Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Imbalanced Nutrition, Less Than Body Requirements related to anorexia and vomiting.

Imbalanced Nutrition, Less Than Body Requirements NANDA Definition: Intake of nutrients insufficient to meet metabolic needs.

Characteristics :

Loss of weight
Lack of interest in food
Pale conjunctiva and mucous membranes
Poor muscle tone
Amenorrhea
Poor skin turgor
Edema of extremities
Electrolyte imbalances
Weakness
Constipation
Anemias

Goals

Client will gain 2 pounds per week for the next 3 weeks.
Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; constipation will be corrected; client will exhibit increased energy in participation in activities).

Nursing Interventions Imbalanced Nutrition, Less Than Body Requirements for Peritonitis

Independent:

1. Monitor bow NG tube, and note the presence of vomiting or diarrhea.
Rational: The large number of gastric aspiration and vomiting or diarrhea is suspected bowel obstruction, requiring further evaluation.

2. Measure body weight each day.
Rationale: Loss of or increase in early showed further changes in hydration but loss is suspected nutritional deficit.

3. Auscultation bowel sounds, record sounds nothing or hyperactive.
Rationale: Although there is no frequent bowel sounds, bowel inflammation or irritation may accompany intestinal hyperactivity, decreased water absorption, and diarrhea.

4. Record the required calorie needs.
Rational: The calories (energy sources) will accelerate the healing process.

5. Monitor Hb and albumin
Rational: Indications adequate protein to the immune system.

6. Assess abdomen with frequent return to the gentle sound, the appearance of normal bowel sounds, flatus smooth dam.
Rationale: Indicates the return to normal bowel function.

Collaboration:

1. Collaborative installation NGT if the client can not eat and drink orally.
Rational: In order to keep the client nutrients are met.

2. Collaboration with a dietitian in your diet.
Rational: A healthy body is not easy for infection (inflammation).

3. Provide information about the food substances which are very important to balance the body's metabolism
Rationale: Clients can strive to meet the needs of eating nutritious food.

Risk for Infection Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Risk for Infection related to tissue trauma

Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

Goal: Reduce infections, improve patient comfort.

Expected outcomes:

Increased healing in time, free of purulent drainage or erythema, no fever.
Stated understanding of the causes of individual / risk factors.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.

Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

Nursing Care Plan for Mitral Stenosis

Mitral stenosis (MS) is a blockage of the mitral valve that causes constriction of blood flow to the ventricles. Patients with Mitral stenosis typically have mitral valve leaflets are thickened, komisura are fused, and the chordae tendineae are thickened and shortened. Transverse diameter of the heart are usually within normal limits, but calcification of the mitral valve and left atrial enlargement can be seen. Here is a picture of mitral valve stenosis.

Mitral stenosis causes a change in shape of heart and changes in blood vessels of the lungs according to severity of Mitral Stenosis and heart conditions. Convexity left border of the heart indicates that the prominent stenosis. In most cases there are two disorders that mitral stenosis and mitral insufficiency, generally one of them stand out. Also very dilated left ventricle when the mitral insufficiency involved are very significant. Classical radiological signs of patients with Mitral stenosis is a double contour (double contour) which leads to an enlarged left atrium, and the presence of septum lines are localized.

This condition makes the pulmonary venous pressure increases, causing diversion of blood, chest X-ray look at the relative dilation of blood vessels compared to the top of the pulmonary blood vessels below the lungs. Narrowing of the mitral valve causes the valve does not open properly and blocks the flow of blood between the left heart chambers. When the mitral valve narrowing (stenosis), blood can not efficiently pass through the heart. This condition causes a person to become weak and become short of breath and other symptoms.

Mitral stenosis, a valve disorder most often caused by rheumatic heart disease. It is estimated that 99% mitral stenosis based on rheumatic heart disease. However, approximately 30% of patients with mitral stenosis can not find any previous history of the disease.

In all valvular heart disease, mitral stenosis most commonly found, namely ± 40% of all rheumatic heart disease, and affects women more than men, with a ratio of approximately 4: 1.

Myxoma (benign tumor in the left atrium) or blood clots can block blood flow as it passes through the mitral valve and cause the same effect as mitral valve stenosis.

Nursing Assessment - Nursing Care Plan for Mitral Stenosis

Anamnesa

Demographic Data
- Name
- Age
- Gender
- Interest / nation
- Religion
- Education
- Works
- Address
Main Complaints: patients with mitral stenosis is usually complain of shortness, cyanosis and coughing.
History of Disease Now: The client is usually taken to hospital after shortness of breath, cyanosis or coughing is accompanied by high fever / no.
History of past illness: The client had suffered from rheumatic fever disease, SLE (Systemic Lupus Erithematosus), RA (Rhemautoid arthritis), myxoma (benign tumor in the left atrium).
Family History of Disease: there are no hereditary factors that influence the occurrence of mitral stenosis.

ROS (Review of Systems)

B1 (Breath): Shortness / increased respiration, low tones at the apex by using a bell on his side to the left, shortness of breath and fatigue, cough, orthopnea in venous congestion there.

B2 (Blood): an increase in the jugular vein, odema leg, in the form of atrial arrhythmia atrial fibrillation (rapid heart rate and irregular), hemoptysis, embolism and thrombus, strength weakened pulse, tachycardia, peripheral edema (started happening right heart failure), BJ 1 harsh systolic murmur, palpitations, hemoptysis, apical diastolic murmurs.

B3 (Brain): chest pain and abdominal

B4 (Bladder): excess fluid imbalance, oliguria

B5 (Bowel): Dysphagia, nausea, vomiting, no appetite B6 (Bone): weakness, sweating, rapid fatigue.

Psychosocial assessment

Shortness of breath affects the interaction
Activities limited
Fear of facing surgery
Stress due to disease condition with a poor prognosis

Nursing Diagnosis Nursing Care Plan for Mitral Stenosis

Nursing Care Plan for Mitral Stenosis

Nursing Diagnosis and Interventions for Mitral Stenosis

Nursing Care Plan for Diabetes Mellitus

Definition of Diabetes Mellitus

Diabetes mellitus is a heterogeneous group of disorders characterized by increased levels of glucose in the blood or hyperglycemia.

Diabetes Melllitus is a collection of symptoms that arise in a person caused by the presence of elevated levels of sugar (glucose) blood due to insulin deficiency both absolute and relative terms.

Signs and Symptoms of Diabetes Mellitus

A common complaint of patients with Diabetes Mellitus such as polyuria, polydipsia, polyphagia in Diabetes Mellitus is generally no. Instead the patient is often disturbing complaints from complications of chronic degenerative blood vessels and nerves. In Diabetes Mellitus elderly there are pathophysiological changes due to aging process, so that the clinical picture varies from asymptomatic cases to cases with extensive complications. A recurring complaint is the presence of impaired vision due to cataracts, tingling in the limbs and muscle weakness (peripheral neuropathy) and injuries to the legs which are difficult to recover with treatment prevalent.

According Supartondo, the symptoms caused by diabetes mellitus in the elderly are often found are:

Cataract
Glaucoma
Retinopathy
Itching around the body
Pruritus Vulvae
Bacterial infections of skin
Fungal infections in the skin
Dermatopati
Peripheral neuropathy
Visceral neuropathy
Amiotropi
Neurotrophic ulcer
Kidney disease
Peripheral vascular disease
Coronary disease
Cerebral vascular disease
Hypertension

Management of Diabetes Mellitus

The main goal of therapy of diabetes mellitus is trying to normalize the activity of insulin and blood glucose levels in an attempt to reduce vascular complications, and neuropathy. Therapeutic purposes in any type of diabetes is to achieve normal blood glucose levels.

There are 5 components in the management of diabetes:

Diet
Exercise
Monitoring
Therapy (if needed)
Education

Nursing Assessment of Diabetes Mellitus

1. Family Health History

Are there families who suffer from diseases such as client?

2. Patient Medical History and Previous Treatment

How long a client suffering from diabetes, how to handle, gets what type of insulin therapy, how to take her medicine whether regular or not, what is being done to address the client's illness.

3. Activity / Rest:

Tired, weak, difficult Moving / walking, muscle cramps, decreased muscle tone.

4. Circulation

Is there a history of hypertension, AMI, claudication, numbness, tingling in the extremities, foot ulcers are healing old, tachycardia, changes in blood pressure

5. Ego integrity

Stress, anxiety

6. Elimination

Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea

7. Food / fluid

Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, use of diuretics.

8. Neuro-sensory

Dizziness, headache, tingling, numbness in the muscle weakness, paresthesias, visual disturbances.

9. Pain / Leisure

Abdomen tense, pain (moderate / severe)

10. Breathing

Cough with / without purulent sputum (tergangung presence of infection / no)

11. Security

Dry skin, itching, skin ulcers.

Nursing Diagnosis for Diabetes Mellitus

Imbalanced Nutrition : Less Than Body Requirements
Deficient Fluid Volume
Impaired skin integrity
Risk for injury

Depression Nursing Diagnosis and Interventions

Risk for Violence: Self-Directed or Other-Directed

Nursing Interventions for Depression

The general objective: There was no violence for Self-Directed or Other-Directed
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
- 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.

Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions

Hypertension Nursing Assessment

Assessment is the main basis 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.

The data collected can be divided into two (Kelliat, Budi Ana., 1995) :

Data base
Specific data relating to the current situation of the client which can be determined by the nurse, client or family.

The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).

Hypertension Nursing Diagnosis

Risk for Decreased Cardiac Output related to Increased afterload, vasoconstriction and myocardial ischemia.
Acute pain related to increased cerebral vascular pressure.

Hypertension Nursing Intervention

Nursing Diagnosis :

Risk for Ineffective Tissue Perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary related to impaired circulation

Nursing Intervention for Hypertension

Maintain bed rest, elevate head of bed

Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if available

Maintain fluid and drugs.

Observe the sudden hypotension.

Measure inputs and expenditures

Monitor electrolytes, BUN, creatinine.

Ambulation according to ability; avoid fatigue

Risk for Decreased Cardiac Output related to Hypertension

Nursing Care Plan for Hypertension in Pregnancy

Ineffective Breathing Pattern NIC NOC

Nursing Diagnosis for Ineffective Breathing Pattern

Definition: The exchange of air inspiration and / or expiration inadequate.

Ineffective breathing pattern related to

Hyperventilation
Hypoventilation syndrome
Damage muskuloskletal
Neuromuscular Dysfunction
Fatigue muscles of respiration

Data:

Changes in chest movement
Bradipnea, tachypnea
Decrease in inspiratory and expiratory pressures
Breath nostril
The use of auxiliary respiratory muscles
Increased vital signs

Nursing Interventions for Ineffective Breathing Pattern
a. Airway Management:

Open the airway with headtilt, chinlift, jaw thrust
Set the position to maximize ventilation
Use tools airway
Perform chest physiotherapy
Teach breath deeply and cough effectively
Auscultation of breath sounds
Give bronchodilators (Collaboration)

b. Oxygen therapy

Provide humidification system of oxygen equipment
Monitor the flow of oxygen and the amount given
Monitor signs of oxygen toxicity

c. Monitoring of respiration

Monitor the frequency, rhythm and depth of breathing
Monitor the use of auxiliary respiratory muscles

d. Monitoring of vital signs

Monitor blood pressure, pulse, respiratory rate, temperature
Monitor blood pressure during sleep, sit, stand up if indicated
Monitor signs and symptoms of hypothermia or hyperthermia
Monitor rhythm and breath sounds

Ineffective Breathing Pattern related to Cardiac Tamponade

Ineffective Airway Clearance NIC NOC

Ineffective Airway Clearance

Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

Ineffective airway clearance related to

The accumulation of secretions
Airway spasm

Data:

Cough
Discharge
Dyspneu
Cyanosis
Respiratory rate increased
Ronkhi
Wheezing

a. Airway Management:

Open the airway with headtilt, chinlift, jaw thrust
Set the position to maximize ventilation
Use tools airway
Perform chest physiotherapy
Teach breath deeply and cough effectively
Perform suction
Auscultation of breath sounds
Give bronchodilators (Collaboration)

b. Oxygenation therapy

Provide humidification system of oxygen equipment
Monitor the flow of oxygen and the amount given
Monitor signs of oxygen toxicity

Urinary Retention

Urinary retention is the inability to empty the bladder. With chronic urinary retention, you may be able to urinate, but you have trouble starting a stream or emptying your bladder completely. You may urinate frequently; you may feel an urgent need to urinate but have little success when you get to the toilet; or you may feel you still have to go after you've finished urinating. With acute urinary retention, you can't urinate at all, even though you have a full bladder. Acute urinary retention is a medical emergency requiring prompt action. Chronic urinary retention may not seem life threatening, but it can lead to serious problems and should also receive attention from a health professional.

Male and female urinary tracts.
Anyone can experience urinary retention, but it is most common in men in their fifties and sixties because of prostate enlargement. A woman may experience urinary retention if her bladder sags or moves out of the normal position, a condition called cystocele. The bladder can also sag or be pulled out of position by a sagging of the lower part of the colon, a condition called rectocele. Some people have urinary retention from rectoceles. People of all ages and both sexes can have nerve disease or nerve damage that interferes with bladder function.
Source : http://kidney.niddk.nih.gov/kudiseases/pubs/UrinaryRetention/

NURSING DIAGNOSIS: Urinary retention

Related to:

stasis of urine in the kidney and bladder associated with prolonged horizontal positioning;
difficulty urinating associated with anxiety regarding use of bedpan or urinal;
incomplete bladder emptying associated with:
- horizontal positioning (the gravity needed for complete bladder emptying is lost)
- decreased bladder muscle tone resulting from the generalized loss of muscle tone that occurs with prolonged immobility.

Desired Outcome
The client will not experience urinary retention as evidenced by:

voiding at normal intervals
no reports of bladder fullness and suprapubic discomfort
absence of bladder distention and dribbling of urine
balanced intake and output.

Constipation

Constipation means different things to different people. For many people, it simply means infrequent stools. For others, however, constipation means hard stools, difficulty passing stools (straining), or a sense of incomplete emptying after a bowel movement. The cause of each of these "types" of constipation probably is different, and the approach to each should be tailored to the specific type of constipation.

Constipation also can alternate with diarrhea. This pattern commonly occurs as part of the irritable bowel syndrome (IBS). At the extreme end of the constipation spectrum is fecal impaction, a condition in which stool hardens in the rectum and prevents the passage of any stool.

The number of bowel movements generally decreases with age. Ninety-five percent of adults have bowel movements between three and 21 times per week, and this would be considered normal. The most common pattern is one bowel movement a day, but this pattern is seen in less than 50% of people. Moreover, most people are irregular and do not have bowel movements every day or the same number of bowel movements each day.

Medically speaking, constipation usually is defined as fewer than three bowel movements per week. Severe constipation is defined as less than one bowel movement per week. There is no medical reason to have a bowel movement every day. Going without a bowel movement for two or three days does not cause physical discomfort, only mental distress for some people. Contrary to popular belief, there is no evidence that "toxins" accumulate when bowel movements are infrequent or that constipation leads to cancer.

It is important to distinguish acute (recent onset) constipation from chronic (long duration) constipation. Acute constipation requires urgent assessment because a serious medical illness may be the underlying cause (for example, tumors of the colon). Constipation also requires an immediate assessment if it is accompanied by worrisome symptoms such as rectal bleeding, abdominal pain and cramps, nausea and vomiting, and involuntary loss of weight. In contrast, the evaluation of chronic constipation may not be urgent, particularly if simple measures bring relief.

Sample of Nursing Care Plan

Nursing care plan

A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Characteristics of the nursing care plan

Its focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.
It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
It focuses on client-specific nursing outcomes that are realistic for the care recipient
It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.
It is a product of a deliberate systematic process.
It relates to the future.

Elements of the nursing care plan

The nursing care plan consists of a nursing diagnosis with defining characteristics (subjective and objective data that support the diagnosis), related factors or risk factors, expected outcomes/goals, and nursing interventions.

from : http://en.wikipedia.org/wiki/Nursing_care_plan

Sample of Nursing Care Plan

Click Here

Schizophrenia Care Plan - Nursing Assessment, Diagnosis, Interventions and Implementation

Schizophrenia Care Plan - Nursing Assessment

1. History. Review the history of the client to the originator stressors and significant data.
Biological-genetic vulnerability (family history)
Stressful life events
The results of the mental status examination
Psychiatric history and medication adherence in the past
History of treatment
The use of drugs and alcohol
Pendidkkan and employment history

2. Assess the client for the presence of characteristic symptoms

3. Assess the support system of family and community
Current living arrangements and level of supervision
The involvement and support of family
Case manager or therapist
Participation in community treatment programs

4. Assess the knowledge base of clients and families. Assess whether the client and his family have enough knowledge about:
schizophrenia disorders
Medication and treatment recommendations
Signs of recurrence
Measures to reduce stress

5. Assess the client for any side effects of antipsychotic medications
Pyramidal system effects (extrapyramidal system; ESE,). Use of certain tools, such as the AIMS scale or neurological Simpson scale, to perform the assessment.
Aphek anticholinergic
cardiovascular effects

Schizophrenia Care Plan - Nursing Diagnosis

1. Analysis of positive and negative symptoms

2. Analysis of strengths and weaknesses of clients, including:
Self-care ability
socialization
communication
reality-testing
job skills
support system

3. Analysis of factors that increase the risk of behavioral expression of the unconscious, including:
agitation
angry
suspicious
The existence of hallucinations that threaten

4. Establish and prioritize nursing diagnoses for clients and their families.
Low self esteem, chronic
Ineffective family coping: worsening
Impaired home maintenance management
Ineffective individual coping
Lack of knowledge (please specify)
Ineffective management of therapeutic progarm: family
Ineffective management of therapeutic progarm: Individual
noncompliance
Changes in role performance
Less self-care (specify)
Changes in sensory / perception: visual, auditory, kinesthetic, taste, touch, smell (please specify)
Changes in the process of thinking
The risk of violence to self / others

Schizophrenia Care Plan - Nursing Interventions

1. Set realistic goals with clients.
2. Specify the desired outcomes for clients with schizophrenia disorder.
3. Set criteria desired outcomes for families that have family members with schizophrenia.

Schizophrenia Nursing Interventions

Schizophrenia Care Plan - Nursing Assessment, Diagnosis, Interventions and Implementation

Family Counseling In Schizophrenia Patients

Nursing Diagnosis and Interventions Impaired Verbal Communication for Schizophrenia

Family Counseling In Schizophrenia Patients

Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.3–0.7%. Diagnosis is based on observed behavior and the patient's reported experiences.

Symptoms

A person diagnosed with schizophrenia may experience hallucinations (most reported are hearing voices), delusions (often bizarre or persecutory in nature), and disorganized thinking and speech. The latter may range from loss of train of thought, to sentences only loosely connected in meaning, to incoherence known as word salad in severe cases. Social withdrawal, sloppiness of dress and hygiene, and loss of motivation and judgment are all common in schizophrenia. There is often an observable pattern of emotional difficulty, for example lack of responsiveness. Impairment in social cognition is associated with schizophrenia, as are symptoms of paranoia; social isolation commonly occurs. In one uncommon subtype, the person may be largely mute, remain motionless in bizarre postures, or exhibit purposeless agitation, all signs of catatonia.

Late adolescence and early adulthood are peak periods for the onset of schizophrenia, critical years in a young adult's social and vocational development. In 40% of men and 23% of women diagnosed with schizophrenia the condition manifested itself before the age of 19. To minimize the developmental disruption associated with schizophrenia, much work has recently been done to identify and treat the prodromal (pre-onset) phase of the illness, which has been detected up to 30 months before the onset of symptoms. Those who go on to develop schizophrenia may experience transient or self-limiting psychotic symptoms and the non-specific symptoms of social withdrawal, irritability, dysphoria, and clumsiness during the prodromal phase.

Family Counseling In Schizophrenia Patients

1. Teach families about schizophrenia

Schizophrenia is a brain disorder that affects all aspects of the functional. No single cause has been determined, but research suggests that the cause, including genetics, brain structure and chemistry changes, and various factors related to stress.

The symptoms may include hearing voices (hallucinations), mistaken beliefs (delusions), communicating in ways that are difficult to understand, as well as occupational and social function badly.

The symptoms may improve, but may also recur continue for life.

2. Teach the family about

Antipsychotic drugs are used; important for clients to take it as prescribed.

Many side effects occur and can be overcome if reported immediately to healthcare providers. (Provide specific information regarding the client's medication).

Follow up treatment with a therapist or care manager is very important.

3. Teach families about ways to overcome the symptoms of the client

Identify the events that typically disappointing clients and provide extra help as needed.

Note when the client became angry and do the actions to reduce anxiety.

Measures to reduce anxiety include rest, relaxation techniques, a balance between rest and activity, and proper diet.

Write down the symptoms that indicated the client when he was sick, and when this happens encourage clients to contact a health care provider (if he refuses, you should contact your own health care providers).

Client does not approve the statement of hallucinations or delusions; let me know about reality, but do not argue with the client.

Additional Information:
Teach families about self-care
Encourage families to talk about their feelings and concerns with health care providers.

Encourage families to want to consider joining a support group or community assistance.

Nursing Care Plan - Assessment, Diagnosis and Interventions for Acute Myocardial Infarction

Acute Myocardial Infarction (AMI)

Acute Myocardial Infarction (AMI) is a sudden loss of blood supply to an area of the heart, causing permanent heart damage or death. There are different types of AMI, classified by the location of the actual event in the heart (e.g., inferior wall vs. anterior wall) or the type of changes seen on an electrocardiogram (ST elevation or non-ST elevation).

Every year, several million people in North America are diagnosed with an AMI, and approximately one-third of these patients die during the acute phase. Health Canada has identified cardiovascular disease or heart diseases as the number one killer in Canada. It is also the most costly disease in Canada, putting the greatest burden on our national healthcare system.

Clinical Manifestations of Myocardial Infarction

Pain

Chest pain that occurs suddenly and constantly not subside, usually above the sternal region and upper abdomen, this is the main symptom.
The severity of pain can increase settled until unbearable pain.
Pain is very ill, such as punctured-pin that can spread to the shoulder and continued down to the arm (usually the left arm).
The pain started spontaneously (not occur after activity or emotional disturbance), persist for several hours or days, and do not disappear with the help of rest or nitroglycerin (NTG).
Pain may spread to the jaw and neck.
Pain is often accompanied by shortness of breath, pale, cold, severe diaphoresis, dizziness or head was floating, and nausea and vomiting.
Patients with diabetes mellitus will not experience severe pain because of neuropathy that accompany diabetes can interfere neuroreseptor (collect the experience of pain).

Laboratory examination Examination of cardiac enzymes :

CPK-MB/CPK
Isoenzymes found in heart muscle increased by between 4-6 hours, peaks in 12-24 hours, returned to normal within 36-48 hours.
LDH / HBDH
Increases in the 12-24 hour time-consuming dams to return to normal
AST
Increases (less real / special) occurred within 6-12 hours, culminating in 24 hours, returning to normal within 3 or 4 days

ECG ECG changes that occur in the early phase of T wave height and symmetrical. After this there is ST segment elevation. Changes that occur later are the presence of a wave of Q / QS which indicate the presence of necrosis.

Pain scores according to White:

= Do not experience pain
= Pain on one side without disturbing activities
= More pain at one place and resulted in disruption of activities, such as difficulty getting out of bed, hard to bend the head and others.

Primary Assessment for Acute Myocardial Infarction Nursing Care Plan (AMI) :

Airways

Blockage or accumulation of secretions
Wheezing or crackles

Breathing

Shortness of breath with mild activity or rest
Respiration more than 24 x / min, irregular rhythm shallow
Ronchi, crackles
The expansion of the chest is not full
Use of auxiliary respiratory muscles

Circulation

Weak pulse, irregular
Tachycardia
Blood pressure increase / decrease
Edema
Nervous
Acral cold
Pale skin, cyanosis
Decreased urine output

Secondary Assessment Acute Myocardial Infarction (AMI) :

Activities
- Symptoms:
  - Weakness
  - Fatigue
  - Can not sleep
  - Settled lifestyle
  - No regular exercise schedule
- Signs:
  - Tachycardia
  - Dyspnea at rest or activity
Circulation
- Symptoms:
  - History of Acute Myocardial Infarction (AMI)
  - Coronary artery disease
  - Blood pressure problems
  - Diabetes mellitus.
- Signs:
  - Blood pressure: normal / up / down. Postural changes recorded from the bed to sit or stand
  - Pulse: normal, full or not strong or weak / strong quality with slow capillary filling, irregular (dysrhythmias)
  - Heart sound: an extra heart sound: S3 or S4 may indicate heart failure or decreased contractility / complaints ventricle
  - Murmur: If there are shows valve failure or dysfunction of heart muscle
  - Friction: suspected pericarditis
  - Heart rhythm can be regular or irregular
  - Edema: juguler venous distention, edema dependent, peripheral, general edema, cracles may exist with heart failure or ventricular
  - Color: Pale or cyanotic, flat nail, on mucous membranes or lips
Ego integrity
- Symptoms: an important symptom or deny the existence of conditions of fear of dying, feeling the end is near, angry at the disease or treatment, worry about finances, work, family
- Signs: turned, denial, anxiety, lack of eye contact, anxiety, anger, aggression, coma pain
Elimination
- Signs: normal, decreased bowel sounds.
Food or fluid
- Symptoms: nausea, anorexia, belching, heartburn, or burning
- Signs: decreased skin turgor, dry skin, sweating, vomiting, weight changes
Hygiene
- Symptoms or signs: difficulty perform maintenance tasks
Neuro Sensory
- Symptoms: dizziness, throbbing during sleep or while awake (sitting or resting)
- Signs: mental changes, weakness
Pain or discomfort
- Symptoms:
  - Sudden onset of chest pain (may or may not relate to activities), not relieved by rest or nitroglycerin (although most deep and visceral pain)
  - Location: Typical on the anterior chest, Substernal, precordial, can spread to the hands, jaw, face. No specific location such as epigastric, elbow, jaw, abdomen, back, neck.
  - Quality: "Crushing", narrow, heavy, settle down, depressed, as can be seen.
  - Intensity: Usually 10 (on a scale of 1-10), may experience the worst pain ever experienced.
  - Note: there may be no pain in postoperative patients, diabetes mellitus, hypertension, elderly
Respiratory:
- Symptoms:
  - Dyspnea with or without job
  - Nocturnal dyspnea
  - Cough with or without sputum production
  - History of smoking, chronic respiratory disease.
- Signs:
  - Increased respiratory rate
  - Shortness of breath / strong
  - Pallor, cyanosis
  - Breath sounds (clean, cracles, wheezing), sputum
Social interactions
- Symptoms:
  - Stress
  - Difficulty coping with the stressors that exist eg illness, treatment in hospital
- Signs:
  - Difficulty rest - sleep
  - Response too emotional (angry constantly, fear)
  - Withdraw

Nursing Diagnosis for Acute Myocardial Infarction (AMI)

Acute Pain
Decreased Cardiac Output
Activity Intolerance
Imbalanced Nutrition: Less than Body Requirements
Ineffective Tissue Perfusion
Anxiety
Ineffective Coping
Ineffective Sexuality Patterns

Emergency Nursing Care Plan For Chest Pain - Heart Attack

Chest pain and heart attack

Chest discomfort or pain is a key warning symptom of a heart attack. Heart attack symptoms include:

Chest pain or pressure, or a strange feeling in the chest.
Sweating.
Shortness of breath.
Nausea or vomiting.
Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or Both shoulders or arms.
Sudden weakness or lightheadedness.
A fast or irregular heartbeat.

Most people fear That chest pain always means something is wrong with the heart. This is not the case. Chest discomfort or pain, ESPECIALLY in People who are younger than age 40, can have many Causes.

Pain in the muscles or bones of the chest Often Occurs When You increase of your activities or add exercise to your schedule. This is Sometimes Called chest wall pain.
Burning chest pain, That Occurs When You cough may be Caused by an upper respiratory infection Caused by a virus.
Burning chest or rib pain, ESPECIALLY Appears just before a rash, may be Caused by shingles.
A broken rib can be quite painful, ESPECIALLY Pls you cough or try to take a deep breath.
Gastroesophageal reflux disease (GERD) can cause pain just below the breastbone. Many people say Will They have "heartburn." This pain is usually relieved by taking an antacid or eating.

Other, more serious problems That can cause chest pain include:

A collapsed lung (pneumothorax), the which usually Causes a sharp, stabbing chest pain and shortness of breath Occurs with.
A blood clot in the lung (pulmonary embolism), the which usually Causes deep chest pain with the rapid development of extreme shortness of breath.
Lung cancer, the which may cause chest pain, ESPECIALLY if the cancer cells spread to involve the ribs.
Diseases of the spine, the which can cause chest pain if the nervous in the spine are "pinched."

http://www.webmd.com/heart-disease/tc/chest-pain-topic-overview

Emergency Nursing Care Plan For Chest Pain - Heart Attack

Nursing Assessment For Chest Pain - Heart Attack

1. Primary Assessment
a. Airway
- How airway clearance?
- Is there a blockage / buildup of secretions in the airway?
- How is the sound of his breathing, is there any additional breath sounds?

b. Breathing
- How does the pattern of breathing? Frequency? The depth and rhythm?
- Does using a respirator muscles?
- Are there any additional breath sounds?

c. Circulation
- What about the peripheral arteries and carotid arteries? The quality (content and voltage)
- How capillary refill, cyanosis or oliguria?
- Is there a decrease in consciousness?
- How vital signs?

Secondary Assessment
The important points that need further examination during chest pain (coronary):
a. Location of pain
Where to start, propagation (coronary chest pain: from sternal spread to the neck, chin or shoulder to the left arm of the ulna)
b. Nature of pain
Feeling of fullness, heaviness such as seizures, squeezing, stabbing, choking / burning, etc..
c. Characteristics of pain
The degree of pain, duration, how many times arise in a certain period.
d. Chronology of pain
Beginning there is pain and progress sequentially
e. The situation at the time of attack
Whether arising at times / specific conditions
f. Factors that reinforce / relieve pain such as attitude / posture, movement, pressure, etc..
g. Other symptoms that may exist whether or not a relationship with chest pain.

Nursing Diagnosis For Chest Pain - Heart Attack

1. Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation
2. Ineffective Tissue Perfusion (heart muscle) related to decreased blood flow
3. Activity intolerance related to imbalance between oxygen supply and metabolic needs of the network

Nursing Intervention For Chest Pain - Heart Attack

The principles of action:
1. Bed rest with Fowler position / semi-Fowler
2. Perform 12 lead ECG, if necessary, 24 leads
3. Observation of vital signs
4. Collaboration: oxygen delivery and administration of drugs according to advice
5. Install a drip and give peace to the client
6. Taking blood samples
7. Reduce environmental stimuli
8. Be calm in the works
9. Observing signs of complications

Nursing Care Plan (NCP) for Cataract

A cataract is a clouding of the lens in your eye. It affects your vision. Cataracts are very common in older people. By age 80, more than half of all people in the United States either have a cataract or have had cataract surgery.

Common symptoms are

* Blurry vision
* Colors that seem faded
* Glare
* Not being able to see well at night
* Double vision
* Frequent prescription changes in your eye wear

Cataracts usually develop slowly. New glasses, brighter lighting, anti-glare sunglasses or magnifying lenses can help at first. Surgery is also an option. It involves removing the cloudy lens and replacing it with an artificial lens. Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay cataracts.

NIH: National Eye Institute
nlm.nih.gov

Nursing Care Plan (NCP) for Cataract

Nursing Diagnosis for Cataract

Preoperatively:
Anxiety related to lack of knowledge of cataract surgery procedures

Intraoperative:
Acute pain related to surgery

Postoperative:
Risk for infection related to inflammation of postoperative wound

Nursing Outcome and Interventions Nursing Care Plan (NCP) for Cataract

Anxiety decreased after nursing actions, with expected outcomes:
1. the patient calm and relaxed
2. can reveal the cause of anxiety
3. patients were able to control anxiety
4. patients may explain the action operations

Interventions:
1. examine the patient's anxiety level, measuring vital signs
2. give patients the information needed prior to surgery
3. provide mental relaxation techniques as well as suport involving elements of religious
4. give patients the opportunity to express his feelings before surgery

Acute pain decreased after nursing actions, with expected outcomes:
1. patients expressed reduced pain
2. the patient's face looked relaxed

Interventions:

1. recommended for, uses management techniques of relaxation, visualization, and breathing in

Infections do not occur during nursing actions

Interventions:

1. Discuss the importance of washing hands before touching or treating the eye
2. Show the proper techniques to clean the eye from the inside out with a wet tissue / cotton ball for each swabs, bandages and anti-insert contact lenses when using
3. Emphasize not to touch or scratch the operated eye
4. Observation / discuss examples of signs of infection redness, eyelid swelling, purulent drainage.

Nursing Care Plan Tonsillectomy

Tonsillectomy

Tonsillectomy is surgery to remove the tonsils. These glands are at the back of your throat. Often, tonsillectomy is done at the same time as adenoidectomy, surgery to remove the adenoid glands.

Etiology of Tonsillectomy

The cause of tonsillitis is viral and bekteri, mostly caused by a virus which is also a predisposing factor of bacterial infection.

Virus Type:

Adenovirus
Virus echo
The influenza virus

Bacteria Type:

Streptococcus
Mycrococcus
Corine bacterium diphterial

The degree of tonsillar enlargement:
a. Grade I (Normal)
Tonsils are behind tonsil pillars (soft structure, cut by the soft palatine).
b. Grade II
Tonsils are among the pillars and uvula.
c. Grade III
Touching tonsils uvula.
d. Grade IV
One or two tonsil extends ketengah uvofaring.

Nursing Assessment of Tonsillectomy

Assess difficulty swallowing, easy to choke.
Assess sore throat acute / chronic.
Assess the history of sore throats and influenza.
Assess allergy history.
Assess the bleeding by mouth.
Assess the presence of asthma, cystic fibrosis.

Nanda Nursing Diagnoses for Tonsillectomy

1. Risk for infection related to the factors of surgery

2. Acute Pain related to surgical operations

3. Fluid Volume Deficit related to decreased fluid intake secondary to pain on swallowing

4. Imbalanced Nutrition Less Than Body Requirements related to reduced input secondary to pain on swallowing

5. Risks to the ineffectiveness of therapeutic management related to inadequate knowledge about the complications, pain, positioning and management activities.
http://nandanursingdiagnoses.blogspot.com/

Interventions Nursing Care Plan Tonsillectomy

Risk for infection related to the factors of surgery

Objectives:
- There is no infection.
- There were no complications.
Intervention:
- Monitor temperature every 4 hours, the state of injury when performing maintenance.
- Give an antibiotic is prescribed, give at least 2 liters of fluid every day while implementing antibiotic therapy.
- Give antipyretics are prescribed if there is fever.

Pain related to surgical operations

Objectives:
- The client states lost pain / controlled.
- The client indicates to relax, rest / sleep and increased activity appropriately.Iintervention:
- Monitor vital signs
- Provide comfort measures, eg changes in position, music, relaxation.
- If prescribed analgesics, analgesics are routinely set during the first 24 hours, not waiting for patients to ask for it.
- Tell your doctor if analgesics can not eliminate the pain.

Tuberculosis (TB) Nursing Diagnosis, Interventions, Implementation and Evaluation

Tuberculosis (TB) is an infectious disease caused by bacteria whose scientific name is Mycobacterium tuberculosis. It was first isolated in 1882 by a German physician named Robert Koch who received the Nobel Prize for this discovery. TB most commonly affects the lungs but also can involve almost any organ of the body. Many years ago, this disease was referred to as "consumption" because without effective treatment, these patients often would waste away. Today, of course, tuberculosis usually can be treated successfully with antibiotics.

There is also a group of organisms referred to as atypical tuberculosis. These involve other types of bacteria that are in the Mycobacterium family. Often, these organisms do not cause disease and are referred to as "colonizers" because they simply live alongside other bacteria in our bodies without causing damage. At times, these bacteria can cause an infection that is sometimes clinically like typical tuberculosis. When these atypical mycobacteria cause infection, they are often very difficult to cure. Often, drug therapy for these organisms must be administered for one and a half to two years and requires multiple medic
ations.
http://www.medicinenet.com/tuberculosis/article.htm

Nursing Diagnosis and Interventions for Tuberculosis (TB)

1. Ineffective airway clearance related to increased production of secretions.

Plan objectives: to maintain patient airway, remove secretions without assistance, indicating the behavior to maintain / improve airway clearance.

Plan of action:
1) Assess respiratory function, eg, breath sounds, rhythms speed, depth and accessory muscle use.
Rational: the Ronchi, wheezing may indicate the accumulation of secretions / inability to clean Yuang airway can lead to the use of accessory respiratory muscles and increased work of breathing.

2) Record the ability to remove mucous or coughing effectively, record the character, amount of sputum, presence of hemoptysis.
Rational: spending will be difficult if the secretions are very thick, the sputum or coughing up blood caused by lung damage or brokeal requiring the evaluation / further intervention.

3) Give high semifowler position, help the patient to cough and deep breathing exercises.
Rational: breath in will increase lung expansion and reduce the effort and helps remove respiratory secretions.

4) Clean the mouth and trachea of secretions as indicated.
Rationale: prevent obstruction / aspiration.

5) Maintain the entry of fluid at least 2500 cc / day unless contraindicated.
Rational: help thin secretions.

6) Give the medication as indicated

Nursing Care Plan - Implementation
1. Increase / maintain adequate ventilation or oxygenation.
2. Preventing the spread of infection.
3. Behavioral supports to maintain health.
4. Enhance effective coping strategies.
5. Provides information about the disease process, prognosis and treatment needs.

Nursing Care Plan - Evaluation
1. Respiratory function is adequate to meet individual needs.
2. Complications prevented.
3. Lifestyle changes to prevent the spread of infection.
4. Disease process or prognosis and treatment programs is understood.

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Nursing Care Plan for Neonatal Hypoglycemia

Neonatal hypoglycemia

Neonatal hypoglycemia is low blood sugar (glucose) in the first few days after birth.

Symptoms of Neonatal Hypoglycemia

Infants with hypoglycemia may not have symptoms. If they do occur, symptoms may include:

Bluish-colored skin (cyanosis)
Breathing problems
Decreased muscle tone (hypotonia)
Grunting
Irritability
Listlessness
Nausea, vomiting
Pale skin
Pauses in breathing (apnea)
Poor feeding
Rapid breathing
Problems with maintaining body heat
Shakiness
Sweating
Tremors
Seizures

Treatment of Neonatal Hypoglycemia

Infants with hypoglycemia may need to receive:

Feeding with breast milk or formula within the first few hours after birth, either by mouth or through a tube inserted through the nose into the stomach (nasogastric lavage)
A sugar solution through a vein (intravenously) if the baby is unable to feed by mouth, or if the blood sugar is very low

Treatment normally continues for a few hours or days to a week.

If the low blood sugar continues, the baby may also receive medication to increase blood glucose levels (diazoxide) or to reduce insulin production (ocreotide).

In rare cases, newborns with very severe hypoglycemia who don’t improve with treatment may need surgery to remove part of the pancreas (to reduce insulin production).

Installation and Catheter Care

Installation and Catheter Care

A PRE-INTERACTION PHASE
- Assess patient and check the medical plan
- Define the procedure with a catheter directly or settle
- Determine the type and size of catheter
- Prepare the tool:
• Foley catheter
• Urine Bag
• Disposable Gloves
• sterile gloves
• Kom small, containing a liquid antiseptic
• Jelly
• Spuit 10cc
• Plaster
• Crooked
• Scissors bandage / plaster
• Sterile Tweezers
• Perlak
• perforated Duk
• Cotton sublimate

ORIENTATION PHASE

• Identification of patients
• Explain procedure and purpose of the act of catheterization

PHASES OF WORK

1 Put the cover
2 Put your tools to near patient
3 Set the lamp or torch
4 Adjust the position of
a child patient or the patient is unconscious with the help
b Female patients with a dorsal recumbent position
c Patients with a supine male

PHASES OF WORK

a Washing hands
b Wear disposable gloves
c Opening under clothing
d Attach waterproof below the buttocks
e Juxtapose bent close to the buttocks
f Put down a hole
g Clean the urethral meatus

CLIENTS IN WOMEN
a Use the dominant hand is not to open the labia majora with the thumb of the index finger.
b Then clean the meatus with an antiseptic fluid using tweezers from the top down, dilanjutkandengan labia minora and majora area further.

CLIENTS IN MEN
a Hold the penis by hand is not dominant
b Clean the meatus with an antiseptic liquid using the dominant hand using tweezers.
- Clean the meatus with a circular motion from the inside out
- When you clean the gland penis Peril proceed from top to bottom.

h Remove the disposable gloves
i Hold the tool with clients
j Open sets and keep the area sterile catheter in the catheter
k If the drainage is still a separate part, open and connect to the catheter
l Wear sterile gloves
m Connect the catheter;
CLIENTS FOR WOMEN
- Still using the hand that is dominant, go back to the labia majora to find the urethral meatus
- With the dominant hand, put the catheter in the urethral meatus -7.5 ± 5 cm or until the urine out.
CLIENTS FOR MEN
- Enforce the penis with the 90o position, insert the catheter with dominant hand ± 17.5 - 20 cm or until the urine out.

n If using a permanent catheter, insert aquabidest ± 20cc
o fixation catheter into the patient
- For men under the abdomen
- For women dipah or loose on the leg without fixation
p Fixation urine bag on the bed
q Adjust the position of the patient as comfortable as possible
r Wash hands

C PHASE TERMINATION
Evaluation by using the following criteria:
- Catheter fixed, drainage lancer or catheter directly into and release tanpaketidaknyamanan
- Patients feel comfortable
- Termination

D Documentation
1 Date and time
2 Type and size of catheter
3 Is specimen was filled
4 Number of urine
5 Description of urine
6 The response of patients to the procedure.

Hyperthermia Care Plan for Nurses

Hyperthermia

DEFINITIONS:

Circumstances where an individual experiencing an increase in body temperature above peroral C 37.80 / 38.80 C per-rectal due to external factors (Carpenito, 1995)

PURPOSE:

Addressing the problem of increase in body temperature to prevent the lack of fluids or other complications due to hyperthermia.

CRITERIA:

Temperature 36 to 37.5 C, no complaints of fever, chills no, elastic skin turgor, vital signs within normal range (blood pressure, pulse, CVP and JVP)

NURSING DIAGNOSIS :

Deficient fluid volume
Altered Body Temperature
Hyperthermia

NURSING ACTION - Care Plan for Hyperthermia:

Monitor body temperature
Monitor blood pressure, respiratory frequency, and pulse
Monitor intake and output every 8 hours
Encourage much to drink when there is no contraindication
Maintain adequate ventilation in the room
Give a warm compress
Use clothing that is thin and absorbs perspiration
Encourage clients to total bedrest
Monitor client's hydration status

HEALTH EDUCATION:

Teach how to properly compress
Explain the importance of fluid to maintain normal body temperature

Act of collaboration:

Maintain intravenous fluids according to program
Give antipyretics according to program
Give therapy, for the cause of fever according to program

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Ineffective Breathing Pattern Care Plan

Ineffective breathing pattern

DEFINITIONS:

Inspiration and / or expiration that does not provide adequate ventilation

PURPOSE:

Addressing the problem of ineffective breathing pattern

CRITERIA:

There was no increased work of breathing
There is no use of accessory muscles / retractions and asymmetrical chest expansion
No dyspnoea and cyanosis
Blood Gas Analysis within normal limits
Vital signs within normal limits
No additional breath sounds

NURSING DIAGNOSIS INEFFECTIVE BREATHING PATTERN CARE PLAN :

Ineffective breathing pattern related to

Fatigue, changes in the ratio of O2 and CO2
Anxiety, hyperventilation, hypoventilation syndrome
Pain
Bone deformities, spinal cord injury
Neuromuscular dysfunction
Obesity

NURSING INTERVENTIONS INEFFECTIVE BREATHING PATTERN CARE PLAN

Review the causes of respiratory failure
Observations of breathing patterns
Auscultation of lung sounds periodically, note the quality of breath sounds, wheezing, expiratory lengthening and observation symmetry chest movement
Determine the location and extent of crackles in the sternum
Ensure breathing in tune with vgentilator and no resistance (Fighting)
Attach and fill the balloon with the proper ETT fixation
Have resuscitation equipment close to the client, perform manual ventilation if necessary