Nursing Care Plan

Impaired verbal communication is defined as decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols.

Related to :

• Physiologic conditions
• Alteration of central nervous system
• Impaired neurologic development or dysfunction
• Disturbance in attachment/bonding with the parent/caregiver

Characterized by :

• Language delay or total absence of language
• Immature grammatic structure; pronoun reversal; inability to name objects
• Stereotyped or repetitive use of language (echolalia, idiosyncratic words, inappropriate high-pitched squealing/giggling, repetitive phrases, sing-song speech quality)
• Lack of response to communication attempts by others

Outcome :

• Communicate in words/gestures that are understood by others

Interventions and Rationales

1. Use one-on-one interactions to engage the client in nonverbal play.
   R/: The nurse enters the client’s world in a nonthreatening interaction to form a trusting relationship.


2. Recognize subtle cues indicating the client is paying attention or attempting to communicate.
   R/: Cues are often difficult to recognize (glancing out of the corner of the eye).


3. Describe for the client what is happening, and put into words what the client might be experiencing.
   R/: Naming objects and describing actions, thoughts, and feelings helps the client to use symbolic language.


4. Encourage vocalizations with sound games and songs.
   R/: Children learn through play and enjoyable activities.


5. Identify desired behaviors and reward them (e.g., hugs,treats,tokens,points,or food).
   R/: Behaviors that are rewarded will increase in frequency. Desire for food is a powerful incentive in modifying behavior.


6. Use names frequently, and encourage the use of correct pronouns (e.g., I,me,he). R: Problems with self-identification and pronoun reversal are common.


7. Encourage verbal communication with peers during play activities using role modeling, feedback, and reinforcement.
   R/: Play is the normal medium for learning in a child’s development.


8. Increase verbal interaction with parents and siblings by teaching them how to facilitate language development.
   R/: Play is the normal medium for learning in a child’s development.

Pleural effusion

Pleural effusion is excess fluid that accumulates in the pleura, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during respiration.

Pulmonary embolism (PE)

A pulmonary embolism is a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a deep vein thrombosis that breaks loose and travels through the bloodstream to the lung. Pulmonary embolism is a serious condition that can cause

• Permanent damage to the affected lung
• Low oxygen levels in your blood
• Damage to other organs in your body from not getting enough oxygen

If a clot is large, or if there are many clots, pulmonary embolism can cause death.





Nursing Care Plan for Pulmonary Embolism

Meningitis is inflammation of the meninges, the covering of the brain and spinal cord. It is most often caused by infection (bacterial, viral, or fungal), but can also be produced by chemical irritation, subarachnoid haemorrhage, cancer and other conditions.
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Signs of meningitis as follows :

• fever
• headache
• stiff neck
• photophobia and vomiting
• confused (possible)

Septicemia patients usually do not show the existence of neurologic failure, but patients showed the existence of:

• circulatory changes
• decreased peripheral perfusion
• tachycardia
• tachypnoe
• hypotension
• ptechie as an indication of the patients had bacteremia by meningococcal

Assessment

Always use the ABCDE approach to assessment


Airway

• Make sure the airway clearance
• Prepare tools to facilitate the airway if necessary
• If there is a decrease in respiratory function immediately contact an anesthesiologist and treated in the ICU

Breathing

• Assess respiratory rate - less than 8 or over 30 is a significant sign.
• Assess oxygen saturation
• Perform blood gas
• Give oxygen
• Chest auscultation
• Make checks thoracic photo

Circulation

• Assess heart rate - more than 100 or less than 40 x / min is a significant sign
• Monitoring blood pressure
• Check the capillary refill time
• Attach infusion using a large cannula
• Replace catheter
• Check the laboratory for complete blood, urine, electrolyte
• Perform blood cultures
• Perform a throat swab for culture and sensitivity
• Record the temperature

Disability

• Assess level of consciousness by using AVPU
• Obserasi focal neurological signs

Exposure

• Assess the ptechie

Sign of the threat to life

If the patient shows signs of distress showing patients should be brought immediately to the ICU as for the sign as follows:

• Redness more
• CRT more than 4 seconds
• Oliguria
• Breathing is less than 8 or more than 30 per minute
• Heart rate less than 40 or more than 140 times per minute
• Signs of impairment of consciousness
• Focal neurology
• Convulsions
• Bradycardia and hypertension
• Papiloedema

Nursing Care Plan for Meningitis

COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.




Assessment

Airway

• Assess and maintain airway
• Do the head tilt, chin lift if necessary
• Use the help of the airway if necessary
• Consider to be referring to the anesthesiologist

Breathing

• Assess oxygen saturation using pulse oximeter
• Do inspection arterial blood gases to assess pH, PaCO2 and PaO2
• If the arterial pH less than 7.2, more profitable patients using non-invasive ventilation (NIV) and references must be made in accordance with local policy
• Control of oxygen therapy to maintain oxygen saturation over 92%
• Strictly monitoring PaCO2
• Record the temperature
• Make checks for signs of:
  • cyanosis
  • clubbing
  • pursed lip breathing
  • movement symmetry
  • intercostal retractions
  • tracheal deviation
• Listen to the:
  • wheezing
  • crackles
  • decrease in airflow
  • silent chest
• Make checks to see piston :
  • pneumothorax
  • consolidation
  • signs of heart failure
• If there is evidence of an infection usually caused by bacterial pathogens including :
  • streptococcus pneumoniae
  • haemophilus influenzae
  • moraxella catarrhalis

Circulation

• assess heart rate and rhythm
• record blood pressure
• check ECG
• do intake output, and do a complete blood
• pairing IV access
• fluid restriction did

Disability

• Assess the level of consciousness by using AVPU
• Patients showed a decrease in consciousness needed medical help immediately and treated in ICU.

Exposure

• If the patient is stable and health history examinations do other physical examination.