Down's Syndrome - Assessment, Nursing Diagnosis, Interventions and Evaluation

Nursing Care Plan for Down's Syndrome

Assessment

1. During the neonatal period, which needs to be studied:

• The state of the body temperature, especially the neonatal period.
• Nutritional needs / food.
• The state of hearing and sight.
• Assessment of cognitive abilities and mental development of children.
• Children's ability to communicate and socialize.
• Motor skills.
• The ability of the family in caring for down syndrome premises, especially on the progress of the child's mental development.

2. Assessment of motor skills.
3. Assessment of cognitive abilities and mental development.
4. Assessment of the child's ability to communicate.
5. A hearing test, vision and bone abnormalities.
6. How family adjustment to diagnosis and progress of mental development.


Nursing Diagnosis for Down's Syndrome

1. Imbalanced nutrition less than body requirements related to difficulty feeding due to tongue far and high palate.

2. Risk for injury related to reduced hearing ability.

3. Ineffective Family Coping related to financial factors required in maintenance.

4. Lack of social interaction related to physical and mental limitations that they have.

5. Knowledge deficit (parents) related to down syndrome child care.


Interventions

1. Provide adequate nutrition.

• See the child's ability to swallow.
• Give parents information on the proper way / correct in giving good food.
• Provide good nutrition in children with good nutrition.

2. Encourage parents to check their hearing and vision regularly.

3. Assess understanding parents about down syndrome.

• Give an explanation to parents about the child's condition.
• Give information to parents about the care of children with down syndrome.

4. Motivation of parents to:

• Provide opportunities for children to play with the same age child to easily socialize.
• Provide flexibility / freedom to children fatherly expression.

5. Give the motivation in the elderly in order to provide an adequate environment for children.

• Encourage the participation of parents in giving motor exercises and instructions so that children are able to speak.
• Encourage the parents to give children practice in their daily activities.

Evaluation
1. There is no difficulty in feeding the child. Child so that the child gets adequate nutrition and adequate.
2. Hearing and vision of the child can be detected early and can be evaluated on a regular basis.
3. Families participate actively in the care of children with down syndrome either.
4. Children are able to socialize and interact well so that children can build relationships with other people do not feel insecure.

NCP for Bronchopneumonia with 7 Nursing Diagnosis

Nursing Care Plan for Bronchopneumonia

Definition

Bronchopneumonia is an inflammation of the lungs that affects one or more lobes of the lungs characterized by patches of infiltrates (Whalley and Wong, 1996).

Bronchopneumonia is the frequency of pulmonary complications, long productive cough, signs and symptoms usually increased temperature, increased pulse rate, increased respiration (Suzanne G. Bare, 1993).

Bronchopneumonia also called lobularis pneumonia, is inflammation of the lungs caused by bacteria, viruses, mold and foreign objects (Sylvia Anderson, 1994).


Etiology

• Bacteria : Diplococcus Pneumoniae, Pneumococcus, Streptococcus Haemolyticus Aureus, Haemophilus Influenzae, Bacillus Friedlander, Mycobacterium Tuberculosis.
• Virus : Respiratory syncytial virus, influenza virus, citomegalic virus.
• Fungi : Histoplasma capsulatum, Cryptococcus Nepromas, Blastomyces Dermatitidis, Coccidioides Immitis, Aspergillus Sp, Candida Albicans, Mycoplasma Pneumonia.
• Foreign body aspiration: Factors that influence the incidence of bronchopneumonia was decreased endurance for example due to protein energy malnutrition (MEP), chronic disease, antibiotic treatment is not perfect.

Clinical Manifestations

Usually preceded by upper respiratory tract infection. This disease usually occurs suddenly, rising temperatures 39-40 OC with shaking chills, shortness of breath and rapid coughing non productive "breath sound" percussion dim when the lung examination, auscultation of breath sounds smooth wet crackles and loud.

Cough and cold which may weigh up to respiratory insufficiency begins with upper tract infection, patients with a dry cough, headache, muscle pain, anorexia, and difficulty swallowing.


Complication

Complications of bronchopneumonia are:

• Atelectasis is the development of the lungs that are not perfect or lung collapse is due to a lack of mobilization or cough reflex is lost.
• Emphysema is a condition in which the accumulation of pus in the pleural space are in one place or the entire pleural cavity.
• Lung abscess is a collection of pus in the inflamed lung tissue.
• Systemic infection.
• Endocarditis is an inflammation of the endocardial each valve.
• Meningitis is an infection that attacks the lining of the brain.

Assessment for Bronchopneumonia

1. Health history

• A history of previous respiratory tract infection: cough, runny nose, fever.
• Anorexia, difficulty swallowing, nausea and vomiting.
• History of immune-related diseases such as malnutrition.
• Other family members were experiencing respiratory illness.
• Productive cough, breathing nostrils, rapid and shallow breathing, anxiety, cyanosis.

2. Physical examination

• Fever, tachypnea, cyanosis, respiratory nostril.
• Auscultation of pulmonary crackles wet.
• Laboratory leukocytosis, increased erythrocyte sedimentation rate or normal.
• Abnormal chest x-ray (spotting, scattered consolidation in both lungs).

3. Psychological factors / developments to understand actions.

• Age level of development.
• Tolerance / ability to understand actions.
• Coping.
• Separate experiences of family / parents.
• Previous experience respiratory infections.

4. Knowledge families / parents

• The level of knowledge of respiratory disease families.
• Family experience of respiratory disease.
• Readiness / willingness to learn to take care of her family.

Nursing Diagnosis for Bronchopneumonia

1. Ineffective airway clearance related to accumulation of secretions.
2. Impaired gas exchange related to changes in alveolar capillaries.
3. Fluid volume deficit related to excessive output.
4. Risk for Imbalanced nutrition less than body requirements related to inadequate nutritional intake.
5. Increased body temperature related to the infection process
6. Knowledge Deficit : parents, about the care of clients related to a lack of information.
7. Anxiety children related to the effects of hospitalization.

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

Definition

• 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).

Etiology

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.

Complications

• 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.

Intervention:

• 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.

Intervention:

• 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

Intervention:

• 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

Intervention:

• 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

Intervention:

• 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 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)

NCP for Abdominal Tumor - Nursing Diagnosis and Interventions

Nursing Care Plan for Abdominal Tumor

DEFINITIONS

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.

CAUSES

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.

SIGNS AND SYMPTOMS

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

DIAGNOSTIC TEST

• 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.

Interventions:
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.

Outcomes:

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

Interventions:
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.

Outcomes:

• Clients sleep 7-8 hours.
• Clients seem cheerful.

Interventions:
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.

Outcomes:

• Clients can be dressed, bathing, bowel movement, bladder itself.
• Clients seem fresh.

Interventions:
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

Outcomes:

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

Interventions:
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.

Risk for Decreased Cardiac Output - NCP Acute Myocardial Infarction (STEMI)

Nursing Care Plan for AMI with ST elevation (STEMI)

Definition

Acute myocardial infarction is the destruction of tissue due to inadequate blood supply so that coronary blood flow is reduced. (Brunner & Suddath, 2002)

Acute myocardial infarction is the death of myocardial tissue caused by myocardial coronary blood damage, due to the inadequate blood flow. (Carpenito, 2000)

Acute myocardial infarction is ischemia or necrosis of the heart muscle caused by decreased blood flow through one or more coronary arteries. (Doengos, 2000)


Etiology

According to Noer, 1999; 103 caused by

a. Causal factors:

1. Oxygen supply to the heart is reduced due to:
a. Vascular factors: Atherosclerosis, spasm, arteritis.
b. Circulation Factor: hypotension, aortic stenosis, insufficiency.
c. Blood factors: anemia, hypoxemia, polycythemia.

2 Cardiac output increased
For example: Activity, emotional, eating too much, anemia, hyperthyroidism.

3. Increased myocardial oxygen demand at:
Myocardial damage, myocardial hypertrophy, diastolic hypertension.


b. Predisposing factors
1 Biological factors that can not be changed:
a. Age over 40 years.
b. Gender. The incidence is higher in men, whereas in women increases after menopause.
c. Heredity.
d. Race.

2 Risk factors that can be changed
a. Major; Hyperlipidemia, hypertension, heavy smoking, diabetes, obesity, a diet high in saturated fat.
b. Minor; physical activity, pattern type A personality (emotional, aggressive, ambitious, competitive).


Clinical Manifestations

Acute myocardial infarction usually occurs in men over 40 years and having artheriosklerosis. In the coronary vessels and is often accompanied by arterial hypertension. The attack also occurs in women and young men, early 30s or even 20s. Women who use the contraceptive pill and smoke have a very high risk. However, the overall incidence of myocardial infarction in men is higher than women at all ages.

Chest pain that lasted all of a sudden and continuous, located at the bottom of the sternum and upper abdomen is the main symptom that usually appears. Pain will be felt increasingly heavy can spread to the shoulder and arm, usually the left arm. Unlike the pain of angina pain arises spontaneously (not after heavy work or emotional disorders) and persist for several hours to several days and will not go away with rest or nitroglycerin. In some cases the pain may spread to the chin and neck, pain is often accompanied by shortness of breath, pallor, cold sweats, dizziness, light-headedness, nausea, vomiting (Brunner & Suddarth, 2002)


Pathogenesis

AMI with ST elevation (STEMI) usually occurs when coronary blood flow decreased abruptly after occlusion of thrombus on atherosclerotic plaque that already exists. STEMI occurs when a coronary artery thrombus occurs rapidly at the site of vascular injury, where the injury is triggered by factors such as smoking, hypertension, and lipid accumulation. In STEMI classical pathological picture consists of rich red fibrin thrombus, which is believed to be the basis of so STEMI respond to thrombolytic therapy. Furthermore, the location of plaque rupture, various agonists (collagen, ADP, epinephrine, serotonin) triggers platelet activity, which in turn will produce and release thromboxane A2 (potent vasoconstrictor local). In addition, platelet activation triggers a conformational change in the receptor glycoprotein IIb / IIIa. After experiencing a conversion function, the receptor has a high affinity for the amino acid sequence in soluble adhesion proteins (integrins) such as von Willebrand factor (vWF) and fibrinogen, both of which are multivalent molecules that can bind to two different platelets simultaneously, resulting in crosslinking of platelets and aggregation.

Coagulation cascade is activated by exposure of tissue factor on endothelial cells are damaged. Factor VII and X are activated, resulting in the conversion of prothrombin into thrombin, which then converts fibrinogen into fibrin. The coronary arteries are involved then will experience the occlusion by thrombus composed of platelets and fibrin aggregates. On rare occasions, STEMI may also be caused by occlusion of the coronary arteries caused by coronary embolism, congenital abnormalities, coronary spasm and systemic inflammatory diseases.



Nursing Care Plan for Acute Myocardial Infarction with ST Elevation (STEMI)

Nursing Diagnosis : Risk for Decreased Cardiac Output related to decreased constriction ventricular function, cardiac muscle degeneration.

Outcomes:

• Lowering episodes of dyspnea, angina, and dysrhythmias.
• Identify the behavior to decrease the heart's workload.

Nursing Interventions:

Independent

1. Monitor cardiac rhythm and frequency.
R /: Tachycardia and cardiac dysrhythmias may occur when attempting to increase cardiac output responds to fever. Hypoxia and acidosis due to ischemia.

2 Auscultation of heart sounds. Note the distance / tone heart, murmurs, S3 and S4 gallops.
R /: To provide early detection of complications such as CHF, cardiac tamponade.

3 Encourage bed rest in a semi-Fowler's position.
R /: Lowering cardiac workload, maximize cardiac output.

4 Provide comfort measures such as changes in position and back rub, and entertainment activity in cardiac tolerance.
R /: Improve relaxation and redirect the attention.

5. Encourage use of stress management techniques such as breathing exercises and guided imagery.
R /: This behavior can control anxiety, increase relaxation and decrease the work of the heart.

6 Evaluation of complaint fatigue, dyspnea, palpitations, chest pain continuously. Note the presence of breath sounds adventisius, fever.
R /: The clinical manifestations of CHF that can accompany endocarditis or myocarditis.


Collaborative

1 Give oxygen complement.
R /: Increase the availability of oxygen to myocardial function and decrease the effects of anaerobic metabolism, which occurs as a result of hypoxia and acidosis.

2 Give drugs in accordance with indications such as digitalis, diuretics.
R /: Can be given to increase myocardial contractility and decrease the workload of the heart in the presence of CHF (miocarditis).

3 Give Antibiotic / anti-microbial.
R /: Given to address the identified pathogens, prevent further heart damage.

4 Assist in emergency pericardiocentesis.
R /: The procedure was done in a bed can to lower the pressure in the fluid around the heart.

5. Prepare patients for surgery if indicated.
R /: Replacement valves may be required to improve cardiac output.

Acute Pain - Nursing Care Plan for Glaucoma

Nursing Diagnosis : Acute Pain r / t Increase in intraocular pressure (IOP)


Definition

Glaucoma is a group of eye disorders characterized by increased intraocular pressure. (Long Barbara, 1996)

Glaucoma often occurs in both eyes, but extra fluid pressure first begins to build up in one eye. If you don't seek treatment for glaucoma and can't control it, your peripheral vision will decrease by time and subsequent eye damage may easily lead to blindness.



Etiology

There are different types of glaucoma. Most occur when pressure in the eye (intraocular) increases, damaging the optic nerve but sometimes optic nerve damage can occur even when intraocular pressure is normal.

Other types of glaucoma are rare and are caused by abnormal eye development, drugs, eye infections or inflammatory conditions, interruption of blood supply to the eye, systemic diseases and trauma.


Symptoms:

• Headaches.
• Sensitivity to light.
• Blurred vision.
• Decreased peripheral vision- gradual loss.
• Nausea and vomiting.
• Severe pain in the eyes.
• Reddening of the eyes.
• One eye becoming bigger than the other.
• Seeing rainbows around the lights at night.
• Visual disturbance in low light.
• Adjustment issues entering a dark room.
• Excessive tearing.
• Swollen eyes.

Nursing Care Plan for Glaucoma

Assessment

a) Activity / Rest:
Change usually activities / hobbies in connection with visual impairment.

b) Food / Fluids:
Nausea, vomiting (acute glaucoma)

c) Neuro-sensory:
Visual disturbances (blurred / unclear), bright lights glare caused by the gradual loss of peripheral vision, feeling in the dark room (cataracts).
Cloudy vision / blurring, halos appear / rainbows around lights, loss of peripheral vision, photophobia (acute glaucoma).
Changes glasses / treatment not improve vision.
Signs:
Papil narrowed and red / hard eyes with cornea cloudy.
Increased tear.

d) Pain / Leisure:
Mild discomfort / watery eyes (chronic glaucoma)
Sudden pain / weight or pressure settled on and around the eyes, headache (acute glaucoma).

e) Guidance / Learning
Family history of glaucoma, diabetes, impaired vascular system.
Stress history, allergies, vasomotor disturbances (eg, an increase in venous pressure), endocrine imbalance.
Exposed to radiation, steroids / toxicity of phenothiazines.



Nursing Diagnosis for Glaucoma

Acute Pain r / t Increase in intraocular pressure (IOP)

Goal: Pain is lost or diminished.

Outcomes:

• The patient demonstrates knowledge of assessment of pain control.
• The patient said that the pain is reduced / lost.
• Relaxed facial expression.

Intervention:

• Assess the type and location of pain intensity.
• Assess the level of pain scale to determine the analgesic dose.
• Encourage rest in bed in a quiet room.
• Set Fowler position of 30 degrees or in a comfortable position.
• Avoid nausea, vomiting as this will increase the IOP.
• Divert attention to the fun stuff.
• Give analgesics as recommended.

Nursing Care Plan for Urinary Incontinence

Urinary Incontinence is urine output unnoticed in sufficient quantity and frequency, resulting in health problems and or social. Variation of urinary incontinence include out just a few drops of urine, to a really great deal, and sometimes also accompanied by incontinence Alvi (with expenditure feces).

The etiology or cause of urinary incontinence is due to weakness of the pelvic floor muscles. This is related to the anatomy and function of the urinary organs. The weakness of the pelvic floor muscles can be due to several causes including pregnancy is repetitive, error in straining. This can lead to such a person can not hold urine (beser). Urine incontinence can also occur due to excessive urine production due to various reasons. For example, metabolic disorders, such as diabetes mellitus, which should continue to be monitored. Another cause is excessive fluid intake can be alleviated by reducing fluid intake as caffeine is a diuretic.

Once we are aware of the meaning and causes of urinary incontinence, which is the review of Urinary Incontinence Medical Concepts, then to the next is our review of the terms of nursing, the Nursing Care Plan for Urinary Incontinence. As usual when we do nursing first step is to do a nursing assessment. And this is the assessment of care of patients with urinary incontinence.


Nursing Assessment for Urinary Incontinence

Assessment of urinary incontinence are we asking a patient about urinary incontinence when it began to appear and the things associated with symptoms of urinary incontinence:

1. How many times incontinence occurs?
2. Is there any redness, blisters, swelling in the perineal area?
3. Is the client obese?
4. Is the time between urine dripping urination, if there are how many?
5. Is incontinence occurs at times that can be expected as during coughing, sneezing, laughing and lifting heavy objects?
6. Is the client aware of or feel the urge to urinate before incontinence occurs?
7. How long the client has difficulty in urinating / incontinence
8. urine?
9. Does the client feel bladder feels full?
10. Is the client experiencing pain during urination?
11. Is this problem getting worse?
12. How do clients overcome incontinence?

Next is the assessment by conducting a physical examination physical examination inspection, palpation and percussion.

Inspection

1. Redness, irritation / blisters and swelling in the perineal area.
2. A lump or tumor in the spinal cord.
3. The presence of obesity or lack of exercise.

Palpation

1. Bladder distension or tenderness.
2. Palpable lump spinal cord tumor area.

Percussion

1. Voice sounded dim in the bladder area.

Nursing Diagnosis for Urinary Incontinence

Nursing Diagnosis Urine Incontinence In Patients were as follows:

1. Anxiety
2. Disturbed Body Image
3. Deficient Knowledge
4. Activity intolerance
5. Low Self-Esteem
6. Impaired Skin Integrity

Action Plan / Interventions:

1. Maintain cleanliness of the skin, the skin is dry, changing bed linen or clothing when wet.
2. Encourage clients to bladder training exercises.
3. Encourage fluid intake of 2-2.5 liters / day if there are no contraindications.
4. Checks taken drugs. May be related to incontinence.
5. Check the client's psychological.
6. Encourage clients to perineal exercises or Kegel's exercises to help strengthen muscular control (if indicated). This exercise can be lying down, sitting or standing and Kegel's the way it is with: Contract the perineal muscles to stop the discharge of urine, the contraction was maintained for 5-10 seconds and then loosen or detach, repeat up to 10 times, 3-4 times / day.

Nursing Care Plan for Conginetal Talipes Equinus Varus

Conginetal Talipes Equinus Varus (CTEV) is a congenital defect that is a combination of abnormalities consisting of:
Front legs (fore foot) adduction and supination through the midtarsal joints.
Heel varus, through the subtalar joint and selalui joint equinus foot (ankle).
Medial deviation to the entire foot, seen from the knee joint.


Etiology of Conginetal Talipes Equinus Varus

The exact cause is unknown.
There are several theories:

• Genetic factors are sometimes obtained familiar (wyne davis).
• Mechanical factors (denis brown).
• Cessation of fetal growth (borm).
• Dysplasia of the muscles, causing imbalance (imbalance) muscle (Garceau).
• Primary abnormality os talus: Kaput and neck strap tapers towards deviase to medial and plantar of the corpus rope (adam, sotile, Irani and Sherman).
• MC Kay added the calcaneus to the medial rotation of the subtalar.

Assessment

a. Data Collection
Identity: name, age, address, occupation, date of admission to the hospital, medical diagnostics.
b. Main complaints
Is most disturbing complaints of discomfort in activities that disrupt or current.
c. Disease History Now
Can not run perfectly because there are abnormalities on the front foot (forefoot).
d. Past history of disease
With CTEV disease is a disease inborn.
e. Family history of disease
Regarding the picture of a family health history of the descendants of the parents.
f. Psychosocial History
Who is caring for the patient, how relationships with family, friends.
g. Pregnancy History
Includes prenatal, natal and post natal.
h. Immunization History
Includes immunization: BCG, DPT, Hepatitis and Polio.
i. Developmental History
In CTEV clients typically experience a delay in walking.


Patterns of Health Functions
1. Patterns and perceptions of governance healthy life.
Lifestyle people or clients who suffer CTEV in maintaining personal hygiene, care and management of a healthy life a little bit disturbed because of a physical condition.
2. Nutrition and metabolic patterns
There is no disruption in this pattern.
3. The pattern of elimination
Bowel and bladder patterns in clients with CTEV not impaired.
4. Rest and sleep patterns
Clients with CTEV on this pattern is not impaired.
5. The pattern of activity and exercise
Clients typically have limitations because of physical activity on the front foot (forefoot).
6. Patterns of perception and self-concept
How perceptions of surgery to be performed and usually patients withdrew due to illness embarrassment.
7. The pattern of sensory and cognitive
Regarding the knowledge of patients and families against illness.
8. Patterns of sexual reproduction
Is there pain during a disturbance / not related to social reproduction.
9. The pattern of relationships and roles
Usually clients with CTEV withdrew because of an illness suffered.
10. The pattern of response to stress
Families need to provide support and encouragement of life for clients.
11. The pattern of values ​​and beliefs
Family and patients are always optimistic and pray that the disease can be cured.

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.

Sample of Nursing Care Plan Tuberculosis (TB)

Nursing Care Plan and Nursing Diagnosis for Tuberculosis (TB)

Pulmonary tuberculosis

Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs, but may spread to other organs.

Symptoms
The primary stage of TB usually doesn't cause symptoms. When symptoms of pulmonary TB occur, they may include:

• Cough (usually cough up mucus)
• Coughing up blood
• Excessive sweating, especially at night
• Fatigue
• Fever
• Unintentional weight loss

Other symptoms that may occur with this disease:

• Breathing difficulty
• Chest pain
• Wheezing

Prevention

TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers.

A positive skin test indicates TB exposure and an inactive infection. Discuss preventive therapy with your doctor. People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative.

Prompt treatment is extremely important in controlling the spread of TB from those who have active TB disease to those who have never been infected with TB.

Some countries with a high incidence of TB give people a BCG vaccination to prevent TB. However, the effectiveness of this vaccine is controversial and it is not routinely used in the United States.

People who have had BCG may still be skin tested for TB. Discuss the test results (if positive) with your doctor.

nlm.nih.gov

Nursing Care Plan Pulmonary Tuberculosis (TB)

Nursing Diagnosis Pulmonary Tuberculosis

1. Ineffective airway clearance

2. Impaired gas exchange

3. Risk for infection

4. Imbalanced Nutrition Less then Body Requirements

5. Knowledge deficit

Source : http://all-nurses.blogspot.com/2011/10/nursing-care-plan-pulmonary.html

Sample of Nursing Care Plan for Heart Failure - Decreased Cardiac Output

Nursing Care Plan for Heart Failure 
 
Nursing Diagnosis : Decreased Cardiac Output 

NANDA Definition:

Inadequate blood pumped by the heart to meet metabolic demands of the body

Nursing Diagnosis:

Decreased cardiac output related to Altered heart rate and rhythm AEB bradycardia

characterized by:

• with pale conjunctiva, nail beds and buccal mucosa
• irregular rhythm of the pulse
• bradycardic
• pulse rate of 34 beats / min
• generalized weakness

Short-Term Objectives:
the patient Will Participate in activities That Reduced the workload of the heart.

Long-Term Objectives:
Will the patient be Able to display hemodynamic stability.

Nursing Interventions Decreased Cardiac Output Congestive Heart Failure:

1. Auscultation apical pulse; examine the frequency, the heart rhythm.
Rational: Usually tachycardia (even at rest) to compensate for the decrease in ventricular contractility.

2. Record the heart sounds.
Rational: S1 and S2 may be weak due to decreased pumping action. Gallop rhythm common (S3 and S4) is generated as the flow of blood to the porch of distension. Mur-mur may indicate incompetence / stenosis of the valve.

3. Palpation of peripheral pulses.
Rational: The decrease in cardiac output may show decreased radial artery, popliteal, dorsalis, pedis and posttibial. The pulse may disappear fast or irregular pulse to be palpable and alternan.

4. Monitor blood pressure.
Rational: In Congestive Heart Failure early, moderate or chronic blood pressure may increase. In Congestive Heart Failure-up body could no longer compensate and hypotension can not be normal again.

5. Assess against pale skin and cyanosis.
Rational: Pale, indicating reduced peripheral perfusion secondary to cardiac output adekutnya not; vasoconstriction and anemia. Cyanosis may occur as refrakstori Congestive Heart Failure. The area of ​​pain is often colored blue striped atu because of increased venous congestion.

6. Give supplemental oxygen by nasal cannula / mask and drugs as indicated (collaboration).
Rationale: Increased dosage of oxygen to the need to counter the effects of myocardial hypoxia / ischemia.

Sample of Nursing Care Plan for Myocardial Infarction

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation).

Every year, several million people in North America are diagnosed with an AMI, and approximately one-third of these patients die during the acute phase. Health Canada has identified cardiovascular disease or heart diseases as the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national healthcare system.




Clinical Manifestations of Myocardial Infarction

Pain

1. Chest pain that occurs suddenly and constantly not subside, usually above the sternal region and upper abdomen, this is the main symptom.
2. The severity of pain can increase settled until unbearable pain.
3. Pain is very ill, such as punctured-pin that can spread to the shoulder and continued down to the arm (usually the left arm).
4. The pain started spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and do not disappear with the help of rest or nitroglycerin (NTG).
5. Pain may spread to the jaw and neck.
6. Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.
7. Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompany diabetes can interfere neuroreseptor (collect the experience of pain).

Laboratory examination Examination of cardiac enzymes :

1. CPK-MB/CPK
   Isoenzymes found in heart muscle increased by between 4-6 hours, peaks in 12-24 hours, returned to normal within 36-48 hours.
2. LDH / HBDH
   Increases in the 12-24 hour time-consuming dams to return to normal
3. AST
   Increases (less real / special) occurred within 6-12 hours, culminating in 24 hours, returning to normal within 3 or 4 days

ECG ECG changes that occur in the early phase of T wave height and symmetrical. After this there is ST segment elevation. Changes that occur later are the presence of a wave of Q / QS which indicate the presence of necrosis.


Pain scores according to White:

1. = Do not experience pain
2. = Pain on one side without disturbing activities
3. = More pain at one place and resulted in disruption of activities, such as difficulty getting out of bed, hard to bend the head and others.

Nursing Care Plan for Myocardial Infarction

Primary Assessment for Acute Myocardial Infarction Nursing Care Plan (AMI) :

Airways

1. Blockage or accumulation of secretions
2. Wheezing or crackles

Breathing

1. Shortness of breath with mild activity or rest
2. Respiration more than 24 x / min, irregular rhythm shallow
3. Ronchi, crackles
4. The expansion of the chest is not full
5. Use of auxiliary respiratory muscles

Circulation

1. Weak pulse, irregular
2. Tachycardia
3. Blood pressure increase / decrease
4. Edema
5. Nervous
6. Acral cold
7. Pale skin, cyanosis
8. Decreased urine output

Secondary Assessment Acute Myocardial Infarction (AMI) :

1. Activities
   • Symptoms:
     
     • Weakness
     • Fatigue
     • Can not sleep
     • Settled lifestyle
     • No regular exercise schedule
   • Signs:
     • Tachycardia
     • Dyspnea at rest or activity
2. Circulation
   • Symptoms:
     
     • History of Acute Myocardial Infarction (AMI)
     • Coronary artery disease
     • Blood pressure problems
     • Diabetes mellitus.
   • Signs:
     
     • Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or stand
     • Pulse: normal, full or not strong or weak / strong quality with slow capillary filling, irregular (dysrhythmias)
     • Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased contractility / complaints ventricle
     • Murmur: If there are shows valve failure or dysfunction of heart muscle
     • Friction: suspected pericarditis
     • Heart rhythm can be regular or irregular
     • Edema: juguler venous distention, edema dependent, peripheral, general edema, cracles may exist with heart failure or ventricular
     • Color: Pale or cyanotic, flat nail, on mucous membranes or lips
3. Ego integrity
   • Symptoms: an important symptom or deny the existence of conditions of fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family
   • Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain
4. Elimination
   • Signs: normal, decreased bowel sounds.
5. Food or fluid
   • Symptoms: nausea, anorexia, belching, heartburn, or burning
   • Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes
6. Hygiene
   • Symptoms or signs: difficulty perform maintenance tasks
7. Neuro Sensory
   • Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)
   • Signs: mental changes, weakness
8. Pain or discomfort
   • Symptoms:
     
     • Sudden onset of chest pain (may or may not relate to activities), not relieved by rest or nitroglycerin (although most deep and visceral pain)
     • Location: Typical on the anterior chest, Substernal, precordial, can spread to the hands, jaw, face. No specific location such as epigastric, elbow, jaw, abdomen, back, neck.
     • Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.
     • Intensity: Usually 10 (on a scale of 1-10), may experience the worst pain ever experienced.
     • Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly
9. Respiratory:
   • Symptoms:
     
     • Dyspnea with or without job
     • Nocturnal dyspnea
     • Cough with or without sputum production
     • History of smoking, chronic respiratory disease.
   • Signs:
     
     • Increased respiratory rate
     • Shortness of breath / strong
     • Pallor, cyanosis
     • Breath sounds (clean, cracles, wheezing), sputum
10. Social interactions
    • Symptoms:
      • Stress
      • Difficulty coping with the stressors that exist eg illness, treatment in hospital
    • Signs:
      • Difficulty rest - sleep
      • Response too emotional (angry constantly, fear)
      • Withdraw

Source : http://careplannursing.blogspot.com/2011/11/nursing-care-plan-assessment-diagnosis.html

Nursing Care Plan for Pleura Effusion

Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during ventilation.

Types of fluids

Four types of fluids can accumulate in the pleural space:

• Serous fluid (hydrothorax)
• Blood (haemothorax)
• Chyle (chylothorax)
• Pus (pyothorax or empyema)

Treatment

Treatment depends on the underlying cause of the pleural effusion.

Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain (either pigtail or surgical). When managing these chest tubes, it is important to make sure the chest tubes do not become occluded or clogged. A clogged chest tube in the setting of continued production of fluid will result in residual fluid left behind when the chest tube is removed. This fluid can lead to complications such as hypoxia due to lung collapse from the fluid, or fibrothorax, later, when the space scars down. Repeated effusions may require chemical (talc, bleomycin, tetracycline/doxycycline), or surgical pleurodesis, in which the two pleural surfaces are scarred to each other so that no fluid can accumulate between them. This is a surgical procedure that involves inserting a chest tube, then either mechanically abrading the pleura or inserting the chemicals to induce a scar. This requires the chest tube to stay in until the fluid drainage stops. This can take days to weeks and can require prolonged hospitalizations. If the chest tube becomes clogged, fluid will be left behind and the pleurodesis will fail.

Pleurodesis fails in as many as 30% of cases. An alternative is to place a PleurX Pleural Catheter or Aspira Drainage Catheter. This is a 15Fr chest tube with a one-way valve. Each day the patient or care givers connect it to a simple vacuum tube and remove from 600 cc to 1000 cc of fluid. This can be repeated daily. When not in use, the tube is capped. This allows patients to be outside the hospital. For patients with malignant pleural effusions, it allows them to continue chemotherapy, if indicated. Generally the tube is in for about 30 days and then it is removed when the space undergoes a spontaneous pleurodesis.

Nursing Care Plan for Pleura Effusion

Nursing Diagnosis

Ineffective airway clearance related to weakness and poor cough effort.

Nursing Intervention

NOC :

• Demonstrate effective airway clearance and proved with respiratory status, gas exchange and ventilation are not dangerous :
  • Having a patent airway
  • Removing the secretion effectively.
  • Having a rhythm and respiratory frequency in the normal range.
  • Having a lung function within normal limits.
• Show that adequate gas exchange is characterized by :
  • Easy to breathe
  • No anxiety, cyanosis and dyspnea.
  • Saturation of O2 in the normal range
  • Chest X-ray within the expected range.

NIC :

• Assess and document :
  • The effectiveness of oxygen and other treatments.
  • The effectiveness of treatment.
  • Trends in arterial blood gases.
• Anterior and posterior chest auscultated to determine the decrease or absence of ventilation and the presence of sound barriers.
• Suction airway
  • Determine the need for sucking oral / tracheal.
  • Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
• Maintain adequate hydration to reduce the viscosity of secretions.
• Explain the use of support equipment properly, such as oxygen, suction equipment lenders.
• Inform patients and families that smoking is an activity that is prohibited in the treatment room.
• Instruct patients about cough and deep breathing techniques to facilitate the release of secretion.
• Negotiate with respiratory therapists as needed.
• Tell your doctor about the results of an abnormal blood gas analysis.
• Assist in the provision of aerosols. Nebulizer and other pulmonary care according to institutional policies and protocols.
• Encourage physical activity to improve the movement of secretions.
• If the patient is unable to perform ambulation, the location of the patient sleeping position changed every 2 hours.
• Inform patients before starting the procedure to reduce anxiety and increase self-control.

Nursing Care Plan for Anemia - Nursing Diagnosis and Interventions

Anemia is a clinical condition in which total number of red blood cells or the quantity of hemoglobin in blood declines than the normal level so the oxygen binding ability of hemoglobin is decreased.
Anemia is a relatively common disorder where one’s body does not produce enough red blood corpuscles (or cells) in the blood. As a result, the reduced number of cells does not have enough of the protein hemoglobin, which contains iron and transports oxygen around one’s bloodstream, thus the patient feels weak and looks pale – the most noticeable symptoms of anemia.
Types of Anemia

• Iron deficiency anemia;
• Folate deficiency anemia;
• Sickle Cell Disease; and
• Thalassemia.

Anemia in some individuals may remain hidden as the symptoms do not arise very frequently. The signs and symptoms may depend upon the underlying cause. Individuals suffering from anemia generally show non-specific symptoms like weakness, general malaise and poor concentration. They may also report shortness of breath on exertion. In very severe forms the body compensates for the lack of oxygen carrying capacity of blood cells by increasing the cardiac output. The patient may also complain of palpitation, angina, and intermittent claudication of legs and signs of heart failure. Other prominent symptoms include jaundice, bone deformities or leg ulcers. In severe forms tachycardia, bounding pulse, flow murmurs and cardiac ventricular hypertrophy may also occur. Symptoms of heart failure may also arise. Pica, a symptom of iron deficiency arises after the consumption of non-food items like paper, wax, glass and ice. Chronic anemia may also cause behavioral changes in the children resulting in impaired neurological development. Restless legs syndrome is very common in individuals with iron deficiency anemia. Less frequent symptoms include swelling of legs, arms, chronic heartburn, vomiting, increased sweating and loss of blood in stool.

Nursing Diagnosis for Anemia – Nursing Interventions for Anemia
1. Nursing Diagnosis: Ineffective Tissue Perfusion
Goal: Adequate tissue perfusion
Nursing Interventions for Anemia:

• Monitoring of vital signs, capillary refill, color of skin, mucous membranes.
• Raising the head position in bed
• Check and document the presence of pain.
• Observation of a delay in verbal response, confusion, or restlessness
• Observing and documenting the existence of the cold.
• Maintain the ambient temperature to keep warm the body needs.
• Provide oxygen as needed.

2. Nursing Diagnosis: Activity Intolerance
Goal: Support the child remain tolerant of the activity
Nursing Interventions for Anemia:

• Assess children’s ability to perform activities in accordance with physical and developmental tasks of children.
• Monitoring vital signs during and after activity, and noted a physiological response to activity (increased heart rate increased blood pressure, or rapid breathing).
• Provide information to the patient or family to stop doing activities if teladi symptoms of increased heart rate, increased blood pressure, rapid breathing, dizziness or fatigue).
• Provide support to children to perform daily activities in accordance with the child’s ability.
• Teach parents techniques provide reinforcement to the participation of children at home.
• Create a schedule of activities with the children and families by involving other health care team.
• Describe and provide recommendations to the school about the child’s ability to perform the activity, the ability to monitor activity on a regular basis and explain to parents and schools.

3. Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements
Goal: Meet the needs of adequate nutrition
Nursing Interventions for Anemia:

• Allow the child to eat foods that can be tolerated child, plan to improve the nutritional quality at the child’s appetite increases.
• Provide food that is accompanied by a nutritional supplement to improve the quality of nutritional intake.
• Allow the child to engage in food preparation and selection
• Evaluate the child’s weight every day.

Source : http://nursingdiagnosisinterventions.com/3-nursing-diagnosis-and-interventions-for-anemia

Family Nursing Diagnosis - Nursing Care Plan for Tuberculosis

Nursing Diagnosis that may arise in families with tuberculosis disease are:

a. Nutrition less than body requirements related to anorexia
b. Risk for Infection related to the secret is out
c. Ineffective airway clearance related to the accumulation of excessive secretions.
d. Disruption of gas exchange related to the decreased oxygen supply

In formulating nursing diagnoses in the family need to be a priority issue and a matter of priority criteria.

Priority issues

Things that need to be considered in the priority issues are as follows:
a. Not possible, the problems of health and nursing are found in the family can be addressed simultaneously.
b. Need to consider the problems that can threaten the lives of families like the problem of disease.
c. Need to consider the response and attention to family nursing care to be provided.
d. Family involvement in solving problems they face.
e. Family resources that can support problem solving health / family nursing.
f. Family and cultural knowledge.

Criteria for priority problems

Some of the criteria in priority setting problems:
1. Nature of the problem, are grouped into: health threats, is ill or unwell and crisis situations.

2. Possible problems can be changed, is the likelihood of success to reduce the problem or prevent a problem when it's done nursing and medical interventions.
Factors that may affect the problem of TB can be changed are:
a. Knowledge and action for the problem of tuberculosis.
b. Family resources, such as finance, personnel, facilities and infrastructure.
c. Care resources, including the knowledge and skills in handling the problem of tuberculosis.
d. Community resources, can be in the form of facilities, organization.

3. Potential problems of tuberculosis, to prevent, is the nature and severity of problems that will arise and TB can be reduced or prevented through nursing and health measures.
Things that need to be considered in view of the potential problem of prevention of tuberculosis are:
a. Severity / difficulty of the problem, this is related to severity of disease or tuberculosis that showed the prognosis and severity of tuberculosis suffered by family members.
b. Action has been and is being run, is an act to prevent and treat tuberculosis in order to improve the health status of the family.
c. The duration of the problem, severity of problems associated with tuberculosis in the family and the potential problems to be prevented.
d. The existence of high-risk groups within the family or a group of highly sensitive adds to the potential to prevent problems.

4. Prominence of the tuberculosis problem, is how families see and assess the tuberculosis problem in terms of severity and urgency to be addressed through nursing and medical interventions.

Nursing Care Plan for Tuberculosis

Tuberculosis Nursing Care Plan includes general and specific objectives based on problems that come with the criteria and standards that refer to the cause. Furthermore formulate action-oriented nursing criteria and standards.

There are several levels of objectives in the planning of nursing according to Friedman (1998: 64). Short-term goals that are measurable, immediate and specific. And long-term goal which is the final level of the broad purposes stated expected by nurses and families to be reached.

The purpose of nursing care in a family with tuberculosis:

A. Short term goals include:
Once the information is given to the families of tuberculosis, the family is able to recognize the problem of tuberculosis, is able to take decisions and be able to care for family members suffering from tuberculosis.

Evaluation criteria:
a. Verbal response, the family is able to mention the understanding, the signs and symptoms, causes, treatment and prevention of transmission of tuberculosis.
b. Effective response, the family able to care for family members suffering from tuberculosis.
c. Psychomotor response, the family is able to modify the environment for people with tuberculosis.

Evaluation standards:
Definition, signs and symptoms, causes, prevention of tuberculosis, prevention of transmission and ways of treatment of tuberculosis.

2. Long-term goals
Problem of TB in the family can be resolved / reduced after nursing actions.

Intervention phase begins with the completion of treatment planning. Like the opinion of Friedman (1998: 67). During the implementation of nursing interventions, new data is continuously flowing into. Because this information (the response from the client, the situation changes, etc.) were collected, nurses need to be quite flexible and can adapt to review the family situation by making modifications to the plan without a plan. In choosing nursing actions depending on the nature of the problem and the resources available for solving.

Nursing Interventions - TB Nursing Care Plan are as follows:

1. Instruct patient to cough / sneeze and remove the tissue and avoid spitting in any place.
2. Urge families to provide nutritious food.
3. Weight control periodically
4. Encourage the patient to eat little but often with a high-carbohydrate diet and high protein.
5. Encourage the patient to take medication regularly.

Implementation - Nursing Care Plan for Tuberculosis

Implementation of nursing actions on the family, based on the nursing plan has been prepared.
Things that need to be considered in the implementation of nursing actions against families with tuberculosis are:

a. Family of resources (financial)
Resources (financial) that are expected to adequately support the healing process to family members suffering from tuberculosis

b. Levels of family education
Family education level may affect the family in identifying problems kemampuam tuberculosis and making decisions about appropriate actions against family members suffering from tuberculosis.

c. Customs applicable
Customs prevailing effect on the ability of families in caring for family members suffering from tuberculosis

d. Response and acceptance of family
Response and acceptance of family is very influential in healing as families are able to provide motivation.

e. Facilities and infrastructure that exist in the family
In the presence of both facilities and infrastructure that will allow families to the family in providing care and treatment to family members suffering from tuberculosis.

Nursing Care Plan for Deficient Knowledge

Knowledge, deficient regarding condition, treatment program, self-care, and discharge needs related to lack of exposure and information, misinterpretation of information and unfamiliarity with information resources.

Deficient Knowledge Definition: Absence or deficiency of cognitive information related to a specific topic
Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Related Factors:

• Lack of exposure
• lack of recall
• information misinterpretation
• cognitive limitation
• lack of interest in learning
• unfamiliarity with information resources

Nursing Interventions Nursing Care Plan for Deficient Knowledge

1. Assess ability to learn or perform desired health-related care.
Rational : Cognitive impairments need to be identified so an appropriate teaching plan can be designed.

2. Determine client’s learning style especially if client had learned and retained new information in the past.
Rational: Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method facilitates success in mastery of knowledge.

3. Assess motivation and willingness of client.
Rational : Some clients are ready to learn soon after they are diagnosed.

4. Instruct client/ family in disease process, progression, what to expect, and answer all questions honestly.
Rational : Promotes optimal learning environment when client show willingness to learn. Family members may assist with helping the client to make informed choices regarding the treatment. Anxiety or large volumes of instruction may impede comprehension and limit learning.

5. Explain purpose of activity restrictions and need for balance between activity/rest.
Rational : Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion.

Nursing Care Plan for Appendicitis Post Operative

Nursing Care Plan for Appendicitis Post Operative

Definition of Appendicitis

a. Appendicitis is a minor surgical diseases most often occur. Although appendicitis can occur at any age, but most often in young adults. Before the antibiotic era, the high mortality of this disease (Sylvia A. Price, 1994).

b. Acute appendicitis is the inflammation spreads to the surface of the parietal peritoneum the pain persists, more powerful and gain weight when moving. (Barbara C. Long, 1996)

c. Acute appendicitis is the most common cause of acute inflammation in the lower right quadrant abdominal cavity, the most common cause for emergency abdominal surgery (Brunner and Suddarth, 2001).

Clinical Manifestations of Appendicitis


a. The main complaint of appendicitis: pain. Abdominal pain lasting more than 6 hours must be taken into consideration. The pain is caused by the blockage of the appendix and its the same as the pain caused by intestinal obstruction. At first intermittent pain such as colic, because the innervation of the appendix and small intestine together. People feel when flatus or bowel movement will relieve the pain.

Manifestations of pain:

• The beginning of the pain felt in the epigastrium, or around the umbilicus.
• Incurred local pain at the Mc. Burney. This inflammation will penetrate through the serosa and serous inflammation will spread to the peritoneum local parietale.
• Any movement will cause pain, severe pain and the pain turned into a sharp and continuous.
• In the event of perforation of the pain suddenly disappeared, but only briefly and then followed by intense pain throughout the abdomen due to peritonitis.

b. Anorexia is almost always the case.
c. Vomiting is a characteristic, vomiting occurs after pain.
d. Usually constipation.
e. Frequent diarrhea especially in children, and especially on the client that the appendix is ​​located in the nearby rectum.




Nursing Care Plan for Appendicitis Post Operative, as follows:

1. Assessment of post-operative data

The data on the client might get appendicitis authors include:
a. The identity of the client

• Name, tribe / nation, age, education, employment, income, address and Registration number.

b. Medical history

• History of the main complaints: Client: There is usually nausea, vomiting, rapid pulse, pain in the operated area.
• Incidence of complaints:Quarter of an hour after surgery.
• Nature of complaints: Since becoming aware of the client to feel the pain that persisted in the operated area.
• Another complaint came: Clients feel nausea, vomiting, and headache / dizziness.

c. Past medical history

• Lower right abdominal pain.

d. Physical examination

• The general situation: Client appears ill.
• Circulation: It may indicate respiratory bradycardia.
• Respiration: It may seem tachipnea clients because there is a sense of nausea and vomiting.
• Abdomen: abdominal distension may be tenderness in the area of ​​incision.
• Extremities: There may be cyanosis.

e. Patterns of daily life

• Nutrition: There is a sense of nausea and vomiting, the client can not eat, maybe a bad skin turgor.
• Elimination :Bowel movements: The client has not / does not defecate, may not flatus. Urinating: There may be disorders of urination
• Hygiene: Regional visible incision closed operations (wound was sterile).
• Convenience: Clients seem grimace.

f. Psychological data

• Clients seem restless.

NANDA Appendicitis

1. Risk for Infection

2. Acute pain

3. Risk for Fluid Volume

4. Anxiety

5. Knowledge Deficit 

Nursing Care Plan for Peritonitis Nursing Diagnosis Risk for Infection

Nursing Diagnosis Risk for Infection Nursing Care Plan

Definition: At increased risk for being invaded by pathogenic organisms
Related Factors: See Risk Factors.

Risk Factors:

Invasive procedures; insufficient knowledge regarding avoidance of exposure to pathogens; trauma; tissue destruction and increased environmental exposure; rupture of amniotic membranes; pharmaceutical agents (e.g., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Immune Status
Knowledge: Infection Control
Risk Control
Risk Detection

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Infection Control
Infection Protection

Client Outcomes

Remains free from symptoms of infection
States symptoms of infection of which to be aware
Demonstrates appropriate care of infection-prone site
Maintains white blood cell count and differential within normal limits
Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.


Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

 Reference : http://careplannursing.blogspot.com/2011/12/risk-for-infection-nursing-care-plan.html