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 Dermatitis

Dermatitis is inflammation of the skin. Dermatitis can have many causes and occurs in many forms. Dermatitis usually involves an itchy rash on swollen, reddened skin.

Dermatitis is a common condition that's not contagious and usually isn't life-threatening. Even so, it can make you feel uncomfortable and self-conscious.

Disturbed Body Image related to the appearance of the skin that is not good.

Goal: Development of an increase in self-acceptance.

Expected outcomes:

• Develop an increase in the willingness to accept a state of self.
• Follow and participate in self-care measures.
• Reported feeling in control of the situation.
• Reinforces the positive support of the self-governing.
• Express attention to self-healthier.
• Seemed not to notice the condition.
• Using a technique to hide flaws and emphasize techniques for improving the appearance.

Interventions :

1. Assess the patient's self-image disturbance in (avoiding eye contact, self-deprecating speech, expression sick state of the condition of the skin).
R /: Disturbed self-image will accompany any disease or condition were apparent to the patient. Impression of someone against itself will affect the self-concept.

2. Identify the psychosocial stages of development stages.
R /: On the relationship between the stages of development, as well as the self-image and understanding of the patient's reaction to the skin condition.

3. Provide an opportunity for disclosure. Listen (by way of an open, non-judgmental) to express mourning / anxiety about body image changes.
R /: Patients in need of the experience that must be listened to and understood.

4. The sense of concern and fear of patients. Help patients who are anxious to develop the ability to assess themselves and identify and resolve problems.
R /: This action provides an opportunity for health workers to neutralize unnecessary anxiety and restore the reality of the situation. Fear is a destructive element patient adaptations.

5. Encourage socialization with other people.
R /: Increase self-acceptance and socialization.

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 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.

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

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 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.

Herniated Nucleus Pulposus

Intervertebral Discs are the cartilage plates that form a cushion between the vertebral bodies. Hard and fibrous material is combined in one capsule. Such as ball bearings in the middle of the disc called the nucleus pulposus. Herniated nucleus pulposus is a rupture of the nucleus pulposus.

Herniated nucleus pulposus into the vertebral bodies can be above or below it, can also directly into the vertebral canal.

Pain can occur in any part such as cervical spine, thoracic (rarely) or lumbar. Clinical manifestations depend on the location, speed of development (acute or chronic) and the effect on surrounding structures. Lower back pain is severe, chronic and recurring (relapse).

Diagnostic Examination
1. Spinal RO: Shows the degenerative changes in the spine
2. MRI: to localize even small disc protrusion, especially for lumbar spinal disease.
3. CT Scan and Myelogram if the clinical and pathological symptoms are not visible on MRI
4. Electromyography (EMG): to localize the specific spinal nerve roots are exposed.


Assessment Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Anamnesa
The main complaint, history of present treatments, medical history past, family health history.

2. Physical examination
Assessment of the patient's problem consists of onset, location and spread of pain, paresthesias, limited mobility and limited function of the neck, shoulders and upper extremities.
Assessment in the area include palpation of the cervical spine which aims to assess muscle tone and rigidity.

3. Examination Support

Read More : Nursing Care Plan : Nursing Diagnosis and Interventions for HNP Herniated Nucleus Pulposus

Definition of Urethral Stricture

A urethral stricture is a narrowing of a section of the urethra. It causes a blocked or reduced flow of urine which can lead to complications.


Symptoms and signs

Symptoms of urethral stricture is a typical small stream of urine and branched irritation and other symptoms of infection such as frequency, urgency, dysuria, sometimes with infiltrates, abces and fistula. Symptoms are retained urine.


Physical Examination

Anamnese

To find the absence of symptoms and signs of urethral stricture also to look for causes of urethral stricture.

General and local examination

To check on the patient also to change in urethral fibrosis, infiltrates, abscesses or fistulas.

Examination Support

Laboratory: urea, creatinine, to see the renal physiology. Radiological Diagnosis must be made with urethrography. Retrograde urethrography to see the anterior urethra. Antegrade urethrography to see the posterior urethra. Bipoler urethrography is a combination of antegrade and retrograde urethrography examinations. With this examination can be expected in addition to the diagnosis of urethral strictures can be also determined the length of urethral stricture are important for therapy planning / operations.


Basic Concepts of Nursing Care

In nursing care is carried out by using the nursing process. The nursing process is a form of dynamic problem-solving process in an effort to improve and maintain optimal patient through a systematic approach to help patients. Nursing theories and concepts are implemented in an integrated manner in which organized phases which include:

Assessment, Nursing Diagnosis, Interventions, Implementation, Evaluation.

Read More : Nursing Care Plan for Urethral Stricture

Thyroid cancer is a disease in which malignant (cancer) cells form in the tissues of the thyroid gland.

The thyroid is a gland at the base of the throat near the trachea (windpipe). It is shaped like a butterfly, with a right lobe and a left lobe. The isthmus, a thin piece of tissue, connects the two lobes. A healthy thyroid is a little larger than a quarter. It usually cannot be felt through the skin. The thyroid uses iodine, a mineral found in some foods and in iodized salt, to help make several hormones. Thyroid hormones do the following:

• Control heart rate, body temperature, and how quickly food is changed into energy (metabolism).
• Control the amount of calcium in the blood.

There are four main types of thyroid cancer:

• Papillary thyroid cancer: The most common type of thyroid cancer.
• Follicular thyroid cancer. Hürthle cell carcinoma is a form of follicular thyroid cancer and is treated the same way.
• Medullary thyroid cancer.
• Anaplastic thyroid cancer.

Possible signs of thyroid cancer include a swelling or lump in the neck.

Thyroid cancer may not cause early symptoms. It is sometimes found during a routine physical exam. Symptoms may occur as the tumor gets bigger. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

• A lump in the neck.
• Trouble breathing.
• Trouble swallowing.
• Hoarseness.

More :

Nursing Management for Thyroid Cancer: Preoperative, Intraoperative and Postoperative

Cataract


A cataract is a clouding of the lens in your eye. It affects your vision. Cataracts are very common in older people. By age 80, more than half of all people in the United States either have a cataract or have had cataract surgery.

Common symptoms are

• Blurry vision
• Colors that seem faded
• Glare
• Not being able to see well at night
• Double vision
• Frequent prescription changes in your eye wear

Cataracts usually develop slowly. New glasses, brighter lighting, anti-glare sunglasses or magnifying lenses can help at first. Surgery is also an option. It involves removing the cloudy lens and replacing it with an artificial lens. Wearing sunglasses and a hat with a brim to block ultraviolet sunlight may help to delay cataracts.

NIH: National Eye Institute


Having cataracts is often compared to looking through a foggy windshield of a car or through the dirty lens of a camera. Cataracts may cause a variety of complaints and visual changes, including blurred vision, difficulty with glare (often with bright sun or automobile headlights while driving at night), dulled color vision, increased nearsightedness accompanied by frequent changes in eyeglass prescription, and occasionally double vision in one eye. Some people notice a phenomenon called "second sight" in which one's reading vision improves as a result of their increased nearsightedness from swelling of the cataract. A change in glasses may help initially once vision begins to change from cataracts; however, as cataracts continue to progress and opacify, vision becomes cloudy and stronger glasses or contact lenses will no longer improve sight.

Cataracts are usually gradual and usually not painful or associated with any eye redness or other symptoms unless they become extremely advanced. Rapid and/or painful changes in vision are suspicious for other eye diseases and should be evaluated by an eye-care professional.

To detect a cataract, the eye-care provider examines your lens. A comprehensive eye examination usually includes the following:

• Visual acuity test: An eye chart test is used to measure your reading and distance vision.
• Refraction: Your eye doctor should determine if glasses would improve your vision.
• Glare testing: Vision may be significantly altered in certain lighting conditions and normal in others; in these circumstances, your doctor may check your glare symptoms with a variety of different potential lighting sources.
• Potential acuity testing: This helps the ophthalmologist get an idea of what your vision would be like after removal of the cataract. Think of this as the eye's vision potential if the cataract was not present.
• Contrast sensitivity testing: This checks for your ability to differentiate different shades of gray, which is often this limited by cataracts.
• Tonometry: a standard test to measure fluid pressure inside the eye (Increased pressure may be a sign of glaucoma.)
• Pupil dilation: The pupil is enlarged with eye drops so that the ophthalmologist can further examine the lens and retina. This is important to determine if there are other conditions which may ultimately limit your vision besides cataracts.

Source : http://www.emedicinehealth.com/cataracts/page6_em.htm#Exams and Tests

1. Objective data: patient's eye's lens appears cloudy. Both pupils appear to look gray.

Subjective data: patients complaining blurred vision / dim and decreased visual acuity and glare, the patient is difficult to see at night.

Nausea

Nausea is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, preceded vomiting. A person can suffer nausea without vomiting. Some common causes of nausea are motion sickness, gastroenteritis (stomach infection) or food poisoning, side effects of many medications including cancer chemotherapy, or morning sickness in early pregnancy. Medications taken to prevent nausea are called antiemetics and include diphenhydramine, metoclopramide and ondansetron. Nausea may also be caused by stress and depression.


Vomiting

Symptomatic treatment may occur while the underlying illness is being investigated because ideally, nausea and vomiting should resolve when the cause of the symptoms resolves.

Nausea and vomiting are often made worse when the patient is dehydrated, resulting in a vicious cycle. The nausea makes it difficult to drink fluid, making the dehydration worse, which then increases the nausea. Intravenous fluids may be provided to correct this issue.

There are a variety of anti-nausea medications (antiemetics) that may be prescribed. They can be administered in different ways depending upon the patient's ability to take them. Medications are available by pill, liquid, or tablets that dissolve on or under the tongue, by intravenous or intramuscular injection, or by rectal suppository.

Common medications used to control nausea and vomiting include promethazine (Phenergan), prochlorperazine (Compazine), droperidol (Inapsine) metoclopramide (Reglan), and ondansetron (Zofran). The decision as to which medication to use will depend on the specific situation.
www.medicinenet.com

Purpose: devisit fluid and electrolyte resolved

Expected outcomes: The signs of dehydration do not exist, the mucosa of the mouth and lips moist, fluid balance.

Nursing Intervention:

• Observation of vital signs.
• Observation for signs of dehydration.
• Measure infut and output of fluid (fluid balance).
• Provide and encourage families to provide drinking a lot of approximately 2000 - 2500 cc per day.
• Collaboration with physicians in the provision of therafi fluid, electrolyte laboratory tests.
• Collaboration with a team of nutrition in low-sodium fluids.

Nursing Diagnosis: Risk for Fluid Volume Deficit related to a sense of nausea and vomiting

Purpose: Maintaining the balance of fluid volume.

Expected outcomes: The client does not nausea and vomiting.

Nursing Intervention:

• Monitor vital signs.
• Rational: This is an early indicator of hypovolemia.
• Monitor intake and urine output and concentration.
• Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one suggestive of dehydration and require increased fluids.
• Give fluid little by little but often.
• Rationale: To minimize loss of fluid.
• The risk of infection associated with an inadequate defense of the body, characterized by: body temperature above normal. Respiratory frequency increased.

Gastritis

Gastritis occurs when the lining of the stomach becomes inflamed or swollen.

Gastritis can last for only a short time (acute gastritis), or linger for months to years (chronic gastritis)



Symptoms
Many people with gastritis do not have any symptoms.

Symptoms you may notice are:

• Loss of appetite
• Nausea and vomiting
• Pain in the upper part of the belly or abdomen

If gastritis is causing bleeding from the lining of the stomach, symptoms may include:

• Black stools
• Vomiting blood or coffee-ground like material

Gastritis is diagnosed through one or more medical tests:

• Upper gastrointestinal endoscopy. The doctor eases an endoscope, a thin tube containing a tiny camera, through your mouth (or occasionally nose) and down into your stomach to look at the stomach lining. The doctor will check for inflammation and may remove a tiny sample of tissue for tests. This procedure to remove a tissue sample is called a biopsy.
• Blood test. The doctor may check your red blood cell count to see whether you have anemia, which means that you do not have enough red blood cells. Anemia can be caused by bleeding from the stomach.
• Stool test. This test checks for the presence of blood in your stool, a sign of bleeding.

Treating Gastritis

1. Conservatives on state of acute
If severe disease, patients need to be treated and given fluids per infusion.

• Bed rest
• Fasting, nasogastric tube pairs
• Analgesics, antibiotics

2. When conservative treatment fails or there is a progressive toxemia cholecystectomy needs to be done. It is necessary to prevent the occurrence of complications (gangrene, perforation, empyema, pancreatitis dam kalangitis)
Cholecystectomy should be done also in the repeated attacks

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Heart failure (HF) often called congestive heart failure (CHF) is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body. Heart failure can cause a number of symptoms including shortness of breath, leg swelling, and exercise intolerance. The condition is diagnosed with echocardiography and blood tests. Treatment commonly consists of lifestyle measures (such as smoking cessation, light exercise including breathing protocols, decreased salt intake and other dietary changes) and medications, and sometimes devices or even surgery.



Common causes of heart failure include myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease, and cardiomyopathy. The term "heart failure" is sometimes incorrectly used to describe other cardiac-related illnesses, such as myocardial infarction (heart attack) or cardiac arrest, which can cause heart failure but are not equivalent to heart failure.

The symptoms of congestive heart failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensated" for the heart muscle weakness.

• An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible underlying congestive heart failure, it is obviously a nonspecific symptom that may be caused by many other conditions. The person's ability to exercise may also diminish. Patients may not even sense this decrease and they may subconsciously reduce their activities to accommodate this limitation.
• As the body becomes overloaded with fluid from congestive heart failure, swelling (edema) of the ankles and legs or abdomen may be noticed. This can be referred to as "right sided heart failure" as failure of the right sided heart chambers to pump venous blood to the lungs to acquire oxygen results in buildup of this fluid in gravity-dependent areas such as in the legs. The most common cause of this is longstanding failure of the left heart, which may lead to secondary failure of the right heart. Right-sided heart failure can also be caused by severe lung disease (referred to as "cor pulmonale"), or by intrinsic disease of the right heart muscle (less common)
• In addition, fluid may accumulate in the lungs, thereby causing shortness of breath, particularly during exercise and when lying flat. In some instances, patients are awakened at night, gasping for air.
• Some may be unable to sleep unless sitting upright.
• The extra fluid in the body may cause increased urination, particularly at night.
• Accumulation of fluid in the liver and intestines may cause nausea, abdominal pain, and decreased appetite.

Nursing Assessment for Congestive Heart Failure

a. Identity

b. Food or liquid
Symptoms:

• Loss of appetite
• Nausea and vomiting
• Swelling of the extremities
• Diit high salt or fat, sugar and caffeine

c. Elimination
Symptoms:

• Decreased urination, dark urine
• Urination at night
• Diarrhea or constipation

d. Activity / rest
Symptoms:

• Fatigue or tiredness constantly throughout the day
• Insomnia
• Chest pain with activity

e. Circulation
Symptoms:

• History of hypertension
• Cardiac surgery
• Anemia
• Endocarditis

f. Ego integrity
Symptoms:

• Anxiety, worry and fear
• Stress-related illnesses

g. Comfort
Symptoms:

• Chest pain, acute or chronic angina
• Muscle pain

h. Respiratory
Symptoms:

• Dyspnea on exertion, while sitting or sleeping with multiple pillows

i. Social interaction
Symptoms:

• Decreased participation in usual social activities

j. Security
Symptoms:

• Changes in mental function
• Loss of strength or muscle tone
• skin blisters

Nursing Diagnosis for Congestive Heart Failure

Decreased cardiac output related to

• Changes in myocardial contractility or inotropic changes.
• Changes in frequency, rhythm, cardiac conduction.
• Structural changes. (eg, valve abnormalities, ventricular aneurysm)

Activity intolerance related to

• Weakness, fatigue.
• Changes in vital signs, presence of dysritmia.
• Dyspnea.
• Pale.
• Sweating.

Excess fluid volume related to

• The decline in glomerular filtration rate (decrease in cardiac output) or increased production of ADH and sodium and water retention.

Risk for impaired skin integrity related to

• Bed rest.
• Edema, decreased tissue perfusion.

Non-Hodgkin's lymphoma


Causes

Nursing Care Plan for Non-Hodgkin's Lymphoma

Priority Nursing

• Providing physical and psychological support for diagnostic tests and treatment programs.
• Preventing complications
• Eliminate pain
• Provides information about the disease / prognosis and treatment needs

Purpose

• Complications prevented / decreased
• Receive real situation.
• Pain relief / control
• The disease process / prognosis, possible complications and treatment programs understand.

Nursing Diagnosis Nursing Care Plan for Non-Hodgkin's Lymphoma

• Ineffective Breathing Pattern
• Ineffective Airway Clearance

Risk factors include
Tracheobronchial obstruction, mediastinal node enlargement or edema and airway path (Hodgkin's and non-Hodgkin's), superior vena cava syndrome (non-Hodgkin's)

Possible evidenced by
(not applicable, the existence of signs and symptoms make the actual diagnosis)

Expected Result / Patient Evaluation Criteria will
Maintaining Normal Breathing Pattern / Effective Free Dyspnea, cyanosis or Signs Other Respiratory distress

Gangrene is a serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies (necrosis). This may occur after an injury or infection, or in people suffering from any chronic health problem affecting blood circulation. The primary cause of gangrene is reduced blood supply to the affected tissues, which results in cell death. Diabetes and long-term smoking increase the risk of suffering from gangrene.

There are different types of gangrene with different symptoms, such as dry gangrene, wet gangrene, gas gangrene, internal gangrene and necrotising fasciitis. Treatment options include debridement (or, in severe cases, amputation) of the affected body parts, antibiotics, vascular surgery, maggot therapy or hyperbaric oxygen therapy.


Nursing Care Plan for Diabetic Gangrene

Nursing diagnosis that appear in diabetic foot gangrene patients are as follows:

Impaired tissue perfusion related to the weakening / decreased blood flow to the area of ​​gangrene due to obstruction of blood vessels.

Objective:

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.
who.int

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.