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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
READ MORE - Nursing Diagnosis and Nursing Interventions for Hirschsprung's Disease

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 :
READ MORE - Nursing Diagnosis and Nursing Intervention for Neonatal Tetanus

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.
READ MORE - Neonatal Tetanus : Definition, Causes and Prevention

Nursing Diagnosis and Nursing Interventions for Hematemesis Melena

Nursing Diagnosis for Hematemesis Melena
  1. Deficient Fluid Volume related to bleeding (loss of active)
  2. Ineffective tissue perfusion related to hypovolemia


Nursing Interventions for Hematemesis Melena

Nursing Diagnosis I
Deficient Fluid Volume related to bleeding (loss of active)

Goal :
  • Fluid requirements are met.
  • Vital signs within normal limits, good skin turgor, moist mucous membranes, the production of urine output is balanced, not vomiting blood and stools are not black.

Nursing Interventions:
  1. Record the characteristics of vomiting and / or drainage.
    Rational:
    Assist in distinguishing gastric distress. Bright red blood indicates the presence or acute arterial bleeding, probably due to gastric ulcer; dark red blood probably old blood (stuck in the intestines) or bleeding from varicose veins.
  2. Monitor vital signs; compared with normal results of client / previous. Measure blood pressure with sitting, sleeping, standing if possible.
    Rational:
    Postural hypotension showed decreased circulating volume.
  3. Record the individual patient's physiological response to bleeding, such as mental changes, weakness, restlessness, anxiety, pale, sweaty, tachypnoea, the increase in temperature.
    Rational:
    Worsening of symptoms may indicate the continued bleeding or inadequate fluid replacement.
  4. Monitor input and output and connect them with changes in body weight. Measure blood loss / fluid through vomiting and defecation.
    Rational:
    Provide guidelines for fluid replacement.
  5. Maintain bed rest; prevent vomiting and stress at the time of defecation. Schedule of activities to provide a rest period without interruption.
    Rational:
    Activities / vomiting increased intra-abdominal pressure and can trigger further bleeding.
  6. Elevate head of bed for antacid drug administration.
    Rational:
    Prevent gastric reflux and aspiration of antacids which can cause serious lung complications.
  7. Collaboration:
    • Give fluid / blood as indicated.
      Rational:
      Replacement fluid hypovolaemia depends on the degree and duration of bleeding (acute / chronic).
    • Give antibiotics as indicated.
      Rational:
      It may be used when the infection causes chronic gastritis.
    • Supervise laboratory examination; eg Hb / Ht
      Rational: A tool to determine the need for blood replacement and oversee the effectiveness of therapy.

Nursing Diagnosis II
Ineffective tissue perfusion related to hypovolemia

Goal :
Effective tissue perfusion

Expected results :
Maintain / improve tissue perfusion with evidence: stable vital signs, skin warm, palpable peripheral pulse, urine output adequate.

Nursing Intervention :
  1. Monitor changes in level of consciousness, dizziness complaints / headaches.
    Rational:
    The change may indicate inadequate cerebral perfusion due to arterial blood pressure.
  2. Auscultation apical pulse. Guard heart rate / rhythm when there is a continuous ECG.
    Rational:
    Change dysrhythmias and ischemia can occur as a result of hypotension, hypoxia, acidosis, electrolyte imbalance, or cooling near the heart area.
  3. Assess the skin to cold, pale, sweating, slow capillary filling, and peripheral pulse is weak.
    Rational:
    Vasoconstriction is a sympathetic response to the decline in circulation volume and / or may occur as a side effect of vasopressin.
  4. Note the report abdominal pain, especially sudden severe pain or pain spreading to shoulders.
    Rational:
    Pain caused by gastric ulcer, often disappear after acute hemorrhage due to buffer the effects of blood.
  5. Observations for pale skin, reddish. Massage with oil. Change positions frequently.
    Rational:
    Disturbances in peripheral circulation increases the risk of skin damage.
  6. Collaboration :
    • Provide supplemental oxygen as indicated.
      Rational:
      Treat hypoxemia and lactic acidosis during acute hemorrhage.
    • Give IV fluids as indicated.
      Rational:
      Maintain circulating volume and perfusion.

Related Articles :
READ MORE - Nursing Diagnosis and Nursing Interventions for Hematemesis Melena

Nursing Assessment for Hematemesis Melena

Nursing assessment in patients with Haematemesis melena, can be done several stages, as follows

General Assessment
  1. Intake: anorexia, nausea, vomiting, weight loss.
  2. Elimination: constipation or diarrhea, is there melena (black blood color, thick consistency, amount)
  3. Urine: dark color, thick consistency
  4. Neuro Sensory: an impairment of consciousness (confusion, hallucinations, coma).
  5. Respiration: tightness, dyspnoe, hipoxia
  6. Activity: weakness, fatigue, lethargy, reduced muscle tone


Physical Assessment
  1. Consciousness, blood pressure, pulse, temperature, respiration
  2. Inspection:
    • Eyes: conjungtiva (there is / there is no anemis)
    • Mouth: the stomach contents mixed with blood
    • Extremity: pale fingertips
    • Skin: Cold
  3. Auscultation:
    • Lung
    • Heart: rapid or slow rhythm
    • Intestine: decreased peristalsis
  4. Percussion:
    • Abdomen: resonant sounds, bloated or not
    • Patellar reflex: decrease
  5. Diagnostic studies
    • Blood tests: Hb, Ht, RBC, prothrombin, Fibrinogen, BUN, serum, ammonia, albumin.
    • Examination of urine: BJ, color, thickness
    • Investigations: esophagoscopy, endoscopy, ultrasound, CT Scan.

Special Assessment
Physiological Needs Assessment

  1. Oxygen
    Nursing Assessments conducted include:
    • The number and the color of blood hematemesis.
    • The color brown: blood from the stomach may still remain, a potential aspiration.
    • Sleeping position: to prevent any vomit into the airway, prevent shock.
    • Signs of shock: can occur when blood counts more than 500 cc and occurs continuously.
    • Number of bleeding: observation of signs of hemodynamic blood pressure, pulse, respiration, temperature. Normally blood pressure (systolic) 110 mmHg, rapid breathing, pulse 110 x / min, temperature between 38-39 degrees Celsius, cold pale skin or cyanosis of the lips, the ends of the extremities, blood circulation to the kidneys is reduced, causing the urine is reduced.
  2. Fluid
    Nursing Assessment of patients with hematemesis melena related to the amount of fluid needs of the bleeding that occurred. The amount of blood, will determine the replacement fluid.

    Assessment: the type of bleeding / extravasation way, to determine the location of bleeding and a ruptured blood vessel types. Bleeding that occurs suddenly, the color of fresh red blood, and continuous discharge describes bleeding that occurs in the upper gastrointestinal tract and rupture of the arteries occurs. If the emergency phase has passed, the next phase of doing an assessment of:
    • Intake output balance. The assessment is done on the patient hematemesis melena caused by rupture of esophageal varices as a result of cirrochis hepatis often experience ascites and edema.
    • Giving intravenous fluids on the patient.
    • Urine output and record the amount per 24 hours.
    • Signs of dehydration such as decreased skin turgor, sunken eyes, a small amount of urine. For patients with frequent melena hemetemesis impaired renal function.
  3. Nutrition
    Assessment:
    • Ability to adapt to the diet: 3 days of liquid, then soft foods.
    • Diet
    • Weight before bleeding
    • Cleanliness of mouth: because hemetemesis and melena, the remnants of bleeding can be a source of infections that cause discomfort.
  4. Temperature
    Patients with hematemesis melena in general experienced a temperature rise of about 38-39 degrees Celsius. In the pre-shock state of the skin temperature becomes cooler as a result of circulatory disturbance. Buildup of residual bleeding is the source of infection in the gastrointestinal tract so that the patient's body temperature can rise. In addition, a long infusion can also be sources of infection which causes the patient's body temperature increases.
  5. Elimination
    On the patient hematemesis melena generally impaired elimination. Nursing assessment includes:
    • he number and how spending due to impaired renal function. Urine is reduced and usually do care bed rest.
    • Defecation, it should be noted the number, color and consistency.
    • Protection
    • Socioeconomic background of patients, because in hematemesis melena needs to be done some actions in the enforcement of diagnosis and therapy for patients.
    • Physical Needs and Psiologis
      • Protection against the danger of infection. Should be studied: personal hygiene, environmental hygiene, cleanliness weaving tools, prepare and perform flushing of the stomach, how to pipe installation and maintenance of the stomach, the way of preparation and delivery of IV or IM injection.
      • Protection against the danger of complications:
        • Assess the endoscopy examination preparation (informed concern).
        • Preparation related to taking / examination of blood.
READ MORE - Nursing Assessment for Hematemesis Melena

Nursing Diagnosis for Tonsillitis

Nursing Diagnosis for Tonsillitis : Preoperative
  1. Swallowing disorders related to inflammatory processes.
  2. Acute pain related to tonsil tissue swelling.
  3. Imbalance nutrition less than body requirements related to tonsil tissue swelling.
  4. Hipertermi related to the disease process.
  5. Anxiety related to discomfort.

Nursing Diagnosis for Tonsillitis : Postoperative
  1. Acute pain related to surgical incision, tissue discontinuities.
  2. High risk of infection related to invasive procedures.
  3. Lack of knowledge about the diet related to less information.
READ MORE - Nursing Diagnosis for Tonsillitis

Nursing Care Plan for Tonsillitis

Tonsillitis Nursing Care Plan



Tonsillitis

Tonsillitis is an inflammation of the glands of the throat, which results in a sore throat.Tonsillitis can be caused by either viruses or bacteria. Most cases of tonsillitis go away without antibiotic medication.

Symptoms
  • Sore throat
  • Difficulty feeding (in babies)
  • Pain with swallowing
  • Fever
  • Headache
  • Abdominal pain
  • Nausea and vomiting
  • Cough
  • Hoarseness
  • Runny nose
  • Redness of the tonsils and throat
  • Tenderness in the glands of the neck (swollen lymph glands)
  • White patches on the tonsils
  • Redness of the eyes
  • Rash
  • Ear pain (nerves that go to the back of the throat also go to the ear)
Source : emedicinehealth.com


Nursing Care Plan for Tonsillitis

Nursing Assessment
  1. Interview

    • Review a history of previous illness (tonsillitis)?
    • Is adequate treatment?
    • When do symptoms appear?
    • What is in the habit of smoking?
    • What about diet?
    • Is Routine / diligent in cleaning the mouth?
  2. Physical examination

    Baseline data assessment by Doengoes, (1999), namely :
    • Ego integrity
      • Symptoms:
        Feelings of fear
        Worry if the surgery affects family relationships, work ability, and financial.
      • Signs: anxiety, depression, refused.
    • Food / Fluids
      • Symptoms: Difficulty swallowing
      • Signs: Difficulty swallowing, easily driven, inflammation, poor dental hygiene.
    • Hygiene
      • Signs: Difficulty swallowing
    • Painful
      • Signs: Nervousness, cautious behavior
      • Symptoms: Sore throat is a chronic, spreading pain to the ear
    • Respiratory
      • Symptoms: History of smoking / chewing tobacco, working with wood powder
  3. Results of physical examination in general :
    • Enlarged tonsils
    • Lethargy
    • Difficulty swallowing
    • Fever
    • Sore throat
    • Poor oral hygiene
  4. Diagnostic tests
    Examination of throat swabs
    This examination should be performed before providing treatment, especially when circumstances permit. By doing this examination we can find germs that cause and drugs that are still sensitive.

    Diagnosis based on symptoms and physical examination.
READ MORE - Nursing Care Plan for Tonsillitis

Glasgow Coma Scale

Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

Eye Response (E)

There are 4 grades starting with the most severe:
  1. No eye opening
  2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
  3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
  4. Eyes opening spontaneously

Verbal Response (V)

There are 5 grades starting with the most severe :
  1. No verbal response
  2. Incomprehensible sounds. (Moaning but no words.)
  3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
  4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
  5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Motor Response (M)

There are 6 grades starting with the most severe :
  1. No motor response
  2. Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response)
  3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
  4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
  5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
  6. Obeys commands. (The patient does simple things as asked.)

Generally, brain injury is classified as :
  • Severe, with GCS ≤ 8
  • Moderate, GCS 9 - 12
  • Minor, GCS ≥ 13.

wikipedia
READ MORE - Glasgow Coma Scale

Glasgow Coma Scale for Infants and Children

Area Assessed Infants Children
Score*






Eye opening

Open spontaneously Open spontaneously 4


Open in response to verbal stimuli Open in response to verbal stimuli 3


Open in response to pain only Open in response to pain only 2



No response No response 1










Verbal response

Coos and babbles Oriented, appropriate 5


Irritable cries Confused 4


Cries in response to pain Inappropriate words 3


Moans in response to pain Incomprehensible words or nonspecific sounds 2



No response No response 1










Motor response**

Moves spontaneously and purposefully Obeys commands 6


Withdraws to touch Localizes painful stimulus 5


Withdraws in response to pain Withdraws in response to pain 4



Responds to pain with decorticate posturing (abnormal flexion) Responds to pain with flexion 3



Responds to pain with decerebrate posturing (abnormal extension) Responds to pain with extension 2

No response No response 1

*Score:
12 suggests a severe head injury.
 8 suggests need for intubation and ventilation.
 6 suggests need for intracranial pressure monitoring.

**If the patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response. This section should be carefully evaluated.

Adapted from Davis RJ et al: Head and spinal cord injury. In Textbook of Pediatric Intensive Care, edited by MC Rogers. Baltimore, Williams & Wilkins, 1987; James H, Anas N, Perkin RM: Brain Insults in Infants and Children. New York, Grune & Stratton, 1985; and Morray JP et al: Coma scale for use in brain-injured children. Critical Care Medicine 12:1018, 1984.


Source : www.northeastcenter.com
READ MORE - Glasgow Coma Scale for Infants and Children

Nursing Diagnosis for Caesarean Section and Nursing Interventions for Caesarean Section

Nursing Diagnosis for Caesarean Section (Postoperative)
  1. Impaired sense of comfort : pain related to postoperative wound
  2. High risk of infection related to bleeding, postoperative wound

Nursing Interventions for Caesarean Section (Postoperative)
  1. Impaired sense of comfort : pain related to postoperative wound

    Goal :
    Pain is reduced / no pain

    Nursing Intervention :
    • Assess the condition of pain experienced by the client.
      R / Measurement of the level of pain can be performed with pain scales.
    • Tell the client suffered pain and its causes.
      R / Improving coping clients, in dealing with pain.
    • Teach relaxation techniques.
      R / Reduced perception of pain.
    • Collaboration of analgesics.
      R / Reduced pain can be done by giving oral or systemic analgesics, in a broad spectrum / specific.

  2. High risk of infection related to bleeding, postoperative wound

    Goal :
    There were no infections, bleeding and wounds, after surgery.

    Nursing Intervention :
    • Assess the condition of output / dischart out; number, color, and odor from the operation wound.
      R / recording the changes in output. The existence of a darker color with a bad smell may be a sign of infection.
    • Tell the client the importance of wound care during the postoperative period.
      R / Infection can arise from lack of cleanliness of the wound.
    • Have a general culture in the output.
      R / Various bacteria can be identified through the output.
    • Perform wound care.
      R / Incubation germs in the wound area can cause infection.
    • Tell the client how to identify signs of infection.
      R / Various clinical manifestations can be nonspecific sign of infection, fever and increased pain may be symptoms of infection.
READ MORE - Nursing Diagnosis for Caesarean Section and Nursing Interventions for Caesarean Section

Caesarean Section Postoperative Management

Cesarean Section

A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. In the United States, about one in four women have their babies this way. Most C-sections are done when unexpected problems happen during delivery. These include
  • Health problems in the mother
  • The position of the baby
  • Not enough room for the baby to go through the vagina
  • Signs of distress in the baby
C-sections are also more common among women carrying more than one baby.
The surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. After healing, the incision may leave a weak spot in the wall of the uterus. This could cause problems with an attempted vaginal birth later. However, more than half of women who have a C-section can give vaginal birth later.
Source : www.nlm.nih.gov


Caesarean Section Postoperative Management
  1. Incision wound care: clean with alcohol and betadin then closed with sterile gauze periodically, wound dressings changed and wounds cleaned, notice of how the extension of injury and time of suture removal.
  2. Postoperative care
    After surgery is completed, the patient was transferred into a special care room (Recovery Room) for a few days, when the state of postoperative patients with severe, immediately moved to the emergency care unit, after the state of the patient begins to recover to move into the room (where the patient initially treated)
  3. Fluid
    Because the first 24 hours, patients with post-operative fasting, then the provision of infusion should be quite a lot and contains electrolytes required to prevent hypertension, dehydration and complications.
  4. Diet
    Actually giving a little to drink is to be given at 6-10 hours post-surgery. After the fluid infusion was stopped given strain the puree food, drink juice and milk, then allowed to eat porridge, and finally ordinary food.
  5. Painful
    Since the patient aware of the first 24 hours, the pain is felt in the area of ​​operations, to reduce pain, can be given analgesic and sedative drugs.
  6. Mobilization
    Mobilization gradually immediately useful to help the course of healing, prevent the occurrence of thrombus and embolism. Leaning right and left to be done since 6-10 hours, after the second day the patient conscious, the patient can be mounted for 3 minutes and were asked to breathe deeply, then exhale with a small cough to loosen respiratory and foster patient confidence, then supine sleeping position transformed into semi-Fowler position.
  7. Catheterization
    To prevent irritation and wound contamination by urine, the bladder emptied by catheter.
  8. Giving medicines
    • Antibiotics chemotherapy, and anti-inflammatory
    • Preventive medicine for flatulence
  9. Skin care
    The things that must be considered in the examination and measurements were done every 4 hours :
    • Vital signs: blood pressure, pulse, respiratory rate
    • The amount of fluid in and out
    • Another examination by type and case
  10. Advice after surgery
    • It is advisable not to become pregnant for 2-3 years with the use of contraception
    • Subsequent pregnancies should be monitored with good antenatal
    • It is advisable to give birth in hospital
    • Explain that the next delivery can be spontaneous or surgical, depending on the indication of surgery and subsequent pregnancies.
READ MORE - Caesarean Section Postoperative Management

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