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Tampilkan postingan dengan label Risk for Injury. Tampilkan semua postingan
Tampilkan postingan dengan label Risk for Injury. Tampilkan semua postingan

Minggu, 19 Januari 2014

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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Selasa, 17 Januari 2012

Risk for Injury related to Dementia

Dementia can be defined as cognitive and memory impairment that can affect daily activities. People with dementia often show some disruption and changes in daily behavior (behavioral symptoms) that interfere (disruptive) or do not disturb (non-disruptive) (Volicer, L., Hurley, AC, Mahoney, E. 1998). Grayson (2004) mentioned that dementia is not just an ordinary disease, but rather a collection of symptoms caused by multiple diseases or conditions resulting in changes in personality and behavior.

Mentioned in the literature that a disease that can cause symptoms of dementia there are some seventy-five. Some diseases can be cured while most can not be cured. (Mace, N.L. & Rabins, P.V. 2006). Most researchers in the research agreed that the main cause of the symptoms of dementia is Alzheimer's disease, vascular disease (blood vessel), Lewy body dementia, frontotemporal dementia and ten percent of which are caused by other diseases.

Fifty to sixty percent of the causes of dementia is Alzheimer's disease. Alzhaimer is a condition in which nerve cells in the brain die, making the signal from the brain can not be transmitted as it should (Grayson, C. 2004). Alzheimer's sufferers experiencing memory impairment, the ability to make decisions and also a decrease in the thinking process.

Risk for Injury related to Dementia

Nursing Diagnosis : Risk for Injury related to Dementia


Nursing Interventions Risk for Injury related to Dementia

A. Action for patients with Dementia 

Goal:

1. Patients are spared from injury
2. Patients are able to control activities that can prevent injuries.

Action

1. Describe risk factors that could cause injury, with simple language
2. Teach ways to prevent injuries: if the fall do not panic but cry out for help
3. Give praise to the patient's ability mentions ways to prevent injuries.

B. Action for patients families

Goal: Families of patients are able to:

1. Identifying factors that could cause injury to the patient
2. Families are able to provide a safe environment to prevent injury

Action

1. Discuss with family factors that may cause injury to the patient
2. Encourage families to create a safe environment such as: floors are not slippery, keep sharp objects out of reach of patients, provide adequate lighting, the lights on during the day, give the tool handle and watch if the patient smokes, cap plugs and other electrical equipment with plaster, avoid power tools other than the reach of the client, provide a low bed
3. Encourage families to always accompany the patient at home and monitor the daily activities undertaken

Evaluation  Risk for Injury related to Dementia

To measure the success of nursing care that you do, it can be done by assessing the ability of clients and families:

The ability of the patient:
1. Mention the simple language of the factors that cause injury
2. Using the proper way to prevent injury
3. Controlling the activity according to ability

The ability of family
1. Families can reveal factors that may cause injury to the patient
2. Providing safety in the home
3. Distancing power tools out of reach of patients
4. Always accompany the patient at home
5. Monitor the daily activities of patients conducted
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