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Nursing Care Plan for Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting duringpregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%

Nursing Care Plan for Hyperemesis Gravidarum

Nursing Assessment for Hyperemesis Gravidarum
  1. Activity / rest
    Systolic blood pressure decreases, pulse rate increased by more than 100 times per minute.

  2. Ego Integrity
    Interpersonal family conflicts, economic difficulties, changes in perception about the conditions, unplanned pregnancies.

  3. Elimination
    Changes in consistency; defecation, increased frequency of urination
    Urinalysis: increased concentration of urine.

  4. Food / fluid
    Excessive nausea and vomiting (4-8 weeks), epigastric pain, weight loss (5-10 kg), oral mucous membrane irritation and red, low hemoglobin and hematocrit, breath smelled of acetone, reduced skin turgor, sunken eyes and dry tongue.

  5. Breathing
    Respiratory frequency increased.

  6. Security
    The temperature sometimes rises, weakness, icterus and may lapse into a coma.

  7. Sexuality
    Cessation of menstruation, when a state endangering the mother carried a therapeutic abortion.

  8. Social Interaction
    Changes in health status / stressors of pregnancy, changes in roles, the response of family members that can be varied to hospitalization and illness, the less support system.

  9. Learning and education
    • Everything is eaten and drunk vomited, especially if lasts long.
    • Weight loss of more than 1 / 10 of normal body berast
    • Skin turgor, dry tongue
    • The presence of acetone in the urine.


Nursing Diagnosis and Intervention : Imbalanced Nutrition - Less Than Body Requirements for Hyperemesis Gravidarum


Nursing Diagnosis for Hyperemesis Gravidarum

Imbalanced Nutrition: Less Than Body Requirements related to the frequency of excessive nausea and vomiting.


Nursing Intervention for Hyperemesis Gravidarum

1. Restrict oral intake until the vomiting stops.
Rationale: Maintaining a fluid electrolyte balance and prevent further vomiting.

2. Give the anti-emetic drugs are prescribed.
Rationale: Preventing vomiting and maintain fluid and electrolyte balance.

3. Maintain fluid therapy can be saved.
Rationale: Correction of hypovolemia and electrolyte balance.

4. Record intake and output.
Rationale: Determining hydration fluids, and spending through vomiting.

5. Encourage to eat small meals but often
Rational: Can adequate intake of nutrients your body needs.

6. Advise to avoid fatty foods
Rational: fatty foods can stimulate nausea and vomiting.

7. Encourage to eat a snack such as crackers, bread and tea (hot) warm before waking up at noon and before bed.
Rational: snack can reduce or prevent nausea, vomiting, excessive excitatory.

8. Record intake, if oral intake can not be given within a certain period.
Rationale: To maintain a balance of nutrients.

9. Inspection of irritation or Iesi the mouth.
Rational: To know the integrity of the oral mucosa.

10. Review oral hygiene and personal hygiene and the use of oral cleaning fluid as often as possible.
Rationale: To maintain the integrity of the oral mucosa.

11. Monitor hemoglobin levels and Hemotokrit
Rationale: To identify the potential presence of anemia and decreased oxygen-carrying capacity. Clients with Hb levels less than 12 mg / dl or hematocrit levels are low, consider-trimester anemia I.

12. Urine Test against acetone, albumin and glucose ..
Rationale: Establish baseline data; done routinely to detect potential high-risk situations such as inadequate intake of carbohydrates.

13. Measure uterine enlargement
Rationale: Malnutrition mother affects fetal growth and aggravate the decrease in the complement of brain cells in the fetus, resulting in deterioration of fetal development and the possibilities further.

Nursing Diagnosis and Intervention : Imbalanced Nutrition - Less Than Body Requirements for Hyperemesis Gravidarum

Nursing Care Plan for Prostatectomy


Nursing Care Plan for Prostatectomy

Prostatectomy

A prostatectomy is the surgical removal of all or part of the prostate gland. Abnormalities of the prostate, such as a tumour, or if the gland itself becomes enlarged for any reason, can restrict the normal fassessment

Nursing Assessment for Prostatectomy
  1. Subjective data:
    • Patients complain of pain at the incision.
    • Patients said they could not have sex.
    • Patients are always asking about the action taken.

  2. Objective Data:
    • There is the incision
    • Tachycardia
    • Restlessness
    • Blood pressure increases
    • Facial expressions of fear
    • Installed catheterlow of urine along the urethra.

Nursing Diagnosis for Prostatectomy

Acute Pain related to muscle spasm spincter


Goal :
After treatment, patients were able to adequately maintain a degree of comfort.

Expected outcomes:
  • Verbally patient expresses pain diminished or disappeared.
  • Patients can rest easy.

Nursing Intervention for Prostatectomy
  • Assess pain, note the location, intensity (scale 0-10)
  • Monitor and record the presence of pain, the location, duration and precipitating factors as well as pain relievers.
  • Observation of non-verbal signs of pain (anxiety, forehead wrinkle, increased blood pressure and pulse)
  • Give a warm ompres the abdomen, especially the lower abdomen.
  • Instruct patient to avoid stimulants (coffee, tea, smoking, abdominal strain)
  • Set the position of the patient as comfortable as possible, teach relaxation techniques
  • Perform therapeutic treatment of aseptic
  • Report your doctor if pain increases.

Nursing Care Plan for Knowledge Deficit

Knowledge Deficit : About the Disease Process

Definition:

The absence or lack of cognitive information in connection with a specific topic.

Defining characteristics:
  • verbalization of problems,
  • inaccuracies follow instructions,
  • inappropriate behavior.

Related factors:
  • cognitive limitations,
  • interpretations of misinformation,
  • lack of desire to seek information,
  • not knowing the sources of information.

NOC:
  • Kowlwdge: disease process
  • Kowledge: health behavior

Results Criteria:
  • Patients and families express an understanding of the disease, condition, prognosis and treatment programs
  • Patients and families are able to perform the procedure correctly explained
  • Patients and families are able to explain again what was described nurse / other health team

NIC:

Teaching: Disease Process
  • Give your assessment of the level of knowledge about the patient's specific disease process
  • Describe the pathophysiology of the disease and how it relates to anatomy and physiology, in a proper way.
  • Describe the usual signs and symptoms appear the disease, in a proper way
  • Describe the disease process, the proper way
  • Identify possible causes, dengna proper way
  • Provide information to patients about the condition, in a proper way
  • Avoid a hopeless
  • Provide information to families about the progress of patients in an appropriate manner
  • Discuss lifestyle changes that may be necessary to prevent complications in the future and controlling disease or process
  • Discuss the choice of therapy or treatment
  • Encourage the patient to explore or get a second view in a proper way or indicated
  • Exploration of possible sources or support, the proper way
  • Refer patients to the group or agency in the local community, in a proper way
  • Instruct the patient about the signs and symptoms to report on health care givers, in a proper way

Nursing Care Plan for Knowledge Deficit

Nursing Care Plan for Acute Pain

Acute Pain Nursing Care PlanAcute Pain

Definition:

An unpleasant sensory and emotional experience arising in an actual or potential tissue damage or describe the damage (International Association of Pain Study): a sudden attack or low in intensity from mild to severe which can be anticipated by the end of a predictable and with a duration less than 6 months .

Defining Characteristics:

  • Report of verbal or non verbal
  • The fact of the observation
  • Antalgic position to avoid pain
  • Movement to protect
  • Cautious behavior
  • Face masks
  • Sleep disturbances (eyes glazed, looking tired, difficult or chaotic motion, grinning)
  • Focused on self-
  • Focus narrowed (decreased perception of time, the damage is thought process, decreased interaction with people and the environment)
  • Behavior distraction, for example: roads, meet other people and / or activities, repetitive activities)
  • Autonomic Response (such as diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils)
  • Changes in muscle tone, autonomic (probably in the range from weak to stiff)
  • Expressive behavior (eg, restlessness, moaning, crying, alert, irritable, breath / bitching)
  • Changes in appetite and drinking

Related factors:

Injury agents (biological, chemical, physical, psychological)


NOC:
  • Pain Level,
  • Pain control,
  • Comfort level

Results Criteria:
  • Ability to control pain (know the cause of pain, able to use the technique nonfarmakologi to reduce pain, seek help)
  • Reported that the pain was reduced by using a pain management
  • Able to identify pain (scale, intensity, frequency and signs of pain)
  • Declare a sense of comfort after pain was reduced
  • Vital signs are within normal ranges

NIC:

Pain Management
  • Perform a comprehensive pain assessment includes the location, characteristics, duration, frequency, quality and factors presipitas
  • Observation of nonverbal reactions of discomfort
  • Use therapeutic communication techniques to determine the patient's pain experience
  • Assess the culture that affect the pain response
  • Evaluation of past experience of pain
  • Evaluate with the patient and other health care team about the ineffectiveness of past pain control
  • Help patients and families to seek and find support

Nursing Care Plan for Bartholinitis

Nursing Care Plan for Bartholinitis

Bartholinitis Bartolinitis

Bartholinitis an inflammatory condition of one or both Bartholin's glands, caused by bacterial infection. Usually the causative microorganism is a species of Streptococcus, Staphylococcus, or Escherichia coli, or a strain of gonococcus. The condition is characterized by swelling of one or both glands, pain, and development of an abscess in the infected gland. A fistula may develop from the gland to the vagina, anus, or perineum. Treatment includes local application of heat, often by soaking in hot water; antibiotics; or, if necessary, incision of the gland and drainage of the purulent material or excision of the entire gland and its duct.


Nursing Assessment Nursing Care Plan for Bartholinitis
  • Changes in skin color
  • Edema
  • Fluid in the gland
  • Pain
  • Lump on vaginal lips
  • The smell of the fluid
  • Cleanliness of the body
  • The number and color of urine

Nursing Diagnosis Nursing Care Plan for Bartholinitis
  1. Self-care deficit related to limitation of motion
  2. Impaired tissue integrity related to edema of the skin
  3. Knowledge Deficit related to a lack of understanding of sources of information
  4. Pain related to the wound
  5. Sexual dysfunction related to the disease process

Nursing Intervention Nursing Care Plan for Bartholinitis
  • Assisting patients to meet the personal hygiene
  • Monitor the state of the wound
  • Provide health education regarding self-care (hygiene tool genetal)
  • Assess the level of pain
  • Use an interactive way that focuses on the need to make adjustments in sexual practices or to improve coping with problems / sexual disorders.

Nursing Care Plan for Pleura Effusion


Nursing Care Plan for Pleura Effusion


Autor : Read More from NCP-Blog

NCP for Pleura Effusion



Pleural effusion


A pleural effusion is an accumulation of fluid between the layers of tissue that line the lungs and chest cavity.


Causes


Your body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity and surrounds the lungs. A pleural effusion is an abnormal, excessive collection of this fluid.

Two different types of effusions can develop:

* Transudative pleural effusions are caused by fluid leaking into the pleural space. This is caused by elevated pressure in, or low protein content in, the blood vessels. Congestive heart failure is the most common cause.
* Exudative effusions usually result from leaky blood vessels caused by inflammation (irritation and swelling) of the pleura. This is often caused by lung disease. Examples include lung cancer, lung infections such as tuberculosis and pneumonia, drug reactions, and asbestosis.


Symptoms


* Chest pain, usually a sharp pain that is worse with cough or deep breaths
* Cough
* Fever
* Hiccups
* Rapid breathing
* Shortness of breath

Sometimes there are no symptoms.
nlm.nih.gov


Assessment
  1. Anamnesis :
    In general, asymptomatic. The more fluid that buried more quickly and clearly the emergence of a complaint because it causes crowding, sub-febrile fever on the condition of tuberculosis.
  2. Needs resting and activity
    • Clients complain weak, short of breath with effort might and main, difficulty sleeping, fever in the afternoon or evening accompanied by sweating a lot.
    • Found a tachicardia, tachypnea / dyspnea with effort to breathe with a vengeance, changes in consciousness (in the advanced stage), muscle weakness, pain and stiffness (rigidity).
  3. Needs personal integrity
    • Clients reveal stress factors are long, and the need for help and hope
    • Can be found in the behavior of denial (especially in the early stages) and anxiety
  4. Needs Convenience / Pain
    • Clients report any chest pain because of cough
    • Can be found to protect the part that pain behavior, distraction, and less resting or fatigue
  5. Respiratory Needs
    • Clients reported cough, whether productive or non-productive, short of breath, chest pain
    • Can be found increased respiratory rate due to advanced disease and pulmonary fibrosis (parenchymal) and pleura, as well as an asymmetrical chest expansion, decreased vocal fremitus, deaf to percussion or decreased breath sounds on the side that suffered terdengan pleural effusion. Tubular breath sounds accompanied by soft pectoriloguy can be found in the lung lesions. Crackles can be found at the apex of short expiratory lung after coughing.
    • Sputum Characteristics: green or purulent, mucoid or yellow spots of blood
    • It can also be found in tracheal deviation
  6. Security Needs
    • Clients reveal circumstances of immunosuppression such as cancer, AIDS, sub-febrile fever
    • Can be found in circumstances of acute sub-febrile fever.
  7. Social interaction needs
    • The client expressed feelings of isolation due to illness, changes in role pattern.

Nursing Diagnosis

Ineffective airway clearance related to weakness and poor cough effort.


Nursing Intervention

NOC :
  • Demonstrate effective airway clearance and proved with respiratory status, gas exchange and ventilation are not dangerous :
    • Having a patent airway
    • Removing the secretion effectively.
    • Having a rhythm and respiratory frequency in the normal range.
    • Having a lung function within normal limits.
  • Show that adequate gas exchange is characterized by :
    • Easy to breathe
    • No anxiety, cyanosis and dyspnea.
    • Saturation of O2 in the normal range
    • Chest X-ray within the expected range.

NIC :
  • Assess and document :
    • The effectiveness of oxygen and other treatments.
    • The effectiveness of treatment.
    • Trends in arterial blood gases.
  • Anterior and posterior chest auscultated to determine the decrease or absence of ventilation and the presence of sound barriers.
  • Suction airway
    • Determine the need for sucking oral / tracheal.
    • Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
  • Maintain adequate hydration to reduce the viscosity of secretions.
  • Explain the use of support equipment properly, such as oxygen, suction equipment lenders.
  • Inform patients and families that smoking is an activity that is prohibited in the treatment room.
  • Instruct patients about cough and deep breathing techniques to facilitate the release of secretion.
  • Negotiate with respiratory therapists as needed.
  • Tell your doctor about the results of an abnormal blood gas analysis.
  • Assist in the provision of aerosols. Nebulizer and other pulmonary care according to institutional policies and protocols.
  • Encourage physical activity to improve the movement of secretions.
  • If the patient is unable to perform ambulation, the location of the patient sleeping position changed every 2 hours.
  • Inform patients before starting the procedure to reduce anxiety and increase self-control.

Nursing Care Plan for Rheumatoid Arthritis


Nursing Care Plan for Rheumatoid Arthritis


Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rheumatoid arthritis is typically a progressive illness that has the potential to cause joint destruction and functional disability.
Source : medicinenet.com


Nursing Assessment for Rheumatoid Arthritis
  1. Activity / rest
    • Symptoms: Joint pain due to movement, tenderness, worsened by stress on the joints, stiffness in the morning, usually bilateral and symmetrical. Functional limitations that affect lifestyle, leisure, work, fatigue.
    • Signs: The limited range of motion, muscle atrophy, skin, contractor / abnormalities in the joints.
  2. Cardiovascular
    • Symptoms: Raynaud's phenomenon fingers / legs (eg intermittent pale, cyanosis, and redness on the fingers before the color returned to normal).
  3. Ego integrity
    • Symptoms: Acute stress factors / chronic: eg, financial, employment, disability, relationship factors, Decision and powerlessness (inability situation), Threats to the self-concept, body image, personal identity (such as dependence on others).
  4. Food / fluid
    • Symptoms: Inability to produce / consume food / fluids adequately: nausea, anorexia, difficulty in chewing.
    • Signs: Weight loss, Drought on mucous membranes.
  5. Hygiene
    • Symptoms: The difficulties to carry out personal care activities. Dependence on others.
  6. Neuro Sensory
    • Symptoms: numbness, tingling in hands and feet, loss of sensation in fingers. Symmetrical joint swelling.
  7. Pain / comfort
    • Symptoms: The acute phase of pain (may not be accompanied by soft tissue swelling in joints).
  8. Security
    • Symptoms: The skin shiny, taut, subcutaneous nodules, skin lesions, leg ulcers. The difficulty in handling light duty / household maintenance. Drought mild fever settled on the eyes and mucous membranes.
  9. Social interaction
    • Symptoms: Damage of social interaction with family / others; changing role; isolation.

Nursing Care Plan for Pneumonia


Nursing Care Plan for Pneumonia


Nursing Care Plan for Pneumonia



Pneumonia

Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States.


Symptoms and Signs

Most people who develop pneumonia initially have symptoms of a cold (upper respiratory infection, for example, sneezing, sore throat, cough), which are then followed by a high fever (sometimes as high as 104 F), shaking chills, and a cough with sputum production. The sputum is usually discolored and sometimes bloody. Depending on the location of the infection, certain symptoms are more likely to develop. When the infection settles in the air passages, cough and sputum tend to predominate the symptoms. In some, the spongy tissue of the lungs that contain the air sacs is more involved. In this case, oxygenation can be impaired, along with stiffening of the lung, which results in shortness of breath. At times, the individual's skin color may change and become dusky or purplish (a condition known as "cyanosis") due to their blood being poorly oxygenated.

The only pain fibers in the lung are on the surface of the lung, in the area known as the pleura. Chest pain may develop if the outer aspects of the lung close to the pleura are involved. This pain is usually sharp and worsens when taking a deep breath and is known as pleuritic pain or pleurisy. In other cases of pneumonia, depending on the causative organism, there can be a slow onset of symptoms. A worsening cough, headaches, and muscle aches may be the only symptoms.

Children and babies who develop pneumonia often do not have any specific signs of a chest infection but develop a fever, appear quite ill, and can become lethargic. Elderly people may also have few symptoms with pneumonia.
www.medicinenet.com



Nursing Care Plan for Pneumonia


Nursing Assessment for Pneumonia
  1. Health History :
    • A history of previous respiratory tract infection / cough, runny nose, takhipnea, fever.
    • Anorexia, difficulty swallowing, vomiting.
    • History of disease associated with immunity, such as; morbili, pertussis, malnutrition, immunosuppression.
    • Other family members who suffered respiratory illness.
    • Productive cough, breathing nostrils, rapid and shallow breathing, restlessness, cyanosis.
  2. Physical Examination :
    • Fever, takhipnea, cyanosis, nostrils.
    • Auscultation of lung: wet ronchi, stridor.
    • Laboratory: leukocytosis, AGD abnormal, the LED increases.
    • Chest X-rays: abnormal (scattered patches of consolidation in both lungs).
  3. Psychosocial Factors :
    • Age, growth.
    • Tolerance / ability to understand the action.
    • Coping.
    • The experience of parting with the family / parents.
    • The experience of previous respiratory tract infections.
  4. Family Knowledge, Psychosocial :
    • The level family knowledge about the disease bronchopneumonia.
    • Experience in dealing with the family of respiratory disease.
    • Readiness / willingness of families to learn to care for her child.
    • Family Coping
    • The level of anxiety.
Nursing Diagnosis and Nursing Interventions for Pneumonia


Source : http://nanda-nursing.blogspot.com/2011/02/nursing-care-plan-for-pneumonia.html

Nursing Care Plan for Risk for Deficient Fluid Volume

Nursing Diagnosis for Risk for Deficient Fluid Volume


Risk for Deficient Fluid Volume

Definition: The decrease intravascular fluid, interstitial, and / or intrasellular. This leads to dehydration, loss of fluids with sodium expenditure.

Characteristics :

  • Weakness

  • Thirst

  • Decreased skin turgor / tongue

  • Mucous membrane / dry skin

  • Increased pulse rate, decreased blood pressure, decrease in volume / pulse pressure

  • Completion of decreased venous

  • Changes in the mental position

  • The concentration of urine increased

  • Increased body temperature

  • Elevated hematocrit

  • Weight loss immediately (except on third spacing)

Related Factors :
  • Loss of active fluid volume

  • Failure of regulatory mechanisms


NOC :

  • Fluid balance
  • Hydration
  • Nutritional Status: Food and Fluid Intake

Results Criteria :
  • Maintain urine output in accordance with age and body weight, urine specific gravity normal, normal HT
  • Blood pressure, pulse, body temperature within normal limits
  • There are no signs of dehydration, good skin turgor, mucous membranes moist, no excessive thirst
NIC :

Fluid Management

  • Weigh nappies / pads if necessary
  • Maintain a record intake and output accurately
  • Monitor position hydration (moisture of mucous membranes, adequate pulse, blood pressure orthostatic), if necessary
  • Monitor vital signs
  • Monitor the input of food / fluids and calculate daily calorie intake
  • Perform IV therapy
  • Monitor nutrition position
  • Give fluids
  • Give IV fluids at room temperature
  • Encourage oral input
  • Encourage families to help patients eat
  • Offer a snack (fruit juice, fresh fruit)
  • Collaboration doctor if signs of excessive fluid appears worse
  • Set possible transfusion
  • Preparations for transfusion

Source : http://nandanursingdiagnosis.blogspot.com/2011/06/risk-for-deficient-fluid-volume.html

Nursing Care Plan for Sepsis Neonatorum

Sepsis is a condition in which the body is fighting a severe infection that has spread via the bloodstream. If a patient becomes "septic," they will likely have low blood pressure leading to poor circulation and lack of perfusion of vital tissues and organs. This condition is termed "shock." This condition can develop either as a result of the body's own defense system or from toxic substances made by the infecting agent (such as a bacteria, virus, or fungus).

Causes

Many different microbes can cause sepsis. Although bacteria are most commonly the cause, viruses and fungi can also cause sepsis. Infections in the lungs (pneumonia), bladder and kidneys (urinary tract infections), skin (cellulitis), abdomen (such as appendicitis), and other areas (such as meningitis) can spread and lead to sepsis. Infections that develop after surgery can also lead to sepsis.

Source : emedicinehealth.com

NCP - Nursing Care Plan for Sepsis

Nursing Assessment
  • The main complaint: The client comes with a yellow body, lethargy, convulsions, did not want to suck, weak.
  • History of present illness: In the beginning it is not clear, and jaundice on the second day, but the incidence of jaundice it lasts more than 3 weeks, accompanied by lethargy, loss of reflexes of rooting, stiffness in the neck, increased muscle tone as well as asphyxia or hypoxia.
  • History of disease first: Mother patients had abnormal liver or liver damage due to obstruction.
  • History of family illness: A parent or family has a history of diseases associated with liver or blood.
  • Prenatal History: History of blood incompatibility, exchange transfusion or a history of light therapy in the previous baby, pregnancy complications, drugs given to the mother during pregnancy / delivery, delivery by action / complication.
  • Neonatal History: In clinical jaundice in neonates can be seen immediately after birth or several days later. Jaundice that appears highly dependent on the cause of jaundice itself. Babies suffering from respiratory distress syndrome, crigler-Najjar syndrome, neonatal hepatitis, pyloric stenosis, hyperparathyroidism, post-natal infections and others.

Nursing Diagnosis for Sepsis and Nursing Interventions for Sepsis
  1. High risk of injury (internal) related to liver damage secondary physiotherapy

    Marked by :
    • Baby's skin looks yellowish
    Goal :
    • injury did not occur
    Nursing Intervention :
    • Monitor bilirubin levels before starting treatment with light, report if there is an increase
    • Inspection of the skin, urine every 4 hours to see the color yellow, report what happened.
    Rational :
    • Knowing the bilirubin level and assist the effectiveness of therapy
    • Knowing how much bilirubin levels.

  2. Anxiety related to ignorance about the disease and the therapy given to infants.

    Goal :
    Parents know about treatment

    Nursing Intervention :
    • Assess family knowledge about infant jaundice treatment
    • Give an explanation of: Causes of jaundice, the process of therapy, and treatment.
    • Give an explanation of each will take action.
    • Talk about the baby and programs that will be done during the hospital.
    • Create a close relationship with the family during treatment.

    Rational :
    • Provide input for the nurse before doing education to the family's health
    • By understanding the causes of jaundice, which provided family therapy programs may accept any measures that are given to their babies.
    • Information is obviously very important in helping to reduce family anxiety
    • Communication openly in solving one problem can reduce the anxiety of the family.
    • An intimate relationship can increase the participation of families in caring for a baby jaundice.

Nursing Care Plan for Cholelitiasis

Definition

Cholelithiasis : Is the presence of gallstones in the gallbladder.


Causes :

The follow list shows some of the possible medical causes of Cholelithiasis that are listed by the Diseases Database :

* Sickle cell disease
* Somatostatinoma
* Clofibrate
* Erythropoietic protoporphyria
* Hypercalcaemia
* Combined oral contraceptive pill
* Hereditary spherocytosis
* Somatostatin
* Cystic fibrosis
* Haemoglobin E disease
* Haemolytic anaemia
* Lanreotide

Source: Diseases Database


Clinical ManifestationPatients with bile duct stones often have symptoms of chronic and acute.

Acute symptoms

* Signs:
o right epigastric pain and spasm
o Business tangible inspiration in the upper right kwadran
o enlarged and gall bladder pain
o mild jaundice

* Symptoms:
o pain (colic gall) that persist
o Nausea and vomiting
o febrile (38.5 ° ° C)


Chronic symptoms

* Signs:
o Normally invisible image on the abdomen
o Sometimes there is pain in the upper right kwadran

* Symptoms:
o pain (colic gall), Venue: upper abdominal (mid epigastrium), Nature: focusing on the epigastrium spreading toward the right scapula
o Nausea and vomiting
o Intolerance to fatty foods
o Flatulence
o Eruktasi (burp)
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Nursing Care Plan for Epilepsy

NCP for Epilepsy


Epilepsy


Epilepsy is a brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness.

Epilepsy has many possible causes, including illness, brain injury and abnormal brain development. In many cases, the cause is unknown.

Doctors use brain scans and other tests to diagnose epilepsy. It is important to start treatment right away. There is no cure for epilepsy, but medicines can control seizures for most people. When medicines are not working well, surgery or implanted devices such as vagus nerve stimulators may help. Special diets can help some children with epilepsy.

NIH: National Institute of Neurological Disorders and Stroke

Nursing Diagnosis

High risk of ineffective airway, breathing patterns related to damage the perception

Nursing Intervention :

Independent
  • Instruct patient to empty the mouth from the object / substance / dentures or other instrument if the aura phase occurs and to avoid the jaws shut if seizures occur without marked initial symptoms.
  • Place the patient in a tilted position, flat surface, tilt the head during a seizure.
  • Remove the clothing at the neck / abdomen.
  • Enter spatel tongue or soft rolls in accordance with an indication of the object.
  • Do imbibing as indicated.

Collaboration
  • Provide additional oxygen as required in phase posiktal.
  • Prepare to perform intubation, if there are indications

Nursing Care Plan for Hepatitis

NCP - Nursing Care Plan for Hepatitis

Hepatitis

Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E.

Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids (e.g. from blood transfusions or invasive medical procedures using contaminated equipment). Hepatitis B is also transmitted by sexual contact.

The symptoms of hepatitis include jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.
www.who.int


Nursing Assessment for Hepatitis
  1. Activity
    • Weakness
    • Fatigue
    • Depression

  2. Circulation
    • Bradycardia (hiperbilirubin weight)
    • Sclera jaundice on the skin, mucous membranes

  3. Elimination
    • Dark urine
    • Diarrhea Stool color clay

  4. Food and Fluids

  5. Neuro Sensory
    • Sensitive to stimuli
    • Tend to sleep
    • Lethargy
    • Asteriksis

  6. Pain / Leisure
    • Abdominal Cramps
    • Pain press, the right quadrant
    • Myalgia
    • Atralgia
    • Headache
    • Itching (pruritus)

  7. Security
    • Fever
    • Urticaria
    • Lesions makulopopuler
    • Erythema
    • Splenomegaly
    • Enlarged posterior cervical nodes

  8. Sexuality
    • Patterns of life / behavior increases the risk of exposure


Nursing Diagnosis for Hepatitis

  1. Imbalanced Nutrition: Less than Body Requirements related to feelings of discomfort in the upper right quadrant, impaired absorption and digestion of food metabolism, input failure to meet the metabolic demands because of anorexia, nausea and vomiting.
  2. Pain related to swelling of the liver is inflamed liver.
  3. Hypertermia related to invasive agent in the blood circulation secondary to hepatic inflammation.
  4. Fatigue related to chronic inflammatory process secondary to hepatitis.
  5. Risk for Impaired Skin Integrity related to pruritus secondary to accumulation of bilirubin pigments in bile salts.
  6. Risk for Infection related to the nature of the infectious viral agent

Nursing Intervention for Hepatitis

Expected results:
Showed increased body weight goals with normal laboratory values ​​and free from signs of mal nutrition.

Nursing Intervention :
  1. Teach and help the client to rest before eating
    R / fatigue continues down the desire to eat.
  2. Watch the dietary intake / amount of calories, offer eating little but often and am most often offer
    R / the enlargement of the liver can suppress the gastro intestinal tract and reduce its capacity.
  3. Maintain good oral hygiene before meals and after meals
    R / accumulation of food particles in the mouth can add a new and unpleasant taste that reduce appetite.
  4. Encourage eating in an upright sitting position
    R / decrease the feeling of fullness in the abdomen and can increase revenue.
  5. Provide high-calorie diet, low fat.
    R / glucose in carbohydrates is quite effective for the fulfillment of energy, while fat is difficult to be absorbed / metabolized so that it will burden the liver.
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Nursing Care Plan for Hepatitis : Assessment, Diagnosis and Interventions


Nursing Care Plan for Ineffective Individual Coping

NURSING DIAGNOSIS: Ineffective individual coping

related to:
  1. depression, fear, anxiety, and ongoing grieving associated with the diagnosis of AIDS and poor prognosis;
  2. need for permanent change in lifestyle associated with impaired immune system functioning and potential for disease transmission to others;
  3. uncertainty of disease course and feelings of powerlessness over course of disease;
  4. need for disclosure of diagnosis with possibility of subsequent rejection and/or distancing by others and loss of employment and health benefits;
  5. guilt associated with past behavior (if it was a factor in contracting HIV) and/or possibility of having transmitted HIV to others;
  6. lack of personal resources to deal with disability and premature death associated with youth (a significant number of clients are in their twenties or thirties and are not developmentally prepared to acknowledge and cope with disability and their own mortality);
  7. multiple losses (e.g. death of close friends with AIDS; loss of normal body functioning, family support, financial security, and/or usual lifestyle and roles);
  8. chronic symptoms (e.g. pain, diarrhea, fatigue) if present.


*The nurse should select the diagnostic label that is most appropriate for the client.

Desired Outcome
  1. The client will demonstrate adjustment to current health status and effective coping as evidenced by:
  2. verbalization of acceptance of having AIDS and ability to cope with the disease
  3. verbalization of a sense of control over health status
  4. utilization of appropriate problem-solving techniques
  5. willingness to participate in treatment plan and meet basic needs
  6. absence of destructive behavior toward self and others
  7. utilization of available support systems.


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Nursing Care Plans for Anxiety

Nursing Care Plans for Anxiety

A nursing care plan for Anxiety is used when a patient feels a vague, uneasy or discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual), a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.

Related factors for Anxiety :
  • Anesthesia
  • Invasive/noninvasive procedure
  • Interpersonal conflicts
  • Anticipated/actual pain
  • Loss of significant other
  • Threat to self-concept

Nursing Care Plan for Activity Intolerance

Nursing Care Plan for Activity Intolerance

A nursing care plan for Activity Intolerance is used when a patient has insufficient physiological or psychological energy to endure or complete required or desired daily activities

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications, or emotional states such as depression or lack of confidence to exert one’s self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Related to:
  • Generalized weakness / Fatigue
  • Malnourishment
  • Chronic disease
  • Stressors
  • Insufficient sleep or rest periods
  • Prolonged immobility/bed rest
  • Depression
  • Lack of motivation
  • Imbalance of oxygen supply and demand
  • Pain

As evidenced by:
  • Verbal report of fatigue or weakness
  • Inability to begin or perform activity
  • Abnormal heart rate or blood pressure (BP) response to activity
  • Exertional discomfort or dyspnea

Outcome:
  • The patient maintains activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.
  • Patient verbalizes and uses energy-conservation techniques.

Nursing Care Plan for Pain


Nursing Care Plans for Pain (Chronic/Acute)



Nursing Care Plans for pain can be used for patients having unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain).
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

*Acute pain – duration of less than 6 months
*Chronic pain – duration of greater than 6 months

RELATED FACTORS:
Acute:
  • Musculoskeletal disorder
  • Trauma
  • Pressure points
  • Emotional, psychological, spiritual or cultural distress
  • Cardiovascular pain
  • Diagnostic test or medical treatments
  • Pregnancy
  • Postoperative pain
  • Immobility/improper positioning
  • Anxiety/stress
Chronic:
  • Physical or psychological disability
AS EVIDENCED BY:
Acute:
  • Patient reports or demonstrates discomfort. (Pain Score)
  • Autonomic response to acute pain: (e.g., diaphoresis, change in BP, P, R, pupillary dilatation, pallor, nausea)
  • Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
  • Facial mask of pain
  • Guarding behavior, protecting body part
  • Relief or distraction behavior (e.g., moaning, crying, pacing, restlessness, seeking out other people or activities)
Chronic:
  • Weight changes
  • Atrophy of involved muscle group
  • Fear of re-injury
  • Reduced interaction of people
  • Altered ability to continue previous activities
  • Sympathetic mediated responses (e.g., temp., cold, changes of body position, hypersensitivity)
  • Verbal or observed evidence of protective behavior, guarding behavior, facial mask, irritability, self-focusing, restlessness, depression
PLAN AND OUTCOME
  • Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.
NURSING INTERVENTIONS:
ON GOING ASSESSMENT
  • Assess characteristics of pain: location, severity on a scale of 1 – 10, type, frequency, precipitating factors, and relief factors using the pain assessment form.
  • Observe or monitor signs and symptoms associated with pain, such as BP, HR, temperature, color & moisture of skin, restlessness and ability to focus. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.
  • Assess for probable cause of pain.
  • Assess patient’s knowledge of or preference for the types of pain relief strategies available. Some patients may be unaware of the effectiveness of non-pharmacological methods and may be willing to try them. Often a combination (e.g., mild analgesics with distraction or heat) may be most effective.
  • Evaluate the patient’s response to pain and medications or therapeutics aimed at abolishing or relieving pain. It is important to help the patients express as factually as possible the effect of pain relief measures.
  • Assess to what degree cultural, environmental, interpersonal, & intrapsychic factors may contribute to pain or pain relief. Evaluate the unique response of each patient rather than stereotyping any patient response.
  • If the patient is on PCA, assess the following: pain relief, patency of IV line, amount of pain medication the patient is requesting & possible PCA complications (excessive sedation, respiratory distress, urinary retention, nausea & vomiting, constipation, & IV site pain, redness or swelling.
  • Anticipate need for pain relief. One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required.
  • Respond immediately to complaint of pain. In the midst of painful experiences, a patient’s perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Teach patient to request analgesics before pain becomes severe.
  • Eliminate additional stressors or sources of discomfort whenever possible.
  • Provide rest periods to facilitate comfort, sleep, and relaxation. A quiet environment and a darkened room are measures that help facilitate rest.
  • Offer analgesics every __ hours or prn (according to physician’s order). Evaluate effectiveness and observe for any signs and symptoms of untoward effects.
  • Explore non-pharmacological methods for reducing pain/promoting comfort:
  1. Back rubs
  2. Slow rhythmic breathing
  3. Repositioning
  4. Diversional activities such as music, TV, etc.
  5. Warm or cold compress
  • Notify the physician if interventions are unsuccessful or if the current complaint is a significant change from the patient’s past experience of pain. Patients who request pain medications at more frequent intervals than prescribed may actually require higher doses or more potent analgesics.
Chronic Pain:
  • Encourage the patient to keep a pain diary to help in identifying aggravating and relieving factors of chronic pain.
  • Acknowledge and convey acceptance of the patient’s pain experience.
  • Provide the patient/family with information about chronic pain.
EDUCATION / CONTINUITY OF CARE
  • Provide anticipatory instruction on pain causes, appropriate prevention, and relief measures.
  • Instruct the patient to report pain & to evaluate and report effectiveness of measures used.
  • Teach patient effective timing of medication dose in relation to potentially uncomfortable activities and prevention of peak pain periods.
  • Teach the patient about non pharmacologic pain management strategies – cold/warm applications, massage, progressive relaxation, music, imagery, diversional activities, etc.
  • Teach the patient & family about the use of pharmacological interventions for pain management:
  1. Nonopioids (paracetamol; NSAIDs; & selective NSAIDs (COX-2 inhibitors) – can be taken orally and not associated with dependency and addiction.
  2. Opioid analgesics (narcotics) – watch for side effects such as nausea, vomiting, constipation, sedation, respiratory depression, tolerance and dependency.
  3. Antidepressants – may be useful adjuncts in a total program of pain management, especially for those with chronic neuropathic pain. In addition to their effect on the patient’s mood, the antidepressants may have analgesic properties apart from their antidepressant actions.
  • Refer the patient and family to community support groups and self-help groups for people coping with chronic pain.


More : Nursing Care Plan for Pain - Assessment, Diagnosis and Interventions

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