Imbalanced Nutrition and Knowledge Deficit related to Bladder Cancer

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

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

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

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

Symptoms can include:

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

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

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

characterized by:

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

Goal:

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

Interventions :

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

Collaboration:

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

Rational:

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

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

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

characterized by:

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

Goal:

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

Interventions:

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

Rational:

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

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Acute Pain and Anxiety - NCP for Bladder Cancer

Bladder cancer is a cancer of the bladder organ. Bladder is the organ that serves to accommodate the urine from the kidneys. If the bladder is full of urine then it will be removed.

The exact cause of bladder cancer is not known. But studies have shown that these cancers have multiple risk factors, namely:

• Age, the risk of bladder increases with age.
• Smoking is a major risk factor.
• Work environment, some workers have a higher risk of developing this cancer because of its place works found carcinogenic substances (cancer-causing).
• Race, white people have a 2 times greater risk, there is the smallest risk among Asians.
• Men, are at risk 2 - 3kali greater.
• Family history, people whose family is suffering from bladder cancer have a higher risk of developing this cancer. Researchers are studying the change of certain genes that may increase the risk of this cancer.

Nursing Diagnosis and Interventions for Bladder Cancer

1. Acute Pain
related to:

• disease process (suppression / destruction of nerve tissue, nerve supply system infiltration, nerve pathway obstruction, inflammation),
• side effects of cancer therapy

characterized by:

• clients say pain,
• clients have difficulty sleeping,
• not able to focus, expressions of pain, weakness.

Goal:

• Clients are able to control pain through activity.
• Reported experiencing pain.
• Following treatment program.
• Demonstrate techniques of relaxation and diversion of pain through activity.

Interventions:

• Determine history of pain, location, duration and intensity.
• Evaluation of therapy: surgery, radiation, chemotherapy, biotherapy, teach the client and family about how to deal with.
• Give diversion such as repositioning and fun activities such as listening to music or watching TV.
• Encourage stress management techniques (relaxation techniques, visualization, guidance), happy, and provide therapeutic touch.
• Evaluation of pain, provide treatment if necessary.
• Discuss pain management with doctor and also with clients.
• Give analgesics as indicated.

Rational:

• Provide the necessary information for planning care.
• To determine the appropriate therapy is carried out or not, or even cause complications.
• To improve the comfort of the clients distract from pain.
• Improving self-control over side effects by lowering stress and anxiety.
• To determine the effectiveness of pain management, pain levels and to the extent the client is able to withstand, and to investigate the needs of the client will be anti-pain medication.
• In order for a given targeted therapy.
• To cope with the pain.

2. Anxiety
related to:

• crisis situations (cancer),
• changes in health,
• socio-economic,
• roles and functions,
• forms of interaction,
• preparation for death,
• separation of the family

characterized by:

• increase in tension,
• fatigue,
• express awkwardness role,
• feeling dependent,
• inadequate ability to help themselves,
• sympathetic stimulation.

Goal:

• Clients can relieve anxiety.
• Relax and be able to see themselves objectively.
• Demonstrate effective coping and able to participate in treatment.

Interventions:

• Determine the client's previous experience of the illness.
• Provide accurate information about prognosis.
• Give the client a chance to express anger, fear, confrontation. Give the information with reasonable emotions and expressions appropriate.
• Explain the treatment, the purpose and side effects. Help clients prepare for the treatment.
• Record ineffective coping as less social interaction, lack of empowerment, etc..
• Encourage to develop interaction with the support system.
• Provide a quiet and comfortable environment.
• Maintain contact with clients, talk and touch with the fair.

Rational:

• Data about previous client experience will provide a basis for extension and avoid duplication.
• Provision of information to assist clients in understanding the disease process.
• Can reduce client anxiety.
• Assist the client in understanding the need for treatment and side effects.
• Knowing and explore coping patterns and handle client / provide solutions in an effort to improve the strength in overcoming anxiety.
• So that clients receive support from the closest person / family.
• Give the client a chance to think / contemplate / break.
• Clients gain confidence and belief that he really helped.

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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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Ineffective Airway Clearance and Ineffective Breathing Pattern NCP for Epilepsy

Definition of Epilepsy

Epilepsy is a chronic neurological disease that causes seizures periodically. The disease is caused by the normal activity of brain cells. Symptoms of seizures that appears may vary. Some people with epilepsy when seizures have an empty view. Mild seizures require treatment, because it can be dangerous in the event when doing activities like driving or swimming.

Treatments such as medical treatment and sometimes surgery is usually successful in eliminating the symptoms or reduce the frequency and intensity of seizures. In some children with epilepsy, they can overcome this condition with age.

Recently, the researchers found, epilepsy affects neurological function disrupt social functioning in the brain, the same properties are also seen in people with autism. These characteristics include impairments in social interaction and communication.

Symptoms of Epilepsy

Because epilepsy is not normally caused by the activity of brain cells, seizures can have an impact on your brain coordination process. Convulsions can result in:

• Temporary confusion.
• Uncontrolled jerking movements of the hands and feet.
• Lost consciousness completely.

Differences symptoms occur depending on the type of seizures. In many cases, people with epilepsy will tend to have this type of seizure is the same every time, so it will be the same symptoms that occur from incident to incident.

Doctors classify partial seizures or generalized, based on how abnormal brain activity begins. In some cases, seizures can be initiated by partial and later became general.

Partial Seizures

When seizures arise as a result of abnormal brain activity on the part of the brain, scientists call it partial seizures. Seizures of this type consists of two categories.

• Simple partial seizures. These seizures do not result in loss of consciousness. These seizures may be changing emotions or changing way of looking at, smell, feel, taste, or hear. These seizures can also produce buffeting parts of the body by accident, such as the hands or feet, and sensory symptoms such as tingling spontaneously, vertigo and blinking against the light.
• Complex partial seizures (complex partial seizures). These seizures resulted in the change of consciousness, it is because you lose vigilance for some time.

General Seizures

Seizures involving all parts of the brain called the general convulsions. Four types of general convulsions are:

• Absence seizures (also called petit mal). This seizure is characterized by the movement of the body has a smooth and striking, and can cause loss of consciousness briefly.
• Myoclonic seizures. These seizures usually cause a jerk or twitch suddenly in the hands and feet.
• Atonic seizures. Also known as drop attacks, these seizures cause loss of harmony with the muscles and the sudden collapse and fall.
• Tonic-clonic seizures (also called grand mal). Convulsions that have most frequently occurring intensity. Having characteristics with loss of consciousness, stiff and trembling, and loss of bladder control.

Nursing Care Plan for Epilepsy

Nursing Diagnosis : Ineffective Airway Clearance and Ineffective Breathing Pattern

related to damage nuromuskuler , tracheobronchial obstruction .

Nursing Interventions:

1) Encourage clients to release the use of objects from the mouth preformance, hammer and other tooth samples.
Rationale: lowering the risk of aspiration or the entry of foreign objects into the pharynx.

2). Place the patient in the lateral position, a flat surface, tilt the head during a seizure occurs.
Rationale: improving drainage secret, to prevent the tongue falling, and obstruct the airway.

3). Remove clothing at the neck, chest and abdomen clients.
Rational: to help clients breathe.

4). Insert the tongue into the mouth spatel clients.
Rational: to prevent biting the tongue and help perform suction mucus, and help open the airway.

5). Perform suction as indicated.
Rationale: lowering the risk of aspiration or asphyxia.

6). Collaboration in the provision of supplemental oxygen.
Rational: can decrease cerebral hypoxia, due to reduced oxygen due to vascular spasm during seizures.

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Pleural Effusion - Assessment and Nursing Diagnosis

Pleural effusion is a medical condition where there is an excessive accumulation of fluid in the lungs, particularly in the pleural space. This fluid is responsible for lubricating the lungs so that they do not experience friction from rubbing against the ribs or other components of the thoracic cavity. Normally, the space around the lungs contains 10-15 milliliters of this fluid.

There are types of pleural effusion, depending on what is causing the issue. These include:

Hemothorax : This occurs when blood builds up in the chest cavity. It is most often due to injury
Hydrothorax : This is the general term for when any fluid accumulates in the chest cavity.
Pneumothorax : This condition arises when the entire lung collapses, which can be the result of pressure from fluid buildup.
Chylothorax : This happens when blood or pleural fluid remains in the thoracic cavity. While this can also be attributed to injury, it is most often related to lymphoma, or cancer of the lymph nodes.


Assessment for Pleural Effusion

1. Systemic Examination

a) Cardiovascular System
Hypotension, increased pulse, temperature sometimes rose.

b) Respiratory System
From this system, the assessment needs to be done related to pleural effusion is dyspnea, tachypnea, cough, fremitus focal weakness, chest wall is more convex on the side that contains fluid.

c) Digestive System
On the client with pleural effusion usually found loss of appetite, nausea, vomiting, hyperactive bowel sounds.

e) Musculoskeletal System
Physical weakness, prefer to lay on the direction that contains fluid.

f) Integumentary System
Dry skin, increased skin temperature, poor turgor.


2. Pattern of Daily Activities
That needs to be studied in daily activities are:

• Personal hygiene: Due to a decrease in the ability or increased need help doing everyday activities.
• Nutrition: There is a change and a problem in meeting the nutritional needs due to the tightness and lack of appetite.
• Elimination: No problem.
• Activities and sports: On the client with pleural effusion occurs fatigue, weakness, malaise, inability to perform daily activities because of difficulty breathing, fatigue or activity intolerance. Can not exercise because of pain due to tightness WSD installation actions.
• Rest and sleep: There was difficulty sleeping at night due to coughing, tightness, pain, fever and sweating.

3. Psychological Data

• Status of emotions: emotional instability can be found facing the disease.
• The concept of self: changes in self-concept for fear of disease, negative views of themselves, due to the changing role of dependence.
• Coping patterns: what is being done to overcome the problem client is maladaptive actions and to whom the client to ask for help or tell me if there is a problem.

4. Social Data
Behavior occurs withdraw from social interactions due to the inability to communicate.

5. Spirituality Data
Difficulty to perform the religious obligations because of illness and limited activity.


6. Diagnostic examination
According Doenges et al (2002) Diagnostic examination consists of:

• Chest X-ray: to declare lung hyperinflation, flattening of the diaphragm, increased retrosternal air area.
• Lung Function Tests: performed to determine the cause of dyspnea, to determine whether the abnormal function is obstruction or retraction.
• Blood gas analysis: estimating progression of chronic disease processes.
• Blood chemistry: to convince deficiency and emphysema primary diagnosis.
• Sputum cultures to determine the presence of infection, identify the pathogen, sitolitik examination to determine malignancy or allergic disorders.
• ECG right axis deviation, P wave elevation, atrial dysrhythmias, P wave elevation leads I, III, aVF, ventricular QRS axis.

7. Care and Treatment
Management of pulmonary tuberculosis disease is the provision of a high-calorie diet and high protein, WSD installation.


Nursing Diagnosis for Pleural Effusion

According Doenges et al (2002), nursing diagnoses that appear in patients with pleural effusion is:

1. Acute pain r / t surgical action (WSD).

2. Ineffective airway clearance r / t inflammatory process and secret accumulation in the respiratory tract.

3. Imbalanced Nutrition: Less Than Body Requirements r / t lack of food intake.

4. Activity intolerance r / t physical weakness

5. Knowledge Deficit: the conditions, rules and precautionary measures r / t the wrong interpretation of the cognitive limitations of the information, the information is inadequate / incomplete information.

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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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