Nursing Care Plan: Nursing Assessment

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Nursing Assessment for Hallucinations (Predisposing and Precipitating Factors)

At this stage the nurse explore the factors that exist below, namely:

1. Predisposing Factors

Are risk factors that affect the type and amount of resources that can be generated by individuals to cope with stress. Obtained either from the patient or his family, the cultural factors of social development, biochemical, psychological and genetic risk factors that affect the type and amount of resources that can be generated by individuals to cope with stress.

Development factors: If the developmental tasks encountered resistance, and impaired interpersonal relationships then the individual will experience stress and anxiety.
Sociocultural factors: A variety of factors can lead to a society ruled by a lonely feeling to the environment in which the client was raised.
Biochemical factors: Having an influence on the occurrence of mental disorders. With the excessive stress experienced by a person inside the body will then produce a hallucinogenic substance that can be Neurochemistry.
Psychological factors: Interpersonal relationships are not harmonious and the dual role conflicting and often accepted by the child will lead to high stress and anxiety disorders and ended with reality orientation.
Genetic factors: what influence gene in schizophrenia is unknown, but research suggests that family factors showed a highly influential on the disease.

2. Precipitating Factors

Namely; stimulus perceived by the individual as a challenge, a threat / demands that require extra energy for coping. The presence of environmental stimuli that often are as participation of clients in a group, far too long encouraged communication, objects that exist in the environment is also a quiet atmosphere / isolation is often a trigger hallucinations because it can increase the stress and anxiety that stimulates the body to secrete hallucinogenic substances.

3. Behavior

Client's response to the hallucinations may be suspicious, frightened, feeling insecure, anxious and confused, self-destructive behavior, lack of attention, not able to take decisions and can not distinguish the real and unreal situation. According to Rawlins and Heacock, 1993 tried to solve the problem of hallucinations based upon the nature of the existence of an individual as a creature that is built on the basis of the elements of the bio-psycho-socio-spiritual that hallucinations can be seen from the dimensions:

Physical dimensions : Man built by the sensory system to respond to external stimuli provided by the environment. Hallucinations can be caused by several physical conditions like fatigue tremendous, drug use, fever up to delirium, alcohol intoxication and difficulty to sleep in a long time.
Emotional dimensions : Feelings of anxiety are excessive on the basis of problems that can not be the cause of the hallucinations occur. The contents of hallucinations can be a force command and scary. Clients no longer able to oppose the order with the condition to the client to do something about these fears.
Intellectual dimension: In this intellectual dimension explains that individuals with hallucinations would show a decrease in the function of the ego. At first it is a hallucination of his own ego to resist the impulse to press, but it is something that raises awareness that can take all the attention of the client and often will control all client behavior.
Social Dimension : The social dimension in individuals with hallucinations showed a tendency to be alone. Individuals preoccupied with hallucinations, as if it is a place to meet the need for social interaction, self-control and self-esteem were not found in the real world. Fill hallucinations control system used by the individual, so if the command hallucinations in the form of a threat, the individual himself or others tend to it. Therefore, an important aspect in implementing nursing interventions to pursue a process of interpersonal interactions that lead to a satisfying experience, and not aloof mengusakan client so that the client always interacts with its environment and hallucinations did not last.
Spiritual Dimension: Humans as social beings, so that interaction with other human beings is a fundamental requirement. In these individuals tend to be aloof until the above process does not occur, the individual is not aware of the existence and hallucination into the control system of the individual. Hallucinations when an individual loses control over him his life.

4. Sources Coping

An evaluation of the person's choice of coping strategies. Individuals can cope with stress and anxiety by using coping resources in the environment. Coping as a capital source to solve the problem, social support and cultural beliefs, can help a person integrate stressful experience and adopt coping strategies that work.

5. Coping Mechanisms

Every effort is directed at the implementation of stress, including efforts to resolve the problem directly and defense mechanisms are used to protect themselves.

Nursing Assessment and Physical Examination for Pre and Postoperative Appendectomy

Appendectomy is the removal of the inflamed appendix with procedures or endoscopic approach.

Complaints that often arise in post appendectomy is the verbal communication of pain that is felt, behavior too cautious, behavioral aberrations, (moaning, crying, restlessness), the face shows pain (eyes gloomy, sullen, restricting movement).

Nursing Assessment for Appendicitis

Assessment is the process whereby data relating to clients systematically collected. This process is dynamic and organized process that involves three basic activities, ie systematically collect, sort and organize the collected data and document data in a format that can be opened again. Assessment is used to recognize and identify health problems and needs of the client and the client's nursing physical, mental, social and environmental.

This Assessment contains:

1) Identity.
The identity of the client Appendicitis Post Operative on which to base the assessment, include: name, age, gender, education, occupation, religion, address, medical diagnosis, medical treatment, medical record number, date of entry, date of surgery and the date of assessment.
The identity of the person in charge, include: name, age, gender, education, occupation, religion, address, relationship with the client and resource costs.

2) The scope of health problems containing the main complaint when assessed client, the client post appendectomy usually complain of pain in the surgical wound and activity limitations.

History of Disease.

1) History of present illness.
History of present illness found during the assessment, which is described from start to enter care facilities to do the assessment. Complaints are now assessed using PQRST (palliative and provocative, quality and quantity, region and radiation, the severity scale and timing). Clients who have undergone appendectomy surgery generally complain of pain at the surgical site will increase when moved or pressed and generally decreases after being given the drug and rested. The pain is felt just as tingling with pain scale of more than five (0-10). The pain will be localized in the area of operation can also be spread throughout the abdomen and right thigh and generally persists throughout the day. Pain may be able to interfere with the activity of the corresponding tolerance range of each client.

2) Formerly medical history.
Contains previous illness experience, whether it impinges on the illness now and if ever experienced before surgery.

3) Family health history.
Keep in mind if there are other family members who suffer from the same illness as clients, also examined the presence of infectious disease in the offspring or family.

4) Psychological History.
In general, clients with post appendectomy, do not undergo psychological aberration function. Nevertheless, you still need to be done on the fifth concept of client self (body image, self-identity, role function, ideal self and self-esteem.

5) Social History.
Clients with post appendectomy is not impaired in social relationships with other people, but still have to compare the social relationship between the client before and after surgery.

6) Spiritual History.
In general, clients who underwent treatment will experience limitations in activities as well as in religious activities. Need to be assessed against sickness client confidence and motivation for recovery.

7) Daily Habit.
Clients who underwent surgical removal of the appendix is generally experienced difficulties in the move, because of acute pain and weakness. Clients may experience a disruption in self-care (bathing, brushing teeth, shampoo and nail clippers), as activity intolerance, impaired.

Clients will experience a restriction digestion oral input to the function back into the normal range. Possible clients will experience nausea, vomiting and constipation in the early postoperative period due to the influence of anesthesia. Oral intake can be started after the digestive functions back into the normal range. Clients can also experience decreased urine output because of the restriction of oral input. Urine output would gradually to normal after an increase in oral input. The pattern can be disturbed ataupu break client is not compromised, depending on client's tolerance to pain is felt.

Physical Examination

Physical examination includes:

General state
Post-appendectomy clients achieve full consciousness after a few hours back from the operating table, the appearance suggests a state of mild pain to severe depending on the period of acute pain. Generally stable vital signs but will experience instability in clients who experienced perforation of the appendix.

Respiratory System
Clients will post appendectomy decreased or increased respiratory rate (tachypnea) and shallow breathing, according to the range tolerated by the client.

Cardiovascular system
Generally clients experience tachycardia (as a response to stress and hypovolemia), had hypertension (as a response to pain), hypotension (weakness and bed rest). Usually normal capillary refill, also examined the state of the conjunctiva, and the presence of cyanosis, auscultation of heart sounds.

Digestive system
The presence of pain at the surgical site in the lower right abdomen when palpated. Clients post appendectomy usually complain of nausea and vomiting, constipation in early postoperative and decreased bowel sounds. Will appear the surgical wound in the lower right abdominal incision surgery.

urinary system
Early postoperative client will experience a decrease in the amount of urine output, this happens because of the restriction of oral intact during the initial period of post-appendectomy. Normal urine output would gradually with increasing oral intake.

Musculoskeletal system
In general, the client may experience weakness due to postoperative bed rest and stiffness. Muscle strength gradually improved with increasing activity tolerance.

Integumentary system
Will appear the surgical wound in the lower right abdomen for surgical incision with redness (usually in early onset). Skin turgor will improve with an increase in oral intake.

Nerve system
Generally clients with post appendectomy is not experiencing irregularities in neural function. Assessment persafan functions include: level of consciousness, cranial nerves and reflexes.

Hearing system
Assessment conducted include: ear shape and symmetry, presence or absence of inflammation and auditory function.

Endocrine system
Generally clients post appendectomy, no abnormal endocrine function. But still need to be assessed adequacy endocrine function (thyroid, etc.).

Nursing Assessment for Dengue Hemorrhagic Fever

Dengue Haemorrhagic Fever (DHF) is a disease caused by the dengue virus which is transmitted through the bite of Aedes aegypti and Aedes albopictus which causes disturbances in capillary blood vessels and the blood clotting system, resulting in bleeding.

Dengue hemorrhagic fever (DHF) is a specific syndrome that tends to affect children under 10 years of age. It causes abdominal pain, hemorrhage (bleeding), and circulatory collapse (shock).

Symptoms such as headache, fever, exhaustion, severe joint and muscle pain, swollen glands (lymphadenopathy), and rash. The presence (the "dengue triad") of fever, rash, and headache (and other pains) is particularly characteristic of dengue fever.
Nursing Assessment for Dengue Hemorrhagic Fever.

Assessment

a. Subjective data

Weak.
Heat or fever.
Headache.
Anorexia, nausea, thirst, painful swallowing.
Heartburn.
Pain in the muscles and joints.
Stiffness throughout the body.
Constipation.

b. Objective data

High body temperature, shivering, redness of the face looks.
Dry oral mucosa, bleeding gums, tongue dirty.
Red spots appear on the skin (petechiae), torniquet test (+), epistaxis, ecchymosis,
Hyperemia of the throat.
Epigastric tenderness.
On palpation palpable enlarged liver and spleen.
On shock (degree IV) rapid and weak pulse, hypotension, cold extremities, restlessness, peripheral cyanosis, shallow breathing.

Laboratory tests in DHF will be found: