Nursing Care Plan

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

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


Hydrocephalus - Nursing Diagnosis and Interventions (NIC - NOC)


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

NOC: Circulation status

Expected outcomes (NOC):

1. Shows the status of circulation which is characterized by the following indicators:

• Systolic and diastolic blood pressure within the expected range.
• No orthostatic hypotension.
• No noisy large blood vessels.

2. Demonstrate the cognitive abilities which is characterized by the following indicators:

• Communicate clearly and in accordance with the age and ability.
• Show attention, concentration and orientation.
• Shows the long-term memory and the present.
• Process information.
• Making the decision properly.

NIC Intervention

Monitor  :

1. Vital signs.
2. Headache.
3. The level of awareness and orientation.
4. Diplopia, nystagmus, blurred vision, visual acuity.
5. Monitoring ICT

• ICT monitoring and neurological response of patients to treatment activities.
• Monitor the tissue perfusion pressure.
• Note the change in the patient's response to a stimulus.

6. Management of peripheral sensation

• Monitor for parestesis: numbness or tingling.
• Monitor fluid status, including intake and output.

Collaborative Activity

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



2. Acute Pain related to an increase in ICT

NOC:

1. Pain Level

• Reports of pain.
• Frequency of pain.
• The duration of pain.
• Facial expressions to pain.
• Anxiety.
• Changes in vital signs.
• Changes in pupil size.

2. Pain Control

• Mention the factors that cause.
• Mention the time of the pain.
• Analgesic use as indicated.
• Mention the painful symptoms.

NIC:

1. Pain Management

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

Nursing Care Plan for Mastoiditis

Mastoiditis is an inflammation of the mastoid bone, usually from the tympanic cavity. The expansion of middle ear infections repeatedly can cause changes in the mastoid, such as thickening of the mucosa and accumulation of exudate. Over time there is inflammation of the bone (osteitis) and collecting exudate / pus that more and more, eventually finding a way out. The weak areas are usually located behind the ear, causing an abscess superiosteum.

According to George (1997: 106), the clinical manifestations in patients with mastoiditis include:

• The fever usually disappear and arise.
• Pain tends to settle and throbbing, located around and inside the ears, and experience tenderness in the mastoid.
• Hearing loss.
• Tympanic membrane bulging contain skin that has been damaged and discuss sebaceous (fat).
• Posterior canal wall hanging.
• Postauricular swelling.
• A large discharge through the ear canal and the odor.

Nursing Diagnosis and Interventions for Mastoiditis

1. Acute Pain is related to inflammation of the mastoid bone because of infection.

Goal: Pain is resolved.

Expected outcomes:

• Pain is reduced.
• Pain scale decreased.
• The face looked relaxed.

Interventions :

1. Review the scale of pain, location, intensity.
R /: Knowing the effectiveness of interventions.

2. Provide a comfortable position.
R /: Reduce pain.

3. Teach relaxation techniques and create a tranquil environment.
R /: Turning his attention to the pain and reduces pain.

4. Collaboration of analgesics, antibiotics, and anti-inflammatory as indicated.
R /: It can reduce pain, kill germs and reduce inflammation and accelerating healing.


2. Hyperthermia related to the inflammatory process.

Goal: The body temperature may be normal (36 0- 37 0 C)

Expected outcomes:

• The body temperature within normal range (36 0-37 0 C).
• The skin does not feel warm.
• The face does not look red.
• Prevent dehydration.

Interventions :

1. Monitor the input and output.
R /: To find out the patient's fluid balance.

2. Measure the temperature every 4-8 hours.
R /: To determine the condition of the client's body temperature.

3. Teach warm compresses, and a lot of drinking
R /: To reduce body heat and replace lost body fluids.

4. Collaboration with the administration of antipyretics.
R /: To reduce the heat.

Acute Pain

Definition:

An unpleasant sensory and emotional experience arising in an actual or potential tissue damage or describe the damage (International Association of Pain Study): a sudden attack or low in intensity from mild to severe which can be anticipated by the end of a predictable and with a duration less than 6 months .

Defining Characteristics:

• Report of verbal or non verbal
• The fact of the observation
• Antalgic position to avoid pain
• Movement to protect
• Cautious behavior
• Face masks
• Sleep disturbances (eyes glazed, looking tired, difficult or chaotic motion, grinning)
• Focused on self-
• Focus narrowed (decreased perception of time, the damage is thought process, decreased interaction with people and the environment)
• Behavior distraction, for example: roads, meet other people and / or activities, repetitive activities)
• Autonomic Response (such as diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils)
• Changes in muscle tone, autonomic (probably in the range from weak to stiff)
• Expressive behavior (eg, restlessness, moaning, crying, alert, irritable, breath / bitching)
• Changes in appetite and drinking

Related factors:

Injury agents (biological, chemical, physical, psychological)


NOC:

• Pain Level,
• Pain control,
• Comfort level

Results Criteria:

• Ability to control pain (know the cause of pain, able to use the technique nonfarmakologi to reduce pain, seek help)
• Reported that the pain was reduced by using a pain management
• Able to identify pain (scale, intensity, frequency and signs of pain)
• Declare a sense of comfort after pain was reduced
• Vital signs are within normal ranges

NIC:

Pain Management

• Perform a comprehensive pain assessment includes the location, characteristics, duration, frequency, quality and factors presipitas
• Observation of nonverbal reactions of discomfort
• Use therapeutic communication techniques to determine the patient's pain experience
• Assess the culture that affect the pain response
• Evaluation of past experience of pain
• Evaluate with the patient and other health care team about the ineffectiveness of past pain control
• Help patients and families to seek and find support