Nursing Care Plan

Nursing Care Plan

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NCP Hydrocephalus : Acute Pain and Ineffective Cerebral Tissue Perfusion

Hydrocephalus is a buildup of fluid inside the skull, leading to brain swelling. Hydrocephalus is caused by cerebrospinal fluid flow problems, the fluid that surrounds the brain and spinal cord. This fluid carries nutrients to the brain, eliminating waste from the brain, and acts as a cushion.

CSF normally moves through the area of the brain called ventricles, around the outside of the brain and spinal cord. This fluid is then absorbed into the bloodstream. Fluid buildup can occur in the brain if the flow or absorption is blocked or if too much fluid is produced. Accumulation of fluid puts pressure on the brain, pushing the brain to the skull and damaging or destroying brain tissue.

Hydrocephalus - Nursing Diagnosis and Interventions (NIC - NOC)

1. Ineffective cerebral tissue perfusion related to the increased volume of cerebrospinal fluid.

NOC: Circulation status

Expected outcomes (NOC):

1. Shows the status of circulation which is characterized by the following indicators:
  • Systolic and diastolic blood pressure within the expected range.
  • No orthostatic hypotension.
  • No noisy large blood vessels.

2. Demonstrate the cognitive abilities which is characterized by the following indicators:
  • Communicate clearly and in accordance with the age and ability.
  • Show attention, concentration and orientation.
  • Shows the long-term memory and the present.
  • Process information.
  • Making the decision properly.

NIC Intervention

Monitor  :

1. Vital signs.
2. Headache.
3. The level of awareness and orientation.
4. Diplopia, nystagmus, blurred vision, visual acuity.
5. Monitoring ICT
  • ICT monitoring and neurological response of patients to treatment activities.
  • Monitor the tissue perfusion pressure.
  • Note the change in the patient's response to a stimulus.
6. Management of peripheral sensation
  • Monitor for parestesis: numbness or tingling.
  • Monitor fluid status, including intake and output.

Collaborative Activity

1. Maintain the thermodynamic parameters within the recommended range.
2. Give medicines to increase intravascular volume, according to the request.
3. Give the drugs that cause hypertension to maintain cerebral perfusion pressure, according to the request.
4. Elevate the headboard of 0 to 45 degrees, depending on the patient's condition.

2. Acute Pain related to an increase in ICT


1. Pain Level
  • Reports of pain.
  • Frequency of pain.
  • The duration of pain.
  • Facial expressions to pain.
  • Anxiety.
  • Changes in vital signs.
  • Changes in pupil size.
2. Pain Control
  • Mention the factors that cause.
  • Mention the time of the pain.
  • Analgesic use as indicated.
  • Mention the painful symptoms.


1. Pain Management
  • Show overall assessment of pain including the location, characteristics, duration, frequency, quality, intensity and pain predisposing factors.
  • Observation of non-verbal cues of discomfort, especially if it can not communicate effectively.
  • Ensure patients receive appropriate analgesic.
  • Determine the impact of pain on quality of life (eg; sleep, activity, etc.).
  • Evaluation with the patient and health care team, the effectiveness of the control of pain in the past used.
  • Assess the patient and family to seek and provide support.
  • Provide information about pain, for example; cause, how long will expire and the anticipation of discomfort from the procedure.
  • Control of environmental factors that may influence a patient's response to discomfort (eg, room temperature, light and noise).
  • Teach for using non-pharmacological techniques (eg relaxation, guided imagery, music therapy, distraction, etc.).

Nursing Diagnosis for Morbid Obesity

Nursing Care Plan for Morbid Obesity

Obesity is defined as having excess fat in the body. Obesity increases the risk of other diseases, such as diabetes and high blood pressure. Doctors use the BMI (body mass index), which is based on weight and height to determine whether you suffer from obesity.

Extreme obesity or severe obesity known as morbid obesity. Morbid obesity is a condition where a person has a BMI over 40 or more.

Symptoms associated with obesity include:
  • Hard to sleep.
  • Snoring.
  • Stop breathing for a while suddenly during sleep.
  • Back pain or joint.
  • Excessive sweating.
  • Always feel hot.
  • Rash or infection of the skin folds.
  • Difficulty breathing.
  • Often sleepy and tired.
  • Depression.

There are genetic and hormonal influences on body weight. The most fundamental thing is that obesity occurs when the body receives more calories rather than burn it. Calories are then accumulate and become fat.

Obesity is usually the result of a combination of the following factors:
  • Not physically active so that the burning of fat becomes a little.
  • Eating high-calorie foods, especially fast food.
  • Some women difficult to lose weight after giving birth, it triggers obesity.
  • Lack of sleep.
  • Certain drugs, such as diabetes drugs, anti-seizure, antidepressants, antipsychotic, steroids and beta blockers.
  • Other medical problems.

Nursing Diagnosis for Morbid Obesity
  1. Imbalanced Nutrition: more than body requirements related to the increase in the intake of nutrients.
  2. Ineffective breathing pattern related to a decrease in lung expansion.
  3. Diarrhea related to changes in dietary fiber.
  4. Impaired tissue perfusion related to immobilization or bed rest.
  5. Disturbed Body Image or Low Self-Esteem related to psychosocial factors (emphasis to lose weight).
  6. Activity intolerance related to being overweight.
  7. Excess fluid volume relate to excess intake of sodium / fluid.

Disturbed Body Image related to Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Rheumatoid arthritis is a disease which has long been known and spread throughout the world and involving all races and ethnic groups. Rheumatoid arthritis is often found in women, with the ratio of women to men is 3: 1. The tendency for women suffering from rheumatoid arthritis and remissions are common in women who are pregnant, this raises the suspicion of the presence of hormonal balance factor as one of the factors that affect this disease.

Most patients show symptoms of chronic intermittent disease, which if left untreated will cause damage to joints and progressive joint deformity that causes disability and even premature death.

Disturbed Body Image related to changes in the ability to perform the duties of a general, an increase in energy use, the imbalance of mobility.

Evidenced by:
  • Changes in the function of diseased body parts.
  • Focus on past strength and appearance.
  • Changes in lifestyle / physical ability to continue the role, job loss, dependence on the nearest person.
  • Changes in social engagement; a feeling of isolation. Feelings of helplessness, hopelessness.

Expected outcomes: The patient will :
  • Expressing increased confidence in the ability to cope with illness, changes in lifestyle, and possible limitations.
  • Develop a realistic plan for the future.

Intervention and Rationale

1. Encourage disclosure about the problem of the disease process, hope for the future.
R /: Give the opportunity to identify the fear / misconceptions and deal with it directly.

2. Discuss the meaning of loss / change in patients / people nearby. Ascertain how the patient's personal views on the functioning of day-to-day lifestyle.
R /: Identify how the disease affects self-perception and interaction with others will determine the need for intervention / counseling further.

3. Discuss the patient's perception of how the people closest to accept limitations.
R /: Gestures verbal / non-verbal people nearby can have a major influence on how the patient sees himself.

4. Acknowledge and accept the feelings of the bereaved, hostile, dependency.
R /: constant pain would be exhausting, and feelings of anger and hostility are common.

5. Pay attention to the behavior of withdrawing, denying use or too noticed a change.
R /: Can demonstrate emotional or maladaptive coping methods, requiring further intervention.

7. Involve patients in the treatment plan and schedule of activities.
R /: Increase the feeling of self-esteem, encourage independence, and encourage participation in therapy.

8. Assist in need of care required.
R /: Maintaining the appearance that can improve self-image.

9. Provide positive support when necessary.
R /: Allows patients to feel good about themselves. Reinforcing positive behavior. Increase confidence.

10. Collaboration: Refer to psychiatric counseling, eg specialist psychiatric nurse, psychologist.
R /: Patient / person nearby may need support for dealing with long-term process / incapacity.

11. Collaboration: Give medicines as directed, eg; antianxiety drugs and mood enhancer.
R /: It may be required at the time of the advent of the Great Depression, until the patient increases coping abilities more effectively.

Gastroesophageal Reflux Disease (GERD) - Assessment and Physical Examination

Gastroesophageal Reflux Disease (GERD) - Assessment

1. General condition
Covering conditions such as the level of tension / fatigue, qualitative level of consciousness or GCS and client verbal response.

2. Vital signs
Includes examining:
Blood pressure: should be examined in a different position, assess the pulse pressure, and pathological conditions.
Pulse rate.
Respiratory rate.

3. Main complaint
Assessed onset, duration, quality and characteristics, severity. Location, precipitating factors, related manifestations:
Typical complaints (esophagus): heartburn, regurgitation, and dysphagia.
Atypical Complaints (extra esophagus): chronic cough, hoarseness, pneumonia, pulmonary fibrosis, bronchiectasis, and non-cardiac chest pain.
Another complaint: weight loss, anemia, hematemesis or melena, odynophagia.

4. Past medical history/Previous health
Other gastrointestinal diseases.
Drugs that affect gastric acid.
Allergy / immune response reaction.

5. Family medical history

Physical Examination

1. General condition: The general condition may include an impression of illness including facial expressions and patient positioning, awareness may include qualitative assessment.

2. Examination of vital signs: pulse (frequency, rhythm, quality), blood pressure, respiration (frequency, rhythm, depth, respiratory pattern) and body temperature.

3. Examination of the skin, hair and lymph nodes.
Skin: The color (pigmentation, cyanosis, jaundice, pale, erythema and others), turgor, skin moisture and the presence / absence of edema.
Hair: color, luxuriance, distribution and other characteristics.
Lymph nodes: the shape and signs of inflammation that can be assessed in the anterior cervical region, inguinal, occipital and retroauricular.

4. Examination of the head and neck
Head: the shape and size of the head, the hair and scalp, the crown of the head (fontanelle), seen from the eyes of vision, palpebrae, eyebrows eyelashes, conjunctiva, sclera, pupil, lens,
Ear: ear canal, tympanic membrane, mastoid, auditory acuity,
Nose and mouth: lips, gums, tongue, salivation.
Neck: Neck stiffness, size, shape, position, consistency, and presence or absence of pain swallow.

5. Chest examination: Examination of the chest is the organ of the lung and heart. In general, the form asked the chest, lungs state which includes symmetric, the movement of the breath.

6. Examination of the abdomen: about the size or shape of the abdomen, abdominal wall, bowel, abdominal wall tension or tenderness, and palpation in the liver, spleen, kidneys, bladder that determined the presence or absence and the enlargement of the organ, then examination of the anus, rectum and genetal.

7. Examination of the limbs and neurologic: checked for range of motion, balance and gait, the grip, the leg muscles, and others.

Chronic Pain related to Stomach Cancer

Nursing Care Plan for Stomach Cancer

Stomach Cancer is a disease that occurs in the stomach. The average age of patients with stomach cancer is 45 years and above. However there are cases where the disease is under the age of 45 years.Like most other types of cancer, stomach cancer cause is not known with certainty.

But according to some experts, the cause of stomach cancer is suspected because of the bacterium Helicobacter pylori, less healthy eating patterns, consuming less vegetable fiber, or fruit and unhealthy lifestyles, such as smoking, alcohol consumption and eating food that is burned.

In the early stages, the symptoms of gastric cancer is not clear. This can lead to gastric cancer patients often come to the doctor in a state of advanced stage. Symptoms at this stage may include a burning sensation in the pit of the stomach, weight loss and discomfort in the upper abdomen.

While symptoms at an advanced stage may include pain in the upper abdomen, nausea, vomiting, drastic weight loss, vomiting of blood, black bowel, anemia and accompanied by symptoms spread in other organs. For example, an enlarged liver, jaundice, enlarged abdomen due to accumulation of fluid or ascites, and so forth.

Nursing Diagnosis : Chronic Pain related to irritation of the mucosa of the esophagus, surgical response.

Goal: Pain is reduced or adapted.

Expected outcomes:
  • Subjectively say the pain is reduced or adapted.
  • Pain scale 0-2.
  • Vital signs within normal limits.
  • The face looks relaxed.

Interventions and Rationale :

1. Explain and help the patient with pain relief measures, non-pharmacological and noninvasive.
R/ : Approach by using relaxation and nonpharmacological therapy has demonstrated effectiveness in reducing pain.

2. Assess pain with PQRST approach.
R/ : PQRST approach can comprehensively assess the condition of the patient's pain. If the patient experiences pain scale 3 (on a scale of 0-4), this is a warning that needs to be alert because the clinical manifestations of postoperative complications esophagectomy.

3. Rest the patient when pain appears.
R /: Rest, physiologically reduces the need for oxygen required for basal metabolic needs.

4. Encourage deep breathing relaxation techniques when pain appears.
R /: Increase the intake of oxygen, thereby decreasing pain, secondary to intestinal ischemia.

5. Teach technique of distraction during painful.
R /: Distraction (diversion) can reduce internal stimulation.

6. Treating patients in intensive care.
R /: In order to control the patient's pain must be treated in intensive care. Quiet environment will reduce external pain stimulus. Restrictions on visitors to help improve the condition of the room oxygen which would be reduced if a lot of visitors who are in the room. Rest will decrease the oxygen demand of peripheral tissues.

7. Perform touch management.
R /: Touch management - a touch of psychological support - can help reduce pain.

8. Increase knowledge of patients regarding the causes of pain and develop how long the pain will last.
R /: Knowledge will help reduce the pain and can help develop a plan patient adherence to therapy.

Hyperthermia related to Neonatal Sepsis

Nursing Diagnosis and Interventions for Neonatal Sepsis

Sepsis is a syndrome characterized by clinical signs and symptoms of severe infection that can progress toward septicemia and septic shock. (Doenges, 1999)

While neonatal sepsis is a severe infection that affects neonates with systemic symptoms and there are bacteria in the blood. Neonatal sepsis course of the disease can take place quickly so often not monitored, without adequate treatment babies can die within 24 to 48 hours. (Surasmi, 2003).

Nursing Diagnosis and Interventions for Neonatal Sepsis

Hyperthermia related to damage control temperature, secondary to infection or inflammation.

Expected outcomes:
  • The body temperature within normal limits.
  • Pulse and breathing frequency within normal limits.

Intervention and Rationale:

1. Monitoring of vital signs every two hours and monitor skin color.
R /: Changes in vital signs that would significantly affect the regulatory processes or metabolism in the body.

2. Observation of seizures and dehydration.
R /: Hyperthermia potential to cause seizures that will worsen the patient's condition and can cause the patient to lose a lot of fluid in the evaporation of an unknown number and can cause the patient goes into a state of dehydration.

3. Give compress with warm water in the axilla, neck and groin, avoid using alcohol to compress.
R /: Compress the axilla, neck and groin are large blood vessels, which helps reduce fever. The use of alcohol is not done because it will cause a decrease and an increase in heat drastically.

4. Collaboration: Give antipyretics as needed if the heat does not go down.
R /: Giving antipyretics are also required to reduce the heat immediately.

Nursing Care Plan for Hyperthermia

Psychotherapy of Anxiety Disorders

Anxiety, worry, fear, is a common psychological symptoms and can be felt by each individual. Anxiety reactions usually occur frequently in adults, but children can also face the anxiety, such as temporarily abandoned by parents, first day of school or at the time wanted the exam. In the case of the elderly, the reaction of anxiety often occur when they face the pressure (stress) with the difficulties that can be faced and the difficulties that can not be faced, such as work pressure, pressure at school / college, the pressure on the issue of romance as well as pressure on health issues.

Excessive anxiety reaction and settled continuously over a considerable period of time can turn into a disorder, which anxiety disorder. The nature of anxiety disorders can produce a response to the physical and psychological.

Anxiety disorder is a serious mental illness characterized by feelings of great anxiety and excessive, such as feelings of excessive fear, heart pounding harder, shortness of breath, sweating, breathing short, easy to feel dizzy and feeling uneasy.

People who have anxiety disorders often experience these reactions and more severe, causing them distress and causes them unable to perform their daily work. They become very alert, because it is afraid of danger, as a result they are difficult to relax and also difficult to feel at ease in many situations.