Nursing Care Plan

Trachoma is the world's leading cause of preventable blindness and the second cause of blindness after cataract. Blindness from trachoma occurs after years of repeated infection with the microorganism, Chlamydia trachomatis. The process of infection and re-infection starts in early childhood and may continue to adulthood, if the cycle is not broken.

Women have a two to three times the rate of advanced trachoma and blindness than men, because as mothers, grandmothers and older sisters who care for children (the main source of active trachoma infection), they are redundant and are constantly exposed to bacteria.

Trachoma is caused by Chlamydia trachomatis and is spread through direct contact with the eyes, nose, and throat are exposed to liquid (containing bacteria) of people living with, or in contact with inanimate objects, such as towels and / or rags, which once contact is similar to the liquid , Flies can also be a route of transmission. If left untreated, repeated trachoma infection can result in entropion which is a form of permanent blindness and accompanied by pain if the eyelid turns inward, as this causes the eyelashes to scratch the cornea. Children are most susceptible to this infection because of their tendency to easily get dirty, but the effects of blurred vision and other more severe symptoms are often not felt until adulthood.

These bacteria have an incubation period of 5 to 12 days after a person experiences symptoms of conjunctivitis, or irritation similar to "pink eye." Endemic trachoma blindness is the result of several episodes of reinfection that produces continuous inflammation of the conjunctiva. Without reinfection, the inflammation will be gradually improved.

Inflammation of the conjunctiva is called "active trachoma" and usually seen in children, especially children of pre-school (elementary). It is characterized by white bumps on the bottom surface of the upper eye lid (conjunctival follicles or germinal centers of lymphoid). Non-specific inflammation and thickening often associated with papillae. Follicles may also appear at the junction of the cornea and sclera (limbal follicles). Active trachoma will often be irritating and have a watery fluid. Secondary bacterial infection may occur and cause a purulent discharge.

Further symptoms include:
Dirty discharge from the eyes - not tears (emissions or secretions containing mucus and pus from the eyes).
Swelling of the eyelids.
Trichiasis (turned eyelashes).
Swollen lymph nodes in the front of the ear.
The appearance of lines scarring of the cornea.
Complications in the ear, nose and throat.

The main complication is the most important or ulcers (sores / irritations) on the cornea due to a bacterial infection.


Nursing Diagnosis for Trachoma

1. Acute pain: eye related to swelling of the lymph nodes, photophobia and inflammation.
2. Disturbed Sensory Perception: Visual related to damage to the cornea.
3. Risk for infection, the spread related to lack of knowledge.
4. Body image disorders related to loss of vision.

Nursing Care Plan for Dysentery

Dysentery is derived from the Greek, ie dys (= disorder) and enteron (= intestine). so dysentery
is a gastrointestinal disease in the form of intestinal infection or inflammation of the intestines caused by bacteria, which causes severe diarrhea. Each individual course of the disease is more varied, with some people suffering from dysentery have mild symptoms, while others may experience severe diarrhea with or without vomiting which can pose a risk of dehydration. Fortunately dysentery can be easily treated with antibiotics and antiparasitic drugs. Dysentery if untreated can lead to severe dehydration.

The most common cause of dysentery and is often found in people are not washing hands after using public restrooms or not washing hands before eating. Indeed simple enough to cause dysentery as a classic case, but that the reality is often the case. Broadly speaking, the cause of dysentery is closely related to the cleanliness of our surroundings and clean living habits.

Symptoms that arise in dysentery, among others:

• Time dysentery symptoms can last between 5-7 days or even longer.
• Patients experiencing abdominal cramps (colic).
• Patients experiencing pain during bowel movements (tenesmus).
• Defecation accompanied by mucus.
• Defecation with bloody stools.
• High fever (39.5 to 40 degrees Celsius).
• Vomiting.
• Anorexia.
• Sometimes accompanied by symptoms like encephalitis and sepsis
• (seizures, headache, lethargy, stiff neck, hallucinations).

Risk for Impaired Skin Integrity : perianal related to an increase in the frequency of bowel movements (diarrhea).

Goal: skin integrity is not compromised.

Expected outcomes:

• No irritation: redness, blisters, hygiene maintained.
• Families are able to demonstrate perianal care of properly.

Intervention:
1) Discuss and explain the importance of keeping the bed.
R / Hygiene prevent the proliferation of germs.

2) Demonstrate and involve families in caring for perianal (when wet clothing and replace the bottom as well as the base).
R /: Preventing skin iritassi unexpected because humidify and stool acidity.

3) Position the bed or sitting at intervals of 2-3 hours
R /: Smooth vascularity, reducing the pressure for a long time, so there is no ischemia, and irritation.

Nursing Care Plan for Diabetic Ketoacidosis

Diabetic Ketoacidosis (DKA) is a potentially life threatening condition of diabetes occurring mostly in patients with Type 1 diabetes but on occasion also in patients with Type 2 diabetes. This disease is a potentially fatal complication of diabetes that occurs when insulin levels are far lower than what the body needs.

The most frequent early signs of Diabetic Ketoacidosis or DKA is a sharp increase in polydipsia and polyuria. Whilst Polydipsia means excessive thirst, Polyuria refers to the excessive production of dilute urine. Other symptoms include malaise, generalized weakness, and tiredness. These may then progress if untreated to vomiting, deep gasping breathing (kussmaul respiration), dehydration, rapid weight loss in patients newly diagnosed with Type 1 diabetes, mild disorientation, confusion and occasionally coma.


Imbalanced Nutrition : Less than Body Requirements related to the insufficiency of insulin, decreased oral input, hyper-metabolic status.

Expected outcomes: The client will;

• Digesting the number of calories / nutrients right.
• Shows the energy level normally.
• Demonstrating steady weight or adding appropriate normal range.

Interventions :

1. Monitor weight daily or as indicated.
R:/ Assessing adequate food intake, including absorption and utilities.

2. Determine the diet and eating patterns of patients and compare it with the food being spent.
R:/ Identify deficiencies and deviations from the therapeutic needs

3. Auscultation bowel sounds, note the presence of abdominal pain / abdominal bloating, nausea, vomit undigested food, keep fasting as indicated.
R:/ Hyperglycemia and disorders of fluid and electrolyte balance may decrease motility / function of the stomach (distention or paralytic ileus) that will affect the choice of intervention.

4. Give foods that contain nutrients then try giving a more solid that can be tolerated.
R:/ Oral feeding is better if the patient is conscious and good gastrointestinal function.

5. Involve patients in planning family as indicated.
R:/ Provide information on the family to understand the nutritional needs of the patient.

6. Observation of signs of hypoglycemia.
R:/ Hypoglycemia can occur because of a reduced carbohydrate metabolism while still given insulin, it can potentially be life threatening and should be recognized.

Collaboration:
1. Monitor proofing acetone, pH and HCO3.
R:/ Monitor the effectiveness of insulin in order to stay in control.

2. Give regular insulin treatment as indicated.
R:/ Facilitate the transition on carbohydrate metabolism and lowers the incidence of hypoglycemia.

3. Examination of blood sugar.
R:/ Monitor blood sugar is more accurate than the reduction of urine to detect fluctuations.

Nursing Care Plan for Congenital Heart Disease

Congenital Heart Disease (CHD) is a heart disease which is inborn, because it occurs when a baby still in the womb. At the end of the seventh week of pregnancy, heart formation is complete; so the formation of cardiac abnormalities occur in early pregnancy. Causes of Congenital Heart Disease (CHD) often can not be explained, although several factors are considered as a potential cause (Rahayoe, 2006).

Congenital heart defects is heart defects or malformations that appear at birth, in addition to congenital heart disease is a disorder of the heart anatomy brought from conception to birth. Most congenital heart defects include structural malformations in the heart and major blood vessels, both the left and that leads to the heart (Nelson, 2000). This disorder is the most common congenital abnormalities in children, about 8-10 of 1,000 live births.

This congenital heart defect does not always give symptoms shortly after birth, it is not uncommon these disorders has been discovered after a few months old, or even found after a few years old. This disorder can be mild so as not detected at birth. However, in particular children, the effects of this disorder is so severe that a diagnosis was enforceable even before birth. With the sophistication of medical technology in the field of diagnosis and treatment, many children with congenital heart defects can be remedied and well into adulthood (Ngustiyah, 2005).

The cause of congenital heart disease can not be known with certainty, but there are several factors that have an influence on the expected increase in the incidence of CHD.

These factors are:
1. Prenatal factors:

• Mothers suffering from infectious diseases: rubella.
• Maternal alcoholism.
• Maternal age over 40 years.
• Peyakit mother suffering from diabetes mellitus who require insulin.
• Mothers taking sedative drugs or herbs.

2. Genetic factors

• Children born before suffering from CHD.
• Father / mother suffering from congenital diseases.
• Down syndrome is a chromosomal abnormality example.
• Born with congenital abnormalities others.

Nursing Care Plan for Congenital Heart Disease

Assessment

1. Physical assessment (color, pulse, respiration, blood pressure, chest auscultation).
2. Family history.
3. Pregnancy history.
4. Assessment manifestations of congenital heart disease.
5. Collagen tissue abnormalities.
6. Complications or consequences of hypoxemia.
7. Construction of a weak body.
8. Dyspnea on activity.
9. Fatigue.

Nursing Diagnosis for Congenital Heart Disease

1. Risk for decreased cardiac output r / t defect structure.
2. Altered Growth and Development r / t inadequate oxygen and nutrients to the tissues.
3. Risk for infection r / t weak physical status.
4. Altered family processes r / t have children with heart disease.
5. Risk for injury (complications) r / t cardiac conditions and therapies.

Intervention

1. Check the blood, red blood cell indices.
2. Assess the arterial blood gas analysis.
3. Test oxygen.
4. Give afterload lowering medications as instructed.
5. Give diuretic as instructed.
6. Provide frequent rest periods and sleep periods without interruption.
7. Encourage quiet activities.
8. Give a diet high in nutrients, which is balanced to achieve adequate growth.
9. Monitor height and weight.
10. Encourage the family to participate in the care process.
11. Teach families to recognize the signs of complications.

Expected Results

1. Heart rate, BP and peripheral perfusion are the age-appropriate upper limit of normal.
2. Exit adequate urine (between 0.5 and 2ml / kg, depending on age).
3. Children achieve adequate growth.
4. Families can confront the child with positive symptoms.
5. Families recognize the signs of complications and take appropriate action.

Nursing Care Plan for Blepharitis

Blepharitis or better known as inflammation of the eyelids is one of the eye diseases to watch out for. The disease is caused by the oil glands at the base of the lashes were damaged, causing itching in the eyelids, irritation, even to inflammation. If this is allowed then it would be blepharitis.

Although blepharitis does not cause permanent damage to the eye, but very disturbing activities of our vision.

Symptoms of Blefarits as follows:

• The eyelids are often greasy.
• Itch on the eyelids.
• Burned in the eye.
• Eyes look red.
• Frequent watery eyes.
• Eye swelling of the eyelids.
• Eyelash gross waking.
• Very sensitive to light.
• Have peeling skin around the eyes.
• Eyelashes fall out.
• Eyelashes abnormal and irregular direction.

Main causes of the occurrence of blepharitis (inflammation of the eyelids)

• Infected by the bacteria.
• Glands damaged eye.
• Dandruff of the scalp to eyebrows.
• Rosacea.
• Allergic to something eg eye drops, eye lens.

Nursing Diagnosis and Interventions for Blepharitis :

Disturbed Sensory Perception (visual) related to reception interference status sensory organs.

Goal: Increase the visual acuity within the limits of individual situations.

Expected outcomes:

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

Intervention:

1) Determine the visual acuity, note whether one or both eyes are involved.
Rational: individual needs and choice of interventions varied causes vision loss occurs slowly and progressively.

2) Observe the signs and symptoms of disorientation.
Rational: woke up in unfamiliar surroundings and have limited vision.

3) Orient the patient on the environment, other people in the area.
Rationale: provides increased comfort and familiarity.

4) Notice about blurred vision and eye irritation, which can occur when using eye drops.
Rational: impaired vision / irritation can end 1-2 hours after use of eye drops, gradually decreases with usage.

5) Place the items needed / call bell within reach positions on the near side.
Rational: allowing patients to see objects more easily and facilitate the call for help when needed.

Nursing Care Plan for Bronchiectasis

Bronchiectasis is a chronic dilatation of the bronchi and bronchioles that may be caused by various conditions, including lung infections and bronchial obstruction; foreign body aspiration, vomit, and objects from the upper respiratory tract; and the pressure due to a tumor, blood vessels dilated and enlarged lymph nodes (Brunner & Suddart, 2002).

According Suyono (2001) etiology of bronchiectasis are:

1. Infection
Bronchiectasis often occur after a child suffering from pneumonia who frequently relapse and long lasting. Pneumonia is generally a pertussis or influenza complications suffered during the child, pulmonary tuberculosis, and so on.

2. Abnormalities hereditary or congenital abnormalities
In this case bronchiectasis occurs in the womb. Genetic factors or growth factors and fetal development plays an important role. Usually has the characteristics on almost all branches of the bronchi in the lungs one or two. Usually accompanied by other congenital diseases.

3. Bronchial obstruction
Obstruction is meant as a corpus alienum, bronchial carcinoma and other external pressure against the bronchi.


Pathophysiology

According to Brunner & Suddarth (2002) pathophysiology of bronchiectasis starting from infections that damage the bronchial wall, causing loss of supporting structure and produce thick sputum that can eventually clog the bronchi. Bronchial walls become stretched permanently as a result of severe coughing, infection extends to peri bronchial, so that in the case of secular bronchiectasis, each tube is actually dilated pulmonary abscess, which exudates to flow freely through the bronchi. Bronchiectasis is usually local, attacking lung lobe segment. Lower lobe most often affected.

Retention secretion and obstruction resulting eventually cause obstruction distal side alveoli collapse (atelectasis). Due to scarring or fibrosis replaces lung tissue inflammatory reaction that function. At the time the patient suffered respiratory insufficiency with a decrease in vital capacity, decreased ventilation, and an increase in the ratio of residual volume to total lung capacity. There is damage to the gas mixture in the inspiration (ventilation-perfusion mismatch) and hypoxemia.


According Suyono (2001) the signs and symptoms of bronchiectasis as follows:

1. Cough
Hemoptysis is characterized, among others; ongoing chronic productive cough, sputum amount varies, generally polynomial in the morning after there is a sleeping position or wake up from sleep. Sputum consists of three layers:

• The top layer; rather cloudy, consisting of mucus.
• The middle layer; clearly consists of saliva.
• The bottom layer; turbid, consisting of pus and tissue necrosis of bronchial damaged.

2. Hemoptysis
Caused by necrosis or destruction of the bronchial mucosa blood vessels (rupture) and the resulting bleeding.

3. Shortness of breath (dyspnea)
Onset of shortness of breath depends on the extent of bronchiectasis, sometimes causing wheezing sound due to bronchial obstruction.

4. Recurrent fever
Bronchiectasis is a chronic disease, often experience recurrent infection of the bronchi and the lungs, often resulting in fever (recurrent fever).

5. Physical Abnormalities

• Cyanosis
• Clubbing
• Bronchi wet
• Whezing

Nursing Care Plan for Bronchiectasis

Nursing Diagnosis : Ineffective airway clearance related to the increased production of secretions, thick secretions.

Goal: Maintain a patent airway with breath sounds clean / clear.

Expected outcomes: Demonstrate behaviors to improve airway clearance (effective cough, and issued a secret.)

Intervention:
1. Auscultation of breath sounds and record their breath sounds.
R /: The degree of bronchospasm occurs with airway obstruction and can / not characterized by the presence of breath sounds.

2. Assess / monitor respiratory frequency. Note the ratio of inspiration and expiration.
R /: Tacipneu common to some degree can be found at the reception or during stress / acute infection process. Slowed breathing and elongated compared inspiration expiration frequency.

3. Assess the patient to a comfortable position, Height head of the bed and sat on the back of the bed.
R /: Elevation headboard ease respiratory function by means of gravity. And make it easier to breathe, and help decrease muscle weakness and can be as a tool chest expansion.

4. Help abdominal breathing exercises or lips.
R / To cope with and control of dyspnea and lower air entrapment.

5. Observe the characteristic cough and aid effectiveness action to cough effort.
R /: Knowing the effectiveness of cough.

6. Increase fluid intake till 3000ml / day as tolerated heart and give a warm and fluid intake between as a meal replacement.
R /: Hydration helps to lower the viscosity of secretions, simplify expenditure warm fluids can reduce bronchospasm. Liquids between meals can increase gastric distension and pressures diaphragm.

7. Give the drug as indicated.
R /: Speed up the healing process.