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