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

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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.

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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.

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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).

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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.

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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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