List of Nursing Diagnosis

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.

Related Articles :

Defining Characteristics of Imbalanced Nutrition Less than Body Requirements

Imbalanced Nutrition Less Than Body Requirements - Diabetes Mellitus

Imbalance Nutrition Less than Body Requirements related to psychological factors

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).