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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.

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Nursing Care Plan for 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


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

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Nursing Care Plan for 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.


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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