NCP for Vomiting - 6 Nursing Diagnosis and Interventions

Nursing Care Plan for Vomiting

Definition

Vomiting is a complex reflex that is mediated by the vomiting center in the medulla oblongata of the brain.

Vomiting is spending gastric contents exclusively through the mouth with the help of contraction of the abdominal muscles. Necessary to distinguish between regurgitation, rumination, or gastroesophageal reflux.
Regurgitation is the food that was issued back-to-mouth due to esophageal peristaltic movement.
Rumination is perpetually conscious of food expenditure to be chewed and then swallowed back.
Gastroesophageal reflux is the return of stomach contents into the esophagus in a passive way that can be caused by hypotonia spingter lower esophagus, abnormal position of the esophagus connection with cardiac or slow emptying of the stomach contents.


Etiology

Discussion of the etiology of vomiting in infants and children by age is as follows:

Age: 0-2 months:

1. Allergic Colitis
Allergy to cow's milk or formula with a soy-based ingredients. Usually followed by diarrhea, rectal bleeding, and cranky.
2. Anatomic abnormalities of the gastrointestinal tract
Congenital anomalies, including stenosis or atresia. Manifestations of food intolerance in the first few days of life.
3. Esophageal Reflux
Regurgitation often occur immediately after feeding. Very often occur in neonates; Clinically important that this situation causes failure to thrive, apnea, or bronchospasm.
4. Increased intracranial pressure
Fussy or lethargy accompanied by abdominal distension, birth trauma and shaken baby syndrome.
5. Malrotation with volvulus
80% of these cases is found in the first month of life, mostly with biliary emesis.
6. Meconium ileus
Inspissated meconium in the distal colon; can be considered a diagnosis of cystic fibrosis.
7. Necrotizing enterocolitis
It often happens, especially in premature babies, especially if experiencing hypoxia at birth. Can be accompanied by irritability or fuss, abdominal distension and hematochezia.
8. Overfeeding
Regurgitation of milk that can not be digested, wet-burps often in infants with excess weight to excess breast milk given.
9. Stenosis pylorus
Peak at the age of 3-6 weeks of life. The ratio of men compared to women is 5: 1 and this situation often occurs in boys first. The clinical manifestations will progressively worsen, projectiles, and non biliary emesis.

Age: 2 months-5 years

1. Brain tumor
Think especially if it is found that the progressive headache, vomiting, ataxia, and no abdominal pain.
2. Diabetic ketoacidosis
Moderate to severe dehydration, a history of polydipsia, polyuria and polyphagia.
3. Corpus alienum
Associated with the incidence of recurrent choking, coughing occurs suddenly or saliva dripping.
4. gastroenteritis
Very often; often their history of contact with sick people, usually followed by diarrhea and fever.
5. Head trauma
Vomiting often or progressive signifies concussion or intracranial hemorrhage.
6. Incarcerated hernia
Onset of crying, anorexia and scrotal swelling that occurs suddenly.
7. Intussusception
The peak occurs at 6-18 months of life; patients rarely experience diarrhea or fever than children who are suffering from gastroenteritis.
8. Posttusive
Often, children will vomit after coughing or coughing repeatedly imposed.
9. pyelonephritis
High fever, looked ill, dysuria or polacisuria. Patients may have a history of urinary tract infections earlier.

Age: 6 years and older

1. Adhesion
Especially after abdominal surgery or peritonitis.
2. Appendicitis
Clinical manifestations and location of pain varies. Symptoms often include increasing pain, radiating to the right lower quadrant, vomiting preceded by pain, anorexia, fever subfebril, and constipation.
3. cholecystitis
More common in women, especially with hemolytic disease (eg, sickle cell anemia). Characterized by epigastric pain or right upper quadrant occurs suddenly after a meal.
4. Hepatitis
Mainly caused by a viral infection or drug-induced; the patient may have a history of bowel movements such as putty colored or tea-colored urine concentrated.
5. Inflammatory bowel disease
Associated with diarrhea, hematochezia, and abdominal pain. Stricture can cause obstruction.
6. Intoxication
More common in children who are learning to walk and adolescents. Suspected if a history of depression. Can also be accompanied by disturbances in mental status.
7. Migraine
Severe headache; often the presence of an aura before an attack such as scotoma. Patients may have a history of chronic headache or a family history of migraine.
8. Pancreatitis
Risk factors include upper abdominal trauma, history of previous infections or moderate infection, corticosteroid use, alcohol and cholelithiasis.
9. Peptic ulcer
In adolescents, the ratio of female: male = 4: 1. Chronic or recurrent epigastric pain, often worse at night time.


Complication

1. Metabolic Complications
Dehydration, metabolic alkalosis, electrolyte and acid-base disorders, depletion of potassium, sodium. Dehydration occurs as a result of fluid loss through vomiting or inputs that are less because of vomiting. Alkalosis as a result of the loss of stomach acid, it is exacerbated by the influx of hydrogen ions into the cell due to potassium deficiency and reduced extracellular sodium. Potassium can be lost along with the material vomit and out through the kidneys together bicarbonate. Sodium can be lost through vomiting and urine. In the state of severe alkalosis, the pH of urine can be 7 or 8, urine levels of sodium and potassium high despite the depletion of sodium and potassium.
2. Failure growth
Repeated vomiting and severe enough cause nutritional disorders due to intake be greatly reduced and when this happens long enough, there will be a failure of growth and development.
3. Aspiration of gastric contents
Material aspiration of vomit can cause asphyxia. Recurrent episodes of mild aspiration cause recurrent respiratory tract infections. This occurs as a consequence of GERD.
4. Mallory Weiss syndrome
A linear laceration on the border of the esophagus and gastric mucosa. Usually occurs in severe vomiting lasts longer. On endoscopic examination found redness of the lower esophageal mucosa LES area. In a short time will heal. When anemia occurs because of heavy bleeding need blood transfusions.
5. Peptic esophagitis
Due to prolonged reflux in chronic vomiting cause mucosal irritation of the esophagus by stomach acid.


Nursing diagnoses that may arise

Fluid volume deficit related to loss of active liquid.
Imbalanced Nutrition: less than body requirements related to absorption disorders.
Nausea related to gastric irritation.
Ineffective tissue perfusion related to hypovolemia.
Risk for Impaired skin integrity related to disruption of metabolic status.
Anxiety related to changes in health status.


Nursing Care Plan for Vomiting

Nursing Diagnosis 1. Fluid volume deficit related to loss of active liquid.
Goal: fluid and electrolyte deficit is resolved.
Expected outcomes:
signs of dehydration: none,
mucosa of the mouth and lips moist, fluid balance.

Intervention:

• Observation of vital signs.
• Observation for signs of dehydration.
• Measure the input and output of fluid (fluid balance).
• Provide and encourage the family to drink a lot more than 2000 - 2500 cc per day.
• Collaboration with physicians in fluid therapy, laboratory tests electrolyte.
• Collaboration with a team of nutrition in low-sodium fluid administration.

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

Goal: nutrients are met.

Intervention:
1. Assess the extent to which the inadequate nutrition clients.
Rational: analyze the causes implement interventions.
2. Estimate / calculate the calorie intake, keep the comments about the appetite to a minimum.
Rationale: Identifying deficiencies / nutritional needs to focus on the problem and create a negative atmosphere affects the input.
3. Measure the weight as indicated.
Rational: Overseeing the effectiveness in diet.
4. Give eat little but often.
Rational: Do not let boredom and nutrient intake can be increased.
5. Encourage oral hygiene before eating.
Rationale: The mouth of the net increase appetite.
6. Offer a drink.
Rationale: It can reduce nausea and relieve gas.
7. consul of a / dislike of patients who cause distress.
Rational: Involve patients in planning, enables patients to have a sense of control and the drive to eat.
8. Provide a varied diet.
Rationale: The food was varied client can increase appetite.

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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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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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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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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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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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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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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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5 Diagnosis - NCP for Corneal Ulcer

Nursing Care Plan for Corneal Ulcer

Definition

Ulcerative keratitis better known as corneal ulceration, namely the presence of destruction (damage) on the corneal epithelium. (Darling, Vera H, 2000, p 112)


Causes

The reasons include:

• Abnormalities of the eyelashes (trichiasis) and systems tears (tears insufficiency, lacrimal duct blockage), and so on.
• External factors, namely: wounds in the cornea (corneal erosio), due to trauma, contact lens use, burns on the face.
• Corneal abnormalities caused by: chronic corneal edema, keratitis-exposure (on lagophtalmus, general anesthesia, coma); keratitis due to vitamin A deficiency, neuroparalytic keratitis, superficial keratitis virus.
• Systemic disorders; malnutrition, alcoholism, Stevens-Jhonson, acquired immune deficiency syndrome.
• Drugs that lower the immune mekaniseme, eg corticosteroids, IUD, local anesthetics and immunosuppressive group.

In etiologic corneal ulcers can be caused by:

• Bacteria: Germs that can cause corneal ulcers pure is streptokok pneumoniae, whereas other bacterial corneal ulcers caused by trigger factors above.
• Viruses: herpes simplex, zooster, vaccinia, variola.
• Fungi: Candida group, Fusarium, Aspergillus, Cephalosporium.
• Hipersensifitas reaction: The reaction to staphylococcus (marginal ulcers), tuberculosis (keratoconjunctivitis flikten), unknown allergens (ulcers ring). (Sidarta Ilyas, 1998, 57-60)

Pathophysiology

1. Progressive : In the process of progressive corneal be terihat, infiltration of leukocytes and lymphocytes cells that eat bacteria or necrotic tissue is formed.
2. Regressive
3. Establish scarring : In the formation of scar tissue there will be epithelial, new collagen tissue and fibroblasts.

Severity of illness was also determined by the physical state of the patient, a large inoculum and virulence.
Clinical symptoms:

1. Red eyes.
2. Mild to severe eye pain.
3. Photophobia.
4. Decreased vision.
5. White opacities in the cornea.

Symptoms that may accompany is the presence of corneal thinning, Descemet folds, corneal tissue reaction (due to interference iris vascularization), a flare, hypopyon, hyphema and posterior synechiae. In corneal ulcers caused by fungi and bacteria are surrounded PMN epithelial defect. When infections caused by viruses, will be seen surrounding hypersensitivity reaction. Usually gram-positive cocci, Staphylococcus aureus and Streptococcus pneumoniae would provide a limited picture of ulcer, round or oval, white gray suppurative ulcers in children. The area that is not exposed cornea will remain clear and no visible color inflammatory cell infiltration. If the peptic ulcer caused by Pseudomonas then be stretched quickly, green yellow purulent material seen attached to the surface of the ulcer.

When ulcers caused by fungi, it will infiltrate surrounded grayed infiltrates surrounding smooth (satellite phenomenon). When the dendrite-shaped ulcer there will be hypesthesia of the cornea. Ulcers can form a fast running descemetocele or corneal perforation which ended by making a form adherent leucoma. When the process of the ulcer is reduced it will show less pain, photophobia, reduced infiltration of ulcers and corneal epithelial defects become increasingly small.


Signs and Symptoms

In ulcers that destroy membranes and stromal bowman, will lead to corneal cicatrix.
Subjective symptoms such as corneal ulcers symptoms of keratitis. Objective symptoms such as ciliary injection, and partial loss of corneal tissue infiltrates. In more severe cases may occur iritis accompanied by hypopyon.
Photophobia.
Pain and lacrimation.

(Darling, Vera H, 2000, p 112)


Diagnostic Examination:

1. Cards eye / Snellen telebinocular (test visual acuity and central vision)
2. Tomography measurements: assessing IOP, normal 15-20 mmHg.
3. Ophthalmoscopy examination.
4. Blood examination, LED.
5. EKG.
6. Glucose tolerance test.

Assessment

1. Activity / rest: activity changes.
2. Neurosensory: blurred vision, glare.
3. Pain: discomfort, pain sudden / severe persistent / pressure in and around eyes.
4. Security: fear, anxiety.

(Doenges, 2000)


Nursing Diagnosis and Interventions for Corneal Ulcer

1. Fear or anxiety related to sensory impairment and lack of understanding of post-operative care, drug delivery.

Intervention:

• Assess the degree and duration of visual disturbance.
• Orient the patient to the new environment.
• Describe the perioperative routine.
• Suggest to run the day-to-day living habits when able.
• Encourage participation of family or people who mean to patient care.

2. Acute pain related to trauma, increased IOP, surgical intervention or administration inflammatory eye drops

Intervention:

• Give medication to control pain and IOP as prescribed.
• Give cold compress on demand for blunt trauma.
• Reduce lighting levels.
• Encourage the use of sunglasses in strong light.

3. Risk for Self-Care Deficit related to impaired vision.

Intervention:

• Give instructions to the patient or the person nearest the signs and symptoms, complications should be immediately reported to the doctor.
• Give oral and written instructions for the patient and the person who means the right techniques in delivering drugs.
• Evaluation of the need for assistance after discharge.
• Teach the patient and family guide vision techniques.

4. Disturbed Sensory Perception: Visual related to impaired vision.

Goal: Patient is able to adapt to changes.

Outcomes:

• Patients receive and resolve in accordance with the limits of vision.
• Using existing vision or other senses adequately.

Iintervention:

• Introduce the patient to the environment.
• Tell patient to optimize other sensing devices that are not impaired.
• Visit frequently to determine the needs and eliminate anxiety.
• Involve people in the care and activities nearby.
• Reduce noise and provide a balanced break.

5. Knowledge Deficit related to lack of information about self-care and disease processes.

Goal: Patients have enough knowledge about the disease.

Outcomes:

• Patients understand medication instructions.
• Patients using verbal communication to express the symptoms to be reported.

Intervention:

• Tell the patient about the disease.
• Teach self-care during illness.
• Teach hatching procedure eyedrops and replacement bandage on the patient and family.
• Discuss the symptoms of the rise in IOP and visual impairment.

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5 Nursing Diagnosis with Interventions for Chronic Kidney Disease

Nursing Diagnosis for Chronic Kidney Disease

According to Doenges (1999) and Lynda Juall (2000), nursing diagnoses that appear in patients with CKD are:

1. Decreased Cardiac Output.
2. Fluid and Electrolyte imbalances.
3. Imbalanced Nutrition.
4. Ineffective Breathing Pattern.
5. Impaired Skin Integrity.

Nursing Interventions for Chronic Kidney Disease

Decreased Cardiac Output related to increased cardiac load.

Goal:

• Decreased cardiac output does not occur with the outcome criteria:
• maintain cardiac output and blood pressure with evidence of cardiac frequency in the normal range, strong peripheral pulses, and the same with capillary refill time.

intervention:
1 Auscultation of heart and lung sounds.
R: The presence of tachycardia, irregular heart rate.

2 Assess for hypertension.
R: Hypertension may occur due to interference with the system of the renin-angiotensin-aldosterone system (caused by renal dysfunction).

3 Investigate complaints of chest pain, note the location, radiation, severity (0-10 scale).
R: HT and CRF can cause pain.

4 Assess activity level, response to activity.
R: Fatigue can also accompany CRF anemia.



Fluid and Electrolyte imbalances related to secondary edema (fluid volume unbalanced because of the retention of Na and H2O).

Goal: Maintain ideal body weight without excess fluid with outcome criteria: no edema, the balance between inputs and outputs.

intervention:
1 Assess fluid status with daily weigh, balance input and output, skin turgor, vital signs.

2 Limit your fluid intake.
R: fluid restriction akn determine ideal body weight, urine output, and response to therapy.

3 Explain to the patient and family about the liquid restrictions.
R: Understanding to increase cooperation of patients and families in the fluid restriction.

d. Instruct the patient / teach the patient to record the use of fluid intake and output mainly.
R: To determine the balance of inputs and outputs.



Imbalanced Nutrition, Less Than Body Requirements related to anorexia, nausea, vomiting.
Goal: Maintain adequate nutrient inputs to the outcome criteria: demonstrate stable weight.

intervention:
1 Monitor the consumption of foods / liquids.
R: Identifying nutritional deficiencies.

2 Notice of nausea and vomiting.
R: Symptoms that accompany the accumulation of endogenous toxins that can alter or lower income and require intervention.

3 Give food a little but often.
R: The portion of a smaller can increase food intake.

4 Increase visits by people nearby during meals.
R: Provides transfer and improve the social aspects.

5. Provide frequent mouth care.
R: Lowering stomatitis oral discomfort and unwelcome taste in the mouth that can affect food intake.



Ineffective Breathing Pattern related to hyperventilation secondary: compensation via respiratory alkalosis.

Goal: breathing pattern back to normal / stable.

intervention:
1 Auscultation of breath sounds, note the presence of crakles.
R: To declare the existence of the collection of secretions.

2 Teach patient effective coughing and deep breathing.
R: Cleaning the airway and facilitate the flow O2.

3 Adjust the position as comfortable as possible.
R: Preventing the occurrence of shortness of breath.

4 Limit to move.
R: Reduce workload and prevent tightness or hypoxia.


Impaired Skin Integrity related to pruritis

Goal: The integrity of the skin can be maintained with the outcome criteria: Maintain intact skin, Shows behaviors / techniques to prevent damage to the skin.

intervention:
1 Inspection of the skin to change color, turgor, vascular, note the presence of redness.
R: Indicates area of ​​poor circulation or damage that may lead to the formation of pressure sores / infections.

2 Monitor fluid intake and hydration of the skin and mucous membranes.
R: Detecting the presence of dehydration or overhydration affecting circulation and tissue integrity.

3 Inspection of the area depends on edema
R: Tissue edema is more likely to be damaged / torn.

4 Change positions as often as possible.
R: Reduce pressure on edema, poorly perfused tissue to reduce ischemia.

5. Give skin care.
R: Reduce drying, skin tears.

6 Maintain a dry linen.
R: Lowering dermal irritation and the risk of skin damage.

7 Instruct the patient to use a damp and cold compresses to put pressure on the area pruritis.
R: Eliminate the discomfort and reduce the risk of injury.

8 Encourage wear loose cotton clothes.
R: Preventing direct dermal irritation and improve skin moisture evaporation.


Nursing Management for Chronic Kidney Disease

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3 Nursing Interventions for Spina Bifida

Spina bifida is an anomaly in the formation of the spine, which is a defect in the closure of the spinal canal. This usually occurs in the fourth week of the embryonic period. This closure is usually a disorder of the posterior spinous processes and laminae; very rarely defects occur in the anterior portion. There is largest at the lumbar spine or lumbosacral.

Spina bifida is a general term for NTD (Neural Tube Defects) that the spinal area. The disorder is a separation of arcus vertebrae and nerve tissue underneath may or may not. (T.W.Sadler, 2010)


Etiology

1. Genetic
2. Hyperthermia, lack of folic acid and hypervitaminosis A.
3. Happen again high risk in children of mothers who had given birth with Spina bifida abnormality (TWSadler, 2010)


Pathophysiology

Pathophysiology of spina bifida easily understood when linked to measures of normal development of the nervous system. At approximately 20 days of gestation determined pressure neural groove. Sightings in the dorsal ectoderm and embryonic. During pregnancy week 4 seemed to deepen the groove quickly, leaving the boundaries of growing to the side, then the axis behind the forming neural tube. Neural tube formation begins in the cervical region near the center of the embryo and advanced caudally and cephalically direction until the end of the 4th week of pregnancy, on the front and rear neuropores closed. The main damage to neural tube defects can be due to neural tube closure.

In pregnancy week 16 and 18 formed serum alpha fetoprotein (AFP) in pregnancy so that an increase in fluid cerebro spinal AFP. Such improvements may result in leakage of cerebro spinal fluid into the amniotic fluid, then the fluid mixes with amniotic fluid AFP forming alpha-1-globulin that affect the process of cell division to be imperfect. Hence the closure of the vertebral canal defect that causes incomplete congenital failure of fusion of the dorsal folds are common in neural tube defects and exophthalmos (John Rendle, 1994).

Clinical manifestations

1. Spina bifida occulta may be asymptomatic / relating to:
a. Hair growth along the spine
b. The bottom middle indentation, usually diarea lumbosacral
c. Abnormalities of gait / foot
d. Control / poor bladder

2. Meningocele may be asymptomatic / relating to:
a. Pouch-like protrusion of the meninges and css from the back
b. Club foot
c. Gait disturbance
d. Urinary Incontinence overdo

3. Myelomeningocele relates to:
a. Protrusion of the meninges, css and spinal cord
b. Neurological deficits as high and below the exposure


Nursing Interventions and Nursing Diagnosis for Spina Bifida


1. Urinary incontinence related to visceral paralysis

Expected outcomes / Goal:
expected: the client urination normal in number and frequency.

intervention:
a. Assess the level of incontinence and voiding patterns.
b. Provide care to the client's skin wet with urine (wipe warm water then wipe dry and give the powder).
c. Instruct the client's mother to check diapers often, if wet immediately replaced.
d. Collaboration with the medical team in giving drugs (eg anticholinergics).


2. Risk for injury related to spastic paralysis

Expected Outcomes / Goal:
expected: the patient's parents know about the things that lead to injury.

intervention:
a. Teach or suggest to parents to prevent children from dangerous objects that could cause injury.
b. Demonstrate to parents that some games do not cause injury.
c. Provide health education to parents regarding drugs or handling of the first case of injury in children.
d. Provide support to children in order not to feel inferior to his condition.


3. Impaired Physical Mobility r / t the motor paralysis

Objectives:
the client is able to carry out physical activity according to ability.

Outcomes: the client can participate in an exercise program, do not happen joint contractures, increased muscle strength. The client indicates action to improve mobility.

intervention:
a. Assess existing mobility and observation of an increase in damage. Assess motor function regularly.
b. Change the client's position every 2 hours.
c. Teach the client to perform active motion exercises of the extremities that are not sick.
d. Perform passive motion on the affected extremity.
e. Maintain a 90-degree joints of the foot board.
f. Inspection of the distal part of the skin every day. Monitor the skin and mucous membranes irritation, redness or blisters.
g. Help clients perform ROM exercises. Self-care as tolerated.
h. Collaboration with physiotherapist for physical exercise.

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Nursing Interventions for Intestinal Obstruction : Imbalanced Nutrition

Nursing Care Plan for Intestinal Obstruction

Nursing Diagnosis : Imbalanced Nutrition Less Than Body Requirements

Intestinal obstruction is an urgency in abdominal surgery is often encountered, is 60-70% of all cases of acute abdomen were not acute appendicitis.

The most common cause is the adhesion / streng, while it is known that abdominal surgery and obstetric-gynecologic surgery performed more frequently which is mainly supported by advances in the field of diagnostic abdominal abnormalities.


Imbalanced Nutrition Less Than Body Requirements related to impaired absorption

characterized by: abdominal pain, quickly full after eating.

Goal: balanced nutrition.

Outcomes:

• Stable weight.
• Return to normal bowel sounds: 6-12x/menit.
• Bloating and abdominal distension decreased.

Nursing Interventions:

1) Assess the nutritional needs of the client.
Rationale: By knowing the nutritional needs of the client can be observed the extent of the client's nutritional deficiencies and subsequent action.

2) Observation of signs of nutritional deficiencies.
Rationale: To determine the extent to which lack of nutrients due to excessive vomiting.

3) Encourage activity restrictions during the acute phase.
Rationale: Reduces the need to prevent a decrease in metabolic calorie and energy savings.

4) Evaluate periodically the condition of intestinal motility.
Rationale: As the basic data for the provision of nutrition.

5) If the obstruction is severe, avoid oral intake.
Rationale: if the obstruction is severe, oral intake can aggravate abdominal distension.

6) Give parenteral nutrition.
Rationale: parenteral nutrition does not cause abdominal distension.

7) Give food in small portions but often.
Rational: small amounts of food can reduce gastric compliance and reduce compliance and reduce labor intestinal peristalsis and facilitate intestinal absorption of food right.

8) Provide oral care.
Rationale: The flavors are delicious, the smell of the mouth can decrease appetite and stimulates nausea and vomiting.

9) Collaboration with a nutritionist about the types of nutrients that will be used by the patient.
Rationale: Nutritionists should be involved in determining the composition and the type of food that will be provided in accordance with individual needs.

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Hemorrhagic Stroke - 2 Nursing Diagnosis and Interventions

Nursing Care Plan for Hemorrhagic Stroke

Stroke is a neurological disease that is common and must be dealt with quickly and appropriately. Stroke is a brain dysfunction arising due to sudden occurrence of circulatory disorders of the brain and can happen to anyone and at anytime.

Stroke is the most common disease-causing defects such as limb paralysis, impaired speech, memory and thought processes forms other disability as a result of brain dysfunction.

Around the world, the incidence of stroke average of about 180 per 100,000 per year (0.2%) with a prevalence rate of 500-600 per 100,000 (0.5%).

In fact, many patients who came to the hospital in a state of decreased consciousness (coma). Such circumstances require special handling and care are: general, special, rehabilitation and discharge planning clients.

Knowing the circumstances mentioned above, the role of the nurse in collaboration with other health care team is needed both acute period, or thereafter. That can be implemented include overall health care, ranging promotive, preventive, curative to rehabilitation.


Hemorrhagic Stroke

Definition

Acute neurological dysfunction caused aleh as circulatory disorders of the brain, where it suddenly (several seconds) or quickly (a few hours) symptoms and signs corresponding to the focal area of disturbed tampered. (Djunaedi W, 1992).

According to Hudak and Gallo in the critical care book launch hemorrhagic CVA sudden onset and lasts 24 hours as a result of cerebrovascular desease.



Nursing Diagnosis for Hemorrhagic Stroke

1. Risk for Ineffective airway clearance related to the decline cough reflex.

Goal: not an interruption in airway clearance

Outcomes:
regular respiration, no stridor, Ronchi, whezing, RR: 16-20 x / min, no cough reflex.

Interventions:

1. Observe the speed, depth and breath sounds.
R /: respiratory rate indicates the body's attempt to meet the needs of O2.

2. Perform suction with extra caution when audible stridor.
R /: decreased cough reflex, causing bottlenecks spending secretions.

3. Maintain a half-sitting position, not pressed to one side.
R /: Ventilation easier when the position of the head in a neutral position, causing the emphasis to one point increase in ICT.

4. Perform chest physiotherapy.
R /: claping and vibrating cilia stimulates bronchial secretions to issue

5. Explain to the family about the change position every 2 hours.


2. Imbalanced Nutrition Less Than Body Requirements related to muscle weakness swallow.

Goal: Nutritional needs of clients are met.

Outcomes: either turgor, the intake can be entered in accordance
needs, there is the ability to swallow, the sonde is removed, increased weight 1kg.

Intervention:
1. Observations texture, skin turgor.
R /: to know the client's nutritional status.

2. Perform oral hygiene.
R /: oral hygiene stimulate appetite.

3. Observation intake out put.
R /: to know the client's nutritional balance.

4. Observation position and the success of the sonde
R / menghundari risk for infection / irritation

5. Collaboration:
- Provision of diet / sonde on schedule
R / help meet the nutritional needs of the client because the client swallow reflex decrease.

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Activity Intolerance and Impaired Verbal Communication NCP for Myasthenia Gravis

Myasthenia gravis is characterized by weakness and rapid fatigue of any muscle out of control. The cause of myasthenia gravis is a breakdown in the normal communication between nerves and muscles. Myasthenia gravis can affect people of any age, but it often occurs in women younger than 40 and in men more than 60 years.

Myasthenia gravis can affect any muscle, but the most commonly affected are the muscles that control eye movements, eyelids, chewing, swallowing, coughing and facial expressions. Shoulders, hips, neck, muscles that control body movement and muscle that helps breathing can also attacked.

Myasthenia Gravis Patients are usually not the same from one person to another person. Based on the data, the disease is still relatively rare because the lack of knowledge about the symptoms of the disease.

The symptoms that arise are the some of the weaker muscles. The muscles most frequently attacked are the muscles that control eye movements, eyelids, speech, swallowing, chewing, and more severe respiratory muscles are attacked.

In 90% of patients with Myasthenia Gravis initial symptoms appear is the ocular muscles that cause the decrease eyelids and double vision. Clearly visible physically. Obviously the symptoms will appear and spread further attack other muscles. Until a more severe attack the respiratory muscles are usually visible from weakening cough. In fact there is shortness of breath and can be fatal.


Nursing Diagnosis for Myastenia Gravis

Activity intolerance related to muscle weakness

Characterized by:
Subjective Data:

• Patients say tired after doing the activity.
• Patients report muscle weakness.

Objective Data:

• Patient seems tired and listless.
• Patient was not able to take action to meet their daily needs.
• Increased pulse.
• Increased blood pressure.
• Breathing increases.
• Decreased muscle strength.

Outcomes:

• Full muscle strength.
• Atrophy does not occur.
• Good muscle tone.
• Patients can perform the activity gradually.
• Muscle weakness does not occur.

Intervention:
1. Assess the strength of muscles, ptosis, diplopia, eye movement, ability to chew, swallow, cough reflex, talk.
R /: The rate of muscle weakness may be different in other parts of the body.

2. Assess muscle strength before and after drug administration.
R /: Knowing the effects of drug administration.

3. Perform scheduled breaks, keep quiet surroundings.
R /: Period after the break, increased muscle strength.

4. Encourage participation in treatment.
R /: Train activity gradually.


Nursing Diagnosis for Myastenia Gravis

Impaired verbal communication related to muscle weakness.

Characterized by:
Subjective Data:

• Patients say difficulty speaking

Data Objective :

• Patients appear to difficulties in verbal expression.
• Changes in behavior are not willing to communicate.
• The use of sign language / body.

Outcomes:
Patients expressing themselves verbally or non-verbally.

Intervention:
1. Assess the patient's ability to speak with the examination of cranial nerves V, VII, IX, X, XII.
R /: knowing the patient's ability to speak.

2. Ask a closed question, yes or no or body movements.
R /: Facilitate patient easily answered.

3. Talk with slow motion.
R /: Can see the speaker's lip movements.

4. Use images, paper or other means.
R /: Using media allows patients to express desire.

5. Inform staff or family, about the limitations of the patient in communication.
R /: Communication patterns that one would add to the frustration of patients.

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Acute Pain - Nursing Diagnosis and Interventions for Urolithiasis

Kidney stones in the urinary tract (urinary calculus) is hard as a rock mass formed in the urinary tract and can cause pain, bleeding, infection or blockage of urine flow.

These stones can form in the kidneys (kidney stones) and in the bladder (bladder stones).
The process of stone formation is called urolithiasis (renal lithiasis, nephrolithiasis). The concentration of stone-forming substances high in blood and urine as well as eating habits or certain medications, can also stimulate the formation of stones. Anything that impedes the flow of urine and cause stasis (no movement) in the urine anywhere in the urinary tract, increasing the likelihood of stone formation.

Stone, especially small ones, may not cause symptoms. Stone in the bladder can cause pain in the lower abdomen. Stones that obstruct the ureter, renal pelvis and renal tubules can cause back pain or renal colic (severe colicky pain). Renal colic is characterized by severe pain intermittent, usually in the area between the ribs and hip bones, which spread to the abdomen,  pubic area and inner thighs. Other symptoms are nausea and vomiting, abdominal distention, fever, chills and blood in the urine. Patients may be frequent urination, especially when the stone passes through the ureter. Stones can cause urinary tract infections. If stones block the flow of urine, the bacteria will be trapped in the urine collected over the blockage, so that there was an infection. If the blockage lasts long, the water will flow back into the urinary tract in the kidney, leading to suppression of which would inflate the kidneys (hydronephrosis) and eventually kidney damage can occur.

Common symptoms of kidney stone disease are:

• Urinate more often occurs
• Pain at the waist
• Sometimes accompanied by fever and seizures
• Cloudy yellow urine
• A history of kidney stones who previously suffered by one member of the family

Nursing Diagnosis for Urolithiasis : Acute Pain related to increase in the frequency of ureteral contractions, tissue trauma, edema and cellular ischemia.

Nursing Interventions:

1. Record the location, duration / intensity of pain (scale 1-10) and its spread. Pay attention to non-verbal signs such as: increase in BP and pulse rate, restlessness, grimacing, moaning, floundering.

2. Explain the causes of pain and the importance of reporting to the nursing staff of any changes that occur pain characteristics.

3. Perform actions that promote comfort (such as light massage / warm compress on the back, quiet environment)

4. Help the patient to deep breathing, guided imagery and therapeutic activity.

5. Help / encourage increased activity (ambulation active) as indicated with at least 3-4 liters of fluid intake per day within cardiac tolerance.

6. Note the increase / persistence of abdominal pain.

7. Collaboration of appropriate drug therapy program.

8. Maintain urinary catheter patency when needed.


Rational:

1. Help evaluate the progress of obstruction and stone movement. Pelvic pain often spreads to the back, groin, genitalia with respect to proximity plexus nerves and blood vessels that supply the other areas. Sudden pain and can lead to severe anxiety, fear / anxiety.

2. Reported early pain, analgesic provision provides an opportunity at the right time and help improve the client's coping ability in reducing anxiety.

3. Promote relaxation and reduce muscle tension.

4. Divert attention and help to relax the muscles.

5. Physical activity and adequate hydration increases the passage of the stone, prevent urinary stasis and prevent further stone formation.

6. Complete obstruction of the ureter may lead to perforation and ekstravasasiurine into perrenal area, this is an acute surgical emergency.

7. Prevent stasis / urinary retention, lowering the risk of increased pressure and kidney infections.

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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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NCP for Hypoglycemia - Nursing Diagnosis and Interventions

Nursing Care Plan for Hypoglycemia

Hypoglycemia is a condition where the fasting plasma blood sugar levels less than 50 mg /%.

Populations that have a high risk of experiencing hypoglycemia are:

• Diabetes mellitus.
• Parenteral nutrition.
• Sepsis.
• Enteral feeding.
• Corticosteroid therapy.
• Infants with mothers with diabetic.
• Infants, with small for gestational age.
• Infants whose mothers drug addiction.
• Burns.
• Cancer of the pancreas.
• Addison's disease.
• Hyperfunctioning adrenal glands.
• Liver disease.

Type of hypoglycemia are classified into several types namely:

• Early neonatal transitional: large size or normal baby, with damage to the pancreatic production system, resulting in hyper-insulin.
• Classic Transient Neonatal: occurs when infants are malnourished, so the deficiency of fat and glycogen reserves.
• Secondary: as a response to the stress of the newborn resulting in increased metabolism that requires a lot of glycogen reserves.
• Recurrent: caused by the enzymatic breakdown, or impaired insulin metabolism.

Assessment

Basic data that needs to be examined are:
1. The main complaint: often unclear, but usually symptomatic, more frequent hypoglycemia and a secondary diagnosis that accompanies other previous complaints such as asphyxia, seizures, sepsis.

2. History:

• ANC.
• Perinatal.
• Post natal.
• Immunization.
• Diabetes mellitus in the elderly / family.
• The use of parenteral nutrition.
• Sepsis.
• Enteral feeding.
• Use of Corticosteroid therapy.
• Mothers who use or drug addiction.
• Cancer.

3. Focus Data
Subjective Data:

• Often entered with complaints that are not clear.
• Complaining baby cold sweat that much.
• Hunger (babies often cry).
• Headache.
• Frequent yawning.
• Irritabel.

Objective data:

• Parestisia on the lips and fingers, restlessness, nervousness, tremors, convulsions, stiff,
• Hight-pitched cry, lethargy, apathy, confusion, cyanosis, apnea, irregular rapid breathing, sweating, eye circles, refusing to eat and coma.
• Plasma glucose less than 50 g /%.

Nursing Diagnosis and Interventions

1. Risk for complications
related to lower plasma glucose levels such as mental disorders, behavioral disorders, autonomic nerve function disorders, hypoglycemic coma

Interventions:

• Check serum glucose before and after meals.
• Monitor: glucose, pallor, cold sweat, skin moist.
• Monitor vital signs.
• Monitor consciousness.
• Monitor sign of nerves, irritability.
• Perform oral administration of sweet milk 20 cc X 12.
• Analysis of environmental conditions that could potentially cause hypoglycemia.
• Weight checks every day.
• Check for signs of infection.
• Avoid the occurrence of hypothermia.
• Collaborate provision of oxygenation.

2. Risk for infection
related to a decrease in endurance

Inerventions:

• Perform maintenance procedures hands before and after the action.
• Ensure that every object that is used in contact with baby be clean or sterile.
• Prevent contact with others who suffer from respiratory tract infections.
• Note the condition of the baby feces.
• Encourage families to follow aseptic procedures septic.
• Give antibiotics as profolaksis in accordance with the order.

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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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4 Nursing Diagnosis and Interventions for Tuberculous Meningitis

Nursing Diagnosis I

Ineffective breathing pattern related to the emphasis on the central respiratory regulation

Goal :
1. Long-term goal
Effective breathing pattern.
2. Short-term goals
Breathing pattern gradually improved

Outcomes:

• Frequency breath : normal 16-20x/menit
• Breath rhythm : regular

Intervention
1. Assess and monitor the frequency of the pattern and rhythm of the breath.
rational :
Ineffective breathing pattern changes a sign of an increase in intracranial pressure weight that presses the medulla oblongata.

2. Maintain effective airway by performing airway clearance such as suctioning and oral hygiene.
rational :
Excessive mucus will accumulate and lead to airway obstruction.

3. Give oxygenation appropriate order and monitor the effectiveness of oxygen administration.
rational :
To meet the need of oxygen in the blood and tissues.

4. Maintain airway patency with neck and neutral position.
rational :
Position neck extension / bending resulted obstructed airway.


Nursing Diagnosis II

Hyperthermia related to inflammation of the meninges

Goal :
1. Long-term goal
Body temperature within normal limits

2. Short-term goals
Body temperature gradually improved

Outcomes:

• The client is able to mobilize .
• The body temperature of 36-37 ° C, reduced perspiration.

Intervention :
1. Give cold compress on the area's many blood vessels until the temperature returns to normal.
rational :
Cold compresses can cause conduction process where there is heat transfer from one object to another by physical contact between the two objects.

2. Instruct the client to wear thin and absorbs sweat.
rational :
With thin clothing facilitate the absorption of sweat and gives a sense of comfort.

3. Observation vital signs : temperature, blood pressure, respiration and pulse.
rational :
To find out more action to be done.

4. Collaboration of antipyretic therapy.
rational :
Antipyretics inhibit heat on hypothalamic function.


Nursing Diagnosis III

Risk for impaired skin integrity related to prolonged bed rest

Goal :
1. Long-term goal
Impaired skin integrity is not happening

2. Short-term goals
Signs of impaired skin integrity is not happening

Outcomes:

• No signs of impaired skin integrity such as : redness and blisters on the skin.

Intervention :
1. Set and change the position of the patient's sleep , every 2 hours.
rational :
Can reduce the pressure that causes continuous optimal circulation in the area of emphasis.

2. Give bearing on areas of the body and are prominent on the surface of the bed.
rational :
With a bearing on area of ​​emphasis is given to reduce the pressure of circulation effects which are not smooth.

3. Do a massage every day.
rational :
Massage action as a stimulus for vasodilatation to vascular kontriksi on the surface so that the experience will help the circulation in the area.

4. Observation sign decubitus like blisters , redness on elbows , heels and back area every day.
rational :
If found signs of decubitus immediately take action to anticipate the occurrence of excessive tissue damage.



Nursing Diagnosis IV

Self - care deficit related to changes in the central nervous system , physical weakness

Goal :
1. Long-term goal
Self-care are met

2. Short-term goals
Less care is gradually being met.

Outcomes:

• Daily activities can be conducted of patients, while pain and can be performed after discharge from the hospital.
• Body weight did not decrease.
• Intact skin.
• Normal bowel and bladder.

Intervention :
1 . Observation of the patient's level of function.
rational :
Determine the patient's level of need.

2. Instruct the patient to express his feelings about his inability to perform self-care.
rational :
Assist patients in getting a better level of functioning.

3. Provide assistance and support as needed such as bathing, defecation and urination, hygiene , dressing and eating.
rational :
Will increase the feeling of independent (standalone).

4. Give all measurements / tools and food hygiene.
rational :
To save energy.

5. Maintain indwelling catheter if necessary.
rational :
To empty the bladder in a patient unconscious.

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