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.

» Read More...

Nursing Care Plan for Diabetic Ketoacidosis

Nursing Diagnosis for Diabetic Ketoacidosis

Definition

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.

Symptoms

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.

Treatment

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

Assessment

Anamnesis:
  • 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.

Circulation
  • 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.

Elimination
  • 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)

Neuro-sensory
  • 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

Respiratory
  • 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.
Security
  • 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).
Sexuality
  • 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.

» Read More...

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.

» Read More...

Nursing Interventions - Acute Pain related to Osteomyelitis

Nursing Care Plan Acute Pain related to Osteomyelitis

Osteomyelitis

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


Symptoms
  • 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.

Goal:

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.

» Read More...

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.

» Read More...

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.

» Read More...