Acute Tonsillitis - 6 Nursing Diagnosis Care Plan

Definition;

Tonsillitis is a common presence of inflammation and swelling of the tonsillar tissue with a collection of leucocytes, dead epithelial cells and pathogenic bacteria in the crypts (Adam Boeis, 1994: 330).

Tonsillectomy is an invasive procedure that is performed to take out tonsils with or without adenoid (Adam Boeis, 1994: 337).


Etiology 

1. Haemolytic streptococcus group A.
2. Pneumococcus.
3. Staphylococci.
4. Haemophilus influenzae.

Symptoms 

1. Sore throat and dysphagia.
2. Patients do not want to eat or drink.
3. Malaise.
4. Fever.
5. Breath odor.
6. Otitis media is one of the originators factor.

Management of Acute Tonsillitis

1. Bed rest.
2. Provision of adequate fluids and light diet.
3. Giving medications (analgesics and antibiotics).
4. If there is no progress then the alternative actions that can be done is surgery.

Nursing Assessment for Acute Tonsillitis

1. Medical history factors associated with the occurrence of tonsillitis as well as supporting the bio-psycho-socio-spiritual.

2. Circulatory
Palpitations, headache at the time of a change in position, drop in blood pressure, bradycardia, body felt cold, pale extremities appear.

3. Elimination
Changes in the pattern of elimination (incontinence uri / Alvi), abdominal distension, bowel sounds disappearance.

4. Activity / rest
There is a decrease in activity due to body weakness, loss of sensation or parese / plegia, tiredness, difficulty in recuperating from muscle spasms and pain or spasm. The reduced level of consciousness, decreased muscle strength, general body weakness.

5. Nutrition and fluids
Anorexia, nausea, vomiting due to increased ICP (intracranial pressure), impaired swallowing, and loss of sensation on the tongue.

6. Nerves system
Dizziness / syncope, headache, decreased visual field wider / blurred vision, decreased touch sensation, especially in the face and extremities. Mental status coma, kelmahan in the extremities, facial muscles paralise, aphasia, dilated pupils, decreased hearing.

7. Comfort
Tense facial expressions, headache, restlessness.

8. Breathing
Shortened breath, inability to breathe, apnea, apnea onset period in breathing patterns.

9. Security
Fluctuations of temperature in the room.

10. Psychology
Denial, disbelief, anguish, fear, anxiety.



Nursing Diagnosis and Interventions for Acute Tonsillitis


1. Ineffective breathing pattern related to tissue damage or trauma to the respiratory center.

Goal: The patient demonstrated the ability to perform adequately the respiratory blood gas results show stable and good as well as the loss of signs of respiratory distress.

Interventions

1. Clear the airway patent (keep the head position in a state parallel to the spine / as indicated).
2. Perform suction if necessary.
3. Assess the function of the respiratory system.
4. Assess the patient's ability to perform cough / discharging effort.
5. Observation of vital signs before and after the action.
6. Observation for signs of respiratory ditress (skin becomes pale / cyanosis).
7. Collaboration with therapists in the provision of physiotherapy.

2. Impaired physical mobility related to neuromuscular weakness in the extremities.

Goal: Patients showed an increased ability to perform physical activity.

Interventions:

1. Assess the patient's ability to perform the activity.
2. Teach the patient about the range of motion that can still be done.
3. Perform active and passive exercises at akstrimitas to prevent stiffness and muscle atrophy.
4. Instruct the patient to take a straight position.
5. Assist patients in performing ROM gradually according to ability.
6. Collaboration in the provision antispamodic or relaxant if necessary.
7. Observation of the patient's ability to perform the activity.

3. Ineffective Cerebral Tissue Perfusion related to the brain, bleeding in the brain.

Goal: The patient showed an increase in awareness, cognitive and sensory function.

Interventions:

1. Assess neurologic status and note the changes.
2. Give the patient supine position.
3. Collaboration in the provision of oxygenation.
4. Observation level of consciousness, vital signs.

4. Acute pain related to physical trauma.

Goal: The patient expresses pain is reduced and shows a relaxed and calm state.

Interventions:

1. Assess the level or degree of pain felt by the patient using a scale.
2. Help the patient in finding factor in precipitation of pain felt.
3. Create a quiet environment.
4. Teach and demontrasikan to patients about several ways to do relaxation techniques.
5. Collaboration in the provision of appropriate indications.

5. Impaired verbal communication related to the effects of damage to the area to talk to the cerebral hemispheres.

Goal: The patient was able to communicate to meet their basic needs and showed improvement in their communication capabilities.

Interventions:

1. Do a personal communication with the patient (often but short and easy to understand).
2. Create an atmosphere of acceptance of the changes experienced by the patient.
3. Instruct patients to improve communication techniques.
4. Use non-verbal communication techniques.
5. Collaboration in the implementation of speech therapy.
6. Observation of the patient's ability to communicate both verbally and non-verbally.

6. Self-concept Disturbance related to a change of perception.

Goal: The patient showed improvement in the ability to accept the circumstances.

Interventions:

1. Assess the patient's degree of self-concept change.
2. Mentor and listen to patient complaints.
3. Give support to actions that are positive.
4. Assess the patient's ability to rest (sleep).
5. Observation of the patient's ability to receive state.

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4 Nursing Diagnosis and Interventions for Postoperative Patient

 Nursing Care Plan for Intraoperative Patient

 1. Ineffective breathing pattern related to the depressant effects of medications and anesthetic agent.

Characterized by:

• Changes in the frequency and depth of breathing.
• Reduction in vital capacity.
• Apnea, cyanosis, noisy breathing (snoring).
• The decrease in oxygen saturation.

Goal: effective breathing pattern

Outcomes:

• Saturation of more than 95%.
• Breathing regularly.
• No additional breath sounds.
• Airway is not blocked.

Interventions:

1. Maintain airway by tilting the head, jaw hyperextension, oropharyngeal airflow.
2. Auscultation of breath sounds, listen wheeze, Ronchi or noise after extubation.
3. Observation frequency and depth of breathing, use of a respirator muscles, expansion of the thoracic cavity retraction or skin color nostril breathing and air flow.
4. Place the client in the appropriate position, depending on the power of breathing, and the type of surgery.
5. Observations refund function of respiratory muscles.
6. Perform the movement as soon as possible on the client reactive.
7. Perform suction mucus if required.
8. Provide supplemental oxygen as needed.
9. Review the breathing pattern, frequency and depth and saturation after a given action for 15 minutes.
10. Collaboration for the provision of drugs to stimulate the movement of the respiratory muscles.
11. Collaboration for the provision of respiratory assistive devices when needed.

2. Disturbed Thought Processes / Sensory Perception related to the effects of anesthesia, excessive sensory stimuli, physiological stress.

Characterized by:

• Disorientation to person, place time.
• Changes in response to stimulation.
• Failure of motor coordination.

Goal: Change in level of consciousness

Outcomes:

• Clients can be oriented to person, place and time.
• Clients can recognize limitations and seek sources of assistance as needed.

Interventions:

1. Orient the continuous back after being out of the influence of anesthesia; stated that the operation had been completed.
2. Talk to the client with a clear and normal voice without snapping, are fully aware of what was said. Minimize negative discussion within earshot of the client. Explain the procedure to be performed even if the client is not aware.
3. Evaluation of sensation / movement of the extremities and the corresponding trachea.
4. Use the pads on the edge of the bed, do binding if necessary.
5. Maintain a calm and comfortable environment.
6. Review the return of sensory ability and thought process before removal.

3. Acute pain related to disorders of the skin, tissue, and muscle integrity, musculoskeletal trauma, or the emergence of drainage channels.

Characterized by:

• Clients reported pain.
• Changes in muscle tone.
• Distraction / guarding behavior is active.

Goal: The client revealed that the pain has been reduced / lost.

Outcomes:

• Clients seemed to relax.
• Clients do not shout.

Interventions:

1. Review the intraoperative process; sizes, / location of the incision, changing channels, a substance used anesthetic agents.
2. Evaluation of pain on a regular basis.
3. Assess vital signs, note tachycardia, hypertension, and increased breathing, even if the client denies the existence of pain.
4. Assess other possible inconveniences besides surgery procedures.
5. Assess characteristics of pain.
6. Encourage use of relaxation techniques, deep breathing exercises.
7. Collaboration of analgesics.

5. Risk for fluid volume deficit related to loss of body fluids is not abnormal, changes in blood clotting ability.

Goal: Lack of fluid volume did not happen.

Outcomes:

• Vital signs are stable.
• Strong pulse palpation.
• Normal skin turgor.
• Mucous membranes moist.
• Appropriate expenditure of individual urine.

Interventions:

• Assess and record income and expenditure, and a review of the operation of intra records.
• Assess vital signs and peripheral circulation.
• Assess the appearance of nausea / vomiting, the patient's history.
• Assess the wound and bandage for signs of bleeding.
• Assess skin temperature and palpation of peripheral pulses.
• Collaboration for the administration of parenteral fluids, blood or plasma expanders as needed.
• Collaboration of antiemetics.
• Collaboration laboratory examination immediately post-surgery and compared with preoperatively.

Nursing Care Plan for Intraoperative Patient

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Nursing Care Plan for Intraoperative Patient

Intraoperative phase started since the patient was transferred to the operating room and ends when the client was transferred to the recovery room. In this phase the scope of nursing activity is the maintenance of patient safety, monitoring of physiological and psychological support, in this phase of nurses also perform the function as "scrub nurse" and "circulating nurse".

Activity in the operating room, focused on patients undergoing surgical procedures, attention focused on the psychological and physiological reactions of the patient. Because surgery is usually a stressful experience, patients need to feel safe, knowing that there are people who give protection (to act as an advocate) during the procedure and when patients in anesthesia, the patient will feel calm and comfortable.

Intraoperative nurse responsible for the safety and well-being of the patient, the operating room personnel coordination, and implementation of the scrub nurse and activity settings during surgery. Another role of nurses in the operating room is the first assistant nurse has received registration and practice remain under the direct supervision of the surgeon. The responsibility of the nurse assistants include tissue handling, providing exposure to the area of ​​operations, the use of instruments, sutures and providing hemostasis.

Assessment

1. Examination of data completeness operating procedures:

• Assessing the approval of medical action is correct, signed by the patient or the person most responsible.
• Completeness results of diagnostic examination and consultation.
• Completeness of records medical history and physical examination.
• Completeness history and health assessment.
• Preoperative check list.

2. Physical and psychological examination

• Make sure the patient's identity: name, age, gender, medical record number, name of person in charge of the patient.
• Physiological status (level: healthy - sick)
• Psychosocial status (expression of concern, level of anxiety, verbal communication problems, coping mechanisms).
• Physical status (where the surgery, tumor or pain conditions, skin conditions and effectiveness of preparation, shearing, state of the joints).

4 Nursing Diagnosis and Interventions for Postoperative Patient

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Risk for Disturbed Body Image - NCP for Endometriosis

Nursing Care Plan for Endometriosis

Endometriosis is a condition that is reflected by the presence and growth of endometrial tissue outside the uterus. The endometrial tissue can grow on the ovaries, fallopian tubes, uterine ligaments forming, or it could be grown in the appendix, colon, ureter and pelvis. (Scott, James R, et al. 2002).

Endometriosis is the presence of endometrial tissue outside the uterine cavity. If there is endometrial tissue within the myometrium is called adenomyosis (internal adenometriosis) whereas when outside of the uterus is called (external endometriorisis).

Endometriosis for about the last 30 years show an increasing incidence. The incidence of between 5-15% can be found among all pelvic surgery. What is interesting is that it is slightly more common in women who are not married at a young age, and did not have many children.

In the United States, endometriosis occurs in 7-10% of the population, usually affects women of childbearing age. The prevalence of endometriosis in infertile women amounted to 20-50% and 80% in women with pelvic pain. There is a family connection, where the risk increased 10-fold in women with first degree relatives who suffer from this disease.

Etiology of endometriosis is not known but there are several theories that have been advanced:

• In congenital existing endometrial cells outside the uterus.
• Displacement of endometrial cells through blood circulation or lymph circulation.
• Menstrual reflux containing endometrial cells into the fallopian tubes, up to the pelvic cavity.
• Hereditary because the incidence is higher in women whose mothers also have endometriosis. (Mary Baradero et al, 2005).

In general, women with endometriosis have no symptoms. Symptoms generally occur when menstruation and intensified every year because of an enlarged area of endometriosis. The most common symptoms are pelvic pain, dysmenorrhea (painful when menstruation), dyspareunia (pain during intercourse), and infertility (impaired fertility, can not have children).

Signs and symptoms of endometriosis include:

1. Pain

• Secondary dysmenorrhea
• Primary dysmenorrhea is bad
• Dyspareunia: Painful ovulation
• Pelvic pain was severe and diffuse pain in the thigh, and pain in the lower abdomen during the menstrual cycle.
• Pain due to physical exercise or during and after sexual intercourse.
• Pain at the time of the examination by the doctor.

2. Abnormal bleeding

• Hypermenorrhea
• Menorrhagia
• Spotting before menstruation
• Menstrual blood is so dark that out before menstruation or at the end of menstruation.
• Complaints defecation and urination.
• Pain before, during and after defecation
• Blood in the stool
• Diarrhea, constipation and colic. (Scott, James R, et al., 2002.)

Nursing Diagnosis : Risk for Disturbed Body Image related to menstrual disorders

Goal: increase client self-image.

Outcomes:

• Clients say do not be ashamed, feel useful, neat appearance of the client, to accept what was happening.

Interventions :

1. Construct a trusting relationship with the client.
R/: Clients can easily express the problem only to those who believe.

2. Encourage clients to express feelings , thoughts , and views about themselves.
R/: Improving the client's self- awareness , and assist nurses in making the settlement.

3. Discuss with the client about the need for support systems deliver value and meaning for their clients.
R/: Submission of the meaning and value of the client's support system makes the client feel welcome.

4. Find the strength and resources that exist on the client and carrying strength as positive aspects.
R/: Identify client strengths can help clients focus on the positive characteristics that support the overall concept of self.

5. Involve the client in any activity in the group.
R/: Allows receiving social and intellectual stimulus which can increase the client's self- concept.

6. Inform and discuss honestly and openly about treatment options such as menstrual disorders clinic to womanhood, obstetrician.
R/: Honest and open to control the feelings of the client and the information provided to make clients look for the handling of his problems.

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Therapeutic Activity Group - Perception / Cognitive: Low Self-Esteem

Self-Concept Disturbances: Low Self-Esteem

Self-Concept, including the individual's perception of the nature of ability, interaction with others and the environment, values ​​and experiences related to the object, purpose and desire (Stuart and Sundeen in Keliat, 1992).

Self-esteem is a respectable value or respect of a person against themselves. It becomes a valuable measure that they have something in the form of ability and should be considered (Townsend, 2005).

Low self esteem is a self-resisted as something precious and can not be responsible for his own life (Yoedhas, 2010).

Low self esteem is a self-evaluation and sense of self or self-capabilities that can negatively directly or indirectly expressed (Townsend, 1998).

Chronic low self esteem is a maladaptive state of self-concept, in which sense of self or negative self-evaluation and maintained for a long time. Included in this low self esteem and a negative self-evaluation associated with feelings of weakness, not helped, there is no hope, fear, feeling sad, sensitive, not perfect, guilt and inadequate. Chronic low self-esteem is also a major component of depression as indicated by the behavior of the prisoner and have no taste (Stuart & Laraia, 2005).

Several studies have shown that depression is caused by low self-esteem, one of which has the result of 15,600 students in American schools, the level of 6 to 10 show the resulting low self esteem due to frequent intimidation / bullying resulting in undue risk of depression in adulthood (Kendree, 2001 ).

Other causes of low self-esteem issues are also expected as a result of past unpleasant, such as drug involved. Based on the results of the overview stated that drug addicts usually have a negative self-concept and low self-esteem. Stunted emotional development, characterized by an inability to express emotions appropriately, anxious, passive aggressive and tend to be depressed. (Shives, 1998).

Nursing therapy that can be given to the client itself can be in the form of cognitive therapy. This therapy aims to change negative thoughts experienced by clients with chronic low self esteem towards positive thinking. In family therapy may be necessary terapy triangle that aims to help families in expressing feelings about the problems faced by members of the family so that the family is expected to maintain a situation that supports the function returns the client's life. At the community also needs to be done psychoeducation therapy that aims to improve public knowledge about the chronic problem of low self esteem, which is one part of the problem of mental illness in the community.



Implementation Process

1. Preparation

• Selecting the client in accordance with the indications, ie clients with impaired self-concept: low self esteem.
• Making a contract with the client.
• Preparing tools and meeting place.

2. Orientation

• Therapeutic Greetings: Greetings and therapist on the client, introduce the name and call the therapist (wearing nameplate), ask for the name and call all clients (give the nameplate).
• Evaluation / Validation: Asking the client's current feelings.
• Contract: The therapist explained the objectives of the activity are conversing about positive self, therapist explains the following rule: If there is clients who want to leave the group, must request permission from the therapist, activity 45 minutes long, each client following the activities from start to finish.

3. Stage of work

• Therapists introduced himself: full name and nickname and wear the nameplate.
• Therapists distribute paper and markers on the client.
• Therapists asks each client to write an unpleasant experience.
• Therapists praise for the role of the client.
• Therapists share the second paper.
• Therapists asks each client to write positive things about self-own: the capabilities, the usual activities at home and in hospital.
• Therapists asks the client read the positive things that have been written in turns until all the clients get to take turns.
• Therapists gave compliments to each role and the client.

4. Termination stage

• Evaluation: The therapist asks the client's feelings after attending the Therapeutic Activity Group. The therapist gave praise to the group.
• Follow-up: The therapist asks the client to write another positive thing that has not been written.
• The contract will come: Agree Therapeutic Activity Group that will come is to train yourself positive things that can be applied in the hospital and at home. Agreed on time and place.

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Disturbed Thought Processes and Disturbed Sensory Perception - NCP for Dementia

Definition of Dementia

Dementia is a decline in intellectual functioning which leads to loss of social independence. (William F. Ganong, 2010)

According to Grayson (2004) states that dementia is not just ordinary disease, but rather a collection of symptoms caused by multiple diseases or conditions resulting in changes in personality and behavior.


Etiology of Dementia

1. The main cause of dementia is Alzheimer's disease, the cause is not known for certain, but suspected Alzheimer's disease due to a genetic abnormality, or abnormalities of certain genes. In Alzheimer's disease, some parts of the brain decline, resulting in cell damage and reduced response to a chemical signal channel in the brain. Found in the brain of abnormal tissue (called senile plaques and tangled nerve fibers) and abnormal proteins, which can be seen at autopsy.
2. The second cause of dementia that is a stroke that row. Single stroke is small in size and cause mild weakness or weaknesses that arise slowly. This small strokes gradually cause damage to brain tissue, brain regions that were damaged due to blockage of blood flow called infarction. Dementia caused by small strokes called multi - infarct dementia. Most sufferers have high blood pressure or diabetes, both of which cause damage to blood vessels in the brain.

Signs and Symptoms of Dementia 

1. Damage to the whole range of cognitive functions.
2. Originally impaired short-term memory.
3. Personality and behavioral disorders (mood swings).
4. Neurological deficits and focal.
5. Irritability, hostility, agitation and seizures.
6. Psychotic Disorders : hallucinations, illusions, delusions and paranoia.
7. Limitations in ADL (Activities of Daily Living)
8. Regulate the use of financial difficulties.
9. Can not go home when traveling.
10. Forgot to put the important stuff.
11. Difficult bathing, eating, dressing and toileting.
12. Easy drop and poor balance.
13. Unable to eat and swallow.
14. Urinary incontinence.
15. Can run away from home and can not go home.
16. Decline in memory that continues to happen. In patients with dementia, "forget" become a part of daily life that can not be separated.
17. Impaired orientation of time and place, for example: forget the day, week, month, year, where people with dementia.
18. The decline and inability to arrange words into correct sentences, using words that are not appropriate for a condition, repeat the word or the same story many times
19. Excessive expression, for example, excessive crying when she saw a television drama, furious at small mistakes committed by others, fear and nervousness unwarranted. People with dementia often do not understand why these feelings arise.
20. The change of behavior, such as : indifferent, withdrawn and anxiety.

Nursing Diagnosis for Dementia

Disturbed Thought Processes

related to physiological changes (degeneration of neurons reversible)

characterized by:

• loss of memory,
• loss of concentration,
• not able to interpret the stimulation and assess reality accurately.

Goal: The client is able to recognize a change in thinking.

Outcomes:

• Able to demonstrate the cognitive ability to undergo the consequences of stressful events on the emotions and thoughts of self-own.
• Able to develop strategies to overcome negative self-perception.
• Able to recognize the behavior and the causes.

Interventions:

1. Develop a supportive environment and nurse-client relationship is therapeutic.
2. Maintain a pleasant and quiet environment.
3. Face-to-face when talking to clients.
4. Call client by name.
5. Use a rather low voice and speak slowly to the client.

Rational:

1. Reduce anxiety and emotional.
2. Excessive noise is a sensory neuron disorders that increase.
3. Raises concern, especially in clients with perceptual disorders.
4. The name is a form of self-identity and lead to the introduction of the reality and the client.
5. Improve understanding. Speech high and hard, stressful sparking angry confrontation and response.

Disturbed Sensory Perception

related to changes in perception, transmission or sensory integration (neurological disease, unable to communicate, sleep disorders, pain)

characterized by:

• anxiety,
• apathy,
• restless,
• hallucinations.

Goal: changes in sensory perception of the client can be reduced or controlled.

Outcomes:

• Decrease hallucinations.
• Developing strategies to reduce psychosocial stress.
• Demonstrate appropriate response stimulation.

Interventions :

1. Develop a supportive environment and nurse-client relationship is therapeutic.
2. Help clients to understand hallucinations.
3. Assess the degree of sensory or perceptual disorder and how it affects the client, including a decrease in vision or hearing.
4. Teach strategies to reduce stress.
5. Take a simple picnic, a walk around the hospital. Monitor activity.

Rational:

1. Improve comfort and reduce anxiety on the client.
2. Improving coping and decrease hallucinations.
3. Involvement of the brain showed asymmetric problem causing the client to lose the ability on one side of the body.
4. To decrease the need for hallucinations.
5. Picnic shows reality and provide sensory stimulation that decreases feelings of suspicion and hallucinations caused by feeling constrained.

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