List of Nursing Diagnosis

Nursing Diagnosis for Hypertension:

Acute Pain (headache) related to increased cerebral vascular pressure

Purpose:

• Having given nursing care, pain expectancy is reduced / controlled.

Expected outcomes:

• Clients reported pain / discomfort disappeared / controlled.

Nursing Intervention for Hypertension - Acute Pain :

1. Maintain bed rest during the acute phase.

2. Give non-pharmacological measures to relieve headaches eg, a cold compress on the forehead, neck and back massage, quiet, Dim the room lights room lights, relaxation techniques (your imagination, diktraksi) and leisure time activities.

3. Eliminate / minimize vasoconstriction activity can increase headache eg, straining during defecation, coughing and bending length.

4. Assist patients in ambulation as needed.

5. Berikancairan, soft foods, regular oral care in the event of bleeding nose or nasal pack has been done to stop the bleeding.

6. Collaboration of analgesic drugs.

Rational:

1. Minimizing stimulation / enhance relaxation.

2. Measures that reduce cerebral vascular pressure and that slow / block sympathetic responses are effective in eliminating the headaches and complications.

3. Activities that enhance vasoconstriction causing headaches in the increased cerebral vascular pressure.

4. Dizziness and blurred vision often associated with pain also experience episodes kepala.pasien postural hypotension.

5. Improve comfort umum.kompres nose can disrupt the ingestion or require breath with your mouth, causing stagnation oral secretions and mucous membranes dry out.

6. Lose / control pain and reduce sympathetic nervous system stimulation.

Nursing Diagnosis: Activity Intolerance related to general weakness, imbalance between supply and oxygen demand.

Purpose:

• Having given nursing care, the client is expected to be able to do activities that are tolerated

Expected outcomes:

• Clients participate in activities desired / required.
• Reported an increase in tolerance activity can be measured.
• Showed a decrease in physiological signs of intolerance.

Intervention Activity Intolerance - Hypertension Care Plan :

• Assess the client's response to the activity, attention pulse rate more than 20 times per minute in the frequency of breaks; significant increase in BP during / after activity, dyspnea, chest pain; excessive fatigue and weakness; diaphoresis; dizziness or fainting.
• Instruct patients about energy saving techniques, eg, using the bath seat, sitting as combing hair or brushing teeth, doing activities slowly.
• Encourage activity / self-care gradually if tolerated. Provide assistance as needed.

Rational:

• Mention parameter helps in assessing response to stress physiology and activity when there is an indicator of excess work-related activity levels.
• Energy saving techniques reduce energy penggurangan also helps balance between supply and oxygen demand.
• Progress activity increased gradually to prevent sudden cardiac work, provide only limited assistance needs will encourage independence in their daily activities.

Nursing Diagnosis Ineffective Individual and Family Coping related to the prognosis of the disease, the false self-image, change roles.

Goal: Individuals or families are able to develop positive coping.

Nursing Intervention:

1. Assess changes in perceptions of disorder and relationship to the degree of disability.
R / determine individual assistance in preparing nursing plans, or the selection of interventions.

2. Identify the meaning of the loss or dysfunction of the client
R / multiple clients can accept and manage change effectively function with minimal adjustment, while others have difficulty comparing recognize and manage shortages.

3. Encourage clients to express their feelings, including hostility and anger.
R / indicates acceptance helps clients to remember and begin to adjust to the feeling.

4. Note when the client states affected like dying or avoid and declare this is death.
R / supports the rejection of the parts of the body or negative feelings about body image and the ability to show the need and intervention as well as emotional support.

5. Provide information on the health status of clients and families.
R / clients with hemophilia often need help in dealing with chronic conditions, life space limitations and the fact that the condition is a disease that will be handed down to the next generation.

6. Supports effective coping mechanisms.
R / since childhood helped clients to accept himself and his illness and to identify positive aspects of their lives. They should be encouraged to be brave and be independent to prevent trauma that can cause acute bleeding episodes and disrupt normal activities.

7. Avoid emotional stress enhancement factor.
R / nurse should know the effect of stress is professionally and personally, and explore all sources of support for themselves as well as for clients and their families.

8. Assist and encourage good maintenance and repair habits.
R / help boost self-esteem and feelings of control over one area of ​​life.

9. Encourage people closest to allow clients do as much stuff for him.
R / revive the feeling of independence and fosters self-esteem and affect the rehabilitation process.

10. Support efforts such behavior or increased interest or participation in rehabilitation activities.
R / improve the independence to help meet the physical needs and indicate the position to be more active in social activities.

11. Monitor sleep disturbances increasing concentration difficulties, lethargy, and low self-esteem.
R / can identify the occurrence of depression generally occurs as the result of a stroke that requires intervention and further evaluation.

12. Collaboration: refer patients to specialists neuropsychology and counseling when indicated.
R / mempasilitasi can change an important role for the development of feelings.

Nursing Diagnosis for CVA - Stroke: Ineffective Cerebral Tissue Perfusion  related to inadequate cerebral blood supply, occlusive disorder, hemorrhage, cerebral vasospasm, cerebral edema

Goal: Maintain adequate cerebral tissue perfusion

Evaluation Criteria:
a) Maintain the level of awareness
b) stable vital signs
c) No increase in ICT

Intervention:
a) Monitor / record neurological status
b) Monitor vital signs
c) Evaluation of the pupil, record the size, shape, equality and reaction to light
d) Put the head with a slightly elevated position
e) Maintain a state of bedrest.

Nursing Care Plan for Palatoschisis and Cheiloschisis

Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation.

A cleft lip or palate can be successfully treated with surgery, especially so if conducted soon after birth or in early childhood.

If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft). Lip cleft can occur as a one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft.

Nursing Diagnosis for Cheiloschisis and Palatoschisis

1. Imbalanced Nutrition, Less Than Body Requirements related to inability to ingest / difficulty in eating, secondary disability and surgery.
2. Risk for aspiration related to inability to secrete secretion, secondary Palatoschisis.
3. Risk for infection related to disability (before surgery) and or surgical incision.
4. Knowledge Deficit: family related to techniques of feeding and care at home.
5. Acute Pain related to surgical incision.
6. Ineffective airway clearance related to the effects of anesthesia, post-operative edema, increased secretions.
7. Impaired skin integrity related to surgical incision.

List of Nursing Diagnosis for Congestive Heart Failure

People with congestive heart failure sometimes do not suspect a problem with their heart or have symptoms that may not obviously be from the heart.

1. Early symptoms may include shortness of breath, cough, or a feeling of not being able to get a deep breath, especially when lying down.
2. If a person has a known breathing problem, such as asthma, chronic obstructive pulmonary disease (COPD), or emphysema, they may they are having an "attack" or worsening of that condition.
3. If a person usually does not have breathing problems, they may think they have a cold, flu, or bronchitis.
4. Any or several of these above conditions may coexist along with congestive heart failure.

List of Nursing Diagnosis for Congestive Heart Failure

1. Activity Intolerance related to insufficient oxygen for activities of daily living.

2. Anxiety related to breathlessness.

3. Imbalanced Nutrition: Less Than Body Requirements related to nausea; anorexia secondary to venous congestion of gastrointestinal tract and fatigue.

4. Impaired Peripheral Tissue Perfusion related to venous congestion secondary to right-sided heart failure.

5. Disturbed Sleep Pattern related to nocturnal dyspnea and inability to assume usual sleep position.

6. Powerlessness related to progressive nature of condition.

7. Risk for Ineffective Therapeutic Regimen Management related to lack of knowledge of low-salt diet, drug therapy (diuretic, digitalis vasodilators), activity program, signs and symptoms of complications.

8. Risk for Impaired Skin Integrity related to edema and decreased tissue perfusion.

Constipation

A situation where an individual experience or a higher risk of static in the large intestine, resulting in a rare bowel movements, hard, dry stools.

Related Factors

• Inadequate fluid intake
• Low-fiber diet
• Inactivity, immobility
• Medication use
• Lack of privacy
• Pain
• Fear of pain
• Laxative abuse
• Pregnancy
• Tumor or other obstructing mass
• Neurogenic disorders

Defining Characteristics

• Infrequent passage of stool
• Passage of hard, dry stool
• Straining at stools
• Passage of liquid fecal seepage
• Frequent but nonproductive desire to defecate
• Anorexia
• Abdominal distention
• Nausea and vomiting
• Dull headache, restlessness, and depression
• Verbalized pain or fear of pain

Expected Outcomes

Individuals will:

   1. Describe the therapeutic program defecation
   2. reported or showed increased bowel elimination
   3. explain the rationale of intervention