Nursing Care Plan for Epilepsy

Epilepsy is a chronic neurological disease that causes seizures periodically. The disease is caused by the normal activity of brain cells. Symptoms of seizures that appears may vary. Some people with epilepsy when seizures have an empty view.

Because epilepsy is not normally caused by the activity of brain cells, seizures can have an impact on brain coordination process. Convulsions can result in:

  • Temporary confusion
  • Uncontrolled jerking movements of the hands and feet
  • Lost consciousness in total
Differences symptoms occur depending on the type of seizures. In many cases, people with epilepsy will tend to have this type of seizure is the same every time, so it will be the same symptoms that occur from incident to incident.

High fever at the time of the children in a long time sometimes associated with seizures for a long time and epilepsy in the future. Especially for those with a family history records with epilepsy.


Nursing Diagnosis for Epilepsy : Low Self-Esteem related to stigma in terms of conditions, perceptions of uncontrolled
characterized by:
  • disclosures about changes in lifestyle,
  • fear of rejection; negative feelings about the body.
Goal: Identify feelings and methods for coping with negative self-perceptions.

Intervention:
  1. Discuss feelings about the patient's diagnostic, self-perception of the treatment used.
  2. Suggest to reveal / express his feelings.
  3. Identify / anticipate possible reactions of people on the state of the disease. Encourage clients to not conceal the problem.
  4. Together with the patient looking for the success that has been obtained or will be achieved next and the power it has.
  5. Determine the attitude / skills of people nearby. Help realize these feelings are normal, whereas guilt and self-blame is useless.
  6. Emphasize the importance of those closest to remain in a state of calm during a seizure.

Rational :

  1. Reactions have varied between individuals and the knowledge / experience with the initial state of the disease will affect reception.
  2. Complaints feel scared, angry and very concerned about the implications in the future could affect the patient to receive its state.
  3. Provide an opportunity to respond to the problem-solving process and provide measures to control the situation.
  4. Focusing on the positive aspects that can help to eliminate the feelings of failure or awareness of self and shaping the patient began receiving handler against the disease.
  5. Negative outlook of the people closest to affect the feelings of capability / client self-esteem and reduce the support received from the closest people who have a risk limit optimal handling.
  6. Anxiety of caregiver is spreading and when it came to patients can improve the negative perception of the state of the environment / self - own.

Source : http://nursing-diagnosis-care-plans.blogspot.com/2014/02/low-self-esteem-related-to-epilepsy.html
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Nursing Care Plan for Headache

A headache or cephalalgia is pain anywhere in the region of the head or neck.

Symptoms :

  • Diplopia
  • Dimming of vision in a single eye
  • Stiff neck
  • Disorientation
  • Rash
  • Fever
  • Eye pain
  • Unilateral paresthesia
  • Unilateral weakness
  • Balance change

There are more than 200 types of headaches. Some are harmless and some are life-threatening. The description of the headache and findings on neurological examination, determine whether additional tests are needed and what treatment is best.

The most common primary headaches are:
  • Cluster headache
  • Migraine (with and without aura)
  • Tension headache (medically known as tension-type headache)


Causes of secondary headaches include :
  • meningitis
  • bleeding inside the brain (intracranial hemorrhage)
  • subarachnoid hemorrhage (acute, severe headache, stiff neck WITHOUT fever)
  • ruptured aneurysm, arteriovenous malformation, intraparenchymal hemorrhage (headache only)
  • brain tumor
  • temporal arteritis
  • acute closed angle glaucoma (increased pressure in the eyeball)


Pain (acute / chronic) related to stress and tension, irritation / nerve pressure, vasospasm, increased intracranial.

Goal: Pain is lost or reduced

Outcomes:
  • Reveal reduced pain.
  • Normal vital signs.
  • Appeared calm and relaxed.
Intervention:
  1. Monitor vital signs, intensity / pain scale.
  2. Encourage clients to rest in bed.
  3. Adjust the position of the patient as comfortable as possible.
  4. Teach relaxation techniques and breathing deeply.
  5. Collaboration for providing analgesic.

Rational:
  1. Recognize and facilitate the nursing action.
  2. Breaks to reduce the intensity of pain.
  3. Right position reduces stress and prevent muscle tension and reduce pain.
  4. Relaxation relieves tension and makes the feeling more comfortable.
  5. Useful analgesic to reduce pain so that the patient becomes more comfortable.

Source : http://nursing-diagnosis-care-plans.blogspot.com/2014/04/pain-acute-chronic-nursing-care-plan.html
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Nursing Care Plan for Anemia - Deficient Knowledge

Nursing Diagnosis for Anemia : Deficient Knowledge Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to :

  • Lack of exposure/recall
  • Information misinterpretation
  • Unfamiliarity with information resources
evidenced by
  • Questions; request for information; statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications

Outcomes :

Knowledge: Illness Care (NOC)
  • Verbalize understanding of the nature of the disease process, diagnostic procedures, and potential complications.
  • Identify causative factors.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary behaviors/lifestyle changes.


Interventions and Rationale :

Teaching: Disease Process (NIC)

Independent

1. Provide information about specific anemia and explain that therapy depends on the type and severity of the anemia.
R/: Provides knowledge base from which client can make informed choices. Allays anxiety and may promote cooperation with therapeutic regimen.

2. Discuss effects of anemias on preexisting conditions.
R/: Anemias aggravate heart, lung, and cerebrovascular disease.

3. Review purpose and preparations for diagnostic studies.
R/ : Anxiety/fear of the unknown increases stress level, which in turn increases the cardiac workload. Knowledge of what to expect can diminish anxiety.

4. Explain that blood taken for laboratory studies will not worsen anemia.
R/: This is often an unspoken concern that can potentiate client’s anxiety.

5. Review required diet alterations to meet specific dietary needs (determined by type of anemia/deficiency).
R/: Red meat, liver, seafood, green leafy vegetables, whole wheat bread, and dried fruits are sources of iron. Green vegetables, whole grains, liver, and citrus fruits are sources of folic acid and vitamin C (enhances absorption of iron).

6. Discuss foods to avoid (e.g., coffee, tea, egg yolks, milk, fiber, and soy protein) at the time when client is eating high-iron foods.
R/: These foods block absorption of iron and should be taken at a different meal. For example, red meat and milk taken at the same time can block absorption of the iron from the meat.

7. Assess resources (e.g., financial) and ability to obtain/prepare food).
R/: Inadequate resources may affect ability to purchase/prepare appropriate food items.

8. Encourage cessation of smoking.
R/: Smoking decreases available oxygen and causes vasonstriction.

9. Provide information about purpose, dosage, schedule, precautions, and potential side effects, interactions, and adverse reactions to all prescribed medications.
R/: Information enhances cooperation with regimen. Recovery from anemias can be slow, requiring lengthy treatment and prevention of secondary complications.

10. Stress importance of reporting signs of fatigue, weakness, paresthesias, irritability, impaired memory.
R/: Indicates that anemia is progressing or failing to resolve, necessitating further evaluation/treatment changes.

Source : http://nursing-diagnosis-care-plans.blogspot.com/2014/02/deficient-knowledge-related-to-anemia.html
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Nursing Care Plan for Appendicitis

Nursing Care Plan for Appendicitis

Appendicitis is an inflammation of the appendix, an additional function as the bag is not located on the inferior and the cecum. The most common cause of appendicitis is obstruction of the lumen by fecal supply eventually undermine and erode the mucosal blood flow, causing inflammation (Wilson & gold man, 1989).

Type of Appendicitis :

1. Acute appendicitis (sudden).
Symptoms of acute appendicitis are fever, nausea, vomiting, decreased appetite, pain around the navel which is then localized in the lower right abdomen, pain worse for walking, but not everyone will show symptoms like this, it could also just be chills, or nausea - vomiting only.

2. Chronic appendicitis.
Symptoms of chronic appendicitis bit similar to stomach acid pain where there is a faint pain (dull) in the area around the navel and sometimes intermittent fever. Often accompanied by nausea, sometimes vomiting, and pain that moves to the right lower abdomen with the typical signs of acute appendicitis.
Spread of pain will depend on the direction of the position / location of the appendix to the colon itself, If the tip of the appendix touching the urinary tract, the pain will be the same as the sensation of urinary tract colic pain, and there may be a urinary disorders. When the position of the appendix to the back, the pain appeared to puncture rectal examination or vaginal puncture . In another appendix position, the pain may not be specific.


Nursing Care Plan for Appendicitis

Acute pain related to intestinal distension

characterized by:
  • respiratory tachypnea,
  • circulation tachycardia,
  • epigastric pain radiating to the local area Mc Burney,
  • clients complained of feeling pain lower right area.

Goal: pain is resolved

Outcomes:
  • normal breathing, 
  • normal circulation
Intervention:
  1. Assess the level of pain, location and characteristics
  2. Encourage deep breathing
  3. Give analgesics

Source : http://painnursingdiagnosis.blogspot.com/2014/01/acute-pain-nursing-care-plan-for.html
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Nursing Care Plan for Coronary Artery Disease

Nursing Diagnosis and Interventions for Coronary Artery Disease : Acute Pain


Coronary artery disease is coronary artery pathological condition characterized by abnormal accumulation of lipids or fatty material and fibrous tissue in the walls of blood vessels resulting in changes in the structure and function of arteries and reduced blood flow to the heart (Brunner and Suddarth)

The main cause of coronary artery disease is atherosclerosis. Atherosclerosis is the hardening of the artery walls. Arteriosclerosis characterized by the accumulation of fat, cholesterol, intimate layer of the artery. This heap is called atheroma or plaque.

Nursing Diagnosis for Coronary Artery Disease : Acute Pain related to a decrease in myocardial blood flow, increased cardiac workload / oxygen consumption

Outcomes:

  • Stating chest pain disappeared / controlled.
  • Demonstrating the use of relaxation techniques.
  • Showed reduced tension, relaxed, easy to move.

Interventions:

1. Monitor / record the characteristics of pain, note the verbal report, nonverbal cues, and the hemodynamic response (grimacing, crying, restlessness, sweating, gripping his chest, rapid breathing, BP / heart rate change).

Rational: Variations in the appearance and behavior of the patient as pain occurs as the assessment findings. Most patients with acute myocardial infarction looks sick, distraction and focus on the pain. Verbal history and education in the precipitating factors should be postponed until the pain is gone. Breathing may be increased as a result of pain and is associated with anxiety, stress cause temporary loss of catecholamines will increase the heart rate and BP.


2. Take full assessment of the patient's pain at the site; intensity (0-10); duration; quality (shallow / spread) and deployment.

Rational : Pain as a subjective experience and should be described by the patient. Help the patient to assess pain by comparing it with other experiences.


3. Review the history of previous angina, pain resembling angina, or myocardial infarction pain. Discuss family history.

Rational : There can compare the pain of the previous pattern, according to widespread identification of complications such as infarction, pulmonary embolism, or pericarditis.


4. Instruct the patient to report pain immediately.

Reporting delay distribution of pain inhibiting pain / need improvement. Doses of the drug. In addition, severe pain can cause shock to stimulate the sympathetic nervous system, resulting in further damage and interfere with diagnostic and pain relief.


5. Provide a quiet environment, the activity slowly, and the action comfortable. Approach calmly and with patient trust.

Rational: Lowering external stimuli in which anxiety and heart strain and limited coping abilities and judgment of the current situation.


6. Aids patients relaxation techniques, eg deep breathing / slow, behavioral distraction, visualization, guided imagery.

Rational: Assist in the reduction in the perception / pain response. Giving control of the situation, increase positive behavior.


7. Check vital signs before and after drug administration.

Rational: Hypotension / respiratory depression can occur as a result of drug administration. This problem can increase the damage miokardia the presence of ventricular failure.


8. Provide supplemental oxygen by nasal cannula or mask as indicated.

Rational: Increase the amount of oxygen available for myocardial consumption and reduce discomfort with respect to tissue ischemia.

Source : http://painnursingdiagnosis.blogspot.com/2014/04/acute-pain-nursing-care-plan-for.html
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Nursing Care Plan for Urinary Tract Infection

A urinary tract infection is usually a bacterial infection that affects the urinary system. Normally, bacteria that enter the urinary tract are rapidly removed by the body before they cause symptoms. However, sometimes bacteria overcome the body’s natural defenses and cause infection. UTI is nearly always caused by bacteria, specifically Escherichia coli (E. coli).

UTI can occur in any part of the urinary system

Any part of the urinary tract may be infected:

Urethritis is infection of the urethra.
Ureteritis is infection of a ureter.
Pyelonephritis is infection of the kidneys.
Cystitis is infection of the bladder.

Symptoms of a Urinary Tract Infection (UTI) vary by age, gender, and whether a catheter is present. Among young women, UTI symptoms typically include a frequent and intense urge to urinate and a painful, burning feeling in the bladder or urethra during urination. The amount of urine may be very small. Older women and men are more likely to be tired, shaky, and weak and have muscle aches and abdominal pain. Urine may look cloudy, dark, or bloody or have a foul smell. In a person with a catheter, the only symptom may be fever that cannot be attributed to any other cause.

Nursing Diagnosis for Urinary Tract Infection

Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

Outcomes :
No pain when urinating, no pain in the pelvic percussion.

Intervention:
1. Monitor urine output to changes in color, odor and voiding patterns, input and output every 8 hours and monitor the results of urinalysis repeated.
Rational: To identify indications of progress or deviations from the expected results

2. Record the location, the length of the intensity scale (1-10) the spread of pain.
Rational: Help evaluate the place of obstruction and cause pain.

3. Provide convenient measures, such as back rubs, environment, rest ;
Rationale : increase relaxation, decrease muscle tension.

4. Help or encourage the use of breath -focused.
Rational : help redirect the attention and for muscle relaxation.

5. Give perineal care.
Rational : to prevent contamination of the urethra.

6. If indwelling catheter, catheter care given 2 times per day.
Rationale : The catheter provides a way for bacteria to enter the bladder and urinary tract rise to.

collaboration:

7. Give analgesics according to program requirements and evaluation of its success.
Rationale: analgesics block pain trajectory, thereby reducing pain.

8. Give antibiotics. Create a wide variety of preparations drink, including fresh water. Giving water to 2400 ml / day.
Rationale: The result of the output of urine facilitate frequent urination and help flush channel urination.

Source :

http://nandanursingdiagnoses.blogspot.com/2014/03/acute-pain-ncp-for-urinary-tract.html
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Nursing Care Plan for Dermatitis

Dermatitis or eczema is inflammation of the skin. It is characterized by itchy, erythematous, vesicular, weeping, and crusting patches.

Dermatitis symptoms vary with all different forms of the condition. They range from skin rashes to bumpy rashes or including blisters. Although every type of dermatitis has different symptoms, there are certain signs that are common for all of them, including redness of the skin, swelling, itching and skin lesions with sometimes oozing and scarring.

Although the symptoms of atopic dermatitis vary from person to person, the most common symptoms are dry, itchy, red skin. Typical affected skin areas include the folds of the arms, the back of the knees, wrists, face and hands.

Nursing Diagnosis for Dermatitis : Impaired skin integrity related to the dryness of the skin

Goal :
The skin can return to normal.

Outcomes:
The client will maintain skin hydration in order to have a good and downs of inflammation.

Characterized by :

revealed an increase in skin comfort,
reduced the degree of exfoliation,
reduced redness,
reduced blisters, due to scratching,
healing damaged skin areas.


Intervention:
1. Shower at least once a day for 15-20 minutes. Immediately apply ointment or cream that has been prescribed after a shower. Bathing more frequently if signs and symptoms increased.
Rationale: With bath water will seep under the skin saturation. Application of a moisturizing cream for 2-4 minutes after bathing to prevent water evaporation from the skin.

2. Use warm water not hot.
Rationale: hot water causes vasodilation which will improve pruritus.

3. Use moisturizing soap, or soap for sensitive skin. Avoid bubble bath.
Rational: soap that contains moisturizers less alkaline content and do not make dry skin, dry soap may increase complaints.

4. Spread / give ointment or cream that has been prescribed two or three times per day.
Rationale: ointment or cream to moisturize the skin.

Source : http://nandanursingdiagnoses.blogspot.com/2014/04/impaired-skin-integrity-ncp-for.html
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