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Nursing Care Plan for Personal Hygiene

Nursing Care Plan for Personal Hygiene

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

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

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

Various of Personal Hygiene

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

1 Skin Care

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

2 Bath

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

3. Oral hygiene

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

4. Eye, nose, and ears care

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

5. Hair Care

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

6. Foot and nail care

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

7 Genital care

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

Nursing Care Plan for Encephalitis - Assessment, Diagnosis and Interventions

Nursing Care Plan for Encephalitis

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


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

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

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

Assessment for Encephalitis

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

Nursing Diagnosis and Interventions for Encephalitis

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

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

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

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

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

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

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

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

5. Acute pain related to irritation encephalon

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

Nursing Care Plan for Impaired Sense of Comfort : Pain

Nursing Care Plan for Pain

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

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


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

Signs and Symptoms

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

Physiological Respon to Pain

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

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

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

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

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

Classification of pain can be divided into:

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

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

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

Nursing Care Plan for Pain


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

Nursing care of clients experiencing pain:

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

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

The things that need to be assessed:

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

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

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

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

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

Quality of pain

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

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

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

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

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

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

Observation of behavioral and physiological responses

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

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

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

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

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

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

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

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

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

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

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

Nursing Care Plan for Tuberculous Spondylitis

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

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

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

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

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

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

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

Nursing Diagnosis  for Tuberculous Spondylitis

1. Impaired physical mobility

2. Acute pain: joints and muscles.

3. Disturbed body image

4. Knowledge deficit: about home care.

(Susan Martin Tucker, 1998: 445)

Home Care : Basic Needs of the Elderly

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

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

1. Meeting the nutritional needs

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

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

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

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

2. Improve safety and security

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

3. Maintaining personal hygiene

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

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

5. Improving interpersonal relationships through communication

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

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

Nursing Care Plan for Hirschsprung's Disease

Assessment of Hirschsprung's Disease

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

Nursing Diagnosis and Interventions for Hirschsprung's Disease - Preoperative

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

Goal: Observation does not happen.

  • Clients say can defecate.
  • Normal intestinal peristalsis.

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

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

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

Goal: Fulfillment of nutrients can be resolved.

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

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

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

3. Anxiety related to ineffective coping.

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

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

Nursing Diagnosis and Interventions for Hirschsprung's Disease - Postoperative

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

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

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

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

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

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

2. Disturbed Sleep Pattern related to postoperative wound pain.

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

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

3 Encourage clients to a lot of rest and enough sleep.
R /: Adequate sleep can give a fresh taste to the clients and accelerate the healing process.
NCP for Abdominal Tumor - Nursing Diagnosis and Interventions

NCP for Abdominal Tumor - Nursing Diagnosis and Interventions

Nursing Care Plan for Abdominal Tumor


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


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

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

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

Nursing Diagnosis and Interventions for Abdominal Tumor

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

3. Disturbed Sleep Pattern related to postoperative wound pain.

Goal: Sleep patterns resolved.

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

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

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

4. Self-care deficit related to activity limitations.

Goal: The client indicates the requirement for self care.

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

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

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

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

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

5. Anxiety related to ineffective coping

Goal: Anxiety is resolved

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

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

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