Nursing Care Plan

Trigeminal Neuralgia

Neuralgia is a stabbing pain that arises occasionally, but short and heavy, which occurs along the distribution of a nerve. Trigeminal neuralgia (NT) is neuralgia on the trigeminal nerve (fifth cranial nerve) that is responsible for sensation in the face. Trigeminal neuralgia (facial pain) is characterized by brief episodes of strong facial pain, stabbing, and like electricity.

According to Dr. Dito Anurogo, Trigeminal Neuralgia is a complaint of pain attacks one side of the face are repeated. Called trigeminal neuralgia, because facial pain occurs in one or more nerves than the three branches of Trigeminal nerve. This large nerve located in the brain and carries sensation from the face to the brain. The pain is caused by a disturbance in Trigeminal nerve function in accordance with the regional distribution of innervation of one branch of the trigeminal nerve caused by a variety of causes.

Etilogy trigeminal neuralgia is still not fully understood. There is one theory that because the blood vessels, especially the superior cerebral artery, into decompression, so that chronic irritation of the trigeminal nerve into the root section. This irritation causes increased afferent controls blame, or sensory nerves. Risk factors that can trigger is multiple sclerosis and hypertension. Other factors that may cause neuralgia including herpes virus infections, infections of the teeth and jaws, and brain stem infarction. (Miller, 2009 in Lewis 2011).

Nursing Diagnosis that may appear on the client with Trigeminal Neuralgia according Muttaqin, Arif (2010) and Ackley, Betty J., Gail B. Ladwig (2013) is as follows.

1. Pain (acute / chronic) r / t trigeminal nerve compression and inflammation of the temporal artery.
2. Imbalanced Nutrition  : Less than Body Requirements r / t pain during chewing.
3. Ineffective individual coping r / t severe pain, excessive threat to the self-alone.
4. Knowledge Deficit: on the condition and needs medication r / t cognitive limitations.
5. Anxiety r / t prognosis of disease and changes in health.
6. Ineffective management of therapeutic regimen r / t less knowledge about the prevention of stimulus triggers pain.
7. Risk for injury to the eyes r / t the risk factors: possible reduction in corneal sensation.

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.

Hypertension is one of the cardiovascular system diseases that are often found in the community. Hypertension is not a contagious disease, but it should always be wary. High blood pressure or hypertension and arteriosclerosis are two basic conditions that underlie many forms of cardiovascular disease.

Furthermore, high blood pressure also causes kidney disorders. Until now, efforts to both prevent and treat hypertension has not been entirely successful, because of the inhibiting factors such as lack of knowledge about hypertension (understanding, signs and symptoms, causation, complications) and also treatment.

Various factors play a role in this case one of them is a modern lifestyle. Selection of fatty foods, unhealthy activity habits, smoking, drinking coffee are some of the things that is suspected as a factor that contributes to this hypertension. This disease can be the result of modern lifestyles and can also be a cause of various non-infectious diseases.

To know more about this disease and to know, then we will discuss about hypertension.


Definition of Hypertension According to the Experts


Hypertension was defined as systolic blood increase greater than or equal to 140 mmHg or diastolic blood pressure greater than or equal to 90 mmHg (Anindya, 2009).


Hypertension is defined as blood pressure persistent, where the systolic pressure above 140 mmHg and diastolic pressure above 90 mmHg. (Tom Smith, 1995)

Hypertension is the increase in systolic blood pressure over 140 mmHg and diastolic blood pressure over 90 mmHg (Luckman Sorensen, 1996).

Hypertension was defined by the Joint National Committee on Detection (JIVC) as pressure higher than 140/90 mmHg and classified according to the degree of severity, ranging from blood pressure (BP) high normal to malignant hypertension.

High blood pressure or hypertension is a condition a person's blood pressure is at levels above normal. And the consequences of this situation is the emergence of diseases that interfere with the patient's body. In hypertensive disease is a health problem and need of prevention. (Sudjaswandi: 2002 h 17)

Hypertension is defined as blood pressure that persistent systolic pressure above 140 mmHg and diastolic above 90 mmHg. The aging population, hypertension is defined as systolic pressure of 160 mmHg and a diastolic pressure of 90 mmHg. (Smeltzer, 2001).

Hypertension is defined as systolic blood pressure of 140 mmHg or a diastolic pressure of at least 90 mmHg. Traditional terms of hypertension "mild" and "moderate" failed to explain the influence of the major high blood pressure in cardiovascular disease. (Anderson: 2006 h 582)

Hypertension is high blood pressure or medical terms, explain hypertension is a condition where an interruption in blood pressure regulation mechanism (Mansjoer, 2000: 144)

Categorized as mild hypertension if diastolic pressure between 95-104 mmHg, moderate hypertension if diastolic pressure between 105 and 114 mmHg, and severe hypertension if diastolic pressure 115 mmHg or more. This division is based on the increase in the diastolic pressure is considered more serious because of the increase in systolic (Tom Smith, 1995).

Hypertension is systolic pressure exceeds the settled state of 140 mmHg or diastolic pressure higher than 90 mmHg. This diagnostic can be ascertained by measuring the average blood pressure at two separate times (School of Medicine, 2001: 453)

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.