Nursing Management for Paranoid Personality Disorder

According to JP Chaplin, PhD. , Paranoid is a feature that psikotic disorder characterized by systematic delusions or delusions with little deterioration. This tends to settle and strong enough influence and incapacity.

Paranoid personality:
A personality is characterized by an attitude of suspicion, is very sensitive in the absence of deterioration or delusions.

Paranoid schizophrenia:
One type of schizophrenia characterized by delusions or symptoms highly suspicious attitude. This is due to dysfunction disorder thinking, hallucinations and deterioration.

According to James C. Coleman, Paranoia A characteristic of psychosis is characterized by systematic delusions.

Paranoid Personality:
Individuals who show behavioral symptoms such as defense mencahnism projections, suspicious, jealous, very jealous and stubborn.

Paranoid Schizophrenia:
One type of schizophrenia is characterized by delusions and hallucinations are usually quite strong.

Currently there are 2 types of paranoid psychosis belonging paranoid disorders, namely:

1. Paranoia, where the delusiyang develop slowly and then becomes complicated, logical and systematic and it is centered on feel persecuted delusions or delusions of grandeur. Despite the presence of delusions, the patient's personality is still intact, there are no serious disorganization and without hallucinations.

2. Paranoid state, a change in the paranoid and delusional thinking becomes ligis and emergence characteristics of paranoia, although it has not shown any strange behavior or deterioration such as that found in the case of paranoid schizophrenia. This condition is usually associated with strong stress and mortality may also be due to the phenomenon. Paranoid states often color the clinical picture of the type of other pathological disorders.

However, our main interest is currently focused on paranoia. Paranoia is relatively less common in patients treated in psychiatric hospitals, but this may occur due to mis-identification of mental disorders. Many of the inventor / inventors, teachers, business executives, reformers fanatical, jealous spouse, eccentric people who study a particular teachings are included in this category. However, they are uniquely able to maintain its existence in the society. In some cases some of the women who developed into a very dangerous man.


Clinical Manifestation of Paranoia

Individuals who experience paranoia feel alone, neglected, spied upon, and other false perception of the threat from 'the enemy.' Delusions are usually centered on one thing, for example concerning the financial problems, labor, ill trustworthy partner or other life issues . People who have failed in work will develop suspiciously like someone else cembutu on his performance so want to drop it.

A paranoia has a particular reason why they are suspicious and do not want to receive another reason which is more correct. Because of the suspicion he may conduct interrogations of those deemed enemies.

Many of these paronoia has delusions where he was a superior and has the unique capability. Sometimes they feel a mandate or revelation to run a sacred mission, social reforms, and modifiers. The paranoiac religious develop the confidence that he got a message from God to save people and do the sermons even invite does holy war.

In connection with the paranoiac delusions experienced can be performed with very perfect, speaks eloquently and has impressed emosian mature. Hallucinations and characterize other disorders rarely found in this paranoiac. They seek to justify the logical ways in order to be believed. In this case very difficult to distinguish where the facts or just images. They are working on making the people around him believe what he says. They fail to see the facts other than what they believe and are less able to prove his faith, kecurigaanya and they become communicative when asked about these delusions.

However this is not always harmful paranoic, but they still have a chance to do something that is detrimental to the perceived enemy.


Stages of thinking that led to paranoia:

1. Suspiciousness / Suspicious - people become distrustful of others, fear of hurt and be very alert.
2. Protective Thinking - selectively reviewing the actions of others and see it suspicious and start blaming others for his failure.
3. Hostility - very sensitive to perceived injustice is not true though, it responded in anger and hostility and suspicion is further increased.
4. Paranoid Illumination / Growing Paranoid - suspicious attitude has become part of him and he felt the presence of something strange, but he he has been immersed in a situation such suspicion.
5. Delusions - feel persecuted or absence of delusions of greatness, but he developed a logical reason and to develop actions that can be understood by others.



Treatment for Paranoid Personality Disorder

In the early stages of paranoia, corporately and individually handling is still effective, especially if the patient has a consciousness to obtain the help of professionalism.

Behavioral therapy techniques show promise such things, paranoid ideas arise due to various combinations of things that are not fun, the various factors of change in a person's life situation further strengthens maladaptifnya behavior and develop into a powerful way to resolve the problem.

Once settled delusional system, the handling will be very difficult. Usually difficult to communicate with paranoiac to tackle the problem in a way that is rational. In this situation the patient is reluctant to consult, but they are trying to find justification and understanding of other people on their mistakes.

At the time of initial identification of psychosis with schizophrenia and paranoia, it was agreed that the clinical manifestations of this case must be distinguished from neurosis or psychosomatic disorders. The hallmark of schizophrenia clearly a failure of understanding / contact with reality and personality disorganization occurs as disturbances in the function of thinking, affective / feeling or behavior problems.

Identification of most types such as acute schizophrenia, paranoid, catatonic, hebephrenic and simple show clinical differences for each type. Various factors cause remains elusive why it can thrive. However experts notice any significant role of genetic factors that cause schizophrenia. Perhaps because neuropshysiological or biochemical changes that disrupt the normal functioning of the brain, including the failure here is in the selection mechanism. The exact cause of these changes must be ascertained to determine whether due to genetic factors or because of a mental disorder. However, it should also be noted that a significant cause of psiikologis other. Besides that psychosocial factors play an important role to consider such innovative pula.Penanganan chemotherapy, psychosocial therapy, post-treatment program would make people better condition.

Paranoid disorder usually do not experience severe personality disorganization compared to other types of psychosis, but they are very resistant / reject any given therapeutic action.

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Treatment for Victims of Physical Abuse and Violence

Common actions for victims of abuse

1. Give first aid as needed.
2. When violence or abuse is very prominent, separate the victims from the perpetrators.
3. Report any abuse in child protection services and the elderly, as required by law.
4. In the case of the persecution of women, reporting is required if the injury was caused by a gun, knife or other weapon.
5. If sexual abuse is suspected, follow the laws and institutional procedures for collecting and storing evidence admitted in evidence a series of procedures.
6. Ensure that victims receive sensitive care and compassionate.
7. Give full support to the victims not to tolerate abuse.
8. Listen with empathy explanation about the victims of persecution now and past.
9. Record all injuries incurred and treatment rendered.
10. In collaboration with a team approach, including inter-agency referral initiate and participate in case conferences.

Action for victims of physical abuse and violence on children

1. Make sure the child is comfortable with making the right introductions and do not touch a child without permission when conducting interviews.
2. Use play activities, including drawing, to encourage children to tell or express feelings, for children who are reluctant or unable to express the trauma they experienced.
3. Describe all tests and medical procedures in terms that can be understood, before the procedure is executed.
4. Improve the child's relationship with parents; nurses can not be a substitute for separating parents with the child's biological parents.

Action for victims of physical abuse and violence on women

1. Communicate acceptance, warm and non-judgmental; do not deliver though indirectly that he is guilty of not leaving the abusive environment.
2. Improve the safety and awareness of his right to be free from persecution.
3. Discuss the various options available, including shelter, legal protection to report abuse and seek protection from persecution through the courts.
4. Respect the victim's decision, including the decision to return to the abusive situation or the decision not to report the abuse.
5. Help her to make plans to ensure safety, including home and auto hide duplicates; asking neighbors to report to the police when violence began to occur; store documents such as birth certificates, bank account numbers, social security numbers, and rental receipts or purchases of goods available; maintains a list of telephone numbers of emergency shelter, legal aid, police, counselors and support groups.

Action for victims of physical abuse and violence on elderly

1. Give it time and patience to be able to make the elderly discuss the situation.
2. Respect the dignity of the client and should not be judge.
3. Discuss the options available to ensure safety, such as temporary hospitalization, placement in a home that is safe and protective orders from the court.
4. Provide a list of resources and support services, including adult protective services, legal aid, victim resource agencies, local units of elderly and 24-hour hotline number for the issue of persecution of the elderly.

Measures for Post Traumatic Stress Disorder

1. Use the implementation associated with anxiety (eg, relaxation techniques, encourage expression of feelings, limiting caffeine and nicotine.
2. Validation on the client that they experienced traumatic events cause enormous stress.
3. Help clients disclose all aspects of the traumatic event, including thoughts and feelings.
4. Teach the client about coping strategies to manage anxiety symptoms that accompany memories of trauma.
5. Encourage clients to participate in a support group or self-help groups.
6. Refer clients to alcoholic anonymous or narcotics anonymous if alcohol or drug abuse problem for clients.

Action for abuses committed against

1. When actors threatening persecution or being under the influence of drugs or alcohol, the nurse should call security or police to ensure the safety of themselves and others.
2. Notify molesters on duty to report maltreatment to the designated agency.
3. Get help from a team of experienced health workers (eg, clinical nurse specialists, social workers, representatives of protection agencies, mental health crisis workers) to start the intervention.
4. In situations of child abuse, the nurse can be helpful with regard parents as clients as victims of abuse and their children.
5. If persecution is recognized by the culprit, encourage him to be responsible for violent behavior does.
6. Communicate belief that violent behavior can be controlled and that there are other functions that could be more appropriate and possible.
7. Advise and refer perpetrators of the abuses to the community resource agencies, such as mental health services, parent education courses, self-help groups, and nursing home.

Action for families

1. Teach the family about the importance of individual responsibility for the behavior of each.
2. Teach the family to recognize stressful situations.
3. Teach the family to develop strategies for problem solving or coping strategies.
4. Teach families about effective parenting skills.
5. Teach the family to use community resources and professional assistance to improve family functioning.

Action for community

1. Seeks to reduce violence-related conditions (eg, poverty, inadequate housing, dysfunction attitudes towards violence, substance abuse). For example: joining volunteer organizations, lobby with local officials.
2. Trying to develop and maintain a family of resources (eg, child care services, nursing homes, educational programs, support groups)
3. Support and enhance the legal and legislative efforts to eliminate domestic violence.

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Sample of NCP Basic Human Needs: Personal Hygiene

ASSESSMENT

1. Client Identification

• Name:
• Address:
• Age:
• Gender:
• Level of education:

2. Health History

• Assess individual patterns of daily hygiene.
• Assess the factors that influence individual hygiene include:
• Culture: for example, the myth that being sick should not shower because it will aggravate the disease.
• Socio-economic status: to fulfill that adequate facilities and infrastructure.
• Religion: beliefs affect individuals within executing daily habits.
• The level of knowledge or the development of the individual to health.
• Health Status: will affect an individual's ability to perform self-care.
• Habit: the habit of using certain products in self-care.
• Physical disability:

3. Physical Assessment

• Hair: look dull? is there a loss?
• Scalp: dandruff, bald and signs of inflammation (redness, swelling)
• Eyes: observe signs of jaundice, pale conjunctiva, discharge on the eyelids, redness and itching of the eyelids.
• Nose: assess for sinusitis, nasal bleeding, signs of a cold that does not go away, the signs of allergy.
• Mouth: observe the presence of lesions, mouth sores, dry or chapped.
• Teeth: observe signs of tartar, caries, cracked teeth, incomplete and false teeth.
• Ear: observe the presence of cerumen, lesions, infections, changes in hearing.
• Skin: observe the texture, turgor and moisture and skin hygiene: Strie, wrinkled skin, lesions, pruritus.
• Hands and feet nails: nail observe cleanliness.
• Genetalia: observe cleanliness.

Etiology

1. Physical fatigue
2. Impairment of consciousness
3. Factors predisposing

• Developments: Family too protect and pamper clients.
• Biological: chronic disease.
• Ability reality down: Mental disorders.
• Social: less support and self-care skills training environment.

4. Factors precipitation

• Less / decreased motivation.
• Impairment in cognition or perceptual.
• Anxious.

5. Partial or total paralysis, secondary to (specify)
6. Coma
7. Visually impaired secondary to (specify)
8. Extremity malfunction
9. External equipment (casts, splints, advocates, IV)
10. Fatigue and post-operative pain
11. Pain


Signs and Symptoms

1. Subjective data

• Patients feels weak.
• Lazy to move.
• Feel powerless.

2. Objective data

• Filthy hair, unkempt.
• Bodies and clothes dirty and smelly.
• Mouth and teeth dirty with stink.
• Skin dull and dirty.
• Long nails and unkempt.
• Untidy appearance.

Psychologically: Lazy, no initiative, self Attractive, self-isolation, Feeling helpless, low self-esteem and feel humiliated.

Social: less interaction, less activity, not able to behave according to normal, eating irregular way, urinate and defecate in any place, brush your teeth and shower are not able to be independent.


Nursing Diagnosis

1. Self-Care Deficit: Bathing / hygiene (Less self care (bathing) is an impaired ability to perform activities of bathing / personal hygiene). relate to:

2. Self-Care Deficit: Wearing apparel / ornate.
Self-Care Deficit (wearing clothes) is an impaired ability to wear their own clothes and dress up activities.

3. Self-Care Deficit: Eat
Self-Care Deficit (eating) is an impaired ability to demonstrate the activity of eating.

4. Self-Care Deficit: toileting
Self-Care Deficit (toileting) is an impaired ability to perform or complete the toileting activity itself. (Nurjannah: 2004, 79).

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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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Care Plan and Nursing Diagnosis for Spina Bifida

Nursing Assessment for Spina Bifida

Subjective and objective data collection on the nervous system disorders, in connection with spina bifida complications depends on other vital organs. Nursing assessment of spina bifida include anamnesis, medical history, physical examination, diagnostic studies, and psychosocial assessment.

1. Anamnesis

The identity of clients includes name, age, gender, education, address, occupation, religion, nationality, date and time of hospital admission, registration number, health insurance, medical diagnostics.

The main complaint is often the reason for a client to ask for help health is the presence of signs and symptoms similar to spinal cord tumors and neurological deficits. Complaints of lumbosacral lipoma on an important sign of spina bifida.


2. History of the disease at this time

Complaints of neurological deficits can manifest as impaired motor (motor paralysis of the lower limbs) and the inferior extremity sensory and / or disorders of the bladder and the sphincter of the stomach. Complaints of unilateral foot deformity and leg muscle weakness is the most common defect. Small feet can occur trophic ulcers and pes cavus. This condition may be accompanied by sensory deficits, especially in the distribution of L3 and S1. Complaints bladder sphincter disorders are found in 25% of infants with neurological involvement, lead to urinary incontinence, urinary dripping, and recurrent urinary tract infections. Usually accompanied by the anal sphincter weakness and sensory disturbance perianal area. Neurological disorders can gradually deteriorate, especially during adolescence mass growth.


3. History of previous illness

Assessment that need to be asked include a history of the growth and development of children, history meningomyelocele ever experienced before, a history of infection subarachnoid space (sometimes chronic or recurrent meningitis), a history of spinal cord tumors, poliomyelitis, spinal developmental disabilities, such as diastematomyelia and foot deformities.


4. Assessment of psychosocial

Assessment of coping mechanisms used and the client's family (parents) to assess the response to illness and changing roles in the family and society as well as responses or influence in their daily lives either in the family or in society. Are there impacts on the client and the parents that raised fears of disability, anxiety, a sense of inability to perform activities optimally.


5. Physical examination

After making the history that led to the complaint the client physical examination is very useful to support the assessment of data from history. Physical examination should be performed by the system (B1-B6) with a focus on examining physical examination B3 (brain) directed and connected with complaints from clients.

a. The general state
In case of spina bifida generally experience loss of consciousness (GCS less than 15), especially if it occurs widely neurological deficits and changes in vital signs.

b. B1 (Breathing)
Changes in the respiratory system associated with inactivity weight. In some circumstances, the results of the physical examination found no abnormalities.

c. B 2 (Blood)
Bradycardia is a sign of changes in brain tissue perfusion. Looked pale skin indicates a decrease in hemoglobin levels in the blood. Hypotension indicates a change in tissue perfusion and early signs of a shock.

d. B3 (Brain)
Spina bifida causes a variety of neurological deficit was primarily due to the effect of increased intracranial pressure. Assessment of B3 (Brain) is a focus and a more complete examination than assessments on other systems.

e. B4 (Bladder)
In the advanced stages of spina bifida, a client may experience urinary incontinence due to confusion and inability to use the urinary system due to damage motor and postural control. Sometimes the external urinary sphincter control is lost or diminished. During this period, intermittent catheterization performed with sterile technique. Urinary incontinence that persists showed extensive neurological damage.

f. B5 (Bowel)
The presence of fecal incontinence that continues to show widespread neurological damage. Bowel examination to assess the presence or absence of bowel sounds and the quality should be assessed prior to abdominal palpation. Bowel sounds are decreased or lost may occur in paralytic ileus and peritonitis.

g. B6 (Bone)
The presence of foot deformity is one important sign of spina bifida. The most common motor dysfunction is the weakness of the lower extremities. To assess the integrity of the skin lesions and sores. Be difficult to move because of weakness, sensory loss or spastic paralysis and fatigue cause problems on the pattern of activity and rest.


6. Diagnostic tests

Spine x-rays to identify any defect in the spine, usually occurs in the posterior arch of the vertebra in the spine midline amount varies. The presence of spinal dyspropism or widening of the spine is a typical sign of radiology at the lumbar (Perkin, 1999).



Nursing Diagnosis for Spina Bifida

1. Urinary incontinence r / t paralysis visceral

2. Risk for injury r / t spastic paralysis

3. Impaired Physical Mobility r / t motor paralysis

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Acute Pain and Anxiety - NCP for Intestinal Obstruction

Intestinal obstruction (ileus) is a disorder passage of intestinal contents due to blockage resulting in accumulation of fluid and air in the proximal part of the blockage. As a result of the blockage, an increase in intraluminal pressure and intestinal disturbances resorption and increased intestinal secretion. Combined with vomiting as a result of an obstruction or reflux due to regurgitation of stomach full of lead to dehydration, febrile and shock. Obstruction ileus is also an urgency in abdominal surgery is often encountered, is 60-70% of all cases of acute abdomen that is not acute appendicitis. Obstructive ileus also called mechanical ileus.

Based on the mechanism of the obstruction, then the mechanical obstruction can be divided into:
A. Obstruction of the bowel lumen (Intra luminaire), namely:

• Polypoid tumor.
• Intussusception.
• Gallstone ileus.
• Feces, meconium bezoar (infants).

B. Abnormalities of the intestinal wall (Intramural), mostly congenital in infants:

• Atresia.
• Stenosis.
• Duplication.

In adult patients:

• Neoplasms.
• Inflammation.
• Crohn's disease.
• Post radiation.
• Gut connection.

C. Abnormalities outside the colon (Luminaire)

• Adhesion.
• External hernia.
• Neoplasms.
• Abscess.

Clinical Manifestations : Small Bowel Obstruction

Complaints arising in patients with intestinal obstruction is typical:

• Abdominal pain, vomiting, obstipation, abdominal distention, no flatus and bowel movement.
• These painful cramps can be repeated at intervals of 4-5 minutes on intestinal obstruction proximal part. In intestinal obstruction distal part of the frequency increases rarely.
• After a long obstructed the cramping pain will diminish or disappear because of intestinal distention or movement will be reduced after the strangulation with peritonitis, abdominal pain became severe and continuous.
• At the proximal intestinal obstruction occurred profuse vomiting with mild distension.
• At the distal intestinal obstruction, vomiting rarely with vomit the contents of feces, but more severe distension.
• Increased abdominal circle occurs because of the removal of liquids and gases within the lumen of the intestine due to obstruction in the distal part of the intestine and colon, or paralytic ileus.
• In the early stages, normal vital signs. Along with the loss of fluid and electrolytes, dehydration will occur with the clinical manifestations of tachycardia and postural hypotension. The body temperature is usually normal but sometimes it can be increased.
• Physical examination found the presence of fever, tachycardia, hypotension and severe dehydration symptoms.
• Fever indicates obstruction strangulate. On examination the abdomen appeared distended abdomen obtained and increased peristaltic (sounds borborygmi). In advanced stages where the obstruction continues, peristaltic will weaken and disappear. The presence of feces mixed with blood on rectal examination can toucher suspected malignancy and intussusception.

Nursing Diagnosis : Acute Pain related to an increase in intestinal intraluminal pressure.

characterized by: grimacing expression, complained of feeling pain in the abdominal area.

Goal: expected pain is resolved or controlled.

Outcomes:

• Revealed a decrease in discomfort.
• Stating pain at a tolerable level, indicating relaxed.
• Showed pain control measures.

Intervention:

1) Assess pain with PQRST technique.
Rationale: Monitor and provide an overview of the characteristics of the client and the pain indicators in subsequent interventions.

2) Maintain bed rest in a comfortable position.
Rationale: Bed rest reduces energy use and help control pain and reduce muscle contractions.

3) Teach relaxation or distraction techniques such as listening to music or watching tv.
Rational: to help clients feel more relaxed until the pain can be reduced.

4) Collaboration of analgetic drugs.
Rational: analgesic drugs will block the pain receptors so that pain can not be perceived.



Nursing Diagnosis : Anxiety related to change in health status.

characterized by: increasing the pain of powerlessness, expressed concern.

Goal: expected to decrease anxiety.

Outcomes:

The client will use relaxation techniques to relieve anxiety.

Intervention:
1) Assess the client's level of anxiety.
Rationale: Knowing the coping abilities of individuals.

2) Take time to listen to express anxiety and fear; provide calming.
Rationale: The client will feel better when heard. trusting relationship can be established with the client.

3) Maintain a quiet environment.
Rationale: quiet surroundings make the client more relaxed and can reduce anxiety.

4) Provide diversion through television, radio, games for lowering anxiety.
Rational: to divert the mind from stress and anxiety.

5) Describe the procedures and actions and give an explanation of the strengthening of disease, and prognosis action.
Rationale: patient involvement in care planning can provide a sense of control and helps reduce anxiety.

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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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