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Nursing Diagnosis for Congestive Heart Failure (CHF) - Activity Intolerance

Nursing Diagnosis for Congestive Heart Failure (CHF)

Activity Intolerance

related to imbalance between oxygen supply. General weakness, long bedrest / immobilized.

Characterized by:
  • Weakness,
  • fatigue,
  • changes in vital signs,
  • presence of dysrhythmias,
  • dyspnea,
  • pallor,
  • sweating.

Goals / evaluation criteria:

Clients will participate in desired activities, meet self-care, achieve increased tolerance activity can be measured, evidenced by a decrease in weakness and fatigue.

Nursing Interventions Activity Intolerance related to Congestive Heart Failure (CHF) :

1. Check vital signs before and immediately after activity, especially when the client is using vasodilators, diuretics and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), the displacement of fluid (diuretics) or influence cardiac function.

2. Note the cardiopulmonary response to activity, note tachycardia, dysrhythmias, dyspnea sweaty and pale.
Rationale: Decrease / inability of the myocardium to increase the volume of activity during dpat sekuncup cause an immediate increase heart rate and oxygen demand is also increasing fatigue and weakness.

3. Evaluation of increased activity intolerant.
Rational: It can show increased activity of cardiac decompensation rather than excess.

4. Implementation of cardiac rehabilitation programs / activities (collaboration)
Rationale: Increasing gradual to avoid the activity of cardiac work / oxygen consumption is excessive. Strengthening and improvement of cardiac function under stress, if cardiac function can not be improved again.

Source : http://nursing-care-plan.blogspot.com/2011/12/nursing-diagnosis-activity-intolerance.html
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Nursing Care Plan for Pain

Pain

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

Definition of Pain

Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation, or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives information on the pain's location, intensity, and something about its nature. The various conscious and unconscious responses to both sensation and perception, including the emotional response, add further definition to the overall concept of pain.

What do you know about Pain ?
  • Pain is tiring and requires a lot of energy
  • Pain is subjective and individualized
  • Pain can not be objectively assessed as X-rays or blood lab
  • Nurses can assess patients' pain just by looking at physiological changes and behavior of client statements
  • Only the client knows when pain and pain arising
  • Pain is a physiological defense mechanism
  • Pain is a warning sign of tissue damage
  • Pain started the inability
  • The false perception that causes pain so pain management is not optimal

In summary, Mahon, argued pain following attributes:
  • Pain is an individual
  • Pain is not fun
  • Is a strength that dominate
  • Are endless

Read More :

7 Seconds Pain Relief


Nursing Care Plan for Pain - Assessment, Diagnosis and Interventions
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Nursing Care Plan for Urethral Stricture

Nursing Care Plan for Urethral Stricture


Definition of Urethral Stricture

A urethral stricture is a narrowing of a section of the urethra. It causes a blocked or reduced flow of urine which can lead to complications.


Symptoms and signs

Symptoms of urethral stricture is a typical small stream of urine and branched irritation and other symptoms of infection such as frequency, urgency, dysuria, sometimes with infiltrates, abces and fistula. Symptoms are retained urine.


Physical Examination

Anamnese

To find the absence of symptoms and signs of urethral stricture also to look for causes of urethral stricture.

General and local examination

To check on the patient also to change in urethral fibrosis, infiltrates, abscesses or fistulas.

Examination Support

Laboratory: urea, creatinine, to see the renal physiology. Radiological Diagnosis must be made with urethrography. Retrograde urethrography to see the anterior urethra. Antegrade urethrography to see the posterior urethra. Bipoler urethrography is a combination of antegrade and retrograde urethrography examinations. With this examination can be expected in addition to the diagnosis of urethral strictures can be also determined the length of urethral stricture are important for therapy planning / operations.


Basic Concepts of Nursing Care

In nursing care is carried out by using the nursing process. The nursing process is a form of dynamic problem-solving process in an effort to improve and maintain optimal patient through a systematic approach to help patients. Nursing theories and concepts are implemented in an integrated manner in which organized phases which include:

Assessment, Nursing Diagnosis, Interventions, Implementation, Evaluation.

1. Assessment

Assessment of clients with urological disorders including data collection and data analysis. In data collection, sources of client data obtained from the client's own self, family, nurse, physician or from medical records.

Data collection include:
Biodata client and the client responsible. Biodata clients consist of the name, age, gender, education, occupation, status, religion, address, date of hospital admission, register number, and medical diagnostics.

Past medical history will provide information about health or disease of the past who have suffered in the past.

Physical Examination
Done by inspection, palpation, percussion, auscultation of the body's system, it will be found to any of the following: general state of the client postoperative urethral stricture should be viewed in terms of: a state generally include appearance, awareness, style of speech. On postoperative urethral stricture impaired bladder elimination patterns that do permanent catheter.

Respiratory system
Needs to be studied starting from the nose shape, presence or absence of pain in the nostrils, the movement of the nostrils during breathing, symmetry chest movement during breathing, auscultation of breath sounds and respiratory problems that arise. Is it clean or there Ronchi, as well as the frequency of breath. This is important because it affects the development of immobilization and mobilization of pulmonary secretions in the airway.

Cardiovascular system
Began to be studied conjunctival color, lip color, presence or absence of elevation of the jugular vein can be assessed by auscultation of heart sounds in the chest and the measurement of blood pressure by palpation of the pulse frequency can be calculated.

Digestive System
That were examined include the state of teeth, lips, tongue, appetite, intestinal peristalsis, and bowel movements. The purpose of this assessment to find out early deviations in this system.

Genitourinary system
Can be assessed from the presence or absence of swelling and pain in the waist area, observation and palpation of the lower abdominal area to determine the presence of urinary retention and review of the state of genitourinary tools shape the outside of the presence or absence of tenderness and lumps and how spending urine, smooth or there painful micturition time, and how the color of urine.

Musculoskeletal system
What needs to be studied on this system Range of Motion is the degree of movement joints from head to lower limbs, discomfort or pain were reported when the client moves, the tolerance time clients move and observation of injuries to the muscles must be studied as well, because the client usually immobility tonus and decreased muscle strength.

Integumentary System
What needs to be studied is the state of skin, hair and nails, skin examination include: texture, moisture, turgor, color and function of touch.

Neurosensori System
Studied is consistent Neurosensori cerebral function, cranial nerve function, sensory function and reflex function.

The pattern of daily activities
The pattern of daily activities on clients who experience post op urethral strictures include the frequency of meals, food types, portion sizes, types and quantity of drinking and elimination that includes defecation (frequency, color, consistency) and urination (frequency, number of urine that come out every day and the color of urine). Personal hygiene (frequency of bathing, washing hair, brushing teeth, changing clothes, combing hair and nails). Sports (frequency and type) and recreation (frequency and recreation).

Urethral Stricture Nursing Diagnosis, Interventions, Implementation and Evaluation

Source : http://nursing-care-plan.blogspot.com/2011/12/nursing-care-plan-for-urethral.html
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Nursing Care Plan for Thyroid Cancer

DEFINITION OF THYROID CANCER

Thyroid cancer is a malignancy of the thyroid, which has 4 types, namely: papillary, follicular, anaplastic and medullary. Thyroid cancer rarely causes enlargement of the gland, more often causes a small growth (nodules) in the gland. Most thyroid nodules are benign, thyroid cancer is usually curable.

Thyroid cancer often limits the ability to absorb iodine, and limit the ability to produce thyroid hormone, but sometimes produce enough thyroid hormone, causing hyperthyroidism.


ETIOLOGY THYROID CANCER

The etiology of this disease is uncertain, which acts specifically to occur well differentiated (papillary and follicular) are the radiation and endemic goitre, and for medullary type is genetic factors. Not known a carcinoma, which for anaplastic and medullary cancer.

Radiation is one of the etiological factors of thyroid cancer. Many cases of cancer in children previously received radiation to the head and neck because of other diseases. Usually the effects of radiation occur after 5-25 years, but an average of 9-10 years. TSH stimulation of the old is also one of etiological factors of thyroid cancer. Other risk factors are family history of thyroid cancer and chronic goiter.

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Nursing Care Plan for Thyroid Cancer - Assessment, Diagnosis and Interventions

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Nursing Care Plan for Mesothelioma

Mesothelioma

Mesothelioma is a form of cancer that is almost always caused by exposure to asbestos. In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the organs. The most common site is the pleura (the outer layer of the lungs and internal chest wall), but may also occur in the peritoneum (the lining of the abdominal cavity), heart, pericardium (the sac that surrounds the heart) or tunica vaginalis.

Mesothelioma Signs and Symptoms

These symptoms may be Caused by mesothelioma or by other, less serious conditions.

That Mesothelioma affects the pleura can cause these signs and symptoms:
  • Chest wall pain
  • Pleural effusion, or fluid Surrounding the lung
  • Shortness of breath
  • Fatigue or anemia
  • Wheezing, hoarseness, or cough
  • Blood in the sputum (fluid) coughed up (hemoptysis)

In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung. The disease may metastasize, or spread, to other parts of the body.

That tumors affect the abdominal cavity Often do not cause symptoms until They are at a late stage. Symptoms include:
  • Abdominal pain
  • Ascites, or an abnormal buildup of fluid in the abdomen
  • A mass in the abdomen
  • Problems with bowel function
  • Weight loss
In severe cases of the disease, the following signs and symptoms may be present:
  • Blood clots in the veins, the which may cause thrombophlebitis
  • Disseminated intravascular coagulation, a disorder Causing severe bleeding in many body organs
  • Jaundice, or yellowing of the eyes and skin
  • Low blood sugar levels
  • Pleural effusion
  • Pulmonary emboli, or blood clots in the arteries of the lungs
  • Severe ascites
A mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs.
Source : wikipedia.org

Mesothelioma Diagnostic Test
  • Pleural biopsy
  • Then histologic study of the specimen ..
  • Chest x-rays
  • Computed tomography scans of the chest
Nursing Assessment Nursing Care Plan for Mesothelioma

Assessment is the main base of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment - a careful collection of data about clients, Their families, the data obtained through interviews, observation and examination.
  1. Patient Identity
    The identity of the client: name, age, sex, marital status, religion, tribe / nation, education, occupation, income, address and registration number.

  2. Main complaint: chest pain and dyspnea, hoarseness cough, anorexia, weight loss, weakness and fatigue.

  3. Previous medical history: exposure to asbestos

  4. Physical examination:
    • Inspection: shortness of breath and, finger clubbing.
    • Auscultation: diminished chest sounds
    • Percussion: dullness over lung fields

Nursing Care Plan for Mesothelioma

Nursing Diagnosis and Nursing Interventions for Mesothelioma

Source : http://nanda-nursing.blogspot.com/2011/08/nursing-care-plan-for-mesothelioma.html
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Nursing Diagnosis and Nursing Interventions for Mesothelioma

Nursing Diagnosis for Mesothelioma
  • Ineffective airway clearance
  • Ineffective breathing pattern
  • Pain
  • Impaired gas exchange
  • Impaired physical mobility
  • Anxiety
  • Excess fluid volume
  • Fatigue
  • Hopelessness
  • Impaired skin integrity
  • Risk for infection

Nursing Interventions for Mesothelioma
  • Monitor respiratory status, Provide oxygen as ordered.
  • Assist the patient to a comfortable position (Fowler's position, for example)
  • Provide action for patient comfort: Such as repositioning and relaxation techniques.
  • Provide treatment to reduce pain, according to therapy programs. Monitor and document the medication's effectiveness.
  • If mobility decreases, turn the patient frequently. Provide skin care, particularly over bony prominences. Encourage him to be as active as possible.
  • Monitor I.V. fluid intake to avoid circulatory overload and pulmonary congestion.
  • Monitor vital signs: blood pressure, respiration, pulse, body temperature.
  • Teach relaxation techniques.
  • Teach breathing and positioning variations to ease the dyspnea associated with progressive disease

Nursing Diagnosis, Nursing Interventions NCP for Mesothelioma
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Nursing Care Plan for Hepatocellular Carcinoma - Hepatoma

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC, also called malignant hepatoma) is the most common type of liver cancer. Most cases of HCC are secondary to either a viral hepatitide infection (hepatitis B or C) or cirrhosis (alcoholism being the most common cause of hepatic cirrhosis).

Signs and symptoms

HCC may present with jaundice, bloating from ascites, easy bruising from blood clotting abnormalities or as loss of appetite, unintentional weight loss, abdominal pain,especially in the upper -right part, nausea, emesis, or fatigue.
wikipedia


Nursing Assessment Nursing Care Plan for Hepatocellular Carcinoma - Hepatoma

Biodata

The assessment is important to know the background, socioeconomic status, customs / culture, and spiritual beliefs, so easy in the communications and determine appropriate nursing actions.


Nursing History


The main complaint: The enlargement of the liver is felt more and more annoying so that it can lead to complaints of shortness of breath is felt more heavily in addition accompanied by abdominal pain.
  1. History of present illness
    Disease history can now be obtained through other people or by the client itself.

  2. Disease history of the past
    Disease history of the past studied to obtain data on disease ever suffered by the client.

  3. Family Disease History
    Family history of disease studied to find out data about the disease that had experienced ol er family members.

Physical Examination

Clinical symptoms

Early Phase: Asymptomatic.
Further Phase: No known symptoms are pathognomonic.

Complaints of abdominal pain, weakness and weight loss, anorexia, feeling of fullness after a meal is sometimes accompanied by vomiting and nausea. If there is metastasis to bone sufferers complain of bone pain.

On physical examination can be obtained:
  • Ascites
  • Jaundice
  • Splenomegaly, spider nevi, palmar erythema, edema.

In general, nursing assessment on the client with a case of hepatoma, include:
  • Metabolic disorders
  • Bleeding
  • Ascites
  • Edema
  • Hypoalbuminemia
  • Jaundice / icterus
  • Endocrine Complications
  • Activities were disrupted by treatment

Nursing Diagnosis for Hepatocellular Carcinoma

Nursing Interventions for Hepatoma - Hepatocellular Carcinoma


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Nursing Diagnosis for Hepatocellular Carcinoma

Nursing Diagnosis for Hepatocellular Carcinoma
  1. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea, impaired absorption, metabolism of vitamins.

  2. Ineffective Breathing Pattern related to the presence of ascites and emphasis diapragma.

  3. Acute pain related to tension in the abdominal wall.

  4. Activity intolerance related to imbalance between supply oxygenation to the needs.

  5. Risk for deficient fluid volume related to excessive ascites, bleeding, and edema.

  6. Risk for infection related to deficiency of white blood cells.

  7. Impaired Skin Integrity related to pruritus, edema, and ascites.

  8. Altered Sexuality and Sexual Dysfunction related to hormonal dysfunction and decreased libido.

  9. Anxiety related to hospitalization.

  10. Knowledge deficient: the disease process and its causes.

  11. Social isolation related to the risk of spreading infection.

Nursing Diagnosis for Hepatocellular Carcinoma

Nursing Intervention for Hepatoma - Hepatocellular Carcinoma

Source : http://nandanursingdiagnosis.blogspot.com
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Nursing Interventions for Hepatoma - Hepatocellular Carcinoma

Nursing Intervention for Hepatoma - Hepatocellular Carcinoma


Nursing Diagnosis for Hepatoma - Hepatocellular Carcinoma

Acute pain related to tension in the wall of the abdomen (ascites)

Goal :
Demonstrate the use of relaxation skills and entertainment activities as indicated pain.
Reported the maximum pain relief.

Nursing Intervention :
  • Determine the history of pain such as location, frequency, duration and intensity (0-10) and measures of pain relievers for example provide a comfortable position.
  • Provide basic comfort measures such as repositioning, rubbing his back.
  • Assess pain level / control value
Rational :
  • Provide basic data to evaluate the need / effectiveness of interventions such as: pain is the individual who combined both physical and emotional responses.
  • Increase relaxation and help refocus attention.
  • Maximum pain control.

Nursing Diagnosis for Hepatoma - Hepatocellular Carcinoma

Activity intolerance related to imbalance between supply oxygenation to the needs

Goal :
Can perform activities according to the ability of the body.

Nursing Intervention :
  • Encourage the patient to do anything if possible, such as bathing, getting up from a chair / bed, walk.
  • Increase activity according to ability.
  • Monitor the physiological response to such activities; changes in blood pressure, heart rate and breathing.
  • Give oxygen as indicated
Rational :
  • Increasing the strength / stamina and enables patients to become more active without significant fatigue.
  • Tolerance depends on the stage of the disease process, nutritional status, fluid balance and reactions to therapeutic rules.
  • The presence of hypoxia, lowering oxygen availability for cellular uptake and aggravate fatigue.

Nursing Diagnosis for Hepatoma - Hepatocellular Carcinoma

Imbalanced Nutrition : Less Than Body Requirements
related to anorexia, nausea, impaired absorption

Goal :
  • Demonstrated stable weight, weight gain progressively towards the goal, with normalization of laboratory values ​​and limit signs of malnutrition.
  • Countermeasures understanding of individual influences on adequate input.
Nursing Intervention :
  • Monitor the input of food every day, give pasein diary about the food as indicated.
  • Encourage patients to eat a diet high in calories and rich in protein with adequate fluid intake.
  • Encourage the use of supplements and foods often / less that divided during the day.
  • Give antiemetics on a regular schedule before / during and after the administration of antineoplastic agents as appropriate.
Rational :
  • The effectiveness of individual dietary assessment in the disappearance of nausea, post-therapy.
  • Patients should try to find a solution / the best combination.
  • Increased metabolic needs as well as the fluid (to remove residual production).
  • Supplements can play an important role within to maintain adequate caloric intake and protein.
  • Nausea / vomiting at least reduce the ability and psychological side effects of chemotherapy that causes stess.

Nursing Interventions Nursing Care Plan for Hepatocellular Carcinoma - Hepatoma
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Sepsis and Septic Shock Emergency Nursing Care Plan

Definition of Sepsis

Sepsis is a systemic response to bacteremia. At the time of bacteremia caused changes in the circulation, leading to decreased tissue perfusion and Septic Shock occurs. Approximately 40% of patients with sepsis caused by gram-positive microorganisms and 60% due to gram-negative microorganisms. The most common organisms causing sepsis are Staphylococcus aureus and Pseudomonas sp.

Signs and Symptoms of Sepsis

Patients with sepsis and septic shock is an acute illness. Assessment and treatment is needed. Patients can die from sepsis. Common symptoms are:
  • fever
  • sweat
  • headache
  • muscle aches

Find out the source of primary infection. Consider the source of infection the following:
  • urinary infection
  • respiratory tract infections
  • dermatitis
  • meningitis
  • endocarditis
  • intra-abdominal infections
  • osteomyelitis
  • pelvic inflammatory disease
  • sexually transmitted diseases

Nursing Assessment - Sepsis and Septic Shock Emergency Nursing Care Plan

Always use the ABCDE approach.

Airway
  • Make sure the airway clearance
  • Give the tool a respirator if necessary (nasopharyngeal)
  • If a decline in respiratory function immediately contact the anesthesiologist and the patient may be brought immediately to the ICU

Breathing
  • Assess the amount of breathing, more than 24 times / minute is a significant symptom
  • Assess oxygen saturation
  • Check arterial blood gases to assess the oxygenation status and the possibility of acidosis
  • Give 100% oxygen via non re-breath mask
  • Chest auscultation, to determine the presence of chest infection
  • Photo thoracic radiograph

Circulation
  • Assess heart rate, more than 100 times / minute is a significant sign
  • Monitoring blood pressure
  • Check the capillary refill time
  • Attach infusion using a large canul
  • Replace catheter
  • Perform a complete blood
  • Record the temperature
  • Prepare the urine and sputum examination

Disability
  • Confused is one of the first signs of sepsis patients, whereas previously there were no problems (healthy and good).
  • Assess level of consciousness

Exposure
  • If the source of infection is unknown, look for the existence of injuries, cuts and the injection site and the source of other infections.

Sign of the threat to life

Severe sepsis defined as sepsis that caused the failure of organ functions. If it is causing a threat to the life of the patient should be taken to the ICU, while the indications are as follows:
  • decline in kidney function
  • decline in cardiac function
  • hypoksia
  • acidosis
  • clotting disorders
  • acute respiratory distress syndrome (ARDS)


Sepsis and Septic Shock Emergency Nursing Care Plan
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Meningitis Emergency Nursing Care Plan

Meningitis Emergency Nursing Care Plan

Meningitis

Meningitis is a bacterial infection of the membranes covering the brain and spinal cord (meninges).

Signs of meningitis as follows:
  • fever
  • headache
  • stiff neck
  • photophobia and vomiting
  • confused (possible)

Assessment - Emergency Nursing Care Plan Meningitis

Always use the ABCDE approach to assessment

Airway
  • Make sure the airway clearance
  • Prepare tools to facilitate the airway if necessary
  • If there is a decrease in respiratory function immediately contact an anesthesiologist and treated in the ICU

Breathing
  • Assess respiratory rate - less than 8 or over 30 is a significant sign.
  • Assess oxygen saturation
  • Perform blood gas
  • Give oxygen via non re-breath mask
  • Chest auscultation
  • Make checks thoracic photo

Circulation
  • Assess heart rate - more than 100 or less than 40 x / min is a significant sign
  • Monitoring blood pressure
  • Check the capillary refill time
  • Attach infusion using a large cannula
  • Attach Catheterization
  • Check the lab for complete blood, urine, electrolyte
  • Perform blood cultures
  • Perform a throat swab for culture and sensitivity
  • Record the temperature

Disability
  • Assess level of consciousness
  • Observations of focal neurological signs

Exposure
  • Assess the ptechie


Sign of the threat to life:

If the patient shows signs of distress, showing patients should be brought immediately to the ICU as for the sign as follows :
  • Redness more
  • CRT more than 4 seconds
  • Oliguria
  • Breathing is less than 8, more than 30 per minute
  • Heart rate less than 40, more dari140 times per minute
  • Signs of impairment of consciousness
  • Focal neurology
  • Convulsions
  • Bradycardia and hypertension
  • Papiloedema

Emergency Nursing Care Plan - Meningitis
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Nursing Diagnosis and Nursing Intervention for Cystitis

Nursing Diagnosis for Cystitis

Acute pain related to bladder infections

Goal : There is no pain and burning sensation during urination

Expected outcomes : The client says the pain is reduced


Nursing Intervention for Cystitis

  1. Monitor:
    • The bow of the urine to change color, odor and urine patterns
    • Input and output every 8 hours
    • The results re urinalis
    Rational: To identify the indications, the progress or the storage of the expected results.

  2. Give analgesics as needed and evaluate its success
    Rational: Analgesics block the path of pain, thereby reducing the pain

  3. Consul doctor if:
    • Previous amber-yellow urine, dark orange, hazy or cloudy
    • Micturition pattern changes, as an example of heat such as burning during urination, a sense of urgency when urinating
    • Persistent pain or increasing pain
    Rational: These findings may indicate further tissue damage and need more extensive checks, such as radiology examination if not previously done

  4. If the frequency becomes a problem, assure access to the bathroom, bedpan under the bed. Instruct the patient to urinate whenever there is a desire.
    Rational: frequent urination, reduce static urine in the bladder and prevent bacterial growth.

Nursing Diagnosis for Cystitis

Risk for infection related to the risk factors of nosocomial

Goal : There is no infection in the bladder

Expected outcomes : Clients can urinate without the inconvenience of clear urine, urinalysis within normal limits, urine culture showed no bacteria.

Nursing Intervention for Cystitis
  1. Provide perineal care with soapy water every shift. If the patient's incontinence, perineal wash as soon as possible
    Rational: To prevent contamination of the urethra

  2. If placed indwelling catheter, catheter care given 2 times per day (part of the shower in the morning and at bedtime) and after defecation
    Rational: Catheter give way on the bacteria to enter the bladder and up into the urinary tract

  3. Reposition the patient every 2 hours and encourage fluid intake of at least 2400 ml / day (unless contraindicated). Help make ambulation as needed
    Rational: To prevent static urine

  4. Take action to maintain the acid urina
    Rational: urina acid prevents the growth of germs.

Nursing Diagnosis and Nursing Intervention for Cystitis

Nursing Care Plan : Nursing Assessment for Cystitis
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Nursing Care Plan for Cystitis

NCP - Nursing Care Plan for Cystitis


Cystitis

Cystitis is a term that refers to bladder inflammation that results from any one of a number of distinct syndromes. It is most commonly caused by a bacterial infection in which case it is referred to as a urinary tract infection.

Symptoms

The symptoms of a bladder infection include:
  • Cloudy or bloody urine, which may have a foul or strong odor
  • Low fever (not everyone will have a fever)
  • Pain or burning with urination
  • Pressure or cramping in the lower abdomen (usually middle) or back
  • Strong need to urinate often, even right after the bladder has been emptied
Often in an elderly person, mental changes or confusion are the only signs of a possible urinary tract infection.

Nursing Assessment for Cystitis

Identity
  • Age: occurs in all age
  • Sex: more common in women and increased incidence according to age and sexual activity
  • Place of residence: whether or not a predisposing factor
Main complaint
  • Pain or burning in the urethra when urinating
  • urine slightly
  • Discomfort in the supra pubic region
Disease history
  • History of UTI
  • Obstruction of the urinary tract
  • Other health problems, such as diabetes mellitus, history of sexual
Physical examination
  • Abdominal infection, and palpation of the lower urinary bledder: no maximum discharge
  • Inflammation and lesions in the urethral meatus and vaginal introitus
  • Assess urination: the urge, frequency, dysuria, the stinging smell of urine, pain in the supra pubic.

Nursing Care Plan for Cystitis

Nursing Diagnosis and Nursing Intervention for Cystitis
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Nursing Diagnosis and Nursing Intervention for Brain Tumor

Nursing Diagnosis for Brain Tumor

Impaired Gas Exchange related to neuromuscular dysfunction (loss of control of respiratory muscles)

Characterized by: changes in depth of breath, dyspnea, airway obstruction, aspiration.

Goal : Impaired gas exchange can be resolved

Nursing Intervention for Brain Tumor
  • Clear the airway
  • Monitor vital signs
  • Monitor the breathing pattern, breath sounds
  • Monitor blood gases penururnan
  • Blood gas analysis
  • Collaboration Oxygenation

Nursing Diagnosis for Brain Tumor

Acute Pain : the head related to increased intra-cranial pressure

Characterized by : headache, especially early morning, the client moaning in pain, the pain increased when the client coughing, straining, bending.

Goal : reduced pain

Nursing Intervention for Brain Tumor
  • Monitor the pain scale
  • Give compress on the area where the sick
  • Monitor vital signs
  • Give a comfortable position
  • Perform Massage
  • Observation of non-verbal signs of pain
  • Assess defisid factors, emotional state of someone
  • Note the influence of pain
  • Cold compresses on the head
  • Use of therapeutic touch technique
  • Observation of nausea, vomiting
  • Collaboration administration of drugs: analgesic, relaxant, prednisone, anti-emetics

Nursing Diagnosis and Nursing Intervention for Brain Tumor

Nursing Assessment Nursing Care Plan for Brain Tumor
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Nursing Care Plan for Brain Tumor

NCP - Nursing Care Plan for Brain Tumor


A brain tumor (or brain tumor) is an intracranial solid neoplasm, a tumor (defined as an abnormal growth of cells) within the brain or the central spinal canal.

Brain tumors include all tumors inside the skull or in the central spinal canal. They are created by an abnormal and Uncontrolled cell division, normally either in the brain Itself (neurons, glial cells (astrocytes, oligodendrocytes, ependymal cells, myelin-producing Schwann cells), lymphatic tissue, blood vessels), in the cranial nervous, in the brain envelopes (meninges), skull, pituitary and pineal gland, or spread from cancers primarily located in other organs (metastatic tumors).(wikipedia)

Signs and Symptoms:
  1. Severe headache in the morning, increased when coughing, bending
  2. Convulsions
  3. Signs of increased intra-cranial pressure: blurred vision, nausea, vomiting, decreased auditory function, changes in vital signs, aphasia.
  4. Changes in personality
  5. Impaired memory
  6. Natural disturbance of taste
Classic triad:
  1. Headache
  2. Papilledema
  3. Vomiting
Diagnostic Examination:
  1. Rontgent anterior-posterior skull
  2. EEG
  3. CT Scan
  4. MRI
  5. Angioserebral

Nursing Assessment for Brain Tumor
  1. Client data: name, age, sex, religion, ethnicity, marital status, education, occupation, blood type, address, etc..

  2. Medical history:
    • Main Complaints
    • Medical history Now
    • Previous Health History
    • Family Health History

  3. Physical Examination
    • Nerves: seizures, bizarre behavior, disorientation, aphasia, decreased / loss of memory, inappropriate affect, hissing
    • Vision: decreased field of vision, blurred vision
    • Hearing: tinnitus, hearing loss, hallucinations
    • Cardiac: bradycardia, hypertension
    • Respiratory system: respiratory rhythm increased, dyspnea, potential airway obstruction, neuromuscular dysfunction
    • Hormonal System: amenorrhoea, hair loss, diabetes mellitus
    • Motor: hyperextension, joints weakness

Nursing Care Plan for Brain Tumor

Nursing Diagnosis anda Nursing Intervention for Brain Tumor
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Nursing Diagnosis and Nursing Intervention for Bronchopneumonia

Nursing Diagnosis for Bronchopneumonia

Ineffective Airway Clearance related to the buildup of secretions

Goal : return effective airway clearance.

Expected outcomes : discharge to exit.

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

Nursing Diagnosis for Bronchopneumonia - Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of nutrients

Goal : Kebuituhan nutrients are met.

Expected outcomes : The client can maintain / improve nutritional intake ..

Nursing Intervention for Bronchopneumonia
  • Assess client's nutritional status.
  • Perform a physical examination the abdomen client (auscultation, percussion, palpation, and inspection).
  • Measure the client's body weight per day.
  • Assess the presence of nausea and vomiting.
  • Give diet a little but often.
  • Provide food in a warm state.
  • Collaboration with a dietitian.
NANDA Pneumonia

Nursing Care Plan for Bronchopneumonia

Nursing Assessment for Bronchopneumonia

Nursing Diagnosis and Nursing Intervention for Bronchopneumonia
 
Ineffective Airway Clearance related to Bronchopneumonia
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Nursing Care Plan for Bronchopneumonia

NCP - Nursing Care Plan for Bronchopneumonia


Bronchopneumonia BrPn Nursing Care Plan
Bronchopneumonia Definition

Bronchopneumonia is a common inflammation of the lung, also referred to as bronchial pneumonia, or lobular pneumonia. Inflammation starts in the small bronchial tubes - bronchioles, and irregularly spreads to the peribronchiolar alveoli and alveolar ducts. The result is that the inflammatory changes lead to the localized inflammatory consolidation in bronchioles and their surrounding alveoli of the lungs.

Bronchopneumonia Causes

Most of the time, broncho- pneumonia is caused by bacterial infection, especially the pyogenic bacteria to form the suppurative pneumonia. Adenovirus, influenza virus, Mycoplasma pneumoniae also plays a role.

Bronchopneumonia often occurs in human due to the lower body resistance and the impaired defense function of the respiratory tract. So, children, elderly persons and the sickly or weak persons are the main susceptible population.

Bronchopneumonia is the most common pneumonia in children.


Nursing Care Plan for Bronchopneumonia


Nursing Assessment for Bronchopneumonia
  1. Medical History
    • History of respiratory tract infection: cough, runny nose, fever.
    • Anorexia, difficulty swallowing, nausea and vomiting.
    • History of immunity-related diseases such as malnutrition.
    • Other family members have respiratory tract illness.
    • Productive cough, breathing nostrils, rapid and shallow breathing, restlessness, cyanosis.

  2. Physical Examination
    • Fever, tachypnea, cyanosis, respiratory nostril.
    • Auscultation of lung wet Ronchi
    • Laboratory of leukocytosis, increased erythrocyte sedimentation rate or normal.
    • Abnormal chest X-ray (spotting, consolidating scattered in both lungs).

  3. Psychological factors / developments to understand the action
    • Age level of development.
    • Tolerance / ability to understand the action.
    • Coping.
    • Experience separated from family / parents.
    • The experience of previous respiratory tract infections.

  4. Knowledge of family / parents.
    • The family of knowledge about respiratory diseases.
    • The experience of the family of respiratory tract disease.
    • Readiness / willingness of families caring for a child to learn.

Nursing Care Plan for Bronchopneumonia

Nursing Assessment for Bronchopneumonia


Nursing Diagnosis for Bronchopneumonia

Nursing Intervention for Bronchopneumonia
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Nursing Diagnosis and Nursing Intervention for Nephrotic Syndrome

Nursing Diagnosis for Nephrotic Syndrome

Risk for Fluid Overload related to retained sodium and water

Goal: The volume of body fluid balance

Expected outcomes:
  • Stable weight
  • Normal vital signs
  • No edema
Nursing Intervention for Nephrotic Syndrome
  • Monitor intake and output, and measuring body weight every day
  • Monitor blood pressure
  • Assessing respiratory status including breath sounds
  • Giving deuretik, according to program
  • Measure and record the abdominal girth

Nursing Diagnosis for Nephrotic Syndrome

Risk for Deficient Fluid Volume (intravascular) related to proteinuria, edema and diuretic effects

Goal: Body fluid balance

Expected outcomes:
  • Oral mucosa moist
  • Stable vital signs

Nursing Intervention for Nephrotic Syndrome
  • Monitor intake and output (in children less than 1ml/kg/jam)
  • Monitor vital signs
  • Monitor laboratory tests (electrolytes)
  • Assess the oral mucous membranes and elasticity of skin turgor
  • Assess capilarry Refill


Nursing Diagnosis and Nursing Intervention for Nephrotic Syndrome

Nursing Care Plan for Nephrotic Syndrome

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Nursing Care Plan for Nephrotic Syndrome

Nursing Care Plan for Nephrotic Syndrome

Definition

Nephrotic Syndrome is a disease with symptoms of edema, proteinuria, hypoalbuminemia and hypercholesterolemia. Sometimes there is hematuria, hypertension and reduced kidney function.

This disease occurs suddenly, especially in children. Usually in the form of oliguria with dark-colored urine, or urine is thick due to heavy proteinuria.

There are many specific Causes of nephrotic syndrome. These include kidney diseases Such as minimal-change nephropathy, focal glomerulosclerosis, and membranous nephropathy. Nephrotic syndrome can also result from systemic diseases That affect other organs in Addition to the kidneys, Such as diabetes, amyloidosis, and lupus erythematosus.

Nephrotic Syndrome Therapeutic Management
  • Diets high in protein, low-sodium diet if severe edema
  • Sodium restriction if the child hypertension
  • Antibiotics to prevent infection
  • Diuretic therapy based on the program
  • Albumin therapy if the child's intake and urine output is less
  • Prednisone therapy with a dose of 2 mg / kg / day based on the program

Nephrotic Syndrome Nursing Care Plan

Nursing Care Plan for Nephrotic Syndrome


Nursing Assessment for Nephrotic Syndrome
  • The identity of the child: name, age, address, education level, etc..

  • Past medical history: previous ever hurt a child like this?

  • Birth history, growth, disease that is often experienced by children, immunizations, previous hospitalization, and medication allergies.

  • The pattern of daily habits: eating and drinking, hygiene patterns, the pattern of bed rest, activity or play, and elimination patterns.

  • General Assessment: vital signs, weight, height, head circumference, chest circumference (associated with edema).

  • Cardiovascular system: the rhythm and quality of pulse, heart sounds, presence or absence of cyanosis, diaphoresis.

  • Respiratory System: examine the pattern of breathing, wheezing or crackles are there, chest retractions, nasal flaring.

  • Nervous system: level of consciousness, behavior (mood, intellectual ability, thought processes), what in accordance with growth and development? Assess sensory function, the function of movement and pupillary function.

  • Gastrointestinal System: auscultation bowel sounds, palpation of hepatomegaly / splenomegaly, is there any nausea, vomiting. Assess bowel habits.

  • Urinary system: review of the frequency of urination, color and amount.

Nursing Care Plan for Nephrotic Syndrome

Nursing Diagnosis and Nursing Intervention for Nephrotic Syndrome
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Nurses Role in Drug Addiction Rehabilitation

Nurses Role in Drug Addiction Rehabilitation Therapy

In the treatment of drug dependence needs to be done until the level of rehabilitation. The reason, besides causing physical and mental health disorders, drug dependence also gives social impact for the patient, family environment and surrounding community.

Rehabilitation is essentially intended to make the patient can perform normal actions, may continue their education according to his ability, to go to work according to their talents and interests, and most importantly, can adjust to living with family environment and surrounding community.

One thing that many expected after following the rehabilitation, the patient can be his religion as well. That is why many rehabilitation centers established under the belief / religion.

Drug Addiction Rehabilitation Therapy, includes several things:
  • Social Rehabilitation : includes all efforts that aim to guide and enhance a sense of awareness and social responsibility for families and communities.

  • Educational Rehabilitation : aims to maintain and improve their knowledge and see to it that patients can take part in education again, if possible, give guidance in choosing a school that suits his talents and intelligence capabilities.

  • Vocational Rehabilitation : the work aims to determine the ability of patients and how to overcome barriers or obstacles to placement in suitable work. Also provide the skills that have not owned by the patient in order to benefit patients for a living.

  • Religious Life Rehabilitation : aims to raise awareness of the patient will be the place of humanity in the midst of living. And worship in accordance with his religion.
READ MORE - Nurses Role in Drug Addiction Rehabilitation

Nursing Intervention for Myasthenia Gravis

Intervention and Implementation for Myasthenia Gravis

Monitoring
  1. Monitor respiratory status of patients to see the possibility of respiratory failure and myasthenic or cholinergic crisis.

  2. Watch for signs of a crisis that threatens :
    • Sudden respiratory distress
    • The signs of dysphagia, ptosis and diplobia
    • Tachycardia, anxiety.

  3. Monitor the patient's response to drug therapy

Nursing Actions
  1. Give the medication so that its peak effects along with food and essential activity.

  2. Help the patient make a realistic schedule of activities.

  3. Provide rest periods to minimize fatigue.

  4. Provide tools to help patients perform daily activities despite the weakness.

  5. If the patient has diplopia given blindfolds to use the other eye to minimize the risk of falling.

  6. To avoid aspiration:
    • Teach the patient to position the head slightly flexed position to protect the airway while eating
    • Provide a vacuum so that the patient can operate it
    • If the patient is in crisis or experiencing swallowing disorders given iv fluids and eating through a tube nasogastrik, elevate the head of the bed after feeding.
    • If the patient is taking mechanical ventilators provide suction that often, review and check for breath sounds, report the results of chest X-rays.

  7. Show the patient how to hold his chin with his hand to prop up the lower jaw to help talk.

  8. If the patient is speaking with very severely disturbed encourage patients to use alternative communication methods such as flash cards or board letter.

Education and Health Care
  1. Instruct patients and families associated with symptoms of myasthenia crisis.

  2. Teach the patient ways to prevent a crisis and a worsening of symptoms ;
    • Avoid exposure to colds and other infections

    • Avoid excessive heat or cold

    • Tell the patient to inform the dentist about the condition, because the use of procaine (navokaine) are not well tolerated and may spark crisis
    • Avoid emotional distress

  3. Teach the patient and family associated with the use of suction house

  4. Revisit the height of the drug and how to schedule mendapatakn akifitas for good results.

  5. Emphasize the importance of scheduled rest periods to avoid fatigue.

  6. Instruct the patient to wear a medical alert bracelet.

Nursing Care Plan : Assessment and Diagnosis for Myasthenia Gravis
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Nursing Care Plan for Myasthenia Gravis

Nursing Care Plan for Myasthenia Gravis

Definition of Myastenia gravis

Myastenia gravis is a disorder that affects neuromuscular transmission in muscles of the body that works under the consciousness of someone (volunteers). The characteristics that emerged in the form of excessive weakness and fatigue generally occur in the muscles of voluntary and it is influenced by cranial nerve function (Brunner and Suddarth 2002)

Myasthenia gravis is a neuromuscular disorder that affects the transmission of impulses to the voluntary muscles of the body (Sandra M. Neffina 2002).


Causes of
Myastenia gravis

The cause of this disorder is unknown, but probably occurs because of disruption or destruction of acetylcholine receptors at the crossroads neoromuskular due to an autoimmune reaction. Muscle contraction muscle damage causing weakness.


Clinical Manifestations of
Myastenia gravis
  • Extreme muscle weakness and easy fatigue
  • Diplobia (double vision)
  • Ptosis (eyelid fall)
  • Dysphonia (voice disorder)
  • The weakness of the diaphragm and intercostal muscles of progressive causes severe breathing.



Nursing Care Plan for Myasthenia Gravis


Nursing Assessment for Myasthenia Gravis
  1. Nervous system dysfunction
    • Impaired vision: diplopia and ptosis due to weakness of ocular
    • Expression on the face like a mask because of the involvement of facial muscles
    • Dysphagia due to pharyngeal and laryngeal weakness.
  2. Extreme muscle weakness and easy fatigue with repetitive activity and talking

  3. The possibility of involvement of respiration with decreased vital capacity

Nursing Diagnosis for Myasthenia Gravis
  1. Ineffective Breathing Pattern related to respiratory muscle weakness.

  2. Impaired Physical Mobility related to weakness of voluntary muscles.

  3. Risk for Aspiration related to the weakness of bulbar muscles.

  4. Self-Care Deficit related to muscle weakness, general fatigue.

  5. Imbalanced Nutrition: Less than Body Requirements related to dysphagia, intubation, or muscle paralysis.


Nursing Intervention for Myasthenia Gravis and Nursing Implementation for Myasthenia Gravis
READ MORE - Nursing Care Plan for Myasthenia Gravis

Nursing Care Plan for Low Self-Esteem

Nursing Care Plan for Low Self-Esteem

Low self-esteem is a person rejects as something precious and is not responsible for their own lives. If the individual often fails it tends to lower self-esteem. Low self-esteem if it loses the love and appreciation of others. Self-esteem derived from self and others, the main aspect is to be accepted and received awards from other people.

Low self-esteem disturbance described as negative feelings about themselves, including the loss of confidence and self esteem, sense of failure to reach the desire, self-criticism, reduced productivity, which is directed destructive to others, feelings of inadequacy, irritable and withdrawn socially.


Nursing Care Plan for Low Self-Esteem


Nursing Assessment for Low Self - Esteem
  1. Subjective Data: Clients say: I can not afford, can not, do not know anything, stupid, self-criticism, expressing feelings of shame about themselves.

  2. Objective Data:
    Clients looked more like himself, confused when asked to choose an alternative action, want to injure himself / want to end life.

Nursing Diagnosis for Low Self - Esteem
  1. Risk for Social Isolation : withdrawing associated with low self-esteem.
  2. Self-Concept Disturbance : low self-esteem associated with dysfunctional grieving.

Nursing Intervention for Low Self - Esteem

Goal
  1. Clients can build a trusting relationship with nurses.

    Action:

    • Construct a trusting relationship: Greetings therapeutic, self introduction, Explain the purpose, Create a peaceful environment, definition of contract (time, place and subject.)
    • Give clients the opportunity to express his feelings.
    • Take time to listen to the client.
    • Tell the client that he is someone who is valuable and responsible and able to help themselves.

  2. Clients can identify the skills and positive aspects that are owned.

    Action:

    • Discuss the capabilities and the positive aspects of client owned.
    • Avoid giving negative assessments of each meet clients, give praise a realistic priority.
    • Clients can assess the ability and positive aspect owned.

  3. Clients can assess the capabilities that can be used.

    Action:

    • Discuss with the client's abilities can still be used.
    • Discuss also the ability to continue after returning home.

  4. Clients can define / plan activities appropriate capabilities.

    Action:

    • Plan your activities with a client that can be done every day according to ability.
    • Increase activities in accordance with client's tolerance condition.
    • Give examples of how implementation of activities that clients should do.

  5. Clients can perform activities according to the conditions and capabilities.

    Action:

    • Give a chance to try activities that have been planned.
    • Give praise for success
    • Discuss the possibility of implementation at home.

  6. Clients can utilize the existing support system.

    Action:

    • Give health education to families about how to care for clients.
    • Helps families provide support for client care.
    • Help prepare the family environment at home.
    • Give positive reinforcement for family involvement.


Nursing Care Plan for Low Self-Esteem
Nursing Assessment for Low Self - Esteem
Nursing Diagnosis for Low Self - Esteem
Nursing Intervention for Low Self - Esteem
Risk for Social Isolation
Self-Concept Disturbance
READ MORE - Nursing Care Plan for Low Self-Esteem

Nursing Assessment for Nephrolithiasis

Nursing Assessment for Nephrolithiasis

Data collected on the client with nefrolitiasis are:
  1. Activity / Rest
  2. The work which a lot of sitting and high temperature environments
  3. Elimination
  4. History of UTI or stone obstruction ever
  5. Eating and Drinking
  6. History of the client to consume food / drink diet high in purine / fruit juice
  7. Pain / comfort
  8. Colic Pain
  9. History of taking drugs
  10. Consuming antibiotics for too long
  11. Family Disease History
  12. History of kidney disease, UTI
  13. Knowledge
  14. Diagnostic Examination
  15. Urine examination
  16. Complete blood examination
  17. Radiology / X-ray
  18. IVP
  19. CT. Scan
  20. Retrograde Cystogram
  21. Ultrasound

Nursing Diagnosis for Nephrolithiasis

Nursing Interventions for Nephrolithiasis
READ MORE - Nursing Assessment for Nephrolithiasis

Nursing Diagnosis and Nursing Intervention for Nephrolithiasis

Nursing Diagnosis for Nephrolithiasis
  1. Acute Pain related to tissue trauma, increased ureteric contraction, edema formation.
  2. Impaired Urinary Elimination related to irritation of the kidney / ureter, mechanical obstruction, inflammation, bladder stimulation by a stone.
  3. Risk for Deficient Fluid Volume related to neusea, vomiting.
  4. Knowledge Deficit related to misinformation.

Expected Results:
  1. Comfort the pain resolved.
  2. Impaired elimination pattern is resolved.
  3. No deficit fluid.
  4. The client will open up requests for information.

Nursing Intervention for Nephrolithiasis
  1. Observe and record the location, duration, intensity of pain distribution.
  2. Explain the cause of pain.
  3. Make a control gate on the back.
  4. Teach relaxation techniques.
  5. Give fluid intake 3000 ml - 4000 ml / day.
  6. Collaborative provision of medicines.
  7. Monitor intake / output.
  8. Observe urination.
  9. Prepare a laboratory urine.
  10. Observation circumstances bladder.
  11. Collaboration laboratory examination.
  12. Observe and record abnormalities such as vomiting.
  13. Monitor vital signs.
  14. Give a diet based on the program.
  15. Collaboration giving intravenous fluids.
  16. Give an explanation of the disease process.
  17. Explain the importance of fluid intake 3000 - 4000 ml / hr.
  18. Explain about diabetes management.
  19. Discuss with the client / kelguarga about the rule of treatment & types of food.
  20. Instruct the client to do activity regularly.

Nursing Diagnosis and Nursing Intervention for Nephrolithiasis

Nursing Care Plan for Nephrolithiasis
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Nursing Care Plan for Syphilis

Syphilis is an infectious venereal disease caused by the spirochete Treponema pallidum. Syphilis is transmissible by sexual contact with infectious lesions, from mother to fetus in utero, via blood product transfusion, and occasionally through breaks in the skin that come into contact with infectious lesions. If untreated, it progresses through 4 stages: primary, secondary, latent, and tertiary.
Syphilis has a myriad of presentations and can mimic many other infections and immune-mediated processes in advanced stages. Hence, it has earned the nickname “the great impostor.” The complex and variable manifestations of the disease prompted Sir William Osler to remark, “The physician who knows syphilis knows medicine.”
Many famous personages throughout history are thought to have suffered from syphilis, including Bram Stoker, Henry VIII, and Vincent Van Gogh. Since the discovery of penicillin in the mid-20th century, the spread of this once very common disease has been largely controlled, but efforts to eradicate the disease entirely have been unsuccessful.

Source : emedicine.medscape.com


Nursing Care Plan for Syphilis

Nursing Assessment for Syphilis
  1. Physical examination
    • General condition
    • Awareness, nutritional status, TB, BB, temperature, BP, pulse, respiration.
  2. Systemic Examination
    Head (eyes, nose, ears, teeth and mouth), neck (there are enlarged thyroid), neck, chest (inspection, palpation, percussion, auscultation), genitalia, upper and lower extremities.
  3. Supplementary Examination
    Laboratory tests (blood chemistry, urea, creatinine, blood glucose, urinalysis, routine blood).

Nursing Diagnosis and Nursing Interventions for Syphilis
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Nursing Diagnosis and Nursing Interventions for Syphilis

Nursing Diagnosis for Syphilis
  1. Chronic pain related to a lesion in body tissue
  2. Hyperthermia related to the infection process
  3. Anxiety related to the disease process

Nursing Interventions for Syphilis


Nursing Diagnosis 1:
Chronic pain related to a lesion in body tissue

Goal:
Pain disappeared and comfort are met

Expected results:
  • Facial expressions are not in pain
  • Reduced pain / no pain

Nursing Intervention:
  • Assess the history of pain and response to pain
  • Assess the needs that can reduce pain and explain the technique reduces pain and causes pain
  • Create a comfortable environment
  • Reduce unpleasant stimulus
  • Collaboration with physicians in providing analgesic


Nursing Diagnosis 2. :
Hyperthermia related to the infection process

Goal:
Clients will have a normal body temperature

Expected results:
  • Temperature 36-37 ° C
  • Clients do not shiver
  • Clients can rest / sleep

Nursing Intervention:
  • Observation of general condition of the client with vital signs every 2 hours
  • Give antipyretics as recommended by your doctor and monitor the effectiveness of 30-60 minutes later
  • Give a compress on the forehead and arm
  • Recommend that clients use a thin and loose clothing
  • Give the drink a lot


Nursing Diagnosis 3. :
Anxiety related to the disease process

Goal:
Anxiety is reduced or lost

Expected results:
  • Clients feel relaxed
  • Vital sign-in normal circumstances
  • Clients can receive his

Nursing Intervention:
  • Assess the level of fear with the approach and establish a trusting relationship
  • Maintain a calm and safe environment and keep dangerous objects
  • Involve client and family in the implementation and maintenance procedures
  • Teach the use of relaxation
  • Tell clients about the disease and actions to be carried out simply.
READ MORE - Nursing Diagnosis and Nursing Interventions for Syphilis

Nursing Care Plan for Depression

Nursing Care Plan for Depression


Depression is a serious medical illness that involves the brain. It's more than just a feeling of being "down in the dumps" or "blue" for a few days. If you are one of the more than 20 million people in the United States who have depression, the feelings do not go away. They persist and interfere with your everyday life. Symptoms can include

  • Sadness
  • Loss of interest or pleasure in activities you used to enjoy
  • Change in weight
  • Difficulty sleeping or oversleeping
  • Energy loss
  • Feelings of worthlessness
  • Thoughts of death or suicide

Depression can run in families, and usually starts between the ages of 15 and 30. It is much more common in women. Women can also get postpartum depression after the birth of a baby. Some people get seasonal affective disorder in the winter. Depression is one part of bipolar disorder.

There are effective treatments for depression, including antidepressants and talk therapy. Most people do best by using both.

NIH: National Institute of Mental Health
Source : nlm.nih.gov


Nursing Care Plan for Depression

Nursing Assessment

Depression

a. Subjective Data:

Not able to express opinions and lazy speech. Often expressed somatic complaints. Feeling themselves are not useful anymore, feel insignificant, there is no purpose in life, feeling desperate and likely to commit suicide.

b. Objective data:

Body movements that are blocked, the body is curved and when sitting in an attitude of slump, depressed facial expression, a slow gait with dragging step. Sometimes it can happen stupor. Patients appear lazy, tired, no appetite, difficulty sleeping and often cry. Thought process too late, as if the mind is empty, disturbed concentration, has no interest, can not think, do not have the imagination depressive psychosis patients have deep feelings of guilt, no sense (irrational), delusions of sin, depersonalization, and hallucinations. Sometimes patients prefer hostile, irritable and does not like to be disturbed.

Maladaptive Coping

a. Subjective Data: states hopeless and helpless, unhappy, hopeless.

b. Objective Data: looks sad, irritable, restless, unable to control impulses.

Read More :

NANDA Depression

Depression Nursing Diagnosis and Nursing Interventions
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Nursing Diagnosis and Nursing Interventions for Depression

Nursing Diagnosis and Nursing Interventions for Depression




Nursing Diagnosis for Depression

Risk for Violence: Self-Directed or Other-Directed


Nursing Interventions for Depression
  1. The general objective: There was no violence for Self-Directed or Other-Directed
  2. Specific objectives
    • Clients can build a trusting relationship

      Action:

      • Introduce yourself to the patient
      • Do interactions with patients as often as possible with empathy
      • Listen to the notice of the patient with empathy and patient attitude more use non-verbal language. For example: a touch, a nod.
      • Note the patient talks and give a response in accordance with her wishes
      • Speak with a low tone of voice, clear, concise, simple and easy to understand
      • Accept the patient is without comparing with others.
    • Clients can use adaptive coping

      Action:

      • Give encouragement to express feelings and say that nurses understand what patients perceived.
      • Ask the patient the usual way to overcome feeling sad / painful
      • Discuss with patients the benefits of commonly used coping
      • Together with patients looking for alternatives, coping.
      • Give encouragement to the patient to choose the most appropriate coping and acceptable
      • Give encouragement to patients to try coping that have been selected
      • Instruct the patient to try other alternatives in solving problems.
    • Clients are protected from violent behavior to self and others.

      Action:

      • Monitor carefully the risk of suicide / violence themselves.
      • Keep and store the tools that can be used by patients for violent behavior, self / others, in a safe place and locked.
      • Keep materials that endanger the patient's appliance.
      • Supervise and place the patient in the room that easily monitored by peramat / officer.
    • Clients can improve self-esteem
    • Action:
      • Help to understand that the client can overcome despair.
      • Assess and mobilize internal resources of individuals.
      • Help identify sources of hope (eg, peer relationships, beliefs, things to be resolved).
    • Clients can use the social support

      Action:

      • Review and make use of individual external sources (the people closest to, the health care team, support groups, religion).
      • Assess support system beliefs (values, past experiences, religious activities, religious beliefs).
      • Make referrals as indicated (eg, counseling, religious leaders).
    • Clients can use the drug correctly and precisely

      Action:

      • Discuss about the drug (name, dosage, frequency, effect and side effects of taking medication).
      • Help using the drug with the principle of 5 correct (right patient, medication, dose, manner, time).
      • Encourage talking about effects and side effects are felt.
      • Give positive reinforcement when using the drug properly.
Depression Nursing Diagnosis and Nursing Interventions
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Nursing Care Plan for Headache

Nursing Care Plan for Headache


Headache

A Headache is defined as a pain in the head or upper neck. It is one of the most common locations of pain in the body and has many causes.


Symptoms of tension headaches

The pain symptoms of a tension headache are:

  • The pain begins in the back of the head and upper neck and is described as a band-like tightness or pressure.
  • Often is described as pressure encircling the head with the most intense pressure over the eyebrows.
  • The pain usually is mild (not disabling) and bilateral (affecting both sides of the head).
  • The pain is not associated with an aura (see below), nausea, vomiting, or sensitivity to light and sound.
  • The pain occurs sporadically (infrequently and without a pattern) but can occur frequently and even daily in some people.
  • The pain allows most people to function normally, despite the headache.
Source : medicinenet.com



Nursing Assessment for Headache

Subjective and objective data is very important to determine the cause and nature of the headaches.

1. Subjective Data

  • Understanding the patient about headache and possible causes.
  • Aware of the existence of trigger factors, such as stress.
  • Measures to reduce symptoms such as drugs.
  • Place, frequency, pattern and nature of headaches, including the pain, duration and intervals between headaches.
  • Initial headache attacks.
  • History of headache in the family (especially important when a migraine).
  • The situation is made more severe headaches.


2. Objective Data
  • Behavior: showing symptoms of stress, anxiety or pain.
  • Changes in the ability to perform daily activities.
  • There abormal assessment of the physical assessment system: cranial nerve system.
  • Body temperature
  • Drainage from the sinuses.

Nursing Diagnosis and Nursing Interventions for Headache
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Nursing Diagnosis and Nursing Interventions for Headache

Nursing Diagnosis for Headache

1. Acute Pain related to stess and tension, irritation of nerve pressure, vasospasm, increased intracranial pressure.
2. Ineffective individual coping related to crisis situations, personal vulnerability, not adequat support system, work overload, inadequate relaxation, not adequat coping methods, severe pain.


Nursing Intervention for Headache

Nursing Diagnosis I

Acute Pain related to stess and tension, irritation of nerve pressure, vasospasm, increased intracranial pressure.

Nursing Interventions:

  • Assess complaints of pain, note the intensity with pain scale 0 -10, pain characteristics (eg heavy, throbbing, constant) location, duration, factors that aggravate or relieve.
  • Observation of nonverbal signs of pain, are like: facial expression, posture, restlessness, crying / grimacing, withdrawal, diaphoresis, changes in the frequency of cardiac / respiratory, blood pressure.
  • Note the distinct possibility of pathophysiology, such as brain / meningeal / sinus infection, cervical trauma, hypertension or trauma.
  • Make sure the duration / episode of the problem, who has been consulted, and drug and / or what therapy was used.
  • Instruct patient to report pain immediately if the pain arises.
  • Assess the relationship between physical / emotional state of a person.
  • Note the influence of pain such as: loss of interest in life, decreased activity, weight loss.
  • Suggest to rest in a quiet room.
  • Observation of nausea / vomiting.
  • Instruct the patient to use a positive statement "I am cured, I'm relaxing, I love this life." Advise patient to realize the internal-external dialogue and say "stop" or "delayed" if it appears that negative thoughts.

Nursing Diagnosis II

Ineffective individual coping related to crisis situations, personal vulnerability, not adequat support system, work overload, inadequate relaxation, not adequat coping methods, severe pain

Nursing Interventions :
  • Approach the patient with a friendly and attentive. Take advantage of activities that can be taught.
  • Assist patients in understanding the changes in the concept of body image.
  • Advise the patient to express his feelings and discussion how the headaches that interfere with the work and pleasures of this life.
  • Ensure the impact of illness on sexual needs.
  • Give information about the causes of headaches, handling, and expected results.
  • Collaboration : Refer to counseling and / or family therapy or class assertiveness training sites as indicated.
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Nursing Care Plan for Hirschsprung's Disease

Hirschsprung's Disease Nursing Care Plan


Hirschsprung’s Disease

Hirschsprung's disease is a blockage of the large intestine due to improper muscle movement in the bowel. It is a congenital condition, which means it is present from birth.


Symptoms

Symptoms that may be present in newborns and infants include:

  • Difficulty with bowel movements
  • Failure to pass meconium shortly after birth
  • Failure to pass a first stool within 24 - 48 hours after birth
  • Infrequent but explosive stools
  • Jaundice
  • Poor feeding
  • Poor weight gain
  • Vomiting
  • Watery diarrhea (in the newborn)

Symptoms in older children:
  • Constipation that gradually gets worse
  • Fecal impaction
  • Malnutrition
  • Slow growth
  • Swollen belly
Source : www.nlm.nih.gov


Nursing Care Plan for Hirschsprung's Disease

Nursing Assessment
  1. The main complaint
    Obstipation is the main sign and in newborn infants. What is often found is a slow exit meconium (more than 24 hours after birth), flatulence and vomiting green. Other symptoms are vomiting and diarrhea.
  2. History of present illness
    Is a congenital disorder that is a functional bowel obstruction. Total obstruction at birth with vomiting, abdominal distension and absence of meconium evacuation. Babies often experience constipation, vomiting and dehydration. Mild symptoms of constipation for several weeks or months, followed by acute intestinal obstruction. But there is also a mild constipation, enterocolitis with diarrhea, abdominal distension, and fever. Fetid diarrhea may occur.
  3. History of previous illnesses
    No previous illnesses that affect the occurrence of Hirschsprung's disease.
  4. Family health history
    No family who suffer from this disease descended to his son.
  5. Immunization
  6. History of growth and development of children
  7. Nutrition
  8. Physical examination
    • Respiratory system
      Shortness of breath, respiratory distress
    • Digestive system
      Generally obstipation. Abdominal bloating / abdominal strain, vomiting green. In older children there are chronic diarrhea. In the plug anus finger will feel the pins and on time withdrawn will be followed by the release of air and meconium or feces spraying.
    • Genitourinarius system
    • Locomotor system / musculoskeletal
      Impaired sense of comfort

Nursing Diagnosis and Nursing Interventions for Hirschsprung's Disease
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Nursing Diagnosis and Nursing Interventions for Hirschsprung's Disease

Nursing Diagnosis for Hirschsprung's Disease
  1. Constipation related to an intestinal obstruction
  2. Imbalanced Nutrition: Less than body requirements related to nausea and vomiting

Nursing Interventions for Hirschsprung's Disease
  1. Constipation related to an intestinal obstruction
    Goal :
    Children can do the elimination with some adaptations to the normal function of elimination and can be done

    Expected results :
    • Patients can perform elimination with some adaptation
    • There is increasing pattern of elimination

    Nursing Intervention :

    • Observation of vital signs and bowel sounds every 2 hours
    • Observations expenditure per rectal stool - forms, consistency, amount
    • Observations intake that affects the pattern and consistency of stools
    • Suggest to a diet that has been recommended
  2. Imbalanced Nutrition: Less than body requirements related to nausea and vomiting
    Goal :
    Patients receive an adequate nutritional intake in accordance with the recommended diet

    Expected results :

    • Weight of patients according to age
    • Patients with moist skin turgor
    • Parents can choose the recommended foods

    Nursing Interventions :

    • Provide adequate nutritional intake in accordance with the recommended diet
    • Measure the weight of children every day
    • Use an alternative route of nutrition (such as NGT and parenteral) to anticipate patients who have started to feel nausea and vomiting
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Nursing Diagnosis and Nursing Intervention for Neonatal Tetanus

Nursing Diagnosis for Neonatal Tetanus
  1. Ineffective breathing pattern related to respiratory muscle fatigue
  2. Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.


Nursing Intervention for Neonatal Tetanus

Nursing Diagnosis I

Ineffective breathing pattern related to respiratory muscle fatigue

Nursing Intervention:
  • Assess the frequency and pattern of breath
  • Note the presence of apnea, the frequency change of heart, muscle tone and skin color.
  • Perform cardiac and respiratory monitoring continuously.
  • Suction airway as needed.
  • Give the tactile stimulation immediately after apnea.
  • Monitor laboratory tests as indicated.
  • Give oxygenation as indicated.
  • Give medications as indicated.


Nursing Diagnosis II

Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.

Nursing Intervention:

  • Assess the maturity of the reflex with respect to feeding, sucking, swallowing and coughing.
  • Auscultation bowel sounds.
  • Review the signs of hypoglycemia.
  • Give appropriate medication electrolyte supplements.
  • Give parenteral nutrition.
  • Monitor laboratory tests as indicated.
  • Make provision of drinking according to tolerance.

Related Articles :
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Neonatal Tetanus : Definition, Causes and Prevention

Definition of Neonatal Tetanus

Tetanus is a neurological disorder (caused by gram-positive rod Clostridium tetani) which is characterized by increased in muscle tone and muscle spasms. If tetanus occurs in neonates (neonate is a baby of age less than 4 weeks or 28 days) it is called “neonatal tetanus”. Neonatal tetanus is commonly seen in the first 2 weeks of life.


Causes of Neonatal Tetanus

Tetanus is caused by bacteria Clostridium tetani, which is gram-positive rod. Clostridium tetani is a motile and an anaerobic (grows in absence of air or oxygen) organism. Clostridium tetani is worldwide in distribution and found in soil, animal feces, and inanimate objects (at the tip of thorns, iron nails and in many other objects) and sometimes even in human excreta.

The specialty of Clostridium tetani is its ability to form “spores” which are colorless, oval, and look like drumstick or tennis racket. The spores can survive for years (may be decades) in some environment and become vegetative form when the environment is favorable. The spores of Clostridium tetani are resistant to boiling for 20 minutes and also resistant to several disinfectants, which makes it very difficult to remove from environment. But the vegetative forms are easily deactivated by various antibiotics (penicillin, metronidazole etc.) and normal disinfection procedures.


Prevention of Neonatal Tetanus

Neonatal tetanus can be effectively prevented by adapting asceptic techniques during delivery and by conducting delivery in hospitals (institutional delivery). If the delivery is done at home (as is the practice in many developing countries) the umbilical cord should be cut with sterile instrument/blade.

As part of prevention, active immunization of all pregnant women with tetanus toxoid should be done. For the first time pregnancy 2 doses of tetanus toxoid should be administered intramuscularly in the deltoid muscle during 16th to 28th week of pregnancy with at least 4 weeks apart, irrespective of immunization status against tetanus. During subsequent pregnancies, single tetanus toxoid should be administered intramuscularly during 16th to 28th week of pregnancy to prevent neonatal tetanus.
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