Disturbed Sleep Pattern, Knowledge Deficit and Anxiety - NCP Nasopharyngeal Carcinoma

Nursing Care Plan for Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma is a malignant tumor derived from epithelial nasopharyngeal mucosa or glands found in the nasopharynx.

Nasopharyngeal carcinoma is the most carcinomas in the ENT.

It was found more in men than in women, with a ratio of 3: 1 by age / average age of 30 -50 years.


1. Nursing Diagnosis for Nasopharyngeal Carcinoma : Disturbed Sleep Pattern related to pain in the head.

Goal: Impaired sleep pattern of patients will be resolved.

Outcomes :

• Patients easily sleep within 30-40 minutes.
• Patients calm and fresh faces.
• Patients can express rested.

Interventions:
1 Create a comfortable and quiet environment.
Rationale: A comfortable environment can help improve sleep / rest.

2 Assess the patient's sleep habits at home.
Rationale: Knowing the change of the things that a patient when sleeping habits will affect the patient's sleep patterns.

3 Assess the causes of sleep disorders such as anxiety, effects of drugs and bustling atmosphere.
Rationale: Knowing the causes of other sleep disorders experienced and perceived patient.

4 Instruct the patient to use at bedtime and relaxation techniques.
Rational: Introduction to sleep will allow the patient to fall into sleep, relaxation techniques will reduce tension and pain.

5. Assess for signs of lack of sleep to meet the needs of patients.
Rationale: To determine whether requirements are met or the patient's sleep due to disruption of sleep patterns so that appropriate action can be taken.




2. Nursing Diagnosis for Nasopharyngeal Carcinoma : Knowledge Deficit: about the disease process, diet, care and treatment related to a lack of information.

Goal: Patient obtaining clear and correct information about the disease.

Outcomes :

• Patients learn about the disease process, diet, care and treatment and able to explain again if asked.
• Patients can perform self-care based on the knowledge gained.

Interventions:
1 Assess the level of knowledge of the patient / family about diabetes disease and Nasopharyngeal Cancer.
Rationale: To provide information on the patient / family, nurses need to know the extent to which the information or knowledge that is known to the patient / family.

2 Assess the patient's educational background.
Rationale: In order for nurses to provide explanations using words and sentences that can be understood according to the level of patient education patient.

3 Explain the disease process, diet, care and treatment in patients with language and words are easy to understand.
Rationale: In order for the information can be received easily and precisely so as to avoid misunderstandings.

4 Describe the procedure performed, the benefits to the patient and involve the patient.
Rationale: With explanatory and there and participate directly in the action taken, the patient will be more cooperative and less anxiety.

5 Use the images to provide an explanation (if there is / enable).
Rational: The pictures can help recall the explanation that has been given.



3. Nursing Diagnosis for Nasopharyngeal Carcinoma : Anxiety related to lack of knowledge about the disease.

Goal: anxiety is reduced / lost.

Outcomes :

• Patients can identify the cause of anxiety.
• Volatile emotions, calm the patient.
• Adequate rest.

Interventions:
1 Assess the level of anxiety experienced by the patient.
Rationale: To determine the level of anxiety experienced by patients so that nurses could provide rapid and appropriate intervention.

2 Give the opportunity for patients to express a sense of anxiety.
Rational: It can lighten the burden of the patient's mind.

3 Use therapeutic communication.
Rationale: To be built up trust between the nurse-patient so that the patient cooperative in nursing actions.

4 Give accurate information about the disease and encourage patients to participate in the act of nursing.
Rationale: Accurate information about the disease and the patient's participation in taking action to reduce the burden of the patient's mind.

5. Give confidence to patients that nurses, physicians, and other health team always strive to provide the best relief and optimal as possible.
Rationale: A positive attitude of the health care team will help reduce the anxiety felt by the patient.

6 Provide opportunities for families to accompany the patient in turn.
Rationale: The patient will feel calmer when there are family members who wait.

7 Create a quiet and comfortable environment.
Rationale: a quiet and comfortable environment can help reduce patient anxiety.

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Nursing Diagnosis : Impaired Physical Mobility, Anxiety and Knowledge Deficit

Nursing Care Plan for Guillain-Barre Syndrome


1. Impaired Physical Mobility related to neuromuscular damage.

Goal / Outcomes:
Maintain body function with no complications (contractures, pressure sores).

Nursing Intervention :

Independent

1. Assess the strength of the motor / functional abilities using a scale of 0-5.
R /: Specifies the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.

2. Provide patient positioning lead to a sense of comfort.
R /: Reduce fatigue, enhance relaxation, reduce the risk of ischemia / damage to the skin.

3. Chock extremities and joints with pillows.
R /: Maintaining the limb in a position fisilogis, prevent contractures and loss of joint function.

4. Perform passive range of motion exercises.
R /: Stimulates circulation, improve muscle tone and increase joint mobilization.

Collaboration

5. Confirm with / refer to the physical therapy / occupational therapy.



2. Anxiety related to situational crisis.

Goal / Outcomes:
Appear relaxed and report anxiety is reduced to the level can be overcome.

Nursing Interventions:

Independent

1. Place the patient near the nurses' station, check the patient regularly.
R /: To provide assurance that immediate assistance can be done if the patient suddenly becomes not have the ability.

2. Provide primary care / nurse relationships are consistent.
R /: Improve mutual trust of patients and help to reduce anxiety.

3. Provide alternative forms of communication if necessary.
R /: Reduce feelings of helplessness and feelings of isolation.

4. Discuss the change in self-image, fear of losing the ability to settle, loss of function, death, problems regarding the need penyebuhan / repair.

Collaboration

5. Provide a brief description of the treatment, the patient's treatment plan, including the closest.
R. /: A good understanding can increase the need for patient cooperation activities and the involvement of patients and also the closest in care planning will be able to maintain some sense of control over themselves for life which will further enhance the self-esteem.



3. Knowledge Deficit related to less remembering, cognitive limitations.

Goal / Outcomes:
Patients know and understand about the disease.

Nursing Interventions:

Independent
1. Determine the patient's knowledge and ability to participate in the rehabilitation process.
R /: Influencing choice of interventions that will be done.

2. Review the patient's knowledge about the disease and its prognosis.
R /: The knowledge base is an important thing to make informed choices and participate in rehabilitation efforts.

3. Suggest to reveal what is in the natural, social, and increase independence.
R /: Increasing returns to normal and the development of his feelings on the situation.

4. Identify safety measures to find defeswit sensory-motor individually.
R /: Reduce the risk of injury / lower the actual risk of complications can still be prevented.

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Imbalanced Nutrition and Knowledge Deficit related to Bladder Cancer

Neoplasm is an abnormal collection of cells formed by cells that grow continuously on a limited basis, is not coordinated with the surrounding tissue and are not useful for the body.

Cancer is a general term used to describe cellular growth disorder and is a group of diseases and not just a single disease.

Cancer is a general term that includes any malignant growth in any part of the body. This growth was not intended, parasitic and developing at the expense of a man who became the host.

Bladder cancer is a malignant tumor that is found in the bladder (nurse87, 2009)

Symptoms can include:

• Hematuria (blood in the urine).
• Burning or pain when urinating.
• Urge to urinate.
• Frequent urination, especially at night and on the next phase of difficult urination.
• Body felt hot and weak.
• Low back pain due to nerve compression.
• Pain on one side because hydronefrosis.

1. Imbalanced Nutrition: Less Than Body Requirements
related to:

• hyper-metabolic-related cancer, the consequences of chemotherapy, radiation, surgery (anorexia, gastric irritation, lack of sense of taste, nausea), emotional distress, fatigue, inability to control pain

characterized by:

• inadequate intake,
• loss of sense of taste,
• loss of appetite,
• weight down to 20% or more below the ideal,
• decreased muscle mass and subcutaneous fat,
• constipation,
• abdominal cramping.

Goal:

• Showed a stable weight, normal laboratory results and no sign of malnutrition.
• Stated understanding of the need for adequate intake.
• Participate in the management of diet-related illness.

Interventions :

• Monitor food intake every day, whether eating in accordance with the needs of the client.
• Measure weight, triceps size and observed weight loss.
• Assess pale, slow wound healing and parotid gland enlargement.
• Encourage clients to consume high-calorie foods with adequate fluid intake. Instruct too little food to clients.
• Control of environmental factors such as foul odors or noise. Avoid foods that are too sweet, fatty and spicy.
• Create a pleasant dining atmosphere for example, a meal with friends or family.
• Encourage relaxation techniques, visualization, moderate exercise before eating.
• Encourage open communication about anorexia problems experienced by clients.

Collaboration:

• Observe laboratory studies such as total lymphocytes, serum transferrin and albumin.
• Give treatment as indicated.
• Attach a nasogastric tube for enteral feeding, balanced with infusion.

Rational:

• Provide information about nutritional status.
• Provides information about the addition and weight loss.
• Showed very poor nutritional state.
• Calories are energy sources.
• Prevent nausea and vomiting, excessive distension, dyspepsia which causes a decrease in appetite and reduce harmful stimulus which can increase anxiety.
• In order for the client to feel like being at home alone.
• To induce a feeling of wanting to eat / arouse appetite.
• In order to overcome together (with a dietitian, nurse and client).
• To determine / establish the occurrence of nutritional deficiencies as a result of the course of disease, treatment and care of the client.
• Facilitate the intake of food and beverages with maximum results and right as needed.

2. Knowledge Deficit about the disease, prognosis and treatment
related to:

• lack of information,
• misinterpretation,
• cognitive limitations.

characterized by:

• often asked,
• stating the problem,
• statement misconceptions, is not accurate in mengikiuti instruction / prevention of complications.

Goal:

• Can accurately say about diagnosis and treatment at the level of proximity ready.
• Following the procedure well and explain the reasons to follow those procedures.
• Having the initiative of changing lifestyles and participate in treatment.
• In cooperation with the furnisher.

Interventions:

• Review understanding of the client and family about the diagnosis, treatment and consequences.
• Determine the client's perception about cancer and its treatment, tell the client about the experience of other clients who have cancer.
• Give accurate and factual information. Answer the questions specifically, avoid unnecessary information.
• Provide guidance to client / family before following the treatment procedure, the old therapy, complications. Be honest with the client.
• Encourage clients to provide verbal feedback and correct misconceptions about the disease.
• Review client / family about the importance of optimal nutrition status.
• Encourage clients to assess the oral mucous membranes regularly, note the presence of erythema, ulceration.
• Encourage clients to maintain the cleanliness of the skin and hair.

Rational:

• Avoid duplication and repetition of the client's knowledge.
• Lets do justification to errors as well as errors of perception and conception of understanding.
• Assist the client in understanding the disease process.
• Assist clients and families in making treatment decisions.
• Knowing the extent of understanding the client and client's family about the disease.
• Increasing knowledge of the client and family regarding adequate nutrition.
• Reviewing the development of the processes of healing and signs of infection and problems with oral health can affect the intake of food and beverages.
• Improving the integrity of the skin and head.

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Epilepsy - 3 Nursing Diagnosis and Interventions

Epilepsy is a symptom or manifestation of excessive loss of electrical charge in neuronal cells of the central nervous which can cause loss of awareness, involuntary movements, abnormal sensory phenomena, the increase in autonomic activity and a variety of physical disorders (Doenges, 2000).

Signs and symptoms of Epilepsy

1. Generalized seizures

• Tonic: muscle contraction, leg and elbow lasts approximately 20 seconds, with marked neck and back arched, screams epilepsy for about 60 seconds.
• Clonic seizures: intermittent flexion spasm, relaxation, hypertension lasted approximately 40 seconds, with a marked mydriasis, tachycardia, hyperhidrosis, hypersalivation.
• Post-attack: halt muscle activity is characterized by the patient regained consciousness, muscle aches and headaches, sufferers fall asleep 1 to 2 hours.

2. Partial seizures

• There are simple with no disturbance of consciousness
• Complex with disorders of consciousness.

Epilepsy - 3 Nursing Diagnosis and Interventions

Nursing Diagnosis I : Risk for Injury 

related to a change of consciousness, weakness, loss of large and small muscle coordination.

1). Assess the originator of the emergence of seizures in patients.
The goal: a controlled seizure.
Rational: alcohol, various medications, and other stimulation (lack of sleep, bright lights, watching television too long), can enhance brain activity which further increases the risk of seizures.

2). Maintain a soft cushion on the bed barrier attached with a low bed position.
Rationale: reducing trauma during seizures.

3). Supervise activities of clients after the seizure occurred.
Rationale: improving patient safety.

4). Record the patient's type of seizure activity such as location, duration, motor, loss of consciousness, incontinence.
Rationale: helps to localize the brain regions affected.


Nursing Diagnosis II : Low Self - Esteem, self-identity is not related to perception of control,
characterized by : fear, and less cooperative medical treatment.

1). Assess the patient's feelings regarding diagnostic, self-perception of the treatment performed on the patient.
Rational : the reaction is between the individual and knowledge is the beginning of the acceptance of the client's medical treatment.

2). Identify and anticipate possible reactions of others to the disease state.
Rationale : provide an opportunity to respond to the problem-solving process and provide control over the situation.

3). Assess the patient's response to the success obtained, or who will be achieved from its strengths.
Rational : focus on the positive aspects can help to eliminate the feelings of failure or awareness of self and patients receiving treatment.

4). Discuss referral to psychotherapy with patients or people nearby.
Rationale : seizures has a profound influence on a person's self esteem and the patient, significant others, probably due to the emergence of stigma from society.


Nursing Diagnosis III : Knowledge Deficit (learning needs), and rules regarding the treatment of conditions related to lack of understanding, misinterpretation of information, lack of recall.

1). Assess the patient's level of knowledge of the type of illness
Rational : to know the extent of the client's ability to understand the type of illness will be more cooperative client understanding the importance of prevention, treatment and so on.

2). Explain again about the pathophysiology or disease prognosis, treatment, and management in the long run according to the procedure.
Rationale : provide an opportunity to clarify misperceptions and the state of the illness.

3). Review the medication, dosage, instructions, and discontinuation of medication as instructed doctors.
Rational : will add to the understanding of the client's health condition suffered.

4). Discuss the benefits of good general health, such as adequate diet, adequate rest, and exercise and moderate exercise regularly, and avoid foods adan beverages containing harmful substances.

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