Risk for Impaired Tissue Integrity related to Graves' Disease

Nursing Diagnosis for Graves' Disease : related to changes in the mechanism of protection of the eyes; damage eyelid closure / exophthalmos.

Goal: Being able to identify measures to provide protection to the eyes and prevention of complications.

Nursing Interventions:

Independent:

1. Observation periorbital edema, eyelid closure disorders, narrow field of vision, excessive tears. Note the presence of photophobia, taste any thing beyond the eyes and eye pain.
R /: general manifestations of excessive adrenergic stimulation associated with thyrotoxicosis who require support to the resolution of crisis intervention can eliminate symptomatology.

2. Evaluation of the sharpness of the eyes, report the presence of blurred vision or double vision (diplopia).
R /: Infiltrative ophthalmopathy (Graves' disease) is the result of an increase in the retro-orbital tissue, which creates exophthalmos and lymphocyte infiltration of the extraocular muscles that cause fatigue. The emergence of visual impairment can worsen or improve the independence of therapy and clinical course of the disease.

3. Instruct the patient to use sunglasses when the patient woke up and cover with a blindfold during sleep as needed.
R /: Protecting corneal damage if the patient can not close their eyes to perfect as edema or fibrosis pads as fat.

4. The head of the bed elevated and limit the use of salt if indicated.
R /: Lowering tissue edema when there are complications such as CHF which can aggravate exophthalmos.

5. Instruct the patient that the extraocular eye muscles if possible.
R /: Improving circulation and maintain eye movements.

6. Give the patient the opportunity to discuss their feelings about the picture changes, body size or shape to improve self-image.
R /: Eyeball rather prominent cause someone unattractive, it can be reduced by using makeup, wearing glasses.

Collaboration:
1. Give the medicine according to the indication.
R /: Awarded to reduce inflammation that develops rapidly.

2. Antithyroid drugs
Can reduce signs / symptoms or prevent the situation getting worse.

3. Diuretics
Can reduce edema in the soft state.

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Fatigue related to Graves' Disease

Nursing Care Plan for Graves' Disease


Nursing Diagnosis : Fatigue related to hypermetabolic with increased energy needs; sensitive stimulation of nerves in connection with disorders of body chemistry.

Supporting Data: reveal very lack of energy to maintain the usual routine, decreased performance, lability / emotional stimuli sensitive, nervous, tense, agitated behavior, damage the ability to concentrate.

Goal: verbally disclose about an increase in energy levels, showed improvement in the ability to participate in the activity.

Nursing Intervention:

Independent:

1. Monitor vital signs and record pulse both at rest and during activity.
R /: pulse widely increased and even at rest, tachycardia (above 160 times / min) may be found.

2. Note the development of tachypnea, dyspnea, pallor and cyanosis.
R /: Needs and oxygen consumption will be increased on a hypermetabolic state, which is potentially hypoxia while doing the activity.

3. Provide / create a quiet environment, cold room, lower sensory stimulation, the colors are cool and relaxing music (calm).
R /: Lowering stimulation is likely to cause agitation, hyperactivity and insomnia.

4. Advise the patient to reduce the activity and increase bed rest as much as possible whenever possible.
R /: Helps combat the effects of increased metabolism.

5. Give the act of making the patient comfortable, such as: touch / massage, powder cool.
R /: Can lose energy in the nerves which further enhances relaxation.

6. Provide alternate activities fun and quiet, like reading, listening to the radio and watching television.
R /: Allows for the use of energy in a constructive way and probably will also reduce anxiety.

7. Avoid talking about a topic that is annoying or threatening the patient, discuss how to respond to these feelings.
R /: Increased sensitivity of the central nervous system can cause the patient easily aroused, agitation and excessive emotion.

8. Discuss with the people in a state of fatigue and emotional unstable.
R /: Understand that the physical behavior improve coping with the current state of encouragement and advice of people nearby to respond positively and provide support to the patient.

Collaboration:
9. Give the drug as indicated.
R /: To cope with the situation (nervous), hyperactivity and insomnia.

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Anxiety and Self-Esteem Disturbances related to Nasal Cavity Cancer

Nursing Care Plan for Nasal Cavity Cancer

Nursing Diagnosis for Nasal Cavity Cancer : Anxiety related to a crisis situation (malignancy), the threat of change in health status-social-economic, function-role changes, changes in social interaction, the threat of death, separation from family.

Nursing Interventions :

1. Orient the client and the people closest to routine procedures and activities are expected.
2. Exploration client anxiety and provide feedback.
3. Emphasize that anxiety is a common problem experienced by many people in the client's current situation.
4. Allow clients accompanied by a family (significant others) during the phase of anxiety and maintain tranquility of the surroundings.
5. Collaboration of sedative drugs.
6. Monitor and record verbal and non-verbal responses that show the client's anxiety.

Rational :

1. Precise information about the situation faced by the clients can reduce anxiety / foreign flavor to the surrounding environment and help the clients to anticipate and accept the situation.
2. Identify trigger factors / ballast anxiety problems and offering solutions that can be done by the client.
3. Indicate that anxiety is normal and not only experienced by the client only in the hope the client can understand and accept his condition.
4. Mobilize support system, prevent feelings of isolation and reduce anxiety.
5. Reduce anxiety, ease of rest.
6. Assessing the development of the client's problem.

Nursing Diagnosis for Nasal Cavity Cancer : Self-Esteem Disturbances related to deformity of the body due to malignancy, effects of radiotherapy / chemotherapy.

Nursing Interventions :

1. Discuss with the client and family influence diagnosis and treatment of the client's personal life and work activities.
2. Explain the side effects of surgery, radiation and chemotherapy are to be anticipated by the client.
3. Discuss on problem-solving efforts in the client's changing role of the family and community associated with the disease.
4. Thank difficulty client adaptation to the problems faced by the client and inform the possible need for psychological counseling
5. Evaluation of the support system that can help the client (family, relatives, social organization, spiritual leaders)
6. Evaluation of the symptoms of hopelessness, helplessness, denial of treatment and feelings of worthlessness that show impaired self-esteem the client.

Rational :

1. Assist the client and the family understand the problems he faced as a first step problem-solving process.
2. Anticipated therapeutic effect further facilitate the process of adaptation to the client's problems that may arise.
3. Changes in health status that brings change socio-economic status-role-function is a problem that often occurs on the client malignancy.
4. Inform alternative professional counseling that may be taken in solving client problems.
5. Identify sources of support that may be used in alleviating the problem the client.
6. Assessing the development of the client's problem.

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Nursing Care Plan for Nasal Cavity Cancer

Nasal Cavity Cancer : 5 Nursing Diagnosis

Nasal Cavity Cancer is cancer that attacks the nasal cavity.

Malignant tumors of the nasal cavity and paranasal sinuses are inseparable because both affect each other.


Causes

The cause of the nasal cavity cancer is not known for certain, but there are some great possibilities, including:

• Heavy smokers, fistula oroantral, atrophic rhinitis, alkolhol addicts.
• Chronic infection of the nose and sinuses paranosal.
• Contact with wood dust on furniture workers (factor of chronic irritation from dust and wood).
• Contact with industrial materials, such as nickel, chrome, isopropanolol.
• Thorium dioxide is used as a contrast fluid on X-ray examination.
• Chronic maxillary sinusitis.

Pathophysiology

Foreign matter (smoke, nicotine, wood dust, nickel, chrome, etc.) into the nasal cavity occurs continuously and for a long time, causing mass formation, changes in the structure and the nasal mucosa, causing obstruction of the nasal cavity to the nasal septum (cavity deformity, nasal septum, trauma cavity / nasal septum, the septum hematoma and septal perforation) or new growth such as nasal polyps, papilloma, inversion and tumor beligna / malignant). In addition, a variety of other reasons cause nasal airway obstruction (adenoid hypertrophy, foreign bodies, atresia, koana, intra-nasal scar tissue, and collapse). This is the mass of the nasal cavity causing edema of the nasal mucosa due to the flow of lymph and venous disorders as well as shaping the polypoid on the nasal cavity. The tumor invades into the upward until cranial fossa and lateral to the orbit.


Signs and Symptoms of Nasal Cavity Cancer

Signs and symptoms of Nasal Cavity Cancer, depending on where the tumor origin and direction as well as the wide-spread.
1. Maxillary sinus tumor and spread to medial.
Signs and symptoms:

• Nasal congestion.
• Persistent unilateral rhinorrhea and smelling.
• Epistaxis.

2. Ethmoid sinus tumors and lamina cribriformis.
Signs and symptoms:

• Nasal congestion.
• Anomsia.
• Runny.
• Pain frontal area.

3. The basic antrum tumor and extends downward.
Signs and symptoms:

• Wobbly tooth.
• Occlusive disorders.
• Pain in molars.
• Swelling and lacerations area palate.

4. Tumor extends to the area of the orbit and the nasolacrimal duct.
Signs and symptoms:

• Diplopia.
• Proptosis.
• Blockage of the tear ducts.
• Eye looks swollen.
• Musa and orbital palpable.
• Eyes stand out.

5. Tumor extends to anterior.
Signs and symptoms:

• Enlargement cheek one side (asymmetric).

6. Advanced stage of the superior alveolar nerve.
Signs and symptoms:

• Numbness in the upper jaw teeth and gums.

7. The tumor spread and invade into the nasopharynx.
Signs and symptoms:

• Conductive deafness due to eustachian tube disorders.

8. Another expansion may affect the nerves.
Signs and symptoms:

• Nerve deafness.
• Not being able to open the mouth.
• Facial paresis.
• Hemiplegia.
• Hyperesthesia.
• Severe headache.
• Changes in eye position.

Nursing Diagnosis for Nasal Cavity Cancer:

1. Anxiety related to a crisis situation (malignancy), the threat of change in health status-social-economic, function-role changes, changes in social interaction, the threat of death, separation from family.
2. Disturbance of self-esteem related to deformity of the body due to malignancy, effects of radiotherapy / chemotherapy.
3. Pain (Acute / Chronic) related to compression / nerve tissue destruction and inflammation.
4. Imbalanced Nutrition: less than body requirements related to the increase in metabolic status due to malignancy, effects of radiotherapy / chemotherapy and emotional distress.
5. Risk for infection related to the inadequate secondary defenses and immunosuppressive effects of radiotherapy / chemotherapy.

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Nursing Interventions for Gastric Cancer

Nursing Care Plan for for Gastric Cancer

Nursing Diagnosis : 1. Pain ( acute / chronic ) elated to the presence of abnormal epithelial cells, nerve impulse disorders of the stomach.

Goal : Pain is reduced, controlled.
Expected outcomes :

• The patient was not seen grimacing.
• Pain scale of 0 (no pain).
• The patient seemed more relaxed.

Intervention :

1. Assess characteristics of pain and discomfort ; location, quality, frequency, duration, etc.
Rational : provide a basis for assessing changes in the level of pain and evaluate interventions.

2. Reassure the patient that you know, the pain is real and that you will assist the patient in reducing the pain.
Rational :
Fear can increase anxiety and reduce pain tolerance.

3. Collaboration in analgesic administration to improve circulation within the optimal pain prescription.
rational :
Tend to be more effective when given early in the cycle of pain.

4. Teach the patient new strategies to relieve pain and discomfort with distraction, imagination, relaxation.
rational :
Improving alternative pain relief strategies appropriately.



Nursing Diagnosis : 2. Imbalanced Nutrition : less than body requirements related to anorexia.

Goal : Nutritional needs of clients are met.
Expected outcomes :

• The client will maintain nutrient inputs to the metabolic needs.
• Increased appetite.
• No weight loss.

Intervention :

1. Teach the patient the following things : avoid the sight, smell, sounds unpleasant in the environment during meal times.
Rational :
Anorexia can be stimulated or enhanced by noxious stimuli.

2. Suggest eating preferred and well tolerated by the patients, better food with high content of calories / protein. Respect the patient's food preferences based on ethnicity.
Rational :
A food that is well tolerated and high in calories and protein will maintain nutritional status during periods of increased metabolic needs.

3. Encourage adequate fluid intake, but limit fluids at mealtime.
Rational :
Fluid level is necessary to eliminate waste products and prevent dehydration.

4. Increase fluid levels with food can lead to a state of satiety. Consider the cold food, if desired.
Rational :
Cold foods high in protein can often be well tolerated and does not smell than hot food.

5. Collaborative provision of commercial liquid diet by way of enteral feeding through a tube, elemental diet.
Rational :
Feeding through a tube may be necessary in the patient with very weak gastrointestinal system is still functioning.



Nursing Diagnosis : 3. Anxiety related to malignancy advanced disease.

Goal : Anxiety clients decreased.
Expected outcomes :

• Clients are more relaxed.
• The normal pulse.
• No increase in respiration.

Intervention :

1. Provide a relaxed environment and non-threatening.
Rational :
The patient can express fear, problems, and the possibility of anger due to the diagnosis and prognosis.

2. Encourage active participation of the patient and family in care and treatment decisions.
Rational :
To maintain independence and control of the patient.

3. Instruct the patient to discuss personal feelings with the supporters of such clergy if desired.
Rational :
Facilitating the process of grieving and spiritual care.

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Gastric Cancer - Assessment and 5 Nursing Diagnosis

Assessment for Gastric Cancer

Nurses get a history of the patient's diet that focuses on issues such as high food intake and input smoked or marinated fruits and vegetables are low. Is the patient experiencing weight loss, if so how much.

Does the patient smoke ? If yes how much a day and how long ? Is the patient complained of stomach discomfort during or after smoking ? Does the patient drink alcohol ? If so how much ? The nurse asks the patient if there is a family history of cancer. If such a close family member or immediate or distant relatives affected ? Is the patient's marital status ? Is there someone who can provide emotional support ?
During the physical examination is possible to palpate a mass. Nurses must observe the presence of anxiety. Organs examined for tenderness or masses. Pain is usually the symptoms are slow. (Brunner & Suddart, 2001).

1. Anamnesis (Hamsafir, 2010) :

• Pain.
• Weight loss.
• Vomiting.
• Anorexia.
• Dysphagia.
• Nausea.
• Weakness.
• Hematemesis.
• Regurgitation.
• Easily satisfied.
• Ascites (abdominal bloating).
• Abdominal cramps.
• Real or faint blood in the stool.
• The patient complained of discomfort in the stomach, especially after eating.

2. Physical Examination (Hamsafir, 2010) :

• Hemodynamic Status : blood pressure, pulse, acral and breathing.
• Less weight, cachexia, conjunctiva sometimes anemic.
• Abdominal examination may be palpable mass epigastric region, epigastric pain. In malignancy can be found hepatomegaly, ascites.
• If there are complaints of melena, do a digital rectal examination.
• Malignancy = search enlargement supraclavicular (Virchow's node), axillary nodes left (Irish 's node), to the umbilicus (Sister Mary Joseph's nodes), palpable tumors pelvic cul - de - sac on the digital rectal examination (Blumer's shelf), enlarged ovaries (Krukenberg's tumor).

Nursing Care Plan for Gastric Cancer

Nursing Diagnosis for Gastric Cancer

1. Pain ( acute / chronic ) related to the presence of abnormal epithelial cells , nerve impulse disorders of the stomach .

2. Imbalanced Nutrition : less than body requirements related to anorexia .

3. Anxiety related to malignancy advanced disease .

4. Risk for Infection related to the surgical incision .

5. Risk for ineffective airway clearance related to the buildup secret .

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Nursing Care Plan for Gastric Cancer

Definition of Gastric Cancer

Gastric cancer is a malignant form of gastrointestinal neoplasms. Gastric carcinoma is a form of gastric neoplasms are the most common and causes about 2.6 % of all deaths from cancer (Cancer Facts and Figures, 1991).

Gastric cancer occurs in the small curvature or gastric antrum and adenocarcinoma. Other factors, in addition to high- acid foods that cause the incidence of gastric cancer include inflammation of the stomach, pernicious anemia, aclorhidria (no hydrochloride). Gastric ulcer, bacteria H. plylori, and offspring. (Suzanne C. Smeltzer).

Cancer of the stomach or abdominal malignant tumor is an adenocarcinoma. This cancer spreads to the lungs, lymph nodes and liver. Risk factors include chronic atrophic gastritis with intestinal metaplasia pernicious anemia, high alcohol consumption and smoking. (Nettina sandra, nursing practice guidelines).

Gastric cancer is a malignancy that occurs in the stomach, most are of the type adenocarcinoma. Other types of gastric cancer are leiomyosarcoma (smooth muscle cancer) and lymphoma. Gastric cancer is more common in the elderly. Less than 25 % of certain cancers occur in people under the age of 50 years (Osteen, 2003).


Etiology of Gastric Cancer

The exact cause of stomach cancer is unknown, but there are several factors that can increase the development of gastric cancer, include the following matters :

1. Predisposing Factors

a. Genetic factors
Approximately 10 % of patients with gastric cancer have a genetic link. Although still not fully understood, but the mutation of the E - cadherin gene was detected in 50 % of gastric cancer types. The presence of a family history of pernicious anemia and adenomatous polyps was also associated with a genetic condition in gastric cancer. (Bresciani, 2003).

b. Age factor
In this case found to be more common in the age of 50-70 years, but about 5 % of gastric cancer patients aged less than 35 years and 1 % less than 30 years. (Neugut, 1996)


2. Precipitation Factors

a. Consumption of pickled food, smoked or preserved.
Several studies explain the dietary intake of pickled food becomes a major factor increase in gastric cancer. The content of salt that goes into the stomach slows gastric emptying, thereby facilitating the conversion of nitrates into carcinogenic nitrosamines group in the stomach. Combined condition of delayed emptying of stomach acid and an increase in the composition of nitrosamines in the stomach contributed to the formation of gastric cancer (Yarbro, 2005).

b. H.pylori infection.
H. pylori is a bacterium that causes more than 90 % of duodenal ulcers and 80 % of gastric ulcers (Fuccio, 2007). These bacteria on the surface of the gastric ulcer, through the interaction between the bacterial membrane lectins, and specific oligosaccharides from glycoproteins membranes of gastric epithelial cells (Fuccio, 2009).

c. Socioeconomic.
Low socioeconomic conditions are reported to increase the risk of gastric cancer, but not specific.

d. Consume cigarettes and alcohol.
Patients with cigarette consumption of more than 30 cigarettes a day and combined with chronic alcohol consumption increases the risk of gastric cancer (Gonzalez, 2003).

e. NSAIDs.
Inflammatory gastric polyps can occur in patients taking NSAIDs in the long term and this (gastric polyps) may be a precursor of gastric cancer. Gastric polyps conditions will increase the risk of gastric cancer (Houghton, 2006).

f. Pernicious anemia.
This condition is a chronic disease with failure of absorption of cobalamin (vitamin B12), caused by a lack of intrinsic factor gastric secretion. The combination of pernicious anemia with H.pylori infection provides an important contribution to tumorigenesis in the stomach wall formation. (Santacrose, 2008).


Clinical Manifestations of Gastric Cancer

Early symptoms of gastric cancer is often uncertain because most of these tumors in the small curvature, which is only slightly causing interference function of the stomach. Several studies have shown that early symptoms such as pain that is relieved by antacids may resemble symptoms in patients with benign ulcer. Symptoms may include a progressive disease can not eat, anorexia, dyspepsia, weight loss, abdominal pain, constipation, anemia and nausea and vomiting (Harnawati).

Clinical symptoms were found among others (Davey, 2005) :

• Anemia , vague gastrointestinal bleeding and resulted in an iron deficiency may be a presenting symptom of gastric carcinoma is the most common.
• Weight loss, common and further illustrates metastatic disease.
• Vomiting, an indication of the occurrence of gastric outflow obstruction.
• Dysphagia.
• Nausea.
• Weakness.
• Hematemesis.
• Regurgitation.
• Easily satisfied.
• Enlarged abdominal ascites.
• Abdominal cramps.
• Real or faint blood in the stool.
• The patient complained of discomfort in the stomach, especially after eating.

Complications of Gastric Cancer

1. Perforation

Perforation can occur acute and chronic perforation :

• Acute Perforation. Perforation often occurs in : ulceration type of cancer that is located in the minor curvature, diantrum near the pylorus. Usually have symptoms similar to perforation of peptic ulcer. These perforations are often found in men (Hadi, 2002).
• Chronic perforation. Perforations that occur frequently covered by the adjacent tissue, for example by omentum or is penetration. Usually more rare when compared with the complications of benign ulcer. Penetration may be found between layers or layer of omentum gastrohepatic bottom of the liver. What often happens is perforated and covered by the pancreas. With the penetration it will form a fistula, for example gastrohepatic, gastroenteric and gastrocolic fistula. (Hadi , 2002).

2. Haematemesis.
Massive hematemesis and melena occurred ± 5 % of carcinomas ventrikuli whose symptoms are similar as in massive bleeding so much blood is lost, causing hypochromic anemia. (Hadi, 2002).

3. Obstruction.
Can occur in the lower part of the stomach near the pylorus region are accompanied by complaints of vomiting (Hadi, 2002).

4. Adhesion.
If a tumor of the stomach wall can occur adhesion and infiltration of the surrounding organs and cause abdominal pain (Hadi , 2002)



Gastric Cancer - Assessment and 5 Nursing Diagnosis

Nursing Interventions for Gastric Cancer

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Digestive System Neoplasm - Nursing Diagnosis and Interventions

Nursing Care Plan for Digestive System Neoplasm


Pre - Operation Nursing Diagnosis and Interventions

1. Pain (acute / chronic) related to the growth of cancer cells.

Goal : Pain is reduced until it disappears.

Interventions
1. Assess characteristics of pain, location, frequency.
R/ : Knowing the level of pain as the evaluation of interventions.

2. Assess the factors causing pain relief (fear, anger, anxiety).
R/ : By knowing the causes of pain, decisive action to reduce the pain.

3. Teach relaxation techniques take a deep breath.
R/ : Relaxation techniques can override the pain.

4. Collaboration with physicians for providing analgesic.
R/ : Analgesic effective for pain.



2. Anxiety related to planned surgery.

Goal : Anxiety can be minimized after the act of nursing.

Interventions :
1. Describe any actions to be performed on the patient .
R/ : The patient was cooperative in every action and reduce patient anxiety.

2. Allow the patient to express feelings of fear.
R/ : To reduce anxiety.

3. Evaluation of the level of understanding of the patient / significant others, on medical diagnosis.
R/ : Provide the information you need to select the appropriate interventions.

4. Acknowledge the fear / patient issues, and push express feelings.
R/ : Support enables the patient to start opening / accept the disease and treatment.



3. Imbalanced Nutrition : less than body requirements related to nausea, vomiting and no appetite.

Goal : The nutritional requirements can be met.

Expected Outcomes :
Nutrition met.
Nausea was reduced to disappear.

Interventions :
1. Serve food in small portions but often and warm.
R/ : warm food increases the appetite.

2. Assess the patient's eating habits.
R/ : Type of food that will help improve the patient's appetite.

3. Teach relaxation techniques that take a deep breath.
R/ : Helps to relax and reduce nausea.

4. Measure the weight whenever possible.
R/ : To determine the weight loss.

5. Collaboration with physicians for the provision of vitamins.
R/ : To prevent deficiency due to reduced absorption of fat-soluble vitamins.



4. Activity intolerance related to physical weakness .

Goal : Activity intolerance resolved.

Expected Outcomes :
Showed an increase in activity tolerance characterized by : do not complain of weakness, can move gradually.

Interventions :
1. Provide adequate rest periods.
R/ : Rest will provide enough energy and helps in the healing process.

2. Review of complaints during the move.
R/ : Identify abnormal activity.

3. Assess the ability to move.
R/ : Specifies the activities that can be done.

4. Help meet the needs.
R/ fulfillment needs.

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Ineffective Thermoregulation related to Asphyxia Neonatorum

Nursing Care Plan for Asphyxia Neonatorum

Neonatal asphyxia is a condition in newborns who fail to breathe spontaneously and regularly soon after birth.

Signs and Symptoms

1. Hypoxia.
2. Respiration rate of more than 60 x / min or less than 30 x / min.
3. Gasping breath until respiratory arrest may occur.
4. Bradycardia.
5. The reduced muscle tone.
6. Cyanotic skin color / pale.

Diagnostic examination

1. Blood Gas Analysis.
2. Blood electrolytes.
3. Blood sugar.
4. Baby grams (chest X-ray).
5. Ultrasound (head).

Nursing Diagnosis : 

Ineffective thermoregulation related to temperature regulation system is not inadequate.

Nursing Outcomes :

Thermoregulation: neonate

Indicators:
Normal body temperature

Assessment scale:
1. Extremely compromised.
2. Substantially compromised.
3. Moderately compromised.
4. Mildly compromised.
5. Not compromised.

Nursing Interventions

Temperature regulation

• Place the baby in a warm temperature environments.
• Monitor axillary temperature in infants unstable.
• Monitor signs of hypothermia: fatigue, weakness, discoloration, skin.
• Avoid situations that may cause the baby to lose heat, such as exposure to cold air, window or shower.

Rationale :

• Maintaining the temperature of the baby's body.
• Monitor the baby's body temperature.
• Avoiding heat loss through conduction.

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Ineffective Airway Clearance related to Asphyxia Neonatorum

Nursing Diagnosis :

Nursing Interventions : Ineffective airway clearance related to obstruction of mucus.

Nursing Outcomes:

Repiration status: Ventilation
Indicators:

• Free of abnormal breath sounds.
• No shortness of breath.
• Respiration rate is within the normal range.
• Regular respiratory rhythm.
• No retraction of the chest.

Assessment scale:

1. Extremely compromised.
2. Substantially compromised.
3. Moderately compromised.
4. Mildly compromised.
5. Not compromised.

Nursing Interventions

Airway management

• Open the airway.
• Position the patient to maximize ventilation.
• Identification of patients need artificial airway appliance installation.
• Remove secretions by suction.
• Auscultation of breath sounds, note the presence of additional noise.
• Set intake to optimize fluid balance.
• Monitor respiration and O2 status every 6 hours.

Vital sign monitoring

• Monitor blood pressure, pulse, temperature, and respiration.
• Monitor quantities and heart rhythm.
• Monitors heart sounds.
• Monitor lung sounds.
• Monitor abnormal breathing patterns.
• Monitor temperature, color, and moisture.
• Monitor peripheral cyanosis.
• Identify the causes of changes in vital signs.

Oxygen therapy

• Setting up the oxygen equipment and a humidifier.
• Provide supplemental oxygen by order.
• Monitor the liter flow of oxygen.
• Monitoring canule position.
• Monitor signs of oxygen toxicity.

Rationale:

• Patency of the airway is the main requirement to obtain adequate ventilation.
• Helping lungs to meet the body's need for oxygen.
• Assessing changes in status, to determine actions to improve / maintain the status respiration.

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Self-care deficit : Hygiene

Self-care deficit : hygiene is a condition in which individuals experience failure or ability to carry out personal hygiene activities completed (Carpenito, 1977).

Several factors influence the occurrence of Self-care deficit:
a. Developments
Family overprotective and indulgent clients that disrupts the development of the initiative and skills.
b. Biological
Chronic disease that causes the client is not able to perform self-care.
c. Social
Less support and training capabilities of the environment.

Data that needs to be studied
a. Self-care deficit.
b. Decreased motivation to self-care

Subjective Data:

• say lazy bath,
• do not want to comb the hairs,
• do not want to rub the teeth,
• do not want to cut the nails,
• do not want to make up,
• can not use a tool bathing / personal hygiene.

Objective Data:

• Body odor, dirty clothes, dirty hair and skin, long nails, dirty teeth, mouth odor, appearance is not neat, can not use a tool shower.

Nursing Diagnosis
Self-care deficit: hygiene related to decline in self-care motivation.


Interventions:

1. General Goals: The client is able to perform self-care: hygiene.

2. Specific Goals:

a. The Client can mention the definition and signs of personal hygiene.
action:

• Discuss with the client about the terms of hygiene and signs of hygiene.
• Give positive reinforcement when the client is able to do something positive.

b. The Client can mention why the client does not want to maintain personal hygiene.
action:

• Discuss with the client what the cause would not maintain personal hygiene.
• Discuss the consequences of not willing to maintain personal hygiene.

c. The Client can call the hygiene.
action:

• Discuss with the client about the benefits of hygiene.
• Help the client identify the ability to maintain personal hygiene.

d. The client can mention how to maintain personal hygiene
action:

• Discuss with the client how to maintain personal hygiene: shower 2 times a day (morning and afternoon) using soap, brush the teeth at least two times a day with toothpaste, wash the hair at least 2 times a week with a shampoo, cut the nails at least 1 time a week cutting the hair at least one time a month.
• Give positive reinforcement when the client successfully.

e. The client can implement self-care hygiene with minimal assistance.
action:

• Lead the client to do a demonstration on how to maintain personal hygiene.
• Encourage the client to perform personal hygiene with minimal assistance.

f. The client can perform self-care hygiene independently.
action:

• Give the client the opportunity to rid themselves gradually.
• Encourage the client to express feelings after self-cleaning.
• Together with the client to schedule self hygiene.
• Guided the client to conduct regular hygiene activities.

g. The client has the support of the family.
action:

• Give health education on caring for clients for personal hygiene through family gatherings.
• Give positive reinforcement on the active participation of the family.

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Risk for Decreased Cardiac Output - NCP for Heart Arrhythmias

Nursing Care Plan for Heart Arrhythmias

Heart rhythm disorder or arrhythmia is a frequent complication of myocardial infarction. Arrhythmia or dysrhythmia is the change in frequency and heart rhythm caused by abnormal electrolyte conduction or automatic (Doenges, 1999).

Arrhythmias arising from myocardial cells electrophysiological changes. These electrophysiological changes manifest as changes in action potential shape ie graphic record of electrical activity of cells (Price, 1994).

Heart rhythm disturbances are not only limited to the irregularity in heart rate but also including rate and conduction disorders (Hanafi, 1996).

Nursing Diagnosis : Risk for Decreased Cardiac Output related to electrical conduction disturbances, decreased myocardial contractility.

Outcomes:

• Maintain / increase cardiac output adequately evidenced by blood pressure / pulse in the normal range, adequate urine output, the same palpable pulse, normal mental status.
• Showed a decrease in the frequency / no dysrhythmias.
• Participate in activities that decrease myocardial work.

Interventions :

1. Feel the pulse (radial, femoral, dorsalis pedis) record the frequency, regularity, amplitude and symmetrical
2. Auscultation of heart sounds, note the frequency, rhythm. Note the extra heart rate, decreased pulse.
3. Monitor vital signs and assess adequacy of cardiac output / tissue perfusion.
4. Determine the type of dysrhythmia and rhythm note: tachycardia; bradycardia; atrial dysrhythmias; ventricular dysrhythmias; block.
5. Provide quiet environment. Assess the reasons for limiting the activity during the acute phase.
6. Demonstrate / encourage use of behavioral stress management eg deep breathing relaxation, guided imagery.
7. Assess pain report, note the location, duration, intensity and factor relievers / ballast. Note the presence of non-verbal pain, for example; frown face, crying, changes in blood pressure.
8. Prepare / do CPR as indicated.
9. Monitor laboratory tests, for example; electrolyte.
10. Provide supplemental oxygen as indicated.
11. Give medications as indicated: potassium, anti dysrhythmias.
12. Prepare for elective cardioversion aids.
13. Help installing / maintaining the function of the pacemaker.
14. Enter / maintain input IV - Prepare for invasive diagnostic procedures.
15. Prepare for the installation of automatic cardioverter or defibrillator.

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Liver Abscess - 7 Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis, Interventions and Evaluation for Liver Abscess

1. Breathing pattern, ineffective related to Neuromuscular, imbalance perceptual / cognitive.

Goal : normal breathing pattern / effective and free from signs of cyanosis or hypoxia .

Intervention :

• Maintain the patient's airway by tilting the head.
• Auscultation of breath sounds.
• Observation of the frequency and depth of breathing, the muscles use the respirator.
• Monitor vital signs continuously.
• Do the motion as soon as possible.
• Observation of the excess.
• Do suction mucus when necessary.
• Provide supplemental oxygen as needed.
• Give treatment as instructed.

2. Disturbed Sensory Perception : the process of thought related to chemical changes : the use of pharmaceutical drugs.

Goal : increasing the level of awareness

Intervention :

• Orient the patient back continuously after coming out of the influence of anesthesia.
• Talk with the patient in a clear voice and normal.
• Minimize negative discussion.
• Use the pads on the edge, do binding if necessary.
• Observations of the existence of hallucinations, depression and others.
• Maintain a calm and comfortable environment.

3. Fluid Volume Deficit, Risk for oral fluid intake restriction (process / medical procedure / nausea).

Goal : there is adequate fluid balance .

Intervention :

• Measure and record the input and output.
• Assess urinary spending, especially for the type of surgical procedure performed.
• Monitor vital signs.
• Note the emergence of nausea / vomiting, history of motion sickness.
• Check the pads, appliance drein at regular intervals , examine the wound for swelling.
• Give parenteral fluids, blood products and / or plasma expanders as directed. Level IV speed if necessary.
• Give back oral intake gradually as directed.
• Give antiemetics as needed.

4. Pain (acute) related to disorders of the skin, tissue, and muscle integrity.

Goal : pain has been controlled / eliminated, the client can rest and activity according to ability.

Intervention :

• Assess pain scale, intensity, and frequency.
• Evaluation of pain on a regular basis.
• Assess vital signs.
• Assess the cause of the discomfort that may be appropriate operating procedures.
• Put repositioning as directed.
• Encourage use of relaxation techniques.
• Give medicines as directed.

5. Impaired Skin Integrity related to the interrupt mechanism of the skin / tissue.

Goal : to improve the metabolic action shows.

Intervention :

• Review the functional capabilities and circumstances.
• Place the client in a particular position.
• Keep the body well-being functionally.
• Help or actions to perform range of motion exercises.
• Give skin care carefully.
• Monitor urine output.

6. Risk for infection related to an operating wounds and invasive procedures.

Goal : There are no signs and symptoms of infection

Intervention :

• Provide anti-septic and aseptic care, maintain good hand washing.
• Observations damaged skin area (stitches) attached regions invasive tool.
• Monitor the entire body on a regular basis, record the presence of fever, chills, and diaphoresis.
• Keep an eye or the number of visitors.
• Give antibiotics as indicated.

7. Disturbed Sleep Pattern related to the disease process, the effects of hospitalization, changes in the environment.

Goal : resting needs can be met

Intervention :

• Assess the client's ability and sleeping habits.
• Provide a comfortable bed with a few personal belongings. Example : pillows, bolsters.
• Suggest to light activity.
• Suggest to take action relaxation.
• Encourage the family to always accompany.
• Supervise and limit the number of visitors.

8. Knowledge deficit (learning need) regarding condition / situation, prognosis, treatment needs.

Goal : Declare, understanding of disease processes / pragnosis.

Intervention :

• Revisit surgery / special procedures performed and on future expectations.
• Discuss drug therapy , including the use of a prescription.
• Identification of specific activity limitations.
• Schedule an adequate period of rest.
• Emphasize the importance of further visits.
• Involve famous people in the teaching program. Provide written instructions / teaching materials.
• Repeat the importance of diet and fluid intake adequate nutrition.

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Nursing Care Plan for Liver Abscess

Anatomy and Physiology of the Liver

The liver is the largest gland in the body, the average weight of 1,500 grams. 2 % of normal weight adults. The liver has two lobes that left and right. Each lobe of the liver is divided into structures called lobules, which is a microscopy unit and functional organ. The human liver has a maximum of 100,000 lobules. Between plates of liver cells are capillaries called sinusoids. Sinusoid limited by phagocytic cells and Kupffer cells. Kupffer cell function is to engulf bacteria and other foreign substances in the blood. (Sylvia a. Price, 2006).

The liver has two sources of blood supply , of the gastrointestinal tract and spleen through the hepatic portal vein and from the aorta through hepatic artery. About one-third of the incoming blood is arterial blood and two-thirds is the portal venous blood. The total volume of blood passing through the liver every minute was 1,500 ml. (Sylvia a. Price, 2006).

The liver is the largest and most important metabolic organ in the body. These organs perform a variety of functions, include the following :

1. Processing metabolic major nutrients (carbohydrates, fats, proteins) after absorption is the digestive tract.
2. Detoxification or degradation of residual substances and hormones as well as drugs and other foreign compounds.
3. Synthesis of plasma proteins, including proteins that are essential for blood clotting, as well as to transport thyroid hormones, steroids and cholesterol in the blood.
4. Deviations of glycogen, fat, iron, copper, and many vitamins.
5. The activation of vitamin D.
6. Spending bacteria from the red blood cells are worn out due to the resident macrophages.
7. Excretion of cholesterol and bilirubin (Sherwood, 2001)

Definition of Liver Abscess

Liver abscess is a form of infection in the liver caused by a bacterial infection, parasites , fungi and sterile necrosis originating from the gastrointestinal tract characterized by the process of suppuration with the formation of pus in the liver parenchyma (Aru W Sudoyo, 2006).

An abscess is a collection of pus fluid thick, yellowish caused by bacterial, protozoal or fungal invasion into the tissues of the body. Abscesses may occur in the skin, gums, bones, and organs such as the liver, lungs, and even the brain, an area that occurred abscess red and puffy, there is usually a sensation of pain and local heat (Microsoft Encarta Reference Library, 2004).



Causes

Liver abscess is generally divided into two, namely ; amebic liver abscess and pyogenic liver abscess.

a. Amebic liver abscess
Obtained several species of amoeba that can live as a non-pathogenic parasite in the mouth and intestines, but only Entamoeba histolytica that can cause disease. Only some individuals infected with Entamoeba histolytica, which gives the symptoms of invasive, so it is thought there are two types of E. histolytica, namely ; pathogenic and non- pathogenic strain. Variations in the virulence of these strains differ based on its ability to cause lesions in the liver (Aru W Sudoyo , 2006).

E.histolytica in the stool can be found in two forms: vegetative or trophozoite and cyst forms that can survive outside the human body. Mature cyst size 10-20 microns, resistant to dry and acidic atmosphere. Forms tropozoit will die in dry atmosphere and acid. Large trophozoite very active, capable of consuming erythrocytes , which contains protease ; hyaluronidase and mucopolysaccharidase capable of resulting in tissue destruction.

b Pyogenic liver abscess
The infection is mainly caused by gram- negative bacteria and the most common cause is E. coli . Moreover, the cause is Streptococcus faecalis also, Proteus vulgaris, and Salmonellla Typhi. Can also anaerobic bacteria such as Bacteroides, aero bacteria, actinomicosis, and anaerobic streptococci . Necessary for the finding of blood culture, pus, bile, and swabs in anaerobic or aerobic (Aru W Sudoyo, 2006).



Signs and Symptoms

Initial complaint : fever / chills, abdominal pain, anorexia / malaise, nausea / vomiting, weight loss, night sweat, diarrhea, fever (temperature greater than 38°), hepatomegaly, right upper quadrant tenderness, jaundice, ascites, and sepsis the cause of death. (Cameron 1997)

An abscess is the last stage of a tissue infection that begins with a process called inflammation.
Initially, such as bacteria activate the immune system, several events occur :

1. Blood flow to the area increases.
2. The temperature of the area increases due to the increased blood supply.
3. The area swells due to the accumulation of water, blood, and other fluids.
4. It turns red.
5. It hurts, because of irritation from the swelling and the chemical activity.
6. The four signs ; heat, swelling, redness, and pain - the characteristics of inflammation.

Diagnostic Examination

According to Julius, the science of diseases in Volume I, (1998). Investigations among others ;
1. Laboratory
To determine the hematologic abnormalities include hemoglobin, leukocytes, and liver function examination.
2. chest x-ray
Can be found in the form of the right diaphragm, decreased movement of the diaphragm, pleural effusion, lung collapse and lung abscess.
3. Plain abdominal X-ray
Abnormalities may include hepatomegaly, ileus picture, picture of free air above the liver.
4. Ultrasonography
Detecting abnormalities of biliary tract and diaphragm.
5. Tomography
See abnormalities in the posterior and superior , but can not see the integrity of the diaphragm.
6. Serology
Shows a high sensitivity to germs.



Nursing Diagnosis for Liver Abscess

According Doenges, EM (2000), nursing diagnoses of patients with liver abscess include:

1. Breathing pattern, ineffective related to Neuromuscular, imbalance perceptual / cognitive.
2. Disturbed Sensory Perception : the process of thought related to chemical changes : the use of pharmaceutical drugs.
3. Fluid Volume Deficit, Risk for oral fluid intake restriction (process / medical procedure / nausea).
4. Pain (acute) related to disorders of the skin, tissue, and muscle integrity.
5. Impaired Skin Integrity related to the interrupt mechanism of the skin / tissue.
6. Risk for infection related to an operating wounds and invasive procedures.
7. Disturbed Sleep Pattern related to the disease process, the effects of hospitalization, changes in the environment.
8. Knowledge deficit (learning need) regarding condition / situation, prognosis, treatment needs.

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Ventricular Septal Defects - 7 Nursing Diagnosis and Interventions

Nursing Care Plan for VSD in Children

1. Decreased Cardiac Output related to cardiac malformations.

Goal: to improve cardiac output.

Outcomes: signs of improvement in cardiac output.

Intervention:

• Observe the quality and strength of the heartbeat, peripheral pulses, skin color and warmth.
• Assess the degree of cyanosis (mucous membranes, clubbing).
• Monitor signs of CHF (anxiety, tachycardia, tachipnea, shortness of breath, tired while drinking milk, periorbital edema, oliguria and hepatomegaly.
• Collaboration for the provision of drugs as indicated.

2. Impaired gas exchange related to pulmonary congestion.

Goal: improved gas exchange.

Outcomes: no signs of pulmonary vascular resistance.

Intervention:

• Monitor the quality and rhythm of breathing.
• Adjust the position of the child with Fowler position.
• Avoid child of an infected person.
• Give adequate rest.
• Give oxygen as indicated.

3. Activity intolerance related to imbalance between oxygen consumption by the body and oxygen supply to the cells.

Goal: client activity are met.

Outcomes: Children participate in activities according to ability.

Intervention:

• Allow the child frequent breaks and avoid disturbances during sleep.
• Suggest to do the game and light activity.
• Help children to choose activities appropriate to the age, condition and capacity of the child.
• Give the period of rest after activity.
• Avoid the ambient temperature is too hot or cold.
• Avoid things that cause fear / anxiety child.

4. Delayed Growth and Development related to an inadequate supply of oxygen and nutrients to tissues.

Goal: There is no change of growth and development.

Outcomes: Growth of children according to the growth curves of weight and height.

Intervention:

• Provide a balanced diet, high nutrients to achieve adequate growth.
• Monitor height and weight.
• Involve the family in providing nutrition to children.

5. Imbalanced Nutrition: less than body requirements related to fatigue at mealtime and increased caloric needs.

Goal: nutritional needs are met.

Outcomes: The child maintains food and beverage intake.

Intervention:

• Measure body weight each day with the same scales.
• Record intake and output correctly.
• Give small portions of food frequently.
• Give drink that much.

6. Risk for infection related to declining health status.

Goal: avoid infection.

Outcomes: no signs of infection.

Intervention:

• Monitor vital signs.
• Avoid contact with infected individuals.
• Give adequate rest.
• Provide optimal nutritional needs.

7. Parental Role Conflict related to hospitalization of children, fears of the disease.

Goal: There is a change in the role of parents.

Outcomes:

• Parents express their feelings.
• Parents are sure to have an important role in the success of the treatment.

Intervention:

• The motivation of parents to express their feelings in relation to the child.
• Discuss with parents about the treatment plan.
• Provide clear and accurate information.
• Involve parents in the care of the child while in hospital.
• The motivation to involve families in the care of other family members of children.

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Impaired Swallowing and Altered Family Processes r/t Newborns with Esophageal Atresia

Nursing Diagnosis and Interventions for Newborns with Esophageal Atresia

Nursing Diagnosis : Impaired Swallowing related to mechanical obstruction.

Goal: Patient getting adequate nutrition.

Outcomes: The baby gets enough nutrients and showed satisfactory weight gain.

Intervention:

• Give fed through gastrostomy in accordance with the provisions.
• Continue oral feeding as applicable, under the conditions of infants and surgical repair.
• With strict observation.
• Monitor input and output weight.
• Teach families about proper feeding techniques.

Rational:

• To meet the nutritional needs of infants
• To assess the adequacy of nutrient inputs.
• To make sure the baby is able to swallow without choking.
• To provide nutrients to allow oral feeding.
• To prepare for the return.

Nursing Diagnosis : Altered Family Processes related to babies with physical defects.

Goal: patient (family) prepared for child care at home.

Outcomes : Families demonstrate the ability to provide care to infants, understanding the signs of complications, and appropriate action.

Intervention:
Teach the family about the skills and needs of nursing home observations:

• Give position.
• Signs of respiratory distress.
• Signs of complications; refusing to eat, dysphagia, increased cough.
• The need for tools and materials needed.
• Gastrostomy care if the infant had surgery, including techniques such as suction, feeding, or ostomy care operasidan side, and a replacement bandage.

Rational

• To prevent aspiration.
• To prevent delays in action.
• So that practitioners can be notified.
• To ensure proper care after discharge.

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Nursing Care Plan for Esophageal Atresia

Esophageal atresia occurs in about one in 3000-4500 live births, one third of affected children are usually born prematurely. In over 85% of cases, a fistula between the trachea and distal esophageal, accompanying atresia. Very rarely, esophageal atresia or tracheal esophageal fistula occur alone or with a strange combination. Esophageal atresia is a congenital abnormality include group consisting of disruption of continuity of the esophagus with or without connection to the trachea. Infants with Esophageal Atresia is unable to swallow saliva and marked with a bunch of very large amount of saliva and requires suction repeatedly.

The possibility of atresia increased with the discovery of polyhydramnios. Nasogastric tube can still be passed at the time of birth of all babies are born with maternal polyhydramnios as well as infants with excessive mucus, soon after the birth to prove or disprove the diagnosis. In esophageal atresia hose will not pass more than 10 cm from the mouth (confirmation with Rongent chest and abdomen).

Until now not known what teratogenic substances that can cause abnormalities Esophageal Atresia, just reported recurrence rate of about 2% if one of the affected siblings. But now, the theory about the occurrence of esophageal atresia according to most experts no longer associated with a genetic disorder. The debate on embryo-pathological process continues, and only a little is known.

The triggers that cause congenital birth as esophageal atresia are as follows:

• In the case of polyhydramnios.
• Preterm infants.
• If the catheter is used for resuscitation at birth can not enter into the stomach.

There are some circumstances that the symptoms and signs of esophageal atresia, among others:

• Mouth foaming (bubbles of air from the nose and mouth) and saliva from the mouth of a baby is always melted.
• Cyanosis.
• Cough and shortness of breath.
• Symptoms of pneumonia caused by regurgitation of saliva from the esophagus were clogged and regurgitation of gastric fluid through the fistula into the airway.
• Abdominal bloating or bulge, because the air through the fistula into the stomach and intestines.
• Oliguria, because there is no fluid intake.
• Usually accompanied by other congenital abnormalities, such as heart defects, atresia of the rectum or anus.
• The presence of aspiration when the baby is drinking.
• Projectile vomiting.

Nursing Diagnosis for Esophageal Atresia

1. Impaired swallowing related to mechanical obstruction.
2. Risk for injury related to surgical procedures.
3. Anxiety related to difficulty swallowing, discomfort due to surgery.
4. Altered family processes related to children with physical defects.

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Thyroid Cancer - 3 Nursing Diagnosis and Interventions

Nursing Care Plan for Thyroid Cancer

Thyroid cancer is a malignancy of the thyroid which has 4 types, namely: papillary, follicular, medullary and anaplastic. Thyroid cancer rarely causes enlargement of the gland, often causing small growth (nodule) in the glands. Most thyroid nodules are benign, thyroid cancer can usually be cured.

Thyroid cancer often limits the ability to absorb iodine and limit the ability to produce thyroid hormone, but sometimes produce enough thyroid hormone resulting in hyperthyroidism.

Thyroid cancer occurs in cells of the thyroid gland, which produces hormones serve to regulate the speed of the heart beat, blood pressure, body temperature and weight.

Nursing Diagnosis for Thyroid Cance

1. Ineffective airway clearance related to obstruction of the trachea by the pressure of the tumor mass.
2. Pain (acute / chronic) related to the presence of pressure / swelling of the tumor nodule.
3. Impaired verbal communication related to vocal cord injury.

Nursing Interventions and Rationale

1. Ineffective airway clearance related to obstruction of the trachea by the pressure of the tumor mass.

Goal: Effective airway.

Outcomes:

• There is no difficulty breathing.
• Easy exit discharge.
• Not complaining of shortness of breath.
• Respiration in the normal range (16-20).

Interventions :

• Monitor respiratory rate, depth and breath work.
• Auscultation of breath sounds, note the presence of crackles.
• Assess for dyspnea, stridor and cianosis.
• Note the quality of breathing.
• Collaboration of oxygen therapy if necessary.

Rationale :

• To determine the presence of early complications.
• To determine the presence of crackles or not.
• Knowing the client's breathing.
• Preventing the occurrence of dyspnea.
• Helping clients breathing.

2. Pain (acute / chronic) related to the presence of pressure / swelling of the tumor nodule.

Goal: reduced pain.

Outcomes:

• Pain reported lost / diminished.
• Pain scale: 0-2.
• Looks relax.
• There are no complaints to swallow.

Interventions :

• Observe for signs of pain both verbal and nonverbal.
• Teach and instruct the patient to use relaxation techniques.
• Collaboration of analgesics.

Rationale :

• Anticipate if there is pain.
• Provide comfort to the client.
• To reduce pain.

3. Impaired verbal communication related to vocal cord injury.

Goal: verbal communication breakdowns resolved.

Outcomes:

• Being able to create a method of communication in which needs can be understood.

Interventions :

• Assess speech function periodically.
• Keep communication simple.
• Provide appropriate alternative communication methods.

Rationale :

• To determine the condition of the client.
• In order not to force the client to speak.
• Adjust to the client's condition.

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Postpartum Hemorrhage - 5 Nursing Diagnosis and Interventions

Nursing Care Plan for Postpartum Hemorrhage

Nursing Diagnosis forPostpartum Hemorrhage

1. Fluid volume deficit related to vaginal bleeding.
2. Ineffective tissue perfusion related to vaginal bleeding.
3. Anxiety / fear related to changes in circumstances or the threat of death.
4. Risk for infection related to bleeding.
5. Risk for shock : hypovolemic related to bleeding.

Nursing Diagnosis 1. Fluid volume deficit related to vaginal bleeding.

Goal : Prevent dysfunctional bleeding and improve fluid volume.

Interventions and Rationale :
1. Advise patients to sleep with feet higher, while the body remained supine.
R / : With feet higher will increase the venous return , and allowing the blood to the brain and other organs.

2.Monitor vital signs.
R / : Changes in vital signs when bleeding occurs more intense.

3.Monitor intake and output every 5-10 minutes.
R / : Change the output is a sign of impaired renal function.

4. Evaluation of the urinary bladder.
R / : Full urinary bladder prevents uterine contractions.

5. Perform uterine massage with one hand and the other hand placed above the simpisis.
R / : Uterine massage stimulate uterine contractions and helps release the placenta, one hand above simpisis prevent inversion uterine.

6. Limit vaginal and rectal examination.
R / : Trauma that occurs in the vagina and rectum increases the incidence of bleeding was greater, in case of laceration of the cervix / perineal, or there is a hematoma.
When the blood pressure decreases, pulse became weak, small and fast, the patient feels sleepy, more intense bleeding, immediate collaboration.


Nursing Diagnosis 2. Ineffective tissue perfusion related to vaginal bleeding.

Goal : Vital signs and blood gases within normal limits.

Interventions and Rationael :
1. Monitor vital signs every 5-10 minutes.
R / : Changes in tissue perfusion causing changes in vital signs.

2. Note the discoloration of the nail, lip mucosa, gums and tongue, skin temperature.
R / : With vasoconstriction and relationship to vital organs, circulation in peripheral tissues is reduced, causing cyanosis and cold skin temperature.

3. collaboration :
Monitor blood gas levels and pH (changes in blood gases and pH levels are a sign of tissue hypoxia)
Give oxygen therapy (oxygen transport is needed to maximize circulation to tissue).


Nursing Diagnosis 3. Anxiety / Fear related to changes in circumstances or the threat of death.

Goal : The client can verbalize anxiety and said anxiety is reduced or lost.

Interventions and Rationael :
1. Assess the client's psychological response to the post- childbirth bleeding.
R / : Perceptions of client influence the intensity of anxiety.

2. Assess the client's physiological responses (tachycardia, tachypnea, shaking).
R / : Changes in vital signs lead to changes in the physiological responses.

3. Treat the patient calm, empathetic and supportive attitude.
R / : Provide emotional support.

4. Provide information about care and treatment.
R / : Accurate information can reduce the anxiety and fear of the unknown.

5. Help clients identify a sense of anxiety.
R / : The expression can reduce feelings of anxiety.

6. Assess the client's coping mechanisms used.
R / : Prolonged Anxiety can be prevented with proper coping mechanisms.


Nursing Diagnosis 4. Risk for infection related to bleeding.

Goal : Not an infection (lochia is no smell , and vital signs within normal limits)

Interventions and Rationale :
1. Note the changes in vital signs.
R / : Changes in vital signs (temperature) is indicative of infection.

2. Note the signs of fatigue, chills, anorexia, uterine contractions were flabby, and pelvic pain.
R / : The signs are an indication of the occurrence of bacteremia, shock is not detected.

3. Monitor uterine involution and lochia spending.
R / : Uterine infection, inhibit involution and lochia spending prolonged occurs.

4. Consider the possibility of infection in other places, such as respiratory infections, mastitis and urinary tract.
R / : Infection elsewhere worsen the situation.

5. Collaboration :
Give iron (anemia aggravate the situation).
Give antibiotics (antibiotics are necessary for the proper state of infection).

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Nursing Care Plan for Premature Babies

Newborn infants with gestational age 37 weeks or less at birth is called premature babies. Although small, premature infants in size according to pregnancy, but the development of intra-uterine rudimentary, can cause complications during the post-natal. Newborns whose weight was 2500 grams, or less with a gestational age of more than 37 weeks is called small for gestational age, is different from the premature, although 75 % of neonates whose weight was below 2500 grams born prematurely.

Clinical problems occur more often in premature infants than in full-term infants. Prematurity caused immaturity system development and function, restricting the infant's ability to cope with the problem of disease.

A common problem among others ; respiratory distress syndrome (RDS), necrotizing enterocolitis, hyperbilirubinemia, hypoglycemia, thermoregulation, patent ductus arteriosus (PDA), pulmonary edema, intraventricular hemorrhage. Another additional stressor in infant and parents include hospitalization for illness in infants. Parental responses and coping mechanisms they can cause interference in the relationship between them. Necessary planning and adequate measures for these problems.


Etiology and Precipitating Factors :

Problems in the mother during pregnancy :

• Diseases / disorders such as hypertension, toxemia, placenta previa, placental abruption, cervical incompetence, multiple fetuses, malnutrition and diabetes mellitus.
• Low socioeconomic level and inadequate prenatal care.
• Preterm labor, or induced abortion.
• Abuse consumption in the mother, such as ; drugs, alcohol, smoking and caffeine.

Assessment
1. History of pregnancy.
2. Status of the newborn.
3. Physical examination head to toe, including : cardiovascular, gastrointestinal, integument, musculoskeletal, neurologic, pulmonary, renal, reproduction.
4. Supporting data

• X-ray of the chest and other organs to determine the presence of abnormalities.
• Ultrasonography to detect abnormalities of organs.
• Stick glucose to determine glucose levels decrease.
• Serum calcium levels, decreased levels means there is hypocalcemia.
• Bilirubin levels, to identify improvement (due to premature are more sensitive to hyperbilirubinemia)
• Electrolyte levels, blood gas analysis, blood type, blood culture, urinalysis, fecal analysis, and so forth.

Nursing Diagnosis

1. Risk for respiratory distress related to immaturity of the lungs, with decreased production surfactan that cause hypoxemia and acidosis.

2. Risk for hypothermia or hyperthermia related to prematurity or changes in ambient temperature.

3. Imbalanced nutrition less than body requirements related to inadequate glycogen reserves, iron, and calcium and loss of glycogen stores due to the high rate of metabolism, inadequate intake of calories, and lose calories.

4. Fluid and Electrolyte imbalances related to immaturity, radiation environment, the effect fototherapy or loss through the skin or lungs.

5. Risk for infection related to immunologic immaturity of the baby and the possibility of infection from mothers or medic / nurse.

6. Risk for impaired skin integrity related to immaturity and fragile skin.

7. Impaired sensory perception : visual, auditory, kinesthetic, gustatory, tactile and olfactory related to less stimulation or excessive in the intensive care environment.

8. Knowledge Deficit (family) about treatment of the sick infant at home.

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Care Plan Examples for Community Health Nursing

Nursing Care Plan - Community Health Nursing


Community is a social group who live in a place, interacting with each other, know each other and have the same interests. Communities are groups of people who live in the same location with the same under the rule, the area or the same location where they live, the social groups that have the same interest.

Health care is a specialized field of nursing which is a combination of science nursing, public health sciences and social sciences are an integral part of the health care provided to individuals, families, groups and communities either healthy or sick comprehensively through promotive, preventive , curative and rehabilitative and resocialization, involving the active participation of the community. Active participation with community health teams are expected to know the health problems faced and solved the problem.

Public health targets are individuals, families / groups and communities, with a focus on primary health efforts, secondary and tertiary. Therefore, public education about the health and social development will help the community in encouraging the spirit to care for themselves, independent living and self-determination in creating optimal health status.

Public participation is required in the individual case. Community as the subject and object of society is able to recognize expected, took the decision to maintain good health. Most of the primary health care goals of society are expected to be able to independently maintain and improve the health status of the community.


Assessment 

Community profile assessment framework (modified)

This assessment is the result of a modification of some previous theories about the community assessment.

Data collection

The data collection is intended to obtain information about health problems in the community to determine which actions should be taken to resolve the issue concerning the physical, psychological, social, economic, spiritual and environmental factors that influence.

Data collection can be done in the following way:

1. Interview or anamnesis

The interview is a mutual communication activities in the form of questions and answers between the nurse with the patient or the patient's family, the community on matters relating to the patient's health problems. Interviews should be conducted with a friendly, open, use simple language and easily understood by the patient or the patient's family, and subsequent interviews or anamnesis recorded in the format of the nursing process.

2. Observations

Observations conducted in community nursing covers aspects of physical, psychological, behavioral and attitude in order to nursing diagnosis. Observations were made using the five senses and the results are recorded in the format of the nursing process.

3. Physical examination

In one community nursing where nursing care is provided nursing care family, the physical examination were performed in an effort to help nursing diagnosis by means of inspection, percussion, auscultation and palpation.



Data processing

Once the data is obtained, the next activity is the processing of data in the following way:

• Classification of the data or categories of data.
• Calculation of percentage of coverage.
• Tabulation of data.
• Interpretation of the data.

Data analysis

Data analysis is the ability to associate the data with the cognitive abilities possessed that can be known about the gaps or problems faced by the community if it's a problem of health, or nursing problems.

1. Determination of the problem or the formulation of health problems

Based on the analysis of the data can be known health and nursing problems faced by the community, and can be formulated hereinafter intervention. However, the problem has been formulated not to be overcome at once. Therefore we need a priority issue.

2. Priority issues

In determining priority public health issues and nursing need to consider various factors such as the criteria are:

• Public attention.
• Prevalence.
• The severity of the problem.
• Possible problems to be overcome.
• Availability of community resources.
• Political aspects.

Selection or screening community health problems, according to the format Mueke (1988) have screening criteria, among others:

• In accordance with the role of community nurses.
• The amount at risk.
• The magnitude of the risk.
• The possibilities for health education.
• The public interest.
• Possibility to overcome.
• In accordance with the government program.
• A resource.
• Time resources.
• Funding resources.
• Equipment resources.
• Human resources.

Nursing Diagnosis

Nursing diagnosis is the individual's response to health problems whether actual or potential. The actual problem is a problem that is obtained at the time of assessment, while the potential problems are problems that may arise later. So the nursing diagnosis is a statement that is clear, concise and definite about the status and health problems that can be addressed by nursing actions. Thus nursing diagnosis is determined based on problems found. Nursing diagnosis will give an overview of public health issues and the status of both the real (actual), and which may occur.


Nursing Care Plan

Planning nursing is nursing action plans to be implemented to address the problems within their nursing diagnosis has been determined with the aim of fulfilling the needs of the client. So public health nursing care plan is based on pre-defined nursing diagnoses and nursing plan drawn up should include the formulation of objectives, plans nursing actions to be performed and the criteria for assessing the results of the achievement of objectives.

The steps in the planning of public health nursing are as follows:

• Identify alternative nursing actions.
• Set techniques and procedures to be used.
• Involve community participation in planning through village community consultation activities, or mini workshops.
• Consider the community resources and facilities available.
• Actions to be implemented must be able to meet the requirement, which was felt by the public.
• Leads to the objectives to be achieved.
• Action must be realistic.
• Arranged sequentially.

References :

(Mubarak, 2005).
(Elisabeth, 2007).
(Riyadi, 2007).

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The Role of Public Health Nurses

Many roles can be performed by Public Health Nurses are:

1. As a service provider (Care provider)

Provide nursing care through reviewing the existing nursing problems, nursing action plan, implement and evaluate nursing care actions, which have been given to individuals, families, groups and communities.


2. As an educator and consultant (Nurse Educator and Counselor)

Provide health education to individuals, families, groups and communities both in the home, community health centers, and in society as organized in order to instill healthy behavior, resulting in a change of behavior as expected in achieving optimal health status.

Counseling is the process of helping the client to recognize and cope with psychological distress or social issues to establish good interpersonal relationships and to increase one's progress. In it are given emotional support and intellectual.

The teaching process has four components: assessment, planning, implementation and evaluation. This is consistent with the nursing process in the assessment phase of a nurse assess patient's learning needs and readiness to learn. During the planning nurses make specific goals and teaching strategies. During the implementation of the nurse implement teaching strategies and for evaluation of the nurse assess the results that have been obtained


3. As a role model (Role Models)

Public health nurses should be able to give a good example in the field of health to individuals, families, groups and the public about how healthy the way of life that can be imitated and emulated by the public.


4. As defenders (Client Advocate)

Defense can be given to an individual, group or community level. At the family level, nurses can perform its functions through social services in the community. A client advocate is an advocate of the rights of clients. Defense including an increase in what is best for clients, ensuring client needs are met and to protect the rights of clients (Mubarak, 2005).

The task of the nurse as a client advocate is responsible for assisting clients and families in interpreting information from a variety of service providers to provide information and other things necessary to take approval (Informed Concent) on nursing actions given to him. Another task is to preserve and protect the rights of the client, because the client must be sick and hospitalized will interact with many health workers.


5. As a case manager (Case Manager)

Public health nurses are expected to manage a variety of health services and community health centers in accordance with the burden of the duties and responsibilities imposed upon him.


6. As collaborators

The role of the nurse as a collaborator can be implemented by means of cooperation with other healthcare teams, both with doctors, nutritionists, radiologists, and others in relation to help speed up the healing process of collaboration or cooperation measures client is a decision-making process with others on the stage of the nursing process . This action plays a very important to plan the actions that will be implemented (Mubarak, 2005).


7. As planners further action (Discharge Planner)

Discharge planning can be provided to a client who has been undergoing treatment at a medical institution or hospital. This plan can be provided to clients who have experienced improved health conditions.


8. As identifiers health problems (Case Finder)

Implement monitoring of the changes that occur in individuals, families, groups and communities on issues of health and nursing as well as the resulting impact on health status through home visits, meetings, observation and data collection.


9. As a health services coordinator (Coordinator of Services)

The role of the nurse as a coordinator among others, direct, plan and organize health services provided to clients. Service of all members of the health team, because the client receives the services of many professionals.


10. As the carrier changes or reformer and leader (Change Agent and Leader)

Agents for Change is a person or group who initiate change or help others to make a change in him or in the system. Torney Marriner describes that the carrier change is that identifying the problem, assessing client's motivation and ability to change, suggesting alternatives, explore the possibility of alternative outcomes, reviewing resources, demonstrate the role of help, build and maintain relationship help, help during the phase of the change process and guiding clients through these phases.

Improvement and change is an essential component of treatment. By using the nursing process, the nurse helps clients to plan, implement and maintain such a change: knowledge, skills, feelings and behaviors that can improve health.


11. As an identifier and community service providers (Community Care Provider And Researcher)

This role is included in the process of nursing care services to the community which includes assessment, planning, implementation and evaluation of health problems and solving the given problem. Search action or identifying other health problems are also part of the role of community nurses.


Source : (Mubarak, 2005)

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Nursing Care Plan for Spinal Cord Tumor

NCP for Spinal Cord Tumor - Assessment, Nursing Diagnosis and Interventions

Spinal cord arranged in the spinal canal and are covered by a layer of connective tissue, dura meter. Spinal cord tumor is an uncommon disorder, and only a few are found in the population. However, if the tumor lesion grows and pressing on the spinal cord, this tumor can cause dysfunction of the limbs, paralysis and loss of sensation.

The incidence of all primary tumors of the spinal cord approximately 10% to 19% of all primary central nervous system tumors. (CNS), and like all tumors in the nervous axis, the incidence increases with age. Gender specific prevalence of almost all the same, except for the meningioma which is generally found in women, and ependymoma are more frequent in males. Approximately 70% of intradural tumors, an extramedullary and 30% is intramedular.

In this case the nurse has an important role in organizing efforts such as improved health (promotion) by way of providing information about the disease, disease prevention (preventive), cure (curative) and rehabilitative.

Complications that can result in spinal cord tumors are very noteworthy because of the impact would worsen the patient's condition, such as; damage the fibers of neurons, loss of sensation of pain (severe circumstances), bleeding metastases, rigidity, weakness, impaired coordination, difficulty urinating or causing loss of control of bladder or constipation.


Definition

Spinal cord tumors are the growth of new tissue in the spinal cord, can be benign or malignant.


Etiology

The pathogenesis of spinal cord neoplasms is unknown, but most arise from abnormal cell growth in the area. Genetic history looks very instrumental in the increased incidence in certain families or syndromic group (neurofibromatosis).


Assessment

• GCS assessment.
• Assessment of the level of consciousness.
• Pathological and physiological reflexes.

Nursing Diagnosis

Diagnosis of tumors of the spinal cord taken based on the results of history and physical examination and investigations. Extradural tumors had a clinical course of spinal cord function will disappear altogether accompanied by spastic weakness and loss of sensation of vibration.

Joint position below the level of the lesion is rapid. On examination of the spine radiogram, most of the patients the tumor will show symptoms of osteoporosis or significant damage to the pedicles and vertebral bodies. Myelogram can confirm the location of the tumor.

In extramedullary tumors, which dominates the symptoms is compression of the spinal nerve fibers, so that the initial look is pain, first in the back and then along the spinal nerve roots. As in the extradural tumors, pain aggravated by traction by movement, coughing, sneezing or straining, and the most severe occurred at night. Pain is intensified at night caused by traction on the nerve root pain, the spine when lengthening after the loss of shortening effect of gravity. Sensory deficits gradually rises to below the level of the spinal cord segments. In extramedullary tumors, CSF protein levels almost always increased. Spinal radiography may show an enlarged foramen and thinning adjacent pedicles. As in the extradural tumors, myelogram, CT scan, and MRI is essential to determine the exact location.

1 Impaired sense of comfort: pain related to increased ICP.

2 Impaired physical mobility related to compression of the blood supply to the corno anterior.

3 Impaired sense of comfort: pain related to intra-thoracic and intradominal.



Nursing Plan

Nursing plan is an action plan that nurses do before nurses perform actions to the patient, who is listed in the nursing plan is:
1. Independent and collaborative interventions, independent intervention is the action to be done independently of nurses to patients, while collaboration is an act of intervention that nurses do in collaboration with other health care team.
2 Criteria of expected results, and
3 Rational, which is the rational benefits of the actions taken by nurses to patients.

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Brain Tumor Assessment, Pre and Post Operative Nursing Diagnosis

Nursing Assessment for Brain Tumor

1. Health Perception and Health Management

• A family history of tumors.
• Exposed to excess radiation.
• A history of visual problems; lost visual acuity and diplopia.
• Alcohol Addiction, heavy smokers.
• There was a feeling abnormal.
• Personality disorder / hallucinations.

2. Nutritional Metabolic Pattern

• History of epilepsy.
• Loss of appetite
• The presence of nausea, vomiting during the acute phase.
• The loss of sensation on the tongue, cheeks and throat.
• Difficulty swallowing (interference on the palate and pharyngeal reflex).

3. Elimination Pattern

• Changes in the pattern of urination and bowel movements (incontinence).
• Bowel sounds; negative.

4. Activity and Exercise Pattern

• Disorders of muscle tone, the muscle weakness, impaired level of consciousness.
• Risk of trauma due to epilepsy.
• Hamiparese, ataxia.
• vision disorders.
• Feel tiredness, loss of sensation.

5. Sleep Rest Pattern

• Hard or easy to relax and fall asleep.

6. Cognitive-Perceptual Pattern

• Dizziness.
• Headache.
• weakness.
• Tinnitus.
• Motor aphasia.
• Loss of sensory stimuli contra-lateral.
• Impaired sense of taste, smell and sight.
• Decline in memory, problem solving.
• Lost the ability influx of visual stimuli.
• Impairment of consciousness up to coma.
• Not able to record images.
• Not able to distinguish right / left.

7. Self-Perception-Self-Concept Pattern

• The feeling of helplessness and despair.
• Emotions unstable and difficult to express.

8. Role-Relationship Pattern

• Speech problems.

9. Reproduction

• The existence of disturbances and irregularities.
• Influence / relationship to disease.

10. Coping-Stress Tolerance Pattern

• Existence of feelings of anxiety, fear, impatient or angry.
• Coping mechanism commonly used.
• Feelings of helplessness, hopelessness.
• Emotional response to the client's current status.
• People who help in solving the problem.
• Irritability.

11. Value-Belief Pattern

• The religion, whether religious activities interrupted.

Nursing Diagnosis for Brain Tumor Pre-Surgery

1. Imbalanced Nutrition Less than Body Requirements related to nausea, vomiting and loss of appetite / growth of cancer cells.
2. Acute Pain / Chronic Pain ; head related to the growth of cancer cells in the brain.
3. Impaired physical mobility related to movement disorders and weakness.
4. Impaired Verbal Communication related to damage to the cerebral circulation.
5. Low self-esteem related to dependency, role changes, changes in self-image.
6. Knowledge Deficit; about the condition and treatment of diseases related to lack of information.
7. Anxiety related to surgical plan.

Nursing Diagnosis for Brain Tumor Post-Surgery

1. Acute Pain related to the effects of surgery.
2. Low self-esteem related to dependency, role changes, changes in self-image.
3. Knowledge Deficit; about brain tumors related to ignorance about resources
4. Anxiety related to chronic disease and an uncertain future.

Brain Tumor - 4 Nursing Diagnosis and Interventions

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Brain Tumor - 4 Nursing Diagnosis and Interventions

Nursing Care Plan for Brain Tumor

Tumor is a general term covering any benign growth in every part of the body. This growth was not intended, is growing at the expense of the parasite and the human host.

Brain tumor is a benign tumor on the lining of the brain or one of the brain.

Brain carcinoma (malignant) is a neoplasm that grows in the lining of the brain.

Neoplasm is a collection of abnormal cells formed by cells that grow continuously in a limited, uncoordinated with the surrounding tissue and not useful to the body.


Nursing Diagnosis and Nursing Interventions for Brain Tumor

I. Acute Pain / Chronic Pain related to the effects of surgery.

Goal: Pain is reduced until it disappears after the act of nursing.

Outcomes:

• Clients can perform activities without feeling pain.
• Relaxed facial expression.
• Clients demonstrate discomfort disappear.

Interventions:
1. Assess the level of pain (location, duration, intensity, quality) every 4-6 hours.
R /: As an early indicator in determining the next intervention.

2. Assess the patient's general condition and vital signs.
R /: As an early indicator in determining the next intervention.

3. Give a pleasant position for the patient.
R /: To assist patients in controlling pain.

4. Give a lot of time resting and less visitors as desired patient.
R /: Can reduce physical and emotional discomfort.

5. Collaboration with physicians in drug delivery.
R /: To assist in the healing of patients.



II. Low self-esteem related to dependency, role changes, changes in self-image.

Goal: Impaired self-resolved after the act of nursing.

Outcomes: Clients can be confident with the disease state.

Interventions:
1. Assess the response, and the patient's family's reaction to disease and treatment.
R /: To simplify the process approach.

2. Assess the relationship between patient and close family members.
R /: Support families helps in the healing process.

3. Involve everyone nearby in education and home care planning.
R /: Can ease the burden on the handling and adaptation at home.

4. Give time / listen to the things that become complaints.
R /: continuous support will facilitate the adaptation process.


III. Knowledge Deficit: about brain tumors related to ignorance about resources.

Goal: Information about self care and nutritional status is understood, after the act of nursing for 1 x 24 hours.

Outcomes:
The client expressed an understanding of the information provided.
Client states of consciousness and changes in patterns of self-care plan.

intervention:
1 Assess the patient's level of knowledge.
R /: To determine the level of knowledge in the receipt of information, so as to give correct information.

2 Discuss the relationship of the causative agent of the disease.
R /: To provide an understanding to the patient about the things that trigger the disease.

3 Explain the signs and symptoms of perforation.
R /: Symptoms of perforation is pain in the chest.

4 Explain the importance of the environment without stress.
R /: To prevent an increase in sympathetic stimulation.

5. Discuss implementation method of stress.
R /: How stress management: relaxation, exercise and medication.


IV. Anxiety related to chronic disease and an uncertain future.

Goal: Anxiety can be minimized after the act of nursing.

Outcomes: Anxiety is reduced.

Intervention:
1. Listen patiently client complaints.
R /: Facing issues of patients and need to be explained and opened the way to resolve it.

2. Answering questions from clients and families, with friendly.
R /: Make sure the patient and believe.

3. Encourage client and family confide.
R /: Creating trust and decrease misperceptions.

4. Using therapeutic communication techniques.
R /: Establishing a trust relationship the patients.

5. Give the physical comfort of the patient.
R /: It is difficult to accept with the issue when it experiences extreme emotional / physical discomfort persist.

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