Functional Health Patterns and 8 Nursing Diagnosis for Asthma

Nursing Care Plan for Asthma : Functional Health Patterns - Nursing Diagnosis

1. Health Perception – Health Management Pattern

• Clients complain of shortness of breath, coughing, mucus difficult out.
• Complain easily tired and dizzy.
• Drug usage data.
• Clients know / do not know the cause of the attack.

2. Nutritional – Metabolic Pattern

• Nausea, vomiting, no appetite.
• Shows signs of dehydration, dry mucous membranes.
• Cyanosis, a lot of sweat.

3. Elimination Pattern

4. Activity – Exercise Pattern

• Activity is limited because of wheezing and shortness of breath.
• Smoking habits.
• Cough and mucus that is difficult to remove.
• Use of accessory muscles during inspiration.

5. Cognitive – Perceptual Pattern

• The extent to which the client's knowledge about the disease.
• The ability to overcome the problem.
• The weakening process of thinking.

6. Sleep – Rest Pattern

• Lack of sleep complaints.
• Tired from the attack of shortness of breath and cough.

7. Self-perception – Self-concept Pattern

• Clients likely to reveal the strategy to overcome the attack, but was unable to cope if the attack comes.

8. Role – Relationship Pattern

• Disruption role in the attack.
• Feel embarrassed if there is an attack.

9. Seuality – Reproductive Pattern

10. Coping – Stress Tolerance Pattern

• Deny.
• Angry.
• Desperate.

11. Value – Belief Pattern

Nursing Diagnosis for Asthma

1. Ineffective Airway Clearance r / t increased production of secretions.
2. Impaired gas exchange r / t O2 supply disruption.
3. Activity intolerance (in performing self-care) r / t shortness of breath, and physical weakness.
4. Risk for imbalanced Nutrition: less than body requirements r / t input inadequate: nausea, vomiting and loss of appetite.
5. Anxiety r / t shortness of breath and scared.
6. Ineffective breathing pattern r / t decline in lung expansion during acute attacks.
7. Risk for infection r / t inadequate primary defense (cilia work and persistence decrease secretions).
8. Knowledge deficit r / t lack of information.

Pulmonary Tuberculosis (TB) - 3 Nursing Diagnosis, Interventions and Rational

Nursing Diagnosis for Plan Tuberculosis (TB) : Ineffective airway clearance related to the accumulation of purulent secretions in the airway.

Goal: Airway clearance back effectively.

Nursing Interventions:

• Assess respiratory function, for example; breath sounds, speed and rhythm.
• Give the patient semi-Fowler's position or high Fowler effectively assist the patient to cough and deep breathing exercises.
• Maintain fluid intake at least 2500 ml / day, except, contra indications.
• Collaboration for the administration of drugs according to indications, mucolytic drugs.

Rational:

• Decreased breath sounds may indicate atelectasis, crackles, wheezing showed accumulation of secretions inability to clean the airway.
• The position helps maximize lung expansion and lower respiratory effort.
• High input of fluids helps to thin the secretions, making it easily removed.
• Mucolytic agents decrease the viscosity and adhesion of lung secretions for easy cleaning.

Nursing Diagnosis for Plan Tuberculosis (TB) : Imbalanced Nutrition Less than Body Requirements related to the production of sputum, anorexia.

Goal: Demonstrate increased weight.

Nursing Interventions:

• Record the patient's nutritional status, record of skin turgor, weight and degree of underweight, ability / inability to swallow, a history of nausea-vomiting.
• Supervise the input or output and weight periodically.
• Provide oral care before and after the act of breathing.
• Encourage eating little and often with foods high in calories and high in protein.
• Collaboration with a nutritionist to determine the composition of the diet.

Rational:

• Useful in defining the degree / problems in determining appropriate intervention options.
• Useful in measuring the effectiveness of nutrition and fluid support.
• Lowering bad taste because the rest of the sputum or leftover medicines.
• Maximize nutrient inputs as energy needs and decrease gastric irritation.
• Provide assistance in planning a diet with adequate nutrients for metabolic and dietary needs.

Nursing Diagnosis for Plan Tuberculosis (TB) : Knowledge Deficit: on the conditions, rules of action and displacement.

Goal: To declare understanding of disease processes / prognosis and treatment needs.

Nursing Interventions:

• Assess the patient's ability to learn. Example: the problem of weakness, the level of participation and the best environment.
• Emphasize the importance of maintaining a high protein and carbohydrate diet and adequate fluid intake.
• Explain the drug dose, frequency, expected work and long treatment reasons
• Emphasize to not drink alcohol and do not smoke.

Rational:

• Learning depends on the emotional and physical readiness improved in individual stages.
• Meet the metabolic needs, help minimize the weaknesses and improve healing.
• Increase cooperation in the treatment program and prevent withdrawal of the drug.

Bronchopneumonia - Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis and Interventions for Bronchopneumonia -

1. Ineffective airway clearance related to accumulation of secretions.

Goal: Airway clearance back effectively.

Outcomes: secretions can come out.

Interventions:

• Monitor respiratory status every 2 hours, assess the increase in respiratory and abnormal breath sounds.
• Do suction as indicated.
• Give oxygen therapy every 6 hours.
• Create an environment / convenient so patients can sleep.
• Give a comfortable position for the patient.
• Monitor blood gas analysis to assess respiratory status.
• Perform chest percussion.
• Provide sputum for culture / sensitivity test.

2. Impaired gas exchange related to changes in alveolar capillaries.

Goal: back to normal gas exchange.

Outcomes: The client showed improved ventilation, gas exchange and oxygenation optimally adequately.

Interventions:

• Observation of level of consciousness, respiratory status, signs cianosis.
• Give appropriate sleeping position fowler / semi-Fowler.
• Give oxygen according to the program.
• Monitor blood gas analysis.
• Ciprtakan comfortable environment.
• Help prevent fatigue.

3. Fluid volume deficit related to excessive output.

Goal: Client will maintain normal body fluid.

Outcomes: no sign of dehydration.

Interventions:

• Record intake and output of fluids (fluid balance).
• Encourage the mother to continue to provide oral fluid.
• Monitor fluid balance, mucous membranes, skin turgor, rapid pulse, decreased consciousness, vital signs.
• Maintain a drip infusion accuracy.
• Observation of vital signs (pulse, temperature, respiration).

4. Risk for Imbalanced nutrition less than body requirements related to inadequate nutritional intake.

Goal: The nutritional requirements are met.

Outcomes: The client can maintain / improve nutritional intake.

Intervetions:

• Assess the client's nutritional status.
• Perform a physical examination of the abdomen (auscultation, percussion, palpation, and inspection).
• Measure the client's body weight every day.
• Assess for nausea and vomiting.
• Give the diet a little but often.
• Provide food in a warm state.
• Collaboration with the nutrition team.

5. Increased body temperature related to the infection process.

Goal: There is an increase in body temperature.

Outcomes: Hyperthermia / increase in temperature can be resolved with no infection process.

Interventions:

• Observation of vital signs.
• Provide and encourage families to provide water compress on the forehead area and armpits.
• Involve the family in every action.
• Give drink orally.
• Replace wet clothing with sweat.
• Collaboration with doctors in febrifuge.

6. Knowledge Deficit : parents, about the care of clients related to a lack of information.

Goal: Knowledge parents about the child's illness increased after the act of nursing.

Outcomes: Parents know about the child's illness.

Interventions:

• Assess the level of parental knowledge about the child's illness.
• Assess the client's level of parental education.
• Help parents to develop a plan of nursing care in the hospital such as: diet, rest and activity accordingly.
• Emphasize the need to protect children ..
• Explain to the client's family about the definition, causes, signs and symptoms, treatment, and prevention of complications by providing health education.
• Give parents the opportunity to ask clients about things not yet understood.

7. Anxiety children related to the effects of hospitalization.

Goal: Anxious children is reduced / lost.

Outcomes: The client can be quiet, anxious lost, comfortable feeling fulfilled after the act of nursing.

Interventions:

• Assess the client's level of anxiety.
• Encourage the mother / family to give suport to the child by way of the mother is always near to the client.
• Facilitating a sense of comfort by way of participating mothers caring for their children.
• Make a visit, contact with clients.
• Encourage other family visiting clients.
• Give A toy according client's home.

Evaluation

The evaluation is expected in patients with Brochopneumonia are:

1. Normal gas exchange.
2. Effective airway clearance.
3. Intake and output balance.
4. Adequate nutritional intake.
5. Body temperature within normal limits.
6. Increase family knowledge.
7. Anxiety resolved.

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 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 Impaired Sense of Comfort : Pain

Nursing Care Plan for Pain

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


Definition

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

Etiology

1. Trauma. Trauma is also divided into several kinds. The cause of the trauma is divided into:

• Mechanics. The pain caused by this mechanical arising from free nerve endings were damaged. Examples of this pain is due to mechanical trauma due to impact, friction, and other injuries.
• Thermal. Painful as this arises because the nerve endings gets receptor stimulation caused by heat, cold, such as fire and water.
• Chemist. Pain caused by contact with chemicals that are strong acids or bases.
• Electric. Pain is caused by the influence of a strong electric current on the pain receptors that cause muscle spasms and burns.

2. Neoplasms. This neoplasm is also divided into two, namely:

• Benign neoplasms.
• Malignant neoplasm.

3. Disorders of blood circulation, and blood vessel abnormalities. This can be exemplified in patients with acute myocardial infarction or angina pectoris that is felt is the typical chest pain.
4. Inflammation. Pain is caused due to damage to nerve endings receptor due to inflammation or pinched by swelling. An example is the pain due to abscess.
5. Psychological trauma.


Signs and Symptoms

Behavioral responses to pain may include:

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

Physiological Respon to Pain

A. Sympathetic stimulation (mild pain, moderate, and superficial)

• Bronchial tract dilatation and increased respiration rate.
• The increase in heart rate.
• Peripheral vasoconstriction, increased BP.
• Increased blood sugar values​​.
• Diaphoresis.
• Increased muscle strength.
• Dilated pupils.
• Decreased GI motility.

B. Stimulus parasympathetic (severe pain and in)

• Pallor.
• Hardened muscles.
• Decreased HR and BP.
• Rapid breathing and irregular.
• Nausea and vomiting.
• Fatigue and exhaustion.

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

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

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

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


Classification of pain can be divided into:

1. According to the location of pain

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

2 According to the nature of pain.

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

3 According to the severity of pain.

• Mild pain is pain that is located in a low intensity.
• Moderate pain is pain that causes a physiological reaction and psychological reactions.
• Heavy pain is pain that is located in a high intensity.

4 According to the time of the attack.

• Acute Pain. Acute pain is usually short-lived, such as pain at the fracture. Clients who experience acute pain will generally show symptoms include: increased respiration, heart rate and increased blood pressure, and pallor.
• Chronic Pain. Chronic pain develops more slowly and occurs in a longer time and in general, people are often hard to remember since when the pain began to be felt.

Nursing Care Plan for Pain

Assessment

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

Nursing care of clients experiencing pain:

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


Characteristics of pain (PQRST)

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

The things that need to be assessed:

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

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

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

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

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


Quality of pain

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

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

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

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

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

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


Observation of behavioral and physiological responses

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

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

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


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


Nursing Diagnosis

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

Interventions:
Nurses develop a plan of nursing diagnoses that have been made​​. Nurses and clients together to discuss realistic expectations of action to overcome the pain, the degree of pain relief that is expected, and the effects are to be anticipated in lifestyle and client functions. Expected outcomes and objectives of nursing and nursing diagnoses are selected based on the client's condition. In general, the purpose of nursing care clients with pain are as follows:

• Clients feel healthy and comfortable.
• Clients retain the ability to perform self-care.
• Clients maintain physical and psychological function held today.
• Clients describe factors that cause pain.
• Clients using the therapy given safely at home.

Nursing Diagnosis : Acute pain r / t physical injury (surgery)

Goal:
Pain level, pain control and comfort level with the expected outcomes:

• Using a pain scale to identify the perceived pain.
• Describing how to manage pain.
• Expressing ability to sleep and rest.
• Describing nonpharmacological therapy to control pain.
• Vital signs within normal limits.

Interventions:
Pain management:

• Assess pain experienced by clients (including PQRST).
• Observation of nonverbal discomfort to pain.
• Assess the client's experience of the past to pain.
• Create a comfortable environment for clients.
• Collaboration of analgesics.
• Teach nonpharmacological techniques to cope with pain.
• Etc. (see more fully in the NIC).

Intervention

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

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

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

The role of nurses in pain management:

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

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

Nursing Care Plan for Hirschsprung's Disease

Assessment of Hirschsprung's Disease

1. Activity / rest

• Symptoms: Malaise, changing patterns of rest / sleep associated with pain, limitations.

2. Ego Integrity

• Symptoms: Anxiety, fear, feelings of helplessness parents.

3. Elimination

• Symptoms: Constipation can be accompanied by diarrhea.
• Symptoms: Abdominal distension progressively, until the thin abdominal wall veins visible, peristaltic activity can be observed.

4. Food / fluid

• Symptoms: Anorexia, nausea, vomiting, weight loss.
• Signs: Decrease subcutan fat / muscle mass, weakness, a sign of malnutrition and growth failure.

5. Pain / comfort

• Symptoms: Abdominal pain.
• Signs: Facial expressions grimacing, moaning / crying, behavioral distraction, abdominal tenderness / distension.

6. Extension / learning

• Parent questions related to the disease, care and treatment of children.
• Patient's discharge plan: Requires assistance / demonstration how irrigation and colostomy care, the ability to assess the incidence of abdominal distension and obstruction.

Nursing Diagnosis and Interventions for Hirschsprung's Disease - Preoperative

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

Goal: Observation does not happen.

Outcomes:

• Clients say can defecate.
• Normal intestinal peristalsis.

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

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


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

Goal: Fulfillment of nutrients can be resolved.

Outcomes:

• Clients no nausea and vomiting.
• Inkate adequate.
• 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 to maintain homeostasis.

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


3. Anxiety related to ineffective coping.

Goal: Anxiety is resolved.
Outcomes:

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

Interventions:
1 Assess the level of anxiety.
R /: Make it easy for the next action.

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



Nursing Diagnosis and Interventions for Hirschsprung's Disease - Postoperative

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

Goal: The client expresses a sense of comfort pain reduced / lost.
Outcomes:

• Clients complained of pain at the surgical wound.
• Cheerful facial expressions.
• Vital signs within normal limits.
• Relationships 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 Give a fun position.
R /: Reduce emphasis on muscle and prevent muscle spasms that can cause pain.

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

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


2. Disturbed Sleep Pattern related to postoperative wound pain.

Goal: Sleep patterns resolved.
Outcomes:

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

Interventions:
1 Assess sleep patterns and intirahat clients.
R /: Knowing the disturbance of rest / sleep clients to determine further intervention.

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

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

NCP for Abdominal Tumor - Nursing Diagnosis and Interventions

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.

Gigantism Nursing Diagnosis: Altered Family Processes

Gigantism is a condition of a person that excess growth, with great height and above normal. Gigantism is caused by excessive amounts of growth hormone. There are no high definition refer as "giants." adult height.

Gigantism is a condition of a person that excess growth, with a large height above normal and is caused by the secretion of growth hormone (GH) excessive and occurs before adulthood or before epiphyseal closure process. (Corwin, 2007)

Growth hormone is a hormone produced by the anterior pituitary which works to increase the growth and metabolism in target cells. Hormone target cells are located in almost all parts of the body. Growth hormone also plays a role in synthesizing somatomedin the liver, to stimulate the epiphyseal growth plate. Metabolic impact of GH is the mobilization of free fatty acids in adipose tissue and muscle glucose metabolism barriers and in adipose tissue.

Pituitary gigantism often occurs as a result of excessive GH secretion due to the onset of pituitary tumors in children before epiphyseal closing. Gigantism usually affects children aged 6-15 years.

Gigantism is a protein hormone increases in many tissues, increasing the decomposition of fatty acids and adipose tissue and blood glucose levels. Gigantism occurs in children when the period skeleton still has the potential to grow, or at pre-puberty.

Gigantism is caused by excessive secretion of GH. This condition can be caused by pituitary tumors that secrete GH or because of abnormalities of the hypothalamus which leads to excessive GH secretion. Gigantism can occur when the state of excess growth hormone occurs before epiphyseal bone plates close or still in its infancy. The cause of excess growth hormone production is mainly in the tumor cells somatrotop which produces growth hormone.

The most frequent cause of gigantism is a pituitary adenoma, but gigantism has been observed in boys aged 2.5 years with hypothalamic tumor secreting GHRH which can be complicated, especially in the pancreas that secrete the already large number of GHRH (Arvin, 2000).

Some people have vision problems and behavior. In most cases recorded abnormal growth become apparent at puberty, but this situation has been established as early as the newborn period in a child and at the age of 1 month. In gigantism, soft tissues such as muscle and other continue to grow. Gigantism can be accompanied by visual disturbances when the tumor enlarges to suppress chiasma opticum which is the optic nerve pathways.

The following are symptoms of gigantism caused by excess secretion of GH:

• The signs of glucose intolerance.
• Nose width, enlarged tongue and rough face.
• Excessive growth of the mandible.
• Teeth become separated.
• Finger and thumb to grow thicker.
• Melting and weaknesses.
• Loss of vision in the visual field examination carefully because the optic nerve khiasma depressed eyes.

Nursing Diagnosis for Gigantism: Altered Family Processes related to families with gigantism.

Goal:

• Preparing the family to be able to care for members with gegantisme.
• Families can adapt to the disease.

Outcomes:

• Families can cope with problems arising from the presence of signs and symptoms that appear and deliver or provide a suitable environment to the client's condition.

Intervention and rationale:

1. Provide emotional support to families and clients.
R /: Families can receive clients.

2. Encourage parents to express their feelings.
R /: Families can adapt to the client's illness.

3. Encourage clients to share a sense of helplessness, shame, fear associated with disease manifestations.
R /: To solve problems that arise.

4. Acting as an advocate and liaison clients and families, with other health care team members.
R /: Preparing families to care for the client.

5. Encourage clients to socialize with their surroundings.
R /: Motivating clients.

6. Encourage client involvement in recreational and diversionary activities are age-appropriate.
R /: Increase client confidence.

Nursing Diagnosis for Biliary Atresia

Nursing Care Plan for Biliary Atresia

Biliary atresia is a serious disease which occurs in one in 10,000 children and is more common in girls than boys and in newborns of Asian and African-American than in Caucasian newborns. The cause of biliary atresia is unknown, and treatment is only partially successful.

Biliary atresia occurs due to prolonged inflammatory process that causes progressive damage to the extrahepatic biliary duct, causing bile flow resistance. Thus, biliary atresia is the absence or small lumen in part or all of extrahepatic biliary tract that causes bile flow resistance. As a result, the blood in the liver and bile salt buildup and increased direct bilirubin.

Biliary atresia is an inhibition in the pipes / ducts that carry bile from the liver to the gallbladder to. It is a congenital condition, which means that at birth.

The etiology of biliary atresia is not known with certainty. Some experts claim that genetic factors play a role, which is associated with a chromosomal abnormality trisomy 17, 18 and 21; as well as the presence of anomalous organs in 30% of cases of biliary atresia. However, most authors suggest that biliary atresia is the result of an inflammatory process that damages the biliary duct, could be due to infection or ischemia.

Some children, especially those with a fetal form of biliary atresia, often have other birth defects in the heart, spleen, or intestines.

An important fact is that biliary atresia is not a hereditary disease. Cases of biliary atresia have occurred in identical twins, where only one child with the disease. Biliary atresia is most likely caused by an event that occurs during fetal life or around the time of birth. The possibility that "triggers" may include one or a combination of the following predisposing factors:

• viral or bacterial infection
• problems with the immune system
• abnormal bile components
• errors in the development of liver and bile duct
• hepatocelluler dysfunction

Infants with biliary atresia usually appear healthy when they were born. Symptoms of the disease usually appear within the first two weeks of life. The symptoms include:

• Jaundice, yellowing of the skin and eyes due to the very high levels of bilirubin (bile pigment) in the bloodstream. Jaundice is caused by an immature liver is common in newborns. It usually goes away within the first week to 10 days of life. An infant with biliary atresia usually appear normal at birth, but jaundice develops in two or three weeks after birth.
• Dark urine caused by a buildup of bilirubin (a breakdown product of hemoglobin) in the blood. Bilirubin is then filtered by the kidneys and removed in the urine.
• Pale stools, because there is no staining of bilirubin or bile into the intestine to color the stool. Also, the abdomen may become swollen due to enlargement of the liver.
• Weight loss, jaundice develops when the rate increases.
• Gradual degeneration of the liver causing jaundice, jaundice, and hepatomegaly, Channel intestine can not absorb fats and fat-soluble in water, causing malnutrition conditions, deficiency of fat-soluble in water as well as failure to thrive.

Nursing Diagnosis for Biliary Atresia

1) Hyperthermia related to inflammatory damage due to progressive extrahepatic biliary duct.

2) Ineffective breathing pattern related to an increase in abdominal distension.

3) Imbalanced Nutrition: Less Than Body Requirements related to anorexia and impaired absorption of fat.
characterized by weight loss and conjunctival pallor.

4) Impaired bowel elimination (diarrhea) related to intestinal malabsorption.
characterized by liquid stool, increased frequency of bowel movements (more than 3 times daily), increased bowel sounds.

5) Impaired skin integrity related to accumulation of bile salts in the network.
characterized by pruritis.

6) Deficient fluid volume related to nausea and vomiting.

7) Anxiety related to lack of information about the disease due to lack of knowledge.

3 Nursing Diagnosis and Interventions for Cystic Fibrosis

Cystic fibrosis (CF) is an inherited disease of the mucus glands and sweat . Cystic fibrosis (CF) affects mostly the lungs, pancreas, liver, intestines, sinuses, and sex organs.

Normally , mucus is watery / runny. Maintaining the layers of certain organs moist and prevents drying out or getting infected. But in CF, an abnormal gene causes mucus to become thick and sticky.

Mucus formed in the lungs and block the airways. It makes it easier for bacteria to grow and leads to repeated lung infections are serious. Over time, these infections can cause serious damage to the lungs.

Thick and sticky mucus can also block tubes, or ducts of the pancreas. As a result, the digestive enzymes produced by the pancreas is not able to reach the small intestine. These enzymes help break down food. Without them, the intestines can not absorb fats and proteins fully.

As a result:

• Nutrients leave the body unused, and can become malnourished.
• Stools become very large.
• May not get enough vitamins A, D, E, and K.
• May have gas in the intestines, the stomach is swollen, and pain or discomfort.

Abnormal genes also cause sweat to become very salty. As a result, when sweating, the body loses salt amounts are large. This can upset the balance of minerals in the blood. The imbalance may lead to getting heat emergency.

Nursing Care Plan for Cystic Fibrosis

Nursing Diagnosis I:

Ineffective airway clearance related to thick mucus secretions and effort and a lot of bad cough.

Goal: Not experiencing aspiration.

Outcomes: Shows an effective cough and increased air exchange in the lungs.

Interventions :

1. Auscultation of breath sounds. Note the example of wheezing breath sounds, crackles, rhonchi.
R /: Some degree of spasm of the bronchial obstruction with airway obstruction and may / not indicated the presence of abnormal breath sounds or crackles eg absence of breath sounds.

2. Perform physiotherapy to issue secret and give the patient a comfortable position, eg, elevation of the head of the bed, sitting on the back of the bed (position semi-Fowler / Fowler).
R /: head of bed elevation facilitate respiratory function using gravity.

3. Assist clients to dilute sputum, with the collaboration expectorant administration to improve airway clearance.
R /: Giving expectorants may help thin the secret, that secret is more easily removed.

4. Provide nebulizer with a solution and in accordance with the right tools.
R /: Nebulization can help spending viscous secretions.

5. Observations clients closely after aerosol therapy and chest physiotherapy to prevent aspiration due to many sputum suddenly become watery.
R /: To prevent aspiration.

6. Provide postural drainage (adjust the area where there is a buildup of mucus) as prescribed to reduce the viscosity of mucus.
R /: Postural drainage aids in the excretion of mucus is thick.


Nursing Diagnosis II :

Impaired gas exchange related to airway obstruction by nasal obstruction.

Goal: Maintaining adequate oxygenation or ventilation.

Outcomes:
The patient showed respiratory rate effectively.
Free of respiratory distress.
Arterial blood gas within the normal range.

Interventions :

1. Maintain a patent airway.
R /: Preventing complications of respiratory failure.

2. Position the patient to obtain maximum efficiency ventilators, such as a high Fowler's position or sitting, leaning forward.
R /: Position Fowler / semi-Fowler can facilitate respiratory function and can reduce airway collapse, dyspnoea, and breath work by using gravity.

3. Monitor vital signs, arterial blood gases (ABGs), and pulse oximetry to detect / prevent hypoxemia.
R /: increased PaCO2 indicates impending respiratory failure during asthmatic. Tachycardia, dysrhythmias, and changes in BP may indicate systemic hypoxemia effects on cardiac function.

4. Provide supplemental oxygen according to the provisions / requirements. Monitor patients closely for carbon dioxide narcosis due to oxygen is danger of oxygen therapy in patients with chronic lung disease.
R /: Occurrence / respiratory failure that would require effort dating lifesaving action. Supplemental oxygen administration can fix / prevent worsening hypoxia.

5. Motivation exercise appropriate physical condition of the patient.
R /: Physical exercise is often effective to clear accumulated lung secretions and to improve endurance exercise capacity before experiencing dyspnea



Nursing Diagnosis III

Ineffective breathing pattern related to tracheobronchial obstruction.

Goal:
Repairing or maintaining a normal breathing pattern.
Patients achieving lung function maximum.

Outcomes:
Patients showed an effective respiratory frequency with the frequency and depth within the normal range and lungs clear / clean.
Patients free of dyspnea, cyanosis, or other signs of respiratory distress.


Interventions :

1. Provide position Fowler or semi-Fowler.
R /: Position Fowler / semi-Fowler enables lung expansion and ease breathing. Changing position and ambulation improve air charging different lung segments which improves gas diffusion.

2. Teach deep breathing techniques, and or lip breathing or diaphragmatic breathing abdominal exercises when indicated and effective cough.
R /: to help spending sputum.

3. Observation vital signs (RR or frequency per minute).
R /: Tachycardia, dysrhythmias, and changes in BP may indicate the effect of systemic hypoxemia pad cardiac function.

Nursing Diagnosis and Interventions for Low Self-Esteem

Definition of Low Self-Esteem

Low Self-Esteem is a self-resisted as something precious and can not be responsible for their own lives.


Process of Low Self-Esteem

Self-concept is defined as all the thoughts, beliefs, and beliefs that make a person knows about themselves and affect relationships with others (Stuart & Sunden, 1995). The concept of self is not formed since birth but learned.

One component is the concept of self-esteem, self-esteem which is about the attainment of individual self-assessment by analyzing how far the behavior in accordance with the ideal self (Keliat, 1999). While low self esteem is rejected him as something of value and not responsible for her own life. If an individual often fails then tend to low self esteem. Low self esteem if the loss of love and appreciation of others. Self-esteem derived from self and others, the main aspect was accepted and received the award from someone else.

Low self esteem disorder described as feeling negative about themselves, including loss of self-confidence and self-esteem, feeling failed to reach the desire, self-criticism, reduced productivity, destructive directed at other people, feelings of inadequacy, irritable and withdrawn socially.

Factors affecting self-esteem include parental rejection, parental expectations are not realistic, repeated failures, have less personal responsibility, dependence on others and the ideal self is not realistic. While the originator stressors may result from internal and external sources such as :

1. Trauma such as sexual abuse and psychological or witnessing events that threaten.
2. Tensions related to the role or roles expected position in which the individual experiencing frustration.

Disorders of self-esteem or low self esteem can occur:

1. Situational, which occurred a sudden trauma, for example, should the operation, accident, her husband divorced, dropping out of school, working breakup, etc.. In patients treated low self esteem can occur because of privacy that less attention: the indiscriminate physical examination, the installation of equipment that is not polite (catheter, perianal inspection checks etc..), Hope for the structure, shape and function of the body that is not achieved because in-patient / illness / disease, treatment of workers who do not appreciate.
2. Chronic, that negative feelings toward themselves have lasted long.

Nursing Diagnosis

1. Risk for social isolation: withdrawal related to low self esteem.
2. Self-concept Disturbance: low self-esteem related to dysfunctional grieving.

Nursing Interventions

1. Clients can build a trusting relationship with caregivers
action:
1.1. Construct a trusting relationship: therapeutic greetings, self-introduction, explain the purpose, creating a quiet environment, create a clear contract (time, place and topic of conversation).
1.2. Give the client a chance to express feelings.
1.3. Take time to listen to clients.
1.4. Tell the client that he is someone who is valuable and responsible and able to help themselves.

2. Clients can identify capabilities and positive aspects possessed.
action:
2.1. Discuss capabilities and positive aspects of client owned.
2.2. Avoid giving a negative assessment of each meeting client, focusing on realistic compliment.
2.3. Clients can assess the capabilities and positive aspects possessed.

3. Clients can assess the capabilities that can be used.
action:
3.1. Discuss with the client the ability to still be used.
3.2. Discuss also the ability to continue after returning home.

4. Clients can assign / plan activities appropriate capabilities.
action:
4.1. Plan with client activity to do each day according to ability.
4.2. Increase activity according to the tolerance of the client's condition.
4.3. Give examples of how the implementation of activities that the client should do.

5. Clients can perform activities according to the conditions and capabilities
action:
5.1. Give a chance to try activities that have been planned.
5.2. Give praise / reward for success.
5.3. Discuss the possibility of implementation at home.

Nursing Diagnosis and Interventions for Constipation

Constipation is a little defecation frequency, stool is not sufficient in number, in the form of hard and dry (Oenzil, 1995).

Constipation is a decrease in frequency of defecation, stool followed by spending long or hard and dry. There was an effort straining during defecation is a sign associated with constipation. If the small intestine motility slowed, a longer period of exposure to feces on the intestinal wall and most of the absorbed water content in the feces. A small amount of water left out to soften and lubricate the stool. Spending dry and hard stools can cause pain in the rectum. (Potter & Perry, 2005).

1. Constipation related to irregular defecation pattern

Goal : Patients can defecate regularly (every day)

Outcomes:

• Defecation can be done once a day.
• Soft stool consistency.
• Faecal elimination without excessive straining.

Nursing Interventions:

Independent:
1. Determine the pattern of defecation and trained to do so.
Rationale: To restore the regularity of defecation pattern.

2. Set the right time for defecation, such as after meals.
Rationale: To facilitate defecation reflex.

3. Provide coverage in accordance with the indications of nutritional fiber.
Rationale: Nutrition high fiber to launch fecal elimination.

4. Give fluids if not contraindicated 2-3 liters per day.
Rationale: To soften the stool elimination.

Collaboration:
5. Provision of laxatives or enemas as indicated.
Rationale: To soften the stool.


2. Imbalanced Nutrition, Less Than Body Requirements related to loss of appetite

Goal: demonstrate good nutritional status

Outcomes:

• Tolerance to dietary needs.
• Maintain body mass and body weight in the normal range.
• Laboratory values ​​within normal limits.
• Reported adequacy of energy levels.

Nursing Interventions:

Independent :
1. Make meal planning to put in a feeding schedule.
Rationale : Keeping the patient's diet, so patients eat regularly.

2. Support family members to bring favorite foods from the patient's home.
Rationale : The patient feels comfortable with food brought from home and can improve the patient's appetite.

3. Offer large meals during the day when the high appetite.
Rationale : By giving a large portion can maintain adequacy of nutrient intake.

4. Ensure that the diet meets the needs of the body as indicated.
Rationale : High carbohydrate, protein, and calories needed or required for treatment.

5. Make sure that the patient's diet is liked or disliked.
Rationale : To support the improvement of the patient's appetite.

6. Monitor input and expenditure and body weight periodically.
Rationale : Knowing the balance of food intake and output.

7. Assess the patient's skin turgor.
Rationale : As the data supporting a change in nutrition less than the requirement.

Collaboration:

8. Monitor laboratory values​​, such as hemoglobin, albumin, and blood glucose levels.
Rationale: In order to determine the level of Hb content deficiencies, albumin, and glucose in the blood.

9. Teach method for meal planning.
Rationale: Clients are accustomed to eating in a planned and orderly.

10. Health Education: Teach patients and families about nutritious food and not expensive.
Rational: Maintain the required nutrition adequacy.

Measles Nursing Diagnosis and Interventions

Measles is a highly contagious viral infection, which is characterized by fever, cough, conjunctivitis (inflammation of the lining of connective eye / conjunctiva) and skin rash. The disease is caused by infection of measles virus, Paramixovirus class. Transmission of the infection occurs because of inhaling spray saliva from patients with measles. Patients can transmit the infection within 2-4 days before the onset of skin rash and 4 days after the rash there. Before the widespread use of measles vaccination, measles outbreaks occur every 2-3 years, especially in children aged pre-school and elementary school children. If someone has had measles, then the rest of his life he normally would be immune to this disease.

Symptoms begin to appear within 7-14 days after infection, which are: body heat, sore throat, runny nose, cough, muscle pain, red eyes (conjuctivitis). And 2-4 days later, small white spots appear on the inside of the mouth. Rash (redness of skin) that feels a bit itchy appear 3-5 days after the onset of the above symptoms. This could take the form of macular rash (rash reddish flat) and papules (red rash that stands out). At first the rash appears on the face, which is in front of and below the ears and on the neck next to the side. Within 1-2 days, the rash spreads to the trunk, arms and legs, while a rash on the face began to fade. At the peak of the disease, the patient was very ill, and the rash extends his body temperature reached 40 ° Celsius. At 3-5 days later his temperature dropped, the patient begins to feel well and left immediately rash disappeared. Fever, lethargy, runny nose, cough and red eyes and inflammation for several days followed by a red blotchy rash that started on the face and spread to the body and there for 4 days to 7 days.

1. Impaired social interaction related to isolation from friends.

Expected results:

• Children demonstrate an understanding of the restrictions.
• Appropriate child activities and interact.

Intervention:
1. Explain the reason for the isolation and use of special vigilance.
Rational: to increase children's understanding of the discussion.

2. Let the children play the gloves and masks.
Rational: to facilitate positive coping.

3. Provide diversion activities.
Rational: the right to perform activities and interact.

4. Encourage parents to stay with their children during hospitalization.
Rational: to reduce separation and provide proximity.

5. Prepare children for changes perampilan friends physically.
Rationale: to encourage the acceptance of friends.


2. Risk for impaired skin integrity related to raking pruritus.

Expected results: the skin remains intact

Intervention:
1. Keep nails short and clean.
Rational: to minimize the trauma and secondary infection.

2. Wear gloves or elbow restrein.
Rational: to prevent scratching.

3. Give clothes are thin, loose, and not to irritate.
Rationale: because excessive heat can increase itching.

4. Close area of ​​pain (long sleeves, long pants, underwear layer).
Rational: to prevent scratching.

5. Give lotion that softens (very little on the open lesions).
Rationale: because the open lesions to reduce drug absorption increased pruritus.

6. Avoid exposure to sunlight or heat.
Rationale: cause rashes.

Colon Cancer Nursing Diagnosis

Most colon cancers originate from small, noncancerous (benign) tumors called adenomatous polyps that form on the inner walls of the large intestine. Some of these polyps may grow into malignant colon cancers over time if they are not removed during colonoscopy. Colon cancer cells will invade and damage healthy tissue that is near the tumor causing many complications.

Colon cancer is not necessarily the same as rectal cancer, but they often occur together in what is called colorectal cancer. Rectal cancer originates in the rectum, which is the last several inches of the large intestine, closest to the anus.

Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. It is common for people with colon cancer to experience no symptoms in the earliest stages of the disease. However, when the cancer grows, symptoms include:

• Diarrhea or constipation
• Changes in stool consistency
• Narrow stools
• Rectal bleeding or blood in the stool
• Pain, cramps, or gas in the abdomen
• Pain during bowel movements
• Continual urges to defecate
• Weakness or fatigue
• Unexplained weight loss
• Irritable bowel syndrome (IBS)
• Iron deficiency (anemia)

9 Nursing Diagnosis for Colon Cancer

1. Constipation related to obstructive lesions.
2. Acute Pain related to tissue compression secondary to obstruction.
3. Fatigue related to anemia and anorexia.
4. Imbalanced Nutrition, Less Than Body Requirements related to nausea and anorexia.
5. Risk for fluid volume deficit related to vomiting and dehydration
6. Anxiety related to cancer diagnosis and surgery planning
7. Knowledge Deficit: the diagnosis, surgical procedures, and self-care.
8. Impaired Skin Integrity related to surgical incision (abdominoperineal), stoma formation, and faecal contamination of the skin periostomal.
9. Disturbed body image related to colostomy.

Preeclampsia Nursing Diagnosis

Preeclampsia/eclampsia is a complex hypertensive disorder of pregnancy affecting multiple systems. Preeclampsia is a condition that pregnant women can get. Preeclampsia and eclampsia are complications of pregnancy. In preeclampsia, the woman has dangerously high blood pressure, swelling, and protein in the urine.




7 Nursing Diagnosis for Preeclampsia

1. Acute pain
reated to post Caesarean section incision

2. Alteration in Bowel Elimination: Constipation
related to decreased intestinal peristalsis.

3. Risk for Infection
related to tissue trauma / skin damage

4. Risk for Fluid Volume Deficit
related to the bleeding

5. Altered family processes
related to the preparation of infant acceptance.

6. Sleep pattern disturbance
related to the tension during the birth process, pain.

7. Knowledge Deficit: perawtan about babies, family planning, nutrition
related to inadequate information. 

Source : http://nanda-nurse-diary.blogspot.com/2012/11/nanda-7-nursing-diagnosis-for.html

Nursing Diagnosis and Interventions for Patent Ductus Arteriosus (PDA)

Nursing Diagnosis for Patent Ductus Arteriosus (PDA)

1. Decreased Cardiac Output related to malformations of the heart.
2. Impaired Gas Exchange related to pulmonary congestion.
3. Activity Intolerance related to imbalance between oxygen consumption by the body and oxygen supply to the cells.
4. Delayed Growth and Development related to an inadequate supply of oxygen and nutrients to the tissues.
5. Imbalanced Nutrition Less than Body related to fatigue at mealtime and increased caloric needs.
6. Risk for Infection related to decreased health status.

Nursing Interventions for Patent Ductus Arteriosus (PDA)
1. Maintain adequate cardiac output:

• Observation of the quality and strength of heart rate, peripheral pulses, skin color and warmth.
• Enforce the degree of cyanosis (circumoral, mucous membranes, clubbing).
• Monitor signs of CHF (restlessness, tachycardia, tachypnea, spasms, fatigue, periorbital edema, oliguria, and hepatomegaly).
• Collaboration of drugs in accordance with the order, using toxicity hazard prevention techniques.
• Provide treatment to reduce afterload.
• Give diuretics as indicated.

2. Reduce the increase in pulmonary vascular resistance:

• Monitor the quality and rhythm of breathing.
• Adjust the position of the child with Fowler position.
• Avoid children from an infected person.
• Give adequate rest.
• Provide optimal nutrition.
• Give oxygen if indicated.

3. Maintaining adequate levels of activity:

• Allow the child to rest frequently, and avoid disturbances during sleep.
• Encourage to engage in play and light activity.
• Help child to choose activities appropriate to the age, condition and abilities.
• Avoid the ambient temperature is too hot or too cold.
• Avoid the things that cause fear / anxiety in children.

4. Provide support for the Growth and Development :

• Assess the level of development of the child.
• Give the stimulation of growth and development, play activities, gaming, watching TV, puzzles, drawing, and others according to the condition and age of the child.
• Involve the family in order to continue to provide stimulation during care.

5. Maintaining growth in weight and height appropriate:

• Provide a balanced diet, high nutrients for adequate growth.
• Monitor height and weight, documented in the form of graphs to determine the trend of growing children.
• Measure weight every day with the same weight and the same time.
• Record intake and output correctly.
• Provide food with small portions but often to avoid fatigue during meals.
• Children who receive diuretics are usually very thirsty, and therefore not restricted fluid.

6. Children will not show signs of infection:

• Avoid contact with infected individuals.
• Give adequate rest.
• Provide optimal nutritional needs.

Source : http://fundamentalsnursing.com/

Perichondritis - Nursing Diagnosis and Interventions

Nursing Diagnosis and Interventions:

Nursing Diagnosis 1.

Acute Pain related to inflammation
Goal: pain can be reduced.
Expected outcomes:

• Reported pain reduced / controlled.
• Facial expression / posture relaxed.

Interventions and Rationale :
1. Assess the level of pain with a pain scale
R /: Giving info to assess the response to intervention.
2. Assess and record the patient’s response to intervention
R: Assist in providing interventions.
3. Collaboration give analgesic preparations
R /: Reduce pain.
4. Replacing the fuse when experiencing auditory canal edema
R /: To keep the canal open.

Nursing Diagnosis 2.

Anxiety related to lack of knowledge about the disease, the cause of infection and preventive actions.
Goal: reduce anxiety
Expected outcomes:

• Clients do not show signs of restlessness
• Clients look calm

Interventions and Rationale:
1. Listen carefully to what the client is saying about the disease and actions.
R /: Listening enables the detection and correction of the misconceptions and misinformation.
2. Provide an explanation of the causative organism; targeted treatment; schedule follow-up
R /: Knowledge of specific diagnoses and actions to improve compliance.
3. Give the client a chance to ask and discuss.
R /: Questions client signifies a problem that needs to be clarified.

Nursing Diagnosis 3.

Knowledge Deficit related to lack of exposure to information about the disease, treatment.
Goal: increased knowledge about the condition and treatment is concerned.
Expected outcomes :
Reported understanding of disease experienced.
Inquire about the treatment options that are clues readiness to learn.
Nursng Diagnosis and Interventions:
1. Assess the patient’s level of knowledge.
R /: Knowing the patient’s level of understanding and knowledge about the disease and indicators in intervention.
2. Provide information to patients about the course of their illness.
R /: Improve understanding of the client’s health condition.
3. Provide a description of the patient on any given act of nursing.
R /: Reduce levels of anxiety and help promote cooperation in support of a given therapy program.

Source : http://fundamentalsnursing.com

Nursing Diagnosis for Postoperative Laminectomy

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


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

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

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

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

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

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

6. Constipation related to immobility, decreased physical activity.

7. Knowledge deficit: the condition, prognosis and actions related to lack of knowledge or information.