ARDS Care Plan - Diagnosis Nanda

Nursing Diagnosis for ARDS

Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition that prevents enough oxygen from getting to the lungs and into the blood.

ARDS also known as respiratory distress syndrome (RDS) or adult respiratory distress syndrome is a serious reaction to various forms of injuries or acute infection to the lung.

It is characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure.

ARDS can be caused by any major injury to the lung. Some common causes include:
  • Breathing vomit into the lungs (aspiration)
  • Inhaling chemicals
  • Lung transplant
  • Pneumonia
  • Septic shock (infection throughout the body)
  • Trauma

  • Difficulty breathing
  • Low blood pressure and organ failure
  • Rapid breathing
  • Shortness of breath

Symptoms usually develop within 24 to 48 hours of the injury or illness. Often, people with ARDS are so sick they cannot complain of symptoms.

There is no specific treatment for ARDS. A person with ARDS is treated in the intensive care unit at the hospital. Often a person with ARDS will need a machine's help to breathe (called mechanical ventilation) and oxygen therapy.

Treatments may include:
  • Oxygen through tubes in your nose or through a mask
  • Oxygen through a breathing tube. The tube is flexible and goes through your mouth or nose into your windpipe. The tube is connected to a ventilator, a machine that helps you breathe.
  • Fluids through an IV line to improve your blood flow and to provide nutrition
  • Medicine to prevent and treat infections and to relieve pain

Nanda Nursing Diagnosis for ARDS

1. Ineffective Airway Clearance

2. Ineffective Breathing Pattern

3. Impaired Gas Exchange

4. Decreased Cardiac Output

5. Risk for Injury

6. Excess Fluid Volume

7. Impaired Physical Mobility

8. Impaired Skin Integrity

9. Impaired Verbal Communication

10. Ineffective Coping

11. Sleep Pattern Disturbance

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Risk for Injury related to Meniere's Disease - NCP

Nursing Care Plan for Meniere's Disease- Risk for Injury

The exact cause of Meniere's disease is unknown. It may occur when the pressure of the fluid in part of the inner ear gets too high.

In some cases, Meniere's disease may be related to:
  • Head injury
  • Middle or inner ear infection

Other risk factors include:
  • Allergies
  • Alcohol use
  • Family history
  • Fatigue
  • Recent viral illness
  • Respiratory infection
  • Smoking
  • Stress
  • Use of certain medications

Risk for Injury : At risk of injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources

Nursing Diagnosis : Risk for Injury related to altered mobility because of gait disturbance and vertigo

Goal: Keep free from injuries related to an imbalance and / falls

Expected outcomes:
  • Not to fall due to impaired balance.
  • Fear and anxiety is reduced.
  • Conduct training in accordance with the provisions.
  • Identify the nature of feeling full or feeling pressure in the ear that happens before the attack.
  • Immediately perform a horizontal position when dizzy.
  • Keep the head remained silent when dizzy.
  • Use prescription drugs as well.
  • Report an effort to reduce vertigo.

Intervention and Rational:

1. Assess vertigo which includes history, onset, description of the attack, duration, frequency, and the presence of symptoms related ear hearing loss, tinnitus, a feeling of fullness in the ear.
Rationale: History provide the basis for further intervention.

2. Assess the extent of disability in connection with the activities of daily living.
Rationale: The extent of disability lowers the risk of falling.

3. Teach vestibular therapy or stress / balance in accordance with the provisions.
Rationale: This exercise can speed up the compensation maze reduce vertigo and impaired way street.

4. Give or teach how anti-drug or vertigo and vestibular sedatives and give instructions to patients about the side effects.
Rationale: Eliminate the symptoms of acute vertigo.

5. Encourage the patient to lie down if feeling dizzy, with fence bed is raised.
Rationale: Reduces the possibility of falls and injuries.

6. Put a pillow on both sides to limit motion fist.
Rationale: Move will aggravate vertigo.

7. Help patients locate and determine the aura (the aural symptoms) that precedes the occurrence of any attack.
Rationale: The introduction of the aura can help determine when the need for drugs before the attack so as to minimize the severity of the effects.

8. Instruct the patient to keep open his eyes and looked straight ahead while lying down and experiencing vertigo.
Rationale: The feeling of vertigo and reduced eye movement when experiencing decelerations remained on guard in a fixed position.

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Management of Dengue Hemorrhagic Fever - Nursing Care

Dengue Hemorrhagic Fever - Nursing Care


1. Identity
Dengue Hemorrhagic Fever is a tropical disease that often leads to the death of children, adolescents and adults (Effendy, 1995).

2. Main complaint
Patients complain of heat, headache, weakness, heartburn, nausea and decreased appetite.

3. History of present illness
Medical history showed headache, muscle aches, the whole body aches, pain on swallowing, weakness, heat, nausea, and decreased appetite.

4. History of previous illness
There is no a specific illness.

5. Family history of disease
History of Dengue Hemorrhagic Fever disease in other family members is crucial, due to Dengue Hemorrhagic Fever disease is a disease that can be transmitted through mosquito bites aigepty aides.

6. Environmental Health History
Usually less than clean environment, many puddles of water like tin cans, old tires, a water bird that rarely changed the water, the tub is rarely cleaned.

7. Developmental History

Nursing Management of Dengue Hemorrhagic Fever

1. Hyperthermia related to the dengue virus infection

Goal: Normal body temperature
Expected outcomes: The body temperature between 36-37 0C, muscle pain disappeared.

1. Assess the patient's body temperature
Rational: find an increase in body temperature, facilitate intervention.
2. Give warm compresses
Rational: reduce heat to heat transfer by conduction. Warm water is slowly control the heat removal without causing hypothermia or shivering.
3. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated).
Rationale: To replace fluids lost due to evaporation.
4. Instruct patient to wear clothes that are thin and easy to absorb sweat.
Rationale: To provide a sense of comfort and wear thin easily absorbs sweat and does not stimulate an increase in body temperature.
5. Observation intake and output, vital signs (temperature, pulse, blood pressure) once every 3 hours or as indicated.
Rationale: Early Detect hydrated and knowing fluid and electrolyte balance in the body. Vital Signs is a reference to determine the patient's general condition.
6. Collaboration: intravenous fluid and drug delivery according to the program.
Rationale: Proper hydration is very important for patients with a high body temperature. Particular drug to lower a patient's body heat.

2. Risk for fluid volume deficit related to intravascular fluid into the extravascular migration.

Goal: Not voume fluid deficit
Expected outcomes: Input and output balanced, vital sign within normal limits, no sign of pre-shock.

1. Monitor vital sign every 3 hours / as indicated.
Rationale: Vital sign helps identify fluctuations in intravascular fluid.
2. Observation of capillary refill.
Rational: Indications adequacy of peripheral circulation.
3. Observation intake and output. Note the color of urine / concentration
Rationale: Decreased urine output with increased density concentrated suspected dehydration.
4. Encourage to drink 1500-2000 ml / day (as tolerated)
Rationale: To meet the needs of the body fluids peroral
5. Collaboration: Intravenous Fluid
Rational: It can increase the amount of body fluid, to prevent hipovolemic shock.

3. Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid into the extravascular migration.

Goal: Not happening hypovolemic shock.
Expected outcomes: Vital signs within normal limits.

1. Monitor the patient's general condition
Rationale: To monitor the condition of the patient during treatment, especially when paused bleeding. Nurses immediately know the signs of pre-shock / shock.
2. Observation of vital sign every 3 hours or more
Rationale: Nurses need to continue to observe the vital sign to ensure it does not happen pre-shock / shock.
3. Explain to the patient and family sign of bleeding, and immediately report if bleeding occurs
Rationale: By involving the patient and family the signs of bleeding can be quickly identified and appropriate action is fast and can be immediately given.
4. Collaboration: Intravenous Fluid
Rationale: Intravenous fluids needed to overcome a severe loss of body fluids.
5. Collaboration: checks: HB, PCV, platelet
Rationale: To determine the level of blood vessel leakage experienced by patients and to take further action reference.

4. Risk for imbalanced Nutrition, Less Than Body Requirements related to inadequate nutritional intake due to nausea and decreased appetite.

Goal: No disruption nutritional needs.
Expected outcomes: There are no signs of malnutrition, indicating a balanced weight.

1. Review the history of nutrition, including food preferences
Rationale: Identify deficiencies, suspect the possibility of intervention.
2. Observation and record the patient's food intake
Rational: Supervise caloric intake / lack of quality food consumption.
3. Measure body weight each day (if possible)
Rational: Supervise weight loss / oversee the effectiveness of interventions.
4. Give food a little but often and or eating between meals
Rational: little food can reduce vulnerabilities and increase input also prevent gastric distention.
5. Give and oral hygiene aids.
Rationale: Increased appetite and input peroral
6. Avoid foods that stimulate and gassy.
Rationale: Reducing distention and gastric irritation.

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5 Gonorrhea Nursing Diagnosis and Interventions

Nursing Care Plan for Gonorrhea

Nursing Care Plan for Gonorrhea

Gonorrhea is an infectious disease caused by Neisseria gonorrhea are transmitted through sexual intercourse either with genito-genital, oro-genital, ano-genital. This disease infects the inner lining of the urethra, cervix, rectum, throat, and conjunctiva.

Gonorrhea can spread through the bloodstream to other parts of the body, especially the skin and joints. In women, gonorrhea can spread to infect the genital tract and mucous in the pelvis, causing pelvic pain and reproductive problems.

The exact cause of gonorrhea is a bacterial disease that are pathogenic Neisseria gonorrhea.
The most easily infected mucosa is an area with a layer of flattened epithelial kuboid or undeveloped in female puberty yet.

In men:
  • The early symptoms of gonorrhea usually appear within 2-7 days after infection
  • Symptoms begin as malaise followed by pain in the urethra when urinating.
  • Dysuria that arise suddenly, feeling urination accompanied by mucoid discharge from the urethra.
  • Urinary retention caused by prostate inflammation.
  • Discharge of pus from the penis.

In women:
  • Early symptoms usually appear within 7-21 days after infection.
  • Patients often experience symptoms for several weeks or months (asymptomatic).
  • If symptoms develop, usually mild. However, some patients showed severe symptoms such as urgency to urinate.
  • Pain when urinating.
  • Discharge from the vagina.
  • Fever.
  • The infection can affect the cervix, uterus, ovaries, urethra, and rectum and cause pain in the hip when having sex.

5 Gonorrhea Nursing Diagnosis and Interventions

1. Acute pain related to the reaction of infection

  • After nursing actions, the client will:
  • Identifying the causes
  • Using the methods of prevention of non-analgesic to relieve pain
  • Using analgesics as needed
  • Reported pain was controlled

  1. Examine in a comprehensive pain include location, characteristics, and onset, duration, frequency, quality, intensity / severity of pain, and precipitation factors.
  2. Observation of non-verbal cues of discomfort, especially the inability to communicate effectively.
  3. Use therapeutic communication so that the client can express pain.
  4. Provide support to clients and families.
  5. Control of environmental factors that can affect the client's response to discomfort (ex.: room temperature, irradiation, etc.)
  6. Teach the use of non-pharmacologic techniques (ex.: relaxation, guided imagery, music therapy, distraction, application of heat and cold, massage, hypnosis, therapeutic activity)
  7. Give analgesics as directed.
  8. Increase sleep or rest.
  9. Evaluate the effectiveness of the measures that have been used to control pain.

2. Hyperthermia related to inflammatory reactions

  • After nursing actions, the client will:
  • The temperature in the normal range
  • Pulse and respiration within the normal range
  • No skin discoloration and no headache

  • Monitor vital sign.
  • Monitor the temperature at least 2 hours.
  • Monitor color.
  • Increase intake of fluids and nutrients.
  • Cover the client to prevent loss of body heat.
  • Compress clients in the groin and axilla.
  • Give antipyretics as needed.

3 Impaired Urinary Elimination related to the inflammatory process

  • After nursing actions, the client will:
  • Urine will be a continent
  • Elimination of urine would not be disturbed: the smell, the number, color of urine within expected ranges and urine output without pain.

  • Monitor urine elimination include: frequency, consistency, odor, volume, and color appropriately.
  • Refer to urologist if the cause of acute discovered.

4 Anxiety related to the disease

  • After nursing actions, the client will:
  • No signs of anxiety
  • Reported a decrease in the duration and episodes of anxiety
  • Reporting needs adequate sleep
  • Demonstrate flexibility role

  • Assess the level of anxiety and physical reactions to high levels of anxiety (tachycardia, takipneu, non-verbal expressions of anxiety).
  • Accompany clients to support the anxiety and fear.
  • Instruct client to use relaxation techniques.
  • Give medication to reduce anxiety in a proper way.
  • Provide current information on the diagnosis, treatment, and prognosis.

5 Low self-esteem related to disease

  • After nursing actions, the client will express a positive outlook for the future and resume previous level of functioning, with indicators:
  • Identifying the positive aspects of self.
  • Analyze own behavior and its consequences.
  • Identify ways to use and control affect the results.

  • Assist individuals in identifying and expressing feelings.
  • Encourage clients to envision the future and the positive outcomes of life.
  • Strengthen skills and positive character traits (eg, hobbies, skills, appearance, occupation).
  • Help clients receive positive and negative feelings.
  • Assist in identifying their own responsibility and control of the situation.

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NCP Ophthalmia Neonatorum - Nursing Diagnosis and Interventions

Nursing Care Plan for Ophthalmia Neonatorum
Nursing Diagnosis for Ophthalmia Neonatorum

1. Ineffective Breathing Pattern related to increased secretions in the airways.

Objective data: the baby looks shortness of breath, anxiety, increased respiratory rate, and excessive secretions.

Goal: Ineffective breathing can be overcome.

Expected outcomes: infant no longer congested, calm baby, decreased respiratory rate, airway secretions in no longer exists.

Nursing Intervention:
1. Put the baby in a comfortable position, head elevated (eg held).
Rationale: good position to help loosen the airway.

2. Give oxygen and airway clear of secretions.
Rationale: Oxygen overcome the body's need for oxygen and clearing the airway would reduce blockages in the airway.

3. Collaboration with the doctor about antibiotics.
Rational: antibiotics to fight infection.

2. Imbalanced Nutrition, Less Than Body Requirements related to lazy drinking, diarrhea, and vomiting.

Objective data: The baby lazy drinking, diarrhea, and vomiting.

Goal: Disorders of nutrition can be addressed.

Expected outcomes: vomiting and diarrhea stopped, the baby would be fed.

Nursing Intervention:
1. Encourage the mother to keep breastfeeding.
Rationale: Breast milk contains IgA, high amounts that can provide immunity.

2. Auscultation bowel sounds.
Rational: decreased blood flow can decrease intestinal peristalsis.

3. Collaboration with physicians about the provision of drugs such as antibiotics and fluid administration.
Rational: antibiotics to fight infection which will aggravate the infection.

3. Fluid Volume Deficit related to diarrhea, vomiting, and a lazy drink.

Objective data:
  • Poor turgor and dry skin.
  • Dry mucous membranes.
  • Hyperthermia.
  • Lactation.
  • Diarrhea.
  • Vomiting.

Goal: The fluid volume returned to normal.
Expected outcomes: normal temperature, mucous membranes and the skin is no longer dry.

Nursing Intervention:
1. Instruct the mother still breastfeeding.
Rationale: Breast milk contains high amounts of IgA may provide immunity.

2. Supervise the input and output, record and measure the frequency of diarrhea and fluid loss.
Rational: changes greatly affect the quality of milk fluid requirements and increased risk of dehydration.

3. Collaboration with physicians about the administration of medication and fluid therapy.
Rational: fluid therapy can help reduce the interference of body fluids.

4. Hyperthermia related to the infection process

Goal: baby's body temperature back to normal.

Expected outcomes: no signs of hyperthermia

Nursing Intervention:
1. Monitor the patient's temperature (degrees and patterns); note sounds chills / diaphoresis.
Rational: temperature of 38.9 degrees to 41 degrees shows an acute infectious disease process. The pattern of fever may help in the diagnosis.

2. Monitor the temperature of the environment, limit or add bed linen, as indicated.
Rational: the temperature of the room or the number of blankets to be changed to maintain near-normal temperatures.

3. Give warm compresses bath; avoid the use of alcohol
Rational: to help reduce fever

4. Collaboration: Give antipyretics
Rational: used to reduce fever by central action on the hypothalamus, although the fever may be useful in limiting the growth of organisms, and increased autodestruksi from infected cells.

5. Collaboration : Give antibiotics
Rational: antimicrobial treat infections that cause disease.

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Nursing Care Plan for Diabetic Ketoacidosis

Nursing Diagnosis for Diabetic Ketoacidosis


Diabetic Ketoacidosis is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia, dehydration, and acidosis-producing derangements in intermediary metabolism. The most common causes are underlying infection, disruption of insulin treatment, and new onset of diabetes.

Diabetic Ketoacidosis is defined clinically as an acute state of severe uncontrolled diabetes associated with ketoacidosis that requires emergency treatment with insulin and intravenous fluids.


A person developing diabetic ketoacidosis may have one or more of these symptoms: excessive thirst or drinking lots of fluid, frequent urination, general weakness, vomiting, loss of appetite, confusion, abdominal pain, shortness of breath, a generally ill appearance, dry skin, dry mouth, increased heart rate, low blood pressure, increased rate of breathing, and a distinctive fruity odor on the breath.


The goal of treatment is to correct the high blood sugar level with insulin. Another goal is to replace fluids lost through urination and vomiting.

Most of the time, you will need to go to the hospital, where the following will be done:
  • Insulin replacement
  • Fluid and electrolyte replacement
  • The cause of the condition (such as infection) will be found and treated

You may be able to spot the early warning signs and make changes at home before the condition gets worse. It is important to stay in close touch with your doctor.

Nursing Care Plan for Diabetic Ketoacidosis


  • History of DM
  • Polyuria, Polidipsi
  • Stop injecting insulin
  • Fever and infection
  • Abdominal pain, nausea, vomiting
  • Blurred vision
  • Weak and headaches

Physical Examination:
  • Orthostatic hypotension (systolic decreased 20 mmHg or more on standing)
  • Hypotension, Shock
  • Breath smelled of acetone (smells sweet like fruit)
  • Hyperventilation: Kusmual (respiration rapid and deep)
  • Awareness can composmentis, lethargy or coma
  • Dehydration

Assessment of Emergency
  • Airways: Assess the patient's airway clearance, presence or absence of sputum or foreign objects blocking the airway.
  • Breathing: Assess frequency of breath, breath sounds, presence or absence of muscle use a respirator.
  • Circulation: Assess pulse, capillary refill.

Objective Data:

Activity / Rest
  • Symptoms: weakness, fatigue, difficulty moving / walking, muscle cramps, decreased muscle tone, impaired resting / sleeping.
  • Signs: Tachycardia and tachypnea in the resting state or activity, lethargy / disorientation, coma.

  • Symptoms: A history of hypertension, acute myocardial infarction, claudication, numbness and tingling in the extremities, foot ulcers, healing time, tachycardia.
  • Signs: Changes in postural blood pressure, hypertension, decreased pulse / no, dysrhythmias, cracels, jugular venous distention, skin hot, dry, and red, sunken eyeballs.

Integrity / Ego
  • Symptoms: Stress, dependent on others, financial problems associated with the condition.
  • Signs: Anxiety, sensitive to stimuli.

  • Symptoms: Changes in the pattern of urination (polyuria), nocturia, pain / burning, difficulty urinating (infection), UTI new / recurrent abdominal tenderness, diarrhea.
  • Signs: Urine thin, pale, yellow, polyuria (may progress to oliguria / anuria, if there is severe hypovolemia), cloudy urine, odor (infection), hard abdomen, presence of ascites, weakness and decreased bowel sounds, hyperactive (diarrhea).

Nutrition / Fluids
  • Symptoms: Loss of appetite, nausea / vomiting, do not comply with the diet, increased input glucose / carbohydrate, weight loss of more than a few days / weeks, thirst, diuretic use.
  • Signs: Dry skin / scaly, ugly turgor, stiffness / abdominal distension, vomiting, enlargement of the thyroid (increased metabolic demands with increased blood sugar), odor halisitosis / sweet smell of fruit (acetone breath)

  • Symptoms: Dizziness, headache, tingling, numbness, muscle weakness, paresthesia, visual disturbances.
  • Signs: Disorientation, drowsiness, allergies, stupor / coma (stage), memory impairment (new, past), messed up mentally, decreased deep tendon reflexes (coma), seizure activity (stage of Diabetic Ketoacidosis).

Pain / comfort
  • Symptoms: Abdomen tense / pain (moderate / severe)
  • Signs: face grimacing with palpitations, looks to be very careful

  • Symptoms: Feeling a lack of oxygen, cough with / without purulent sputum (depending on the presence of infection / no)
  • Signs: Hungry air, cough with / without purulent sputum, increased respiratory rate.
  • Symptoms: Dry skin, itching, skin ulcers.
  • Symptoms: Fever, diaphoresis, damaged skin, lesions / ulcerations, decreased general strength / range of motion, paresthesias / paralysis of muscles, including the respiratory muscles (if potassium levels declined sharply).
  • Symptoms: vaginal discharge (likely an infection).
  • Problems impotence in men, orgasm difficulties in women.

Guidance / learning
  • Symptoms: family risk factors diabetes, heart disease, stroke, hypertension. Healing is slow, or may not need to order diabetic medication. Repatriation plans: Possibly need help in diet, medication, self-care, monitoring of blood glucose.

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4 Nursing Diagnosis for Osteomyelitis

Nursing Care Plan for Osteomyelitis

Osteomyelitis is an infection of the bones and is caused due to the S. aureus bacteria breaking into the body's tissues and entering the bloodstream through an open wound. Osteomyelitis may be debilitating, disabling, and devastating, both physically and psychologically.

Osteomyelitis does not occur more commonly in a particular race or gender. However, some people are more at risk for developing the disease, including:
  • People with diabetes
  • Patients receiving hemodialysis
  • People with weakened immune systems
  • People with sickle cell disease
  • Intravenous drug abusers
  • The elderly

Osteomyelitis is often difficult to diagnose and may go undetected for weeks, months, and even years.

A physical exam shows bone tenderness and possibly swelling and redness.
  • Tests may include:
  • Blood cultures
  • Bone biopsy (which is then cultured)
  • Bone scan
  • Bone x-ray
  • Complete blood count (CBC)
  • C-reactive protein (CRP)
  • Erythrocyte sedimentation rate (ESR)
  • MRI of the bone
  • Needle aspiration of the area around affected bones

4 Nursing Diagnosis for Osteomyelitis

1. Acute Pain related to inflammation and swelling.

2. Impaired Physical Mobility related to pain

3. Impaired Skin Integrity related to the effects of surgery; immobilization.

4. Risk for infection related to abscess formation of bone, skin damage.

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Nursing Interventions - Acute Pain related to Osteomyelitis

Nursing Care Plan Acute Pain related to Osteomyelitis


Osteomyelitis is an acute or chronic inflammatory process of the bone and its structures secondary to infection with pyogenic organisms.

  • Bone pain
  • Fever
  • General discomfort, uneasiness, or ill-feeling (malaise)
  • Local swelling, redness, and warmth

Other symptoms that may occur with this disease:
  • Chills
  • Excessive sweating
  • Low back pain
  • Swelling of the ankles, feet, and legs

Nursing Diagnosis for Osteomyelitis : Acute Pain related to inflammation and swelling.


Pain and discomfort is reduced, and not the case of recurrence of pain and complications.

Expected outcomes:

There is no pain, the client looks relaxed, no moaning and protect the painful behavior, respiratory rate 12-20 per minute, the temperature of the clients in the normal range (36 º C - 37 º C) and the absence of complications.

Nursing Interventions - Acute Pain related to Osteomyelitis
  1. Maintain immobilization on the pain part, with bed rest.
  2. Elevate ekstermitas experiencing pain.
  3. Avoid the use of sheets, plastic or pillow under extremity pain.
  4. Evaluation of pain or discomfort. Note the location and characteristics, including intensity (pain scale 1-10). Note the hint of pain and changes in vital signs of emotion or behavior.
  5. Encourage patients to discuss issues in relation to infection in the bone.
  6. Perform range of motion exercises and watch passively or actively.
  7. Give alternative comfort measures such as massage, back or change in position.
  8. Encourage use of stress management techniques, such as progressive relaxation, breath exercises, visualizations imagination, and therapeutic touch.
  9. Investigate any unusual pain or a sudden, progressive or bad location unrelieved by analgesics.
  10. Explain the procedure before performing nursing.
  11. Perform a cold compress first 24-48 hours and as needed.
  12. Give analgesics as indicated.

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7 Ways To Always Keep Healthy with Immune System

Keep Healthy with Immune System

Having a healthy body is the desire of every person, including you. By staying healthy, the activities we do can be smoothly and in line with our expectations. With healthy too, so we do not have to spend time and money to buy drugs or go to the hospital. So we should always be grateful to God.

Friend. Size sense that when we are able to keep our immune system against infections that always hits such as dengue fever, flu, cough and others. Then how can we keep the immune system the right to keep it healthy and fit every day ....?

Here are 7 Ways To Always Keep Healthy with Immune System:
  1. Get plenty of rest each day, is one of the factors to keep your immune system.
  2. In a healthy body there is a sound mind and healthy too. So try to always think positive about all the problems that hit us.
  3. Every morning, try to always do regular exercise. It aims to maintain the condition of the body to keep it fit and healthy.
  4. Always make sure that the food you eat is already in the hygienic or clean or wash thoroughly cooked perfect.
  5. Eat reasonable portions do not overdo it. In fear of your body will be obese and at risk of disease associated with being overweight or obese.
  6. Fill fibrous foods every day. Fibrous foods are apples, carrots and beans. The function of these fibrous foods that keep the body from bacteria.
  7. Meet the needs of vitamin D. because vitamin D is working to stimulate immune cells to block viruses and bacteria. Vitamin D can be found in sunlight, eggs, liver and fish.

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Nursing Diagnosis for Pre Operative and Post Operative Benign Prostatic Hyperplasia

Nursing Care Plan for Benign Prostatic Hyperplasia - Pre Operative and Post Operative

Benign Prostatic Hyperplasia Benign prostatic hyperplasia is an enlargement of prostrate which is non malignant. In the men, prostrate is a small gland which surrounds the neck of the bladder. Contribution to seminal fluid is its major function. If there is an enlargement of the prostrate then there is a pressure on the urethra. It acts like a partial clamp. This problem causes varieties of urinary symptoms. Usually 50% of men suffer from this problem with advancing age.

The prostate is an organ that sits just below the bladder and surrounds part of the urethra. Is the normal size of a golf ball? One of its roles is to keep sperm alive in the reproductive stage, but has no role in the ability to have sexual relation. For effects of age and dihydrotestosterone -a waste product of testosterone, growth originates from the gland and, as it grows, it compresses the urethra causing two types of symptoms: obstructive symptoms and irritative symptoms.

Some of the major symptoms
  1. A weak stream of urine
  2. Facing difficulty in starting urination
  3. Especially after urination, dribbling of urine
  4. Leaking of urine
  5. Blood in the urine
  6. Frequent urination and sometimes sudden desire to urinate especially in the night
  7. Feeling of not fully emptying the bladder

The symptoms of BPH are the result of obstruction; there is a decrease in the size and strength of urinary stream, increased frequency of urination both day and night, and eventually a permanent desire to urinate. If the disease progresses without treatment is presented urinary incontinence or complete retention of urine.

Nursing Diagnosis for Benign Prostatic Hyperplasia - Pre Operative

1. Impaired Urinary Elimination
related to:
obstruction due to prostate enlargement / decompress detrusor muscle
characterized by:
urine dripping,
frequent urination,
urinate, a little bladder can not empty completely,
bladder distension.

2. Acute Pain
related to:
mucosal irritation / bladder distension / colic renal / urinary tract infection
characterized by:
bladder spasm pain,
changes in muscle tone,
moaning in pain.

3. Anxiety
related to:
plan surgery and loss of health status and decreased sexual ability
characterized by:
increased tension,
expression of fear

4. Sexual Dysfunction
related to:
urinary obstruction.

5. Knowledge Deficit: about the nature of the disease, the goal of the program of action and the diagnostic
related to:
lack of information / lack of information / misinformation
characterized by:
patients often ask,
orders are not obeyed
progression of infection can not be prevented.

6. Disturbed Sleep Pattern
related to:
frequent micturition at night

7. Risk for Injury
related to:
urinary obstruction.

8. Risk for Infection
related to:
urine catheter installation

Nursing Diagnosis for Benign Prostatic Hyperplasia - Post Operative

1. Risk for Bleeding
related to:
surgery (resection).

2. Acute Pain
related to:
uninterrupted continuity of tissue, due to resection.

3. Anxiety
related to:
disease process can still relapse.

4. Risk for Urinary Retention
related to:
catheter obstruction by blood clots.

5. Risk for Excess Fluid Volume
related to:
the excessive absorption of irrigation fluid.

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Activity Intolerance - Hypertension Nursing Interventions

Nursing Care Plan fro Hypertension

Nursing Diagnosis for Hypertension : Activity Intolerance related to general weakness, imbalance between supply and oxygen demand.


Having given nursing care are expected to perform activities that are tolerated.

Expected outcomes:
  • clients participate in activities desired / required.
  • reported an increase in tolerance activity can be measured.
  • showed a decrease in physiological signs of intolerance.

Nursing Intervention:

1. Assess the client's response to the activity, attention pulse rate more than 20 times per minute in the frequency of breaks; significant increase in BP during / after activity, dyspnea, chest pain; excessive fatigue and weakness; diaphoresis; dizziness or fainting.

2. Instruct patients about energy saving techniques, eg, using the bath seat, sitting as combing hair or brushing teeth, doing activities slowly.

3. Encourage activity / self-care gradually if tolerated. Provide assistance as needed.


1. Mention parameter helps in assessing response to stress physiology and activity when there is an indicator of excess work-related activity levels.

2. Energy saving technique reduces energy reduction also helps balance between supply and oxygen demand.

3. Progress activity increased gradually to prevent sudden cardiac work, provide only limited assistance needs will encourage independence in their daily activities.

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The Impact of Menopause for Health

The Impact of Menopause for Health

One of the important problems in the elderly are older reproductive health. Reproductive problems in the elderly, especially in a woman is perceived as fertility period ends (menopause), despite the fact that a man will also face the same thing that has decreased reproductive function (andropause) although in this case it happened older than a woman .

In the discussion of reproductive health of older times more likely to focus on the problems of menopause in women.

Definition of Menopause

Menopause is a condition where a woman stops menstruating (menopause). Diagnosis of menopause is when a woman has not menstruated for at least 1 year.

Before menopause occurs, it first entered the climacterium. Climacterium is a period of 4-5 years before menopause where a woman begins to feel the changes that the symptoms are not the same to everyone.

Menopause is closely related to menarche (first menstruation in women). In the circumstances the earlier occurrence of menarche occurs, the slower the rise and vice versa menopause menarche occurs more slowly accelerated menopause arise.

Menopause is not the same in every person affected by several factors:
  • descent
  • general health
  • habits

The Impact of Menopause for Health

Short-term effects:
  • Hot flush the chest burning sensation that radiates to the face often occur at night
  • Psychological disorders: depression, irritability, irritability, lack of confidence, sexsual arousal disorder, change in behavior.
  • Eye disorders: dry and itchy eyes due to decreased tear production.
  • Urinary tract and genitals: simple infections, painful intercourse, bleeding after sexual intercourse due to atrophy of the genitals.

Long-term effects:
  • Osteoporosis is loss of bone density in women due to a lack of estrogen so that bones become brittle and easily broken.
  • Coronary heart disease: Decreased estrogen can lower levels of good cholesterol and increase bad cholesterol levels that increase the incidence of coronary heart disease in women.
  • Dementia (Alzheimer's type Dementia): estrogen deficiency affects the central nervous system / brain, causing difficulty concentrating, memory loss on short-term events.

How to deal with sexual problems at menopause
  • Maintaining health in general, both physically and psychologically, for example by doing regular exercise.
  • Fostering a previous sexual life that takes place in harmony.
  • Realize and accept menopause as part of our life.
  • Do not use drugs or chemicals intended to improve sexual function without a clear indication and without the guidance of a health professional or doctor.
  • Need to do both behavioral and mood variation in sexual intercourse so it does not get bored.
  • Maintain good communication with his wife, including sexual problems.
  • Immediately consult with experts when experiencing sexual problems to immediately get proper treatment.

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Physical and Psychic Changes In The Menopause

Physical and Psychic Changes In The Menopause

Physical Changes In The Menopause

Due to the cessation of menstruation, various reproductive organs will be amended. Uterus having anthropic, penile length, and wall thinning. Myometrial tissue (uterine muscle) becomes less and contains more fibrotic tissue (fibrous nature of the excess). Neck of the womb (cervix) to shrink, not protruding into the vagina, even after a long time will be evenly distributed to the vaginal wall.

The folds of the oviduct becomes shorter, thinner, and puckered. Hair shakes that existed at the end of the fallopian tubes or fimbria disappear.

Due to changes in the reproductive organs and the body's hormones during menopause affects various physical state of a woman's body. This state of discomfort in the form of complaints that arise in everyday life.

Physical Changes In The Menopause :

1) Hot flushes

It is an incredible burning sensation on the face and upper body (such as the neck and chest). By touching hands will feel an increase in temperature in the area. Hot flushes occur due to the sensitive tissues or that depend on estrogen to be affected when estrogen levels decline. Radiant heat is thought to be a result of the influence of hormones in the brain that is responsible for regulating body temperature.

2) Excessive Sweat

How it works exactly is not known, but the radiant heat in the body due to the influence of the hormones that regulate the body's thermostat at a lower temperature. As a result, the air temperature felt comfortable initially, suddenly became too hot and the body starts to heat and sweat to cool itself. In addition, the life of a woman, vaginal tissues become thinner and reduced humidity as estrogen levels decline. Other symptoms experienced by women are sweating at night.

3) Dry Vagina

Changes in the reproductive organs, such as the vaginal area which can cause pain during intercourse. In addition, due to lack of estrogen causes vaginal epithelial disruption complaints, supporting tissue and the elasticity of the vaginal wall. In fact, vaginal epithelium contains many estrogen receptors which help reduce pain in intercourse.

4) Unable to hold urine

As age increases, urine is often not arrested at the time of sneezing and coughing. This is due to decreased estrogen so any impact is urinary incontinence (unable to control bladder function). Keep in mind, the walls and the female urethral smooth muscle layer also contains many estrogen receptors. Estrogen deficiency leads to impaired urethral closure and the changing patterns of abnormal flow of urine becomes so easy to avoid infection in the lower urinary tract.

5) The loss of supporting tissue

Low levels of estrogen in the body affects the collagen tissue that serves as the supporting tissue of the body. The loss of collagen causes dry skin and wrinkles, hair split apart, falling out, teeth easily shake and bleeding gums, canker sores, broken nails, and the onset of pain and soreness in the joints.

6) Weight gain

When she started at the age of 40, his body is usually easy to be fat, but otherwise very difficult to lose weight. According to the study, each of the past 10 years, will increase weight or body gradually widens laterally. This is apparently something to do with the decline in estrogen and Substance exchange disorders of fat metabolism.

7) Eye Disorders

Lack and loss of estrogen production affects tear glands so that eyes feel dry and itchy.

8) bone and joint pain

Along with the increasing age of the organ no longer hold some remodeling, including bone. Fact, undergo a process of decline due to the effect of changes in other organs. In addition, with increasing age diseases arising increasingly diverse. This is of course related to women's fitness and health.

Psychic Changes In The Menopause :

In addition to the physical, psychological changes also affect the quality of life of a woman in undergoing the menopause. Indeed, psychological changes during the menopause greatly depends on each individual. The effect is highly dependent on the views of each woman's menopause. Enough knowledge will help them understand and prepare himself through this period better.

Psychic Changes In The Menopause :

1. Psychological changes that appear

In women pramenoupose emerging concerns, caused by physical and hormonal changes, which resulted in the sensitive emotions. On the basis of emotion towards activities are divided into four types, namely: fear, anger, love and depression.

2. Range of emotions resulting from psychic change woman in the face menopause:
  • Angry, frustrated people to move against the source.
  • Anxiety, the move left the source of frustration.
  • Depression, people stop opening responses and emotions turned into his own

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10 Basic Principles of Nursing Management

Basic Principles of Nursing Management - In the world of nursing course, the implementation of nursing management is one of the main things that affect all of the nursing process. And nursing actions and all things related to nursing can not be separated from these nursing management. This time of Nursing blog will try to share a little about the management of nursing and hopefully useful and can provide benefits.

The process in accordance with the nursing management of open systems approach in which each of the components are interrelated and interact and be influenced by the environment. Because it is a system that will consist of five elements of input, process, output, control and feedback mechanisms.

Input from the nursing management among other information, personnel, equipment and facilities. The process in nursing management is the manager of the highest level of nursing management to implementing nurse have a duty and authority for planning, organizing, directing and monitoring the implementation of the nursing service. Output is nursing care, staff development and research.

Controls used in the budget process, including nursing management of the nursing, nursing job performance evaluations, standards and accreditation procedures. Feedback mechanism in the form of financial statements, audit of nursing, quality control and performance survey of nurses.

The principles underlying nursing management are:

1. Nursing management should be based on planning because through the planning, leaders can reduce the risk of decision-making, effective problem solving and planning.

2. Nursing management implemented through effective use of time. Nursing managers who appreciate the time will develop a well-rounded program planning and implementing activities in accordance with a pre-determined time.

3. Nursing management will involve decision making. Various situations and problems that occur in the management of nursing activities require decision making at various managerial levels.

4. Meet the nursing care needs of patients is the focus of attention of the nurse manager to consider what the patient saw, thought, believe and desire. Patient satisfaction is the main point of the whole purpose of nursing.

5. Nursing management should be organized. Organizing conducted in accordance with the needs of the organization to achieve goals.

6. The briefing is an element of nursing management activities covering the delegation, supervision, coordination and control of the implementation of the plans that have been organized.

7. Good nursing division motivate employees to demonstrate a good working performance.

8. Nursing management using effective communication. Effective communication will reduce misunderstandings and provide shared vision, direction and understanding among employees.

9. Staff development is important to be implemented as a preparatory effort implementing nurses occupy a higher position or manager attempts to improve employee knowledge.

10. Control is an element of nursing management that includes an assessment of the implementation of the plan has been created, providing instruction and establish principles - principles through standard-setting, comparing performance with standards and correct deficiencies.

Leadership in Nursing

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Nursing Care Plan for Pneumonia with Diagnosis Interventions

3 Nursing Diagnosis for Pneumonia

Nursing Care Plan for Pneumonia


Pneumonia is a breathing (respiratory) condition in which there is an infection of the lung.


Pneumonia caused by bacteria tends to be the most serious kind. In adults, bacteria are the most common cause of pneumonia.
  • The most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pneumococcus).
  • Atypical pneumonia, often called walking pneumonia, is caused by certain other bacteria.
  • Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system is not working well.

Many other bacteria can also cause pneumonia.

Viruses are also a common cause of pneumonia, especially in infants and young children.

Signs and Symptoms

Symptoms of pneumonia caused by bacteria usually come on quickly. They may include:
  • Cough.
  • Fever.
  • Fast breathing and feeling short of breath.
  • Shaking and "teeth-chattering" chills. You may have this only one time or many times.
  • Chest pain that often feels worse when you cough or breathe in.
  • Fast heartbeat.
  • Feeling very tired or feeling very weak.
  • Nausea and vomiting.
  • Diarrhea.


Pathogenesis of pneumonia include interactions between microorganisms (MO) causes that go through various avenues, with patient endurance. Germs reach the alveoli by inhalation, aspiration of oropharyngeal bacteria, hematogenous spread from another focus of infection, or direct spread from the site of infection. At the lower respiratory tract, the bacteria encounter in the form of immune defense system mukosilier, cellular resistance alveolar macrophages, bronchial lymphocytes and neutrophils. Also humoral immune IgA and IgG from bronchial secretions.
The occurrence of pneumonia depends on the virulence of MO, the ease and extent of endurance.

Assessment - Nursing Care Plan for Pneumonia

A. Subjective Data
  • Sudden onset of fever accompanied by convulsions
  • Clients complained weak
  • Shortness of breath
  • Complaining tired when on the move
  • Insomnia
  • Coughing up phlegm
  • Nausea, vomiting, no appetite
  • Sometimes diarrhea
  • Weight loss

B. Objective Data
  • Cyanosis of the mouth and nose
  • Dry skin with poor turgor
  • Clients look tired
  • Breathing fast (tachypnea) and shallow accompanied nostril
  • Dyspnoea, bronchial breath sounds, crackles.
  • Breathing using accessory muscles
  • Dullness found in percussion
  • Awareness of decreased / lethargy
  • Communication substandard
  • Orientation to person, place and time poor
  • Laboratory results: leukocytosis, increased erythrocyte sedimentation rate, abnormal blood gas analysis
  • Photos chest: there are patches lobe infiltrates.

Nursing Diagnosis for Pneumonia

1.Ineffective Airway Clearance related to inflammation, the accumulation of secretions,
characterized by:
  • Tachypnea / rapid breathing, shallow accompanied nostrils.
  • Bronchial breath sounds, crackles wet, accessory muscle use.
  • Dyspnoea, cyanosis
  • Cough with sputum production.

2.Impaired Gas Exchange related to alveolar capillary membrane changes
characterized by:
  • Dyspnea, cyanosis
  • Tachycardia
  • Restless

3.Imbalanced Nutrition Less Than Body Requirements related to the lack of oral intake
characterized by:
  • Decreased appetite
  • Weight loss: weakness, decreased muscle tone

4. Hyperthermia related to inflammatory processes
characterized by:
  • Increased body temperature

Outcome :

1. Effective airway,
with the following criteria:
  • Adequate ventilation
  • No buildup

2. Optimal gas exchange, adequate oxygenation to the tissue,
with the following criteria:
  • No dyspnoea
  • No cyanosis

3. Clients can meet the needs adequate nutrition,
with the following criteria:
  • Increased appetite
  • Maintain / increase weight

4. No fever
with the following criteria:
  • Body temperature fell within normal limits

Nursing Interventions for Pneumonia

Ineffective Airway Clearance


Assess the frequency / depth of breathing and chest movement
R :/ takipneu, shallow breathing, and asymmetrical chest movements often occur because of discomfort or movement of the chest wall and lung fluid.

Help patients breathing exercises frequently. Show / aids patients studied did cough, such as chest presses and effective cough while sitting high
R :/ Breath in facilitating the maximum expansion of the lung / airway smaller. Coughing is a natural cleaning mechanism of airway / help the cilia to maintain a patent airway. Emphasis lower chest discomfort and breathing effort seating position allows deeper and more powerful.

Exploitation as indicated
R :/ Stimulate cough or mechanical airway clearance in patients who are unable to perform because of ineffective cough or a decreased level of consciousness.

Give fluids at least 2500 ml / day (unless contraindicated). Offer warm water rather than cold.
R :/ liquids (especially warm) mobilize and remove secretions.


Assist to monitor the effects of treatment and physiotherapy another nebuliser. For example, an incentive spirometer, blowing bottles, percussion, postural drainage. Take action in between meals and limit fluids when possible.
R :/ Facilitate dilution and removal of secretions. Postural drainage is not effective in causing interstitial pneumonia or alveolar exudate or damage. Coordination of treatment / schedule and oral input vomit degrade because of cough, sputum spending.

Give medications as indicated: mucolytics, expectorants, bronchodilators, analgesic
R :/ equipment for lowering the mobilization of secretions bronchospasm. Analgesics are given to improve the cough by decreasing discomfort but should be used with caution, because it can reduce the effort cough / depress respiration.

7 Nursing Diagnosis Care Plan for Pneumonia

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Hyperthermia - Nursing Diagnosis Interventions for Meningitis

Nursing Care Plan Hyperthermia - Diagnosis Interventions for Meningitis

Hyperthermia Definition: The body temperature rises above the normal range.

Characteristics :
  • Increase in body temperature above the normal range
  • Attacks or convulsions (seizures)
  • Skin redness
  • Increase respiratory rate
  • Tachycardia
  • Hands felt warm to the touch

Meningitis means swelling of the lining around the brain and spinal cord. Septicaemia is blood poisoning caused by the same germs. Meningitis and septicaemia can occur together or separately. Symptoms can appear in any order, but the first symptoms are usually fever, vomiting, headache and feeling unwell, just like many mild illnesses

Nursing Diagnosis for Meningitis : Hyperthermia related to the infection process

Expected outcomes:
  • Normal body temperature is 36.5 to 37, 5o C.
  • Normal vital signs.
  • Good skin turgor.
  • Expenditures are not concentrated urine, electrolytes within normal limits.

Nursing Intervensi Hyperthermia - Nursing Care Plan for Meningitis :

1. Monitor the temperature every 2 hours.
R /: Knowing the temperature of the body.

2. Monitor vital signs.
R /: Effect of temperature increase is a change in pulse, respiration and blood pressure.

3. Monitor for signs of dehydration.
R /: The body can lose water through the skin and evaporation.

4. Give anti pyrexia.
R /: Reduce body temperature.

5. Give the drink a pretty 2000 cc / day.
R /: Prevent dehydration.

6. Perform a cold compress and warm.
R /: Reduce body temperature through conduction.

7. Monitor signs of seizures.
R /: hot body temperature risk for a seizure.

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Impaired Physical Mobility - Nursing Care Plan for Meningitis

Nursing Interventions for Meningitis - Impaired Physical Mobility

Nursing Care Plan for Meningitis - Impaired Physical Mobility

Meningitis is an inflammation of the membranes that cover the brain and spinal cord. Symptoms of meningitis are fever, headache, and stiff neck. Meningitis can be caused by a variety of things, including bacteria (the most serious cases), viruses, fungi, reactions to medications, and environmental toxins such as heavy metals. Cerebrospinal fluid can be tested to determine the type of meningitis causing the symptoms. Such identification is important in selecting effective antibiotics for treating bacterial meningitis cases.

In other patients, the symptoms can be severe and begin suddenly with fever, headache and stiff neck accompanied by some combination of other symptoms: decreased appetite, nausea, vomiting, sensitivity to bright light, confusion and sleepiness.

Impaired Physical Mobility - Nursing Care Plan for Meningitis

Impaired Physical Mobility related to general weakness, neurologic deficit.

Characterized by:
  • Patients said weakly.
  • Paralysis, parese, hemiplegia, tremor.
  • Less muscle strength.
  • Contractures, atrophy.

Expected outcomes:
  • Patients can maintain an optimal mobilization.
  • Skin integrity intact.
  • Did not happen atrophy.
  • Did not happen contractures.

1. Assess the ability to mobilize.
R /: Hemiparese may occur.

2. Instead of positioning the patient every 2 hours.
R /: Avoid skin damage.

3. Perform masage depressed parts of the body.
R /: Smooth flow of blood and prevent pressure sores.

4. Perform passive ROM.
R /: Avoiding contractures and atrophy.

5. Monitor thromboembolism, constipation.
R /: Complications of immobility.

6. Consul at physiotherapist if necessary.
R /: Planning more important.

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10 Nursing Diagnosis for Guillain-Barre Syndrome

Nursing Care Plan for Guillain-Barre Syndrome : 10 Nursing Diagnosis 

Guillain-Barre Syndrome is a problem with nervous system. It is a serious disorder that occurs when the body's defense (immune) system mistakenly attacks part of the nervous system. It causes muscle weakness, loss of reflexes, and numbness or tingling in your arms, legs, face, and other parts of your body. Exactly what triggers Guillain-Barre syndrome is unknown. The syndrome may occur at any age, but is most common in people of both sexes between ages 30 and 50.

Guillain-Barre syndrome may occur along with viral infections such as:
  • AIDS
  • Herpes simplex
  • Mononucleosis

Symptoms of GBS include:
  • Numbness or tingling in your hands and feet and sometimes around the mouth and lips.
  • Muscle weakness in legs and arms and the sides of your face.
  • Trouble speaking, chewing, and swallowing.
  • Not being able to move your eyes.
  • Back pain.

Emergency symptoms :
  • Breathing temporarily stops
  • Can't take a deep breath
  • Difficulty breathing
  • Difficulty swallowing
  • Drooling
  • Fainting
  • Feeling light-headed when standing

Symptoms usually start with numbness or tingling in the fingers and toes. Over several days, muscle weakness in the legs and arms develops. After about 4 weeks, most people begin to get better.

Nursing Care Plan for Guillain-Barre Syndrome

10 Nursing Diagnosis for Guillain-Barre Syndrome

1. Ineffective Breathing Pattern, Ineffective Airway Clearance, Impaired Gas Exchange related to respiratory muscle weakness or paralysis, decreased cough reflex, immobilization.

Characterized by:

Subjective Data:
  • The patient said it was hard to breathe.
  • Families of patients said that patients experienced loss of consciousness.

Objective Data:
  • Patients seen trouble breathing.
  • Decreased breath sounds.
  • Changes in the value of blood gas analysis.
  • Changes in skin color (pale)
  • Loss of consciousness.
  • Changes in respiratory rate, shortness of breath.
  • Accumulation of secretions.

2. Impaired Physical Mobility related to paralysis, ataxia.

Characterized by:

Subjective Data:
  • Patients say weakness and paresthesia.

Objective Data:
  • The inability to perform the activity.
  • Muscle weakness spreads upward.
  • Decreased muscle strength.
  • Atrophy.
  • Sensory loss.
  • The loss of tendon reflexes.

3. Risk for Impaired Skin Integrity: pressure sores related to muscle weakness, paralysis, impaired sensation, changes in nutrition, incontinence.

Characterized by:

Subjective Data:
  • Patients say weakness and paresthesia.

Objective Data:
  • The inability to perform the activity.
  • Muscle weakness spreads upward.
  • Decreased muscle strength.
  • Atrophy.
  • Sensory loss.
  • The loss of tendon reflexes.
  • Changes in nutrition.
  • Incontinence.

4. Imbalanced Nutrition, Less Than Body Requirements related to difficulty chewing, swallowing, fatigue, limb paralysis.

Characterized by:

Subjective Data:
  • The patient stated, can not chew and swallow.
  • Patients say, the hand can not be moved.

Objective Data:
  • The inability to perform the activity.
  • Patients using the NGT.
  • Diet food, nutritional value.
  • Weight loss.
  • Albumin and hemoglobin values​​.
  • Signs of malnutrition.
  • The presence of nausea.
  • Intake of the food intake is not in proportion.

5. Impaired Elimination: constipation, diarrhea, related to inadequate food intake, immobilization.

Characterized by:

Subjective Data:
  • Patients said they could not defecate or diarrhea.

Objective Data:
  • The inability to perform activities / lack of mobilization.
  • Muscle weakness spreads upward.
  • Decreased muscle strength.
  • The pattern of bowel movements in the house.
  • Increased or decreased bowel sounds.
  • Low-fiber diet.
  • Hard or liquid stool.

6. Impaired Verbal Communication related to the VII cranial nerve paralysis, tracheostomy.

Characterized by:

Subjective Data:
  • Families of patients said that patients have problems in speaking.

Objective Data:
  • Difficulties in communication.
  • The use of sign language.
  • Facial nerve paralysis.
  • The existence of tracheostomy.

7. Ineffective Coping related to the patient's disease state.

Subjective Data:
  • Families of patients said that patients have difficulty sleeping.

Objective Data:
  • Apathy.
  • Sensitive.
  • withdraw

8. Knowledge Deficit: patients / families related to disease, treatment, prognosis and treatment.

Characterized by:

Subjective Data:
  • Patient / family said they did not know the disease.

Objective Data:
  • Patient / family was not cooperative in patient care.
  • Patient / family inquire about his illness.

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Role and Function of Nursing Home Care

Nursing Home Care - Role and Function

Home Care (HC)

Home health services are nursing services provided to patients in the home, which is synthesized from community nursing services and specific technical skills that come from certain health specialties, the individual-focused nursing care, involving family, with the goal of healing, maintain and improve health physical, mental / emotional patients.

Home Care (HC) by Habbs and Perrin, 1985 is a health services performed at the patient's home (Lerman D. & Eric B.L, 1993) so that home care nursing services in a nursing home patient who has gone through a long history.

Rice. R, (2001) identify the types of cases that can be served in the home care program that covers common cases of post-treatment in hospitals and clinics special cases and are usually found in the community. Common case is the post-treatment in hospital are:
  1. Clients with COPD
  2. Clients with heart failure
  3. Clients with impaired oxygenation
  4. Clients with chronic injury suffered
  5. Clients with diabetes
  6. Clients with urinary dysfunction
  7. Clients with medical conditions of recovery (rehabilitation)
  8. Clients with home infusion therapy
  9. Clients with impaired function persyarafan
  10. Clients with AIDS

While cases with special conditions, include:
  1. Clients with post partum
  2. Clients with mental health disorders
  3. Clients with conditions of old age
  4. Clients with terminal condition (Hospice and Palliative care)
(Rice R, 2001., Allender & Spradley, 2001)

1. Case manager: manage and collaborate on services, with the function:
  • Identifying the needs of patients and families
  • Service plan
  • Coordinate the activities of the team
  • Monitor the quality of service

2. Implementing provide direct services and evaluate the service with the function:
  • Conduct a comprehensive assessment
  • Nursing plan
  • Nursing action
  • Observe the patient's condition
  • Assist patients in developing effective coping behavior
  • Involve families in service
  • Guiding all family members in health maintenance
  • To evaluate the nursing care
  • Documenting nursing care.

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Deep Breathing and Effective Cough

Deep Breathing and Effective Cough Exercise

Deep Breathing and Effective Cough

The Concept of Deep Breathing Exercises

Practice deep breathing is to breathe slowly and using the diaphragm, allowing abdominal and chest lifted slowly inflate fully. The purpose is to achieve a deep breath ventilation more controlled and efficient and to reduce the work of breathing, increased maximal alveolar inflation, increase muscle relaxation, relieve anxiety, get rid of the pattern of activity of respiratory muscles useless, uncoordinated, slow the breathing frequency, reduce air trapped and reduce labor breathing.

Practice deep breathing is not a form of physical exercise, it is a technique of soul and body that can be added in a variety of routines to get the relaxing effect. Long-term practice of breathing exercises will improve in health. Breathe slowly is the healthiest form of deep breathing (Brunner & Suddarth, 2002).

a. Respiratory Diaphragm
  • Administration of oxygen if the patient received oxygen therapy at home.
  • Position the patient can sit, supine, half sitting, sleeping on your left or right, horizontal or semi-Fowler.
  • Patients put one hand on the center of the abdomen, the other in the chest. Will be felt on the upper abdomen and rib cage expands the bottom opening. Patients need to be aware that the diaphragm was down at the time of inspiration. When movement (excursion) minimal chest. Chest wall muscles and breathing aids relaxation.
  • Patients inhale through nose and slowly expiratory time through the mouth (lips pursed breathing), during inspiration, the diaphragm and maximize active deliberately protrusion (development) of the abdomen. Made the front abdominal muscles contract during inspiration to facilitate the movement of the diaphragm and increase the expansion of the lower thoracic cage.
  • During the expiratory patients can use abdominal muscle contraction to move the diaphragm higher. Load weighing 0.51 kg can be placed on the wall of the stomach to help this activity.

b. Pursed Lips Breathing
  • Breathing (inspiration) was used a few seconds through the nose (not a deep breath) with the mouth closed
  • Then exhale (expiration) slowly through the mouth with a whistling position
  • PLB performed with or without abdominal muscle contraction during expiration
  • During PLB no expiratory air flow through the nose
  • With pursed lips breathing (PLB) will increase the pressure in the oral cavity, then the pressure will be passed through the bronchial branches so as to prevent air trapping and small airway collapse during expiration.

Concepts of Effective Cough

Effective Cough and Deep Breathing

Effective cough: a cough with correct method, where clients can save energy so tired and can not easily remove phlegm optimally.

Effective coughing and deep breathing is an effective cough techniques that emphasize maximal inspiration starting from expiration, which aims to: stimulate the opening of the collateral system, Improving the distribution of ventilation, lung volume Boost, facilitate airway clearance (Jenkins, 1996).
The ineffective cough causes:
  1. Respiratory collapse
  2. Rupture of alveoli walls
  3. Pneumothorax

Performed on patients such as: COPD, Emphysema, Fibrosis, asthma, chest infection, bedrest or postoperative patients

Effective Cough

Huff coughing is a technique that can be used to control cough in patients suffering from lung diseases such as COPD, emphysema or cystic fibrosis.

Huff Coughing:
  • To prepare the lungs and airways of huff coughing technique, remove all the air out of the lungs and airways. Start by breathing slowly. Take a breath slowly, ending with secar exhale slowly for 3-4 seconds.
  • Inhale the diaphragm, Do it quietly and comfortably, not to overventilasi lungs.
  • After perpetually inhale slowly, hold the breath for 3 seconds, is to control the breath and prepare effectively perform huff cough.
  • Lift your chin slightly up, and use your abdominal muscles to perform a quick exhalation 3 times with the airway and mouth open, take out the sound Ha, ha, ha or huff, huff, huff. This helps to open and facilitate expenditure epligotis mucus.
  • Control breath, then slowly breathe 2 times.
  • Repeat the above techniques cough up mucus to the back of the throat
  • After that batukkan and remove mucus / phlegm.

Post-surgical Deep Coughing

Step 1:
Sitting in the corner of a bed or chair, but can also help lay on your back with your knees slightly bent.
Grasp / hold pillow or rolled towel against the wound with both hands
Breathe normally

Step 2:
Breathe slowly and deeply through your nose.
Then exhale through your mouth full, Repeat for the second time.
For the third time, Take a slow, deep breath through your nose, Fill your lungs until they felt full as possible.

Step 3:
Batukkan 2-3 times in a row. Try to remove the air from your lungs semaksimalkan possible when coughing.
Relax and breathe as usual
Repeat the above action.

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Impaired Gas Exchange related to Pneumonia

Nursing Care Plan Impaired Gas Exchange related to Pneumonia


Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs (alveoli)—associated with fever, chest symptoms, and a lack of air space (consolidation) on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes. Infectious agents include: bacteria, viruses, fungi, and parasites.

Pneumonia is due primarily to infections, with less common causes including irritants and the unknown. Although more than one hundred strains of microorganisms can cause pneumonia, only a few are responsible for most cases. The most common types of infectious agents are viruses and bacteria, with its being less commonly due to fungi or parasites. Mixed infections with both viruses and bacteria may occur in up to 45% of infections in children and 15% of infections in adults. A causative agent is not isolated in approximately half of cases despite careful testing. The term pneumonia is sometimes more broadly applied to inflammation of the lung (for example caused by autoimmune disease, chemical burns or drug reactions), however this is more accurately referred to as pneumonitis.

Impaired Gas Exchange

Impaired Gas Exchange a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolocapillary membrane. Etiological and contributing factors include an altered oxygen supply, changes in the alveolar-capillary membrane, altered blood flow, and altered oxygen-carrying capacity of the blood. Defining characteristics include changes in mental status such as confusion, somnolence, restlessness, and irritability; ineffective coughing and inability to move secretions from the air passages; hypercapnia; and hypoxia.

Nursing Diagnosis and Interventions for Pneumonia

Nursing Diagnosis for Pneumonia : Impaired Gas Exchange related to changes in the alveolar-capillary membrane (inflammatory effect), the oxygen-carrying capacity of blood disorders (fever, displacement curves of oxyhemoglobin), impaired oxygen delivery (hypoventilation).

Goal: Demonstrate improved ventilation and oxygenation of tissues with blood gas analysis within the normal range and no symptoms of respiratory distress.

Expected outcomes: Participate in actions to maximize oxygenation.

Nursing Interventions:
  1. Assess the frequency / depth and ease breathing.
  2. Observation color skin, mucous membranes and nails, record the cyanosis
  3. Assess mental status and level of anxiety
  4. Monitor heart rate and body temperature
  5. Keep resting-sleeping
  6. Elevate the head and thrust frequently change position, breath deeply and cough effectively
  7. Give oxygen properly as indicated.

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Glaucoma Specific Characteristics

Glaucoma is an eye condition that affects the optic nerve, causing an increase in intraocular pressure or pressure in the eye. If you ever feel pressure in the eye, you should contact an eye-care professional as soon as possible. Even people with healthy eyes and regular pressure may experience glaucoma in the future. An eye expert can let you know if you have glaucoma. Testing for this disorder is one of the main reasons that regular eye exams are important. Glaucoma damages the nerve over a period of time and if this condition is left untreated it is a leading cause of eye damage and blindness.

Glaucoma is the leading cause of blindness in adults over 40 years old. Without symptoms or warning that you have the condition it is difficult to know if you have it. It is not yet known the exact cause of glaucoma and it is important that you always remain on the lookout with regards to your eye health. It is crucial that you consider protecting your eyes regularly.

Specific characteristics make an individual more disposed to having glaucoma:
  • The main consideration is age. The older someone becomes, the greater the chance of glaucoma developing.
  • Someone suffering from short-sightedness or myopia also has a greater chance to develop glaucoma.
  • Another significant factor is one's family history in identifying those people who can be at risk for glaucoma. If you have a family member with glaucoma, your chances of developing the condition are considerably greater.
  • Ethnicity is another factor that can have an affect on both an individual's likelihood of developing glaucoma and the variety of glaucoma. Those of Asian descent are prone to "closed angle" glaucoma, while those of African or Afro-Caribbean nationality are prone to "open angle" glaucoma.
Risk Groups
  • People known to have a family history of glaucoma
  • People that have suffered from diabetes, anemia and other systemic diseases
  • Men and women of Hispanic or African American origin
One simple way to protect your eyes is by wearing sunglasses, especially with polarized lenses. Wearing protective eyewear like those with polarized lenses is one of the best ways to protect your eyes and sight. Polarized lenses can reduce the stress on your eyes by limiting the entry of excess light and UV rays into your eyes.

Talk to a glaucoma doctor whenever you have any type of symptoms related to this condition or when your primary care physician tells you it is a good idea for you to contact these professionals. If you do have regular eye exams, your optometrist will likely catch this occurring sooner than you will notice symptoms. That is one of the most important reasons for you to have screenings on an annual basis especially as you get older and the risks become larger.

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Knowledge Deficit: Illness Care

Nursing Diagnosis: Knowledge Deficit

After nursing intervention, increased client knowledge.
Knowledge: Illness Care
with criteria:
  • Knowing diet
  • The disease process
  • Energy Conservation
  • Control of infection
  • Treatment
  • Activities recommended
  • Procedure of treatment
  • Regimen
  • Health resources
  • Disease management
Nursing Interventions:
Teaching: Dissease Process
  1. Assess the level of knowledge of the client and family about the disease process.
  2. Describe the pathophysiology of the disease, signs and symptoms and possible causes.
  3. Provide information about the condition of the client.
  4. Prepare the client's family or the people who mean the information about the client's development.
  5. Provide information on the diagnosis of the client
  6. Discuss lifestyle changes that may be needed to prevent complications in the future, and or control the disease process.
  7. Discuss the choice of therapy or treatment.
  8. Explain the reason for the implementation of the action or therapy.
  9. Encourage clients to explore options or obtain alternative.
  10. Describe complications that may occur.
  11. Encourage clients to prevent side effects of the disease.
  12. Dig resources or support available.
  13. Instruct the client to report signs and symptoms to health care workers.
  14. Collaboration with other teams.

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Leadership in Nursing

Management of Nursing

Nursing management essentially focuses on human behavior. To achieve the highest level of productivity in nursing care, patients need a nurse manager who trained in the knowledge and skills of human behavior for nurses manage nursing professional and non-professional workers.

Mc. Gregor states that every human being is an individual's life as a whole is always interaction with the world of other individuals. What happened to these people is a result of the behavior of others. Attitudes and emotions of others influence people. Subordinates depends on the leadership and desire to be treated fairly. A relationship will succeed if desired by both parties.

Subordinates need a sense of security and will fight to protect themselves from the threats that are false or really a threat to the unmet needs in the work situation.

Leaders create the conditions to bring effective leadership to form an atmosphere that can be accepted by subordinates, so that subordinates do not feel threatened and frightened.

To be able to do the things mentioned above, both superiors and subordinates need to understand about the kind of leadership management, which in turn formed the motivation and attitude of professional leadership.

Leadership will come when someone because of the properties and behavior have the ability to encourage others to think, act, and or do something according to what is desired.

Leadership in the context of major organizational emphasis on the function of the direction that includes telling, showing, and motivate subordinates. Management function is closely related to the human factor in an organization, which includes the interaction between humans and focuses on a person's ability to influence others.

In the nursing leadership is a leader's use of skills (nurses) in influencing the other nurses that are under its control for the division of tasks and responsibilities in providing nursing care services so that the goal of nursing is reached. Each nurse has a different potential for leadership, but these skills can be learned so it can always be applied and improved.

It has been mentioned that the leadership style is influenced by the nature and behavior of which is owned by the leader. Because of the nature and behavior of the person with the other person is not exactly the same, the style of leadership that is shown is not the same. Based on the opinion of the relationship between the leadership styles of behavior, then in discussing leadership styles to the field of administration is often associated with a pattern of management, often associated with talk about behavior.

Depending on the nature and behavior encountered in an organization and or owned by the leader, the leadership style exhibited by a leader can differ from one another.

An effective leader is a leader who can influence others to work together to achieve a satisfactory outcome for the beneficial changes.

Leadership tasks:
  1. As decision-makers
  2. As the bearer of responsibility
  3. Mobilize resources to achieve goals as a conceptual thinker
  4. Working with and through others
  5. As a mediator, politician, and diplomat.
The role of the leader of the group:
  • As liaison interpersonal, which is a symbol of a group in performing duties legally and socially, has the responsibility and motivate, manage people and organize the development of connective tissue and is working outside the group.
  • As an innovator or reformer
  • As an information provider, which monitors the information in the organization's environment, disseminate information from the outside to subordinates and represented the group as a speaker.
  • gathering strength
  • Stimulate public debate
  • Creating the position of nurses in the media
  • Choosing a strategy that is most effective, acting at the right time
  • Maintaining activity
  • Maintaining formaf decentralized organization
  • Acquiring and developing the best research data
  • studying the experience
  • Do not give up without trying.
Nursing is a profession that continues to change, more extensive functions, either as executor of care, managers, experts, educators, and researchers in nursing. Seeing a broad functions as described above, then the nurse should be prepared to gain knowledge and skills about leadership. Nursing leaders are needed both as implementing nursing care, educators, managers, experts, and the field of nursing research.

With a model of effective leadership, it is expected in the future of the nursing profession can be accepted with a good image in the community as a profession that was developed based on science and emerging technologies.

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