Search This Blog

Nursing Intervention for Myasthenia Gravis

Intervention and Implementation for Myasthenia Gravis

  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
READ MORE - Nursing Intervention for Myasthenia Gravis

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

  1. Clients can build a trusting relationship with nurses.


    • 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.


    • 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.


    • 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.


    • 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.


    • 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.


    • 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
READ MORE - Nursing Diagnosis and Nursing Intervention for Nephrolithiasis

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 :

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
READ MORE - Nursing Care Plan for Syphilis

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

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

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

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