List of Nursing Diagnosis

Nursing Care Plan for Anemia

Nursing Diagnosis : Risk for Infection

Definition : Increased risk of entry of pathogenic organisms.

Risk factors :

• Invasive procedures.
• Insufficient awareness to avoid exposure to pathogens.
• Trauma.
• Tissue damage and increased environmental exposure.
• Rupture of amniotic membranes.
• Pharmaceutical agents (immunosuppressants).
• Malnutrition.
• Increased exposure to environmental pathogens.
• Imonusupresi.
• Imum ketidakadekuatan made.
• Inadequate secondary defenses (decreased hemoglobin , Leukopenia , suppression of inflammatory response).
• Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary, static body fluids, secretions changes in pH, changes in peristalsis).
• Chronic disease.

Goal : increase the client 's immune status .

Outcomes :

• Free from signs and symptoms of infection.
• Demonstrated ability to prevent infection.
• The number of leukocytes within normal limits.
• Demonstrate healthy behavior.

NIC :

Infection Control

• Clean up the environment after use for other patients.
• Maintain isolation techniques.
• Limit visitors when necessary.
• Instruct visitors to wash their hands when leaving the visit and after visiting a patient.
• Use antimicrobial soap for hand washing.
• Wash hands before and after each nursing action.
• Use suit , gloves as protective gear.
• Maintain aseptic environment during the installation of equipment.
• Change the location of the peripheral IV and central line and dressing in accordance with the general instructions.
• Use intermittent catheters to decrease bladder infection.
• Increase the intake of nutrients.
• Provide antibiotic therapy if necessary.

Infection Protection

• Monitor signs and symptoms of systemic and local infections.
• Monitor granulocyte count, WBC.
• Monitor susceptibility to infection.
• Limit visitors.
• Filter visitors to infectious diseases.
• Partahankan aspesis technique in patients who are at risk.
• Maintain isolation techniques if necessary.
• Give the skin of the treatment area epidema.
• Inspection of skin and mucous membranes of the redness, heat, drainage.
• Inspection of the condition of the wound / incision surgery.
• Encourage enter adequate nutrition.
• Encourage fluid intake.
• Instruct the break.
• Instruct the patient to take antibiotics as prescribed.
• Teach the patient and family the signs and symptoms of infection.
• Teach how to avoid infection.
• Report suspicion of infection.
• Report positive cultures.

Anemia Definition

Anemia is characterized by levels of hemoglobin (Hb) and red blood cells (erythrocytes) is lower than normal. If the hemoglobin level is less than 14 g / dl and erythrocyte less than 41 % in men, then a man is said to be anemic. Similarly in women, women with hemoglobin levels less than 12 g / dl and erythrocyte less than 37 %, then the woman was said to be anemic. Anemia is not a disease, but rather a reflection of the state of a disease or disorder caused by the body's functions. Physiologically anemia occurs when there is a shortage of hemoglobin to carry oxygen to the tissues.

Anemia was defined as a decrease in the volume of red blood cells or hemoglobin level to below the range of accepted values ​​for healthy people. Anemia is a symptom of an underlying condition, such as loss of blood components, elements inadequate or lack of nutrients needed for the formation of blood cells, resulting in decreased oxygen-carrying capacity of the blood, and there are many types of anemia with different causes.

Etiology

1. Hemolysis (erythrocytes easily broken).
2. Bleeding.
3. Bone marrow suppression (eg by cancer).
4. Nutrient deficiency (nutritional anemia), including iron deficiency, folic acid, pyridoxine, vitamin C and copper.

According to various sources the causes of anemia include:

1. Less consumption of foods containing iron, vitamin B12, folic acid, vitamin C, and the elements necessary for the formation of red blood cells.
2. Excessive menstrual blood. Women who are menstruating prone to iron deficiency anemia when much menstrual blood and not enough iron stores.
3. Pregnancy. Pregnant women are prone to anemia because the fetus to absorb iron and vitamins for growth.
4. Certain diseases. Diseases that cause continuous bleeding in the digestive tract such as gastritis and appendicitis can lead to anemia.
5. Certain drugs. Several types of medications can cause stomach bleeding (aspirin, anti- inflammatory, etc.). Other drugs can cause problems in the absorption of iron and vitamins (antacids, birth control pills, antiarthritis, etc.).
6. Retrieval operation of part or all of the stomach (gastrectomy). It can cause anemia because the body absorbs less iron and vitamin B12.
7. Chronic inflammatory diseases such as lupus, rheumatoid arthritis, kidney disease, thyroid gland problems, some types of cancer and other diseases can cause anemia because they affect the process of the formation of red blood cells.
8. In children, anemia can occur due to hookworm infection, malaria, or dysentery that caused a severe shortage of blood.

Pathophysiology

The presence of an anemia marrow reflects the existence of a failure or loss of red blood cells or both. Marrow failure (for example, reduced erythropoiesis) can occur as a result of nutritional deficiencies, toxic exposure , tumor invasion or other unknown causes.

Red blood cells can be lost through bleeding or hemolysis (destruction).
Red blood cell lysis (dissolution) occurs primarily in phagocytic cells or in the reticuloendothelial system, mainly in the liver and spleen. Byproducts of this process is bilirubin that would enter the bloodstream. Any increase in red blood cell destruction (hemolysis) immediately reflected by an increase in plasma bilirubin (normal concentration of ≤ 1 mg / dl, levels above 1.5 mg / dl result in jaundice in the sclera).

If the destruction of red blood cells in the circulation experience, (in hemolytic disorders) then it will appear in the plasma hemoglobin (hemoglobinemia). If the plasma concentration exceeds the capacity of plasma haptoglobin ( protein binding to free hemoglobin ) to bind everything, hemoglobin diffuses in the renal glomerulus and into the urine (hemoglobinuria).

Conclusions about whether an anemia in patients caused by destruction of red blood cells or red blood cell production is not sufficient usually be obtained on the basis of : 1 . reticulocyte count in the blood circulation ; 2 degree of the proliferation of young red blood cells in the bone marrow and maturation ways, as seen in the biopsy ; and presence or absence of hyperbilirubinemia and hemoglobinemia.


Signs and Symptoms

1. Weak, tired, lethargic and tired.
2. Often complain of headache and dizziness.
3. Further symptoms such as eyelids, lips, tongue, skin and palms became pale. Pale because of lack of blood volume and hemoglobin, vasoconstriction.
4. Tachycardia and heart murmur (an increase in blood flow velocity) Angina (chest pain).
5. Dyspnea, shortness of breath, tired quickly when activity (reduced O2 delivery).
6. Headache, weakness, tinnitus (ringing in the ears) illustrates the reduced oxygenation of the CNS
7. Severe anemia GI disorders, and CHF (anorexia, nausea, constipation or diarrhea).

Complication 

• Heart failure.
• Seizures.
• Poor muscle development (long-term).
• Concentration decreases.
• The ability to process information that is heard decrease.

Test

• Hemoglobin concentration, hematocrit, red blood cell indices, white blood cell studies, the levels of Fe, iron binding capacity measurement, folate, vitamin B12, platelet count, bleeding time, prothrombin time, and partial thromboplastin time.
• Bone marrow aspiration and biopsy. Unsaturated iron - binding capacity of serum.
• Diagnostic assay to determine the presence of acute and chronic diseases as well as the source of chronic blood loss.

Nursing Care Plan for Anemia

Nursing Diagnosis for Anemia

1. Ineffective Cerebral Tissue Perfusion related to changes in the oxygen bond with hemoglobin, decrease in hemoglobin concentration in the blood.
2. Imbalance nutrition less than body requirements related to inadequate food intake .
3. Self-care deficit related to weakness
4. Risk for infection related to inadequate secondary defenses (decreased hemoglobin )
5. Activity intolerance related to imbalance between supply and demand of oxygen .
6. Impaired gas exchange related to ventilation perfusion .
7. Ineffectivene breathing pattern related to fatigue .
8. Fatigue related to anemia .

Nursing Care Plan for Lower Back Pain (LBP)


Low Back Pain is chronic pain in the lumbar, usually caused by a recessive the vertebral muscles, herniation and regeneration of the nucleus pulposus, osteoarthritis of the lumbar sacral spine (Brunner, 1999).

Causes

• Changes in posture usually because primary and secondary trauma. Primary trauma such as : Trauma spontaneously, for example accidents. Secondary trauma such as : HNP, osteoporosis, spondylitis, spinal stenosis, spondylitis, osteoarthritis.
• Lumbosacral ligament instability and muscle weakness.
• Procedures degeneration in elderly patients.
• The use of heels that are too high.
• Obesity.
• Lifting weights the wrong way.
• Sprain.
• Prolonged exposure to vibration.
• Gait.
• Smoking.
• Sitting too long.
• Less exercise (by sport).
• Depression / stress.
• Sports (golp, tennis, soccer).

Risk Factors of Low Back Pain

Physiological risk factors.

• Age ( 20-50 years ).
• Lack of physical exercise.
• Less anatomical postures.
• Obesity.
• Severe scoliosis.
• HNP.
• Spondylitis.
• Spinal stenosis (narrowing of the spine).
• Osteoporosis.
• Smoking.

Environment risk factors .

• Sitting too long.
• Prolonged exposure to vibration.
• Sprains or twisted.
• Sports ( golf, tennis, gymnastic, and football).
• Vibration old.

Psychosocial risk factors.

• Inconvenience of work.
• Depression.
• Stress.

Clinical Manifestations

Changes in gait.

• Walking stiff.
• No bias play back.
• Lame.

Innervation

• When tested with a light and a touch of the pin, the patient felt a sensation on both limbs, but having a stronger sensation in areas that are not stimulated.
• Uncontrolled defecation and urination.

Pain.

• Acute and chronic back pain for more than two months.
• Pain when walking with the heel.
• Pain in the muscles.
• Lower back pain gets spread legs.
• Painful heat on the back of the thigh or calf.
• Severe pain in the feet increases.

Nursing Care Plan for Lower Back Pain

Nursing Diagnosis : Disturbed Sleep Pattern related to pain, discomfort

Defining characteristics :

• Patients appear to endure pain ( moaning, grinning )
• Patients express can not sleep because of pain .

Goal : sleep needs can be met.

Outcomes :

Sleep

• The amount of time to sleep enough.
• Normal sleep patterns.
• Enough quality sleep.
• Sleep on a regular basis.
• Not often awakened.
• Vital signs within normal limits.

Rest

• Adequate rest.
• The quality of a good rest.
• Enough physical rest.
• Enough psychic rest.

Anxiety control

• Adequate sleep.
• There is no physical manifestation.
• No behavioral manifestations.
• Seeking information to reduce anxiety.
• Using relaxation techniques to reduce anxiety.
• Interact socially.

Interventions for Lower Back Pain

Improved sleep / Sleep Enhancement

1. Assess patterns of sleep / activity patterns.
2. Encourage clients to sleep on a regular basis.
3. Explain the importance of adequate sleep during illness and treatment.
4. Monitor sleep patterns and note the physical, psychosocial disrupt sleep.
5. Discuss on the client and family about the technical improvement of sleep patterns.

Environmental management

1. Limit visitors.
2. Take care of the noisy environment.
3. No nursing action when clients sleep.

Anxiety Reduction

1. Explain all procedures including the feelings that may be experienced while undergoing the procedure.
2. Give the object that can provide a sense of security.
3. Speaking slowly and calmly.
4. Build a trusting relationship.
5. Listen attentively clients.
6. Create an atmosphere of mutual trust.
7. Encourage parents to express feelings, perceptions and anxiety verbally.
8. Provide equipment / entertaining activities to reduce tension.
9. Suggest to use relaxation techniques.
10. Provide a quiet environment.
11. Limit visitors.

Nursing Care Plan for Asthma

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

Goal :
Clients are able to :

• Respiratory Status: Ventilation.
• Respiratory status : Airway patency.
• Vital sign status.

Outcomes :

• Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips)
• Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
• Vital signs within normal range (blood pressure, pulse, respiration).

NIC :

Airway Management

• Open the airway , use techniques jaw thrust or chin lift if necessary.
• Position the patient to maximize ventilation.
• Identification of the patient's need for installation of an artificial airway.
• Attach mayo if necessary.
• Perform chest physiotherapy if necessary.
• Remove secretions by coughing or suctioning.
• Auscultation of breath sounds, note the presence of additional noise.
• Perform suction on orofaringeal airway.
• Give a humidifier.
• Set intake to optimize fluid balance.
• Monitor respiration and O2 status.

Oxygen Therapy

• Clean the mouth, nose and trachea.
• Maintain a patent airway.
• Set oxygenation equipment.
• Monitor the flow of oxygen.
• Maintain the position of the patient.
• Observe for signs of hypoventilation.
• Monitor the presence of the oxygenation of the patient's anxiety.

Monitoring vital signs

• Monitor BP , pulse , temperature , and RR .
• Note the fluctuations in blood pressure .
• Monitor VS when the patient is lying down , sitting , or standing .
• Auscultation of blood pressure in both arms and compare .
• Monitor BP , pulse , RR , before , during , and after activity .
• Monitor the quality of the pulse .
• Monitor respiratory rate and rhythm .
• Monitor lung sounds .
• Monitor abnormal breathing pattern .
• Monitor temperature , color , and moisture.
• Monitor peripheral cyanosis .
• Monitor the presence of Cushing's triad ( widened pulse pressure , bradycardia , increased systolic ) .
• Identify the cause of vital sign changes

The most frequent cause of dementia is Alzheimer's disease. The cause of Alzheimer's disease is unknown , but is thought to involve genetic factors, because the disease seems to be found in some families and is caused or influenced by some specific gene abnormality. In Alzheimer's disease, some parts of the brain decline, resulting in cell damage and reduced response to a chemical that transmits signals in the brain.

By: Silvia (2006 ) , dementia associated with some types of diseases as follows :

• Diseases associated with medical syndromes : These include hypothyroidism, Cushing's disease, nutritional deficiencies, AIDS dementia complex, and so on.
• Diseases associated with neurological syndromes : This group includes Huntington's chorea, Schilder's disease, and other demyelinating processes ; Creutzfeldt- Jakob disease ; brain tumors ; brain trauma ; the brain and meningeal infection ; and others.
• Disease with dementia as the only sign of conspicuous : Alzheimer's disease and Pick's disease are included in this category.
• Dementia in terms of anatomy to distinguish between cortical dementia and subcortical dementia. Of the etiology and course of the disease to distinguish between reversible and irreversible dementia.

According to (Silvia , 2006) In general, signs and symptoms of dementia are as follows :

• Decline in memory that continues to happen. In patients with dementia , " forget " become a part of daily life that can not be separated.
• Impaired orientation time and place, for example : forget the day, week, month, year, place of people with dementia are.
• The decline and inability to arrange words into a correct sentence, using words that are not appropriate for a condition, repeat the word or the same story many times.
• Excessive expression, such as excessive crying when she saw a television drama, furious at small mistakes committed by others, fear and nervousness unwarranted. People with dementia often do not understand why these feelings arise.
• A change in behavior, such as : indifferent, withdrawn and anxious.

At first the disease is damaging the nerves cells in the brain that regulate memory, particularly in the hypothalamus and related structures. When the nerve cells of the hypothalamus stops functioning properly, there is a failure of short -term memory, followed by a failure of the ability to perform actions and tasks as usual. The disease is also on the cerebral cortex, particularly the areas responsible for language and thought. A loss of language skills, lower the person's ability to make decisions, and the resulting changes in personality. Explosive emotions and behavioral disorders, such as walking without purpose and agitation began to arise, and the more slowly over the course of the disease (Sylvia, 2005). Finally, many areas are involved, the atrophy and the patient is usually unable to interact with others, and very dependent on other people to do the most basic personal tasks, such as eating, drinking, defecation urination, and defecation. Macroscopically, the brain changes in this disease involves severe damage to cortical and hypothalamic neurons, and amyloid accumulation in the intracranial vessels. Morphological changes consist of two characteristic lesions that eventually evolved into soma degeneration, axons and dendrites of neurons (Wiwik, 2005). One sign of lesion is neurofibrillary tangles, the intracellular structures containing fibers tangled, twisted, which is composed mostly of proteins. In the central nervous system, most of these proteins have been studied as inhibitors structurally related shaper in stabilizing microtubules and is an important component of the cytoskeleton of neuronal cells (Muttaqin, 2008).

According Silvia, (2006), a complication that will arise are as follows :

• Acute or chronic disease, such as congestive heart failure, pneumonia, kidney and liver disease, cancer and stroke.
• Hormonal and nutritional factors, diabetes, adrenal imbalance, or thyroid, malnutrition and dehydration.
• Sensory damage associated with loss of vision and hearing as well as sleep deprivation.
• Treatment, including taking a variety of medications, prescription (especially the drug combinations that are anticholinergic).
• Drugs that interfere with the cholinergic system, and the neurotransmitter acetylcholine can affect memory, learning ability.

7 Nursing Diagnosis for Dementia

1. Relocation stress syndrome
related to changes in the activities of daily life
Characterized by :
confusion, concern, anxiety, looking anxious, irritable, defensive behavior, mental confusion, suspicious behavior, and aggressive behavior.

2. Disturbed Thought Process related to physiological changes (irreversible neuronal degeneration)
Characterized by :
memory loss or memory, loss of concentration, not able to interpret the stimulation and assess reality accurately.

3. Disturbed Sensory perception related to changes in perception, transmission or sensory integration (neurological disease, unable to communicate, sleep disorders, pain)
Characterized by :
anxiety, apathy, anxiety, hallucinations.

4. Distrubed Sleeping Pattern related to changes in the environment
Characterized by : a verbal complaint about difficulty sleeping, constantly awake, not able to determine the needs / sleep time.

5. Self-care Deficit related to activity intolerance, decreased endurance and strength
Characterized by :
decreased ability to perform activities of daily living.

6. Risk for injury related to the difficulty of balance, weakness, uncoordinated muscle, seizure activity.

7. Risk for Imbalanced Nutrition Less Than Body Requirements related to forgetfulness , setbacks hobby , sensory changes .

Nursing Care Plan for Dementia

One of the degenerative disease is dementia, ie which have insidious onset and progressive in general, be getting worse. Overview of various aspects of specialty include loss of intellectual abilities such as memory, judgment, abstract thought, and other higher cortical functions , as well as changes in keperibadian and behavior (Townsend , 2000) .

Dementia is a clinical syndrome that includes loss of intellectual function and memory were so serious that it causes dysfunction of everyday life. Dementia is a condition when a person experiences memory loss and other thinking power which significantly interfere with daily activities (Arif muttaqin, 2008) .

Nursing Diagnosis : Disturbed Thought Process related to physiological changes (irreversible neuronal degeneration).

Characterized by :

• memory loss,
• loss of concentration,
• not able to interpret the stimulation,
• not able to assess reality accurately.

Goal : expected to be able to recognize a change in thinking.

Outcomes :

• Able to demonstrate the ability to undergo cognitive consequences of stressful events on the emotions and thoughts of self.
• Able to develop strategies for overcoming negative self- perception.
• Be able to identify the behavior and the causes.

Interventions :

• Develop a supportive environment and nurse - client relationship is therapeutic.
• Maintain a pleasant and quiet environment.
• Face-to- face when talking to clients.
• Call client by name.
• Use a rather low voice and speak slowly to the client.

Rationale :

• Reduce anxiety and emotional.
• Noise is excessive sensory neurons that increase interference.
• Raises concern , especially in clients with perceptual disorders.
• The name is a form of self-identity and lead to the introduction of reality and the client.
• Increase understanding. High Speech and hard cause stress and confrontation that sparked an angry response.

Imbalanced Nutrition Less Than Body Requirements
related to :

• Decreased oral intake, discomfort in the mouth, nausea, vomiting.
• Decreased absorption of nutrients.
• Vomiting, anorexia, impaired digestion.
• Depression, stress, social isolation.

Outcomes : The client will :
consume the daily nutritional needs in accordance with the level of activity and metabolic demand.

Indicator :

• Explaining the importance of adequate nutrition.
• Identify gaps or deficiencies in the daily intake.
• Mention the methods to increase appetite.

Intervention


1. Explaining the need for the consumption of carbohydrates, fats, proteins, vitamins, minerals and adequate fluid.
2. Consult with a nutritionist to establish a daily calorie needs and the type of food that is in accordance with the client.
3. Discuss with the client the possible causes of loss of appetite.
4. Encourage clients to rest before eating.
5. Instruct food in small amounts but often .
6. On the condition of decreased appetite, limit fluid intake during meals and avoid consuming fluids one hour before and after meals.
7. Encourage and assist clients to maintain good oral hygiene.
8. Set the position of foods high in calories and high in protein are presented when the client is usually the most hungry.
9. Perform the following steps to increase appetite :

• Determine the client's food preferences and set it to the food presented whenever possible.
• Eliminate odors and unpleasant sight of the dining area.
• Control pain and nausea before eating.
• Instruct the nearest person is allowed to bring food from home if possible.
• Create a relaxing environment while eating.

10. Give the client a list of diet nutrient material , which consists of :

• High intake of complex carbohydrates and fiber .
• Reduction of the intake of sugar , salt , cholesterol , total fat and saturated fat .
• The use of alcohol only in moderation .
• Appropriate caloric intake to maintain ideal weight .

Constipation is a common digestive problem. Usually characterized by constipation bear or irregular bowel movements. In addition to people who suffer from constipation often experience bowel movement, and a knotted stomach ache. People who experience constipation defecate normally only 3 times a week or even less.

Usually constipation is only temporary. Lifestyle changes along with a proper diet, which contains lots of fiber and nutrients are able to overcome this.

To learn more about the constipation, please read the following description, from the symptoms, causes and ways of treatment.


Symptoms of Constipation

Signs and symptoms of constipation include:

• A bowel movement fewer than three times a week.
• Difficult defecation.
• Excruciating abdominal pressure when the movement of the intestine.
• Feeling of blockage in the rectum.
• The feeling was not finished after a bowel movement.

Causes and Risk Factors

Normally feces in the intestine is driven by the contraction of the intestinal muscles. In the large intestine the water and salt absorbed back because it is important for the body. But when the colon absorbs too much water, or colon muscle contractions slowly then the stool will be hard and dry so that the movement of the large intestine becomes too slow.

You may also experience constipation if the muscles are used to move the intestines do not function properly. This problem is called anismus.


A number of factors which led to, among others :

• Lack of fluids or dehydration.
• Lack of fiber in the diet.
• Lack of physical activity (especially in the elderly).
• Irritable bowel syndrome.
• Changes in lifestyle or routine, including pregnancy, aging and travel.
• Pain ('re having a disease).
• Frequent use or misuse of laxatives.
• Certain diseases, such as stroke, diabetes, thyroid disease, and Parkinson's disease.
• Problems in the colon and rectum, such as bowel obstruction or diverticulosis.
• Certain drugs.
• Hormonal disorders, such as thyroid gland is not active.
• Damage to the anal skin and hemorrhoid.
• The loss of salt levels in the body due to vomiting or diarrhea.
• Injury to the spinal cord, which can have an effect on the intestine.

In rare cases, constipation can be a sign that you are experiencing a serious medical condition, such as colon cancer, hormone disruption or interference with the autoimmune. In children, constipation may indicate Hirschsprung disease - nerve cells lost condition inborn.


Prevention

There is a saying that prevention is better than cure . And here's how to prevent constipation or constipation :

• Eating foods rich in fiber .
• Limit foods low in fiber .
• Drinking enough.
• Regular exercise .
• Do not delay when you want to defecate .
• Try fiber supplements .
• Be careful in choosing a laxative .

Causes of Constipation In Pregnancy

1. Increased Progesterone.
Progesterone plays a role in the process of relaxation of the smooth muscle work. Increased hormone (progesterone), resulting in movement or mobility of the digestive organs become relaxed or be slow. As a result, the process so much longer gastric emptying and transit time of food in the stomach increases. In addition, intestinal peristalsis (intestinal massage, one of the activities of digesting food) also slowed down so that the thrust and contraction of the intestines to weaken the leftovers. As a result, food waste accumulates in the colon longer and difficult to remove.

2. Pressure rectum.
The growing pregnant belly, also advanced impact, namely the rectum (the lower part of the colon) depressed. The pressure makes the feces becomes smooth, so that constipation occurs.

3. Enlarged abdomen. 
Maternal abdominal swelling , causing the pressure of the uterus on the pelvic veins and inferior vena cava (a large vein on the right side of the body, which receives blood flow from the lower body). Pressure was increasingly affect the working system of the small intestine and colon. That is why, constipation often occurs in the third trimester of pregnancy, when belly bigger.

4. Less fiber.
Body needs fiber for the digestive system. Facilitate fiber intake work in breaking down food digestion, to remove feces or dirt. In a normal person once, lack of fiber can cause constipation. Moreover, in pregnant women is a special condition.

5. Not exercising.
Exercise makes the body healthy and launch a process of metabolism in the body. Exercising on a regular basis, for example, walking or swimming, will stimulate the muscles of the stomach and intestines, one of them, triggering intestinal peristalsis, thereby preventing constipation.

6. Consuming iron. 
Consumption of high doses of iron, for example, from supplements, took part in causing constipation.

Nursing Care Plan for Pneumonia


Nursing Diagnosis 1. Ineffective Airway Clearance related to excessive secretions secondary to infection.

Goal : demonstrate a patent airway with breath sounds clean.

Interventions :
1. Assess the frequency / depth of breathing and chest movement.
Rationale : tachypnea , shallow breathing and chest movement is not symmetrical movements often occur due to discomfort or chest wall and the lung fluid.

2. Auscultation of the lung area, note areas of decreased / no air flow and breath sounds crackles.
Rationale : reduction in air flow occurs in the area of ​​consolidation with fluid, crackles audible in response to fluid collection, secret.

3. Provide warm water rather than cold water.
Rationale : warm fluid mobilizing and removing secret.

4. Collaboration of mucolytic , expectorant.
Rationale : helps reduce bronchospasm with secret mobilization.



Nursing Diagnosis 2. Acute Pain related to inflammation of the lung parenchyma.

Goal : pain diminished or disappeared.
Interventions :
1. Determine the characteristics of the pain, ie sharp, stabbed, constant.
Rationale : Chest pain is usually present in some degree in pneumonia, a complication of pneumonia can also occur as pericarditis and endocarditis.

2. Monitor vital signs.
Rationale : changes in heart rate or BP indicates that the patient is experiencing pain.

3. Provide convenient measures, such as : relaxation, massage your back.
Rationale : non- analgesic action is given with a gentle touch can eliminate the discomfort and increase the therapeutic effect of analgesics.

4. Collaboration in analgesic administration.
Rationale : expected to help reduce pain.



Nursing Diagnosis 3. Ineffective Breathing Pattern related to excessive secretion secondary to infection.

Goal : maintain adequate ventilation.

Interventions :
1. Assess the frequency, depth of breathing.
Rationale : tachypnea, shallow breathing often occurs due to discomfort or movement of the chest wall and the lung fluid.

2. Auscultation of breath sounds.
Rationale : indicates the occurrence of complications (additional sound indicates the presence of fluid accumulation / secretion).

3. Monitor vital signs.
Rationale : continuous vital sign abnormalities requiring further evaluation.

4. Collaboration of O2 as indicated.
Rationale : maintain PaO 2 above 60 mmHg.



Nursing Diagnosis 4. Imbalanced Nutrition Less Than Body Requirements related to decreased appetite secondary to nausea and vomiting.

Goal : show increased appetite .

Intrervention :
1. Identification of factors that cause nausea and vomiting.
Rationale : the choice of intervention depends on the causes of the problem.

2. Auscultation of bowel sounds.
Rationale : bowel sounds may be reduced / no if the infection is severe / elongated.

3. Feed small portions but frequently , including food attractive to patients.
Rationale : This action can increase appetite though slow to return.

4. Collaboration of antiemetics.
Rationale : expected to prevent vomiting.



Nursing Diagnosis 5. Activity Intolerance related to imbalance between oxygen supply and demand.

Goal : show increased tolerance to activity.

Interventions :
1. Evaluation of the patient's response to the activity.
Rationale : define needs and facilitate patient choice of intervention.

2. Provide quiet environment and limit visitors during the acute phase as indicated.
Rationale : reduce stress and excessive stimulation , increasing the break.

3. Help needed self-care activities.
Rationale : minimize fatigue and help balance supply and oxygen demand.



Nursing Diagnosis 6. Hyperthermia related to inflammatory lung parenchyma.

Goal : maintain the temperature within normal limits.

Interventions :
1. Monitor the patient's temperature.
Rationale : temperature 38.9 ° C - 41.1 ° C showed an acute infectious disease process.

2 . Give compress warm bath.
Rationale : can help reduce fever.

3. Collaboration of antipyretics.
Rationale : expected to help reduce fever by central action on the hypothalamus.



Nursing Diagnosis 7. Disturbed Sleep Pattern related to frequent waking tehadap secondary respiratory disorders, cough.

Goal : Sleep patterns of patients adequately.

Interventions :
1. Determine usually sleeping habits and changes that occur.
Rationale : the need to assess and identify appropriate interventions.

2. Give a comfortable bed.
Rationale : improve sleep comfort and psychological support.

3. Instruct relaxation action.
Rationale : to help induce sleep.

4. Provide a comfortable position, aids in changing positions.
Rationale : changing the position of the pressure change and improve rest area.


Nursing Diagnosis 8. Risk for Fluid Volume Deficits related to excessive fluid loss from vomiting.

Goal : demonstrate adequate fluid volume.

Interventions :
1. Assess changes in vital signs.
Rationale : the increase in temperature increases the metabolic rate and fluid loss through evaporation.

2. skin turgor , mucous membrane moisture.
Rationale : a direct indicator of the strength of the liquid volume.

3. Make a note of the report of nausea and vomiting.
Rationale : the presence of these symptoms indicate oral input.

4. Collaboration of antipyretics, antiemetics.
Rationale : useful decrease fluid loss.

Nursing Care Plan for Pneumonia

Definition

Pneumonia is a breathing condition in which there is an infection of the lung. Pneumonia is a common lung infection caused by bacteria, a virus or fungi.


Causes

Pneumonia can be caused by many types of germs.

• The most common type of bacterium is Streptococcus pneumoniae (pneumococcus).
• Viruses, such as the flu virus, are also a common cause of pneumonia.
• The bacterium called Pneumocystis jiroveci can cause pneumonia in people whose immune system is not working well.
• Atypical pneumonia, often called walking pneumonia, is caused by other bacteria.

Risk Factors

• Chronic lung disease (bronchiectasis, COPD, cystic fibrosis).
• Dementia, brain injury, cerebral palsy, stroke or other brain disorders.
• Cigarette smoking.
• Recent surgery or trauma.
• Immune system problem (during cancer treatment, or due to HIV/AIDS, organ transplant, or other diseases).
• Surgery to treat cancer of the neck, mouth, or throat.
• Other serious illnesses, such as heart disease, diabetes mellitus or liver cirrhosis.

Symptoms

• Fever.
• Chest pain that often feels worse when you cough or breathe in.
• Cough. You will likely cough up mucus (sputum) from your lungs. Mucus may be rusty or green or tinged with blood.
• Fast breathing and feeling short of breath.
• Fast heartbeat.
• Shaking and "teeth-chattering" chills.
• Nausea and vomiting.
• Feeling very tired or very weak.
• Diarrhea.

Nursing Diagnosis related to Pneumonia

1. Ineffective Airway Clearance related to excessive secretions secondary to infection.
Characterized by :

• Patients complained of cough sputum mixed,
• Patients seem a cough productive of sputum,
• Physical examination : percussion dullness, inspiratory rales, crackles loudly.

2. Acute Pain related to inflammation of the lung parenchyma.
Characterized by :

• The patient complains of chest pain,
• Looks grimacing,
• Examination of vital signs : increased pulse (tachycardia).

3. Ineffective Breathing Pattern related to excessive secretion secondary to infection.
Characterized by :

• Patients complain of difficulty breathing, shortness Looks,
• Examination of vital signs : respiration decreases,
• Physical examination : use of accessory muscles, bronchial breath sounds.

4. Imbalanced Nutrition Less Than Body Requirements related to decreased appetite secondary to nausea and vomiting.
Characterized by :

• Patients complained of nausea, loss of appetite and vomiting.

5. Activity Intolerance related to imbalance between oxygen supply and demand.
Characterized by :

• Patients complain of fatigue, difficulty breathing, looking weak, congested,
• Examination of vital signs : respiration decreases.

6. Hyperthermia related to inflammatory lung parenchyma.
Characterized by :

• Patients say the body heat,
• Looks chills,
• Examination of vital signs : temperature rise.

7. Disturbed Sleep Pattern related to frequent waking tehadap secondary respiratory disorders, cough.
Characterized by :
Patients say often wake up at night because of difficulty breathing and coughing, looked tired.

8. Risk for Fluid Volume Deficits related to excessive fluid loss from vomiting.

Nursing Diagnosis and Interventions for Hypoglycemia

Ineffective Airway Clearance related to airway obstruction / increase in tracheobronchial secretions.

Defining characteristics :

• Dyspnoea.
• Orthopnea.
• Cyanosis.
• Crackles / crepitations.
• Difficulty speaking.
• Cough is ineffective or non-existent.
• Eyes widened.
• Increased sputum production.
• Restless.
• Changes in the frequency and rhythm of breathing.

NOC :

Goal : Effective airway

Outcomes :

• Respiration Status : Patency Road Breath :
• Breath sounds clean.
• No cyanosis.
• No shortness of breath / dyspnea.
• The rhythm of breathing and respiratory rate within normal range.
• Do not feel suffocated.
• No cyanosis.
• No agitated.
• Sputum is reduced.

Respiratory Status : Ventilation

• Demonstrate effective cough.
• Breath sounds were clean.
• No cyanosis.
• No dyspnoea (able to breathe more easily).
• No pursed lips.

NIC / Intervention

Airway Suctioning :

1. Ensure suctioning needs .
2. Auscultation of breath sounds before and after suctioning.
3. Inform the client and family about suctioning.
4. Asking clients a deep breath before suctioning.
5. Give oxygen by nasal cannula to facilitate nasotracheal suctioning.
6. Use sterile equipment every action.
7. Encourage clients a deep breath and rest after the catheter is removed from the nasotracheal.
8. Monitor the status of the client oxygen.
9. Stop suction when the client showed bradycardia.

Airway Management :

1. Open the airway, use techniques chin lift or jaw thrust if necessary.
2. Position the client to maximize ventilation.
3. Identification of the need for client installation artificial airway.
4. Attach the OPA if necessary.
5. Perform chest physiotherapy if necessary.
6. Remove secretions by coughing or suctioning.
7. Auscultation of breath sounds, note the presence of additional noise.
8. Collaboration of bronchodilators if necessary.
9. Monitor respiration and oxygen status.

Cough Enhancement :

1. Monitor lung function, vital capacity, and maximal inspiration.
2. Encourage the patient to do deep breathing, coughing arrested last 2 seconds 2-3 times.
3. Encourage clients a deep breath several times, released slowly and cough at the end of expiration.

Oxygen Therapy :

1. Clean the secret in the mouth, nose and trachea / throat.
2. Maintain airway patency.
3. Explain to the client / family about the importance of giving oxygen.
4. Give oxygen as needed.
5. Select the appropriate equipment needs : nasal cannula 1-3 l / min, head box 5-10 l / min , etc..
6. Monitor O2 flow.
7. Monitor O2 hose.
8. Periodically check the O2 hose, humidifier, O2 flow.
9. Observation O2 deficiency signs : restlessness, cyanosis, etc..
10. Monitor signs of poisoning O2.
11. Maintain O2 during transport.
12. Instruct client / family to observe the O2 supply, water humidifier, if the report finished guard.

Adjusting the position

• Adjust the position of the patient semi-Fowler , head extension .
• Tilt the head when vomiting .

Cchest Physiotherapy

1. Determine the presence of contraindications chest physiotherapy .
2. Determine lung segments that require chest physiotherapy .
3. Position the client with lung segments which require drainage placed higher .
4. Use a pillow to help position the head .
5. Combine techniques posturnal percussion and drainage .
6. Combine fibrasi and posturnal drainage techniques .
7. Manage inhalation therapy .
8. Manage administration of a bronchodilator , mucolytics .
9. Monitor and type of sputum .
10. Encourage coughing before and after posturnal drainage .

Nursing Care Plan for Diabetes Mellitus

Nursing Diagnosis : Acute Pain related to injury of biological agents (decreased peripheral tissue perfusion)

NOC :

• level of pain
• pain controlled
• level of comfort

Clients can :
1 Controlling pain, with indicators :

• Know the factors that cause.
• Know the onset of pain.
• Non-pharmacological aid measures.
• Analgesic use.
• Reported pain symptoms to the health care team.
• Pain controlled.

2. Shows the level of pain, the indicator :

• Reported pain.
• Frequency of pain.
• The duration of pain episodes.
• The expression of pain ; face.
• Changes in respiration rate.
• Changes in blood pressure.
• Loss of appetite.

Interventions (NIC)

Pain Management :

• Perform a comprehensive pain assessment includes the location, characteristics, duration, frequency , quality and ontro precipitation.
• Observation of nonverbal reactions of discomfort.
• Use therapeutic communication techniques to determine the client's experience of pain before.
• Environmental controls that affect pain such as room temperature, lighting, noise.
• Reduce pain ontro precipitation.
• Choose and pain management (pharmacological / non- pharmacological).
• Teach non- pharmacological techniques ( relaxation , distraction, etc.) to mengetasi pain.
• Give analgesics to reduce pain.
• Evaluation of pain -reducing action / ontrol pain.
• Collaboration with a physician if there are complaints about the administration of analgesics to no avail.
• Monitor client acceptance of pain management.

Analgesics Administration :

• Check program providing analogetik ; the type, dosage, and frequency.
• Check history of allergy.
• Determine the analgesic of choice, the optimal route of administration and dose.
• Monitor vital signs before and after the administration of analgesics.
• Give analgesic especially timely when the pain arises.
• Evaluation of the effectiveness of analgesics, signs and symptoms of side effects.

Nursing Care Plan for Acute Lymphoblastic Leukemia


Acute lymphoblastic leukemia (ALL) also called acute lymphocytic leukemia or acute lymphoid leukemia is a malignant (clonal) disease of the bone marrow in which early lymphoid precursors proliferate and replace the normal hematopoietic cells of the marrow.

Causes

• Most of the time, no clear cause can be found. But the following may play a role in the development of leukemia in general:
• Certain chromosome problems
• Past treatment with chemotherapy drugs
• Exposure to radiation, including x-rays before birth
• Toxins, such as benzene
• Receiving a bone marrow transplant

Signs and symptoms

• Fever
• Bone and joint pain
• Feeling weak or tired
• Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
• Pain or feeling of fullness below the ribs
• Loss of appetite and weight loss
• Paleness
• Swollen glands (lymphadenopathy) in the neck, under arms, and groin
• Night sweats
• Pinpoint red spots on the skin (petechiae)

Nursing Diagnosis for Acute Lymphoblastic Leukemia : Imbalanced Nutrition Less Than Body Requirements related to fluid restriction, diet, and the loss of protein.

Definition : Intake of nutrients is not sufficient for the purposes of the body's metabolism.

Defining characteristics :

• Weight 20 % or more below the ideal.
• Reports of food intake less than RDA (Recomended Daily Allowance)
• Pale mucous membranes and conjunctiva.
• Weakness of the muscles used for swallowing / chewing.
• Wounds, inflammation of the oral cavity.
• Easy to feel full , shortly after the chewing of food.
• Reported or the fact that there is a shortage of food.
• Reported a change in taste sensation.
• The feeling of inability to chew food.
• Misconceptions.
• Losing weight with enough food.
• Reluctance to eat.
• Cramps in the abdomen.
• Poor muscle tone.
• Abdominal pain with or without pathology.
• Less interested in food.
• Fragile capillary vessels.
• Diarrhea and or steatorrhea.
• Hair loss is quite a lot (loss).
• Hyperactive bowel sounds.
• Lack of information, misinformation.

Related factors :

• Inability to enter or digest food or absorb nutrients associated with biological factors, psychological or economic.

NOC :
Nutritional status : food and Fluid Intake

Outcomes :

• An increase in body weight in accordance with the purpose.
• Ideal weight according to height.
• Being able to identify nutritional needs.
• No signs of malnutrition.
• Weight loss does not happen that means.

NIC :

Nutrition Management

• Assess the food allergy.
• Collaboration with a nutritionist to determine the amount of calories and nutrients needed by the patient.
• Instruct the patient to increase the intake of Fe.
• Instruct the patient to increase the protein and vitamin C.
• Give the substance of sugar.
• Make sure the diet contains high fiber eaten to prevent constipation.
• Give foods elected (already consulted with a nutritionist).
• Teach patients how to make food diaries.
• Monitor the amount of nutrients and calories.
• Provide information about nutritional needs.

Nutrition Monitoring

• Patient's weight within normal limits.
• Monitor change in body weight.
• Monitor the type and amount of regular activity.
• Monitor interaction between children or parents during meals.
• Monitor the environment for eating.
• Schedule of treatment and no action during a meal.
• Monitor dry skin and pigmentation changes.
• Monitor skin turgor.
• Monitor dryness, dull hair, and brittle.
• Monitor nausea and vomiting.
• Monitor levels of albumin, total protein, hemoglobin, and hematocrit levels.
• Monitor food preferences.
• Monitor growth and development.
• Monitor pale, redness, and dryness of the conjunctiva tissue.
• Monitor and calorie intake nuntrisi.
• Note the presence of edema, hyperaemic, hypertonic papillae of the tongue and oral cavity.
• Note if the tongue magenta, scarlet.
• Assess the patient's ability to get needed nutrients.

Nursing Care Plan for Schizophrenia

Nursing Diagnosis :
Social isolation related to low self-esteem

General objectives

• Clients can engage social, gradually

Specific objectives 1.

• Clients can build a trusting relationship.

Outcomes :

• The client can express his feelings.
• Friendly facial expression.
• There is eye contact.
• Show some love.
• Want to shake hands.
• Want to reply greetings.
• Clients want to sit side by side.
• Clients want to express the problems encountered.

Interventions :

• Develop a relationship of mutual trust :

• ·Greet clients friendly, both verbally and nonverbally.
• · Introduce yourself politely.
• · Ask the client 's full name and preferred nickname.
• · Explain the purpose of the meeting , be honest and keep our promises.
• · Show empathy and receives the client is.
• · Pay attention to the client.

• Give a chance to express his feelings about the illness.
• Take time to listen to the client.
• Tell the client that he is a valuable and responsible and able to help themselves.

Rationale :

• Trusting relationship will lead to trust the client to the nurse that will facilitate the implementation of further action .

Specific objectives 2.

• Clients can identify the capabilities and positive aspects possessed.

Outcomes :

• Clients are able to maintain the positive aspects.

Interventions :

• Discuss capabilities and positive aspects of the client owned and reinforcement give up the ability to express feelings.
• When meeting with clients avoid giving a negative assessment.

Rationale :

• Positive reinforcement will increase the client's self-esteem.
• Prioritizing realistic compliment.

Specific objectives 3.

• Clients can assess the ability of the data used.

Outcomes :

• Clients' needs are met.
• Clients can perform purposeful activity.

Interventions :

• Discuss the ability of clients that can still be used when sick.
• Discuss also the ability that can be continued in hospital use it at home later.

Rationale :

• Improved client capabilities will encourage the client to an Independent.

Specific objectives 4.

• Clients can define and plan activities according to ability.

Outcomes :

• Clients are able to move according to ability.

Intervention :

• Plan with client activity to do each day according to ability, independent activities, activities with minimal assistance , the activities with the help of the total.
• Increase activity as tolerated client client's condition.
• Give an example of how to implement the activities the client should do (often clients are afraid to carry it out).

Rationale :

• Implementation activities independently into the initial capital to boost self-esteem.

Specific objectives 5.

• Clients can perform activities in accordance with the conditions of pain and ability.

Outcomes :

• Clients are able to move according to ability.

Interventions:

• Give the client the opportunity to try activities that have been planned.
• Give praise to the efforts and success of the client.
• Discuss the possibility of implementation at home.

Rationale :

• Through the activity, the client will know the capabilities.

Specific objectives 6.

• Clients can take advantage of existing support systems.

Outcomes :

• Clients are able to do what has been taught.
• Clients want to provide support.

Interventions :

• Give health education to families about how to care for clients with social isolation and low self esteem.
• Help provide support for the family of the client being treated.
• Help families prepare a home environment.

Rationale :

• Attention families and family understanding will help improve self esteem clients.

Nursing Diagnosis and Interventions for Schizophrenia

Schizophrenia is a syndrome with various descriptions of the cause (many not yet known) and the course of the disease (not always a chronic or "deteriorating") wide, as well as a number of which depends on the balance due to the influence of genetic, physical, and social culture. Generally characterized by fundamental and characteristic deviations of mind and perception, as well as the affect that is not fair (inappropiate) or blunt. Consciousness is clear (clear consciousness) and intellectual ability is usually maintained, although certain cognitive decline may develop later.

Schizophrenia is equally prevalence between men and women. However, there are differences in the onset and course of the disease. Men have earlier onset than women. Peak age of onset for males is 15 to 25 years ; the peak age for women is 25 to 35 years. Onset of schizophrenia before age 10 years or after 50 years is very rare.

Principal symptoms of schizophrenia can be grouped into four disturbance on :
1). Natural Mind

• Thought disorder in patients with schizophrenia is a disorder of mind and the current form of the content of thought disorder. (Roan, 1997). In schizophrenic patients there was indeed a core disturbance in thought processes and is particularly disturbed association, namely :
• Patients sometimes have an unfinished idea expressed, but had other ideas arise.
• People with schizophrenia often using symbolic meaning, so that the schizophrenic mind can not be followed and understood by others.
• In patients with schizophrenia often also found what is called the blocking, ie the contents of the mind which sometimes arise stops and no idea anymore.
• Other symptoms are hallucinations that the patient feels no noises in his ears.
• Strange way of thinking (ambivalence).
• The presence of delusions are under control.
• Feeling no pain and feel self -righteous themselves (egocentric). (Yusuf and Ismed, 1991).

2). Responsiveness (Perseption)

• In this disorder can occur any illusion that an event response of an outside stimulus. Or a response in the absence of external stimuli. Major disruption of perceptual disorders are various types of true hallucinations (Roan, 1997).

3). Natural feelings
At the beginning of mood disorders , patients are usually more sensitive than normal people. Patients who appear are easily offended, irritable and sensitive to things that small should not be offended or upset. In a state of further disruption or worse, the atmosphere will actually care about the people around it (Yusuf and Ismed, 1991). Feelings or emotional disturbances in people with schizophrenia can be classified in two ways, namely :

• Mood disorder.
• Impaired expression of feelings.

In daily life the sense of disorder appears in behavior, usually expressed as :

• Chirpy (nood elevasion).
• Sad (depression).
• Lost sense (perplekxity).
• Excessive emotion.
• Loss of emotional rapport.
• Ambivalaensi (fragmented personality).

4). Behavior disorders
Behavior disorder (psychomotor) of diverse often seen , especially in the form of acute attacks and real. Schizophrenic behavior is often strange and incomprehensible. such as :

• Can occur from the great reduction in reactivity to the environment in the form of reduced movement and spontaneous activity, the patient will be stiff and reject efforts to move.
• Excessive motor movements (exited) and looks not intended and are not influenced by external stimuli (such as no noise / furor catatonic).

Lots of behavior that can be found in people with schizophrenia , but most often are :

• Restless rowdy (exitement).
• Stupor.
• Impulsive behavior. (Wibisono, S. 1998).

Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Self-Care Deficit related to withdraw

General objectives :

• Clients expressed a desire to perform activities of daily living.

Specific objective :

• Able to perform activities of daily living independently and demonstrate a desire to do so.

Outcomes :

• Clients are able to perform daily activities.
• Clients feed themselves without assistance.
• Clients choose appropriate clothing, taking care to dress themselves without help.
• Clients maintain optimal personal hygiene by bathing every day and perform procedures unassisted defecation and urination.

Interventions :

• Encourage the patient to perform activities of daily living fit the patient's level of ability .
• Support the patient's autonomy , but give assistance when the patient can not perform some activities .
• Show concretely , how do the activity to which the client is difficult to do so.
• Assist in preparing equipment ADLs .
• Give positive recognition and awards for its ability to be independent.

Rationale :

• Independent activity can improve the ability to do client activity.

Nursing Diagnosis and Interventions

Leptospirosis is a zoonotic disease caused by microorganisms, ie Leptospira that regardless of serotype -specific form. This disease can be passed on via the male or female of all ages. Mostly found in the tropics, and usually the disease is also known by various names such as mud fever, slime fever, swamp fever, autumnal fever, infectious jaundice, filed fever, fever cutre cane and others.

Manifestations of leptospirosis infection have a very varied and sometimes asymptomatic. Nearly 15-40 % of patients exposed to infection are asymptomatic but serologically positive. The incubation period of 7-12 days with a range of 2-20 days. Approximately 90% of patients with mild jaundice , severe jaundice 5-10 % is often known as Weil's disease. Leptospires disease course consists of two phases , namely phase and phase immune septicemia. In the period of 1-3 days during the phase transition condition of the patient improved.

1. Initial phase is known as septicemic phase or leptospiremic phase because bacteria can be isolated from blood, cerebrospinal fluid, and most of the body's tissues. Initial phase of approximately 4-7 days, marked nonspecific flu-like symptoms with a few variations. The clinical manifestations of fever, chills, weakness and pain especially the ribs, back and stomach. Other symptoms are sore throat, cough, chest pain, vomiting of blood, rash, frontal headache, photophobia, mental disturbances, and meningitis. Physical examination often get a fever of about 40 0C accompanied by tachycardia. Subconjunctival suffusion, pharyngeal injection, splenomegaly, hepatomegaly, mild jaundice, mild jaundice, muscle weakness, lymphadenopathy and skin manifestations in the form of macular, maculopapular, erythematous, urticaria, or rash was also obtained in the early phase of disease.

2. Second phase is often called the immune phase or leptospiruric phase, because circulating antibodies can be detected by isolation of bacteria from the urine ; may not be obtained again from the blood or cerebrospinal fluid. This phase occurs at 0-30 days due to the response of the body's defense against infection. Symptoms depend the body's organs such as the lining of the brain, heart, eyes or kidneys. Nonspecific symptoms such as fever and muscle aches may be lighter than the initial phase for 3 days to several weeks. Approximately 77 % of patients experienced a continuous headache unresponsive to analgesics. These symptoms are often associated with the early symptoms of meningitis other than delirium. In the more severe phases obtained prolonged mental disorders including depression, anxiety, psychosis and dementia.



Nursing Diagnosis for Leptospirosis : Fluid volume deficit related to lack of fluids and electrolytes active

NOC :

• Fluid balance
• Hydration
• Nutritional Status : Food and Fluid Intake

Outcomes :

• Maintain urine output in accordance with the age and body weight, urine specific gravity normal.
• Blood pressure, pulse, body temperature within normal limits.
• No signs of dehydration, good elasticity of skin turgor , moist mucous membranes, no excessive thirst.

NIC :

• Fluid management
• Measure diapers if needed.
• Maintain a record of intake and output accurately.
• Monitor hydration status ( mucous membrane moisture, adequate pulse, orthostatic blood pressure ) , if necessary.
• Monitor vital signs.
• Monitor the input of food / fluids and calculate daily caloric intake.
• Collaborate IV fluid administration.
• Monitor nutritional status.
• Give IV fluids at room temperature.
• Encourage oral input.
• Provide appropriate replacement nesogatrik output.
• Encourage families to help patients eat.
• Give snack (fruit juice , fresh fruit).
• Collaboration doctor if signs of excess fluid appears to worsen.
• Adjust the possibility of transfusion.
• Preparation for transfusion.

Nursing Care Plan for Ischialgia

Ischialgia is one manifestation of lower back pain is caused due to the clamping nervous ischiadicus.

Pain in the lumbar region can basically be:

• Radicular pain ( often ) patients with radicular pain and low back pain showed radicular pain along the nerve ischiadicus.
• Referred pain.
• Pain does not radiate.

Nursing Diagnosis for Ischialgia

Impaired Physical Mobility related to pain, muscle spasm, restrictive therapies and neuromuscular damage.

NOC :

• Joint Movement : Active
• Mobility Level
• Self care : ADLs
• Transfer performance

Outcomes :

• Clients increase in physical activity.
• Understand the purpose of improving mobility.
• Verbalize feelings in improving the strength and ability to move.
• Demonstrate the use of aids to mobilization (walker).

NIC :

• Exercise therapy : ambulation
• Monitoring vital signs before / after exercise and see the patient's response during exercise.
• Consult with a physical therapy plan of ambulation as needed.
• Help clients to use a cane when walking and prevent against injury.
• Teach the patient or other health professionals about ambulation techniques.
• Assess the patient's ability to mobilize.
• Train patients in meeting the needs of ADLs independently according to ability.
• Facilitate and assist the patient when the mobilization and help meet the needs of ADLs.
• Give the tool if the client requires.
• Teach patients how to change the position and provide assistance if needed.

Nursing Care Plan for Acute Myocardial Infarction

The term myocardial infarction pathologically denotes the death of cardiac myocytes due to extended ischemia, which may be caused by an increase in perfusion demand or a decrease in blood flow. AMI falls in the spectrum of acute coronary syndromes (ACS), which includes unstable angina (UA), non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)

Persistent elevation of the ST-segment on ECG signifies total occlusion of a coronary artery that causes necrosis of the myocardial tissue. This condition is STEMI. ACS without ST-segment elevation may either be NSTEMI or UA

NSTEMI is more severe than UA. In this condition, the ischemia in the cardiac tissue is extensive enough to release cardiac biomarkers (troponin I or T) into the blood, but the occlusion is not as complete enough to cause elevation of the ST-segment.(www.clinicalkey.com)


Nursing Diagnosis for Acute Myocardial Infarction

Ineffective Breathing Pattern related to hyperventilation, anxiety

Goal :
Breathing pattern becomes effective

Outcomes :

• Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips)
• Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
• Vital signs within normal range.

NIC

Airway Management :

• Open the airway, use techniques jaw thrust or chin lift if necessary.
• Position the patient to maximize ventilation.
• Identification of patients need artificial airway equipment installation.
• Attach mayo if necessary.
• Perform chest physiotherapy.
• Remove the secret by coughing or suctioning.
• Auscultation of breath sounds, note the presence of additional noise.
• Perform suction on the mayo.
• Give bronchodilators if necessary.
• Give a humidifier.
• Set intake to optimize fluid balance.
• Monitor espirasi and O2 status.

Respiratory Monitoring :

• Monitor the average depth, rhythm and expiratory efforts.
• Note the movement of the chest, observe symmetry, the use of additional muscles, supraclavicular and intercostal muscle retraction.
• Monitor breath sounds like snoring.
• Monitor breathing patterns : bradipnea, tachypnea, kusmaul, hyperventilation, cheyne stokes, biot.
• Note the location of the trachea.
• Monitor the diaphragm muscle fatigue (paradoxical movement).
• Auscultation of breath sounds , note areas of decreased / no ventilation or extra sound.
• Determine the need auscultation suction with crakles and crackles, in the main airway.
• Auscultation of lung sounds after the action to find the results.

Nursing Diagnosis :  Risk for Infection

Ovarian cysts are small fluid-filled sacs that develop in a woman's ovaries.


Risk factors :

• Irregular menstrual cycles
• History of previous ovarian cysts
• Early menstruation (11 years or younger)
• Increased upper body fat distribution
• Infertility
• Hypothyroidism
• Infertility treatment with gonadotropin medications
• Tamoxifen (Soltamox) therapy for breast cancer
• Cigarette smoking also increases the risk of functional ovarian cysts.

Symptoms

• Lower abdominal or pelvic pain, which may start and stop and may be severe, sudden, and sharp.
• Feeling of lower abdominal or pelvic pressure or fullness.
• Irregular menstrual periods.
• Long-term pelvic pain during menstrual period that may also be felt in the lower back.
• Pain or pressure with urination or bowel movements.
• Pelvic pain after strenuous exercise.
• Nausea and vomiting.
• Infertility.

Nursing Diagnosis for Ovarian Cysts :

Risk for Infection related to a decrease in the primary defense


Goal (NOC)

expected infection control.

NOC :

• Immune Status.
• Knowledge : Infection control.
• Risk control.

Outcome :

• Free from signs and symptoms of infection.
• Describe the process of transmission of the disease, factors that influence the transmission and management.
• Demonstrated ability to prevent infection.
• The number of leukocytes within normal limits.
• Demonstrate healthy behavior.

Interventions (NIC)

Infection Control.

• Clean up the environment after use for other patients.
• Maintain isolation techniques.
• Limit visitors when necessary.
• Instruct visitors to wash their hands during a visit and after leaving the patient's visit.
• Use antimicrobial soap for hand washing.
• Wash hands before and after each nursing action.
• Use suit , gloves as protective gear.
• Maintain aseptic environment during the installation of equipment.
• Change the location of the peripheral IV and central line and dressing in accordance with the general instructions.
• Use intermittent catheters to decrease bladder infection.
• Tingktkan nutritional intake.
• Provide antibiotic therapy if necessary.

Infection Protection (protection against infection)

• Monitor signs and symptoms of systemic and local infections.
• Monitor granulocyte count, WBC.
• Monitor susceptibility to infection.
• Limit visitors.
• Filter visitors to infectious diseases.
• Keep aspesis technique in patients who are at risk.
• Maintain isolation techniques if necessary.
• Give skin care on epiderma area.
• Inspection of skin and mucous membranes of the redness, heat, drainage.
• Ispeksi condition of the wound / incision surgery.
• Push enter adequate nutrition.
• Encourage fluid intake.
• Suggest to break.
• Instructed to take antibiotics as prescribed.
• Teach the patient and family the signs and symptoms of infection.
• Teach how to avoid infection.
• Report suspicion of infection.
• Report positive cultures.

Nursing Care Plan for Vertigo

Vertigo is a sensation of motion or spinning that is often described as dizziness.

Vertigo is actually different from the dizzy in the head or headache. People with impaired vertigo feel as though they are actually spinning or moving, and the nature that is around them also began to spin.

The main symptom is a sensation felt like moving or rotating space. The spinning sensation may cause nausea and vomiting.

Other symptoms can include :

• Difficulty focus look.
• Dizziness.
• Hearing loss in one ear.
• Loss of balance (can lead to falls).
• Ringing in the ears.

If interference vertigo due to problems in the brain (central vertigo), usually feel other symptoms, such as :

• Difficulty swallowing.
• Double vision.
• Eye movement problems.
• Facial paralysis.
• Slurred speech.
• The weakness of the limbs on a limb.

Nursing Diagnosis for Vertigo : Imbalance Nutrition Less than Body Requirements related to loss of appetite, nausea and vomiting


NOC :

• Nutritional status : the level of nutrients available to meet metabolic needs.
• Nutritional status : food and fluid intake : the amount of food and fluid intake in the body for 24 hours.
• Nutritional status : nutritional value : adequacy of the body of nutrients consumed.

Outcomes : The client will :

• maintaining ideal body weight.
• expressed tolerance to the recommended diet.
• maintain body mass and body weight in the normal range.
• reported adequacy of energy levels.

NIC Interventions :

• Management of eating disorders.
• Nutrient management.
• Help raise the weight.

Nursing Interventions :

• Measure weight at appropriate intervals.
• Determine the client's weight idea.
• Provide information regarding the resources available. Such as dietary counseling, exercise programs.
• Discuss with client regarding a medical condition affecting body weight.
• Discuss the risks associated with excess weight or deficiency.
• Assist clients in developing a balanced eating plan and consistent with the level of energy use.

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Nursing Care Plan for Lower Back Pain

Nursing Diagnosis for Lower Back Pain : Acute pain related to the agent of injury (physical, musculo skeletal disorders and vascular nervous system).

Defining characteristics :
Verbal

• Took a deep breath, moaning.
• Complained of pain.

Motor

• Grinning face.
• Step struggling.
• Rigid posture / unstable.
• Movement is very slow or forced.

Autonomic response

• Changes in vital signs.

Goal :
Pain is reduced / lost

Outcome :

Levels of pain

• Reported pain reduced / lost.
• Frequency of pain reduced / lost.
• Long of pain pain reduced / lost.
• Oral expression is reduced / lost.
• Muscle tension is reduced / lost.
• Can rest.
• Pain scale decreased.

Control of pain

• Know the factors that cause.
• Know the onset of pain.
• Rarely / never done action / relief with non- analgesic.
• Rarely / never use of analgesics.
• Rarely / never reported pain to the healthcare team.
• Pain controlled.

Level of comfort

• Report needs a break - sleeping fulfilled.
• Reported good physical condition.
• Reported good psychological condition.

Interventions :


Pain Management

• Perform a comprehensive pain assessment (location, characteristics, duration, frequency, quality, and precipitation factors).
• Observation of non-verbal reactions of discomfort.
• Use therapeutic communication techniques to determine the client's experience of pain.
• Assess the culture that affects pain response.
• Evaluation of past painful experiences.
• Evaluation with clients and other health team about the ineffectiveness of pain control past.
• Help clients and families to seek and find support.
• Control environment that may affect pain (room temperature, lighting, and noise).
• Reduce pain precipitation factor.
• Choose and pain management (pharmacological, non-pharmacological and interpersonal).
• Assess the type and source of pain to determine the intervention.
• Teach about non-pharmacological techniques.
• Give analgesics to reduce pain.
• Evaluation of the effectiveness of pain control.
• Increase the break.
• Collaboration with doctors, if there is a complaint and the action of pain that did not work.
• Monitor client acceptance of pain management.

Analgesic Andministrasi

• Determine the location, quality characteristics, and the degree of pain as drug delivery.
• Check the doctor's instructions about the type of medication, dosage and frequency.
• Check history of allergy.
• Select the required analgesics or combination of analgesics when giving more than one.
• Determine analgesic choice , depending on the type and severity of pain.
• Determine the route of administration of analgesic options, and the optimal dose.
• Select the route of administration of intravenous / intramuscular, for the treatment of pain on a regular basis.
• Monitor vital signs before and after the administration of first analgesic.
• Give analgesic especially timely when severe pain.
• Evaluation of the analgesic effectiveness of signs and symptoms (side effects).