
  • San Bernardino Valley College Nursing Department, San Bernardino
  • San Diego State University College of Health & Human Services School of Nursing, San Diego
  • San Francisco State University
  • San José State University
  • Sonoma State University, Rohnert Park
  • University of California, Irvine Program in Nursing Science
  • University of California, Los Angeles School of Nursing, Los Angeles
  • University of San Francisco
  • Dr. Prem Reddy School of Health Sciences, Victor Valley College, Victorville
  • West Hills College Lemoore
  • Western University of Health Sciences College of Graduate Nursing, Pomona

Nursing Interventions for Hypothyroidism - Disturbed Sensory Perception

Nursing Interventions for Hypothyroidism - Disturbed Sensory Perception

Nursing Interventions for Hypothyroidism - Disturbed Sensory Perception

Disturbed Sensory Perception (visual) based interference as a result of the transmission of sensory impulses ophtalmopathy.

Purpose: that patients do not experience decreased visual acuity worse and there is no trauma / injury to the eye.

Nursing Intervention:
1. Instruct the patient when sleeping with the head elevated position.
2. Moisten the eye with sterile borwater.
3. If there is photophobia, instruct the patient to use sunglasses rayben.
4. If the patient can not close eyes tightly while sleeping, use non-allergenic plaster.
5. Give steroid medications according to the program. In severe cases, doctors usually prescribe medications such as steroids to reduce edema and diuretics.
Risk for Infection related to Nasopharyngeal Carcinoma

Risk for Infection related to Nasopharyngeal Carcinoma

Nursing Diagnosis for Nasopharyngeal Carcinoma : Risk for Infection

Objectives: After nursing intervention, there were no risk factors for infection in the client,

evidenced by adequate client imune status: free of symptoms of infection, normal leukocyte numbers (4-11000).

Nursing Interventions:

  Control of infection:
1. Clean up the environment after use for other patients.
2. Maintain isolation techniques.
3. Limit visitors when necessary.
4. Instruct family to wash their hands when contact and thereafter.
5. Use anti-microbial soap to wash hands.
6. Make hand washing before and after nursing actions.
7. Use clothes and gloves as a protective device.
8. Maintain aseptic environment during the installation of equipment.
9. Perform wound care and infusion dresing every day.
10. Increase the intake of nutrients.
11. Give antibiotics according to the program.

Protection against infection
1. Monitor signs and symptoms of systemic and local infections.
2. Monitor granulocytes and WBC count.
3. Monitor susceptibility to infection.
4. Maintain aseptic technique for each action.
5. Maintain isolation techniques if necessary.
6. Inspection of the skin and mucous mebran redness, heat, drainage.
7. Inspection of the condition of wounds, surgical incisions.
8. Take culture if necessary
9. Push the input of nutrients and adequate fluid.
10. Encourage adequate rest.
11. Monitor changes in energy levels.
12. Encourage increased mobility and exercise.
13. Instruct the client to take antibiotics according to the program.
14. Teach family / client about the signs and symptoms of infection.
15. Report suspicion of infection.
16. Report if positive cultures.
Hyperthermia - Hyperthyroidism

Hyperthermia - Hyperthyroidism

Nursing Diagnosis and Interventions for Hyperthyroidism

Hyperthermia related to the status of hypermetabolic

characterized by heat.

After nursing actions, expected normal temperature 36.5 C - 37.5 C.

Nursing Intervention:
  • Give warm compresses as needed.
  • Use clothing and a thin bed of felt.
  • Maintain a cool environment.
  • Give febrifuge to order.
  • Increase fluid intake to 2500 ml / day.
  • Monitor vital signs, level of consciousness, urine output every 2 to 4 hours.
  • Collaborate with physicians in the use of additional cooling measures when the situation requires.
Expected results / evaluation:
  • Patient is conscious and responsive.
  • Vital signs and normal urine output.

Pathophysiology of Heart Failure

Pathophysiology of Heart Failure
In case of heart failure, the body has several adaptations, both in the heart and systemically. If both ventricular stroke volume is reduced, therefore the emphasis contractility or afterload was increased, the volume and end-diastolic pressure in the two chambers of the heart increased. This will increase the length of myocardial fibers end-diastolic, systolic rise time becomes shorter. If this condition persists, ventricular dilatation occurs. Cardiac output at rest can still be good, but the increase in diastolic pressure that lasts longer / chronicle will spread to both the atrium and the pulmonary circulation and the systemic circulation. Finally, capillary pressure will increase which will lead to transudation of fluid and edema arising systemic or pulmonary edema. Decrease in cardiac output, especially if associated with a reduction in arterial pressure or decreased renal perfusion, will activate several neural and humoral systems. Increased activity of the sympathetic nervous system will stimulate myocardial contraction, heart rate and veins; recent changes that will increase central blood volume, which in turn increase the preload. Although these adaptations are designed to increase cardiac output, adaptation itself can interfere with the body. Therefore, tachycardia and increased myocardial contractility can stimulate the occurrence of ischemia in patients with coronary artery disease earlier and increased preload may worsen pulmonary congestion.

Activation of the sympathetic nervous system will also increase peripheral resistance; adaptation designed to maintain perfusion to vital organs, but if activation is increased instead will decrease the flow to the kidneys and tissues. Peripheral vascular resistance may also be a major determinant of ventricular afterload, so that excessive sympathetic activity can improve the function of the heart itself. One important effect is a decrease in cardiac output decreased renal blood flow and filtration rate decreased glomerolus, which will cause sodium and fluid retention. Sitem renin - angiotensin - aldosterone system will also be activated, leading to increased peripheral vascular resistance and penigkatan selanjutnta left ventricular afterload as sodium and fluid retention. Heart failure is associated with increased levels of arginine vasopressin in the circulation increases, which also is vasokontriktor and inhibiting the excretion of fluids. In heart failure increased atrial natriuretic peptide due to increased atrial pressure, which indicates that here there is resistance to the effects of natriuretic and vasodilator.
Impaired Skin Integrity related to Diabetes Mellitus

Impaired Skin Integrity related to Diabetes Mellitus

Nursing Diagnosis for Diabetes Mellitus: Impaired Skin Integrity

Goal: After nursing Interventions, improved wound healing:

Expected outcomes:
  • Luka shrink in size and increase in granulation tissue.

Nursing Interventions:

Wound care
  1. Note the characteristics of the wound: determine the size and depth of the wound, and the classification of the influence ulcers
  2. Note the characteristics of the fluid that comes out secret
  3. Clean with a liquid anti-bacterial
  4. Rinse with 0.9% NaCl fluid
  5. Perform nekrotomi, if necessary
  6. Perform the appropriate tampon
  7. With sterile gauze dressing as needed
  8. Make dressing
  9. Maintain a sterile dressing technique when performing wound care
  10. Observe any changes in the packing
  11. Compare and note any changes in the wound
  12. Give position to avoid pressure
Assessment of injuries, will be more realible done by the same caregiver in the same position and the same techniques.

17 Benefits of Bananas

Benefits of Bananas for your health

Banana, Fruit of the easiest to find. Even plants can grow wild your yard. Bananas proved to have very many benefits. What are the benefits of this fruit of the people's health? Lets check it:

1. Anemia
Bananas are rich in iron that can increase the production of hemoglobin in the blood.

2. Blood pressure
Rich in potassium and low salt content. Even the U.S. Food and Drug Administration recommends the banana producer added that bananas can reduce the risk of blood pressure and stroke.

3. Constipation
Rich in fiber, include bananas in the diet can restore normal bowel action.

4. Depression
According to a survey of MIND, people with depression feel better after eating a banana. This is because of the content of tryptophan which is a protein that the body converts into serotonin can-can create a relaxing, improve your mood and generally make you happier.

5. Tipsy
How to eliminate it is to make a banana milkshake mixed with honey. Relieve stomach banana, honey reinstate sugar and milk were able to re-hydrate your system.

6. Heartburn
Bananas have a natural antacid effect in the body so as to relieve the pain.

7. Feeling sick in the morning
This feeling often experienced by pregnant women, women on HRT and who use hormonal contraception. Ease that Cemil is bananas in the morning between meals.

8. Mosquito bites
Use the inside of the banana skin, and rub the mosquito bite. It can reduce swelling and irritation.

9. Restless
Bananas are rich in B vitamins that can calm the nerves.

10. Regulation of body weight
Bananas have a role in weight loss as well as increase weight. For dieting, eating four bananas and four glasses of non-fat milk or liquid milk per day at least three days a week. In addition to weight, diet can make your skin clean and not oily. To fatten, consumption of one glass of banana milkshake mixed with honey, fruits, nuts and mangoes after dinner.

11. PMS (premenstrual syndrome)
Vitamin B6 it contains regulates blood glucose levels, which can affect your mood.

12. Smoke
Can help smokers to quit is because bananas have a high content of Vitamin C, A1, B6, B12, potassium and magnesium. The content can help the body to return to normal from the effects of nicotine.

13. Temperature control: many cultures in the world using a banana as a coolant temperature of expectant mothers physically and emotionally. In Thailand, pregnant women eat bananas so that the baby is born with a cool temperature.

14.Luka stomach
Bananas can neutralize over-acidity and reduces irritation by coating the lining of the stomach.

15. Wart
Traditional medicine is believed to be able to remove warts. Take a little banana peel with the position of the yellow on the outside and stick it on the wart and then paste with plaster.

16. Beauty facial
Make banana porridge mixed with a little honey and milk and apply on the face every day for 30-40 minutes on a regular basis. Rinse with warm water and then rinse with cold water or ice, repeated for 15 days. It will produce a stunning effect on the skin.

17. Patients Lever
Consumption of two bananas plus one tablespoon of honey, will increase appetite and makes it stronger.

Nutrition for Beauty

Nutrition for Beauty


water Nutrition for Beauty
The water is very beneficial to every living creature because of the many benefits that can be through the consumption of water in sufficient quantities. There are some health benefits include:

digestive system launched
prevent dangerous diseases such as kidney stones or liver
as balancing the body, etc.

whereas for beauty, body water can nourish and moisturize the skin, and is believed to be a potent drug ageless ^ _ ^. Therefore, consume water in sufficient quantities or 8 to 10 glasses per day.


Breakfast can make the body more healthy and ready to perform all daily activities. The ideal breakfast is the menu that contains at least 4 grams of fiber, because the amount is considered suitable and fit to reduce the risk of cholesterol and fat levels in the blood. At 10 grams of fiber may reduce the number of heart disease and diabetes risk by 30%. Fiber can also reduce the risk of cancer. Breakfast consumption course with 4 healthy 5 perfect menu could increase the level of immunity or resistance to disease. It would be better to apply the consumption of breakfast more than lunch and dinner. Regulate eating during the day with ample servings and fewer servings evening, in order to avoid excess fat deposits.


There are 2 different types of green vegetables at lunch will help us look beautiful and healthy. Green vegetables contain nutrients that the body needs with the content of carotene (provitamin A), which serves to slow down the aging process with a lot of wrinkles symptoms found in women aged over 40 years. Besides the benefits of vegetables is to prevent cancer, improve lung function and reduce komlikasi associated with diabetes.

Eliminate Body Odor

Here is Tips to Eliminate Body Odor :

Bath Two Times A Day And More

Bath Two Times A Day And More
The function of a shower is to eliminate excessive sweating, removes dirt and bacteria, keeps the body clean and fresh. Do not forget to clean and scrub the areas of skin folds, back, between the legs, which is a bacteria breeding center.

Use antiseptic soap

Besides being able to eliminate germs and bacteria, soap can also prevent itching of the body due to prickly heat.

Use Deodorant

Use Deodorant
Function deodorant to eliminate body odor anti perspirant to minimize the production of excessive sweat. Do not use powder, because it can cause the skin to become black armpit / mole.

Note the intake of food
Note the intake of food
Avoid pungent foods that cause body odor like garlic, onions, spicy and oily foods. Basil leaves for eliminating body odor. Can be consumed directly as fresh vegetables or processed for spiced mixture. Betel leaf boiled water is also good to get rid of body odor.
Filariasis Treatment and Prevention

Filariasis Treatment and Prevention

Filariasis Treatment and Prevention

Filariasis Treatment and Prevention

Filariasis is a parasitic disease (usually an infectious tropical disease) that is Caused by thread-like nematodes (roundworms) belonging to the superfamily Filarioidea, also known as "filariae". These are transmitted from host to host by blood-feeding arthropods, mainly black flies and mosquitoes.

Caused by three species of filarial worms that infect humans are:
  • Wuchereria bancrofti
  • Brugia timori
  • Brugia malayi

Signs and Symptoms
  • Fever repeatedly for 3 s / d 5 days every 1-2 months
  • On the thighs and underarms swelling of the lymph nodes that looked redness, heat and pain
  • Swelling of the legs or arms, breasts, testicles that look red and feel hot because the lymph fluid unstoppable
  • Can cause defects in the form of an enlarged settling legs, arms and genitals
  • Unable to work optimally

Prevention Method
a. Check themselves to the health of the possibility of clinical symptoms of disease.
b. Trying to avoid mosquito bites by:
  • Sleep-wear mosquito nets
  • The holes / ventilation houses covered with fine mesh wire
  • Do not let the mosquitoes nesting in or around the home
  • Killing mosquitoes with mosquito sprays
c. Wash water or sewer plants to eliminate mosquito breeding places

Care and Treatment
  • To prevent fever give febrifuge
  • Immediately taken to the nearest health center or local health department (Hospital)

Prevention and treatment of Leptospirosis

Prevention and treatment of leptospirosis

Leptospirosis is a disease caused by a spiral-shaped bacterium Leptospira infection surrendered animals and humans and can live in fresh water for about a month.

  • Contact with water, soil or plants that have been polluted by animal urine of patients with leptospirosis.
  • Spiral shaped bacteria Leptospira

Signs and Symptoms
  • High fever, chills
  • Headache
  • Malaise (lethargy / weak)
  • Vomiting
  • Conjunctivitis (inflammation of the eye)
  • Calf muscle pain and back
  • Renal failure
  • Heart Failure
  • Shortness of breath
  • Chest pain
  • Washing hands with soap before eating
  • Keeping the environment clean
  • Cleaning water spots and swimming pools
  • Avoid the rats in your home or building
  • Disinfection to certain places contaminated by rat
  • Storing food and drink well in order to avoid rats

4 Nursing Diagnosis for Alzheimer's Disease

Nursing Care Plan : Nursing Diagnosis for Alzheimer's Disease

Alzheimer's Disease, also known in medical literature as Alzheimer disease, is the most common form of dementia. There is no cure for the disease, which worsens as it progresses, and eventually leads to death. It was first described by German psychiatrist and neuropathologist Alois Alzheimer in 1906 and was named after him.

Alzheimer's disease is usually diagnosed clinically from the patient history, collateral history from relatives, and clinical observations, based on the presence of characteristic neurological and neuropsychological features and the absence of alternative conditions. Advanced medical imaging with computed tomography (CT) or magnetic resonance imaging (MRI), and with single photon emission computed tomography (SPECT) or positron emission tomography (PET) can be used to help exclude other cerebral pathology or subtypes of dementia. Moreover, it may predict conversion from prodromal stages (mild cognitive impairment) to Alzheimer's disease.

Assessment of intellectual functioning including memory testing can further characterise the state of the disease.[5] Medical organisations have created diagnostic criteria to ease and standardise the diagnostic process for practicing physicians. The diagnosis can be confirmed with very high accuracy post-mortem when brain material is available and can be examined histologically.

4 Nursing Diagnosis for Alzheimer's Disease

1. Self-care deficit (eating, drinking, dressing, hygiene) related to changes in the process of thought.

2. Imbalanced nutrition: less than body requirements related to inadequate intake, changes in thought processes.

3. Impaired verbal communication related to the changes in thought processes.

4. Ineffective individual coping related to changes in thought processes and dysfunction due to disease progression.

Nursing Diagnosis Risk for Infection - NCP Impetigo

Nursing Care Plan Risk for Infection - Impetigo

Nursing Diagnosis Risk for infection - NCP Impetigo

Nursing Diagnosis Risk for Infection related to decreased immune system, malnutrition, inflammation, and invasive procedures.

Expected outcomes are:
  • Clients are free from signs and symptoms of infection.
  • Showed the ability to prevent infection.
  • Demonstrate healthy behavior.
  • Describe the process of transmission of the disease, factors that influence transmission.

Nursing Interventions - Nursing Care Plan for Impetigo :
  • Monitor for signs and symptoms of infection.
  • Monitor susceptibility to infection.
  • Limit the visitor when necessary.
  • Instruct patient visitors to wash their hands during a visit and after leaving the patient.
  • Maintain aseptic environment during ongoing treatment.
  • Give skin care in the area epidema.
  • Inspection of skin and mucous membrane of the redness, heat.
  • Inspection of the condition of the wound.
  • Give antibiotic therapy if necessary.
  • Teach how to avoid infection.

Nursing Diagnosis for Knowledge Deficit - NCP Impetigo

Nursing Interventions for Impetigo

Nursing Diagnosis of Knowledge Deficit - Nursing Care Plan for Impetigo 

Nursing Diagnosis: Knowledge Deficit: the disease, prognosis and treatment needs.

Patients showed an understanding of disease processes and treatment procedures,

with the expected outcomes: the patient can explain the status of the disease, treatment, care understand that done.

Nursing Interventions ;

Teach About the Disease:
  • Determine the level of knowledge of patients and families related to disease processes.
  • Describe the pathophysiology of the disease and connect with the anatomy and physiology.
  • Describe the signs and symptoms of the disease.
  • Describe the disease process.
  • Identification of possible causes.
  • Provide information about the patient's condition.
  • Provide information about the diagnostic measures.
  • Describe the rationality of therapy / treatment given.
  • Describe complications.
  • Talk about lifestyle changes in patients who may be required.
  • Discuss treatment options.
  • Take time to explore a second opinion.
  • Instruct patients and families to recognize signs and symptoms to report.
  • Clarification of information provided by other health team prior to the information provided.

  • To facilitate the client and the appropriate use of health services.
  • Assist clients in understanding the information related to the occurrence of disease in particular.
  • Clients know what foods are recommended.
  • Clients understand the handling done / recommended.
  • Clients experiencing what activities to do.

Knowledge Deficit related to Tuberculosis

Nursing Care Plan for Impetigo - Impaired Skin Integrity

Nursing Care Plan for Impetigo - Impaired Skin Integrity

Nursing Care Plan for Impetigo - Nursing Diagnosis and Interventions : Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity related to lesions and mechanical injury (scratching the itchy skin)

Expected outcomes are:
  • A good skin integrity can be maintained (sensation, elasticity, temperature)
  • No injuries or lesions on the skin.
  • Able to protect skin and keep skin moist and natural treatments.
  • Good tissue perfusion.

Nursing Interventions:

1. Instruct the patient to use, loose clothing.
Rational: a loose shirt, shirt will reduce friction on the skin lesions.

2. Cut nails and keep the client's hand hygiene.
Rational: the nail that will reduce the short and avoid scratching the impetigo lesion severity.

3. Keep clean skin, to keep them clean and dry.
Rational: the skin clean and dry, will reduce the spread or proliferation of bacteria.

4. Monitor skin color, the existence of redness.
Rational: to know the progression of the disease and the effectiveness of actions taken.

5. Bathe the patient with warm water and soap (antiseptic).
R: warm water will kill bacteria and reduce the rash. Anti-septic soap can reduce or kill the bacteria on the skin.

6. Collaboration for the administration of topical antibiotics on the client.
Rational: topical antibiotic may discontinue or inhibit the growth of bacteria.

7. Give the knowledge of the client not to scratch the wound.
Rational: the knowledge of patients on the treatment process can accelerate the success of the nursing process.

Nursing Interventions Risk for Decreased Cardiac Output in Hypertension

Nursing Interventions Hypertension

Nursing Interventions Risk for Decreased Cardiac Output in Hypertension

Nursing Diagnosis: Risk for Decreased Cardiac Output - Nursing Care Plan for Hypertension

Risk for Decreased Cardiac Output related to vasoconstriction

Expected outcomes are:
  • Clients participating in activities that lower blood pressure / load
  • cardiac work, maintaining blood pressure within an acceptable range of individuals, showing stable norms and cardiac frequency in the normal range.

Nursing Intervention:

1. Observation of blood pressure (the ratio of pressure to give an overview more complete, the involvement / field of vascular problems).

2. Note the presence, quality of the central and peripheral pulsation (throbbing carotid, jugular, radial and femoral probably observed / palpation.

3. Auscultation of heart and breath sounds tone. (S4 commonly heard in patients with severe hypertension due to atrial hypertrophy, the development of S3 showed ventricular hypertrophy and malfunction, the presence of crackles, wheezing may indicate the occurrence of pulmonary congestion secondary to
or chronic heart failure).

4. Observe skin color, moisture, temperature, and capillary refill time. (a pale, cold, moist skin and slow capillary refill time reflect decompensation / decrease in cardiac output).

5. Note the presence of fever, general / specific. (may indicate a failure heart, kidney or vascular damage).

6. Provide a comfortable, quiet, reduce the activity / fray environment, limit the number of visitors and length of stay. (helping to decrease sympathetic stimulation, increased relaxation).

7. Encourage relaxation techniques, imagination and distraction guide. (can stimuli that lead to lower stress, create a calming effect, that will lower blood pressure).

8. Collaboration with physicians in the delivery of anti-hypertensive therapy, deuritik. (lowers blood pressure).

Risk for Decreased Cardiac Output related to Hypertension

Nursing Care Plan for Hypertension in Pregnancy

Nursing Interventions for Hyperemesis Gravidarum

Nursing Care Plan for Hyperemesis Gravidarum
Nursing Interventions for Hyperemesis Gravidarum

1. Assess for signs of dehydration
Rational: improve fluid balance, and maintain a homeostatic mechanism, is the basis for the mother and fetus to maintain balance.

2. Assess vital signs
Rational: temperature, pulse rate increased and decreased BP are signs of dehydration and hypovolemia.

3. Give parenteral fluids: electrolytes, glucose and vitamins according to program
Rational: This fluid will provide or meet the needs of the body's acid-base balance, electrolytes and hypoavitaminosis.

4. Provide nutrition in small but frequent portions.
Rational: feeding gradually or slowly may help.

5. Monitor the provision of fluids and food in 24 hours as well as expenditures and recorded fluid intake.
Rational: the provision of fluids and electrolytes is a way to deal with persistent vomiting, this recording will be able to assess the balance of electrolytes are given, while the number of how many calories can already be given.

6. Review of edema in the legs or elsewhere.
Rational: the edema may also occur due to lack of albumin or renal failure.

7. Assess the presence of ketones in the urine.
Rational: presence of ketones in the urine indicates maternal fat supplies for energy use due to inadequate caloric intake.

8. Do collaborations with other teams for the administration of antiemetic drugs.
Rational: usually to cope with vomiting.

9. Give the food a light, when it is allowed in small portions and frequent (liquid and solid)
Rational: the provision of solid and liquid foods in small portions and often may reduce vomiting.

10. Increase feeding of this, if the client is able to accept (tolerance).
Rational: an increase in feeding demonstrate efficacy in the treatment.

11. Monitor FHR and fetal activity.
Rational: FHR and fetal movement is an indication that the fetal / fetus in good condition.

12. Monitor symptoms of morning sickness.
Rational: hormonal changes, maternal Hypoglycemia and decreased gastric motility, emotional and cultural factors.

13. Examine the skin: the texture and turgor.
Rational: dry skin and poor turgor is a sign of dehydration.

14. Encourage clients to multiply the rest.

15. Create a comfortable environment.

Nursing Assessment for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%

Nursing Diagnosis for Hyperemesis Gravidarum

1. Fluid and electrolyte imbalances related to excessive vomiting or lack of fluid intake.

2. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting or lack of nutritional intake.

3. Anxiety related to hyperemesis influence on the health of the fetus.

4. Knowledge deficit related to lack of information about the treatment of hyperemesis.

5. Sleep pattern disturbance related to persistent vomiting.

6. Activity Intolerance related to weakness.

Nursing Assessment for Hyperemesis Gravidarum

Nursing Assessment for Hyperemesis Gravidarum

Nursing Care Plan for Hyperemesis Gravidarum : Nursing Assessment for Hyperemesis Gravidarum

1. Main complaint:
  • Severe vomiting
  • Nausea, vomiting in the morning and after meals
  • Epigastric pain
  • Feeling thirsty
  • No appetite
  • Vomiting of food / liquid acid

2. Predisposing factors
  • Maternal age <20 years
  • Multiple gestation
  • Obesity
  • Trophoblastic Disease

3. Physical Examination
  • Metabolic acidosis is characterized by headache, disorientation
  • Tachycardia, hypotension, vertigo
  • Conjunctival jaundice
  • Impaired consciousness, delirium

Signs of dehydration:
  • Dry skin, mucous membranes dry lips
  • Slow return of skin turgor
  • Sunken eyelids
  • Weight loss
  • Increase in body temperature
  • Oliguria, ketonuria
  • Concentrated urine

Laboratory data:
  • Proteinuria
  • Ketonuria
  • Urobilinogen
  • Decreased levels of potassium, sodium, chloride, and protein
  • Decreased levels of vitamin
  • Increased Hb and Ht
Nursing Diagnosis for Hyperemesis Gravidarum
Nursing Assessment for Epilepsy - ABCDE

Nursing Assessment for Epilepsy - ABCDE

Nursing Assessment for Epilepsy - ABCDE

In the ictal phase, the client usually found clenched his teeth so that obstruct the airway, the client bite the tongue, mouth foaming, and the postictal phase, usually found injury to the tongue and gums due to the bite.

In the ictal phase, the client breathing down / speed, increased mucus secretion, and skin was pale even cyanosis. In phase posiktal, clients have apnea.

In the ictal phase pulse and cyanosis increase, the client usually unconscious.

Clients can be realized or not depends on the type of attacks or characteristics of epilepsy suffered. Usually the patient was confused, and do not remember the incident when the seizures.

Client's clothing was opened to thoracic examination, whether there are additional injuries due to seizures.

Nursing Diagnosis for Epilepsy

Nursing Diagnosis and Interventions Risk for Injury - Seizures
Social Isolation related to Low Self-esteem

Social Isolation related to Low Self-esteem

Social isolation related to low self-esteem

  • Clients can build a trusting relationship.
  • Clients can positively identify the capabilities they have.
  • Clients can assess the capability of being used.
  • Clients can (set) to plan activities in accordance with the capabilities.
  • Clients can perform activities according to the condition of pain and ability.
  • Clients can take advantage of existing support systems.

Nursing Interventions:
  • Construct a trusting relationship with therapeutic communication:
    • Therapeutic greet.
    • Introduce yourself.
    • Explain the purpose of interaction.
    • Create a calm environment.
    • Create a clear contract.
    • Stay on time.
  • Discuss the capability and the positive aspects of the client owned.
  • Every meeting with clients avoid from giving negative ratings.
  • Polar realistic praise.
  • Discuss with the client the ability to still be used for ill.
  • Discuss with the client capabilities that can be shown to the user.
  • Plan activities with clients who may be continued every day according to ability:
    • Work independently.
    • Activities that require total assistance.
  • Increase activity in accordance with the tolerance of the client's condition.
  • Give examples of how implementation of the activities that the client did.
  • Give the client a chance to try activities that are planned
  • Give credit for the success of the client.
  • Discuss the possible implementation of the home.
  • Give health education to families about how to treat clients with dignity help families provide support for clients cared for, help prepare the family home environment.
Nursing Diagnosis for Congestive Heart Failure - CHF related to

Nursing Diagnosis for Congestive Heart Failure - CHF related to

Nursing Diagnosis for CHF - Congestive Heart Failure

1 Decreased Cardiac Output
related to
  • changes in left ventricular contractility,
  • rhythm frequency changes,
  • electrical conduction
2. Ineffective Tissue Perfusion
related to
  • decrease in cardiac output
  • tissue hypoxemia,
  • acidosis and,
  • the possibility of thrombus or emboli.
3. Ineffective Airway Clearance
related to
  • decrease in lung volume,
  • hepatomegaly,
  • splenomegaly
4. Activity Intolerance
related to
  • imbalance between myocardial oxygen supply and demand of the body, the ischemic / necrotic myocardial tissue
5. Excess Fluid Volume
related to
  • Systemic fluid overload,
  • interstitial fluid permeation in the systemic secondary to decreased cardiac output, right heart failure
6. Imbalanced Nutrition: Less Than Body Requirements
related to
  • anorexia,
  • dyspnoea,
  • nausea, vomiting,
  • side effects of drugs,
  • sputum production
7. Sleep pattern disturbance
related to
  • paroxysmal nocturnal disease,
  • hospitalization,
  • crowded
8. Anxiety
related to
  • fear of death,
  • decline in health status,
  • crisis situations,
  • changes in consciousness.

Nursing Assessment for Congestive Heart Failure

Nursing Assessment for Congestive Heart Failure

Nursing Assessment for Congestive Heart Failure

1. Activity / rest
Symptoms: fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
Symptoms: Anxiety, mental status changes such as lethargy, changes in vital signs of activity.

2. Circulation
Symptoms: history of hypertension, acute myocardial infak, previous episodes of Chronic Heart Failure, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
Signs: blood pressure; may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia, apical pulse; PMI may spread and change in an inferior position to the left, heart murmurs; S3 (gallops) is diagnostic, S4 may, occur, S1 and S2 may be weakened, systolic and diastolic murmur, Color: blue, pale gray, cyanotic, nail backs; pale or cyanotic with a filling, capillary slow, Liver; enlargement / can be palpated, breath sounds ; crackles, rhonchi, edema; may be dependent, general or pitting especially on the extremities.

c. Ego integrity
Symptoms: Anxiety, worry and fear. Stress-related illness / financial concerns (job / cost of medical care).
Signs: A variety of behavioral manifestations, such as anxiety, anger, fear and irritability.

d. Elimination
Symptoms: Decreased urination, dark colored urine, nighttime urination (nocturia), constipation / diarrhea.

e. Food / fluid
Symptoms: Loss of appetite, nausea / vomiting, significant weight gain, swelling of the lower extremities, clothes / shoes feel tight, high-salt diet / food that has been processed and the use of diuretics.
Symptoms: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, stress and pitting).

f. Hygiene
Symptoms: fatigue / weakness, fatigue during activities of self care.
Signs: Appearances indicate negligence personal care.

g. Neurosensory
Symptoms: weakness, dizziness, fainting episodes.
Symptoms: Lethargy, tangled thought, oriented, behavioral changes and irritability.

h. Pain / Comfort
Symptoms: Chest pain, acute or chronic angina, upper right abdominal pain and muscle pain.
Signs: No quiet, insecure, narrow focus and behavior to protect themselves.

i. Breathing
Symptoms: Dyspnea on exertion, sleeping, sitting or with several pillows, cough with less / no sputum formation, history of chronic disease, use of rescue breathing.
Signs: Respiratory: tachypnea, shallow breathing, use of accessory respiratory muscles. Cough: Dry / loud / or non productive cough may be continuous with / without sputum formation. Sputum; Perhaps blood Flushed, pink / frothy (pulmonary edema). Breath sounds; may not be heard. Mental function; may decrease, anxiety, lethargy. Skin color; Pallor and cyanosis.

j. Security
Symptoms: Changes in mental function, loss of strength / muscle tone, skin abrasions.

k. Social interaction
Symptoms: Decreased participation in social activities are wont to do.

l. Learning / teaching
Symptoms: use / forgot to use heart medications, such as calcium channel blockers.
Symptoms: Evidence of lack of success to increase.

Diagnostic Examination for CHF

Diagnostic Examination for CHF
Diagnostic Examination for CHF

1. Thoracic X-ray: may reveal an enlarged heart, edema or pleural effusion which confirmed the diagnosis of CHF.

2. ECG: reveals tachycardia, ventricular hypertrophy and ischemia, an echocardiogram.

3. Laboratory examination: includes electrolytes, serum sodium levels revealed a low blood hemodilution that results from the presence of excess water retention, potassium, sodium, chloride, urea and blood sugar.

4. Sonogram (echocardiogram) to indicate the dimensions of ventricular enlargement, changes in the function / structure of the valve or area decreased ventricular contractility.

5. Cardiac catheterization: an indication of abnormal pressure and helps to distinguish right and left heart failure and valvular stenosis or insufficiency. Also assess patency of coronary arteries. Contrast agent is injected into the ventricles show abnormal size and ejection fraction / change in contractility.

6. Ultrasonography (USG): get an overview of free fluid in the abdominal cavity, and the picture of the liver and spleen enlargement. Enlarged liver and spleen is sometimes difficult to be checked manually when accompanied by ascites.
Constipation / Diarrhea related to Anemia

Constipation / Diarrhea related to Anemia

Constipation / Diarrhea related to Anemia

Nursing Diagnosis: Constipation / Diarrhea related to a reduction in dietary inputs, changes in digestion, the side effects of oral therapy.

Signs :
  • frequency change
  • characteristics and the amount of feces
  • nausea / vomiting
  • anorexia
  • sudden abdominal pain
  • impaired bowel sounds.

Expected outcomes are:
  • normal bowel function
  • behavioral changes necessary to live as the cause.

Nursing Intervention:
  • Observation of color, consistency, frequency, amount.
  • Auscultation of bowel sounds
  • Supervise the input / output
  • Encourage input 2500-3000 ml
  • Consult with a nutritionist: high-fiber diet
  • Give an enema as indicated
  • Give anti-diarrheal medications as indicated.
Imbalanced Nutrition: Less Than Body Requirements - Anemia Nursing Diagnosis and Interventions

Imbalanced Nutrition: Less Than Body Requirements - Anemia Nursing Diagnosis and Interventions

Imbalanced Nutrition: Less Than Body Requirements - Anemia Nursing Diagnosis and Interventions

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

  • weight loss,
  • oral mucosal changes,
  • loss of muscle tone

Expected outcomes are: weight gain / stable with normal laboratory values​​, no sign of malnutrition.

Nursing Intervention:
  • Observation and record food intake
  • Measure weight every day
  • Observation of nausea / vomiting, flatulence and other symptoms
  • Give and good oral hygiene aids
  • Give your dessert is diluted when the oral mucosa injury
  • Monitor lab results: Hb / HMT, protein, iron, B12, folic acid and serum electrolytes
  • Give the drug as interuksi: vitamins, minerals, oral iron
  • Give soft diet, low in fiber, did not stimulate.
Source :
    Activity Intolerance - Anemia Nursing Diagnosis and Intervention

    Activity Intolerance - Anemia Nursing Diagnosis and Intervention

    Activity Intolerance - Nursing Diagnosis and Intervention for Anemia

    Nursing Diagnosis: Activity Intolerance
    Symptoms: weakness, plenty of rest, palpitations, tachycardia, increased BP, dyspnea.

    Expected outcomes are:
    increase in activity tolerance; pulse, respiration and blood pressure normal.

    Nursing Intervention:
    • Assess the ability to perform the task, record the presence of fatigue and difficulty performing tasks
    • Assess the running balance disorders and muscle weakness
    • Monitor vital signs during and after activity
    • Change position slowly, monitor for dizziness
    • Give assistance activity / ambulation if necessary
    • Encourage to stop activity when palpitations, chest pain, shortness of breath, weakness and dizziness.

    Impaired Social Interaction related to Self-concept Disturbance

    Impaired Social Interaction related to Self-concept Disturbance

    Impaired Social Interaction related to Self-concept Disturbance

    • Shows the appearance of a role
    • Indicate the involvement of social

    Expected outcomes are:
    • Social interaction skills: the use of effective social interaction behavior.
    • Social engagement: social interaction of individuals who are with other people, groups.

    Nursing Interventions:
    • Increase socialization.
    • Assess the interaction patterns among patients with other people.
    • To improve patient interactions with others.
    • To determine the pattern of patient interaction with others.
    Urinary Incontinence related to Pelvic Muscle Degenerative

    Urinary Incontinence related to Pelvic Muscle Degenerative

    Nursing Diagnosis: Urinary incontinence related to pelvic muscle degenerative

    • Showed urinary continence.
    • Adequacy of time to reach a small room between urgency and urinary output.
    • Underwear stays dry all day
    • Able to urinate on their own.
    Expected outcomes are:
    • Urinary continence. Maintain the frequency of urination over 2 hours.

    Nursing Interventions Urinary Incontinence:
    • Perform pelvic floor muscle exercises
    • Perform treatment of urinary incontinence
    • Identification of the multifactorial causes of incontinence
    • Muscle strengthening volunteer pubotogsigeal with repeated contractions.
    • To improve urinary continence and to maintain intregitas perineal skin.
    • To find out the cause of urinary incontinence.

    Nursing Interventions Risk for Social Isolation

    Nursing Interventions Risk for Social Isolation

    Nursing Care Plan for Risk for Social Isolation - Nursing Diagnosis for Risk for Social Isolation

    Risk factors may include, changes in health conditions, changes in physical appearance or sexual perception of social behavior is unacceptable, inadequate resources and or the fear of losing their personal resources.

    Desired outcomes / evaluation criteria:
    • Identification of a stable support system.
    • Use of resources for appropriate help.
    • Reveal an increase in self-esteem.

    Nursing Interventions Risk for Social Isolation:

    1. Determine the client's response to the conditions, feelings about self, concerns or worries about the other person's response, his ability to control the situation, and a sense of hope.
    Rational: How to receive individual and relate to the situation will help determine treatment plans and interventions.

    2. Assess the coping mechanisms and methods of dealing with the problems of life previously.
    Rational: Assessing reveals successful techniques that can be used in the current situation.

    3. Discuss concerns about work and leisure involvement. Note the potential for problems involving finance, insurance, and housing.
    Rationale: Clients with a potentially terminal disease, which carries a stigma, faced a big problem with the possibility of losing their jobs, health insurance, housing, and they become unable to care for themselves independently.

    4. Identification of the availability and stability of family and community support systems.
    Rational: This information is very important to help clients plan for future care.

    5. Encourage honesty in the appropriate relationship.
    Reason: As a rule, do not need to be told acquaintances about the client's health status. However, information should be shared with a close relationship such as SO, family, and sexual partners. Honesty can help identify the stable support.

    6. Encourages contact with family and friends.
    Rational: Many clients are afraid to say SO, family, and friends for fear of rejection, and some clients withdrew because of the tumultuous feelings. Contact promote a sense of support, concern, involvement, and understanding. Supporting a loved one when they learned of the diagnosis is useful and can provide long-term optimism.

    7. Helping clients to solve the problem of isolation for short-term solutions, such as acts of infectious disease or immune system is threatened.
    Rational: anticipatory planning can ease the sense of isolation and loneliness that can accompany this situation.

    8. Help clients distinguish between isolation and loneliness or solitude, which may be by choice.
    Rational: To provide an opportunity for clients to achieve the control he must make a decision about the choice to take care of themselves on this issue.

    9. Alert to verbal cues and nonverbal, such as withdrawal, a statement of despair, and sense of loneliness. Determine the presence and level of risk for suicidal thoughts.
    Rational: Indicators of despair and suicide may be present. When the signal is recognized, the clients are usually willing to express their thoughts and feeling of alienation and despair.

    10. Identifying community resources, self-help groups, and drug rehabilitation program or termination, as shown. Reason: To provide an opportunity to resolve any problems that may contribute to a sense of loneliness and isolation, the risk of transmission, and guilt.
    Nursing Interventions for Hepatitis B

    Nursing Interventions for Hepatitis B

    Nursing Interventions for Hepatitis B

    Setting energy use to treat or prevent fatigue and optimize function. Regular physical exercise to maintain fitness and health.

    Anxiety reduction and minimize anxiety, fear or anxiety associated with unknown source or anticipated danger.

    Teaching people about the disease, diagnosis and treatment. Facilitation of Learning: Promoting the ability to process and understand information. Increased Readiness Learning: Improving the ability and willingness to receive information.

    Infection Protection: Prevention and early detection of infection in patients at risk. Infection Control, Minimizing the acquisition and transmission of infectious agents. Supervision: purposeful and ongoing acquisition.

    Surveillance and safety. purposeful and ongoing collection and analysis of information about the client and the environment to be used in promoting and maintaining client safety. Analysis of potential risk factors, determining the health risk, risk reduction strategies and priorities for an individual or group.
    5 Nursing Diagnosis for Hepatitis B

    5 Nursing Diagnosis for Hepatitis B

     Hepatitis B
    • Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease.
    • The virus is transmitted through contact with the blood or other body fluids of an infected person.
    • Two billion people worldwide have been infected with the virus and about 600 000 people die every year due to the consequences of hepatitis B.
    • The hepatitis B virus is 50 to 100 times more infectious than HIV.
    • Hepatitis B is an important occupational hazard for health workers.
    • Hepatitis B is preventable with the currently available safe and effective vaccine.
    Most people do not experience any symptoms during the acute infection phase. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

    In some people, the hepatitis B virus can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer.

    There is no specific treatment for acute hepatitis B. Care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.

    Some people with chronic hepatitis B can be treated with drugs, including interferon and antiviral agents. Treatment can cost thousands of dollars per year and is not available to most people in developing countries.

    Liver cancer is almost always fatal and often develops in people at an age when they are most productive and have family responsibilities. In developing countries, most people with liver cancer die within months of diagnosis. In high-income countries, surgery and chemotherapy can prolong life for up to a few years.

    People with cirrhosis are sometimes given liver transplants, with varying success.

    5 Nursing Diagnosis for Hepatitis B
    1. Activity intolerance
    2. Anxiety
    3. Knowledge Deficit
    4. Risk for infection
    5. Risk for injury

    Imbalanced Nutrition: Less Than Body Requirements of Gastritis

    Nursing Diagnosis Imbalanced Nutrition: Less Than Body Requirements of Gastritis

    Nursing Diagnosis and Nursing Interventions : Imbalanced Nutrition: Less Than Body Requirements of Gastritis

    Gastritis is a common name for all kinds of inflammation of the inner lining of the stomach, which is known as the mucosa. It is characterized by severe stomach ailments like cramps in the stomach, diarrhea and constipation and even blood with the stools.

    Symptoms of Gastritis

    1. Upper abdominal pain or dyspepsia
    2. Nausea
    3. Vomiting
    4. Belching
    5. Acid reflux
    6. Bloating
    7. Indigestion
    8. Loss of appetite
    9. Bad breath
    10. Feeling of fullness in upper abdomen
    11. Concentrated burning sensation in upper abdomen
    12. Passing of blood in stool
    13. Blood vomiting
    14. Passing black, tarry stool.

    Nursing Diagnosis for Gastritis : Imbalanced Nutrition: Less Than Body Requirements related to the lack of food intake.

    After the patient's nutritional needs of nursing actions are met.

    Expected outcomes are:
    • General condition is quite
    • Good skin turgor
    • Increased weight
    • Difficulty swallowing is reduced
    Nursing Interventions :
    • Instruct patient to eat small meals but frequently.
    • Give soft foods.
    • Perform oral hygiene.
    • Measure weight basis.
    • Texture observation, the patient's skin turgor.
    • Observations of nutritional intake and output.
    • Keeping the patient remained stable nutritional prevent nausea and vomiting.
    • To facilitate the patient to swallow.
    • Oral hygiene can stimulate the appetite of the patient.
    • Knowing the development of nutritional status of patients.
    • Knowing a patient's nutritional status.
    • Knowing a patient's nutritional balance.
    Source :
      Acute Pain related to Gastritis

      Acute Pain related to Gastritis

      Nursing Diagnosis : Acute Pain - NCP Gastritis

      Gastritis is basically an erosion of the stomach lining, which can occur suddenly due to certain factors or happen gradually over a longer period of time. Inflammation or irritation of the lining of the stomach is also a form of gastritis.

      Gastritis can occur in adults and in children, which when left untreated can give rise to other gastrointestinal problems. There can be a number of different causes that give rise to gastritis. An infection caused by Helicobacter pylori (H. pylori) or other bacteria and viruses living in the mucous lining of the stomach could be one of the causes. A back flow of bile from the bile tract into the stomach, which is known as bile reflux could give rise to gastritis. Pernicious anemia, which is the stomach's inability to properly digest vitamin B12 could be another cause.

      Acute Pain Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

      Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

      Nursing Care Plan for Gastritis

      Nursing Diagnosis: Acute pain related to irritation of the gastric mucosa secondary to psychological stress.

      After the act of nursing, pain can be reduced, patients can rest and generally good condition.

      Expected outcomes are:
      • Clients express the pain diminished or disappeared.
      • The client does not grimace in pain.
      • Vital signs are within normal limits.
      • The pain intensity was reduced (reduced pain scale 1-10).
      • Demonstrate relax, rest, sleep, increased activity quickly.

      Nursing Interventions:
      • Investigate complaints of pain, note the location, intensity of pain, and pain scale.
      • Instruct patient to report pain as soon as it began.
      • Monitor vital signs.
      • Explain the causes and effects of pain on the client and his family.
      • Encourage rest during the acute phase.
      • Encourage relaxation techniques.
      • Provide an environment conducive situation.
      • Collaboration with the medical team in the delivery of the action.


      • To find out where the pain and facilitate interventions to be performed.
      • Early intervention to facilitate recovery of muscle control pain by decreasing muscle tension.
      • Autonomic responses include, changes in blood pressure, pulse, respiration, associated with pain relief.
      • With the causes and consequences of pain the client is expected to participate in treatment to reduce pain.
      • Reduce pain that was exacerbated by movement.
      • Decrease muscle tension, increase relaxation, and increased sense of control and coping abilities.
      • Provide support (physical, emotional, increased sense of control, and coping skills).
      • Eliminate or reduce the client's complaints of pain.
      Source :

      Pathophysiology of Osteomyelitis

      Pathophysiology of Osteomyelitis

      Pathophysiology of Osteomyelitis

      Staphylococcus aureus is the cause of 70-80 percent of bone infection. Other pathogenic organisms commonly found in osteomyelitis include: Proteus, Pseudomonas and E.coli. There is an increased incidence of penicillin-resistant infections, nosocomial, gram negative and anaerobic.

      Onset of osteomyelitis after orthopedic surgery can occur within the first 3 months (acute fulminant stage I) and is often associated with accumulation of hematoma or superficial infection. Late onset infection (stage 2) occurred between 4 and 24 months after surgery. Osteomyelitis long onset (stage 3) is usually due to haematogenous spread and occurred 2 years or more after surgery.

      Initial response to infection is one of inflammation, increased Vascularization and edema. After 2 or 3 days, thrombosis in blood vessels occurs in the area, resulting in ischemia with bone necrosis associated with an increased and can spread to soft tissue or joints in the vicinity, unless the infection process can be controlled, then the bone will form an abscess.

      Abscess formed in the walls forming the dead tissue, but as in the abscess cavity in general, the bone tissue dies (sequestrum) is not easy to melt and flow out. Cavity can not be deflated and healed, as occurs in soft tissues. New bone growth occurs (involukrum) and surrounds the sequestrum. Although there appeared to be healing, but the sequestrum remains vulnerable to infectious chronic recurrent abscesses issue.

      Source :
      Nursing Management of Diabetic Ulcers

      Nursing Management of Diabetic Ulcers

      Nursing Management of Diabetic Ulcers

      Diabetic ulcers are sores, or pain that occurs at the foot of the person who has suffered from diabetes mellitus.

      Meanwhile, according to Askandar (2001) Diabetic Ulcers are sores on the feet of red-black and foul smelling due to the blockage that occurred in medium or large vessels in the legs.

      The cause of diabetic ulcers

      Diabetic ulcers occur because of complications of diabetes mellitus called sensory neuropathy. People with diabetes also have poor blood circulation, thereby causing injury to the toe easily or toes which can lead to ulcer / gangrene.

      Diabetic ulcer wound care
      • Dressing and wound control and help protect the wound from further damage.
      • Keep the circulation in the legs with active passive movement.
      • Control blood sugar levels.
      • If necessary, collaboration with medical debridement for action.

      Prevention to avoid diabetic ulcers
      • For patients with diabetes mellitus are at risk for diabetic ulcers should consult immediately to health care. If you experience itching, blisters, blisters between the toes or on the skin around the toes. Pale-colored toes, aching or tingling, skin cracks and breaks, signs of inflammation.
      • Clean your feet every day with water that is not too cold or hot and use a soft cloth to clean your toes.
      • Use a moisturizing cream on dry skin. Not be used in between the toes.
      • Prevent skin irritation on the foot.
      • Maintenance / cut nails should be done with caution. Cut nails straight and smooth after immersion for 20 minutes in water, so that the nail is not hard.
      • Wear clean socks every day. Socks should not be too tight so that air circulation is not obstructed.
      • Avoid using tight shoes to prevent blisters.
      Source :
        Knowledge Deficit Definition and Related Factors

        Knowledge Deficit Definition and Related Factors

        Nursing Diagnosis for Knowledge Deficit

        Knowledge Deficit : About the Disease Process

        Knowledge Deficit Definition:

        The absence or lack of cognitive information in connection with a specific topic.

        Defining characteristics:

        verbalization of problems,
        inaccuracies follow instructions,
        inappropriate behavior.

        Knowledge Deficit Related Factors:

        cognitive limitations,
        interpretations of misinformation,
        lack of desire to seek information,
        not knowing the sources of information.


        Kowlwdge: disease process
        Kowledge: health behavior

        Results Criteria:

        Patients and families express an understanding of the disease, condition, prognosis and treatment programs
        Patients and families are able to perform the procedure correctly explained
        Patients and families are able to explain again what was described nurse / other health team


        Teaching: Disease Process

        Give your assessment of the level of knowledge about the patient's specific disease process
        Describe the pathophysiology of the disease and how it relates to anatomy and physiology, in a proper way.
        Describe the usual signs and symptoms appear the disease, in a proper way
        Describe the disease process, the proper way
        Identify possible causes, dengna proper way
        Provide information to patients about the condition, in a proper way
        Avoid a hopeless
        Provide information to families about the progress of patients in an appropriate manner
        Discuss lifestyle changes that may be necessary to prevent complications in the future and controlling disease or process
        Discuss the choice of therapy or treatment
        Encourage the patient to explore or get a second view in a proper way or indicated
        Exploration of possible sources or support, the proper way
        Refer patients to the group or agency in the local community, in a proper way
        Instruct the patient about the signs and symptoms to report on health care givers, in a proper way

        Nursing Management of Low Back Pain

        Nursing Management of Low Back Pain

        1. Relieves Pain

        To reduce pain nurses can encourage patients to bed rest and modification of the position is determined to improve lumbar flexion. Patients are taught to control and adjust the pains that go through the respiratory diaphragm and relaxation can help reduce muscle tension that contributes to lower back pain. Distract patients from pain with other activities such as reading books, watching TV and with imagination.

        Massage of the soft tissue, gently is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. When given the drug the nurse should assess the patient's response to each drug.

        2. Improving physical mobility

        Physical mobility is monitored through continuous assessment. Nurses assess how patients move and stand. Once back pain is reduced, self-care activities may be performed with minimal strain on the injured structure. Change of position should be done slowly and assisted if necessary. Circular motion and sway should be avoided. Patients are encouraged to switch activities lying, sitting and walking around for a long time. Nurses need to encourage patients comply with exercise programs according to established, that one just does not exercise effective.

        4. Health education

        Patients must be taught how to sit, stand, lie down and lifting objects properly.

        5. Improving the performance of the role

        Responsibilities associated with the role may have changed since the occurrence of lower back pain. Once the pain healed, patients can return to his role of responsibility again. But when the activity is impacting on the bottom of back pain occurs again, it may be difficult to return to the original responsibility without bearing the risk of chronic low back pain with disability and depression caused.

        6. Changing nutrition and weight loss

        Weight loss through eating way of adjustment can prevent recurrence of back pain, by means of the rational nutrition plan that includes changes in eating habits to maintain a desired weight.


        1. Experienced pain relief

        - Rest in comfort
        - Change the position comfortably
        - Avoidance of drug dependence

        2. Shows the return of physical mobility

        - Return to activity gradually
        - Avoid positions that cause discomfort which causes muscle
        - Plan rest breaks throughout the day

        3. Demonstrate body mechanics that maintain back

        - Improved posture
        - Changing the position of its own to minimize back stress
        - Demonstrating the use of good body mechanics
        - Participate in training programs

        4. Back to the responsibilities associated with roles

        - Use techniques facing problems to adjust to stressful situations
        - Shows the reduction in dependence on others for self care
        - Back to work when the back pain has been healed
        - Return to full productive lifestyle

        5. Achieving the desired body weight

        - Identify the need for weight loss
        - Participate in the development of weight loss plan
        - Faithful to the weight-loss program

        Source :

        LBP Low Back Pain Nursing Diagnosis

        Nursing Diagnosis for Low Back Pain

        The lower back is an intricate structure of interconnected and overlapping elements:
        • Tendons and muscles and other soft tissues
        • Highly sensitive nerves and nerve roots that travel from the lower back down into the legs and feet
        • Small and complex joints
        • Spinal discs with their gelatinous inner cores.
        An irritation or problem with any of these structures can cause lower back pain and/or pain that radiates or is referred to other parts of the body. Pain from resultant lower back muscle spasms can be severe, and pain from a number of syndromes can become chronic.

        These lower back pain symptoms include any combination of the following:
        • Difficulty moving that can be severe enough to prevent walking or standing
        • Pain that does not radiate down leg or pain that also moves around to the groin, buttock or upper thigh, but rarely travels below the knee;
        • Pain that tends to be achy and dull
        • Muscle spasms, which can be severe
        • Local soreness upon touch

        Nursing Diagnosis of Low Back Pain

        1. Acute pain associated with musculoskeletal problems.

        2. Impaired physical mobility related to pain, muscle spasm, and reduced flexibility.

        3. Deficient knowledge related to body mechanics techniques to protect the back.

        4. Ineffective Role Performance related to impaired mobility and chronic pain.

        5. Imbalanced Nutrition: more than body requirements related to obesity.
          Anxiety Nursing Diagnosis

          Anxiety Nursing Diagnosis

          Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

          Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks.


          Related to :

          • Anesthesia
          • Anticipated/actual pain
          • Disease
          • Invasive/noninvasive procedure:
          • Loss of significant other
          • Threat to self-concept

          Evidenced by
          • Physiological :
            • Increase in blood pressure, pulse, and respirations
            • Dizziness, light-headedness
            • Perspiration
            • Frequent urination
            • Flushing
            • Dyspnea
            • Palpitations
            • Dry mouth
            • Headaches
            • Nausea and/or diarrhea
            • Restlessness
            • Pacing
            • Pupil dilation
            • Insomnia, nightmares
            • Trembling
            • Feelings of helplessness and discomfort

          • Behavioral :
            • Expressions of helplessness
            • Feelings of inadequacy
            • Crying
            • Difficulty concentrating
            • Rumination
            • Inability to problem-solve
            • Preoccupation

          Outcome :

          1. Demonstrate a decrease in anxiety A.E.B.:
          • A reduction in presenting physiological, emotional, and/or cognitive manifestations of anxiety.
          • Verbalization of relief of anxiety.

          Nursing InterventionAssist patient to reduce present level of anxiety by :
          • Provide reassurance and comfort.
          • Stay with person.
          • Don't make demands or request any decisions.
          • Speak slowly and calmly.
          • Attend to physical symptoms. Describe symptoms:

          2. Discuss/demonstrate effective coping mechanisms for dealing with anxiety.

          Nursing Intervention
          • Discuss alternate strategies for handling anxiety. (Eg.: exercise, relaxation techniques and exercises, stress management classes, directed conversation (by nurse), assertiveness training)
          • Set limits on manipulation or irrational demands.
          • Help establish short term goals that can be attained.
          • Identify and reinforce coping strategies patient has used in the past.
          • Discuss advantages and disadvantages of existing coping methods.
          • Give clear, concise explanations regarding impending procedures.
          • Focus on present situation.
          • Reinforce positive responses.
          • Initiate health teaching and referrals as indicated 

          Nursing Diagnosis Ineffective Airway Clearance

          Nursing Diagnosis Ineffective Airway Clearance

          Nursing Diagnosis: Ineffective Airway Clearance

          NANDA Definition : Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency

          Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

          Defining Characteristics: Abnormal breath sounds (crackles, rhonchi, wheezes)
          * Changes in respiratory rate or depth
          * Cough
          * Hypoxemia/cyanosis
          * Dyspnea
          * Chest wheezing
          * Fever
          * Tachycardia

          Related Factors: Decreased energy and fatigue
          * Ineffective cough
          * Tracheobronchial infection
          * Tracheobronchial obstruction (including foreign body aspiration)
          * Copious tracheobronchial secretions
          * Perceptual/cognitive impairment
          * Impaired respiratory muscle function
          * Trauma

          NOC Outcomes (Nursing Outcomes Classification)

          * Respiratory Status: Airway Patency

          NIC Interventions (Nursing Interventions Classification)

          * Cough Enhancement
          * Airway Management
          * Airway Suctioning

          Expected Outcomes Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.

          Nursing Management of Rheumatoid Arthritis (RA)

          Nursing Management of Rheumatoid Arthritis (RA)

          The main objective of Nursing Management program are as follows:
          • To relieve pain and inflammation
          • To maintain joint function and the maximum ability of the patient
          • To prevent and or correct deformity that occurs in joints
          • Maintaining independence so as not to depend on others.

          There are several ways the management to achieve the goals mentioned above, namely:

          The first step of this management program is to provide adequate education about the disease to patients, families and anyone associated with the patient. Education will include understanding the pathophysiology (disease course), the causes and estimated journey (prognosis) of the disease, all components of program management including complex drug regimens, sources of help to overcome this illness and effective method of management provided by health teams . This educational process must be done continuously.

          It is important because rheumatic usually accompanied by severe fatigue. Although fatigue may arise every day, but there are times when patients feel better or heavier. Patients should be divided into several time a day time activity which was followed by a period of rest.

          Physical Exercise
          Specific exercises can be useful in maintaining joint function. This exercise includes active and passive movement on all the joints are sore, at least twice a day. Drugs for pain relief should be given before starting the exercise. Hot compresses on the sore and swollen joints may reduce pain. Paraffin bath with temperature can be regulated and shower with hot and cold temperatures can be done at home. Exercise and termoterapi is best regulated by the health workers who have received specialized training, such as a physical therapist or occupational therapist. Excessive exercise can damage the supporting structure of the joints that are already weakened by the disease.

          Diet / Nutrition
          Rheumatic Patients do not require a special diet. There are a number of ways with a variety of diets that vary, but all of them unsubstantiated. The general principle for obtaining a balanced diet is important.

          Administration of drugs is an important part of all rheumatic disease management programs. Drugs used to reduce pain, relieve inflammation and to try to change the course of the disease.

          Source :