Showing posts with label Nursing Care Plan. Show all posts

Nursing Care Plan for Hyphema : Acute Pain

Hyphema or blood in the anterior chamber can occur due to blunt trauma (Sidarta, 1998). When the patient is sitting, hyphema will be seen to collect in the bottom of the anterior chamber and hyphema can occupy the entire space anterior chamber. Blood in the aqueous humor fluid can form a layer that is visible. This type of injury does not have to lead to perforation of the eyeball.

Acute pain related to exposure of pain receptors secondary to blunt trauma.

Goal: The pain is reduced

Expected outcomes:

The patient demonstrated knowledge of pain control.
The patient experience and demonstrate a period of sleep is not disturbed.
The patient expresses pain decreased with mild pain scale (1-3).

Interventions:

Assess the type, intensity and location of pain.
Use pain scale levels to determine the dose of analgesics.
Maintain bed rest in an upright position or the position of head of 60º.
Perform eye bandage on the affected part.
Give a cold compress to reduce pain and swelling.
Give sedation to minimize activity.
Collaboration: Giving therapy to reduce pain.
Give a back rub, a change of position for
increase comfort.
Help teach relaxation techniques.

Deficient Knowledge - Rheumatoid Arthritis Nursing Care Plan

Nursing Care Plan for Rheumatoid Arthritis

Deficient Knowledge (about the disease, prognosis, and treatment needs) related to the lack of exposure / recall, misinterpretation of information.

Evidenced by:

Questions / requests for information, statements misconceptions.
Not exactly follow the instruction / complications can be prevented.

Expected outcomes: The patient will be:

Demonstrate an understanding of the condition / prognosis, treatment.
Develop a plan for self-care, including lifestyle modifications consistent with mobility or activity restrictions.

Intervention and Rationale

1. Review the process of the disease, prognosis, and future expectations.
R /: Provide knowledge of where patients can make informed choices.

2. Discuss the habits of the patients in the management of the hospital, through; diet, medication, and a balanced diet, exercise and rest.
R /: The purpose of disease control is to suppress the inflammatory own / other tissue to maintain joint function and prevent deformity.

3. Assist in planning integrated realistic schedule of activities, rest, personal care, administering medications, physical therapy, and stress management.
R /: Provide structure and reduce anxiety during the handling of complex chronic disease processes.

4. Emphasize the importance of continuing management pharmacotherapeutics.
R /: Advantages of drug therapy depends on the accuracy of the dose.

5. Encourage digest medication with food, milk, or an antacid at bedtime.
R /: Limiting irrigation gastric, pain reduction will improve sleep and reduce stiffness in the morning.

6. Identification of the side effects of drugs that harm, eg tinnitus, gastrointestinal bleeding, and purpuric rash.

7. Emphasize the importance of reading product labels and reduce drug use-the-counter medicines without a doctor's approval.
R /: Many products contain salicylic hidden that can increase the risk of servings worth of drugs / dangerous side effects.

8. Review the importance of a balanced diet with foods rich in vitamins, protein and iron.
R /: Increase the general healthy feeling and tissue repair.

9. Encourage obese patients to lose weight and provide information about weight loss as needed.
R /: Weight reduction will reduce the pressure on the joints, especially the hips, knees, ankles, feet.

10. Provide information about the tools.
R /: Reduce compulsion to use the joints and allows individuals to participate more comfortably in activities that are necessary.

Nursing Care Plan for Cellulitis

Cellulitis is a skin disorder that is characterized by redness, swelling, tenderness and pain in the skin due to inflammation of the connective tissue of the skin caused by a bacterial infection. Infected people generally feel unwell with fever, chills and shaking. It occurs when bacteria like streptococcus and staphylococcus attack injured or damaged skin, such as body piercing, eczema or open wounds. Although the infection can spread to the adjacent skin, this disorder is not contagious because it occurs in the deepest skin layers. This condition can occur any body part, but more often in the arms, lower legs, neck and head area. Can be cured with antibiotics, but it needs to do a skin biopsy to detect bacteria. If left untreated, can cause blood poisoning (sepsis), endocarditis (an infection of the heart valves form) or necrotizing fasciitis (a serious infection of the tissue), where all of this is a medical emergency.

Nursing Care Plan for Cellulitis

Assessment

1. Identity
Name, gender, age, marital status, religion, ethnicity, education, language spoken, occupation, address.

2. History of the disease.

3. The main complaint
Patients usually complain of pain in the wound, sometimes accompanied by fever, chills and malaise.

4. Past medical history.
Asked cause injury to the patient and the disease before it ever like this, is there any allergy owned and history of drug use.

5. History of present illness
There are injuries to specific body parts with characteristic red color, soft, swollen, warm, painful, tense and shiny skin.

6. The family medical history
Usually there is a history in the family of patients suffering from diseases of cellulitis or other skin diseases.

7. The state of emotion psychology
The patient was calm, and emotionally stable.

8. The state of socio-economic
Usually attack on socioeconomic simple.

Physical Examination
1. General condition : Weak
Blood Pressure : decreased (less than 120/80 mmHg).
Pulse : decreased (less than 90 times / min).
Temperature : Increased (more than 37.5 degrees Celsius).
Respiration : Normal.
2. Head : Seen cleanliness, shape, is there any edema or not.
3. Eyes : Not anemic, no jaundice, light reflex (+).
4. Nose : No respiratory lobe.
5. Mouth : Health, not pale.
6. Ear : No wax.
7. Neck : No enlargement of the gland.
8. Heart : Heart rate increased.
9. Extremities : Are there any injuries to the extremities.
10. Integumentary : Early symptoms include redness and tenderness felt in a small area on the skin. Infected skin becomes hot and swollen, and looks like an orange peel peeling (peau d'orange). On the infected skin can be found a small fluid-filled blisters (vesicles) or a large fluid-filled blisters (bullae), which can rupture.

Nursing Diagnosis for Cellulitis

Acute pain related to local inflammatory response of subcutaneous tissue.
Hyperthermia related to the process of infection / inflammation systemic.
Risk for infection related to the presence of skin lesions.
Impaired tissue integrity related to the presence of red lesions.
Impaired physical mobility related to neuromuscular disorders, pain / discomfort, decreased strength and resistance.

Nursing Care Plan for Low Birth Weight - Risk for Infection

Low birth weight babies are babies born with birth weight less than 2500 grams regardless of pregnancy. Birth weight is the weight of a baby who weighed within 1 hour after birth.

The cause of LBW is very complex. LBW can be caused by pregnancy preterm, small for gestational age baby or a combination of both.

Preterm babies are babies born before 37 weeks' gestation. Most preterm infants are not ready to live outside the womb and find it difficult to start breathing, sucking, fight infection and keep the body in order to keep warm.

Low birth weight (LBW) is newborn birth weight less than 2500 grams (up to 2499 grams). Associated with the handling and life expectancy, low birth weight babies are distinguished in:

Low birth weight 1500-2500 g birth weight.
Very low birth weight, birth weight less than 1500 grams.
Extreme low birth weight, birth weight less than 1000 grams.

(Prawirohardjo, 2002)

Immediate complications that can occur in infants of low birth weight among others:

Hypothermia.
Hypoglycemia.
Fluid and electrolyte disturbances.
Hyperbilirubinemia.
Respiratory distress syndrome.
Infection.
Intravascular hemorrhage.
Apnea of prematurity.
Anemia.

Long-term problems that may arise in LBW among others:

Developmental disorders.
Impaired growth.
Visual impairment.
Hearing disorders.
Chronic lung disease.
The increase in the frequency of congenital abnormalities.

Nursing Diagnosis : Risk for infection related to immunological defense ineffective.

Goal: There are no signs of infection.

Expected outcomes:

Normal temperature.
No signs of infection.
Leukocytes 5000-10000.

Nursing Interventions :

Assess for signs of infection.
Perform insulation another baby suffering from an infection at the discretion of institutions.
Before and after handling the baby, do handwashing.
Make sure all equipment is in contact with the baby clean and sterile.
Prevent personal transmitted infections for no direct contact with the baby.

Rationale:

To find early signs of infection.
Actions taken to minimize the occurrence of infection wider.
To prevent infection.
To prevent infection persists in infants.

Nursing Care Plan for Osteosarcoma - Impaired Physical Mobility

Osteosarcoma is a primary malignant bone tumors are the most common and often fatal and can occur as a secondary metastases from extremity limb in 50% of cases. Usually found on the former site of radiation or more often as a broadcaster in Paget's disease. Osteosarcoma often occurs in men in the age group 10-25 years and the parents who have Paget's disease.

Nursing Diagnosis for Osteosarcoma : Impaired physical mobility related to muskuluskletal damage, pain, and amputation.

Goal: mobillitas physical damage is resolved entirely.

Subjective data: The client said it was difficult to move.
Objective data: The client looks impaired coordination; decreased muscle strength, control and mass.

Expected outcomes:

The patient stated understanding of individual situations, treatment programs, and security measures,
The patient seemed to participate in training programs / shows willingness to participate in activities,
The patient showed technique / behaviors enabling the move action, and
The patient seemed to maintain coordination and mobility corresponding optimal level.

Intervention:

1. Assess the level of immobilization caused by edema and the patient's perception of immobilization.
R /: The patient will restrict the movement as one of perception (perception are not proportional).

b. Encourage participation in recreational activities (watching TV, reading newspapers, etc.).
R /: Provides the opportunity to expend energy, focus, improve the patient's sense of self control and help in reducing social isolation.

3. Instruct the patient to perform active and passive exercises on the injury or not.
R /: Increases blood flow to the muscles and bones to improve muscle tone, maintain joint mobility, prevent contractures / atrophy and reapsorbsi Ca unused.

4. Assist patients in self-care.
R /: Increases strength and muscle circulation, improve the patient in control of the situation, increasing the willingness of the patient to recover.

5. Provide High-protein diet and High calories, vitamins, and minerals.
R /: Speed up the process of healing, prevent weight loss, because the immobilization usually weight loss.

6. Collaboration with the physiotherapy department.
R /: To determine the exercise program.

Nursing Care Plan - Diarrhea : Assessment and Diagnosis

Nursing Care Plan for Diarrhea

Diarrhea is a disease characterized by increased frequency of defecation more than usual (more than 3 times / day) accompanied by a change in stool consistency (a liquid), with / without blood and / or mucus (Suraatmaja, 2007).

Around the world there are approximately 500 million children suffer from diarrhea each year, and 20% of all deaths in children living in developing countries associated with diarrhea and dehydration. Diarrheal disorders can involve the stomach and intestines (gastroenteritis), small intestine (enteritis), colon (colitis) or colon and intestines (enterocolitis). Diarrhea is usually classified as acute and chronic diarrhea (Wong, 2009).

Diarrhea is a condition of increased fecal weight (more than 200 mg / day) which can be attributed to increased fluid, the frequency of bowel movement, not feeling the perianal, and a sense of urgency for bowel movements with or without fecal incontinence. Diarrhea is divided into Acute and Chronic diarrhea. Acute diarrhea lasts 2 weeks or less, while chronic diarrhea duration of more than 2 weeks. Further discussion regarding devoted chronic diarrhea (Hooward, 1995 cit Sutadi 2003).

Classification

According to WHO (2005) diarrhea can be classified to:

Acute diarrhea, ie diarrhea lasting less than 14 days.
Dysentery, the diarrhea is accompanied by blood.
Persistent diarrhea, the diarrhea that lasts more than 14 days.
Diarrhea accompanied by severe malnutrition.

According to Ahlquist and Camilleri (2005), diarrhea divided into:

Acute, if less than 2 weeks, persistent if it lasts for 2-4 weeks. More than 90% of the causes of acute diarrhea are the causative agents of infectious and will be accompanied by vomiting, fever and abdominal pain. 10% were caused by the treatment, intoxication, ischemia and other conditions.
Chronic, if it lasts more than 4 weeks. In contrast to acute diarrhea, a common cause of chronic diarrhea caused by non-infectious causes such as allergic and others.

According Kliegman, Marcdante and Jenson (2006), states that based on the amount of loss of fluid and electrolytes from the body, diarrhea can be divided into:

Diarrhea without dehydration: At this rate of diarrhea sufferers do not become dehydrated because of diarrhea frequency is still within tolerable limits and there are no signs of dehydration.
Diarrhea with mild dehydration (3% -5%): At this level patients with diarrhea 3 times or more, sometimes vomiting, thirsty, have decreased urination, decreased appetite, activity has begun to decline, the pressure pulse is normal or tachycardia minimum and a physical examination within normal limits.
Diarrhea with moderate dehydration (5% -10%): In this situation, the patient will experience tachycardia, urinating less or no, irritability or lethargy, eye and large fontanel becomes concave, reduced skin turgor, mucous membranes of the lips and mouth and the skin appears dry, reduced tear and the elongated capillary refill (greater or equal to 2 seconds) with skin cold and pale.
Diarrhea with severe dehydration (10% -15%): In this situation, the patient has lost a lot of fluid from the body and is usually in a state of patients experienced tachycardia with weak pulse, hypotension and pulse pressure spreads, no urine output, eyes and large fontanel becomes very concave, no tear production, not being able to drink and the situation began to apathy, decreased consciousness and also the very elongated capillary refill (greater or equal to 3 seconds) with a cold and pale skin.

Nursing Care Plan for Diarrhea

Assessment

1. Identity
Noteworthy is the age. Episodes of diarrhea occurred in the first 2 years of life. Highest incidence is 6-11 months age group. Most bacteria stimulate gut immunity against infection, it helps explain the decline insidence disease in older children. At the age of 2 years or more of active immunity begins to form. Most cases are due to intestinal infection and asymptomatic enteric bacteria spread mainly clients are not aware of the infection. Economic status also influential, especially from the diet and treatment.

2 The main complaint
Defecate more than 3 times, vomiting, diarrhea, bloating, fever.

3. History of present illness
Defecating yellow-green color, mixed with mucus and blood or mucus only. Watery consistency, frequency is more than 3 times, spending time: 3-5 days (acute diarrhea), more than 7 days (prolonged diarrhea), more than 14 days (chronic diarrhea).

4. Past medical history
Never before have diarrhea, use of antibiotics or corticosteroids long term (candida albicans changes from saprophyte become parasites), food allergies, respiratory infections, UTI, OMA measles.

5. History of nutrition
At toddler age children are given food as in adults, the portion given 3 times per day with additional fruit and milk. Malnutrition in children toddler age are particularly vulnerable. The way good food management, food hygiene and sanitation, hand washing habits.

6. Family health history
There is one family that is experiencing diarrhea.

7 History of environmental health
Food storage at room temperature, less hygiene, neighborhood.

Nursing Diagnosis for Diarrhea

Diarrhea
Hyperthermia
Deficient Fluid Volume
Anxiety: parents
Deficient Knowledge : on diarrheal disease
Decreased cardiac output
Ineffective breathing pattern
Activity intolerance

Nursing Care Plan for Endocarditis

Nursing Diagnosis for Endocarditis

Endocarditis is an inflammation of the endocardium (the membrane that lies in the heart).

Causes

Endocarditis more often caused by bacteria, fungi, or other microorganisms, can be caused by the operation; resulting from intravenous injection using dirty needles or through wounds found on the skin and mucous. Organisms can run in the blood flow towards the heart. As a result, the heart valves become inflamed, valves become damaged, and the formation of blood clots in the infected area. A person who has suffered injury or illness in the endocardium the easier it is for people suffering from endocarditis. This caused a blood clot from the surface of a wound can adsorb microorganisms, which can reproduce more and more on the injured area. Intravenous drug could cure endocarditis.

Symptoms

Endocarditis can be found in the acute or subacute form. In the subacute form, general and non-specific symptoms, including stiffness, fever, and pain. On physical examination, the evidence is just an abnormality of heart murmurs. Acute endocarditis is less happening can occur suddenly and cause a short breathing, fever, high fever, rapid heartbeat and irregular. Infection can be easily expanded and can destroy the valves of the heart, causing heart failure.

Test and Diagnosis

Various test and diagnosis done is:

Blood test.
Echocardiogram.
Electrocardiogram.
X-ray of the chest.
CT and MRI scans.

Nursing Diagnosis for Endocarditis

Acute pain related to systemic effects of the infection.
Risk for decreased cardiac output related to disturbances in heart valve and the endothelium.
Risk for Imbalanced Body Temperature.
Risk for Ineffective Tissue perfusion related to embolization

Constipation Care Plan - Nursing

Constipation

Constipation is a disorder of the digestive system where a person experiencing excessive hardening of feces making it difficult to remove and can cause great pain in patients. Constipation is pretty great also called obstipation. And severe obstipation can cause fatal intestinal cancer for patients.

Causes

Constipation or constipation is a complaint on the digestive system of the most common and is found in the wider community including around us. Even estimated that around 80% of people have experienced constipation or constipation. Common causes of constipation or constipation that is around us, among others:

Lack of body fluids or dehydration.
Hot suffer.
Stress or depression and compact enough activity.
Influence of hormones in the body (eg in menstruation or pregnancy).
Bowel less elastic (usually because it is in the pregnancy or old age).
Anatomic abnormalities in the digestive system.
Lifestyle and irregular eating patterns (such as poor diet).
Side effects from drinking something that contains a lot of calcium or aluminum (eg antidiare drugs, analgesics, and antacids).
Lack of vitamin C intake and lack of fiber.
Is a symptom of disease (eg, typhus and hernia).
Often withhold stimulus to defecate in a long time.
Emotion, because the emotion or anxiety intestines spasm, sehigga pertaltik intestine and large intestine absorbs stopped returning fluid feces. Consequently stool becomes hard.
Rarely or less work.
Advantages of fiber consumption.
The advantages of eating meat. Especially red meat because it was difficult to digest and has a lot of iron. Iron is the substance that makes the hardening of feces, making it dark and black.
Of drug abuse, such as drug laxatives. For example, the application of mineral oil is useful for launching peristaltic motion. Eventually the intestines become accustomed to and dependent on the drug, resulting in a slow intestinal reactions, and inhibits intestinal peristalsis self.
Frozen foods save time and energy, but cause many health problems. Frozen foods have very low fiber and a lot of preservatives that can disrupt the bowel movement. Like ice cream barely contain fiber so it can help regulate bowel movements combined with sugar and milk in it can harden the stool.
Eating certain fruits or vegetables that can compress excess dirt naturally like bananas.

Signs and symptoms

Symptoms and signs will vary from person to person, because of diet, hormones, lifestyle and shape of the large intestine of each person is different, but usually the symptoms and signs commonly found on most or sometimes some patients are as follows :

Stomach feels full, and even feels numb manure pile (if manure has accumulated about 1 week or more, patients with stomach looks like being pregnant).
Feces become harder, warm, darker, a little more than usual amount (less than 30 grams), and can even form a small bow when it is severe.
At the time of bowel removed or discarded hard stools, sometimes must mengejan or pressing his stomach in advance so as to remove the feces (even to suffer hemorrhoid and cold sweat).
Heard noises in the stomach.
The anus feels full, and as something hampered accompanied with pain as a result of frictional heat and hard stools.
Frequency throw up wind accompanied a more disagreeable odor than usual (even sometimes patients may have trouble or can not totally get rid of the wind).
A decline in the frequency of bowel movements, and increased bowel transit time (usually defecate be 3 days or more).
Sometimes experiencing nausea and even vomiting if it is severe.
Back pain when feces accumulated quite a lot.
Bad breath.

As for the psychological symptoms that can occur in the patients with constipation, among others:

Lack of confidence
Prefers to be alone or away from the vicinity.
Still feel hungry but when eating faster satiety (especially when pregnant stomach will feel heartburn) because the space in the stomach is reduced.
Emotion is increasing rapidly.
Often pounding so fast that lead to emotional stress so vulnerable headaches or even fever.
The body does not fit, uncomfortable, tired, tired quickly, and droop so lazy to do things sometimes even sleepy.
Less zealous in carrying out the activity.
Daily activities have been disrupted as a body feels overburdened resulting quality and decreased work productivity.
Can decrease appetite.

Prevention

Do not junk at an arbitrary point.
Avoid foods that are high in fat and sugar.
Drink at least 1.5 to 2 white liters of water (about 8 glasses) of fluid a day and others every day.
Sports, such as walking (jogging) can be done. At least 10-15 minutes for light exercise, and at least 2 hours for a heavier workout.
Familiarize defecate regularly and do not like to hold a bowel movement. No need to force a bowel movement every day when there is no stimulus for the digestive cycle every person differently.
Consumption of foods that contain enough fiber, such as fruits and vegetables.
Sleep at least 4 hours a day.
Add herbal flavor in food, except chili.
Diet is not excessive.
Consuming anti-inflammatory foods, such as avocado, apples, and coconut.

Nursing Care Plan for Deficient Fluid Volume (Hypovolemia)

Definition

Extracellular Fluid Volume Deficient or hypovolemia (FVD) is isotonic body fluid loss, which is accompanied by loss of sodium and water in the same relative amount. Volume deficits often termed isotonic dehydration that should be used for conditions of relatively pure water loss resulting in hypernatremia.

Etiology

Factors that affect the body's fluid and electrolyte balance, among others:

Age:

Fluid intake needs vary depending on age, because age affects the surface area of the body, metabolism, and weight. Infant and children are more susceptible to interference than the fluid balance adulthood. In old age often occurs due to fluid balance disorders with impaired renal function or heart.

Climate:

People who live in areas that are hot (high temperature) and low air humidity has an increased loss of body fluids and electrolytes through sweat. While someone who indulge in a hot environment can lose up to 5 L of fluid per day.

Stress:

Stress can increase cell metabolism, blood glucose, and the breakdown of muscle glykogen. This mechanism can increase sodium and water retention so that when prolonged can increase blood volume.

Diet:

Diet affects the intake of fluids and electrolytes. When inadequate nutritional intake, the body will burn protein and fat so it will spare protein and serum albumin will be decreased even though both are indispensable in the process fluid balance so that this will lead to edema.

Clinical manifestations

Clinical signs and symptoms which may be obtained on the client with hypovolemia include: dizziness, weakness, fatigue, syncope, anorexia, nausea, vomiting, thirst, mental confusion, constipation, oliguria. Depending on the type of fluid loss. Hypovolemia may be accompanied by acid-base imbalance, or osmolar electrolyte. Depletion (CES) severe, can lead to hypovolemic shock.

Compensatory mechanisms of the body on the condition of hypovolemia, is to be an increase in the sympathetic nervous system stimulation (increased frequency of heart, inotropic [contraction of the heart] and vascular resistance), thirst, release of antidiuretic hormone [ADH], and the release of aldosterone. The condition can lead to hypovolemia long acute renal failure.

Complication

Loss of abnormal GI: vomiting, NG suction, diarrhea, intestinal drainage.
Abnormal skin loss: excessive diaphoresis secondary to fever or exercise, burns, cystic fibrosis.
Abnormal kidney loss: diuretic therapy, diabetes insipidus, osmotic diuresis (polyuria form), adrenal insufficiency, osmotic diuresis (uncontrolled diabetes, post-use of contrast agents.
Spasium third or plasma to interstitial fluid displacement: peritonitis, intestinal obstruction, burns, acites.
Hemorragia.
Changes in input: coma, lack of fluids.

Nursing Care Plan for Deficient Fluid Volume (Hypovolemia)

Assessment

Intake-output.
Weight.
Breath sounds.
Edema.
Check skin turgor.

Nursing Diagnosis

Deficient Fluid Volume: less than body requirements related to diarrhea, gastric fluid loss, diaphoresis, polyuria.
Impaired skin integrity related to dehydration and or edema.

Outcomes:

Individuals will:

Increasing fluid intake of at least 2000 ml / day (unless contraindicated).
Telling the need to increase fluid intake during stress or heat.
Maintain urine specific gravity within normal limits.
Showed no signs and symptoms of dehydration.

Interventions:

Assess the preferred and non-preferred; give a favorite drink in the diet limits.
Plan objectives fluid intake (eg, 1000 ml during the morning, afternoon 800 ml, and 200 ml of the evening).
Assess individual understanding of the reasons to maintain adequate hydration and methods to achieve goals fluid intake.

Nursing Care Plan for Dysphagia

Dysphagia is the medical term for difficulty swallowing symptoms.
Swallowing disorders can occur in all age groups resulting from congenital abnormalities, structural damage, and / or medical condition. in patients who have had a stroke, and in patients who are admitted hospital acute or chronic care facilities.

Dysphagia is classified into two major groups, namely oropharyngeal dysphagia (or transfer dysphagia) and esophageal dysphagia.

1. Oropharyngeal dysphagia

Oropharyngeal dysphagia arises from abnormalities in the oral cavity, pharynx, and esophagus, can be caused by stroke, Parkinson's disease, neurological disorders, muscular dystrophy Oculopharyngeal, decreased flow of saliva, xerostomia, dental problems, oral mucosal abnormalities, mechanical obstruction (malignancy, osteofi, increasing the upper esophageal sphincter tone, radiotherapy, infection, and drugs (sedatives, anticonvulsants, antihistamines). oropharyngeal dysphagia symptoms are difficulty swallowing, including the inability to recognize food, difficulty putting food in the mouth, inability to control food and saliva in the mouth, difficulty to start swallowing, coughing and choking during swallowing, weight loss is not clear why, changes in eating habits, recurrent pneumonia, voice alteration (wet voice), nasal regurgitation. Upon examination, treatment can be done with techniques postural, swallowing maneuvers, dietary modification, environmental modification, oral sensory awareness technique, vitalstim therapy, and surgery. Bilatidak untreated, dysphagia can lead to aspiration pneumonia, malnutrition, or dehydration.

2 . Esophageal dysphagia

Esophageal dysphagia arises from abnormalities in the corpus of the esophagus , the lower esophageal sphincter , or gastric cardia . Usually caused by esophageal stricture , esophageal malignancy , esophageal rings and webs , achalasia , scleroderma , spastic motility disorders including diffuse esophageal spasm and non-specific esophageal motility disorders . Food is usually held some time after ingestion , and it will be as high as suprasternal notch or behind the sternum as the site of obstruction , oral or pharyngeal regurgitation , changes in eating habits , and recurrent pneumonia . If there is a solid and liquid food dysphagia , most likely a motility problem . When the patient initially experienced solid food dysphagia , but subsequently with liquid food dysphagia , it is most likely a mechanical obstruction . After being able to distinguish between problems motility and mechanical obstruction , it is important to pay attention to whether temporary or progressive dysphagia . Dysphagia can be caused motility while diffuse esophageal spasm or nonspecific esophageal motility disorder . Progressive motility dysphagia can be caused by scleroderma or achalasia with a burning sensation in the area of chronic heartburn , regurgitation , respiratory problems , or weight loss . Dysphagia can be caused by temporary mechanical esophageal ring . And progressive mechanical dysphagia can be caused by esophageal stricture or esophageal malignancy . When it can be concluded that the disorder is esophageal dysphagia , then the next step is a barium examination or upper endoscopy . Barium examination should be performed before endoscopy to avoid perforation . When the suspected presence of achalasia on barium examination , then performed manometry for diagnosis of achalasia . When suspected esophageal strictures , then endoscopy . If no abnormalities are suspected as above , the endoscope can be done prior to barium examination . Normal endoscopy , should be continued denganmanometri , and if manometry is also normal , then the diagnosis is functional dysphagia . Thorax is simple to pneumonia.CT examination and MRI scans provide a good overview of structural abnormalities , especially when used to evaluate patients with dysphagia who is suspected due to central nervous system disorders . Having known the diagnosis , the patient is usually sent to the ENT , gastrointestinal , pulmonary , or oncology , depending on the cause . Consultation with a dietician is also necessary , as most patients will need your dietary modification .

Nursing Assessment for Dysphagia

Nursing Assessment is necessary in patients with impaired swallowing or disphagya include:

History of previous illness
History of stroke
History of use of medical devices: tracheostomy, NGT, mayo tube, ETT, post endoscopy examination
History surgery laryx blood, pharynx, esophagus, thyroid
Postoperative oral region
Physical examination
Mouth shape is not symmetrical
Seemed an inflammation of the pharynx
Presence of candida in oral / mouth
Pharyngeal edema

Nursing Diagnosis for Dysphagia

1. Impaired Swallowing
2. Risk for Imbalanced Nutrition: less than body requirements
3. Risk for aspiration

Nursing Management for Dysphagia

Nursing Care Plan for Scoliosis

Nursing Care Plan for Scoliosis

Analysis of data

Subjective Data:

Patients say back pain.
Patients say fatigue in the spine after sitting or standing for long.
Patients say trouble breathing.

Objective Data:

Shoulder, did not seem as high.
Visible protrusion of the scapula is not the same.
Looks are not the same hip.

Nursing Diagnosis for Scoliosis

Ineffective Breathing Pattern related to the suppression of pain.
Acute Pain: back related to the position of lateral body tilt.
Impaired Physical Mobility related to postural imbalance.
Disturbed Body Image related to kelateral tilted posture.

Nursing Interventions for Scoliosis

1. Ineffective Breathing Pattern related to the suppression of pain.

Purpose: The pattern of breathing effectively.

Plan of action:

Assess respiratory status every 4 hours.
Help and teach the patient to breath in any one hour. Rationale: Increasing the maximum ventilation and oxygenation.
Adjust bed semi-Fowler position to improve lung expansion. Rational: Sitting height allowing easier breathing and lung expansion.
Monitor vital signs every 1 hour. Rational: general indicators, circulation status and adequacy of perfusion.

2. Acute pain: back related to the position of lateral body tilt.

Purpose: Pain is reduced or lost

Plan of action:

Assess the type, intensity and location of pain. Rational: Influencing choice / control the effectiveness of interventions can influence the level of anxiety to pain.
Teach relaxation and distraction techniques. Rational: To divert attention, thereby reducing pain.
Teach and encourage use of the brace. Rational: To reduce pain during activity.
Collaboration in the provision of analgesia. Rational: To relieve pain.

Nursing Care Plan for COPD

Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath. In clinical practice, COPD is defined by its characteristically low airflow on lung function tests. In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time. In England, an estimated 842,100 of 50 million people have a diagnosis of COPD; thus, approximately 1 person in 59 is diagnosed with COPD at some point in their lives.
wikipedia

Nursing Care Plan for COPD : Nursing Assessment for COPD

The assessment includes information about past symptoms and manifestations of the disease earlier. Here are some guidance questions to obtain data on the health history of the disease process:

How long patients have difficulty breathing?
Does the activity increase dyspnea?
How much restriction on the patient's activity tolerance?
When do patients complain most tired and shortness of breath?
Is eating and sleeping habits are affected?
History of smoking?
Drugs that are used every day?
Drugs used in acute attacks?
What patients know about the condition and the disease?

Additional data collected through observation and examination as follows:

Pulse rate and respiratory patients?
Is the same breathing without effort?
Is there a contraction of abdominal muscles during inspiration?
Is there any use of accessory respiratory muscles during breathing?
Barrel chest?
Do look cyanotic?
Is there a cough?
Is there peripheral edema?
Are the neck veins look bigger?
What color, number and consistency of sputum of patients?
How, the sensor status of patients?
Is there an increase stupor? Anxiety?

Source : http://nursing-assessment.blogspot.com/2011/05/nursing-assessment-for-copd.html

Nursing Care Plan for COPD : Nursing Diagnosis for COPD

1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.

3. Impaired Gas Exchange related to ventilation perfusion inequality.

4. Activity Intolerance related to imbalance between supply with oxygen demand.

5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

6. Disturbed Sleep Pattern related to discomfort, the setting position.

7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.

8. Anxiety related to threat to self-concept, the threat of death, unmet needs.

9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.

10. Knowledge Deficit related to lack of information, do not know the source of information.

Source : http://nandanursingdiagnosis.blogspot.com/2011/05/nursing-diagnosis-for-copd.html

Nursing Care Plan for Alzheimer's Disease

Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 60.

Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person’s daily life and activities. Estimates vary, but experts suggest that as many as 5.1 million Americans may have Alzheimer’s.
nia.nih.gov

Nursing Care Plan for Alzheimer's Disease : Assessment of Alzheimer's Disease

1. Activity / rest
Signs: anxiety, helplessness, sleep pattern disturbance, lethargy and impaired motor skills.
Symptoms: feeling melting

2. Circulation
Symptoms: History of cerebral vascular disease / systemic, hypertension, embolic episodes

3. Ego integrity
Signs: hide incompetence, sit down and
watch the other, the first activity might accumulate
objects are not moving and emotional stability
Symptoms: suspicious or afraid of the situation / person fantasies, misperceptions of the environment, loss of multiple.

4. Elimination
Signs: Incontinence of urine / feaces
Symptoms: The urge to urinate

5. Food / fluid
Signs: loss of ability to chew, avoiding / refusing to eat and looked increasingly thin.
Symptoms: Historical episodes of hypoglycemia, changes
in taste, appetite, weight loss.

6. Hygiene
Signs: a lack of personal habits, forget to go to the bathroom and less interested in eating time
Symptoms: Need help, depending on other people

7. Neuro Sensory
Symptoms: Improvement of symptoms that exist primarily
cognitive changes, loss of sensation and existence propriosepsi
history of cerebral vascular disease / systemic as well as seizure activity.

8. Comfort
Signs: ekimosis laceration and a sense of hostile / attack others
Symptoms: A history of serious head trauma,
accident trauma

9. Social Integrity
Signs: Loss of social control, inappropriate behavior
Symptoms: Feeling lost power
Source : http://nursing-assessment.blogspot.com/2011/05/nursing-assessment-for-alzheimers.html

Nursing Care Plan for Alzheimer's Disease : Nursing Interventions for Alzheimer's Disease

1. Nursing Diagnosis : Risk for Injury related to:

Unable to recognize / identify hazards in the environment.
Disorientation, confusion, impaired decision making.
Weakness, the muscles are not coordinated, the presence of seizure activity.

Nursing Intervention :

Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in visual perception.
Help the people closest to identify the risk of hazards that may arise.
Eliminate / minimize sources of hazards in the environment
Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.

Rational:

Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.
An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.
Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.

2. Nursing Diagnosis : Disturbed Thought Processes related to :

Irreversible neuro degeneration
Memory Loss
Psychological Conflict
Deprivation lie

Nursing Intervention :

Assess the level of cognitive disorders such as changes orientasiterhadap people, places and times, range, attention, thinking skills.
Talk with the people closest to the usual behavior change / length of the existing problems.
Maintain a nice quiet neighborhood.
Face-to-face when talking with patients.
Call patient by name.
Use a rather low voice and spoke slowly in patients.

Rational:

Provide the basis for the evaluation / comparison that will come, and influencing the choice of intervention.
Noise, crowds, the crowds are usually the excessive sensory neurons and can increase interference.
Cause concern, especially in people with perceptual disorders.
The name is a form of self-identity and lead to recognition of reality and the individual.
Increasing the possibility of understanding.

Source : http://nursinginterventions-diagnosis.blogspot.com/2011/05/nursing-intervention-for-alzheimers.html

Nursing Assessment for Alzheimer's Disease

Nursing Diagnosis for Alzheimer's Disease

Nursing Care Plan for Gastritis

Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract. Chronic causes are infection with bacteria, primarily Helicobacter pylori, chronic bile reflux, stress and certain autoimmune disorders can cause gastritis as well. The most common symptom is abdominal upset or pain. Other symptoms are indigestion, abdominal bloating, nausea, and vomiting and pernicious anemia. Some may have a feeling of fullness or burning in the upper abdomen. A gastroscopy, blood test, complete blood count test, or a stool test may be used to diagnose gastritis. Treatment includes taking antacids or other medicines, such as proton pump inhibitors or antibiotics, and avoiding hot or spicy foods. For those with pernicious anemia, B12 injections are given. wikipedia

Nursing Care Plan for Gastritis : Nursing Diagnosis for Gastritis

1. Risk for Imbalanced Fluid Volume and Electrolytes : less than body requirements related to inadequate intake, vomiting

2. Imbalanced Nutrition: Less Than Body Requirements related to decreased nutrition intake.

3. Activity Intolerance related to physical weakness.

4. Deficient Knowledge: about diseases related to lack of information.

5. Acute Pain related to an increase in stomach acid.

Nursing Care Plan for Gastritis : Nursing Interventions for Gastritis

1. Risk for Imbalanced Fluid Volume and Electrolytes : less than body requirements related to inadequate intake, vomiting

Goal:
Disorders of fluid balance did not occur.

Expected results:
Moist mucous membranes, good skin turgor, electrolytes returned to normal, capillary filling pink, vital signs stable, the balance of input and output.

Nursing Intervention :

Assess signs and symptoms of dehydration, observation of vital signs, measuring intake and output, encourage clients to drink ± 1500-2500ml, observation of skin and mucous membranes, collaboration with doctor in the provision of intravenous fluids.

2. Imbalanced Nutrition: Less than Body Requirements: less than body requirements related to inadequate intake, anorexia

Goal:
Nutritional deficiencies resolved.

Expected results:
Normal albumin value, no nausea and vomiting, weight within normal limits, normal bowel sounds.

Nursing Intervention :

Assess food intake, body weight measured regularly, give oral care on a regular basis, encourage clients to eat little but often, give food in warm, auscultation bowel sounds, assess food preferences, check the laboratory, for example: Hemoglobin, hematocrit, albumin.

Source : http://nursinginterventions-diagnosis.blogspot.com/2011/05/nursing-care-plan-for-gastritis.html

Nursing Care Plan for Varicella Zoster virus

Assessment for Varicella Zoster virus

Subjective symptoms: complaints of headache, anorexia and malese.
On the skin and mucous membrane: lesions in various stages of development: from erythematous macules that appear for 4-5 days and then quickly become vesicles and crusting that began in the body and spread sentrifubal prominent and extremities. Lesions may also occur in the mucosa, palate and konjunctiva.
Temperature: fever may occur between 38-39 C

Nursing Diagnosis for Varicella Zoster virus

1. Impaired skin integrity related to trauma

2. Acute pain related to damage to the skin / tissue

3. Risk for Infection related to damage skin protection

4. Knowledge deficient related to incorrect interpretation of information

Nursing interventions for Varicella Zoster virus

DX 1

Impaired skin integrity related to trauma

Intervention:

Encourage regular bathing
Avoid scratching the lesions
Use a soft clothes

DX2

Acute pain related to damage to the skin / tissue

Intervention:

Use a powder analgesic and anti-pruritic.
Keep the room temperature is still cool with adequate moisture.

DX3

Risk for Infection related to damage skin protection

Intervention:

Perform isolation (strict isolation):

Strict isolation procedures:

Single room: the door should always be closed. Clients who become infected by the same organism can be placed in the same room.
Use masks, special clothing, and gloves for all those who come into the room.
Always wash your hands after touching the client or objects that may be contaminated, and before giving the action to other clients.
All contaminated items disposed of or put into a special place and labeled prior to decontamination or reprocessed back

DX4

Knowledge deficient related to incorrect interpretation of information

Teach the parents in the treatment of children in ruamah on things above.
Explain that fever d apat treated with tepid sponge bath did.
Explain that the use of medication must be in accordance with doctor's instructions.

Nursing Care Plan for Decubitus Ulcer

Definition of Decubitus Ulcer

Decubitus ulcer is damage or death of tissue under the skin until the skin even through the muscle to the bone, because of the emphasis on an area on an ongoing basis, resulting in impaired blood circulation.

Decubitus ulcers are ulcers that result from the strong pressure by the weight on the bed.

Etiology

Pressure
Humidity
Friction

Pathophysiology

Pressure immobilization a long time, will result in pressure sores, if one part of the body is on a gradient (the difference between the two pressure points). Deeper tissue near the bone, especially muscle tissue with good blood supply will shift towards a lower gradient, while the skin is maintained at the contact surface by increasing friction with the presence of moisture, this situation led to stretching and angulation of blood vessels (micro circulation) in blood and tissue shear forces experienced in, it will be able to experience ischemia and necrosis before moving on to the skin.

Clinical Manifestations and Complications

Initial injury is a sign of redness that does not disappear when pressed thumb.
On a more serious injury encountered skin ulcers.
Can arise pain and signs of systemic inflammation, including fever and increased white blood cell count.
Infection can occur as a result of weakness and hospitalization is prolonged even in a small ulcer.

Diagnostic Examination

Culture: artificial growth of microorganisms or tissue cells.
Serum albumin: a major protein in plasma and other serous fluids.

Medical Management

Changing the position of the patient who is bed rest.
Relieving pressure on the skin reddened and placement of the pads are clean and thin when they have been shaped decubitus ulcers.
Systemic: broad-spectrum antibiotic

Nursing Care Plan for Decubitus Ulcer

Assessment - Nursing Care Plan for Decubitus Ulcer

a) Activity / rest
Signs: decreased strength, endurance, limited range of motion in the area of pain disorders, such as muscle buds change.

b) Circulation
Signs: hypoxia, decreased peripheral pulses distal to the injured limb, general peripheral vasoconstriction with loss of pulse, white and cold, the formation of tissue edema.

c) elimination
Signs: decreased urine output is the absence of the emergency phase, the color may be reddish black, in the event, identify potentially damage the muscle.

d) Food / fluid
Signs: tissue edema, anorexia, nausea and vomiting.

e) Neuro-sensory
Symptoms: The area of numbness / tingling

f) Respiratory
Symptoms: decreased function of the spinal cord, cord edema, neurologic damage, abdominal and respiratory muscle paralysis.

g) The integrity of the ego
Symptoms: family problems, employment, finances, disability.
Signs: anxiety, crying, dependency, self mmenarik, angry.

h) Security
Signs: a fracture due to location (fall, accident, tetanik muscle contraction, up to an electric shock).

Nursing Diagnosis - Nursing Care Plan for Decubitus Ulcer

1.Impaired Skin Integrity related to tissue destruction secondary to mechanical pressure, friction and factions.

2.Impaired Physical Mobility related to restriction of movement required, the conditioned status, loss of motor control due to changes in mental status.

3. Imbalanced Nutrition Less Than Body Requirements related to the inability of oral intake.

Assessment, Physical Examination and Nursing Care Plan for Hemophilia

Hemophilia

Hemophilia is a bleeding disorder caused by deficiency and hereditary factors essential for blood coagulation (Wong, 2003).

Hemophilia is a congenital blood clotting disease caused by deficiency of blood clotting factors, ie factor VIII and factor IX. Factor VIII and factor IX is a plasma protein that is a component needed for blood clotting, these factors are required for fibrin clot formation in the area of trauma. (Hidayat, 2006).

Hemophilia is a congenital coagulation disorders the most frequent and serious. The disorder is associated with a deficiency of factor VIII, IX or XI is determined genetically (Nelson, 1999).

Hemophilia is a hereditary or acquired coagulation disorders are most common, manifest as intermittent episodes of bleeding (Price & Wilson, 2005)

Hemophilia there are 3 kinds:

Hemophilia A: Disorders of the factor VIII (Anti - hemophilic factor)
Hemophilia B: Disorders of the factor IX (Christmas factor)
Van Willebrand disease

Clinical symptoms:
1. Infant (for diagnosis)

Prolonged bleeding after circumcision
Subcutaneous ecchymoses over the bumps of bone (at the age of 3-4 months)
Large hematoma after infection
Bleeding from the oral mucosa
Soft tissue bleeding

2. Bleeding episodes (during the life span)

Early symptoms, including pain
After the pain, the swelling, warmth, and decreased mobility

3. Long-term sequelae

Prolonged bleeding in the muscle can cause nerve compression and muscle fibrosis.

Pathophysiology of Hemophilia
Bleeding due to clotting disorder usually occurs in such a network that is located in muscles, joints, and other disorders because they can occur in the first, second and third, here the only disturbance will be discussed at the first stage, wherein the first stage is exactly what is the mechanism of interference freezing found in hemophilia A and B. Easy bleeding occurs in hemophilia, due to clotting disorder, at the start when a person is ± 3 months old or moments will begin to crawl the initial bleeding will occur due to minor injuries, followed by subsequent complaints.

Hemophilia can also cause cerebral hemorrhage, and fatal. Rationale is that when bleeding, there is a vascular injury (ie a channel where blood flows through the body) → blood out of the vessel. Blood vessels to shrink / shrank → Platelet (platelets) will close the wound on the vessel → Lack of a specific amount of blood clotting factors, resulting in wound closure webbing is not fully formed blood → did not stop flowing out → bleeding vessels (normal: blood clotting factors work to make webbing (fibrin strands) which will close the wound so that the blood stops flowing vessels).

Assessment and Physical Examination for Hemophilia

1. Assessment

Family history of bleeding disorder
Ask an unusual bleeding (bleeding that is difficult to stop a long time)
Spontaneous bleeding (hemorrhage without trauma)

2. Physical examination
a. Activity
Symptoms: Muscle weakness
Symptoms: fatigue, malaise, inability to perform activities.
b. Circulation
Symptoms: skin, mucous membranes pale, cerebral nerve deficit / signs of cerebral hemorrhage
Symptoms: Palpitations
c. Elimination
Symptoms: Hematuria
d. Ego integrity
Symptoms: Depression, withdrawal, anxiety, anger.
Symptoms: Feelings of hopelessness and helplessness.
e. Nutrition
Symptoms: Anorexia, weight loss.
f. Painful
Mark:. Cautious behavior, anxiety, irritability.
Symptoms: Pain in the bones, joints, central tenderness, muscle cramps
g. Security
Signs: hematoma
Symptoms: mild trauma history.
- There was spontaneous bleeding in joints and muscles over and over accompanied by pain and swelling occurs.
- Recurrent joint bleeding caused by hemophilia Atropati give rise to joint space, bone crest and limited joint movement.
- Usually found in the Gastrointestinal bleeding also, excessive hematuria, and brain hemorrhage.
- There was hematoma at the extremities.
- Limitations and joint pain continued to hemorrhage

3. Psychology
- Assess the patient's self-concept à body image, roles, etc.
- Assess the patient and family understanding about the condition and action
- Assess the impact on lifestyle lung condition

Nursing Care Plan for Hemophilia

Nursing Management for Hemophilia

People with hemophilia should be aware of circumstances that can cause bleeding. They should really pay attention to teeth care to not have to undergo a tooth extraction. Rest of the body where there are injuries. When the leg is bleeding, use a tool such as a cane. Compressed injured body part and the surrounding area with ice or other soft material and frozen / cold. Press and tie, so the bleeding body part can not be moving (immobilization). Use an elastic bandage but keep in mind, do not press too hard and tie. Put these body parts in a higher position than the position of the chest and place it on a soft object like a pillow.

Nursing Care Plan for Acute Respiratory Infections (ARI)

Acute respiratory infections are respiratory tract infection that lasts up to 14 days. Respiratory tract includes the organs from the nose to the lungs, along with the surrounding organs such as the sinuses, middle ear space and the pleura.

Acute Respiratory infection is a disease that often occurs in children, because the immune system of children is still low.

Terms of ARI include three elements namely : infections, respiratory tract, and acute, where the notion as follows:

1. Infection

Is the entry of germs or microorganisms into the human body and multiply, causing symptoms of the disease.

2. Respiratory tract

Is the organ, from the nose to the alveoli, along with the sinuses, middle ear cavity and the pleura.

3. Acute infections

Acute infection is a direct infection of up to 14 days. limit of 14 days is taken to indicate an acute process although for some diseases that can be classified in a process may take more than 14 days.

Assessment - Nursing Care Plan for Acute Respiratory Infections (ARI) for Acute Respiratory Infection

Things that need to be assessed in patients with Upper Respiratory Infection:

History: fever, cough, runny nose, anorexia, weakness / listlessness, respiratory disease history, treatment done at home and accompanying diseases.
Physical signs: fever, dyspnea, tachypnea, use of additional respiratory muscles, enlarged tonsils, painful swallowing.
Growth factor: General, level of development, daily habits, coping mechanisms, ability to understand the action taken.
Knowledge of the patient / family: the experience of respiratory diseases, respiratory diseases and knowledge about the action taken.

Nursing Diagnosis for Acute Respiratory Infection

1. Hyperthermia related to the invasion of microorganisms

2. Risk for Imbalanced Nutrition: Less Than Body Requirements related to painful swallowing, decreased appetite secondary to acute respiratory tract infections.

3. Knowledge deficient: on the management of Acute Respiratory Infections related to lack of information

4. Ineffective breathing pattern related to decreased lung expansion

Hyperthermia Nursing Care Plan for Tetanus

Nursing Care Plan for Tetanus - Nursing Diagnosis : Hyperthermia and Interventions

Hyperthermia

Definition: The body temperature rises above the normal range.

Characteristics :

Increase in body temperature above the normal range
Attacks or convulsions (seizures)
Skin redness
Increase respiratory rate
Tachycardia
Hands felt warm to the touch

Tetanus is an infectious disease which is caused due Clostridium tetani bacterium.

Tetanus is transmitted through the environment and not from person to person contact. It is also known as lockjaw as it causes spasms that lock the muscles of the jaw. In severe cases, respiratory muscles get locked due to spasm and the person dies due to lack of oxygen to the brain and other parts of the body.

The chief tetanus symptoms generated by the neurotoxins include lockjaw and other contraction of the skeletal muscles of the face and upper body. Highly painful spasms become evident, accompanied by the voluntary muscles becoming increasingly rigid. The limbs and trunk follow, along with an arching of the back that is technically called opisthotonos. As the symptoms progress, so generally do the severity of the spasms, especially the masseter muscle contributing to lockjaw.

Nursing Diagnosis for Tetanus

Hyperthermia related to efeks toxin (bacteremia)

characterized by :
body temperature 38-40 ° C,
hyper-hydration,
white blood cells more than 10,000 / mm3

Purpose: Normal body temperature

Results Criteria:

Temperature :36-37 ° C,
Laboratory results: white blood cells (WBCs) between 5.000-10.000/mm3

Nursing Interventions - Hyperthermia Nursing Care Plan for Tetanus :

1. Set the ambient temperature, which is convenient.

Rational: The climate and environment can affect an individual's body temperature as a process of adaptation through the process of evaporation and convection.

2. Monitor body temperature every 2 hours

Rasioanl: Identify the symptoms progress to the shock.

3. Provide adequate hydration or drinking adequat

Rationale: Fluids help refresh the body and the compression of the body.

4. Take action on aseptic technique and antiseptic treatment of wounds.

Rational: wound care eliminate the possibility of a toxin that is located around the wound.

5. Implement programs and antipieretik antibiotic treatment.

Rational: These drugs may have antibacterial properties to treat a broad spectrum of gram-positive bacteria or gram negative bacteria. Antipyretic worked as a process of thermoregulation, heat anticipation.

6. Collaborative laboratory examination of leukocytes.

Rational: The results of leukocytes increased by more than 10,000 / mm 3 indicates the presence of infection and to keep abreast of the prescribed treatment.

Acute Pain / Chronic Pain - Rheumatoid Arthritis Nursing Care Plan

Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammation of the joints. This disease is categorized as an autoimmune disease because people suffering from this condition have antibodies in their blood that target their own body tissues.

Rheumatoid arthritis can attack various organs and tissues in the human body. However, it mainly attacks synovial joints in the hands, wrists, ankles, and knees.

There are, typically, three distinctive types of discomfort which go along with chronic RA. The foremost of these types of discomfort is often called "flair up pain." It is caused by the inflammation of the joints which goes along with periods when your RA is flaring and active.

The next type of rheumatoid pain is often simply called joint pain. It is caused by damage to the joints, which is a consequence of the inflammation. This is the everyday discomfort which is present, even while your RA is not active.

Finally, the very last rheumatoid aspect of the pain equation might be called "emotional pain." It involves the emotions, your psychological well being, and your stress level. The tiredness which you will feel is a part too. This aspect of RA really makes "everything hurt worse."

Management / Treatment of Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis : Acute Pain / Chronic Pain

related to:

Tissue distension by accumulation of fluid / inflammatory process
Destruction of joints.

Can be evidenced by:

Complaints of pain, discomfort, fatigue.
Focusing on self / narrowing of focus
Behavior distraction / autonomic response
Behavior that is care / protect

Expected results / patient evaluation criteria will be:

Showed pain relief / control
Looks relaxed, able to sleep / rest and participate in activities according to ability.
Follow the program prescribed pharmacological
Combining the skills of relaxation and entertainment activities into a program of pain control.

Nursing Interventions and Rational - Nursing Care Plan for Rheumatoid Arthritis

1. Record complaints of pain, record the location and intensity (scale 0-10). Write down the factors that accelerate and signs of pain - non-verbal.

Rational: To assist in determining the need for pain management and program effectiveness.

2. Give a hard mattress, a small pillow. Elevate the bed linen as needed.

Rational: a soft mattress, pillow that would prevent maintenance of proper body alignment, placing stress on the joints that hurt. Elevation of the bed linen lowering the pressure in the inflamed joints / pain.

3. Place / monitor the use of pillows, sandbags, splint, brace.

Rational: Resting sore joints and maintain a neutral position. The use of the brace can reduce pain and can reduce damage to the joints.

4. Advise to change position frequently. Help to move in bed, prop joint pain above and below, avoid jerky movements.

Rationale: Prevent the occurrence of general fatigue and joint stiffness. Stabilize joints, reduce the movement / pain in the joints.

5. Instruct the patient to a warm bath or shower at the time awake and / or at bedtime. Provide a warm washcloth compress for sore joints several times a day. Monitor the temperature of the water compresses, baths, and so on.

Rational: The heat increases muscle relaxation, and mobility, reduce pain and stiffness in the morning release. Sensitivity to heat can be removed and dermal wound can be healed.

6. Give a gentle massage

Rationale: Increase relaxation / reducing pain.

7. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeed back, visualization, guidelines imagination, self hypnosis, and breath control.

Rationale: Increase relaxation, provide a sense of control and may enhance coping abilities.

8. Engage in activities appropriate entertainment for individual situations.

Rationale: Focusing attention back, providing stimulation, and increased self-confidence and feeling healthy.

9. Give drug before the activity / planned exercise as directed.

Rationale: Increasing realaksasi, reduce muscle tension / spasm, making it easier to participate in therapy.

10. Collaboration: Give medications as directed.

Rational: As an anti-inflammatory and mild analgesic effect in reducing stiffness and increasing mobility.

11. Give ice-cold compress if needed

Rational: The cold can relieve pain and swelling during the acute period

Care Plan Nursing

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