Nursing Care Plan

Nursing Care Plan for Empyema

Nursing Care Plan for Empyema

Empyema

Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space).

Symptoms

Chest pain, which worsens when you breathe in deeply (pleurisy)
Dry cough
Excessive sweating, especially night sweats
Fever and chills
General discomfort, uneasiness, or ill feeling (malaise)
Shortness of breath
Weight loss (unintentional)

Nursing Diagnosis of Empyema 1:

Ineffective airway clearance related to bronchus spsame, increased production of secretions, weakness

Nursing Intervention and Rational:

Auscultation of breath sounds: note the presence of breath sounds, assess and monitor breathing sounds
R /: To determine the presence of airway obstruction, the degree yan tachipneu found the process of acute infection.

Assess the frequency of respiratory
R /: The process of acute infection (tachipnea)

Nursing diagnosis of empyema 2:

Impaired Gas Exchange related to airway obstruction secondary to the buildup of secretions, Bronchospasme

Nursing Intervention and Rational:

Assess the frequency and depth of breathing, note the use of auxiliary respiratory muscles and an inability to speak due to shortness
R /: Evaluation of the degree of respiratory distress or failure and chronic disease processes.

Help clients to find a position that facilitates breathing, with the head higher
R /: Supply of oxygen can be updated, in order to practice breathing lungs do not collapse.

Nursing diagnosis of empyema 3:

Imbalanced Nutrition, Less Than Body Requirements related to Shortness of breath, anorexia, nausea, vomiting, drug effects, weakness

Nursing Intervention and Rational:

Obserasi intake and output / 8 hours. The amount of food consumed each day and measuring body weight each day
R /: Identifying the lack of progress / storage of the expected goal

Create a fun atmosphere, an environment free of odor during meal times:

Perform mouth care before and after meals
Clean environment in which the presentation of food
Avoid use of foul-smelling fragrances
Perform chest physiotherapy and nebulizer at least one hour before meals
Provide a place to dispose of tissues / secretions cough

R /: The smells and sights that are not pleasant during the meal can lead to anorexia. The drugs are given soon after a meal can trigger nausea and vomiting.

Nursing Care Plan for Perinatal Asphyxia

Nursing Care Plan , Nursing Care Plan for Perinatal Asphyxia

NCP - Nursing Care Plan for Perinatal Asphyxia

Perinatal asphyxia or neonatal asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually to the brain. Hypoxic damage can occur to most of the infant's organs (heart, lungs, liver, gut, kidneys), but brain damage is of most concern and perhaps the least likely to quickly or completely heal. In the more pronounced cases, an infant will survive, but with damage to the brain manifested as either mental, such as developmental delay or intellectual disability, or physical, such as spasticity — in fact, spastic diplegia and the other forms of cerebral palsy almost always feature asphyxiation during the birth process as a major, if not defining, factor.

Nursing Assessment for Perinatal Asphyxia

Physical Examination

Respiratory system
- Low Apgar scores
- Breathing shallow, irregular, tachypnea
- Snoring, breathing nostrils, retracted suplasternal / substernal, cyanosis
- Baby does not breathe / breath over 30 x

Cardiovascular system
- Optimal pulse, rapid or irregular may be within the normal range (120-160 x / min)
- Heart rate more than 100

Integument system
- Presence of cyanosis / pallor - indication of gravity hypoksia
- Pitting edema of the hands and feet
Digestive system
- Weak reflexes
- Lethargy
- Small stomach capacity
Muskoloskeletas system
- Decreased muscle tone
- Edema, weak reflexes, there are no lines on the soles of the feet most / all of the palm.

Nursing Diagnosis Nursing Care Plan for Perinatal Asphyxia

Ineffective Breathing Pattern related to immaturity of the respiratory organs

Risk of hypothermia related to systems that have not been mature thermoregulasi

Imbalanced Nutrition, Less Than Body Requirements related to weak sucking reflex

Nursing Care Plan for Cerebral Palsy (CP)

Cerebral Palsy , Nursing Care Plan

NCP - Nursing Care Plan for Cerebral Palsy (CP)

Cerebral palsy (CP) is an umbrella term for a group of disorders affecting body movement, balance, and posture. Loosely translated, cerebral palsy means “brain paralysis.” Cerebral palsy is caused by abnormal development or damage in one or more parts of the brain that control muscle tone and motor activity (movement). The resulting impairments first appear early in life, usually in infancy or early childhood. Infants with cerebral palsy are usually slow to reach developmental milestones such as rolling over, sitting, crawling, and walking.

Treatment

Treatment for cerebral palsy is a lifelong multi-dimensional process focused on the maintenance of associated conditions. In order to be diagnosed with cerebral palsy the damage that occurred to the brain must be non-progressive and not disease like in nature. The manifestation of that damage will change as the brain and body develop, but the actual damage to the brain will not increase. Treatment in the life of cerebral palsy is the constant focus on preventing the damage in the brain from prohibiting healthy development on all levels. The brain, up to about the age of 8, is not concrete in its development. It has the ability to re-organize and re-route many signal paths that may have been affected by the initial trauma; the earlier it has help in doing this the more successful it will be. Various forms of therapy are available to people living with cerebral palsy as well as caregivers and parents caring for someone with this disability. They can all be useful at all stages of this disability and are vital in a person with cerebral palsy's ability to function and live more effectively. In general, the earlier treatment begins the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them. The earliest proven intervention occurs during the infant's recovery in the neonatal intensive care unit (NICU). Treatment may include one or more of the following: physical therapy; occupational therapy; speech therapy; drugs to control seizures, alleviate pain, or relax muscle spasms (e.g. benzodiazepienes, baclofen and intrathecal phenol/baclofen); hyperbaric oxygen; the use of Botox to relax contracting muscles; surgery to correct anatomical abnormalities or release tight muscles; braces and other orthotic devices; rolling walkers; and communication aids such as computers with attached voice synthesizers. For instance, the use of a standing frame can help reduce spasticity and improve range of motion for people with CP who use wheelchairs. Nevertheless, there is only some benefit from therapy. Treatment is usually symptomatic and focuses on helping the person to develop as many motor skills as possible or to learn how to compensate for the lack of them. Non-speaking people with CP are often successful availing themselves of augmentative and alternative communication systems such as Blissymbols. Constraint-induced movement therapy (CIMT) has shown promising evidence in helping individuals with neurological disorders that have lost most of the use of an extremity. Research has proven the positive benefits of CIMT for people who have had a stroke and traumatic brain injury. However, later studies have addressed the application of CIMT for children with CP challenged with hemiparesis, that show a significant benefit in constraint induced movement therapy for children with cerebral palsy who are challenged with hemiparesis.wikipedia

Nursing Diagnosis Nursing Care Plan for Cerebral Palsy (CP)

Risk for Injury related to disturbances in motor function
Imbalanced Nutrition, Less Than Body Requirements related to difficulty swallowing and increased activity
Activity Intolerance related to disorders of movement and posture that is not progressive
Ineffective Tissue Perfusion related to cerebral edema that change / stop the blood flow of arterial / venous
Risk for Infection related to suppression of inflammatory response (due to - drugs)
Knowledge Deficit related to home care and therapeutic needs

Nursing Care Plan for Peptic Ulcer

Nursing Care Plan , Nursing Care Plan for Peptic Ulcer

A peptic ulcer is a sore in the lining of your stomach or your duodenum, the first part of your small intestine. A burning stomach pain is the most common symptom. The pain :

May come and go for a few days or weeks
May bother you more when your stomach is empty
Usually goes away after you eat

Peptic ulcers happen when the acids that help you digest food damage the walls of the stomach or duodenum. The most common cause is infection with a bacterium called Helicobacter pylori. Another cause is the long-term use of nonsteroidal anti-inflammatory medicines (NSAIDs) such as aspirin and ibuprofen. Stress and spicy foods do not cause ulcers, but can make them worse.

Nursing Assessment Nursing Care Plan for Peptic Ulcer

Assess for chronic use of certain medications (such as aspirin, steroids).
Collect information of complaints that brought client to the hospital.
Obtain history of onset and progression of symptoms.
Obtain information of diet, use of alcohol and tobacco, ingestion of irritating foods, previous diseases or infections of GI tract, emotional stress.
Assess connection of pain attacks to meals, certain drugs, ingestion of coffee, alcohol.
Perform complete physical assessment including weight, vital signs, signs of GI bleeding, and acute abdomen.
Assess diagnostic tests and procedures for abnormal values

Nursing Diagnosis for Peptic Ulcer

Acute Pain related to irritation of the mucosa and muscle spasms.
Anxiety related to the nature and management of long-term illness
Imbalanced Nutrition: Less than Body Requirements related to pain associated with food.
Knowledge deficient the prevention, symptoms and treatment of conditions related to inadequate information.

Nursing Intervention Nursing Care Plan for Peptic Ulcer

Goals :

Reduce or completely eliminate contributing factors.
Assist with stress management.
Promote adequate nutrition.
Prevent avoidable injury.
Then surgical intervention prescribed, prevent postoperative complications.
Relief or diminish symptoms.
Decreased anxiety with increased knowledge of disease, it treatment, way of prevention and follow-up.

Nursing Interventions

Assess, report , and record signs and symptoms and reactions to treatment.
Monitor fluids input and output closely.
Administer antacid agents, analgesics, H2-receptors antagonists, anticholinergics, sedatives as prescribed, monitor for side effects.
Monitor client’s vital signs and signs of possible GI bleeding or perforation closely.
Monitor laboratory tests results (CBC, electrolytes, Hb levels) for abnormal values.
Undertake appropriate intervention in case of GI bleeding, vomiting, or perforation.
Provide prescribed diet – avoid irritating foods, coffee, etc.
Prepare client and his family for surgical intervention if required for recurrent ulcer, hemorrhage, or perforation.
For client after surgical intervention provide postoperative care and inform about possible postoperative complications, such as dumping syndrome.
Provide emotional support to client, explain all procedures to decrease anxiety and to obtain cooperation.
Instruct client regarding disease progress, diagnostic procedures, treatment and its complications, home care, daily activities, diet, restrictions and follow-up.

Nursing Care Plan for Delusional Disorders

Delusional Disorder , Nursing Care Plan

NCP For Delusional Disorders

Delusional Disorder

Delusional disorder is an illness characterized by the presence of nonbizarre delusions in the absence of other mood or psychotic symptoms, according to the Diagnostic Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). It defines delusions as false beliefs based on incorrect inference about external reality that persist despite the evidence to the contrary and these beliefs are not ordinarily accepted by other members of the person's culture or subculture.

Nonbizarre refers to the fact that this type of delusion is about situations that could occur in real life, such as being followed, being loved, having an infection, and being deceived by one's spouse.

Delusional disorder is on a spectrum between more severe psychosis and overvalued ideas. Bizarre delusions represent the manifestations of more severe types of psychotic illnesses (eg, schizophrenia) and "are clearly implausible, not understandable, and not derived from ordinary life experiences".

On the other end of the spectrum, making a distinction between a delusion and an overvalued idea is important, the latter representing an unreasonable belief that is not firmly held. Additionally, personal beliefs should be evaluated with great respect to complexity of cultural and religious differences: some cultures have widely accepted beliefs that may be considered delusional in other cultures.

Unfortunately, patients with delusional disorder do not have good insight into their pathological experiences. Interestingly, despite significant delusions, many other psychosocial abilities remain intact, as if the delusions are circumscribed. Indeed, this is one of the key differences between delusional disorder and other primary psychotic disorders. However, the individual may rarely seek psychiatric help, remain isolated, and often present to internists, surgeons, dermatologists, policemen, and lawyers rather than psychiatrists. Despite this, their prognosis, while not good, is not as bad as other more severe disorders.

Current Diagnosis Criteria

DSM-IV-TR defines delusional disorder with the following criteria:

A: Nonbizarre delusions (ie, involving situations that occur in real life, such as being followed, poisoned, infected, loved at distance, deceived by spouse or lover, or having a disease) occurring for at least 1 month's duration.
B: Criterion A for schizophrenia has never been met (ie, patients do not have simultaneous hallucinations, disorganized speech, negative symptoms such as affective flattening, or grossly disorganized behavior). Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme.
C: Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
D: If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
E: The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition.

Subtypes are defined as erotomanic, grandiose, jealous, persecutory, somatic, mixed, and unspecified.
emedicine.medscape.com

Diagnoses for Delusional Disorders

Anxiety
Disabled family coping
Disturbed personal identity
Disturbed sensory perception (visual, auditory)
Disturbed thought processes
Fear
Imbalanced nutrition: Less than body requirements
Impaired home maintenance
Impaired social interaction
Ineffective coping
Powerlessness
Risk for injury
Risk for other-directed violence
Risk for self-directed violence
Social isolation

Key outcomes for Delusional Disorders

The patient will consider alternative interpretations of a situation without becoming hostile or anxious.
The patient and his family will participate in care and prescribed therapies.

The patient will identify internal and external factors that trigger delusional episodes.
The patient will maintain functioning to the fullest extent possible within the limitations of his visual or auditoryimpairment.
The patient will remain oriented to person, place, time, and situation.
The patient will express all fears and concerns.
The patient will show no signs of malnutrition.
The patient will recognize symptoms and comply with medication regimen.
The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
The patient will demonstrate adaptive coping behaviors.
The patient will identify and perform activities that decrease delusions.
The patient will remain free from injury.
The patient won't harm others.
The patient won't harm self.
The patient will maintain family and peer relationships.

Interventions for Delusional Disorders

In dealing with the patient, be direct, straightforward, and dependable. Whenever possible, elicit his feedback. Move slowly, with a matter-of-fact manner, and respond without anger or defensiveness to his hostile remarks.
Accept the patient's delusional system. Don't attempt to argue with him about what's real.
Respect the patient's privacy and space needs. Avoid touching him unnecessarily.
Take steps to reduce social isolation, if the patient allows. Gradually increase social contacts after he has become comfortable with the staff.
Watch for refusal of medication or food, resulting from the patient's irrational fear of poisoning.
Monitor the patient carefully for adverse effects of neuroleptic drugs: drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome.

http://ncp-blog.blogspot.com/2010/11/ncp-for-delusional-disorders.html

Nursing Care Plan for Bowel Incontinence

Bowel Incontinence , Nursing Care Plan for Bowel Incontinence

Definition:

Change in normal bowel habits characterized by involuntary passage of stool.

Related Factors:

Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele); sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles); neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (cerebrovascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellitus, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis)

Defining Characteristics:

Constant dribbling of soft stool, fecal odor; inability to delay defecation; rectal urgency; self-report of inability to feel rectal fullness or presence of stool in bowel; fecal staining of underclothing; recognizes rectal fullness but reports inability to expel formed stool; inattention to urge to defecate; inability to recognize urge to defecate, red perianal skin

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Bowel Continence
Bowel Elimination

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Bowel Incontinence Care
Bowel Training
Bowel Incontinence Care: Encopresis

Client Outcomes

Regular, complete evacuation of fecal contents from the rectal vault
Defecates soft-formed stool
Decreased or absence of bowel incontinence incidences
Intact skin in the perianal/perineal area
Demonstrates the ability to isolate, contract, and relax pelvic muscles , Increases pelvic muscle strength .

Nursing Care Plan for Deficient Knowledge

Deficient Knowledge , Nursing Care Plan for Deficient Knowledge

NANDA Definition: Absence or deficiency of cognitive information related to specific topic

Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Teaching may take place in a hospital, ambulatory care, or home setting. The learner may be the patient, a family member, a significant other, or a caregiver unrelated to the patient. Learning may involve any of the three domains: cognitive domain (intellectual activities, problem solving, and others); affective domain (feelings, attitudes, beliefs); and psychomotor domain (physical skills or procedures). The nurse must decide with the learner what to teach, when to teach, and how to teach the mutually agreed-on content. Adult learning principles guide the teaching-learning process. Information should be made available when the patient wants and needs it, at the pace the patient determines, and using the teaching strategy the patient deems most effective. Many factors influence patient education, including age, cognitive level, developmental stage, physical limitations (e.g., visual, hearing, balance, hand coordination, strength), the primary disease process and other comorbidities, and sociocultural factors. Older patients need more time for teaching, and may have sensory-perceptual deficits and/or cognitive changes that may require a modification in teaching techniques. Certain ethnic and religious groups hold unique beliefs and health practices that must be considered when designing a teaching plan. These practices may vary from "home remedies" (e.g., special soups, poultices) and alternative therapies (e.g., massage, biofeedback, energy healing, macrobiotics, or megavitamins in place of prescribed medications) to reliance on an elder in the family to coordinate the plan of care. Patients with low literacy skills will require educational programs that include more simplified treatment regimens, simplified teaching tools (e.g., cartoons, lower readability levels), a slower presentation pace, and techniques for cueing patients to initiate certain behaviors (e.g., pill schedule posted on refrigerator, timer for taking medications).

Although the acute hospital setting provides challenges for patient education because of the high acuity and emotional stress inherent in this environment, the home setting can be similarly challenging because of the high expectations for patients or caregivers to self-manage complex procedures such as IV therapy, dialysis, or even ventilator care in the home. Caregivers are often overwhelmed by the responsibility delegated to them by the health care professionals. Many have their own health problems, and may be unable to perform all the behaviors assigned to them because of visual limitations, generalized weakness, or feelings of inadequacy or exhaustion.

Deficient Knowledge This care plan describes adult learning principles that can be incorporated into a teaching plan for use in any health care setting.

Defining Characteristics:

Questioning members of health care team
Verbalizing inaccurate information
Inaccurate follow-through of instruction
Denial of need to learn
Incorrect task performance
Expressing frustration or confusion when performing task
Lack of recall

Related Factors:

New condition, procedure, treatment
Complexity of treatment
Cognitive/physical limitation
Misinterpretation of information
Decreased motivation to learn
Emotional state affecting learning (anxiety, denial, or depression)
Unfamiliarity with information resources

Expected Outcomes

Patient demonstrates motivation to learn.
Patient identifies perceived learning needs.
Patient verbalizes understanding of desired content, and/or performs desired skill.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Knowledge (Specify Type)
Information Processing

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Learning Facilitation
Teaching: Individual

Ongoing Assessment

Determine who will be the learner: patient, family, significant other, or caregiver. Many elderly or terminal patients may view themselves as dependent on their caregiver, and therefore will not want to be part of the educational process.
Assess motivation and willingness of patient and care-givers to learn. Adults must see a need or purpose for learning. Some patients are ready to learn soon after they are diagnosed; others cope better by denying or delaying the need for instruction. Learning also requires energy, which patients may not be ready to use. Patients also have a right to refuse educational services.
Assess ability to learn or perform desired health-related care. Cognitive impairments need to be identified so an appropriate teaching plan can be designed. For example, the Mini-Mental Status Test can be used to identify memory problems that would interfere with learning. Physical limitations such as impaired hearing or vision, or poor hand coordination can likewise compromise learning and must be considered when designing the educational approach. Patients with decreased lens accommodation may require bolder, larger fonts or magnifying mirrors for written material.
Identify priority of learning needs within the overall plan of care. Adults learn material that is important to them.
Question patient regarding previous experience and health teaching. Adults bring many life experiences to each learning session. Adults learn best when teaching builds on previous knowledge or experience.
Identify any existing misconceptions regarding material to be taught. This provides an important starting point in education.
Determine cultural influences on health teaching. Providing a climate of acceptance allows patients to be themselves and to hold their own beliefs as appropriate.
Determine patient’s learning style, especially if patient has learned and retained new information in the past. Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method will facilitate success in mastery of knowledge.
Determine patient or caregiver’s self-efficacy to learn and apply new knowledge. Self-efficacy refers to one’s confidence in his or her ability to perform a behavior. A first step in teaching may be to foster increased self-efficacy in the learner’s ability to learn the desired information or skills.

Therapeutic Interventions

Provide physical comfort for the learner. This allows patient to concentrate on what is being discussed or demonstrated. According to Maslow’s theory, basic physiological needs must be addressed before patient education.
Provide a quiet atmosphere without interruption. This allows patient to concentrate more completely.
Provide an atmosphere of respect, openness, trust, and collaboration. This is especially important when providing education to patients with different values and beliefs about health and illness.
Establish objectives and goals for learning at the beginning of the session. This allows learner to know what will be discussed and expected during the session. Adults tend to focus on here-and-now, problem-centered education.
Allow learner to identify what is most important to him or her. This clarifies learner expectations and helps the nurse match the information to be presented to the individual’s needs. Adult learning is problem-oriented. Determine priorities (i.e., what the patient needs to know now versus later). Patients may want to focus only on self-care techniques that facilitate discharge from the hospital or enhance survival at home (e.g., how to take medications, emergency side effects, suctioning a tracheal tube) and are less interested in specifics of the disease process.
Explore attitudes and feelings about changes. This assists the nurse in understanding how learner may respond to the information and possibly how successful the patient may be with the expected changes.
Allow for and support self-directed, self-designed learning. Adults learn when they feel they are personally involved in the learning process. Patients know what difficulties will be encountered in their own environments, and must be encouraged to approach learning activities from their priority needs.
Assist the learner in integrating information into daily life. This helps learner make adjustments in daily life that will result in the desired change in behavior (or learning).
Allow adequate time for integration that is in direct conflict with existing values or beliefs. Information that is in direct conflict with what is already held to be true forces a reevaluation of the old material and is thus integrated more slowly.
Give clear, thorough explanations and demonstrations.
Provide information using various mediums (e.g., explanations, discussions, demonstrations, pictures, written instructions, computer-assisted programs, and videotapes). Different people take in information in different ways. Match the learning style with the educational approach.
Ensure that required supplies or equipment are available so that the environment is conducive to learning. This is especially important when teaching in the home setting.
When presenting material, move from familiar, simple, and concrete information to less familiar, complex, or more abstract concepts. This provides patient with the opportunity to understand new material in relation to familiar material.
* Focus teaching sessions on a single concept or idea. This allows the learner to concentrate more completely on material being discussed. Highly anxious and elderly patients have reduced short-term memory and benefit from mastery of one concept at a time.
Pace the instruction and keep sessions short. This prevents fatigue. Learning requires energy.
Encourage questions. Learners often feel shy or embarrassed about asking questions and often want permission to ask them.
* Allow learner to practice new skills; provide immediate feedback on performance. This allows patient to use new information immediately, thus enhancing retention. Immediate feedback allows learner to make corrections rather than practicing the skill incorrectly.
Encourage repetition of information or new skill. This assists in remembering.
Provide positive, constructive reinforcement of learning. A positive approach allows learner to feel good about learning accomplishments, gain confidence, and maintain self-esteem while correcting mistakes. Incorporate rewards into the learning process.
Document progress of teaching and learning. This allows additional teaching to be based on what the learner has completed, thus enhancing the learner’s self-efficacy and encouraging most cost-effective teaching.

Education/Continuity of Care

Provide instruction for specific topics.
Explore community resources.
Refer patient to support groups as needed. These allow patient to interact with others who have similar problems or learning needs.
Include significant others whenever possible. This encourages ongoing support for patient.

Nursing Care Plan for Gastroenteritis

Gastroenteritis , Nursing Care Plan

Gastroenteritis

Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). Diarrhea, crampy abdominal pain, nausea, and vomiting are the most common symptoms.

Viral infection is the most common cause of gastroenteritis but bacteria, parasites, and food-borne illness (such as shellfish) can be the offending agent.

Many people who experience the vomiting and diarrhea that develop from these types of infections or irritations think they have "food poisoning," and they may indeed have a food-borne illness. Many people also refer to gastroenteritis as "stomach flu," although influenza has nothing to do with the condition.

Travelers to foreign countries may experience "traveler's diarrhea" from contaminated food and unclean water.

The severity of infectious gastroenteritis depends on the immune system's ability to resist the infection. Electrolytes (these include essential elements of sodium and potassium) may be lost as you vomit and experience diarrhea.
Most people recover easily from a short bout with vomiting and diarrhea by drinking fluids and easing back into a normal diet. But for others, such as infants and the elderly, loss of bodily fluid with gastroenteritis can cause dehydration, which is a life-threatening illness unless the condition is treated and fluids restored.

Symptoms

By definition, gastroenteritis affects both the stomach and the intestines, resulting in both vomiting and diarrhea.

Common symptoms may include:

Low grade fever to 100°F (37.7°C)
Nausea with or without vomiting
Mild-to-moderate diarrhea:
Crampy painful abdominal bloating

More serious symptoms

Blood in vomit or stool
Vomiting more than 48 hours
Fever higher than 101°F (40°C)
Swollen abdomen or abdominal pain
Dehydration - weakness, lightheadedness, decreased urination, dry skin, dry mouth and lack of sweat and tears are characteristic findings.

Nursing Diagnosis

Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.
Imbalanced Nutrition, Less Than Body Requirements related to nausea and vomiting.

Intervention

Diagnosis 1

Imbalanced Nutrition, Less Than Body Requirements related to nausea and vomiting.

Purpose :
Nutritional needs disturbances resolved

Outcomes :

Clients increased nutritional intake, low dietary portion 1 provided, nausea, vomiting does not exist.

Intervention:

Examine patterns of clients and nutritional changes. Measure client weight. Examine factors cause the fulfillment of nutritional disorders. Perform physical examination of the abdomen (palpation, percussion, and auscultation). Give your diet in warm conditions and the small but frequent portions. Collaboration with the team in determining diet nutrition clients.

Diagnosis 2

Fluid volume deficit and electrolyte less than body requirements related to excessive fluid output.

Purpose :
Fluid and electrolyte Devisit resolved

Outcomes:Signs of dehydration are not there, mouth and lip mucosa moist, well-balanced fluid exchange

Intervention

Observation of vital signs. Observation of signs of dehydration. Measure the liquid infut and output (balanc ccairan). Provide and encourage families to provide a lot of drinking more or less 2000 - 2500 cc per day. Collaboration with physicians in providing therafi fluid, electrolyte lab tests. Collaboration with a team of nutrition in low-sodium fluids.

Nursing Care Plan for Anorexia Nervosa

Anorexia Nervosa , Nursing Care Plan

NCP For Anorexia Nervosa

Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600-800 calories per day, but there are extreme cases of complete self-starvation. It is a serious mental illness with a high incidence of comorbidity and the highest mortality rate of any psychiatric disorder.

Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. However, it can affect men and women of any age, race, and socioeconomic and cultural background. Anorexia nervosa occurs in females 10 times more than in males.
(wikipedia)

Nursing Care Plan for Anorexia Nervosa
NCP for Anorexia Nervosa

Assessment and collection of data

record inadequate nutrition
record the weight loss of 15% below normal, or more
examine skin turgor
leg muscle strength
amenorrhea
electrolyte imbalance
dental erosion

Examination information:

anemia
electrolyte imbalance
electrocardiogram

Nursing diagnosis, planning, and implementation
Imbalances nutrition: less than body requirements related to inadequate intake, vomiting

Expected outcome : diet according to individual body weight.

monitoring of patient weight
monitoring vital signs and laboratory
increase patient confidence
give eat little but often

Body image disorders associated with psychosocial and cognitive changes

Expected outcome: patients verbally expressed satisfaction with the body.

review and document verbal and nonverbal responses
listen to patients and bring to reality
monitor the expression of negative patient and document patient's verbal and nonverbal
examine the need referral to counseling and social services
give an award verbally

Evaluation

Patients receive the appropriate weight
patients satisfied with her body
patients to assess the positive effect in the body.

Source : http://ncp-blog.blogspot.com/2011/03/ncp-for-anorexia-nervosa.html

Nursing Care Plan for Appendicitis

Appendicitis , Nursing Care Plan

NCP For Appendicitis

Appendicitis

Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".

Signs & Symptoms

For the most part symptoms relate to disturbed function of bowels. Pain first, vomiting next and fever last has been described as classic presentation of acute appendicitis. Pain starts mid abdomen,and except in children below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various signs. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is severe pain on suddenly releasing a deep pressure in lower abdomen rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention.
wikipedia

Assessment

Patient Identity
The identity of the client's name, age, sex, marital status, religion, tribe / nation, education, occupation, income, address and registration number.
Nursing History
- Health history now : complaints of pain in post operative wounds, nausea, vomiting, increased body temperature, increased leukocytes.
- Health history of the past
Physical examination
- Cardiovascular System: To check vital signs, presence or absence of jugular vein distension, pale, edema, and abnormal heart sounds.
- Hematological System: To determine whether there is increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
- Urogenital System: There are at least tension of the bladder and back pain complaints.
- Musculoskeletal System: To determine whether there is difficulty in movement, pain in bones, joints and there is a fracture or not.
- The immune system: To determine whether there is lymph node.
Examination Support
- Routine Blood tests: to determine an increase in leukocytes is a sign of infection.
- Abdominal x-ray examination: to know the existence of post-surgical complications.

Nursing Diagnosis

Pain related to abdominal wound incision in the lower right quadrant of postoperative

Nursing Intervensi

Goal :
Pain is reduced / lost

Result Criteria :
Seemed relaxed and could sleep properly.

Intervention :

Assess the scale of pain location, pain characteristics and report changes accordingly.
Maintain a break with the semi powler.
Encourage early ambulation.
Give your entertainment activities.
Collaborate with team doctors in the provision of analgesics.

Rational :

Useful in the supervision and efficient medicine, healing progress, changes and characteristics of pain.
Eliminating stress is increased by abdominal supine position.
Improve kormolisasi organ function.
Increase relaxation.
Pain relief.

Source : http://ncp-blog.blogspot.com/2010/10/ncp-for-appendicitis.html

Nursing Care Plan for Psoriasis

Nursing Care Plan , Nursing Care Plan for Psoriasis

Psoriasis is a chronic immune-mediated disease that appears on the skin. It occurs when the immune system sends out faulty signals that speed up the growth cycle of skin cells. Psoriasis is not contagious. There are five types of psoriasis: plaque, guttate, inverse, pustular and erythrodermic. The most common form, plaque psoriasis, is commonly seen as red and white hues of scaly patches appearing on the top first layer of the epidermis (skin). Some patients, though, have no dermatological symptoms.

In plaque psoriasis, skin rapidly accumulates at these sites, which gives it a silvery-white appearance. Plaques frequently occur on the skin of the elbows and knees, but can affect any area, including the scalp, palms of hands and soles of feet, and genitals. In contrast to eczema, psoriasis is more likely to be found on the outer side of the joint.

The disorder is a chronic recurring condition that varies in severity from minor localized patches to complete body coverage. Fingernails and toenails are frequently affected (psoriatic nail dystrophy) and can be seen as an isolated symptom. Psoriasis can also cause inflammation of the joints, which is known as psoriatic arthritis. Between 10% and 40% of all people with psoriasis have psoriatic arthritis.(wikipedia)

Impaired skin integrity related to inflammation between dermal - epidermal secondary to psoriasis
Fear related to changes in appearance
Anxiety related to changes in health status secondary to psoriasis
Impaired self-concept related to the crisis of confidence
Lack of knowledge related to not knowing the source of information.

Nursing Intervention and Rationale Nursing Care Plan Psoriasis

Assess skin condition
R /: Knowing the damage to the skin to make appropriate interventions.

Observation of vital signs
R /: Knowing the patient's health status changes.

Assess skin color changes.
R /: Knowing the effectiveness of the circulation and identify the occurrence of complications.

Keep the infected area clean and dry.

R /: Helps accelerate the healing process.

Support the preferred type of coping when the adaptive mechanism is used.
R /: Anger is an adaptive response that accompanies fear.

Encourage to express his feelings.
R /: Can reduce the stress on patients.

Suggest to use normal coping mechanisms.
R /: Accuracy in the use of coping is one way of reducing fear.

Assess the level of anxiety and discuss the cause if possible
R /: Identify the specific issues will enhance the ability of individuals to deal with more realistic.

Give the patient time to express the problem and the encouragement of free expression, such as anger, fear, doubt
R /: In order for the patient to feel accepted.

Explain all procedures and treatments
R /: Ignorance and lack of understanding can lead to anxiety

Discuss alternative coping behaviors and problem-solving techniques
R /: Reduce patient anxiety

Assess the patient's behavioral changes such as introvert, shy dealing with others.
R /: Knowing the level of distrust of the patient in determining interventions.

Be realistic and positive during treatment, in patient counseling.
R /: Improving trust and partnership between the nurse-patient relationship.

Give hope within the parameters of individual situations.
R /: Improve positive behavior

Give positive reinforcement of progress.
R /: Words can support the strengthening of positive coping behaviors.

Encourage family interaction.
R /: Maintaining lines of communication and providing ongoing support to patients.

Nursing Care Plan for Tuberculosis TB

Nursing Care Plan , Nursing Care Plan for Tuberculosis TB

Tuberculosis (TB) is a bacterial infection caused by a germ called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they can also damage other parts of the body. TB spreads through the air when a person with TB of the lungs or throat coughs, sneezes or talks. If you have been exposed, you should go to your doctor for tests. You are more likely to get TB if you have a weak immune system.

Symptoms of TB in the lungs may include

A bad cough that lasts 3 weeks or longer
Weight loss
Coughing up blood or mucus
Weakness or fatigue
Fever and chills
Night sweats

If not treated properly, TB can be deadly. You can usually cure active TB by taking several medicines for a long period of time. People with latent TB can take medicine so that they do not develop active TB.nlm.nih.gov

Centers for Disease Control and Prevention

Nursing Care Plan for Pulmonary Tuberculosis

Nursing Assessment

IdentityThe assessment includes name, age, sex, religion, ethnicity, education, employment and housing clients. In addition, it is necessary also reviewed the name and address of responsible person, and its relationships with clients.
History Formerly Disease
Review the history of the disease who had suffered from childhood to adulthood, including the experience of surgery or injury resulting from accidents, it is important to expose the client health issues that may cause more severe complications of the disease is tuberculosis.
Disease History Now
- Main Complaint
  Complaints night fever, night sweats, coughing up phlegm / bleeding, difficulty breathing, fatigue, night sweats, decreased appetite, weight loss.
- History of Disease
  How long illness experienced, the things that lighten / aggravate the disease.
- Efforts taken to resolve complaints.
Health Patterns
1. Activity / Rest
  Clients may experience areduction in weakness ,shortness of breath due to work, difficulty sleeping at night ,night fever ,chills or sweating . Characterized by muscle weakness, pain, and shortness (advanced stage).
2. Ego Integrity
  Clients can experience stress, financial problems, feeling helpless / hopeless marked denial, anxiety, fear, easily aroused.
3. Nutrition / fluid
  Clients may complain of poor appetite, unable to digest, weight loss. Marked by poor skin turgor, dry / scaly skin, loss of muscle / subcutaneous fat loss.
4. Pain / Leisure
  Increased chest pain due to recurrent cough, marked behavioral distraction and anxiety.
5. Respiratory
  Clients complain of cough, productive or non-productive, short breath, a history of tuberculosis or exposure to an infected individual. Characterized by increased frequency, deaf percussionist and a decrease fremitus, breath sounds: decreased, tubular and / or pectoral whisper above the lesion area. Krekels recorded over the lung during inspiration stale quickly after a short cough. Characteristics of green sputum / purulent, mukoid yellow, or blood spots, mental changes (advanced stage).
6. Social interaction
  Clients feel isolated / rejection due to communicable diseases, unusual patterns of change in responsibilities or change in physical capacity to perform the role.
7. Counseling / learning
  Characterized by a family history of suffering from tuberculosis, the general inability / poor health status, failed to improve / recurrence of disease and do not want to participate in therapy.

Nursing Diagnosis for Pulmonary Tuberculosis

Ineffective Airway Clearance related to :
- thick secretions
- weakness, bad cough efforts
- edema, tracheal / pharyngeal
Impaired Gas Exchange related to :
- reduced effectiveness of lung surface
- atelectasis
- alveolar capillary membrane damage
- thick secretions
- bronchial edema
Risk For Infection and spread of infection related to :
- decreased immune system
- cilia function declines
- secretions that settle
- tissue damage due to the spread of infection
- malnutrition
- contaminated by the environment
- lack of knowledge about infectious germs
Imbalanced Nutrition Less than Body Requirements related to :
- fatigue
- coughing frequently
- the production of sputum
- dyspnea
- anorexia
- impairment of financial capability
Knowledge Deficit : about the condition, treatment, prevention relating to :
- nothing is explained
- wrong interpretation
- the information obtained is incomplete / inaccurate
- lack of knowledge / cognitive.

Nursing Care Plan for Asthma

Asthma , Nursing Care Plan

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air. This can cause wheezing, coughing, chest tightness and trouble breathing, especially early in the morning or at night.

When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks.

Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

NIH: National Heart, Lung, and Blood Institute

Nursing Assessment for Asthma

Assessment of nursing in asthma patients, as follows:

Past medical history:

Assess personal or family history of previous lung disease.
Assess history of allergic reaction or sensitivity to the substances / environmental factors.
 Assess patient's employment history.

Activities:

The inability to perform activities because of difficulty breathing.
The decline in the ability / improvement needs help doing daily activities.
Sleep in a sitting position higher.

Respiratory:

Dipsnea at rest or in response to activity or exercise.
Breath worsened when the patient lay supine in bed.
Using the breathing aids drug, for example: raising the shoulders, widen the nose.
The existence of wheezing breath sounds.
The recurrent coughing.

Circulation:

There is an increasing blood pressure.
There is an increasing frequency of heart.
The color of skin or mucous membranes normal / gray / cyanosis.
Flushing or sweating.

Integrity ego:

Anxiety
Fear
Sensitive stimulation
Fidget

Nutrient intake:

Inability to eat due to respiratory distress.
Weight loss due to anorexia.

Social relations:

The limited physical mobility.
Hard talk
The existence of dependence on others.

Sexuality:

Decrease in libido

Nursing Diagnosis, Nursing Interventions, Nursing Care Plan for Asthma

Impaired Gas Exchange

Related to :

Altered oxygen supply,
obstruction of airways by secretions,
bronchospasm

Nursing Interventions :

Monitor vital signs
Monitor and graph serial ABGs and pulse oximetry.
Administer medications as indicated
monitor skin and mucous membrane color.

Ineffective Airway Clearance

Related to :

Bronchospasm,
Increased production of secretions,
Retained secretions, thick, viscous secretions