List of Nursing Diagnosis

NCP for Dissociative Disorders
Definition

In general, dissociative disorders can be defined as a loss of (some or all) of the normal integration (under conscious control) includes memories of the past, awareness of identity and immediate sensations, and control of body movement.

In diagnosis, dissociative disorders should be a disorder that causes failure of coordinating identity, perception or consciousness of memory, and cause a significant disruption in social functioning, work and take advantage of free time.

There are several penggolonga in dissociative disorders, including dissociative amnesia is, dissociative fugue, dissociative stupor, trance disorder, dissociative motor disorder, dissociative convulsions and anesthesia, and dissociative sensory loss.


Causes

Dissociative Disorders exact cause is not yet known, but it usually occurs as a result of severe trauma of the past, but no organic disturbance experienced. This disorder occurs when the first children but not distinctive and can not be identified, dissociative disorders in the course of the disease can occur at any time and trauma of the past never happen again, and again and again so that the symptoms of dissociative disorders.

Dissociative Disorders refers to a mechanism, dissociation, which is suspected to be the cause. The basic idea is the unity of consciousness is usually an experience, including cognition, emotion and motivation. However, under conditions of stress, trauma memory can be stored in a way so that in the future can not be accessed by normal consciousness back in line with the conditions in question, so the result is the possibility of amnesia or fugue.

Behavioral view of the dissociative disorders is somewhat similar to the initial speculation. In general, behavioral theorists assume full dissociation in response to stress and memory of the incident.
In some references say that the trauma that occurs in the form of:

• Unstable personality.
• Harassment.
• Physical abuse.
• Domestic violence (father and mother divorced).
• Social environment that often show violence.

Personal identity is formed during childhood, and during even then, the children more easily step out of himself and observe trauma although it happens to someone else.


Classification

Dissociative Disorders differentiated or classified into several classifications, namely:

Dissociative Amnesia

In dissociative amnesia usually found specific memory impairment only and is not general. The information is usually forgotten about stressful or traumatic events, in one's life. The general form of amnesia dissociative amnesia for personal identity involves a person, but general information memory is intact.

Dissociative Fugue

Person's behavior patients with dissociative fugue is more integrated with the aims and amnesia than patients with dissociative amnesia. Patients with dissociative fugue has physically walk way from home and work situation and unable to remember important aspects of their previous identity (name, family, work). These patients are often, but not always, take the identity and job completely new, although the new identity is usually less complete than that seen in multiple personality dissociative identity disorder.

Dissociative Stupor

Dissociative stupor can be defined as a significant reduction or loss of voulunter movements and a normal response to external stimuli, such as light, sound, and tactile (while consciousness is not lost in the physiological sense).

Trans Disorder or Trance

Trance Trans disorder or a disorder that showed a temporary loss of identity aspects appreciation and awareness of the environment; in some instances, individuals behave as if controlled by another personality, magical powers, angels or "other forces".

Dissociative Motor Disorders

Dissociative motor disorder in the form of the most common is the inability to move all or part of the limbs (arms and legs).

Dissociative Convulsions

Dissociative convulsions or also called pseudo seizures may be very similar to epileptic seizures in terms of movement, but very rarely accompanied by tongue biting, serious injuries from falls when the attack took place and incontinent. Also not found to lose consciousness.



Signs and Symptoms

In dissociative disorders, the ability of control under the selective control of consciousness and impaired to the extent that can last from a day to day or even hour to hour.

Symptoms common to all types of dissociative disorders, including:

• Loss of memory (amnesia) of the specified time period, events and people,
• The problem of mental disorders, including depression and anxiety,
• Perceptions of people and objects around them are not real (derealization)
• The identity of the opaque
• Depersonalization.

Therapy

Psychotherapy is the primary treatment against this dissociative disorder. Forms of treatment such as talk therapy, counseling or psychosocial therapy, including talking about the disorder suffered by the patient's soul. Therapy will help you understand the causes of the conditions experienced.

Psychotherapy for dissociative disorders often involve techniques such as hypnosis which helps us to remember the trauma that causes dissociative symptoms.

Handling other dissociative disorders include:

• Creative arts therapy. In some references say that this type of therapy uses the creative process to help patients who are difficult to express their thoughts and feelings. Creative arts can help improve self-awareness. Creative arts therapies include art, dance, drama and poetry.
• Cognitive therapy. Cognitive therapy can help to identify negative behaviors and unhealthy and replace it with a positive and healthy, and it all depends on the idea in mind for determining what the examiner behavior.
• Drug therapy. This therapy is very good to be used as initial handler, although there is no specific medicine in dealing with this dissociative disorder. Usually the patient is given a prescription anti-depressant and anti-anxiety drugs to help control the symptoms of dissociative disorder is mental.

Nursing diagnosis for Gastritis : Ineffective Management of Therapeutic Regimen

Gastritis is an inflammation of the gastric mucosa is happening area, which is caused by germs, which can occur in acute and chronic.

Food / drinks that can damage the gastric mucosa, consuming alcohol, using drugs. Bacterial infections especially sreptococcus, stapylococcus, as well as chemicals and beverages which are corrosive like concentrated acid. Food and beverages that are too acidic, spicy, hot, fatty, can also cause gastritis. Too much thinking or stress can increase stomach acid.

Clinical manifestations

a. Acute gastritis.
Epigastric pain that may plus nausea. Pain can arise again when the stomach is empty. When pain, sweating, restlessness, abdominal pain and may be accompanied by an increase in body temperature, takicardia, cyanosis, such as a burning feeling in the epigastric, seizures and weakness.

b. Chronic gastritis.
signs and symptoms of acute gastritis is almost the same as, only accompanied by weight loss, chest pain, anemia pain, such as peptic ulcer, high serum gastrin levels.


Nursing Diagnosis for Gastritis : Risk for Ineffective Management of Therapeutic Regimen related to lack of knowledge about the disease process, contra indications, signs and symptoms, complications, and treatment programs.

Interventions :

1. Describe the pathophysiology of gastritis, using appropriate terminology and media to the level of knowledge of the client and family.

2. Describe the behavior that can be changed or eliminated to reduce the risk of recurrence :

• tobacco use,
• excessive alcohol input,
• foods and beverages that contain caffeine,
• large number of products containing milk.

3. Discuss about further treatment even when there are no symptoms.

4. Instruct client and family to notice and report these symptoms :

• stool red / black
• bloody vomit / black
• epigastric pain settled
• severe abdominal pain and a sudden
• constipation
• nausea and vomiting settled
• weight loss is not clear why

5. Refer to community resources, when indicated ( eg, smoking cessation programs, drink alcohol, stress management).

The author suggests the use of this diagnosis only if there is one among the following signs :

• Weight less than 20 % or more below ideal weight for height and body frame.
• Food intake is less than the metabolic needs, both total calories and certain nutrients.
• Losing weight baan with adequate food intake.
• Reported inadequate food intake less than RDA.

Subjective :
Abdominal cramps.

• Abdominal pain.
• Refusing to eat.
• Perception inability to digest a meal.
• Reported changes in taste sensation.
• Reported a lack of food.
• Feeling full quickly after eating.

Objective :

• Fragile capillaries.
• Diarrhea or steatorrhea.
• Evidence of lack of food.
• Excessive hair loss.
• Hyperactive bowel sounds.
• Lack of information / misinformation.
• Lack of interest in food.
• Oral cavity hurt.
• Muscle weakness which serves to swallow or chew.

Imbalanced Nutrition Less Than Body Requirements - Diabetes Mellitus

Imbalance Nutrition Less than Body Requirements related to psychological factors

Rheumatic heart disease is a condition in which permanent damage to heart valves is caused by rheumatic fever. The heart valve is damaged by a disease process that generally begins with a strep throat caused by bacteria called Streptococcus, and may eventually cause rheumatic fever.

Symptoms may include:

• Joint inflammation - including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days.
• Small nodules or hard, round bumps under the skin.
• A change in your child's neuromuscular movements (this is usually noted by a change in your child's handwriting and may also include jerky movements).
• Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs).
• Fever.
• Weight loss.
• Fatigue.
• Stomach pains.

Nursing Diagnosis and Interventions for Rheumatic Heart Disease

Risk for Impaired Gas Exchange related to the accumulation of blood in the lungs due to increased atrial filling

Goal: risk for impaired gas does not occur

Expected outcomes:

• Demonstrating adequate ventilation and oxygenation of the tissue, indicated by blood gas analysis / oximetry in the normal range and free of symptoms of respiratory distress.
• Participate in a treatment program within the ability / situation.

Intervention and rationale:

1. Auscultation of breath sounds, note: crackles, mengii.
2. Instruct the patient to cough effectively, breathing deeply.
3. Maintain a semi-Fowler position, chock the hand with a pillow if possible
4. Collaboration in the provision of supplemental oxygen as indicated.
5. Collaboration for the examination of blood gas analysis.
6. Collaboration for the administration of diuretics.
7. Collaboration for the administration of bronchodilator drugs.

Rational:

1. Stating pulmonary congestion / collecting secretions indicate the need for further intervention.
2. Clearing the airway and facilitate the flow of oxygen.
3. Lowering the oxygen consumption / needs and enhance maximum lung expansion.
4. Increasing alveolar oxygen concentration, which can improve / lower tissue hypoxemia.
5. Can be severe hypoxemia during pulmonary edema.
6. Lowers alveolar congestion, improve gas exchange.
7. Increasing the flow of oxygen to dilate small airways and emit a mild diuretic effect to reduce pulmonary congestion.

Nursing Care Plan for Atherosclerosis

Atherosclerosis is a slow disease in which your arteries become clogged and hardened. Fat, cholesterol, calcium, and other substances form plaque, which builds up in arteries.

Signs and Symptoms:

Many times, people with atherosclerosis don't have any symptoms until an artery is 40% clogged with plaque. Symptoms vary depending upon which arteries are affected.


Nursing Diagnosis for Atherosclerosis : Acute Pain related to an impaired ability of blood vessels to supply oxygen to the tissues.

Goal: reduced pain

Expected outcomes: patient states chest pain disappear, or can be controlled, the patient did not seem grimace, demonstrate relaxation techniques.

Intervention and Rational:

1. Monitor characteristics of pain through verbal and hemodynamic responses (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
Rationale: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

2. Assess the description of pain experienced by patients include: place, intensity, duration, quality, and distribution.
Rationale: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other symptoms to obtain accurate data.

3. Provide a comfortable environment, reduce the activity, limit visitors.
Rationale: Helps reduce external stimuli that can add to the tranquility so patients can rest in peace and the power of the heart is not too hard.

4. Teach relaxation techniques with a sigh
Rationale: Helps relieve pain experienced by patients psychologically which can distract the patient that is not focused on the pain experienced.

5. Observation of vital signs before and after drug administration.
Rationale: Knowing the patient's progress, after being given the drug.

Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Nursing Diagnosis for Atherosclerosis : Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Goal: clients show improvement perfusion with

Expected outcomes: a peripheral pulse / same, normal skin color and temperature, an increase in behaviors that increase tissue perfusion.

Intervention and Rational:

1. Observation of skin color on the sick.
Rationale: The skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; traffic change skin (no color, glossy / tense).
Rationale: This change indicates progress or chronic process.

3. View and examine the skin for ulceration, lesions, gangrene area.
Rationale: Lesions may occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue seriously.

4. Advise for the proper nutrients and vitamins.
Rationale: The balance of a good diet includes protein and adequate hydration, necessary for healing of the sick.

5. Monitor signs of tissue perfusion adequacy.
Rationale: To identify the early signs of impaired perfusion.

6. Encourage patients perform the exercises or exercises gradually extremities.
Rationale: For circulation.

Nursing Diagnosis Risk for impaired skin integrity related to pitting edema.

Expected outcomes:
clients can demonstrate behaviors / techniques to prevent skin damage.
Maintaining the integrity of the skin.

Interventions:

1. Change position often in bed / chair, assistive range of motion exercises passive / active.
2. Provide frequent skin care, minimizing the moisture / excretion.
3. Check narrow shoes / sandals and change as needed.
4. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
5. Massage the area red or white.

Rational:

1. Improving circulation / lowering an area that interfere with blood flow.
2. Too dry or moist skin damage and accelerating damage.
3. Dependent edema can cause the shoe is too narrow, increasing the risk of stress and damage to the skin on the feet.
4. Lowering the pressure on the skin, improve circulation.
5. Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status. Increase blood flow, minimizing tissue hypoxia.