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Nursing Diagnosis for Encephalitis and Nursing Interventios for Encephalitis

Nursing Diagnosis for Encephalitis
  1. High risk of infection associated with lower body resistance to infection
  2. High risk of injury associated with seizure activity

Nursing Interventios for Encephalitis
  1. High risk of infection associated with lower body resistance to infection

    Goal :
    no infection

    Expected results :
    Healing on time with no evidence of spread of infection endogenous

    Nursing Intervention :
    • Defense aseptic technique and proper hand washing techniques either nurses or visitors. Monitor and limit visitors.
      R /. reduce the risk of patients exposed to secondary infection. control the spread of the source of infection.
    • Measure the temperature on a regular basis and clinical signs of infection.
      R /. Detecting early signs of infection
    • Give antibiotics as indicated
      R /. Drugs are selected depending on the type of infection and sensitivity of the individual.

  2. High risk of injury associated with seizure activity

    Goal :
    There was no trauma

    Results expected :
    • Not having a seizure
    • No trauma

    Nursing Intervention :
    • Give safety to patients by giving bearings, fixed the bed barriers and give a booster attached to the mouth, the airway remains free.
      R /. Protect patients in case of seizure, booster mouth somewhat tongue is not bitten.
      Note: enter the booster mouth when the mouth just relaxation.
    • Maintain bed rest in the acute phase.
      R /. Lowering the risk of falling / injury during the vertigo.
    • Collaboration
      Give the drug as an indication as delantin, valum, etc..
      R /. An indication for treatment and prevention of seizures.
    • Observation of vital signs
      R /. Early detection of seizures for possible further action.
READ MORE - Nursing Diagnosis for Encephalitis and Nursing Interventios for Encephalitis

Nursing Care Plan for Encephalitis

Encephalitis - Nursing Care Plan for Encephalitis



Encephalitis

Encephalitis is an acute infection and inflammation of the brain itself. This is in contrast to meningitis, which is an inflammation of the layers covering the brain.

Encephalitis is generally a viral illness. Viruses such as those responsible for causing cold sores, mumps, measles, and chickenpox can also cause encephalitis. A certain family of viruses, the Arboviruses are spread by insects such as mosquitoes and ticks. The equine (meaning horse), West Nile, Japanese, La Crosse, and St. Louis encephalitis viruses are all mosquito-borne. Although viruses are the most common source of infection, bacteria, fungi, and parasites can also be responsible.

The illness resembles the flu and usually lasts for 2-3 weeks. It can vary from mild to life-threatening, and even cause death. Most people with a mild case can recover fully. Those with a more severe case can recover although they may have damage to their nervous system. This damage can be permanent.
Source : emedicinehealth.com


Nursing Assessment Encephalitis
  1. Identity
    Encephalitis can occur at any age
  2. The main complaint
    High heat loss, seizures, decreased consciousness
  3. History present illness
    At first the child fussy, anxiety, vomiting, increased body heat approximately 1-4 days, headaches.
  4. History advance disease
    Previous clients suffering from coughs, colds approximately 1-4 days, had suffered from herpes disease, infectious diseases of the nose, ear and throat.
  5. Family Health History
    The family is suffering from diseases caused by viruses eg Herpes etc.. Bacteria eg Staphylococcus aureus, Streptococcus, E, Coli, etc..
  6. Immunization
    When was the last given DTP immunization
    Because encephalitis can occur post-pertussis immunization.
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Nursing Care Plan for Urinary Tract Infection

A urinary tract infection (UTI) is an infection caused by pathogenic organisms (for example, bacteria, fungi, or parasites) in any of the structures that comprise the urinary tract. However, this is the broad definition of urinary tract infections; many authors prefer to use more specific terms that localize the urinary tract infection to the major structural segment involved such as urethritis (urethral infection), cystitis (bladder infection), ureter infection, and pyelonephritis (kidney infection). Other structures that eventually connect to or share close anatomic proximity to the urinary tract (for example, prostate, epididymis, and vagina) are sometimes included in the discussion of UTIs because they may either cause or be caused by UTIs. Technically, they are not UTIs and will be only briefly mentioned in this article.

UTIs are common, more common in women than men, leading to approximately 8.3 million doctor visits per year. Although some infections go unnoticed, UTIs can cause problems that range from dysuria (pain and/or burning when urinating) to organ damage and even death. The kidneys are the active organs that, during their average production of about 1.5 quarts of urine per day, function to help keep electrolytes and fluids (for example, potassium, sodium, water) in balance, assist removal of waste products (urea), and produce a hormone that aids to form red blood cells. If kidneys are injured or destroyed by infection, these vital functions can be damaged or lost.
Source : medicinenet.com


Nursing Care Plan for Urinary Tract Infection


Nursing Assessment

In conducting the assessment on the client's urinary tract infection using a holistic approach that is :

Biological data include :
  • The identity of the client
  • The identity of insurer

Medical history :
  • History of urinary tract infection
  • History of kidney stones
  • History of diabetes mellitus, heart.

Physical Assessment :
  • Palpation bladder
  • Inspection area meatus
    • Assessment of color, amount, odor and clear urine
    • Assessment of costovertebralis

Psychosocial History :
  • Age, sex, occupation, education
  • Perceptions of disease conditions
  • Coping mechanisms and support system
  • Assessment of knowledge of the client and family :
    • An Understanding of the cause / course of the disease
    • An Understanding of the prevention, treatment and medical therapy
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Nursing Diagnosis for Urinary Tract Infections and Nursing Interventions for Urinary Tract Infections

Nursing Diagnosis Urinary Tract Infections
  1. Impaired sense of comfort: pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.
  2. Elimination pattern changes related to mechanical obstruction of the bladder or other urinary tract structures.


Nursing Interventions Urinary Tract Infections
  1. Impaired sense of comfort: pain related to inflammation and infection of the urethra, bladder and other urinary tract structures

    Expected results :
    • Pain reduced / lost during and after micturition

    Nursing Intervention :
    • Monitor changes in urine color, monitor the pattern of urination, the input and output every 8 hours and monitor the results of urinalysis repeated.
      R /: to identify indications of progress or deviations from expected results
    • Record the location, the length of the intensity scale (1-10) pain.
      R /: to help evaluate the place of obstruction and cause pain
    • Provide comfort measures, such as massage.
      R /: increase relaxation, decrease muscle tension.
    • Provide perineal care.
      R /: to prevent contamination of the urethra
    • If you installed the catheter, catheter treatment 2 times per day.
      R /: The catheter gives way to bacteria entering the bladder and up into the urinary tract.
    • Divert attention on something fun.
      R /: relaxation, avoiding too feel the pain.

  2. Elimination pattern changes related to mechanical obstruction of the bladder or other urinary tract structures

    Expected results :
    • The pattern of elimination improved, there is no signs of urinary disorders (urgency, oliguric, dysuria)

    Nursing Intervention :
    • Monitor the income and expenditure characteristics of urine.
      R /: provides information about renal function and complications
    • Encourage increased fluid intake.
      R /: increased hydration rinse bacteria.
    • Review the complaints of the bladder.
      R /: urinary retention may occur causing distention of tissues (bladder / kidney)
    • Observation of changes in level of consciousness.
      R /: accumulation of residual uremic and electrolyte imbalance can be toxic to the central nervous system
    • Collaboration :
      • Supervise laboratory examination, electrolytes, creatinine.
        R /: oversight of renal dysfunction
      • Take action to maintain acidic urine: improved input Berri fruit juices and give the medications to increase urine aam.
        R /: urinary acid prevents the growth of germs. Increased input juice can affect the treatment of urinary tract infections.
READ MORE - Nursing Diagnosis for Urinary Tract Infections and Nursing Interventions for Urinary Tract Infections

Nursing Care Plan for Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis


Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.
Source : medicinenet.com


Nursing Assessment for Rheumatoid Arthritis
  1. Activity / rest
    • Symptoms: Joint pain due to movement, tenderness, worsened by stress on the joints, stiffness in the morning, usually bilateral and symmetrical. Functional limitations that affect lifestyle, leisure, work, fatigue.
    • Signs: The limited range of motion, muscle atrophy, skin, contractor / abnormalities in the joints.
  2. Cardiovascular
    • Symptoms: Raynaud's phenomenon fingers / legs (eg intermittent pale, cyanosis, and redness on the fingers before the color returned to normal).
  3. Ego integrity
    • Symptoms: Acute stress factors / chronic: eg, financial, employment, disability, relationship factors, Decision and powerlessness (inability situation), Threats to the self-concept, body image, personal identity (such as dependence on others).
  4. Food / fluid
    • Symptoms: Inability to produce / consume food / fluids adequately: nausea, anorexia, difficulty in chewing.
    • Signs: Weight loss, Drought on mucous membranes.
  5. Hygiene
    • Symptoms: The difficulties to carry out personal care activities. Dependence on others.
  6. Neuro Sensory
    • Symptoms: numbness, tingling in hands and feet, loss of sensation in fingers. Symmetrical joint swelling.
  7. Pain / comfort
    • Symptoms: The acute phase of pain (may not be accompanied by soft tissue swelling in joints).
  8. Security
    • Symptoms: The skin shiny, taut, subcutaneous nodules, skin lesions, leg ulcers. The difficulty in handling light duty / household maintenance. Drought mild fever settled on the eyes and mucous membranes.
  9. Social interaction
    • Symptoms: Damage of social interaction with family / others; changing role; isolation.

READ MORE - Nursing Care Plan for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis and Nursing Interventions for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis
  1. Acute Pain / Chronic related to tissue distension by fluid accumulation / inflammation, joint destruction.
  2. Impaired physical mobility related to skeletal deformities, pain, discomfort, activity intolerance, decreased muscle strength.

Nursing Interventions for Rheumatoid Arthritis
  1. Acute Pain / Chronic Pain related to tissue distension by fluid accumulation / inflammation, joint destruction.

    Goal :

    Pain is reduced / lost

    Expected results :
    • Indicates no pain
    • Looks relaxed, to sleep / rest and participate in activities based on ability.
    • Following program prescribed pharmacologic
    • Combining the skills of relaxation and entertainment activity in the pain control program.

    Nursing Intervention :
    • Assess pain, note the location and intensity (scale 0-10). Write down the factors that accelerate and signs of pain non-verbal.
      R / Assist in determining the need for pain management and program effectiveness.
    • Give a hard mattress, small pillows, elevate the bed linen as needed.
      R / soft mattress, large pillows, will prevent the maintenance of proper body alignment, placing stress on joints that hurt. Bed linen elevation decrease the pressure on painful joints.
    • Instruct to frequently change positions. Helps to move in bed, prop a pain in the joints above and below, avoid jerky movements.
      R / Prevent the occurrence of general fatigue and joint stiffness. Stabilize joints, reduce the movement / pain in the joints.
    • Instruct the patient to a warm bath or shower at the time awake. Monitor the water temperature, water bath, and so forth.
      R / Heat enhance muscle relaxation, and mobility, reduce pain and stiffness in the morning release. Sensitivity to heat, can be removed and dermal wound can be healed.
    • Give a massage
      R / enhance relaxation / reduce pain
    • Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeed back, visualization, guidelines imagination, self hypnosis, and breathing control.
      R / Increase relaxation, provide a sense of control and may improve coping abilities.
    • Engage in activities of entertainment that is suitable for individual situations.
      R / Focusing attention back, provide stimulation, and increased self-confidence and feeling healthy.
    • Give the drug prior to activity / exercise that is planned as directed.
      R / Increase relaxation, reduce muscle tension / spasm, making it easier to participate in therapy.
    • Collaboration: Provide drugs according to doctor's instructions.
      R / as anti-inflammatory and mild analgesic effect in reducing stiffness and increasing mobility.
    • Give the ice-cold compress if needed.
      R / The cold can relieve pain and swelling during the acute period.
  2. Impaired physical mobility related to skeletal deformities, pain, discomfort, activity intolerance, decreased muscle strength.

    Expected results :
    • Maintaining a function of position with no presence / restrictions contractures.
    • Maintain or increase the power and functionality of and / or compensation of the body.
    • Demonstrate techniques / behaviors that allow doing activities.

    Nursing Intervention :
    • Evaluation / continue monitoring the level of inflammation / pain in the joints.
      R / level of activity / exercise depends on the development / resolution of the inflammatory process.
    • Maintain a rest / sit if necessary scheduled events
      R / Rest is recommended during the acute exacerbation phase of disease and all that important, to prevent fatigue and maintain power.
    • Assist with range of motion active / passive
      R / Maintain / improve joint function, muscle strength and general stamina.
      Note: inadequate exercise lead to joint stiffness, excessive activity can damage the joints.
    • Change positions frequently.
      R / Eliminate pressure on the tissue and increase circulation.
    • Use a small pillow / thin below the neck.
      R / Prevent flexion of the neck.
    • Instruct the patient to maintain an upright posture and sitting height, standing, and walking.
      R / Maximize maintain joint function and mobility.
    • Collaboration: consul with physiotherapy.
      R / Useful in formulating training programs / activities that are based on individual needs and in identifying tools.
    • Collaboration: give drugs as indicated.
      R / may be needed to suppress the acute inflammatory system.
READ MORE - Nursing Diagnosis for Rheumatoid Arthritis and Nursing Interventions for Rheumatoid Arthritis

Treating and Preventing Glaucoma

Medications are available that can reduce eye pressure and prevent damage. Most are given as eye drops. Beta-blockers (e.g., betaxolol*, levobunolol, timolol), alpha2-agonists (e.g., brimonidine), and carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide) slow the production of eye fluid (aqueous humour), while prostaglandin analogs (e.g., latanoprost, travoprost, bimatoprost) and miotics (medications that contract the pupil, such as pilocarpine) improve drainage. Medications have to be used indefinitely, so many people with glaucoma end up opting for surgery or laser treatment.

The most common operation is laser trabeculoplasty, a painless 15-minute outpatient procedure. The laser is unfocused and harmless when it passes through the surface of the eye, but it concentrates its energy on the trabecular meshwork, shrinking it and reopening the holes. Many patients are able to stop using their glaucoma medications after this operation. There are other surgical procedures available if this doesn't work.

With early treatment, vision loss can be minimized or prevented. Because glaucoma isn't obvious, it's vital to get your eyes checked regularly, especially if you have any of these risk factors :
  • family history of glaucoma
  • African descent
  • myopia (nearsightedness)
  • previous eye injury
  • high blood pressure
  • diabetes
  • long-term use of prednisone, cortisone, or other steroids

If you are between the ages of 20 and 64 years, you should have your eyes checked every 1 or 2 years. From the age of 65 years onwards, you should have them checked every year. But if you have any of these risk factors, you should go as often as your eye care professional recommends.


*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For more information on brand names, speak with your doctor or pharmacist.


Source : chealth.canoe.ca
READ MORE - Treating and Preventing Glaucoma

Nursing Diagnosis and Nursing Intervention for Pleural Effusion

Nursing Diagnosis for Pleural Effusion
  1. Ineffective breathing pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, the inflammatory process.
  2. Chest pain related to biologic factors (tissue trauma) and physical factors (chest tube installation)


Nursing Intervention for Pleural Effusion
  1. Ineffective breathing pattern related to decreased lung expansion (accumulation of air / liquid), musculoskeletal disorders, pain / anxiety, the inflammatory process.

    Marked by :
    Dyspnea, Tachypnoea, changes in depth of breathing, accessory muscle use, impaired development of the chest, cyanosis.

    Goal :
    The pattern of effective breath

    Expected results :
    • Indicate the normal breathing pattern / effective
    • Free cyanosis and signs of hypoxic symptoms

    Intervention :
    • Identify the etiology or trigger factor
    • Evaluation of respiratory function (rapid breathing, cyanosis, changes in vital signs)
    • Auscultation for breath sounds
    • Note the position of the chest and trachea development, review fremitus.
    • Maintain a comfortable position is usually elevated headboard
    • Give oxygen through a cannula / mask
    • If the chest tube is installed :
      • Check the vacuum controller, liquid limit
      • Observations of air bubbles bottle container
      • Hose clamps on the bottom of the drainage unit if a leak
      • Watch the ebb and flow of water reservoir
      • Note the character / amount of chest tube drainage.


  2. Chest pain related to biologic factors (tissue trauma) and physical factors (chest tube installation)

    Goal :
    Pain is reduced or lost

    Expected results :
    • The patient said the pain is reduced or can be controlled
    • Patients calm

    Intervention :
    • Assess for the presence of pain, the scale and intensity of pain
    • Teach the client about pain management and relaxation with distraction
    • Secure the chest tube to restrict movement and avoid irritation
    • Assess pain reduction measures
    • Provide analgesics as indicated
READ MORE - Nursing Diagnosis and Nursing Intervention for Pleural Effusion

Nursing Care Plan for Pleural Effusion

NCP for Pleural Effusion

Nursing Care Plan for Pleural Effusion

Pleural Effusion

A pleural effusion is an excess accumulation of fluid in the pleural space around the lungs. Medical ImageThe pleura are thin membranes that enclose the lungs and line the inside of the chest cavity. The 'pleural space' describes the small space between the inner and outer layers of pleura, which normally contains a small volume of lubricating pleural fluid to allow the lungs to expand without friction. This fluid is constantly being formed through leakage of fluid from nearby capillaries and then re-absorbed by the body's lymphatic system. With a pleural effusion, some imbalance between production and reabsorption of pleural fluid leads to excess fluid building up in the pleural space. There are two major types of pleural effusion :
  • Transudative effusions, where the excess pleural fluid is low in protein; and
  • Exudative effusions, where the excess pleural fluid is high in protein.

Causes

Anything that causes an imbalance between production and reabsorption of pleural fluid can lead to development of a pleural effusion. Medical Image Transudative pleural effusions (those low in protein) usually form as a result of excess capillary fluid leakage into the pleural space. Common causes of transudative effusions include :
  • Congestive heart failure;
  • Nephrotic syndrome;
  • Cirrhosis of the liver;
  • Pulmonary embolism; and
  • Hypothyroidism.
Exudative effusions, which are high in protein, are often more serious than transudative effusions. They are formed as a result of inflammation of the pleura, which might happen for example in lung disease. Common causes of exudative effusions include :
  • Pneumonia;
  • Lung cancer, or other cancers;
  • Connective tissue diseases, including rheumatoid arthritis and systemic lupus erythematosus;
  • Pulmonary embolism;
  • Asbestosis;
  • Tuberculosis; and
  • Radiotherapy.
Source : virtualmedicalcentre.com


Nursing Care Plan for Pleural Effusion

Nursing Assessment
  1. Activity / rest
    Symptoms: dyspnea with activity or rest
  2. Circulation
    Signs: Tachycardia, dysrhythmias, heart rhythm Gallop, hypertension / hypotension
  3. Ego integrity
    Signs: fear, anxiety
  4. Food / fluid
    The existence of the installation of central venous IV / infusion
  5. Pain / comfort
    Symptoms depend on the size / area involved: Pain is aggravated by breathing in, the possibility of spread to the neck, shoulders, abdomen
    Signs: Be careful on the area of pain, behavioral distraction
  6. Respiratory
    Symptoms: Difficulty breathing, cough, history of chest surgery / trauma,
    Signs: Tachypnoea, use of accessory respiratory muscles in the chest, intercostal retraction, decreased breath sounds and decreased fremitus (on the side involved),
    Chest percussion: hyper resonant in the area filled with air and noise deaf in fluid-filled area
    Observation and palpation of the chest: chest movement is not the same (paradoksik) when trauma. Skin: pale, cyanosis, sweating.

Nursing Diagnosis and Nursing Interventions for Pleural Effusion
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