Nursing Care Plan Stroke

Nursing Diagnosis Self-Care Deficit

related to weakness, neuromuscular disorders, decreased muscle strength, decreased muscle coordination, depression, pain, damage to the perception

Goal: The ability to care for self-rising

Expected outcomes:

a. Demonstrating changes in lifestyle to meet the needs of daily living

b. Perform self-care according to ability

c. Identify and utilize sources of aid


Nursing Interventions Self-Care Deficit Nursing Care Plan for Stroke

1. Monitor the client's skill level in caring for themselves

2. Provide assistance to the needs that really need it

3. Create an environment that allows clients to perform ADLs independently

4. Involve the family in helping clients

5. Client's motivation to perform ADLs according to ability

6. Provide aids themselves when possible

7. Collaboration: plug the DC if necessary, consultation with a occupational or physiotherapy.

Source : http://nanda-nursing-diagnosis.blogspot.com/2012/06/nursing-diagnosis-self-care-deficit.html
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Nursing Care Plan for Conjunctivitis

Conjunctivitis is an inflammation of the conjunctiva, the mucous membrane that covers the white part of the eye and the inner eyelid. Condition characterized by red eyes is the most common eye disorder in children.

Types of Conjunctivitis

Conjunctivitis can be caused by bacterial infections, viral infections, allergies or irritation.:

  • Bacterial conjunctivitis : infections caused by bacteria, such as staphylococci, streptococci or Haemophilus. Eyes are usually issued dung eyes yellow / greenish yellow which may spread to the lashes and cause a sticky eyelids, especially in the morning.
  • Viral conjunctivitis : an infection caused by a virus called adenovirus, often associated with the common cold. Types of conjunctivitis are very contagious among humans and can cause epidemics. Eye redness and discharge may be watery. Often the swollen eyelids. This type of conjunctivitis may also spread to the cornea and cause blurred vision.
  • Allergic Conjunctivitis : allergy due to objects such as pollen, dust mites, or dust. Itchy eyes and redness that may be accompanied by many tears, eyelid crusting and photophobia (eye glare). This condition can occur at certain times of the year, for example during a drought when a lot of pollen and dust flying through the air. Children who have a history of allergic conjunctivitis often have other atopic diseases such as allergic rhinitis, eczema or asthma.
  • Irritation Conjunctivitis : caused by chlorine in the pool, smoke, or steam.
In addition, the newborn child called neonatal conjunctivitis or ophthalmia neonatorum which is transmitted during the birth process and including sexually transmitted diseases such as gonorrhea or chlamydia infection. In small infants, symptoms of watery eyes and more eyes droppings caused by tear drainage problems that have not evolved than conjunctivitis. The condition is known as the naso-lacrimal duct obstruction, which will disappear when the baby is getting older.


Nursing Diagnosis for Conjunctivitis

  1. Acute pain related to inflammation of the conjunctiva.
  2. Anxiety related to lack of knowledge about the disease process.
  3. Risk of spread of infection associated with inflammatory processes.
  4. Impaired self-concept (body image decreases) related to the change of the eyelids (swelling / edema).
  5. Risk for injury related to limited vision.

Source : http://nanda-nursing-diagnosis.blogspot.com/2014/02/nursing-care-plan-for-conjunctivitis.html
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Nursing Care Plan for Mental Retardation (MR)

Mental retardation (MR) is a condition in which a person has the mental capacity is insufficient. Mental retardation is a subnormal intellectual function abnormalities occur during development and is associated with one or more disorders of maturation, learning and social adjustment.

Mental retardation is defined as weakness / inability cognitive appeared in childhood (before the age of 18 years) is characterized by the function under normal intelligence (IQ 70-75 or less), and accompanied by at least two other limitations in the following areas: speech and language; self-care skills, ADL; social skills; using community facilities, health and safety; functional academic, work and relax, etc..

Clinical manifestations

Clinical manifestations of mental retardation, among others:
1. Cognitive impairment (pattern, thought process).
2. The slow reception skills and language expression.
3. Failed to get past the main stages of development.
4. Head circumference is above or below normal (sometimes larger or smaller than normal size).
5. Possibility of slow growth.
6. Possibility of abnormal muscle tone (more frequent weak muscle tone).
7. Possibility of dysmorphic features.
8. Delays in fine and gross motor development.

Pathophysiology

Mental retardation refers to the real limitations of daily living function. Mental retardation include weakness or cognitive disability that appears in childhood (before age 18 years) were characterized by below-normal intelligence function (IQ 70 to 75 or less) and with other limitations in adaptive functioning at least two areas: speaking and language, abilities / skills of self-care, homemaking, social skills, use of community facilities, self-direction, health and safety, functional academic, leisure and work. Cause of mental retardation can be classified into prenatal, perinatal and post-natal. Diagnosis of mental retardation established early in childhood.

Complication

1. Cerebral palsy
2. Seizure disorders
3. Psychiatric disorders
4. Impaired concentration / hyperactivity
5. communication deficits
6. constipation

Prevention

1. Increase healthy brain development and the provision of care and an environment that stimulates growth.
2. Should focus on the biological health and early life experiences of children living in poverty in terms of prenatal care, regular health monitoring and family support services.


Nursing Care Plan for Mental Retardation (MR)

A. Assessment

The assessment consists of a comprehensive evaluation of the shortcomings and strengths associated with the adaptive skills; communication, self-care, social interaction, use of facilities in the community self-direction, health care and safety, functional academic, recreational skill formation, and tranquility.

B. Nursing Diagnosis

1. Impaired growth and development related to cognitive dysfunction.
2. Impaired verbal communication related to cognitive dysfunction.
3. Risk for injury related to aggressive behavior imbalance of physical mobility.
4. Impaired Social Interaction related to difficulty speaking / social adaptation difficulties.
5. Interrupted family processes related to having a child with mental retardation.
6. Self care deficit related to changes in physical mobility / lack of developmental maturity.

C. Intervention

1. Assess the factors causing impaired child development.
2. Identification and use of educational resources to facilitate optimal child development.
3. Provide consistent care.
4. Increase communication verbal and tactile stimulation.
5. Give simple instructions and repeat.
6. Give positive reinforcement on child outcomes.
7. Encourage children to do their own maintenance.
8. Difficult child behavior management.
9. Encourage children to socialize with the group.
10. Create a safe environment.

D. Education on Parents

1. Each stage of child development for ages.
2. Support parental involvement in child care.
3. Anticipatory guidance and management face a difficult child behavior.
4. Inform existing educational facilities and groups.

E. Expected results
1. Children to function optimally the relevant level.
2. Families and children are able to use coping with challenges due to disability.
3. Families are able to obtain the resources community facilities.

Source : http://nandanursingdiagnoses.blogspot.com/2013/10/nursing-care-plan-for-mental.html
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Nursing Care Plan for Ineffective Thermoregulation

Definition of Thermoregulation

Thermoregulation is a physiological regulation of the human body, the balance of heat production and heat loss so the body temperature can be maintained constantly.

Balance body temperature is regulated by physiological and behavioral mechanisms. In order for the body temperature remains constant and is within normal limits, the relationship between heat production and heat dissipation must be maintained. The relationship is regulated through the mechanism of neurological and cardiovascular. Nurses apply knowledge of temperature control mechanism to improve temperature regulation.

The hypothalamus is located between the cerebral hemispheres, controlling body temperature as the thermostat in the house work. The hypothalamus senses light changes in body temperature. Anterior hypothalamus controlling heat dissipation, and posterior hypothalamic control of heat production.


Factors influencing thermoregulation

Many factors affect body temperature. Changes in body temperature within the normal range occurs when the relationship between heat production and heat loss plagued by physiological or behavioral variables. Here are the factors that influence body temperature:

1. Age

At birth, the baby left the warm environment, which is relatively constant, entered in an environment where the temperature fluctuates rapidly. Baby's body temperature may respond dramatically to changes in environmental temperature. Newborns spend more than 30% of body heat through the head is therefore necessary to use a head covering to prevent heat dissipation. When protected from extreme environments, the baby's body temperature was maintained at 35.5 º C to 39.5 º C. Heat production will increase along with the growth of infants entering children. Individual difference of 0.25 º C to 0.55 º C is normal (Whaley and Wong, 1995).

Temperature regulation is not stable until puberty. Normal temperature range down gradually until someone nearing the elderly. Elderly have a narrower temperature range than early adulthood. Oral temperature of 35 º C are not uncommon in the elderly in cold weather. However, the range of body temperature in elderly around 36 º C. Elderly particularly sensitive to extreme temperatures due to deterioration mechanisms of control, especially in vasomotor control (control of vasoconstriction and vasodilatation), a decrease in the amount of subcutaneous tissue, decreased sweat gland activity and a decrease in metabolism.

2. Sports

Muscle activity requires an increased blood supply in the breakdown of carbohydrates and fats. This leads to increased metabolism and heat production. Any type of exercise can increase heat production, consequently increasing the body temperature. Long strenuous exercise, such as long-distance running, can increase body temperature temporarily to 41 º C.

3. Hormone levels

In general, women experience fluctuations in body temperature greater than men. Hormonal variations during the menstrual cycle causes fluctuations in body temperature. Progesterone levels increase and decrease gradually during the menstrual cycle. When progesterone levels are low, the body temperature a few degrees below the limit level. Low body temperature that lasted until ovulation. Temperature changes also occur in postmenopausal women. Women who had stopped menstruation may experience periods of body heat and sweating a lot, from 30 seconds to 5 minutes. This is due to the unstable vasomotor control in doing vasodilation and vasoconstriction. (Bobak, 1993)

4. Circadian rhythms

Normal body temperature change of 0.5 º C to 1 º C over a period of 24 hours. However, the temperature is a steady rhythm in humans. Lowest body temperature is usually between 1:00 pm and 4:00 am. Throughout the day the body temperature rises, until about 18:00 and then down like in the early days. Important note, the temperature patterns are not automatically on the people who work at night and sleep during the day. It took 1-3 weeks for the rotation change. In general, the temperature circadian rhythm does not change with age. Research shows, the peak temperature is early days in the elderly (lenz, 1984)

5. Stress

Physical and emotional stress increases the body temperature through hormonal and neural stimulation. The physiological changes increase the heat. Clients are anxious while in the hospital or doctor's office, her body temperature can be higher than normal.

6. Environment

Environment affecting body temperature. If the temperature is studied in a very warm room, the client may not be able to regulate body temperature through heat flushing mechanism and body temperature will rise. If the client is in an environment without warm clothes, body temperature may be low due to the effective deployment and conductive heat dissipation. Infants and the elderly most often influenced by environmental temperature because they are less efficient mechanism of temperature.



Changes in body temperature

Changes in body temperature outside the range of normal influences hypothalamic set point. These changes may be associated with the production of excessive heat, excessive heat dissipation, heat production is minimal. Spending minimal heat or any combination of these changes. The nature of these changes affect the clinical problems experienced by clients.

1. Fever

Fever or hyperpyrexia occur because heat dissipation mechanism is not able to maintain the speed of spending excess heat production, resulting in an abnormal increase in body temperature. Health-threatening levels when fever is often a source of debate among health care providers. Fever is usually not harmful if it is at a temperature below 39 º C. Single temperature readings may not signify a fever. Davis and Lentz (1989) recommends for determining fever by some temperature readings at different times in one day compared to the normal temperature at the same time, in addition to vital signs and symptoms of infection. Fever is actually a consequence of changes in the hypothalamic set point.

2. Tired due to the heat

Exhausted by heat occur when diaphoresis which many result in loss of fluid and electrolytes in excess. Caused by exposure to hot environments. Signs and symptoms of fluid volume is less common during melting due to the heat. The first action is to move clients to cooler environments as well as improving the balance of fluids and electrolytes.

3. Hyperthermia

Increased body temperature with respect to the inability of the body to increase or decrease the heat dissipation of heat production is hyperthermia. Each disease or trauma to the hypothalamus may affect the mechanism of heat dissipation. Malignant hyperthermia is a congenital condition can not control the heat production, which occurs when people are prone to use certain anesthetic drugs.

4. Heatstroke

Long exposure to sunlight or high temperature environments may affect the mechanism of heat dissipation. This condition is called heatstroke, heat a dangerous emergency with a mortality rate that high. Clients at risk include very young or very old, who has cardiovascular disease, hypothyroidism, diabetes or alcoholism. Also included is a risk that people who consume a drug that lowers the body's ability to remove heat and those who underwent exercise or heavy work. Signs and symptoms of heatstroke include; giddy, confusion, delirium, thirst, nausea, muscle cramps, visual disturbances, and even incontinence. Signs of heatstroke are the most warm and dry skin.

Heatstroke patients do not sweat because of the loss of electrolytes is very heavy and the hypothalamus malfunctions. Heatstroke at temperatures greater than 40.5 º C lead to tissue damage in the cells of all organs of the body. Vital signs stating body temperature sometimes as high as 45 º C, tachycardia and hypotension. The brain may be the first organ affected because of their sensitivity to electrolyte imbalance. If the condition persists, the client becomes unconscious, non-reactive pupils. Nourologis permanent damage occurs unless the cooling action is about to begin.

5. Hypothermia

Spending heat due to continuous exposure to cold affects the body's ability to produce heat, resulting in hypothermia. Hypothermia is classified by measuring core temperature. This can happen by chance or accident during a surgical procedure to reduce the metabolic needs and the needs of the body for oxygen.

Accidental Hypothermia usually occurs gradually and go unnoticed for several hours. When the body temperature drops to 35 ° C, client experience uncontrollable shaking, memory loss, depression, and are not able to judge. If the body temperature drops below 34.4 ° C, heart rate, respiration, and blood pressure drops. skin becomes cyanotic.



Nursing Care Plan for Ineffective Thermoregulation

Nursing Diagnosis:

Risk for Infection r / t:

  • The decrease in the body's system.
  • Failure to recognize and treat infections.
  • Invasive procedures.
  • Nosocomial.

Objectives / outcomes:
  • Showed healing over time.
  • Free of purulent secretion, free from febrile.

Interventions

1. Give isolation / monitor indications within their visitors.
R :/ Isolation wound / linen and wash hands for wound drainage / visitor restrictions are needed to protect patients and reduce the chance of infection.

2. Wash hands before and after the action.
R :/ Reduces cross-contamination.

3. Encourage the patient to cover mouth and nose when coughing / sneezing.
R :/ Preventing the spread of infection by droplet infection.

4. Limit the use of tools / invasive procedures if possible.
R :/ Subtraction number of locations that can be the entry point of the organism.

5. Use gloves in wound care.
R :/ Preventing the spread of infection / contamination.

6. Use sterile technique at the time of dressing change / exploitation / gave the location of care, for example ; infusion, catheter.
R :/ Prevent entry of bacteria, reducing the risk of nosocomial infection.

7. Monitor body temperature
R :/ Fever 38.5 C - 40 C endotoxin effect on the hypothalamus.
Hypothermia sign of decreased tissue perfusion.

8. Give anti-infective drugs as directed.
R : To eradicate / provide temporary immunity to common infection / disease specific.

Source : http://nandacareplan.blogspot.com/2014/03/nursing-care-plan-for-ineffective.html
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Nursing Care Plan for Angina Pectoris


Nursing Diagnosis : Acute Pain

Goal: pain is reduced / resolved.

Outcomes:
Patient states / shows the pain is relieved,
Patient reported angina episodes decreased in frequency, duration and severity.

Interventions:

1. Instruct the patient to notify nurse quickly in the event of chest pain.
Rationale: Pain and decreased cardiac output can stimulate the sympathetic nervous system to release large amounts of nor epinephrine, which increases platelet aggregation and thromboxane A2 issued. Pain can not be detained cause vasovagal response, reducing BP and heart rate.

2. Identification of the precipitating factors, if any: frequency, duration, intensity and location of pain.
Rationale: Helps distinguish chest pain early and the possibility of progress evaluation tool becomes unstable angina (stable angina usually ends 3 to 5 minutes while unstable angina longer and can last more than 45 minutes.

3. Evaluation report pain in the jaw, neck, shoulder, hand or arm (especially on the left side).
Rationale: cardiac pain may spread to the sample surface pain more often innervated by the same spinal level.

4. Instruct the patient on bed rest during episodes of angina.
Rationale: Reduce myocardial oxygen demand to minimize the risk of tissue injury or necrosis.

5. Elevate the head of the bed when the patient is short of breath.
Rationale: Facilitate the exchange of gases to reduce repetitive hypoxia and shortness of breath.

6. Monitor the speed or rhythm of the heart.
Rationale: Patients with unstable angina have increased life-threatening dysrhythmias in acute, which occurs in response to ischemia and or stress.

7. Monitor vital signs every 5 minutes during an attack of angina.
Rational: BP can rise early with respect to sympathetic stimulation, then dropped when the cardiac output is affected.

8. Maintain a calm, comfortable environment, limit the visitor when necessary.
Rationale: mental or emotional stress increase myocardial work.

9. Give soft foods. Let the patient rest for 1 hour after eating.
Rationale: Reduces Myocardial work in connection with the work of digestion, manurunkan risk of angina attacks

10. Give antianginal as indicated.
Rationale: For the treatment and prevent angina pain.

Source : http://nandanursingdiagnoses.blogspot.com/2014/02/acute-pain-ncp-angina-pectoris.html
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Gout Nursing Care Plan

Gout is inflammation caused by the deposition of uric acid crystals in the joints and fingers.

Pathophysiology

The presence of purine metabolism disorders in the body, the intake of materials containing high uric acid, and uric acid excretion systems are inadequate, would result in an excessive accumulation of uric acid in the blood plasma (Hiperurecemia), thus resulting in uric acid crystals accumulate in the body. This hoarding cause local irritation and cause inflammatory responses.

Hiperurecemia is the result:
  • Increased production of uric acid due to abnormal purine metabolism.
  • Decreased excretion of uric acid.
  • Combination of both.
Gout commonly affects post-menopausal women aged 50-60 years. Also can affect males and puberty or age over 30 years. The disease most commonly affects the joints metatrsofalangeal, toe, knee and ankle joints.

Nursing Assessment
  • health history
  • age
  • male / female
  • pain (in the big toe or other joints)
  • stiffness in the joints
  • activity (easy to accomplish)
  • diet
  • family
  • treatment
  • dizziness, fever, malaise, and anorexia
  • tachycardia
  • patterns of health care
  • kidney stone disease
Physical Examination
  • identification of signs and symptoms of existing bicycle nursing history
  • tenderness in the joints affected
  • pain when moved
  • swollen joint area (warm skin, tense, purplish color)
  • pounding heartbeat
  • identification of weight loss
Psychosocial History
  • anxious and afraid to do kativitas
  • helpless
  • disruption of activity in the workplace
Diagnostic Tests
  • uric acid
  • white blood cells, red blood cells
  • joint aspiration contained uric acid
  • urine
  • roentgen

Nursing Care Plan for Gout : Nursing Diagnosis 
  1. Acute pain r / t presence of inflammation in the joints.
  2. Impaired physical mobility r / t presence of joint pain.
  3. Knowledge Deficit: about treatment and care at home.
  4. Impaired skin integrity r / t tophi.

Source : http://nandacareplan.blogspot.com/2013/12/gout-care-plan-and-nursing-diagnosis.html
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Idiopathic Thrombocytopenic Purpura Care Plan

Nursing Care Plan for Idiopathic Thrombocytopenic Purpura (ITP)

Definition of ITP

ITP or Idiopathic Thrombocytopenic Purpura. Idiopathic means the cause is unknown. Thrombocytopenic means that the blood does not have enough blood platelets (thrombocytes). Purpura means someone has bruised many (redundant). The term is also an ITP Immune Thrombocytopenic Purpura stands. (Family Doctor, 2006).

Idiopathic (autoimmune) Trobocytopenic Purpura (ITP / ATP) is an autoimmune disorder in which autoantibodies Ig G, formed to bind platelets.

It is unclear whether the antigen on the surface of platelets formed. Although antiplatelet antibodies can bind complement, platelets are not damaged by direct lysis. Insident most common at the tender age of 20-50 and is more frequent in women than men (2:1). (Arief Mansoer, et al).

Idiopathic thrombocytopenia purpura is called an autoimmune disorder characterized by persistent thrombocytopenia (peripheral blood platelet numbers less than 15.000/μL) caused by autoantibodies that bind to platelet antigens causing premature destruction of platelets in the reticuloendothelial system, especially in the spleen. Or it can mean that idiopathic thrombocytopenia purpura is a bleeding condition in which the blood does not come out properly. Occurs due to a low platelet count or platelet count. Circulating platelets through the blood vessels and help stop bleeding by means of clot. Idiopathic means that the cause of the disease itself is not known. Thrombocytopenia is the number of platelets in the blood is below normal. Purpura is a bluish bruises caused by bleeding under the skin. Bruising showed that bleeding has occurred in small blood vessels under the skin. (ana information center, 2008).


Etiology of ITP

The cause of ITP is not known for certain, the mechanism that occurs through the formation of antibodies that attack the cells of platelets, so platelets cell death. (Imran, 2008). The disease is thought to involve an autoimmune reaction, where the body produces antibodies that attack its own platelet count . Under normal conditions, the antibody is a healthy body's response to bacteria or virus that enters the body. But for patients with ITP, antibodies attack even cells ubuhnya own blood platelets. (Family Doctor, 2006).
Although the bone marrow to increase platelet formation, platelet existing inventory still can not meet the body's needs. In most cases, it is suspected that ITP is caused by the body's immune system. Normally the immune system makes antibodies to fight off foreign substances that enter the body. In ITP, the immune system against the body's own platelets. The reason the immune system attacks the platelets in the body remains unknown. (ana information center, 2008).

a. ITP may also be caused by hypersplenism, viral infection, food intoxication or drug or chemical, physical influence (radiation, heat), lack of maturation factors (eg malnutrition), disseminated intravascular coagulation (DIC), autoimmune. Based on etiology , ITP is divided into 2 primary ( idiopathic ) and secondary. Based on the type of acute onset of illness distinguished when it happened less than or equal to 6 months (generally occurs in children ) and chronic if more than 6 months (umunnya occurs in adults). (ana information center, 2008)

b. ITP also occurs in people with HIV . whereas drugs such as heparin, liquor, quinidine, sulfonamides may also cause thrombocytopenia. Usually the signs of disease and the factors that blessings with this disease are as follows : purpura, bleeding and menstrual blood are much longer maturity, bleeding nostrils, bleeding jaw teeth, the latest virus immunization, recent viral illness and hack or bruising.


Symptoms and Signs of ITP
  • Red spots on the skin (especially in the legs), often clustered and resemble a rash. These spots, known as petechiae, caused due to bleeding under the skin.
  • Bruising or bluish areas on the skin or mucous membranes (such as below the mouth) due to bleeding under the skin. The bruises may occur for no apparent reason. This type of bruise called purpura. Bleeding is more likely to form a three-dimensional mass called a hematoma.
  • Nose bleeds or bleeding of the gums. There is blood in the urine and feces. Some kind of bleeding can be a sign of difficult discontinued ITP. Including prolonged menstruation in women. Bleeding in the brain is rare, and symptoms of bleeding in the brain can indicate the severity of the disease.
  • Low platelet count will cause pain, fatigue (tiredness), difficulty concentrating.

Source : http://nandacareplan.blogspot.com/2013/12/idiopathic-thrombocytopenic-purpura.html
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