Search This Blog

Ineffective Tissue Perfusion related to Glomerulonephritis

Glomerulonephritis- Ineffective Tissue Perfusion
Nursing Care Plan for Glomerulonephritis

Nursing Diagnosis: Ineffective Tissue Perfusion related to water retention and hypernatremia

Expected outcomes:
Clients will show marked normal cerebral tissue perfusion with blood pressure within normal limits, decrease water retention, no signs of hypernatremia.

Nursing Interventions Ineffective Tissue Perfusion related to Glomerulonephritis:

1. Monitor and record blood pressure every 1-2 hours a day during the acute phase.
Rational: to detect early symptoms of blood pressure changes and determine interventions.

2. Keep the airway, suction prepare.
Rational: the attack can occur due to lack of oxygen to the brain perfusion.

3. Arrange provision of anti hypertension, monitor client reactions.
Rationale: Anti-Hypertension can be given, because uncontrolled hypertension can lead to kidney damage.

4. Monitor the status of the volume of fluid every 1-2 hours, monitor urine output (N: 1-2 ml / kg / hour).
Rationale: Monitor is necessary for the expansion of the volume of fluid can cause increased blood pressure.

5. Assess neurological status (level of consciousness, reflexes, pupil response) every 8 hours.
Rational: To detect early changes that occur in neurological status, facilitate interventions.

6. Set diuretic administration.
Rational: A diuretic can increase the excretion of fluids.

Knowledge Deficit NCP Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis

Knowledge Deficit (learning need): the disease, prognosis, and treatment

Related to:
  • Lack of exposure / recall.
  • Misinterpretation of information.

Can be evidenced by:
  • Questions / requests for information, statements misconceptions.
  • Not exactly follow the instructions / occurrence of complications that can be prevented.

The expected outcomes / evaluation criteria, patients will:
  • Demonstrate an understanding of the condition / prognosis, treatment.
  • Develop a plan for self-care, including lifestyle modification and consistent with mobility or activity restrictions.

Knowledge Deficit Nursing Interventions NCP Rheumatoid Arthritis:

1. Review the process of disease, prognosis, and future expectations.
Rationale: Provides knowledge that patients can make informed choices.

2. Discuss the habits of the patient in pain management through diet, medication, and a balanced diet, exercise and rest.
Rationale: The purpose of control is to suppress inflammatory disease self / other tissue to maintain joint function and prevent deformities.

3. Assist in planning a realistic schedule of activities integrated, rest, personal care, administration of medication, physical therapy, and stress management.
Rationale: Provide structure and reduce anxiety at the time of handling complex chronic disease processes.

4. Emphasize the importance of continuing medication management.
Rationale: The advantage of drug therapy depends on the accuracy of dose.

5. Encourage digest medicine with food, milk, or an antacid at bedtime.
Rationale: Limiting gastric irrigation, reduction of pain in the HS will improve sleep and reduce morning stiffness.

6. Emphasize the importance of reading product labels and reduce the use of drugs are sold freely without doctor's approval.
Rationale: Many products contain hidden salicylates may increase the risk of a decent pint of drugs / dangerous side effects.

7. Review the importance of a balanced diet with foods rich in vitamins, protein and iron.
Rationale: Increased sense of well-general and tissue repair.

8. Encourage obese patients to lose weight and weight loss provide information as needed.
Rationale: Weight loss will reduce the pressure on the joints, especially the hips, knees, ankles, feet.

9. Provide information about the tools
Rationale: Reduce compulsion to use the joints and allows individuals to participate more comfortably in activities that are needed.

10. Discuss energy saving techniques, eg sitting than standing for preparing food and bathing.
Rationale: Prevent fatigue, providing ease of self-care, and independence.

11. Push maintain correct posture both at rest and during activity, such as keeping the joints remain stretched, no flexion, using a splint for the specified period, placing hands near the center of the body during use, and shifting rather than lifting if possible.
Rationale: good body mechanics should be part of the patient's lifestyle to reduce joint stress and pain

12. Review the need for frequent inspection of the skin and other skin care under the bandage, plaster, backer tool. Indicate giving proper bearings.
Rationale: Reduce the risk of irritation / skin breakdown.

13. Discuss the importance of continued drug / laboratory test.
Rational: drug therapy requires assessment / continuous improvement to ensure optimal effect.

14. Give sexual counseling as needed
Rationale: Information on different positions and techniques or other options for sexual fulfillment may improve personal relationships and a sense of self esteem / confidence

15. Identify community resources, eg: arthritis foundation (if any).
Rationale: Help / support from others to increase the maximum recovery.

Acute Pain - Hydatidiform Mole

Acute Pain Nursing Care Plan Hydatidiform Mole

Nursing Diagnosis for Hydatidiform Mole: Acute Pain

Objective: Clients will show pain reduced / lost

Expected outcomes:
  • Clients say the pain is reduced / lost
  • Calm facial expression
  • Vital signs are within normal limits

Nursing Intervention:

1. Assess the level of pain, location and scale of pain, perceived client.
Rationale: Knowing the level of pain that is felt so it can help determine appropriate interventions.

2. Observation of vital signs every 8 hours
Rationale: Changes in vital signs, especially temperature and pulse rate is one indication of increased pain experienced by the client.

3. Instruct client to perform relaxation techniques
Rationale: Relaxation techniques can make the client feel comfortable and a little distraction to divert the attention of clients to pain so that they can help children reduce the pain.

4. Give a comfortable position
Rationale: a comfortable position to avoid an emphasis on the area of ​​injury / pain.

5. Collaboration of analgesic
Rational: analgesic drugs block the pain receptors so that the pain can not be perceived.

Risk for Ineffective Tissue Perfusion - NCP Gastritis

Nursing Care Plan for Gastritis

Gastritis is an inflammation of the stomach lining. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections.

In some cases, the stomach lining may be "eaten away," leading to sores (peptic ulcers) in the stomach or first part of the small intestine. Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). In most cases, gastritis does not permanently damage the stomach lining.

Risk Factors:
  • Infection with H. pylori
  • Acquired immunodeficiency syndrome (AIDS)
  • Any condition that requires relief from chronic pain using NSAIDS, such as chronic low back pain, fibromyalgia, or arthritis
  • Alcoholism
  • Cigarette smoking
  • Older age
  • Herpes simplex virus or cytomegalovirus
  • Inflammatory bowel disease

Signs and Symptoms:

The most common symptoms of gastritis are stomach upset and pain. Other possible symptoms include:
  • Indigestion (dyspepsia)
  • Heartburn
  • Abdominal pain
  • Hiccups
  • Loss of appetite
  • Nausea
  • Vomiting, possibly of blood or material that looks like coffee grounds
  • Dark stools

Risk for ineffective Tissue Perfusion - Nursing Care Plan Gastritis



Nursing Diagnosis: Risk for Ineffective Tissue Perfusion related to Hypovolemia

Nursing Intervention:

1. Investigate changes in level of consciousness, complaining of dizziness / headaches.
Rationale: The change may indicate inadequate cerebral perfusion as a result of artery blood pressure.

2. Investigate complaints of chest pain
Rationale: May indicate cardiac ischemia in relation to decreased perfusion.

3. Assess skin to cold, pale, sweating, slow capillary refill and peripheral pulses are weak.
Rational: Sympathetic Vasoconstriction is a response to the decline in circulating volume and / or can occur as a side effect of vasopressin administration.

4. Record the output of urine specific gravity and
Rationale: Decreased systemic perfusion can lead to ischemia / renal failure manifested by decreased urine output.

5. Record report abdominal pain, particularly sudden, severe pain or pain spreading to the shoulders.
Rationale: Pain caused by gastric ulcers are often lost after acute hemorrhage due to buffer the effects of the blood. Severe pain persists or suddenly can show respect to ischemia vasokinstriksi therapy.

6. Observation for pale skin, redness, massage with oil. Change positions frequently
Rational: disturbances in the peripheral circulation increases the risk of skin damage.

collaboration
7. Provide supplemental oxygen as indicated
Rational: treat hypoxemia and lactic acidosis during acute hemorrhage.

8. Give IV fluids as indicated
Rational: to maintain circulating volume and perfusion.

Imbalanced Nutrition Less Than Body Requirements - Diabetes Mellitus

Nursing Care Plan Diabetes Mellitus Imbalanced Nutrition Less Than Body Requirements

Nursing Diagnosis for Diabetes Mellitus: Imbalanced Nutrition Less Than Body Requirements related to an increased metabolism of proteins, fats.

Goal: patient's nutritional needs can be met.

the expected outcomes:
Patients can ingest calories or nutrients right.
Stable weight or addition to the usual range.

Nursing Interventions imbalanced Nutrition Less Than Body Requirements - Nursing Care Plan for Diabetes Mellitus

Independent

1. Measure weight as indicated.
Rational:
Assessing adequate food intake.

2. Determine the diet program, diet, and compare it with foods that can be spent on the client.
Rational:
Identify deficiencies and irregularities of therapeutic needs.

3. Auscultation of bowel sounds, record abdominal pain, or abdominal bloating, nausea, vomiting and maintain a state of fasting as indicated.
Rational:
Hyperglycemia, fluid and electrolyte balance disorders decrease gastric motility or function (distension or paralytic ileus).

4. Give liquid foods that contain nutrients and electrolytes. Furthermore, providing a more solid foods.
Rational:
Oral feeding is better given to the client's conscious and gastrointestinal function well.

5. Identify the preferred food.
Rational:
Cooperation in planning meals.

6. Involve the family in meal planning.
Rational:
Increase the sense of involvement, providing information to families to understand the nutritional needs of the client.

7. Observation sign of hypoglycemia (altered levels of consciousness, or cold clammy skin, rapid pulse, hunger, sensitive stimuli, anxiety, headache, dizziness).
Rational:
On carbohydrate metabolism (blood sugar will be reduced and while still given insulin, the hypoglycemic events occurred without showing changes in level of consciousness.

Collaboration

8. Make checks blood sugar with a finger stick.
Rational:
Analysis on a bed of blood sugar monitoring is more accurate than the sugar in the urine.

9. Monitor laboratory tests (blood glucose, acetone, pH, HCO3)
Rational:
Blood sugar decreases slowly with the use of fluid and insulin therapy can be controlled so that glucose enter the cells and be used for a source of calories. Currently, acetone levels decreased and acidosis can be corrected.

10. Give regular insulin treatment with iv
Rational:
Regular insulin has a rapid onset and quickly too helps move glucose into the cells. Giving through IV because of absorption from the subcutaneous tissue is very slow.

11. Give glucose solution (destroksa, half normal saline).
Rational:
Glucose solution was added after insulin and blood sugar liquids carrying about 250 mg / dl. With nearly normal carbohydrate metabolism, care be taken to avoid hypoglycemia.

12. Consultation with a dietician.
Rational:
Useful in calculating and adjusting the diet to meet nutritional needs.


Defining Characteristics of Imbalanced Nutrition Less than Body Requirements

Imbalance Nutrition Less than Body Requirements related to psychological factors

Disturbed Sleep Pattern NCP Alzheimer's Disease



Signs and Symptoms of Alzheimer's Disease

Mild Alzheimer's disease

As the disease progresses, memory loss worsens, and changes in other cognitive abilities are evident. Problems can include:
getting lost
trouble handling money and paying bills
repeating questions
taking longer to complete normal daily tasks
poor judgment
losing things or misplacing them in odd places
mood and personality changes

Moderate Alzheimer's disease

Symptoms may include:
increased memory loss and confusion, problems recognizing family and friends, inability to learn new things, difficulty carrying out tasks that involve multiple steps (such as getting dressed), problems coping with new situations, hallucinations, delusions, and paranoia, impulsive behavior

Severe Alzheimer's disease

Their symptoms often include:
inability to communicate, weight loss, seizures, skin infections, difficulty swallowing, groaning, moaning, or grunting, increased sleeping, lack of control of bowel and bladd


Nursing Diagnosis for Alzheimer's Disease: Disturbed Sleep Pattern related to changes in the sensory.
Nursing Care Plan for Alzheimer's Disease

Purpose:

Having given nursing care, the client is expected to change in sleep patterns can be resolved
the expected outcomes:
No changes in the behavior and appearance (agitated), Being able to create adequate sleep patterns with a decrease of the mind hovering (daydreaming), Being able to determine the cause of inadequate sleep.

Nursing Interventions:

1. Provide a comfortable environment for improving sleep (turn off the light, adequate ventilation, appropriate temperature. Avoiding noise)

2. Encourage exercise during the day and lower mental activity / physical in the afternoon.

3. Give the afternoon snack, warm milk, bath, and massage back.

4. Decrease the number of drinks the afternoon. Perform voiding before bed.

5. Encourage clients to listen to music.


Rational:

1. Cortical inhibition in the reticular information will be reduced during sleep, improving automatic response, thereby increasing cardiovascular response to noise during sleep.

2. Physical activity and mental fatigue that can lead to long increase confusion, programmed activities without excessive stimulation increased sleep time.

3. Increase relaxation with drowsiness.

4. Reduce the need for up to urinate during the night.

5. Lowering the sensory stimulation by blocking other sounds from the environment around that will inhibit sleep.

Impaired Gas Exchange - Pleural Effusion

Nursing Diagnosis for Pleural Effusion : Impaired Gas Exchange related to changes in capillary membrane - alveolar

Purpose:
  • Breathing the air in the balance between the concentration of arterial blood
The expected outcomes:
  • Showed an increase in ventilation and oxygen sufficient
  • Analysis of blood gases within normal limits.
Nursing Interventions:

Airway Management
  • Clear the airway
  • Encourage breathing long and lasting cough
  • Set the appropriate humidity
  • Set the position to reduce dyspnoea
  • Monitor frequency of breath associated with oxygen adjustment
Respiration Monitor
  • Monitor rate, rhythm, depth and effort to breathe
  • Note the movement of the chest, breast symmetry, using tools and intercostal muscle retraction
  • Monitoring nasal breathing, the snoring
  • Monitor breathing patterns, bradipneu, takipneu, hyperventilation, resirasi kusmaul, etc.
  • Palpation similarity lung expansion
  • Anterior and posterior chest percussion of both lungs
  • Monitor the diaphragm muscle fatigue
  • Auscultation breath sounds, record or ketidakadanya area reduction and ventilation and breath sounds
  • Monitor restlessness, anxiety and anger
  • Note the characteristic cough and duration
  • Monitor respiratory secretions
  • Dyspnoea and monitor the development and progression of events
  • Perform maintenance nebulized therapy if necessary
  • Place the patient laterally to prevent aspiration
Management Asid Base
  • Send a laboratory examination of acid-base balance (eg, blood gas analysis, urine and serum levels)
  • Monitor blood gas analyzer for low PH
  • Position the patient for optimum ventilation perfusion
  • Maintain the cleanliness of the air (suction and chest therapy)
  • Monitor respiration pattern
  • Monitor work pernafsan (respiratory rate).

Acute Pain related to Surgical Incision

Appendicitis Nursing Diagnosis Acute  Pain related to Surgical Incision
Nursing Care Plan for Appendicitis

Nursing  Diagnosis: Acute  Pain related to Surgical Incision

Purpose:
After nursing care, client comfort level increased, pain controlled with the expected outcomes:
  • Clients report reduced pain, pain scale 2-3
  • Calm facial expression, and can rest, sleep.
  • Vital signs are within normal limits.
Nursing  Intervention for Appendicitis : Acute  Pain related to Surgical Incision

Pain Management:
  • Assess pain comprehensively including location, characteristics, duration, frequency, quality factor and precipitation.
  • Observation of nonverbal reactions inconvenience.
  • Use therapeutic communication techniques to determine the client's experience of pain before.
  • Provide a quiet environment
  • Reduce pain precipitation factor.
  • Teach non-pharmacological techniques (relaxation, distraction, etc.) to overcome the pain.
  • Give analgesics to reduce pain.
  • Evaluation of pain reducers / pain control.
  • Collaboration with the doctor if there are complaints about the administration of analgesics to no avail.
  • Monitor client's acceptance of pain management.
Analgesic  Administration:.
  • Check program providing analgesic; types, dosage, and frequency.
  • Check history of allergy.
  • Determine the analgesic of choice, route of administration and optimal dosage.
  • Monitor vital signs
  • Give analgesics on time especially when pain appears.
  • Evaluation of analgesic efficacy, side effects signs and symptoms.

NANDA Nursing