Nursing Care Plan for Neonatal Hyperbilirubinemia

Neonatal hyperbilirubinemia or Neonatal jaundice or Neonatal icterus is a yellowing of the skin and other tissues of a newborn infant. In newborns, jaundice is detected by blanching the skin with digital pressure so that it reveals underlying skin and subcutaneous tissue. Jaundiced newborns have an apparent icteric sclera, and yellowing of the face, extending down onto the chest. In neonates the dermal icterus is first noted in the face and as the bilirubin level rises proceeds caudal to the trunk and then to the extremities.

Jaundice is the most common condition that requires medical attention in newborns. In most infants, unconjugated hyperbilirubinemia reflects a normal transitional phenomenon. However, in some infants, serum bilirubin levels may excessively rise, which can be cause for concern because unconjugated bilirubin is neurotoxic and can cause death in newborns and lifelong neurologic sequelae in infants who survive (kernicterus).


1. History of the parents:
The imbalance of maternal and child blood type as Rh, ABO, polycythemia, infection, hematoma, gastrointestinal obstruction and breast milk.

2. Physical Examination:
Yellow, pallor convulsions, lethargy, hypotonic, shrill cry, weak reflexes feeding, irritability.

3. Psychosocial Assessment:
The impact of child illness on relationships with parents, whether the parents feel guilty, problems Bonding, separation from children.

4. Family knowledge include:
The cause of the disease and treatment, further treatment, whether the family knew others who had the same level of education, the ability to learn hyperbilirubinemia (Cindy Smith Greenberg. 1988)

Nursing Diagnosis Intervetions - Neonatal Hyperbilirubinemia

1. Fluid Volume Deficit related to inadequate fluid intake, photo-therapy, and diarrhea.

Goal: Body fluids of neonates adequate

Record the amount and quality of feces, skin turgor monitor, monitor intake output, give water between nursing or giving a bottle.

2. Hyperthermia related to the effects of phototherapy

Goal: The stability of a baby's body temperature can be maintained.

Give a neutral ambient temperature, keep the temperature between 35.5 ° - 37 ° C, check vital signs every 2 hours.

3. Impaired skin integrity related to hyperbilirubinemia and diarrhea

Goal: baby skin integrity can be maintained.

Assess skin color every 8 hours, monitor direct and indirect bilirubin, change position every 2 hours, massage areas that stand out, keep skin clean and moisture.

4. Impaired Parenting related to separation

Goal: Parents and infants showed behavior "Attachment", parents can express a lack of understanding of the Bounding.

Take the baby to the mother for feeding, close eyes open at the breast, for social stimulation with mothers, encourage parents to talk to their children, involve parents in treatment whenever possible, encourage the parents to express their feelings.

5. Anxiety related to therapy given to infants.

Goal: Parents know about care, it can identify the symptoms to pass the health care team.

Assess the client's knowledge of the family, give health education the cause of yellow, the process of therapy and treatment. Give health education on how to care of the baby.

6. Risk for injury related to transfusion rate

Goal: exchange transfusion can be performed without complications.

Note the umbilical condition, if the umbilical vein is used; wet umbilical with NaCl for 30 minutes before taking action, fasting neonates 4 hours before the procedure, keep the baby's body temperature, record the mother's blood type and Rh and blood to be transfused blood is fresh; monitor signs vital signs, during and after the transfusion; prepare suction when required; observe for fluid and electrolyte disturbances; apnoe, bradycardia, seizures; monitor laboratory according to the program.

Planing Discharge Application.

Growth and development and the changing needs of infants with hiperbilirubin (such as stimulation, exercise, and social contact) are always the responsibility of the parents to comply with the rules and the description given during hospitalization and follow-up care at home.

Factors that should be delivered so that the mother can perform the best action in the treatment of infants with hyperbilirubinemia (Warley & Wong, 1994):
Encourage the mother revealed / reported when babies have disorders of consciousness such as seizures, anxiety, apathy, appetite decreased breastfeeding.
Encourage her to use a pump milk for a few days to maintain smooth milk.
Provide an explanation of the photo-therapy procedure, a replacement for the lower levels of bilirubin baby.
Advised the mother to consider stopping breastfeeding in preventing an increase in bilirubin.
Teach about skin care.

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NCP Diarrhea : Fluid and Electrolyte Imbalances and Risk for Impaired Skin Integrity

Diarrhea is the frequent passage of loose, watery, soft stools with or without abdominal bloating, pressure, and cramps commonly referred to as gas.

Acute diarrhea, meaning diarrhea that is not long-term, is a very common cause death in developing nations, especially among young children and babies. It usually appears rapidly and may last from between five to ten days.

Chronic diarrhea, meaning long-term diarrhea is the second cause of death among children in developing countries.

The most significant cause of severe illness is loss of water and electrolytes. In diarrhea, fluid passes out of the body before it can be absorbed by the intestines. When the ability to drink fluids fast enough to compensate for the water loss because of diarrhea is impaired, dehydration can result. Most deaths from diarrhea occur in the very young and the elderly whose health may be put at risk from a moderate amount of dehydration.

Nursing Care Plan for Diarrhea

Nursing Diagnosis : Fluid and Electrolyte Imbalances related to fluid loss secondary to diarrhea

Goal: fluid and electrolyte balance is maintained to the fullest.

Expected outcomes:
  • Vital signs within normal limits
  • Elastic turgor, mucous membranes moist lips
  • Consistency soft bowel movements, frequency of 1 time per day.

Interventions and Rational:

1. Monitor signs and symptoms of fluid and electrolytes:
R / Decrease in circulating fluid volume causes mucosal dryness and urinary concentration. Early detection enables immediate fluid replacement therapy to correct the deficit.

2. Monitor intake and output
R / Dehydration may increase the glomerular filtration rate, making the output is not adequate to clear metabolic waste.

3. Measure your weight every day
R / Detecting fluid loss, a decrease of 1 kg equal to 1 ltr of fluid loss

4. Encourage the family to give the drink a lot on the client, 2-3 lt / day
R / Replace lost fluids and electrolytes orally.

Nursing Diagnosis : Risk for Impaired Skin Integrity related to an increase in the frequency of diarrhea.

Goal: no impaired skin integrity.

Expected outcomes:
  • Avoid irritation: redness, blisters, cleanliness maintained,
  • Families are able to demonstrate perianal care properly.

Intervention and Rational:

1. Discuss and explain the importance of keeping the bed:
R / Hygiene prevent the proliferation of germs.

2. Demonstrate and involve families in the treatment of perianal (when wet and dressed down as well as the base):
R / Prevent skin irritation is not expected because of the humidity and the stool acidity.

3. Adjust the position of sleeping or sitting with an interval of 2-3 hours:
R / Smooth vascularization, reducing the emphasis on time so did not happen ischemia and irritation.

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Nursing Management for Patients with Diphtheria

Nursing Management for Diphtheria

Diphtheria is a bacterial infection that spreads easily and occurs quickly. Diphtheria is an infectious disease caused by the bacterium Corynebacterium diphtheriae. This disease primarily affects the mucous membranes of the respiratory tract (respiratory diphtheria), although it may also affect the skin (cutaneous diphtheria) and lining tissues in the ear, eye, and the genital areas.

Diphtheria is caused by toxin-producing strains of the gram-positive bacillus Corynebacterium diphtheriae. There are four biotypes of the bacterium (gravis, mitis, intermedius, and belfanti), and each differs in the severity of disease it produces. Nontoxigenic strains are usually responsible for less severe cutaneous diphtheria.

The symptoms and signs of respiratory diphtheria may include the following : sore throat, fever, hoarseness, difficulty swallowing, malaise, weakness, headache, cough, nasal discharge (that may contain pus or blood-tinged fluid), enlarged lymph nodes in the neck and neck swelling (producing a "bull neck" appearance), difficulty breathing

Diphtheria patients must be treated in isolation rooms closed. Health care workers should wear special dresses (aprons) and masks should be replaced every turn of duty or at any time when dirty. Instead, the keeper of the patient must also wear an apron to prevent transmission to the outdoors. Hand-washing equipment should be provided: disinfectant, soap, washcloth, or towels are always dry, clean water, if there is also a place to soak faucet cutlery filled with disinfectant. The risk of complications of airway obstruction, myocarditis, pneumonia. Patients with diphtheria, although mild illness need to be hospitalized because of potential life-threatening complications are caused by pseudomembranous and exotoxin released by the diphtheria bacillus.

Airway obstruction

This disorder occurs because of edema of the larynx and trachea, and the pseudomembranous. Symptoms of blockage is hoarseness and stridor inspiratoir. When more severe shortness of breath occurs, cyanosis, muscle retraction looks, sounds stridor:
  • Give oxygenation.
  • Lay half sitting.
  • Call the doctor.
  • Install an infusion (if not already installed).
  • Contact the parents let the situation of children and the dangers that can occur.


Exotoxin released by the bacillus of diphtheria, when absorbed by the heart, will cause myocarditis this disorder usually occurs in the second week to the third. To know the symptoms of myocarditis need continuous observation and the patient should rest for at least 3 weeks, or until the results of the ECG two consecutive normal. During the treatment, observation pulse, respiration and temperature recorded in special care.

If no ECG equipment:

Monitoring the pulse is very important and should be done every hour and recorded on a regular basis. If there is a change in pulse rate continues to drop (bradycardia) should immediately contact a doctor. Treatments other than vital signs and general condition:
Patients should not be a lot of moves, but recumbency must often be changed, for example, every 3 hours to prevent complications of bronchopneumonia (hypostatic pneumonia).
Keep the skin on the body to prevent pressure sores (remember, the patient bed rest for 3 weeks, can not wake up).

The complications of the nervous

The complications of the nerve can occur in the first week and the second. If the soft palate nerve (nerve swallow) with the patient's symptoms when drinking water / milk will come out through the nose. If this occurs:
  • How to give a drink to be careful, while the patient is seated.
  • If the patient is eating a liquid that is slightly thicker and given little by little.

Complications in renal

During the diphtheria patients in care, the state of the urine, in addition to be aware of color, too much is normal or not.
Impaired nutrient inputs. Impaired nutrient inputs diphtheria patients, in addition to pain caused by swallowing, as well as anorexia. If the child is willing to swallow persuade him to want to eat little by little and give a liquid or pureed diet solution and give more milk. If the patient does not eat at all or very little, or in a state of shortness of breath, infusion needs to be installed. After 2-3 days, then shortness of breath have decreased, before the infusion was stopped trying to eat by mouth and apbila children have to eat infusion is stopped. Give drink frequently to maintain oral hygiene and help smooth elimination.

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Fluid Volume Deficit related to Diabetic Ketoacidosis

Nursing Diagnosis : Fluid Volume Deficit related to
  • osmotic diuresis due to hyperglycemia,
  • excessive discharge: diarrhea, vomiting;
  • restriction of intake due to nausea

Defining characteristics:
  • Increased urine output
  • Weakness, thirst, weight loss suddenly
  • Dry skin and mucous membranes, poor skin turgor
  • Hypotension, tachycardia, decreased capillary refill

Expected outcomes:
  • Vital signs are within normal limits
  • Peripheral pulse can be palpated
  • Skin turgor and capillary refill good
  • Balance of urine output
  • Normal electrolyte levels

Nursing Care Plan for Diabetic Ketoacidosis

Intervention and Rational:

1. Assess history of duration / intensity of nausea, vomiting and excessive urination.
Rationale: Helps to estimate the total volume reduction. The process of infection that causes fever and hypermetabolic state, increased discharge insensibel.

2. Monitor vital sign and orthostatic blood pressure changes.
Rational: Hypovolemia can be manifested by hypotension and tachycardia. Excessive hypovolemia can be shown to decrease blood pressure greater than 10 mmHg from a lying position to a sitting or standing.

3. Monitor changes in respiration: kussmaul, the smell of acetone.
Rationale: The release of carbonic acid through respiration, resulting in respiratory alkalosis, compensated in ketoacidosis. Acetone breath odor, due to breakdown of amino ketones and will be lost when it is corrected.

4. Observation of breathing quality, accessory muscle use, and cyanosis.
Rationale: The increase in expenses breath showed an inability to compensate for acidosis.

5. Observation urine output and quality.
Rationale: Describe the ability of the kidneys and the effectiveness of therapy.

6. Measure weight
Rationale: Shows the status and adequacy of rehydration fluids.

7. Maintain fluid 2500 ml / day if indicated.
Rationale: Maintaining hydration and circulation volume.

8. Create a comfortable environment, consider the emotional changes.
Rationale: Reduce the temperature increases causing a reduction in fluid, emotional changes showed decreased cerebral perfusion and hypoxia.

9. Write down the things that are reported such as nausea, abdominal pain, vomiting and gastric distention.
Rationale: Lack of fluid and electrolyte alter gastrointestinal motility, often cause vomiting and potentially lead to lack of fluids and electrolytes.

10. Observation increases the feeling of fatigue, edema, weight gain, irregular pulse and the presence of vascular distension.
Rationale: Fluid for quick fixes may be a potential cause fluid load and congestive heart failure.


11. Monitor laboratory tests:

Rationale: Assessing the level of dehydration due to hemoconcentration.

BUN / Creatinine
Rationale: The increase reflects the value of cell damage due to dehydration or the onset of kidney failure.

Blood osmolality
Rationale: Increase in hyperglycemia and dehydration.

Rationale: Decrease reflects the movement of intracellular fluid (osmotic diuresis), higher mean fluid loss / dehydration or respond to sodium reabsorption in the aldosterone secretion.

Rationale: Potassium occurs in early acidosis and subsequently lost through urine, the absolute levels in the body is reduced.

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Acute Pain - Nursing Care Plan for Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections.

Rheumatoid arthritis can affect many areas of the body. These effects all result from the general process of inflammation, leading to a wide variety of symptoms of rheumatoid arthritis:
  • Fatigue
  • Malaise (feeling ill)
  • Loss of appetite, which can lead to weight loss
  • Muscle aches

Nursing Diagnosis and Interventions for Rheumatoid Arthritis

Long-term goal: After the intervention for 3 x 24 hours, it is hoped, acute pain on the client is reduced / lost.

Short-term goal: After a 1 x 45 minutes, the client is expected to be able to:

1. Knowing the problems of rheumatoid arthritis.

a. Mention the definition of rheumatoid arthritis.

  • Rheumatoid arthritis is a chronic infectious disease of unknown cause, characterized by destruction and joint disorders that cause joint deformation.

  • Assess the client's knowledge about rheumatoid arthritis.
  • Discuss with the client about rheumatoid arthritis.

b. Mention the causes of rheumatoid arthritis


The cause of rheumatoid arthritis is:
  • the process of aging
  • descent
  • injury
  • infection of bone
  • obesity

  • Assess the client's knowledge about the causes of rheumatoid arthritis.
  • Discuss with the client about the causes of rheumatoid arthritis.

c. Mention the signs and symptoms of rheumatoid arthritis


Signs and symptoms of rheumatoid arthritis are:
  • joint pain and stiffness
  • tingling in the feet / hands
  • swollen joints, limited mobility
  • joints reads
  • weight loss
  • decreased appetite
  • fever

  • Assess the client's knowledge about the signs and symptoms of rheumatoid arthritis
  • Discuss with the client about the signs and symptoms of rheumatoid arthritis

2. Taking the right decision to take care of the client, with:

a. Knowing the result of the disease rheumatoid arthritis

  • Clients can mention the effect of the disease is the inability of active rheumatoid arthritis.

  • Assess the client's knowledge about the effects of information from rheumatoid arthritis.
  • Motivation to repeat, due to continued from rheumatoid arthritis.
  • Clients can mention the effect of the disease rheumatoid arthritis, is the inability to move.

b Decided to treat clients with rheumatoid arthritis.

  • The client decided to treat himself with rheumatoid arthritis.

  • The motivation to treat himself with rheumatoid arthritis.

3. After a 1 x 45-minute meeting, the client able to treat himself with rheumatoid arthritis.

a. Mention how to cope with rheumatoid arthritis.

  • The client decided to treat himself with rheumatoid arthritis.

  • Assess the client's knowledge about self-care.


Clients can mention how to care for themselves, namely:
  • accustom themselves to train active and passive movements.
  • warm compresses on the sore and swollen joints.
  • regular exercise
  • do not work too hard
  • foods high in protein, vitamin C and iron
  • adjusting diet

Intervention :
  • Discuss with the client about self-care.

4. After meeting 1x30 minutes, meeting client is able to modify the environment to himself

a. Maintaining a conducive environment.


Conducive environment for clients with rheumatoid arthritis are:
  • a clean environment
  • a safe environment
  • comfortable environment

  • Assess the client's knowledge about the environment is clean, safe and comfortable.
  • Motivation clients to maintain a clean safe environment condition and comfortable.

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Benefits of Papaya Fruit for the Human Body

What are the benefits of papaya fruit for the human body ..

Papaya plants are everywhere. And papaya have many health benefits for the human body. In addition to a delicious fruit to eat, leaves and flowers are also good for vegetables that would be delicious taste. Almost all parts of the papaya plant can be utilized.

1. As an acne medicine.

Take 30 grams of papaya leaf aging. Then drying and mash until smooth. Add 30 cc of water, and then used as a mask in advance of existing acne, avoid contact with eyes, made ​​it easy.

2. As improving digestion.

The leaves of the papaya plant, contain chemical compounds carpain. Substances that can kill microorganisms that often interfere with digestion.

3. Increase appetite.

Take 100 grams of papaya leaves, crushed, give 150 cc of water, then strain. Add honey to taste. Drink 2 times a day. It is usually given to children who are difficult to eat.

4. Overcoming fever in children.

Use 200 grams of ripe fruit, mix 300 grams pumpkin, add rock sugar. Blender and Drinks. If things do not improve immediately taken to the doctor, just think of this for first aid!

5. Anti cancer.

It is still uncertain, but from several studies that the benefits of papaya leaves can also be developed as anti-cancer. Actually, not only the leaves but also stems papaya can be used. Since both have milky latex (sap white like milk).

6. Overcoming burns.

Use papaya latex is applied on burns, or young papaya, crushed, and then apply on the sore spot.

Apparently many well benefit from the fruit of this one .. besides it tastes good, it turns out, papaya can also as a means of healing of various diseases.

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Types of Sleeping Disorders in the Elderly

Sleeping disorders in the elderly is often experienced by the elderly. Sleep disorders in the elderly is caused by many factors, such as physical, psychological or mental. Sleep disorders in the elderly can include difficulty sleeping disturbances or disorders maintain a restful sleep.

Types of Sleeping Disorders in the Elderly

Primary Sleep Disorders

Primary sleep disorder is a sleep disorder that is not caused by other mental disorders, general medical condition, or substance. Sleep disturbance is divided into two, namely dyssomnia and parasomnia. Dyssomnia characterized by disturbances in the amount, quality, and time to sleep. Parasomnia associated with sleep behavior or physiological events associated with sleep, specific sleep stages or sleep wake displacement. Dyssomnia consists of primary insomnia, primary hypersomnia, narcolepsy, sleep disorders related to breathing, rhythmic circadian sleep disorders, and dyssomnia that can not be classified. Parasomnia consisting of nightmare disorder, sleep terror disorder, night wakings, and parasomnia that can not be classified.

Sleep disorders related to another mental disorder

Sleep disorders related to another mental disorder, namely the presence of a prominent complaint of sleep disturbance caused by another mental disorder (often for mood disorders) but do not qualify to be established as a separate sleep disorder. There are allegations that the pathophysiological mechanisms underlying mental disorder also affect sleep-wake disturbances. Sleep disturbance is composed of: Insomnia related to axis I or II, and hypersomnia associated axis I or II.

Sleep disorders due to general medical condition

Disorders due to general medical condition is a prominent complaint of sleep disturbance caused by the direct physiological effect of the general medical condition on the sleep-wake cycle.

Sleep disorders due to substance

Namely the prominent sleep complaints were due to use or stop using the substance (including medications). Systematic assessment of someone who had sleep complaints such as evaluation forms specific sleep disorders, mental disorders today, general medical condition, and substance or medication use, needs to be done.

Sleep Disorders in the Elderly

Sleep disorders in the elderly may be a non-pathological, due to aging and some specific sleep disorders are often found in the elderly. There are some common sleep disorders in the elderly.

Primary insomnia

Characterized by:

Complaints difficult getting to sleep or maintaining sleep or remain fresh, even though it was asleep. This situation lasted at least one month.
Cause clinically significant distress or impairment of social, occupational, or other important functions. Sleep disturbance does not occur exclusively during no other mental disorders.
Not due to the direct physiological effect of the general medical condition or substance.

Chronic insomnia

Also called psychophysiology persistent insomnia. Insomnia can be caused by anxiety; addition, it can also occur due to habit or learning or maladaptive behaviors in bed. For example, solving a serious problem in bed, anxiety, or negative thoughts on sleep (was thinking could not sleep). The presence of excessive anxiety, inability to sleep cause someone trying hard to sleep but he was increasingly unable to sleep.

Idiopathic insomnia

Idiopathic insomnia, is insomnia that has occurred since early life. Sometimes insomnia is already present at birth and continues throughout life. The cause is not clear, there is a suspicion caused by an imbalance of brain neurochemistry in the brain stem reticular formation, or forebrain dysfunction. Elderly living alone or a sense of fear exacerbated at night can lead to can not sleep. Chronic insomnia can lead to decreased mood (the risk of depression and anxiety), decrease motivation, attention, energy, and concentration, as well as cause a feeling lazy. Reduced quality of life and lead to the elderly are more likely to use health facilities. A person with primary insomnia often have a history of sleep disorders before. Many people with insomnia self medicate with drugs or alcohol, sedative-hypnotics. Anxiolytikum often used to cope with stress and anxiety.

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Anemia - Nursing Interventions for Risk for Infection

Anemia is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood.

There are more than 400 types of anemia, which are divided into three groups:
  • Anemia caused by blood loss
  • Anemia caused by decreased or faulty red blood cell production
  • Anemia caused by destruction of red blood cells
Symptoms that may occur first include:
  • Feeling grumpy
  • Feeling weak or tired more often than usual, or with exercise
  • Headaches
  • Problems concentrating or thinking

If the anemia gets worse, symptoms may include:
  • Blue color to the whites of the eyes
  • Brittle nails
  • Light-headedness when you stand up
  • Pale skin color
  • Shortness of breath
  • Sore tongue

Treatment should be directed at the cause of the anemia, and may include:
  • Blood transfusions
  • Corticosteroids or other medicines that suppress the immune system
  • Erythropoietin, a medicine that helps your bone marrow make more blood cells
  • Supplements of iron, vitamin B12, folic acid, or other vitamins and minerals

Nursing Diagnosis for Anemia : Risk for Infection related to an inadequate secondary defenses (decreased hemoglobin, leukopenia, or a decrease in granulocytes (inflammatory response depressed).

Goal: Infection does not occur.

Expected outcomes:
  • identify behaviors to prevent / reduce the risk of infection.
  • improve wound healing, free purulent drainage or erythema, and fever.

Nursing Interventions for Risk for Infection - Anemia :

1. Increase good hand washing; by the care givers and patients.
Rational: to prevent cross contamination / bacterial colonization. Note: patients with severe anemia / aplastic be at risk due to the normal flora of the skin.

2. Maintain strict aseptic technique on the procedure / treatment of wounds.
Rational: to reduce the risk of colonization / infection of bacteria.

3. Give skin care, perianal, and oral carefully.
Rational: reducing the risk of damage to the skin / tissue and infection.

4. Motivation changes in position / ambulation often, coughing and deep breathing exercises.
Rationale: increased pulmonary ventilation all segments and help mobilize secretions to prevent pneumonia.

5. Increase fluid intake adequate.
Rational: to assist in the dilution secret breathing, to ease spending and prevent stasis of body fluids such as respiratory and kidney.

6. Monitor / limit visitors. Give isolation room whenever possible.
Rational: limiting exposure to bacteria / infection. Protection in isolation required in aplastic anemia, when the immune response is very disturbed.

7. Monitor body temperature. Note the chills and tachycardia with or without fever.
Rational: the process of inflammation / infection require evaluation / treatment.

8. Observe erythema / wound fluid.
Rational: indicators of local infection.
Note: the formation of pus may not exist when granulocytes depressed.

9. Take a specimen for culture / sensitivity as indicated (collaboration)
Rational: to distinguish the presence of infection, identify specific pathogens and influence the choice of treatment.

10. Leave a topical antiseptic; systemic antibiotics (collaboration).
Rational: may be used to reduce colonization or prophylactic treatment for localized infection process.

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Knowledge Deficit - Nursing Care Plan for Hepatitis B

Nursing Diagnosis for Hepatitis B : Knowledge Deficit about the condition, prognosis, and treatment needs related to lack of exposure / recall; incorrect interpretation of information, do not know the source of information.

Goal: learning needs of clients are met.

Expected outcomes: expressed understanding of the disease process and treatment.

Intervention and Rational:

1. Assess the level of understanding of the disease process, expectations / prognosis possible treatment options.
Rational: identify areas of lack of knowledge / misinformation and provide the opportunity for additional information as needed.

2. Provide specific information about the prevention / transmission of the disease. Examples of gamma globulin contacts requiring personal problems do not need to be divided, emphasizing hand washing and sanitizing clothes, washing dishes, and the facilitation of the shower when the liver enzymes are high.
Avoid intimate contact such as kissing, sexual contact and exposure to infections especially respiratory tract infections (UTI).
Rationale: the need / recommendation will vary due to the type of hepatitis (the causative agent) and individual situations.

3. Plan started its activity as tolerated with adequate rest periods.
Discuss the heavy lifting restrictions and rigorous training / sports. Rationale: It is not necessary to wait until billirubin serum returned to normal to start activity (takes 2 months). But the loud activity should be limited to the liver returned to normal size.

4. Help patients identify diversionary activity.
Rationale: activities that can be enjoyed will help patients avoid breaking the healing length.

5. Encourage sustainability balanced diet.
Rational: improve public health and enhance healing / tissue regeneration.

6. Identify ways to maintain bowel function normally. For example, inadequate fluid intake / dietary fiber, activity / exercise tolerance was appropriate.
Rational: decreased level of activity, changes in the intake of food / fluids and intestinal motility may result konstiipasi.

7. Discuss the side effects and dangers of drinking nonprescription / absorbed. Some anesthetics and the need to report to the caregiver about the diagnosis.
Rational: some drugs are toxic to the liver: the number of other drugs metabolized by the liver and should be avoided in severe liver disease because it causes toxic effects of cumulative / chronic hepatitis.

8. Emphasize the importance of evaluating the physical examination and laboratory evaluation.
Rational: the disease process can take many months to improve, if there are symptoms for longer than 6 months of liver biopsy is needed to ensure the existence of chronic hepatitis.

9. Review the need to avoid alcohol during 6-12 months of age or longer suit individual tolerance.
Rationale: increased hepatic irritation and menpengaruhi recovery.

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Risk for Injury - Post Operative Cataract Care Plan

Cataract is a clouding of the eye's lens.
Cataracts are the most common cause of vision loss in people over age 40 and is the principal cause of blindness in the world. In fact, there are more cases of cataracts worldwide than there are of glaucoma, macular degeneration and diabetic retinopathy combined, according to Prevent Blindness America (PBA).

Types of cataracts include:
  • A cortical cataract is characterized by white, wedge-like opacities that start in the periphery of the lens and work their way to the center in a spoke-like fashion. This type of cataract occurs in the lens cortex, which is the part of the lens that surrounds the central nucleus.
  • A subcapsular cataract occurs at the back of the lens. People with diabetes or those taking high doses of steroid medications have a greater risk of developing a subcapsular cataract.
  • A nuclear cataract forms deep in the central zone (nucleus) of the lens. Nuclear cataracts usually are associated with aging.

Besides advancing age, cataract risk factors include:
  • Diabetes
  • Eye inflammation
  • Eye injury
  • Radiation exposure
  • Family history of cataracts
  • Long-term use of corticosteroids (taken by mouth) or certain other medications
  • Smoking
  • Surgery for another eye problem
  • Too much exposure to ultraviolet light (sunlight)

The best prevention involves controlling diseases that increase the risk of a cataract, and avoiding exposure to factors known to promote cataract formation.

Wearing sunglasses when you are outside during the day can reduce the amount of ultraviolet (UV) light your eyes are exposed to. Some sunglasses do not filter out the harmful UV. An optician should be able to tell you which sunglasses filter out the most UV. For patients who smoke cigarettes, quitting will decrease the risk of cataracts.

Cataract surgery is the removal of the natural lens of the eye (also called "crystalline lens") that has developed an opacification, which is referred to as a cataract. Metabolic changes of the crystalline lens fibers over time lead to the development of the cataract and loss of transparency, causing impairment or loss of vision. Many patients' first symptoms are strong glare from lights and small light sources at night, along with reduced acuity at low light levels. During cataract surgery, a patient's cloudy natural lens is removed and replaced with a synthetic lens to restore the lens's transparency.

Nursing Care Plan for Cataract

Nursing Diagnosis : Risk for Injury related to intraocular hemorrhage, vitreous loss.

Goal : injuries can be prevented.

Expected outcomes: environmental change as an indication for increased security.

Interventions and Rational
1. Discuss what happened to the post-surgery, on pain, activity restrictions, appearance, eye bandage.
Rationale: helps reduce fear and increase cooperation within the necessary restrictions.

2. Give the patient leaning position, head height, or tilted position to no pain, as desired.
Rational: break just a few minutes to a few hours at an outpatient surgery or an overnight stay in case of complications. Lowering the pressure on the sore eye, minimizing the risk of bleeding or stress on the seams open.

3. Limit activities such as moving the head suddenly, scratched eyes, bowed.
Rational: reduce stress on the area of operation.

4. Ambulatory with assistance; give special bathroom when recovering from anesthesia.
Rational: take a little strain rather than use the potty.

5. Encourage deep breath, cough to lung clearance.
Rational: cough increased intra-ocular pressure.

6. Encourage use of stress management techniques instance, guidance imagination, visualization, deep breathing and relaxation exercises.
Rational: increase relaxation and coping.

7. Maintain eye protection as indicated.
Rational: used to protect from accidental injury and reduce eye movements.

8. Ask the patient to tell the difference between discomfort and pain sudden sharp eye. Investigate restlessness, disorientation, impaired bandage. Observation of bleeding in the eye with a flashlight as indicated.
Rational: discomfort may be due to the surgical procedure; acute pain showed bleeding, occurs because strain or unknown causes (tissue vascularization cured many, and is unbelievably fragile capillaries).

9. Observation crusting sores, pear-shaped pupil.
Rational: iris prolapse or rupture showed injuries caused by damage to seams or eye pressure.

10. Collaboration: give the drug as indicated.
Rationale: nausea / vomiting can increase the risk of ocular injury, requiring immediate action to prevent ocular injury.

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12 Nursing Diagnosis for Tetanus

Tetanus is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin produced by the Gram-positive, rod-shaped, obligate anaerobic bacterium Clostridium tetani.

Clostridium tetani spores can be found most commonly in soil, dust and manure, but also exist virtually anywhere. If deposited in a wound the neurotoxin interferes with nerves that control muscle movement.

The signs and symptoms of tetanus may include:
  • Muscle spasms that begin in the jaw and neck
  • Inability to open the mouth (lockjaw)
  • Swallowing problems
  • Breathing difficulties
  • Painful convulsions
  • Abnormal heart rhythms.
Tetanus is a life-threatening disease and sometimes, a person dies despite prompt medical attention.

Treatment for tetanus may include:
  • Antitoxin called tetanus immunoglobulin to neutralise the tetanus toxin
  • Hospitalisation
  • Anti-convulsive medications
  • Antibiotics
  • Life support – for example, the person may be placed on an artificial respirator if they have severe breathing problems
  • Vaccination, if the adult hasn’t had a booster shot in the previous five years.

Nursing Diagnosis for Tetanus

1. Ineffective Airway Clearance related to accumulation of secretions result of damage to the muscles of swallowing.

2. Acute Pain related to injury agents (biological).

3. Risk for Aspiration related to loss of consciousness, swallowing disorders.

4. Ineffective Tissue Perfusion related to damage to transport oxygen through the alveolar and capillary membranes.

5. Risk for Injury related to an increase in muscle coordination (convulsions), irritability.

6. Imbalanced Nutrition, Less Than Body Requirements related to decreased swallowing reflexes, less intake.

7. Risk for Infection related to immune primary, invasive procedures.

8. Impaired Swallowing related to neuromuscular damage swallowing muscles.

9. Impaired Urinary Elimination related to damage to sensory motor.

10. Self Care Deficit related to weakness, illness.

11. Knowledge Deficit: about the disease and treatment related to lack of exposure to sources of information.

12. Impaired Verbal Communication related to decreased blood circulation to the brain.

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Varicose Veins - 5 Nursing Diagnosis and Interventions

Varicose Veins Care Plan

1. Acute Pain related to tissue ischemia secondary

Goal: Pain is lost or controlled

1) Assess the degree of pain. Note the behavior of protecting the extremities.
R / Degree of pain is directly related to the extent of the circulation shortfall, the inflammatory process.
2) Maintain bed rest during the acute phase.
R / Decrease discomfort in relation to muscle contraction and movement.
3) Elevate the affected extremity.
R / Pushing to facilitate venous return circulation, reduce static formation.
4) Encourage the patient to change positions frequently.
R / Reduce / prevent muscle weakness, helps minimize muscle spasm.
5) Collaboration of drugs as indicated.
R / Reduce pain and reduce muscle tension.

2. Impaired skin integrity related to vascular insufficiency.

Goal: Maintain the integrity of the skin.

1. Assess skin integrity, record changes in turgor, color noise, local warm, erythema, excoriation.
R / Skin condition is influenced by circulation, nutrition, and immobilization. Tissue can become brittle and prone to infection and damage.
2. Assess the extremities for venous obvious protrusion.
R / Superficial venous distension may occur in TVD because backflow through the veins branching.
3. Change position often, and avoid massaging the affected limb.
R / Improve circulation, massage the potential to solve / deploy thrombus causing embolus.
4. Range of motion exercises help to passive or active.
R / Improves circulation of body tissue, prevents stasis.
5. Perform warm compresses, moist heat to the extremities or the hospital if indicated.
R / Increase vasodilation and venous return and repair of local edema.

3. Impaired physical mobility related to activity limitations due to pain.

Goal: Demonstrate techniques / behaviors enabling activities.

1) Maintain proper body position.
R / Improving tissue stability (reducing the risk of injury), the functional position of the extremities.
2) Note the circulation, movement and sensation are frequent.
R / Edema can affect circulation to the extremities so that the potential occurrence of tissue necrosis.
3) Assist with range of motion active / passive.
R / Improve maintenance of tissue function.
4) Schedule of activities and treatments to provide uninterrupted rest period.
R / Prevent fatigue, maintain strength and patient tolerance of the activity.
5) Encourage the support and help of family / significant other on range of motion exercises.
R / Enabling a family / significant other to be active in patient care and provide more consistent treatment.

4. Imbalanced Nutrition, Less Than Body Requirements related to increased metabolic needs.

Goal: Demonstrate an increase in food intake, maintain / gain weight.

1) Perform a thorough nutritional assessment.
R / Identify deficiencies / needs to help choose interventions.
2) Provide eat small portions and often include dry food and interesting food for patients.
R / This could increase the input and requires less energy.
3) Provide a diet high in calories / protein with additional vitamins.
R / Help meet metabolic demands, maintain weight and tissue regeneration.
4) Encourage activity restrictions during the acute phase.
R / Lowering metabolic requirements to prevent degradation of calories and energy savings.
5) Consult with a dietitian.
R / Help assess the patient's nutritional needs change in digestion and bowel function.

5. Disturbed Body Image relateed to varicose veins.

Goal: Improved confidence in ability to cope with illness.

1) Encourage disclosure of concerns about the disease process, hope for the future.
R / Give a chance to identify the fear / guilt concept and deal with them directly.
2) Discuss the patient's perception of how the people closest to accept limitations.
R / Verbal cues / nonverbal people nearby could have a major effect on how patients view themselves.
3) Recognize and accept feelings of grief, resentment, dependence.
R / Constant pain would be tiresome, and feelings of anger and hostility are common.
4) Consider withdrawing behavior, or deny the use of too much attention to the body / changes.
R / Can indicate emotional or maladaptive coping methods, requiring further intervention / psychological support.
5) Arrange limits on maladaptive behavior. Help patients to identify the positive behaviors that can help coping.
R / Assisting patients to maintain self-control, which can increase feelings of self-worth.
6) Involve the patient in the treatment plan and schedule activities.
R / Increase feelings of competence / self-esteem, encourages independence and participation in therapy.

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Disturbed Thought Processes - NCP Dementia

Nursing Diagnosis : Disturbed Thought Processes - Dementia Care Plan

Definition: Disruption in cognitive operations and activities.

Dementia is a term that describes a collection of symptoms that include decreased intellectual functioning that interferes with normal life functions and is usually used to describe people who have two or more major life functions impaired or lost such as memory, language, perception, judgment or reasoning; they may lose emotional and behavioral control, develop personality changes and have problem solving abilities reduced or lost.

There are many different causes of dementia, the most common being degenerative neurological diseases, such as Alzheimer's disease, Parkinson's disease, Huntington's disease, and some types of multiple sclerosis. Alzheimer’s disease is the most common, causing fifty percent of all dementia. Other common causes are vascular disorders - such as multiple-infarct dementia, which is caused by multiple strokes; infections - such as HIV dementia complex and Creutzfeldt-Jakob disease, chronic drug use, depression, and types of hydrocephalus - an accumulation of fluid in the brain caused by developmental abnormalities, infections, injury, or brain tumors.

Nursing Interventions :

1. Clients can build a trusting relationship

Expected outcomes:
  • Clients show a sense of fun, friendly facial expression, like shaking hands, making eye contact, sitting side by side.

Interventions :
  • Greet clients well, verbal and non-verbal.
  • Introduce yourself politely.
  • Explain the purpose of the meeting.
  • Honest and keeping promises.
  • Show empathy and accept clients with what it is.
  • Pay attention to the client, and note the basic needs.

2. Clients are able to know / oriented towards people's time and place

Expected outcomes:
  • Clients are able to mention which people around him,
  • Clients are able to mention the day and place the visit.

Interventions :
  • Give the patient the opportunity to get to know the personal belongings, such as a bed, dresser, clothes etc..
  • Give the patient the opportunity to get to know the time using the clock, a calendar that has a sheet with a big day.
  • Give the patient the opportunity to mention his name and family members.
  • Give the opportunity for clients to know where he is.
  • Give praise, if the patient can answer correctly.

3. Patient are able to do daily activities optimally.

Expected outcomes:
  • Patient are able to meet their daily needs independently.

Interventions :
  • Observation of the patient's ability to perform daily activities.
  • Give the patient the opportunity to choose activities that can be done.
  • Help the patient to perform activities that have been chosen.
  • Give praise, if patients can do their activities.
  • Ask the patient's feelings, if able to do activities.
  • Together with the patient, create a schedule of daily activities.

4. Families of patients were able to orient the patient to time, person and place.

Expected outcomes:
  • Families are able to give precise guidance about the time and place and the people around him and the family is able to provide a good attitude to clients.

Interventions :
  • Patient's family, was able to orient the patient to time, person and place.
  • Discuss with the patient's family, ways of orienting time, people and places to the patient.
  • Encourage the family to provide a clock, a calendar with writing great.
  • Discuss with the patient's family, who once owned the ability of the patient.
  • Encourage the family to give praise to the abilities that are still owned by the patient.
  • Encourage the family to monitor the daily activities of patients according to the schedule have been made.
  • Encourage the family to praise, if the patient carried out in accordance with the schedule of activities that have been made.

5. The patient's family can provide the tools needed by the patient to do reality orientation.

Expected outcomes:
  • Clients can / afford things or something that have or are experiencing.

Interventions :
  • Providing the tools needed to conduct patient-oriented.
  • Encourage families to help patients perform activities according to capabilities.

6. Families of patients able to assist patients in performing day-to-day of activity,
  • Families of patients able to assist clients in the activities and guiding clients well.

Interventions :
  • Assist patients in performing day-to-day of activity.
  • Encourage the family to help the elderly carry out activities in accordance capabilities.
  • Help the patient's family, choose the capabilities that made ​​the patient at this time.

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Self-Care Deficit related to Stroke

NANDA Definition : Impaired ability to perform or complete activities of daily living, such as feeding, dressing, bathing, toileting.

A stroke is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused by a blood vessel that breaks and bleeds into the brain. "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly interrupted.

Symptoms of a stroke can include:
  • A numb or weak feeling in the face, arm or leg
  • Trouble speaking or understanding
  • Unexplained dizziness
  • Blurred or poor vision in one or both eyes
  • Loss of balance or an unexplained fall
  • Difficulty swallowing
  • Headache (usually severe or of abrupt onset) or unexplained change in the pattern of headaches
  • Confusion

Nursing Diagnosis for Stroke : Self-Care Deficit

May be related to
  • Pain/discomfort
  • Depression
  • Perceptual/cognitive impairment
  • Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination

Expected outcomes:
  • Clients can perform self-care activities in accordance with the client's capabilities.
  • Clients can identify the source of personal / community to provide assistance as needed.

Nursing Interventions and Rationale :

1. Test capabilities and deficient levels (using a scale of 0-4) to perform daily needs.
R: Assist in anticipating / planning needs individually.

2. Avoid doing things for the patient, do the patients themselves, but provide assistance as needed.
R: The patient may be very frightened and very dependent and despite the help given useful in preventing frustration, it is important for patients to do as much as possible for themselves to maintain self-esteem and improve recovery.

3. Be aware of the behavior of impulsive activity because of impaired decision-making.
R: May indicate need for intervention and monitoring to enhance patient safety.

4. Maintain support, assertive attitude. Give the patient enough time to do their job.
R: Patient will need empathy but caregivers need to know that will help patients consistently.

5. Give positive feedback for any work done or success.
R: Increased feelings of self-significance. Increasing independence, and encourage patients to seek a sustainable manner.

6. Use personal assistive devices, such as a combination of blade fork, brush stem length, stem length to pick up something from the floor; seat shower; toilet seat a bit high.
R: Patients can handle self, increasing self-reliance and self-esteem.

7. Assess the patient's ability to communicate about the need to avoid and / or the ability to use a urinal, bedpan. Bring the patient to the bathroom regularly / intervals to urinate if possible.
R: Maybe having a nervous breakdown bladder, can not tell his needs in the acute recovery phase, but usually can control this function again with the development of the healing process.

8. Identify the previous defecation habits and return to the normal habits. Levels of fibrous foods, recommended to drink a lot and increase activity.
R: Assessing the development of an exercise program (standalone) and assist in the prevention of constipation (long-term effects).

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Risk for Infection Care Plan COPD

Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

COPD or Chronic obstructive pulmonary disease is one of the most common lung diseases. It makes it difficult to breathe. There are two main forms of COPD:
  • Chronic bronchitis, which involves a long-term cough with mucus
  • Emphysema, which involves destruction of the lungs over time
  • Most people with COPD have a combination of both conditions.

  • Cough, with or without mucus
  • Fatigue
  • Many respiratory infections
  • Shortness of breath (dyspnea) that gets worse with mild activity
  • Trouble catching one's breath
  • Wheezing

The diagnosis of COPD requires lung function tests. Important management strategies are smoking cessation, vaccinations, rehabilitation, and drug therapy (often using inhalers). Some patients go on to require long-term oxygen therapy or lung transplantation.

Risk factors may include :
  • Inadequate acquired immunity (tissue destruction, increased environmental exposure)
  • Inadequate primary defenses (decreased ciliary action, stasis of secretions)
  • Malnutrition
  • Chronic disease process

Outcomes :
  • Remains free from symptoms of infection
  • States symptoms of infection of which to be aware
  • Demonstrates appropriate care of infection-prone site
  • Maintains white blood cell count and differential within normal limits
  • Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care

Nursing Care Plan for COPD - Nursing Diagnosis : Risk for Infection

Interventions and Rationale :

1. Monitor temperature
R : Fever may be present because of infection and/or dehydration.

2. Observe color, character, odor of sputum.
R : Odorous, yellow, or greenish secretions suggest the presence of pulmonary infection.

3. Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake.
R : These activities promote mobilization and expectoration of secretions to reduce risk of developing pulmonary infection.

4. Encourage balance between activity and rest.
R : Reduces oxygen consumption/demand imbalance, and improves patient’s resistance to infection, promoting healing.

5. Monitor visitors; provide masks as indicated.
R : Reduces potential for exposure to infectious illnesses, e.g., upper respiratory infection (URI).

6. Obtain sputum specimen by deep coughing or suctioning for Gram’s stain, culture/sensitivity.
R : Done to identify causative organism and susceptibility to various antimicrobials.

7. Discuss need for adequate nutritional intake.
R : Malnutrition can affect general well-being and lower resistance to infection.

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How to do Home Care for the Elderly

Elderly care, or simply eldercare is the fulfillment of the special needs and requirements that are unique to senior citizens. This broad term encompasses such services as assisted living, adult day care, long term care, nursing homes, hospice care, and home care. Because of the wide variety of elderly care found globally, as well as differentiating cultural perspectives on elderly citizens, the subject cannot be limited to any one practice. For example, many countries in Asia use government-established elderly care quite infrequently, preferring the traditional methods of being cared for by younger generations of family members.

How to do Home Care for the Elderly?

Considering the characteristics of elderly patients with different young people, especially those who are post-hospital care still need help for recovery, perform assessments and provide care for the elderly at home there are specific things that must be considered. In general, elderly patients (geriatric) needed a special assessment which includes a variety of components referred to as Comprehensive Geriatric Assessment (CGA) or Session Approach to Geriatric Patients (P3G).

The components that must be assessed at the time geriatric care home is:
1. Physical condition of medical
2. Mental status and cognitive
3. functional status
4. nutritional Status
5. The use of drugs
6. social support
7. Assessment of the safety and security of home / environment

As already mentioned above, elderly health care in the home should be done by the health workers who are equipped with the principles of a comprehensive and interdisciplinary care. A doctor or nurse who does elderly care in the home, due to the limitations often come alone, had established itself as a member and serves as the representative of an interdisciplinary team.

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Nursing Management of Stroke

Stroke Management for Nurses

Stroke can be defined as a neurological deficit of sudden onset that has lasted 24 hours as a result of cerebrovascular disease (CVD), which is a common neurologic disorder in adults (Huddak & Gallo, 1996).

Based on the cause, stroke can be divided into two kinds, namely:

1. Ischemic stroke

Stroke occurs as a result of the blockage of the arteries that causes a decrease suply of oxygen in brain tissue (ischemic) to induce necrosis. 87% of strokes being caused because of blockage in the form of thrombus or embolus. Thrombus is a clot / blockage bersasal of brain blood vessels. Embolus is a clot / blockage from elsewhere, such as the heart or other major artery. Another influential factor is an irregular heartbeat (atrial fibrillation), which is a sign of a blockage in the heart to go out to the brain. The presence of fat accumulation in the brain blood vessels (atherosclerosis) will increase the risk of ischemic stroke.

2. Hemorrhage stroke

Stroke occurs as a result of rupture of the fragile blood vessels in the brain. Two types of blood vessels of the brain that can cause hemorrhagic stroke, namely, aneurysms and arteriovenous malformations (AVMs). Aneurysms are blood vessels developing brain more vulnerable so that the data burst. Arteriovenous malformations are blood vessels that have an abnormal shape, so easy to break and cause a brain hemorrhage.

Risk Factors

Stroke risk factors that can be modified are:
  • high blood pressure
  • diabetes mellitus
  • smoke
  • carotid artery disease and peripheral
  • atrial fibrillation
  • cardiovascular disease (heart failure, congenital heart defects, coronary heart disease, cardiomegaly, kardiomyopathy)
  • transient ischemic attack (TIA)
  • hypercholesterolemia
  • sickle cell disease
  • obesity and lack of activity
  • use of alcohol
  • the use of illegal drugs

Stroke risk factors that can not be modified are:
  • Age: the age, the increased risk of stroke.
  • Gender: Men have a greater risk of suffering a stroke than women.
  • Family history
  • Ever had a stroke

Clinical Manifestations

Patients with vascular disease may indicate a TIA (transient ischemic attact). It is a neurological deficit that can recover within 24 hours, the average duration was 10 minutes, after which the symptoms disappear. Patients also may exhibit reversible ischemic neurologic deficit. These events can occur at TIA that lasted more than 24 hours, but can eventually recover completely. The symptoms seen with TIA is highly dependent on the affected vessels. If the carotid and cerebral arteries are affected, patients can suffer blindness in one eye, hemiplegia, hemianesthesia, speech disorders, and mental derangement. If the vertebrobasilar arteries affected, there will be dizziness, diplopia, tingling, abnormal vision in one or both fields of view, and dysarthria (speech disorder in the muscles). Possible disability related to stroke.

Nursing Management of Stroke

With cerebral infarction are irreversible loss of central brain tissue. Zone around the dead tissue, there may still be salvaged tissue. Early action should be focused as much as possible to save an ischemic area. The three most important elements for the area is oxygen, glucose, and blood flow adequately. Oxygen levels can be monitored via the arterial blood gases and oxygen can be administered to patients if indicated. Hypoglycemia can be evaluated with a series of blood glucose checks. Cerebral perfusion pressure is a reflection of systemic blood pressure, ICT, still functioning autoregulation in the brain as well as heart rate and rhythm. The easiest parameter to be controlled externally is rhythm, heart rate, and blood pressure. Dysrhythmias can usually be repaired. The causes of tachycardia include fever, pain, and dehydration that can be handled. If ICT increases in stroke patients, it usually occurs after the first day. While this is a natural response of the brain to some cerebrovascular lesions, but it is damaging the brain. Destructive responses such as edema, or atrial spasm, sometimes can be prevented or overcome. Common method to control increased intracranial pressure may be performed such as hyperventilation, fluid retention, raised his head, avoiding flexion of the head, and excessive head rotation that could compromise venous return to the head.

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Causes, Symptoms and Nursing Diagnosis for Septic Shock

NCP Septic Shock

Septic shock is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure.

Septic shock is a possible consequence of bacteremia, or bacteria in the bloodstream. Bacterial toxins, and the immune system response to them, cause a dramatic drop in blood pressure, preventing the delivery of blood to the organs. Septic shock can lead to multiple organ failure including respiratory failure, and may cause rapid death. Toxic shock syndrome is one type of septic shock.

Septic shock still remains the one of the leading causes of death in hospital patients. Barely more than 50% of the patients with severe sepsis survive their hospital admission. This unacceptable high mortality can only be reduced if there is greater awareness and understanding of the condition .and the knowledge of most effective treatment measures available. Unplanned admissions to the Intensive Care Unit (ICU) and potentially preventable deaths on wards are associated with a failure to institute early preventive conditions. Greater than 40% of the intensive Care Unit admissions are potentially preventable with improved ward care.

Septic shock causes a very low blood pressure, which causes a decrease the amount of blood and oxygen reaching the other organs, leading to multi-system organ failure (MSOF). In MSOF, the major organs, including the brain, liver, kidneys and lungs, all stop working properly. If a patient in septic shock does not receive the appropriate antibiotics, medications to support the blood pressure, and respiratory support with oxygen or a breathing machine (ventilator), it could lead to death. Sometimes, even if a patient does receive the proper treatments for septic shock, the infection may be too overwhelming for the body to be able to respond to the medications. That is why it is so important to diagnose and treat infections prior to them causing sepsis or septic shock.

Septic shock can affect any part of the body, including the heart, brain, kidneys, liver, and intestines. Symptoms may include:
  • Cool, pale extremities
  • High or very low temperature, chills
  • Lightheadedness
  • Low blood pressure, especially when standing
  • Low or absent urine output
  • Palpitations
  • Rapid heart rate
  • Restlessness, agitation, lethargy, or confusion
  • Shortness of breath
  • Skin rash or discoloration
Septic shock is treated initially with a combination of antibiotics and fluid replacement. The antibiotic is chosen based on the bacteria present, although two or more types of antibiotics may be used initially until the organism is identified. Intravenous fluids, either blood or protein solutions, replace the fluid lost by leakage. Coagulation and hemorrhage may be treated with transfusions of plasma or platelets. Dopamine may be given to increase blood pressure further if necessary.
Respiratory distress is treated with mechanical ventilation and supplemental oxygen, either using a nosepiece or a tube into the trachea through the throat.
Identification and treatment of the primary infection site is important to prevent ongoing proliferation of bacteria.

Nursing Diagnosis for Septic Shock

1. Decreased Cardiac Output

2. Ineffective tissue perfusion

3. Fluid Volume Deficit

4. Impaired gas exchange

5. Ineffective breathing pattern

6. Imbalance nutrition: less than body requirements

7. Risk for imbalanced body temperature

8. Impaired physical mobility

9. Risk for Impaired skin integrity

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3 Easy steps that can be done to treat the facial skin

treat the facial skin

Plastic surgery is not the only solution to beautify our faces. With a healthy pattern of living and doing facials simple things we can do everyday at home, so, the skin we have will be better than the results in getting from operations. At noon today I will give to notify you about 3 easy steps that can be done to treat the facial skin.

Here are 3 easy ways facials you can do at home:

1. Clean your face

Clean your face. Actually this is the most fundamental thing in facial skin care. This should be very in mind, cleanse skin is not just clean but also caring. In terms of choosing a facial cleanser that you use should be very careful because our skin is fairly sensitive. If we choose the wrong facial cleanser that will make our skin will look older later. The first step that we must learn first is identify each skin type, and then choose a facial cleanser products according to skin type of each. Read carefully cleaning components and reviews of the product will be very helpful. Buy the smallest package when trying a facial cleanser product for the first time.

2. Facial Exfoliation

Exfoliation. Exfoliation is actually very important to the owners with the type of normal skin types and dry. Exfoliation process is intended to allow the dead skin cells can remove the skin leaving a shine. It is better when there is exfoliation, so be sure to give a little massage blood circulation in your face to be smooth. For the type of oily skin types, the actual process is less recommended because it can trigger acne later. But in the traditional can use lemon juice that is mixed with flesh peeling tomatoes as an ingredient.

3. Moisturize Skin

You should make sure to choose a facial moisturizer that suits the type of skin and also adjust as needed. For example, gunkan moisturizers that contain collagen to disguise wrinkles on the face and so on. Virtually all types of skin types that need a moisturizer. For oily skin types who wear facial moisturizers that are water. For those who want a natural facial moisturizer, you can read the info is below: Many moisturizing ingredients you can find in your kitchen. To use examine your skin type first.

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ABCDE Assessment for Septic Shock

Septic shock is a serious condition as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause a dramatic drop in blood pressure, preventing the delivery of blood to the organs. Septic shock can lead to multiple organ failure including respiratory failure, and may cause rapid death. Toxic shock syndrome is one type of septic shock.

Risk factors for septic shock include:
  • Diabetes
  • Diseases of the genitourinary system, biliary system, or intestinal system
  • Diseases that weaken the immune system such as AIDS
  • Indwelling catheters (those that remain in place for extended periods, especially intravenous lines and urinary catheters and plastic and metal stents used for drainage)
  • Leukemia
  • Long-term use of antibiotics
  • Lymphoma
  • Recent infection
  • Recent surgery or medical procedure
  • Recent use of steroid medications

Septic shock is usually preceded by bacteremia, which is marked by fever, malaise, chills, and nausea. The first sign of shock is often confusion and decreased consciousness. In this beginning stage, the extremities are usually warm. Later, they become cool, pale, and bluish. Fever may give way to lower than normal temperatures later on in sepsis.

Other symptoms include:
  • rapid heartbeat
  • shallow, rapid breathing
  • decreased urination.
  • reddish patches in the skin

Septic shock may progress to cause "adult respiratory distress syndrome," in which fluid collects in the lungs, and breathing becomes very shallow and labored. This condition may lead to ventilatory collapse, in which the patient can no longer breathe adequately without assistance.

ABCDE Assessment for Septic Shock

  • Assure effective airway
  • Give a ventilator if necessary (Guedel or nasopharyngeal)
  • If a decline in respiratory function immediately contact an anesthesiologist and take it as soon as possible to the ICU.

  • Assess the amount of breathing more than 24 times per minute is a significant symptom.
  • Assess oxygen saturation.
  • Check arterial blood gases to assess oxygenation status and possible acidosis.
  • Give 100% oxygenation via the non re-breath mask.
  • Auscultation of the chest, to determine the presence of infection in the chest.
  • Check out the thoracic.

  • Assess heart rate> 100 beats per minute is a significant sign.
  • Monitoring of blood pressure.
  • Check the capillary refill time.
  • Attach infusion using a large canul.
  • Give fluids.
  • Insert the catheter.
  • Perform complete blood count.
  • Prepare for culture.
  • Record the temperature, the possibility of patients pyrexia or temperature of less than 36oC.
  • Prepare urine and sputum.
  • Give broad spectrum antibiotics according to local policies.

  • Confused is one of the first signs of sepsis patients where previously no problems (healthy and good).
  • Assess level of consciousness using AVPU.

  • If the source of infection is unknown, looking for any injury, cuts and the injection site and the source of other infections.

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Decreased Cardiac Output related to Angina Pectoris

Care Plan Decreased Cardiac Output

Nursing Diagnosis and Interventions for Angina Pectoris

Decreased Cardiac Output NANDA Definition :
Inadequate blood pumped by the heart to meet metabolic demands of the body

Angina pectoris, or angina, is a symptom of chest pain or pressure that occurs when the heart is not receiving enough blood and oxygen to meet its needs. Stable angina usually occurs in a predictable fashion during or after physical exercise or emotional stress.

Angina is classified into two types – stable angina and unstable angina.

Unstable angina results from the sudden rupture of a plaque, which causes a rapid accumulation of platelets at the plaque and increased obstruction of blood flow in the coronary artery. Accordingly, unstable angina symptoms occur in an unexpected or unpredictable fashion, such as at rest. The symptoms may be more severe and less responsive to nitroglycerin medication. Unstable angina is a medical emergency. Unchecked, it can result in a heart attack. This risk of heart attack remains even if the unstable angina symptoms lessens or disappears. Thus, if unstable angina occurs, seeking immediate medical attention is very important.

Stable angina results from the gradual accumulation of plaque in the coronary artery. As this accumulation increases, angina symptoms begin to occur in a predictable fashion during or after physical exercise or emotional stress. This predictable pattern can persist for weeks, months, or even years. The kinds of activities that can cause stable angina include walking up a hill or a flight of stairs, doing housework, experiencing severe emotional stress or anxiety, having sex, exposure to cold temperatures, or consumption of heavy meals. Although the symptoms are bothersome, they do not usually indicate that a heart attack is imminent.

Nursing Diagnosis : Decreased Cardiac Output

related to inotropic changes, such as transient or prolonged myocardial ischemia and effects of medications;
alterations in rate, rhythm, and electrical conduction.

Expected Outcome :
  • Demonstrate increased activity tolerance.
  • Cardiac Pump Effectiveness
  • Participate in behaviors and activities that reduce the workload of the heart.
  • Report or display decreased episodes of dyspnea, angina, and dysrhythmias.

Intervention :

1. Record the color and the presence / quality of the pulse.

2. Monitor vital signs, eg heart rate, blood pressure.

3. Provide supplemental oxygen as needed

4. Maintain bed rest in a comfortable position during the acute episode.

Rational :

1. Decreased peripheral circulation when cardiac output falls, making skin color pale or gray (depending on the level of hypoxia) and decreased strength of peripheral pulses.

2. Tachycardia can occur because of pain, anxiety, hypoxemia, and decreased cardiac output. Changes also occur in blood pressure (hypertension or hypotension) due to cardiovascular response.

3. Increase the supply of oxygen to the need to improve myocardial contractility, decrease ischemia, and lactic acid levels.

4. Lowering the oxygen consumption / demand, lowering employment and risk of myocardial decompensation.

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