Nursing Care Plan

Fatigue

Fatigue is a condition with signs of reduced capacity of a person, for work and reduced efficiency of accomplishment, and this is usually accompanied by a feeling tired and weak. Fatigue can be acute and come on suddenly or chronic and persist. According to other sources of fatigue is a condition of the human body naturally feel tired, which usually happens after physical exercise or mental harm. Fatigue can be acute and come on suddenly or chronic and persist.

Usually after a long exercise, surely people will feel tired, because of all the moving limbs, limbs will be ill and do not want to continue the exercise. However, this fatigue will soon be replaced with good health and well-being. Just like a mix between fatigue and the sense of satisfaction that people feel after working hard in the office or study, this is a healthy and natural fatigue.

Fatigue at the beginning and at the end of pregnancy is also a natural thing, the reason is the increase in the activity of the hormone to be one of the causes as well as fatigue when weight babies in the womb which also makes people pregnant. Tired also can arise from psychological reasons and can be a symptom of certain diseases. But rarely the only symptom of the disease. In undetected diabetes, high levels of sugar than usual and this condition can lead to fatigue. Uncontrolled diabetes can also lead to increased levels of blood sugar and fatigue. In severe anemia, generally dilute blood, heart and lungs should strive to supply oxygen and deliver it to all the rest of the body. Fast heart rate in severe anemia may be accompanied by fatigue, anxiety, fainting, pale biscuits, and shortness of breath.

Nursing Diagnosis for Dehydration

1. Fluid volume deficit related to excessive output, less intake.
2. Risk for ineffective tissue perfusion related to decreased blood flow.
3. Risk for impaired skin integrity related to decreased skin turgor.
4. Activity intolerance related to physical weakness.
5. Risk for Decreased cardiac output related to a decrease in systemic vascular resistance.

Nursing Care Plan for Dehydration

Nursing Interventions for Dehydration

1. Fluid volume deficit related to excessive output, less intake.

Goal: adequate fluid volume so that fluid volume deficiency can be overcome.

Expected outcomes:

• Maintain fluid balance.
• Vital signs (pulse = 80-100 beats / min, temperature = 36-37oC)
• Capillary refill less than 3 seconds.
• Akral warm.
• Urine output: 1-2 cc / kg body weight / hour.

Intervention:

• Monitor vital signs, capillary refill, the status of the mucous membranes.
• Discuss strategies to stop vomiting and use of laxatives / diuretics.
• Identification of a plan to increase the optimal fluid balance.
• Assess the results of the test function electrolyte / kidney.
• Give / supervise administration of IV fluids.
• Additional potassium, oral or N as indicated.

2. Risk for ineffective tissue perfusion related to decreased blood flow.

Goal: Maintain / improve tissue perfusion.

Expected outcomes:

• Vital signs are stable BP = 120/80 mmHg, pulse = 80-100 beats / min, no pale skin.
• Warm skin.
• Palpable peripheral pulses.
• Adequate urine output from 0.5 to 1.5 cc / kg / body weight.
• CRT is less than 2 seconds.
• Composmentis consciousness.
• No chest pain.

Intervention:

• Assess changes in the level of consciousness, dizziness complaints.
• Auscultation apical pulse, watch heart rate / rhythm.
• Assess the skin against the cold, pale, sweating.
• Record output and urine specific gravity.
• Observation pale skin, redness, change positions frequently.
• Keep an eye on pulse oximetry.
• Give IV fluids as indicated.

3. Risk for impaired skin integrity related to decreased skin turgor.

Goal: Identify and maintain the skin smooth, supple, intact.

Expected outcomes:

• Good skin turgor, skin intact, no blisters, no redness.

Intervention:

• Observation reddish, pale.
• Use skin cream.
• Discuss the importance of changes in position, it is necessary to maintain the activity.
• Emphasize the importance of nutrient input / adequate fluid.

Dehydration

Definition

Dehydration is a condition in which a person who is not fasting experiencing or at risk of dehydration vascular, interstitial or intra-vascular (Sell Lynda Carpenito, 2000: 139).


Classification

Classification of dehydration by Donna D. Ignatavicus there are 3 types:

a. Isotonic dehydration
Isotonic dehydration is lost water followed by the electrolyte so that the density remained normal, then this type of dehydration is usually not result in ECF fluid move to the ICF.

b. Hypotonic dehydration
Hypotonic dehydration is the loss of solvent from the ECF exceeds fluid loss, resulting in blood vessels become more concentrated. ECF osmotic pressure decreases, resulting in fluid moves from the ECF to ICF. Vascular volume also decreased, as well as cell swelling occurs.

c. Hypertonic dehydration
Hypertonic dehydration is ECF fluid loss exceeds the solvent is non-osmotic dehydration ECF decreased, resulting in fluid moves from ICF to ECF.


Etiology

Various causes dehydration determine the types of dehydration (According to Donna D. Ignatavicus, 1991: 253).

1. Dehydration

• Bleeding.
• Vomiting.
• Diarrhea.
• Hypersalivation.
• Fistula.
• Ileustomy (cutting intestine).
• Diaporesis (excessive sweating).
• Burns.
• Fasting.
• Hypotonic therapy.
• Suction gastrointestinal (stomach wash).

2. Hypotonic Dehydration

• DM disease.
• Excess fluid rehydration.
• Severe and chronic malnutrition.

3. Hypertonic Dehydration

• Hyperventilation.
• Diarrhea water.
• Diabetes Insipedus (ADH hormone decreases).
• Excessive fluid rehydration.
• Dysphagia.
• Impaired thirst.
• Disorders of consciousness.
• Systemic infection: increased body temperature.

Clinical Manifestations

Here are the symptoms or signs of dehydration based on its level (Nelson, 2000):
1. Mild dehydration (loss of fluid 2-5% of its original weight)

• Thirsty, restless.
• Pulse rate 90 -110 x / minute, normal breath.
• Normal skin turgor.
• Urine output (1300 ml / day).
• Good awareness.
• Heart rate increased.

2. Moderate Dehydration (loss of fluid 5% of its original weight)

• Increased thirst.
• Rapid and weak pulse.
• Dry skin turgor, dry mucous membranes.
• Reduced urine output.
• Increased body temperature.

3. Severe dehydration (loss of fluids 8% of its original weight)

• Loss of consciousness.
• Weak, lethargic.
• Tachycardia.
• Sunken eyes.
• No urine output.
• Hypotension.
• Rapid pulse and smooth.
• Cold extremities.

Nursing Diagnosis and Interventions for Dehydration

Risk for Infection related to the invasion of microorganisms in the body

Goal : after the act of nursing for 3x24 hours of infection did not occur.

Expected outcomes:

• Patients will show a careful hand-washing techniques.
• Patients will be free of the nosocomial infection during hospitalization.
• Patients will demonstrate knowledge of the risk factors associated with infection and appropriate precautions to prevent infection.

Intervention - Risk for Infection:

1. Monitor for signs and symptoms of infection.
R /: To determine whether there is an infectious process.

2. Monitor laboratory results, Monitor the patient's temperature.
R /: Leukocyte increased and increased body temperature is not expected, a sign of infection.

3. Use antiseptic technique when taking action to clients.
R /: Prevent cross-infection.

4. Emphasize the need to wash hands regularly / thoroughly before and when handling food, after toileting.
R /: Many viruses such as cytomegalovirus (CMV) can be excreted in the urine for more than 4 years after exposure and possibly transmitted through poor hygienic.

5. Encourage clients to drink 6 to 8 glasses of fluid every day. Discuss the role of acidic residues in the diet and add juice or orange cranberr.
R /: Helps to acidify the urine and help prevent UTIs.

6. Encourage clients to try Kegel exercises (tightening the perineum) throughout the day.
R /: Fix support for pelvic organs, strengthen and increase the elasticity of the pubococcygeus muscle, better control urination.

7. Encourage the use of cotton underwear, and avoid using bath tub, if a client has a history of Urinary Tract Infections (UTIs).
R /: Static urinary and glycosuria may mempredisposisikan prenatal clients on a urinary tract infection or UTI, especially when history include urinary problems / kidney.

8. Get a routine urine sample for microscopic examination, pH, presence of leukocyte cells, and also culture and sensitivity, according to the indication. Report the number of colonies greater than one hundred thousand per milliliter.
R /: This is to detect the presence of microorganisms in the body. This is to detect the presence of microorganisms in the body. High leukocyte cell count is an indicator of infection.

9. Instruct the patient to always clean the areas that are reddish.
R /: Prevent the entry of other bacteria that can cause infection.

10. Collaboration with the medical team to provide antibiotics.
R /: Antibiotics can help fight infection.

Risk for Activity Intolerance related to physical weakness

Activity Intolerance is a decrease in physiological capacity to maintain activity to the level desired or required.


Defining Characteristics:

Major :

• Change the client's physiological response to the activity undertaken.
• Respiratory: dyspnea (breathing frequency increased exaggeration).
• Shortness of breath (decrease frequency).
• Pulse: weak, declining, excessive increase, the increase in the rhythm, failed to return to the level before the activity after 3 minutes.
• Blood pressure: failed to increase the activity, an increase in diastolic over 15 mmHg.

Minor:

• fatigue, 
• weakness, 
• cyanosis or pale, 
• mental chaotic, 
• vertigo

Subjective Data:

• weakness
• fatigue
• dyspnea
• lack of sleep

Objective Data :

Assess the strength and balance, the evaluation of an individual's ability to:

• Changing positions himself on the bed.
• Ambulation.
• Doing ADL (activity daily living) or daily activities.

Assess for the presence of:

• pale
• cyanosis
• mental chaotic
• vertigo

Nursing Interventions:

Activity intolerance related to physical weakness

Goal: after the act of nursing for 5 x 24 hours the patient does not experience injury.

Expected outcomes:

• The patient is able to identify risk factors and individual strengths that affect tolerance to activity.
• Participate in rehabilitation programs to improve the ability to move.
• Being able to choose several alternatives to maintain the level of activity.

Intervention:

1. Assess the level of the client's ability to exercise.
R /: As a base to provide an alternative and appropriate motion exercises with ability.

2. Plan on giving training program according to the ability of the patient.
R /: Exercise may increase the movement of muscles and stimulate blood circulation.

3. Provide a diet high in calcium.
R /: Helps replace calcium lost.

4. Teach the client on how to perform daily activities.
R /: To improve the movement and perform safe movement.

5. Involve the family to train the patient's mobility.
R /: To support the patient.

6. Consult with a physical therapist.
R /: Helpful in developing individualized exercise program and identify the need for a tool to eliminate muscle spasm, improving motor function, prevent / decrease atrophy and contractures in the muscular system.

(doengoes, 2000)

Nursing Diagnosis for Activity Intolerance

Nursing Care Plan for Febrile Seizures

According to Doengoes (1999: 259-261 and 871-872) includes:

History of causative factors:

• Idiopathic no cause is known.
• Post-trauma, head injury, inflammation of the lining of the brain, high fever.

History of seizures

• Since what age?
• How long seizures occur?
• How many times a seizure occurs within 1 hour?
• When was the last seizures experienced?

Physical examination, by inspection, palpation, percussion and auscultation.

a. Activity / rest.
Symptoms:

• Fatigue, general weakness.
• Limitations in activities / work caused by self-/ significant other / nursing care giver or others.

Signs:

• Change of tone / muscle strength.
• Involuntary movements / muscle contraction.

b. Circulation
Symptoms:

• Ictal: hypertension, increased pulse and cyanosis.
• Post-ictal: normal vital signs or depression with decreased pulse and respiration.

Signs:

• Heart sound: disratmia and development can lead to myocardial dysfunction, effects of acidosis / electrolyte imbalance.
• The skin is warm, dry, luminous, pale, moist, and mottled.

c. Ego integrity
Symptoms:

• Stressor external / internal related to the state and or a treatment.
• Receptors: feeling no / not helpless, changes in relationships.

Signs:

• Widening of emotional response.

d. Elimination
Symptoms:

• Episodic urinary incontinence.

Signs:

• Ictal: increased pressure bladder and sphincter tone.
• Post-ictal: muscle relaxation resulting in urinary incontinence.

e. Food / fluid
Symptoms:

• Sensitivity to food, anorexia, nausea, vomiting associated with seizure activity.

Signs:

• Weight loss, decreased subcutaneous fat.
• Decreased urine output concentration, progress towards oligoria and anuria.
• Soft tissue damage / teeth (injury during a seizure).
• Gingival hyperplasia.

f. Neurological
Symptoms:

• Headache, dizziness, fainting, history of head trauma, cerebral anoxia and infection.
• Post-ictal: weakness, muscle pain, paralysis area.

Signs:

• Anxiety, fear, mental chaotic, disorientation, delirium / coma.
• Involuntary movements / muscle contraction.

g. Pain / comfort
Symptoms:

• Headache, muscle pain / back to the post-ictal period abdominal seizures.
• Localization of pain / discomfort urticaria.

Signs:

• Attitude / behavior that careful changes in muscle tone.
• Agitated behavior.

h. Breathing
Symptoms:

• Ictal phase: teeth shut, cyanosis, decreased breathing rapidly, increased secretion mokus.
• Post-ictal phase: apnea.

Signs:

• Temperatures generally rising to 37.5 0C or more.
• Chills.

i. Security
Symptoms:

• History dropped / trauma or invoice.

Signs:

• Trauma to the soft tissue / ecchymosis overall decrease in muscle strength.

j. Interaction
Symptoms:

• Related interpersonal problems in the family or social environment.

k. Education / learning
Symptoms:

• A history of seizures or epilepsy in the family.
• The use of antibiotic drugs recently or long term.

Nursing Care Plan for Pediatric Febrile Seizures

Definition of Febrile Seizures

Febrile seizures are seizures that occur on the rise in body temperature (rectal temperature of more than 380C) which is caused by an extra-cranial process. Febrile seizures occur in 2-4% of children aged 6 months - 5 years. Children who have had seizures without fever, then re febrile seizures are not included in the febrile seizures. Febrile seizures in infants younger than 1 month are not included in the febrile seizures. When children aged less than 6 months or more than 5 years experience seizures preceded by fever, think of other possibilities, such as central nervous system infections, or epilepsy that happen to occur along a fever.


Etiology

Until now, the etiology of febrile seizures is not known with certainty. Fever is often caused by:

• upper respiratory tract infection,
• otitis media,
• pneumonia,
• gastroenteritis, and
• urinary tract infection.

Seizures are not always arise at high temperatures. Sometimes that is not so high can cause seizures.
Other causes of febrile seizures is the use of certain drugs such as diphenhydramine, tricyclic antidepressants, amphetamines, cocaine, and dehydration resulting in disruption of water-electrolyte balance.


Risk Factors

While the factors that affect febrile seizures are:
1. Age

• 3% of children under 5 years old have experienced febrile seizures.
• The highest incidence occurred in the age of 2 years and decreased after 4 years, rarely occurs in children under the age of 6 months or more than 5 years.
• The first attack usually occurs within the first 2 years and then declines with age.

2. Gender

• Febrile seizures are more common in boys than girls by a ratio of 2: 1. This may be caused by cerebral maturation faster in women than in men.

3. Body temperature

• The increase in body temperature is an absolute requirement of febrile seizures. High body temperature at the time of the attack raised seizure threshold value. Seizure threshold is different for each child, ranging between 38.3 ° C - 41.4 ° C. The big difference in this seizure threshold, explain why in a new child seizures arising after body temperature rises very high, while the other child has seizures arise even if the temperature increase is not too high. From this fact it can be concluded that the recurrence of febrile seizures will be more frequent in children with a low seizure threshold.

4. Heredity

• Heredity plays an important role for the occurrence of febrile seizures. Some authors found that 25-50% of children who have febrile seizures have family members (parents, siblings) who have experienced febrile seizures at least once.

Risk factor for febrile seizures first important thing is fever. Febrile seizures tend to arise within the first 24 hours at the time of illness with fever or during high fever.

Other Factors include:

• a history of febrile seizures in parents or siblings,
• delayed development,
• problems in the newborn period,
• children in special care, and
• low sodium levels.

After the first febrile seizure, approximately 33% of children will experience one or more recurrences, and approximately 9% of children experienced recurrence or 3 times more. The risk of recurrence increases with an early age, children quickly get after febrile seizures arise, low temperatures when convulsions, a family history of febrile seizures, and family history of epilepsy.

About 1/3 of children with first febrile seizure may experience recurrent seizures.
Risk factors for recurrent febrile seizures include the following:

• Young age when the first febrile seizure.
• Low temperature when the first seizure.
• Family history of febrile seizures.
• The duration between onset of rapid onset of fever and convulsions.

Patients with these risk factors have more than 70% chance of recurrence. Patients without these risk factors have less than 20% chance of recurrence.


Assessment - Nursing Care Plan for Febrile Seizures

Nursing Diagnosis for Schizophrenia : Risk for Self or Other- Directed Violence

Goal: The patient can control violent behavior,
with the following criteria:

• Bright face, smiling.
• Want to get acquainted and there is eye contact.
• Willing to tell the feeling.
• Telling cause irritation / anger.
• Can identify signs of violent behavior.
• Can identify, form of violence that is done.
• Can be identified as a result of violent behavior.
• Able to practice taught how to control anger.
• Able to engage in group activity therapy.
• Can taking medication with minimal assistance.
• Clients can continue the relationship in accordance with the responsibilities of the role.

Interventions

Client Intervention

1. Perform a trusting relationship.
2. Identify the causes of violent behavior.
3. Identify the signs and symptoms of violent behavior.
4. Identification form of violence that is ever done.
5. Identification due to violent behavior.
6. Teach how to control violent behavior, among others:
   • Physically (relaxation, activities and sports)
   • Verbally (sharing / telling others)
   • Spiritually (pray).
7. Help the patient to practice healthy ways to express the way to control the violent behavior that has been taught.
8. Suggest to choose how to control violent behavior accordingly.
9. Suggest to include ways to control violent behavior that have been to the daily activity schedule.
10. Help the patient to plan the schedule of daily activities.
11. Explain to patients on oral medication (type, dose, time drinking, benefits and side effects of drugs)
    Give appropriate medication treatment program.
12. Monitor the effectiveness of the treatment and its side effects (vital signs and physical examination of the other).
13. Involve patients in group therapy, cognitive therapy, and in the day-to-day activities in the room.
14. Keep the patient environment at low stimulus levels (low irradiation, little people, the decor is simple and low noise level).
15. Strict observation of behavior and signs of angry patient every 15 minutes.
16. Remove objects that can harm the environment around the patient.
17. If necessary, do fixation or restrain and observation every 15 minutes.

Family Interventions

1. Discuss family perceived problems in patient care violent behavior.
2. Provide health education on understanding the signs and symptoms of violent behavior occurrence of violent behavior.
3. Explain how to care for patients with violent behavior.
4. Teach and practice how to involve the family in caring for patients with violent behavior directly in hospital (constructive manner, Follow-up)

Nursing Care Plan for Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia is an acute form of leukemia, which are classified according to the cell that is more in the bone marrow, which is the form lymphoblasts.

In case of leukemia occurred abnormal leukocyte cell proliferation, malignant, often accompanied by other forms of leukocytes than normal, excessive amounts, and can cause anemia, thrombocytopenia, and ends with death.

Causes of Acute lymphoblastic leukemia is unknown, but it is possible because of the interaction of a number of factors:

• neoplasia
• infection
• radiation
• descent
• chemicals
• gene mutations

Clinical manifestations

• Anemia: tiredness, lethargy, dizziness, tightness, chest pain.
• Anorexia.
• Bone and joint pain (bone marrow infiltration).
• Fever, sweating (hypermetabolism symptoms).
• Mouth infections, upper and lower respiratory tract, cellulitis, or sepsis.
• Skin bleeding (petechiae, ecchymosis atraumatic), bleeding gums, hematuria, gastrointestinal bleeding, brain hemorrhage.
• Organomegaly (hepatomegaly, splenomegaly, lymphadenopathy).
• Mass in the mediastinum (often in ALL cells T).
• Leukemia central nervous system: headache, vomiting (symptoms of increased intracranial pressure), mental status changes, particularly the brain nerve paralysis nerve VI and VII, focal neurologic abnormalities.
• The involvement of other organs: testis, retina, skin, pleura, pericardium, tonsils.

Nursing Diagnosis for Acute Lymphoblastic Leukemia

1. Risk for infection related to the changes in red blood cell maturation, increased number of immature lymphocytes, immunosuppression.
2. Risk for fluid volume deficit related to excessive output such as vomiting, bleeding, diarrhea, decreased fluid intake.
3. Acute pain related to enlarged lymph nodes, secondary effects of giving antileukemic agents.
4. Activity intolerance related to weakness, decreased energy sources, increase metabolic rate due to excessive production of leukocytes, an imbalance of oxygen supply to the needs.

Treatment of Schizophrenia

Treatment should be as fast as possible, because the psychotic state in a long time lead to a greater likelihood of patients leading to mental deterioration. Even though the patient may not recover completely, but with treatment and good guidance, the patient can be helped to be able to function continuously, simple work at home or outside, and can raise and educate their children (Maramis, 2009). The type of treatment in patients with schizophrenia (Maramis, 2009), are as follows:

1. Pharmacotherapy

An indication of antipsychotics in schizophrenia is to control the active symptoms and prevent relapse.

Treatment strategy depends on the phase of the disease is acute or chronic. The acute phase is usually characterized by psychotic symptoms (experienced new or recurrent) that need to be addressed immediately. The aim here is to reduce the treatment of severe psychotic symptoms. With phenothiazines, delusions and hallucinations usually disappear within 2-3 weeks. Even still there are delusions and hallucinations, patients are less affected again and become more cooperative, willing to participate in environmental activities and would also work therapy.

After 4-8 weeks, the patient entered the stage of stabilization when the symptoms had resolved to some extent, but the risk of relapse is still high, especially when treatment is interrupted or patients experiencing stress. After the symptoms subside, then the dose was maintained for several more months, if the attack is new the first time. If an attack of schizophrenia was already more than once, then after symptoms subside, the drug was given continuously for one or two years.

After 6 months, patients maintenance phase that aims to prevent recurrence. Patients with chronic schizophrenia, neuroleptic given within a period of unspecified length of time with doses up and down according to the patient's condition. Always have to be wary of the side effects of drugs.

Maintenance strategy is to find the lowest effective dose that can provide protection against recurrence and does not interfere with the patient's psychosocial functioning. Results of treatment would be better if antipsychotic start given in the first two years of the disease. There is no standard dose for this drug, but the dose set individually.

More drug selection based on the profile of side effects and the patient's response to previous treatment. There are some special conditions that need to be considered, such as pregnant women preferred haloperidol, because these drugs have data with the best security. In patients who are sensitive to extrapyramidal side effects better given the atypical antipsychotic, as well as in patients presenting with symptoms of cognitive or prominent negative symptoms.

For the first time patient experienced episodes of schizophrenia, drug treatment should be sought in order not to give any side effects, because a bad experience with the treatment will reduce ketaatanberobatan (compliance) or ketidaksetiaberobatan (adherence). It is recommended to use atypical antipsychotics or typical antipsychotics, but with a low dose.


2. Electroconvulsive Therapy

Electroconvulsive therapy, good results on the kind of catatonic, especially stupor, against schizophrenia simplex effect is disappointing, if only mild symptoms then given electroconvulsive therapy, sometimes the symptoms become more severe.


3. Psychotherapy and rehabilitation

Psychotherapy in the form of psychoanalysis did not bring the expected results, some have argued should not be performed in patients with schizophrenia because it can add insulation and autism. Supportive Psychotherapy individual or group can help patients as well as practical guidance for the purpose of restoring the patient to the community. Cognitive behavioral therapy techniques to try to psien schizophrenia with promising results.

Therapy is an excellent work to encourage people to hang out again with another person, other patients, nurses and doctors. It means that patients do not isolate themselves anymore, because if the patient withdrew and formed bad habits.


From : various source

Nursing Care Plan for Schizophrenia, Nursing Diagnosis : Disturbed Sensory Perception

Schizophrenia is a disease that affects the brain and cause thoughts, perceptions, emotions, movement, strange and disturbed behavior (Videbeck, 2008).

Nursing Diagnosis : Disturbed Sensory Perception hearing / vision related to:

• freaking out
• withdraw
• strss heavy, threatening the weak ego.

Defining characteristics:

• talking and laughing themselves
• behave like listening to something (tilt the head to one side as if someone was listening to something).
• stop talking in the midst of a sentence to listen to something.
• disorientation
• low concentrations
• rapidly changing minds
• chaos groove mind
• response is not appropriate.

Expected outcomes:

• Patients can be admitted that the hallucinations occur during extreme anxiety increased.
• Patients can say signs of increased anxiety and use certain techniques to break the anxiety.

Planning:

General purpose :
Patients are able to define and examine the reality, reducing the occurrence of hallucinations.

Specific purpose :
Patients can discuss the content of the hallucinations to nurse within 1 week.

Intervention and Rationale :

1. Observe the patient of the signs of hallucinations (attitude like listening to something, talk or laugh alone, silent in the midst of the conversation).
Rationale :
Early intervention will prevent aggressive response that ruled from hallucinations.

2. Avoid touching the patient before beckoned.
Rationale :
Patients can only interpret the touch as a threat and respond in an aggressive way.

3. Acceptance will encourage the patient to tell the contents of hallucinations with nurses.
Rationale :
It is important to prevent the possibility of injury to the patient or another person because of the command of hallucinations.

4. Do not support hallucinations. Use the words "voice" instead of the words "they", which indirectly will validate it. Let the patient know that nurses are not being distributed perception. Say "although I realize that these sounds real to you, I did not listen to the voices that speak anything."
Rationale :
Nurses need to be honest with the patient so that the patient realizes that the hallucinations are not real.

5. Try to connect the timing of the hallucinations, with a time of increased anxiety. Help the patient to understand this relationship.
Rationale :
If the patient can learn to stop the increase in anxiety, hallucinations can be prevented.

6. Try to divert patients from hallucinations.
Rationale :
Patient involvement in activities interpersonal and explain about the situation of these activities, it will help the patient to return to reality.

Nursing Care Plan for Cataracts

Cataract is the medical term for each state turbidity occurs in the eye lens that can occur as a result of hydration (adding liquid lens), the lens protein denaturation, or can also be a result of both. Usually on both eyes and walked progressive. Cataracts cause the patient can not see clearly because of the cloudy lens is difficult light reaches the retina and will produce a blurred shadow on the retina. The number and shape of the eye lens opacities in each may vary.

Causes of Cataracts

• Aging (Senile Cataracts): Most cataracts occur due to degenerative process or the age of a person. The average age of a cataract is at age 60 years and older.
• Trauma: Eye injury can be informed of all ages such as a hard blow, puncture objects, clipped, high heat, and chemicals can damage the eye and the lens is called cataract traumatic circumstances.
• Other eye diseases (uveitis)
• Systemic disease (Diabetes Mellitus).
• Congenital defects.

Cataract is diagnosed mainly by subjective symptoms. Clients reported a decrease in visual acuity and glare as well as some degree of functional impairment caused by loss of vision. Objective findings usually include condensation so that the retina would not be visible with the ophthalmoscope.

Cataracts usually develop gradually over the years and when the cataract has greatly deteriorated more powerful lens would not be able to improve vision. Common symptoms of cataracts include:

• Vision is not clear, as there is a fog blocking objects.
• Sensitive to light.
• Can see the double in one eye (diplopia).
• Require bright lighting to be able to read.
• Eyepiece turned into opaque like milk glass.

Impaired vision can be:

• Difficulty seeing at night.
• See the circle around the light or feel dazzle.
• Decreased visual acuity (even in daylight).
• Frequent sight in one eye.
• Sometimes cataract lens causing swelling and increased pressure in the eye (glaucoma), which can cause pain.

Nursing Diagnosis : Disturbed Sensory Perception : Visual related to disorders of sensory reception / status sensory organs.

Goal:

• Improving visual acuity within the limits of individual situations, recognize sensory disturbances and compensate for changes.

Expected outcomes:

• Know the sensory disturbances and compensate for changes.
• Identify / fix potential hazards in the environment.

Nursing Interventions :

1. Determine the visual acuity, and note whether one or two eyes are involved. Observe signs of disorientation.
Rational: The discovery and early treatment of complications can reduce the risk of further damage.

2. Orient the client to the environment.
Rationale: Improving safety and mobility in the environment.

3. Notice of blurred vision and eye irritation, which can occur when using eye drops.
Rational: strong light causes discomfort after use eye drops dilator.

4. Place the items needed / call bell within reach position / positions that are not operated.
Rational: Communications addressed can be more readily accepted by the obvious.

Nursing Care Plan for Endocarditis

NURSING DIAGNOSIS

1. Acute pain related to systemic effects of infection.

Interventions :

Independent

• Assess the complaint of chest pain. Pay attention to nonverbal cues of discomfort.
• Provide a quiet environment and comfort measures, such as: changes in position, back rub, use a warm compress / cold.
• Give proper entertainment activities.

Collaboration

• Give medications as indicated.
• Give O2 supplementation as indicated.

Rationale :

• Chest pain may and may not accompany the presence or absence of ischemia depends endocarditis.
• This action can reduce the patient's physical and emotional discomfort.
• Redirecting attention, provide distraction in the level of individual activities.
• Can relieve pain, decrease the inflammatory response.
• Maximize the availability of O2 to reduce the workload of the heart and prevent ischemia.

2. Risk for decreased cardiac output related to disorders of the heart valves and the endothelium.

Interventions :

Independent

• Monitor frequency / rhythm, heart sounds.
• Provide comfort measures, for example; back rub, semi-Fowler's position and entertainment.

Collaboration

• Give medications as indicated.

Rationale :

• Tachycardia and distritmia can occur when the heart is working to increase, rising to fever, hypoxia and ischemia.
• Increase relaxation and redirecting attention.
• Increase ventricular contraction.

3. Altered body temperature related to the infection process.

Interventions :

Independent

• Assess for dehydration, diaphoresis, poor skin turgor, dry mucous membranes.
• Measure the body temperature 4-8 hours.
• Monitor the input and output of fluids every 8 hours.
• Monitor the IV presence of redness and swelling, change places every 24 hours.

Collaboration

• Give antibiotics antipyretic to order, make sure the drug is administered according to the time.

Rationale:

• Increased heat causes the discharge through evaporation.
• Further support the diagnosis.
• Knowing the fluid balance while an increase in temperature.
• Prevent the occurrence of phlebitis.

4. Risk for Ineffective tissue perfusion related to embolization

Interventions :

Independent

• Assess for signs of embolization, report any signs of embolization to the doctor immediately.
• Perform a neurological examination or according client's condition.
• Instruct the client about the need to continue anticoagulation, if ordered for further prevent embolic period.
• Encourage active with range of motion exercises as tolerated.

Collaboration

• Give anticoagulant therapy.

Rationale

• The presence of emboli causing blockage of blood flow resulting in tissue hypoxia.
• Help enforce the subsequent diagnosis.
• Reduce the formation of embolism due to freezing blood cells.
• Improves peripheral circulation and venous return to reduce thrombus formation and embolism.

EVALUATION

1. Acute pain related to systemic effects of infection.

• Reported pain gone / controlled.
• Demonstrate the use of the skills of relaxation and diversion activities as indicated for individual situation.
• Identify methods that give disappearance.

2. Risk for decreased cardiac output related to disorders of the heart valves and the endothelium.

• Nutritional status is maintained / repaired.
• Achievement fixes weight according to age, gender.
• Clients revealed increased appetite.

3. Altered body temperature related to the infection process.

• Inflammatory process has been lost.
• Moist and dry skin.

4. Risk for Ineffective tissue perfusion related to embolization

• Cerebral tissue perfusion is maintained.
• Clients conscious and oriented.
• No signs of embolization.

(reference: Marilynn E. Doenges)