Sample Nursing Care Plan for Uterine Prolapse (Post Operative)

Uterine Prolapse (Post Operative)

Assessment

Subjective Data:

• Pain in the area of operation.
• Tired.
• Dizzy.
• Nausea, bloating.

Objective Data :

• There is a wound in the groin.
• Fasting.
• Mucous membranes dry mouth.

Possible Nursing Diagnosis for Uterine Prolapse (Post Operative)

1. Acute pain related to the surgical wound.
2. Risk for fluid volume deficit related to vomiting after surgery.
3. Impaired skin integrity related to the surgical wound.
4. Risk for hypertermia related to surgical wound infection.
5. Knowledge deficit: surgical wound care related to lack of information.

Nursing Interventions for Uterine Prolapse (Post Operative)

1. Acute pain related to the surgical wound.

Goal: Pain disappeared after the act of nursing.
Expected outcomes:

• Pain is reduced gradually.

Interventions:

• Assess the patient's pain intensity.
• Observation of vital signs and patient complaints.
• Place the patient on a bed with a technique that is appropriate to the surgery performed.
• Give the sleeping position that is fun and safe.
• Instruct the patient to immediately move gradually.
• Give appropriate analgesic therapy medical program.
• Take action with the child nursing care.
• Teach relaxation techniques.

2. Risk for fluid volume deficit related to vomiting after surgery.

Goal: There is no shortage of fluid volume.
Expected outcomes:

• Elastic skin turgor, not dry,
• No nausea and vomiting.

Interventions:

• Observation of vital signs every 4 hours.
• Monitor the infusion.
• Give drink and eat gradually.
• Monitor for signs of dehydration.
• Monitor and record the fluid in and out.
• Measure body weight per day.
• Record and inform the doctor about vomiting.

3. Impaired skin integrity related to the surgical wound.

Goal: Damage to skin integrity is resolved.
Expected outcomes:

• The surgical wound is clean, dry, no swelling. no bleeding.

Interventions:

• Observation of the state of the surgical wound of signs of inflammation: fever, redness, swelling and discharge.
• Treat the wound with sterile technique.
• Keep around the surgical wound.
• Give nutritious foods and encourage patients to eat.
• Involve the family to keep the clan surgical wound environment.
• Teach family in the care of the surgical wound.

4. Risk for hypertermia related to surgical wound infection.

Goal: Hyperthermia is resolved.

Expected outcomes:

• The surgical wound is clean, dry, not swollen. no bleeding.
• The temperature in the normal range (36-37 ° C).

Interventions:

• Observation of vital signs every 4 hours.
• Give appropriate antibiotic therapy medical program.
• Give a warm compress.
• Monitor the infusion.
• Ambulatory surgical wound with sterile technique.
• Keep the surgical wound.
• Monitor and record the fluid in and out.

5. Knowledge deficit: surgical wound care related to lack of information.

Goal: The client knows how to take care of the surgical wound.

Expected outcomes:

• Parents understand the operation wound care.
• Parents can maintain cleanliness and surgical wound treatment.

Interventions:

• Teach parents how to care for the surgical wound and keep it clean.
• Discuss about the wishes of the family wanted to know.
• Allow the patient's family to ask.
• Explain about the care of patients at home, do not wet and dirty bandage.
• Suggest to continue treatment / take medication regularly at home, and control back to the doctor.

Evaluation

1. Obtain pain relief.
2. Patients receive adequate fluid intake volume.
3. Improved patient skin integrity.
4. Good skin turgor.
5. The client's body temperature within normal limits.
6. Gain knowledge about uterine prolapse and treatment program.
7. Mentions how the surgical wound care is good and right.

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Nursing Care Plan for Hyperbilirubinemia in Infants

Hyperbilirubinemia is a condition where excessive concentration of bilirubin in the blood, causing joundice in neonates (Dorothy R. Marlon, 1998)



1. Impaired Skin Integrity related to jaundice or radiation.

Goal: good skin integrity / normal.

Expected outcomes:

• Good skin integrity could be maintained.
• No injuries / lesions on the skin.
• Good tissue perfusion.
• Protect the skin and retain moisture and natural treatments.

Intervention:

• Avoid wrinkles in the bed.
• Keep your skin to stay clean and dry.
• Mobilization of the patient every 2 hours.
• Monitor the existence of skin redness.
• Wash with soap and warm water.

2. Hyperthermia related to exposure to a hot environment.

Goal: temperature in the normal range.

Expected outcomes:

• Body temperature within normal range.
• Pulse and respiration within normal limits.
• There is no change in skin color.

Intervention:

• Monitor the temperature as much as possible.
• Monitor skin color.
• Monitor blood pressure, pulse, and respiration.
• Monitor intake and output.

3. Fluid volume deficit related to inadequate fluid intake, phototherapy, and diarrhea.

Goal: adequate body fluids.

Expected outcomes:

• Adequate fluid.

Intervention:

• Record the number and quality of feces.
• Monitor the skin turgor.
• Monitor intake output.
• Give water between breastfeeding or giving a bottle.

4. Knowledge Deficit related to the limitations of exposure.

Goal: family got knowledge about the disease that affects children.

Expected outcomes:

• The family said the understanding of the disease, condition, prognosis and treatment programs.
• Families are able to carry out the procedure described correctly.
• The family was able to explain again what is described nurse / other health team.

Iintervention:

• Describe the pathophysiology of the disease.
• Describe the signs and symptoms of the disease that usually appears in the right way.
• Describe the disease process in a proper way.
• Provide information on the patient's family about the conditions in an appropriate manner.

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Nursing Care Plan for Decubitus Ulcer / Pressure Sores

Decubitus Ulcer / Pressure Sores

Definition

Decubitus ulcer is a local tissue necrosis that tends to happen when the soft tissues between the bony prominences depressed, with the external surface in the long term. (National Pressure Ulcer Advisory Panel [NPUAP], 1989a, 1989b).

Decubitus ulcer is an area of dead tissue caused by lack of blood flow area concerned. Decubitus comes from the Latin that means lying. Lying does not always lead to bedsores. Therefore, some people prefer the term pressure sores because of pressures that is the main cause of decubitus ulcers (Wolf, Weitzel & Fuerst (1989: 354) in Fundamentals of Nursing)


Etiology

Decubitus sores are caused by a combination of extrinsic and intrinsic factors in patients.

Extrinsic Factors

• Pressure: stressed skin and underlying tissue between the bones with another hard surface, such as beds and operating tables. Light pressure for a long time as dangerous as great pressure in a short time. Local microcirculation disorders occur later lead to hypoxia and necrosis. (interface pressure). Interfacial pressure is force per unit area of the body with the mattress surface. If the interfacial tension is greater than the average capillary pressure, the capillaries will easily collapse, the area becomes easier to ischemia and necrotic. Average capillary pressure is about 32 mmHg.
• Friction and shifts: repeated friction will cause abrasion, so that the damaged tissue integrity. The strained skin, the skin layer shifts, local microcirculation disturbances.
• Humidity: will cause maceration, usually due to incontinence, drain and perspiration. Macerated tissue will be easily eroded. In addition, the moisture also lead to skin prone to friction and tearing of tissue (shear). Alvi incontinence is more significant in the development of pressure sores than urinary incontinence because of bacteria and enzymes in the stool can damage the surface of the skin.
• Cleanliness of the beds, appliances weaving a tangled and dirty, or medical equipment that causes the client fixed on a certain attitude also facilitate the occurrence of pressure sores.

Intrinsic Factor

• Age: the elderly will decrease the elasticity and vascularity. Older patients have a high risk of developing pressure sores because of skin and tissue will change with aging. Aging results in muscle loss, decreased levels of serum albumin, a decrease in inflammatory response, decreased skin elasticity, as well as a decrease in cohesion between the epidermis and dermis. These changes, combined with other aging factors will make your skin decreases tolerance to pressure, friction, and energy tearing. In addition, as a result of aging is the reduction of subcutaneous fat tissue, reduced collagen and elastin tissue. decreasing the efficiency of collateral capillaries in the skin so the skin becomes thinner and fragile.
• Decrease in sensory perception: Patients with decreased sensory perception will be decreased to feel the sensation of pain due to pressure on the bone protruding. When this happens in a long duration, the patient will be susceptible to pressure sores. because pain is a sign that normally encourages a person to move. Nerve damage (eg due to injury, stroke, diabetes) and coma can cause a reduced ability to feel pain.
• Loss of consciousness: a neurological disorder, trauma, narcotic analgesics.
• Malnutrition: People who are malnourished (malnutrition) does not have a protective layer of fat, and skin does not undergo complete recovery due to shortage of nutrients that are important. Therefore, the client with malnutrition are also at high risk of suffering from decubitus ulcers. In addition, malnutrition can be impaired wound healing. Usually associated with hypo-albumin. Hypoalbuminemia, weight loss, and malnutrition is generally identified as a predisposing factor for the occurrence of pressure sores. According to research Guenter (2000) stages three and four of pressure sores in elderly people associated with weight loss, low levels of albumin, and inadequate food intake.
• Mobility and activities: Mobility is the ability to change and control the position of the body, while the activity is the ability to move. Patients who lie constantly in bed without being able to change the position at high risk for developing pressure sores. People who can not move (eg paralyzed, very weak, deprived). Immobility is the most significant factor in the incidence of pressure sores.
• Smoking: Nicotine found in cigarettes can reduce blood flow and have toxic effects on the endothelium of blood vessels. According to the research Suriadi (2002) there was a significant association between smoking and the development of the pressure sores.
• Skin temperature: According to the research Sugama (1992) rise in temperature is a significant factor in the risk of pressure sores.
• The ability of the cardiovascular system decreases, so that the skin perfusion decreased.
• Anemia.
• Hypoalbuminemia, high risk of pressure sores and slow down healing.
• Diseases that damage blood vessels also facilitate exposed to pressure sores and pressure sores worsen.

Clinical Manifestations

Occur in patients with paraplegia, quadriplegia, spina bifida, multiple
sclerosis and prolonged immobilization in the hospital. In addition, other factors need to be known of the history of the patient, including; onset, duration, history of previous treatment, wound care, previous surgical history, nutritional status and changes in body weight, a history of allergies, alcohol consumption, smoking and socio-economic circumstances of the patient. Anamnesis systems including include fever, night sweats, spasm (rigid), paralysis, odor, pain (Arwaniku, 2007). According NPUAP (National Pressure Ulcer Advisory Panel).

Pressure sores is divided into four stages, namely:

Stage 1: ulceration limited to the epidermis and dermis with erythema on the skin. Patients with good sensibility will complain of pain, this stage is usually reversible and can be cured in 5-10 days.
Signs and Symptoms:
A change of the skin that can be observed. When compared with normal skin, it will appear as a sign of the following: changes in skin temperature (colder or warmer), changes the consistency of tissue (more hard or soft), changes in sensation (itching or pain), In people who have white skin, sores may appear as redness persist. Whereas in people with dark skin, the wound will appear as a persistent red, blue or purple.

Stage 2: ulceration of the dermis, epidermis and into broad to the adipose tissue visible erythema and induration, and partial damage to the skin (epidermis and dermis partially) characterized by blisters. This stage can be cured in 10-15 days.
Signs and Symptoms:
Loss of partial layers of the epidermis or dermis of the skin, or both. Character is a superficial wound, abrasion, blister, or forming a shallow pit.

Stage 3: ulceration extending into the layer of fat and muscle subshell has begun to interfere with the edema and inflammation, infection will disappear fibril structure. Damage to all layers of the skin to the subcutaneous, do not pass through the fascia. Usually heal in 3-8 weeks.
Signs and Symptoms: 
Loss of skin layers are complete, including damage or necrosis of subcutaneous tissue or deeper, but not to the fascia. The wound looks like a deep hole.

Stage 4: ulceration and necrosis extends the fascia, muscles and joints. Can be cured in 3-6 months.
Signs and symptoms :
The loss of skin layers complete with extensive damage, tissue necrosis, damage to the muscles, bones or tendons. The presence of a deep hole and sinus passages are also included in stage IV of pressure sores.

NCP for Pressure Sores / Decubitus Ulcer - Physical Examination, Assessment and 6 Nursing Diagnosis

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Risk for Infection - Nursing Care Plan for Tuberculosis

Nursing Diagnosis for Tuberculosis : Risk for Infection related to inadequate primary defenses, decreased ciliary function / static discharge, malnutrition, environmental contamination, lack of information about the bacterial infection.

Expected outcomes are:

• Identify interventions to prevent / reduce the risk of spreading infection.
• Show / lifestyle changes to promote a safe environment.

Nursing Interventions: Risk for Infection - Nursing Care Plan for Tuberculosis:

1. Review of pathology of the disease phase (active / inactive) the spread of infection, through the bronchi of the surrounding tissues or the bloodstream or lymph system and the risk of infection through coughing, sneezing, spitting, laughing, kissing, or singing.
Rational: Helping the patient to want to understand and accept the therapy given to prevent complications.

2. Identification of persons at risk for infections such as family members, friends, people in one assembly.
Rational: People who are at risk to drug treatment programs to prevent the spread of infection.

3. Instruct the patient to close mouth and remove phlegm in an enclosed shelter if the cough.
Rational: This habit is to prevent transmission of infection.

4. Use a mask every action.
Rational: Reduce the risk of spreading infection.

5. Monitor the temperature.
Rational: febrile, an indication of infection.

6. Identification of individuals at high risk for pulmonary tuberculosis re-infection, such as: alcoholism, malnutrition, intestinal bypass surgery, using immune-suppressing drugs / corticosteroids, presence of diabetes mellitus, cancer.
Rationale: Knowledge of these factors help the patient to change lifestyle and avoiding / reducing conditions worse.

7. Emphasize not to discontinue therapy undertaken.
Rational: contagious period can occur only 2-3 days after onset of chemotherapy if it happens cavity, the risk, the spread of infection can continue for 3 months.

Collaboration:

8. Monitor sputum smear
Rational: To monitor the effectiveness of drugs and their effects as well as patient response to therapy.

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Sample of Assessment - Nursing Care Plan Gastritis

Sample of Nursing Care Plan for Gastritis

Nursing Assessment

1. Anamnese include:
   • Name :
     
   • Age :
     
   • Gender :
     
   • Type of work :
     
   • Address :
     
   • Tribe / Nation :
     
   • Religion :
     
   • The level of education: for those with low education level / low gain knowledge of gastritis, it will underestimate the disease, even just think of gastritis as upset stomach and will eat regular foods that can cause and exacerbate the disease.
   • History of illness and health
     • The main complaint: Pain in the pit of the stomach and lower right abdomen.
     • History of the disease at this time: Covers the journey of illness, initial symptoms are felt from the client, complaints arise suddenly or gradually felt, trigger factors, efforts to resolve the issue.
     • Past history of disease: Includes diseases associated with the disease now, history of the hospital, and a history of drug use.
   
   
   
2. Physical examination, the Review of systems (ROS)
   
   General condition: there was pain on physical examination there is tenderness in the epigastric quadrants.
   
   • B1 (breath): tachypnea
   • B2 (blood): tachycardia, hypotension, dysrhythmias, weak peripheral pulses, peripheral charging slow, pale skin color.
   • B3 (brain): headache, weakness, level of consciousness can be disturbed, disorientation, pain epigastrum.
   • B4 (bladder): oliguria, fluid balance disorders.
   • B5 (bowel): anemia, anorexia, nausea, vomiting, heartburn, intolerance to spicy foods.
   • B6 (bone): fatigue, weakness



3. Assessment Focus
   1. Activity / Rest
      Symptoms: weakness, fatigue
      Signs: tachycardia, tachypnea / hyperventilation (in response to activity)
   
   
   2. Circulation
      Symptoms: weakness, sweating
      Signs:
      
      • Hypotension (including postural)
      • Tachycardia, dysrhythmias (hypovolemia / hypoxemia)
      • Weak peripheral pulse
      • Slow capillary refill (vasoconstriction)
      • Skin color pale, sianosis (depending on the number of blood loss)
      • Weakness of skin / mucous membranes, sweating (shows status of shock, acute pain, psychological responses)
      
      
   3. Ego integrity
      Symptoms: acute or chronic stress factors (financial, labor relations), feelings of helplessness.
      Sign: a sign of anxiety, such as anxiety, pallor, sweating, narrowing of attention, shaking, trembling voice.
   
   
   4. Elimination
      Symptoms: a history of previous hospitalization due to bleeding gastroenteritis (GE) or problems associated with GE, such as injury or gastric ulcer, gastritis, gastric surgery, gastric irradiation area. Changes in bowel habit / characteristic stool.
      Signs:
      
      • Abdominal tenderness, distention
      • Bowel sounds: often hyperactive during hemorrhage, hypo-active after the bleeding.
      • The characteristics feses: diarrhea, blood color of dark, brownish or sometimes red bright, foamed, odor rotten (steatorrhoea), constipation can occur (a change diet, the use of antacids).
      • Urinary output: decreased, concentrated.
      
      
   5. Food / fluid
      Symptoms:
      
      • Anorexia, nausea, vomiting (throwing up that extends beyond the pyloric obstruction suspected in connection with a duodenal injury),
      • Swallowing problems: hiccups
      • Heartburn, sour belching, nausea or vomiting
      Symptoms: vomiting with a dark coffee color or bright red, with or without blood clots, dry mucous membranes, decreased mucus production, poor skin turgor (chronic bleeding).
   
   
   6. Neurosensory
      Symptoms: flavor pulsed, dizziness / sick heads because of rays, weakness.
      Sign: the level of consciousness can be impaired, the range of slightly inclined to sleep, disorientation / confusion, fainting and coma (depending on the volume of circulation / oxygenation).
   
   
   7. Pain / Comfort
      Symptoms:
      
      • Pain, described as a sharp, shallow, burning, stinging, sudden severe pain may be accompanied by perforation. Sense of discomfort / distress faint after eating a lot and lost with a meal (acute gastritis).
      • Pain epigastrum left until the middle / back or spread to occur 1-2 hours after eating and relieved by antacids (gastric ulcers).
      • Pain left to epigastrum / or spread to his back occurred approximately 4 hours after eating when the stomach is empty and relieved by food or antacids (duodenal ulcer).
      • No pain (esofegeal varices or gastritis).
      • Trigger factors: food, cigarettes, alcohol, the use of certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors.
      Signs: wrinkled face, be careful in the area of ​​pain, pallor, sweating, narrowing attention.
   
   
   8. Security
      Symptoms: allergy to the drug / sensitive
      Sign: an increase in temperature, spider angioma, palmar erythema (showing cirrhosis / portal hypertension)
   
   
   9. Guidance / Learning
      Symptoms: the use of prescription drugs

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Nursing Care Plan for Angina pectoris - 4 Diagnosis and Interventions

1. Acute Pain related to myocardial ischemia

Nursing interventions:

• Review the description and the factors that aggravate the pain.
• Observation of vital signs every 5 minutes on each attack of angina pectoris.
• Create a quiet environment, limit the visitor when necessary.
• Put the client on total bedrest during episodes of angina (the first 24-30 hours) with a semi-Fowler position.
• Give soft foods and let the client rest 1 hour after meals.
• Teach distraction and relaxation techniques.
• Medical collaboration in terms of drug delivery.

2. Activity intolerance related to decreased cardiac output.

Nursing interventions:

• Maintain bed rest in a comfortable position.
• Provide adequate rest periods, aids in the fulfillment of self-care activities in accordance with the indication.
• Record the color and quality of the pulse.
• Increase client activity on a regular basis.
• ECG Monitor with frequent, and record ECG if there are complaints of angina pectoris.

3. Anxiety related to fear of the threat of sudden death.

Nursing interventions:

• Explain all procedures act.
• Increase expression of feelings and fear.
• Encourage family and friends to consider the client as before.
• Tell the client that the medical program has been made to reduce / limit the attack to come and increase the stability of the heart.
• Collaboration.

4. Knowledge Deficit: (need to learn) about the disease, treatment needs related to the lack of information.

Nursing interventions:

• Emphasize the need to prevent angina attacks.
• Push to avoid the factors / situations as the originator of angina episodes.
• Assess the importance of weight control, smoking cessation, dietary changes and exercise.
• Show / encourage clients to monitor their own pulse rate during the activity, avoid stress.
• Discuss the steps taken in the event of an attack of angina.
• Encourage clients to follow a predetermined program.

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Nursing Care Plan for Tetralogy of Fallot

Tetralogy of Fallot

Definition

Tetralogy of Fallot is a congenital heart disease with cyanosis, a combination of the four main symptoms are:

1. obstruction of the flow out of the right ventricle (pulmonary stenosis),
2. ventricular septal defect,
3. the position of the right of the aorta and
4. right ventricular hypertrophy together form a tetralogy of Fallot.

Clinical manifestations

1. cyanosis
2. dyspnoea
3. dyspnoea attacks paroksimal (blue anoxia attacks)
4. delay in growth and development
5. normal rate of blood vessels
6. systolic murmur

Assessment - Nursing Care Plan for Tetralogy of Fallot

Data that is commonly found in patients with tetralogy of Fallot are:

• thorough cyanosis of mucous membranes or lips, tongue, conjunctiva. Cyanosis also occur at the time of crying, eating, tight, soak in water, can be peripheral or central.
• dyspnoea usually accompanies the activity of eating, crying or tension / stress.
• weakness, commonly in the legs.
• growth and development not in accordance with age.
• digital clubbing
• headache
• epistaxis

Nursing Diagnosis for Tetralogy of Fallot

1. Risk for Decreased cardiac output related to structural abnormalities of the heart.
2. Activity Intolerance related to imbalance in the fulfillment of oxygen to the body's needs.
3. Impaired growth and development related to inadequate oxygenation, tissue nutrisis needs, social isolation.
4. Risk for infection related to the general conditions is inadequate.

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8 Nursing Diagnosis - Nursing Care Plan for Bladder Cancer

Nursing Care Plan for Bladder Cancer

Symptoms of Bladder Cancer are blood while passing urine, heavy hurt at times of urinating, sensation of urinating but no passage of urine.

During the early stages of the bowel cancer, there may not be any obvious symptoms, however as the Cancer Grows, one can notice blood in stools or rectal bleeding is common. When one notices a change in their normal bowel habits Such as diarrhea, Constipation or frequent visits to the toilet, It could be an indication of something not right.

Also Unexplained loss of weight or appetite and stomach pain can also occur. As the cancer Grows the bleeding in the bowel can lead to anemia Causing breathless and fatigue, as there is not enough oxygen in the body.

Bladder cancer has the which Various types of symptoms are determined by where the cancerous cells have started. The symptoms of bladder cancer can originate from bladder infection / UTI (urinary tract infection) and therefore require tests to find the true cause of the problem.

8 Nursing Diagnosis for Bladder Cancer

1. Anxiety
2. Acute Pain
3. Imbalanced Nutrition Less Than Body Requirements
4. Knowledge deficient
5. Fluid Volume Deficit
6. Risk for infection
7. Risk for Sexual Dysfunction
8. Risk for Impaired Skin Integrity

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Nursing Care Plan for Cerebral Palsy

Cerebral Palsy

Cerebral Palsy is a condition lasting damage to brain tissue and not progressive, occurring in a young (since birth) and hinder normal brain development, with the clinical picture may change throughout life and showed abnormalities in the attitude and movement, accompanied by neurological abnormalities in the form of spastic paralysis , ganglia disorders, basal, cereblum and mental disorders.

Etiology

Causes can be divided into three parts, namely:

a. prenatal

Infection occurs in the womb, causing abnormalities in the fetus, for example by Lues, toxoplasmosis, rubella and cytomegalic inclusion body disease. The disorder is usually marked movement disorder and mental retardation. Anoxia in the womb, exposed to X-ray radiation and toxicity of pregnancy may cause "cerebral palsy".

b. perinatal

1) anoxia / hypoxia
The cause of the most found in the perinatal period is a brain injury. Disorder that causes anoxia. It is found in the state percentage of abnormal babies, cephalopelvic disproportion, parturition length, placenta previa, placental infection, parturition using the help of certain instruments and born with caesarean sectio.

2) Bleeding brain
Hemorrhage and anoxia can occur together, that it is difficult to distinguish, for example, bleeding around the brain stem, the respiratory center and interrupt blood circulation, resulting in anoxia. Bleeding may occur in the subarachnoid space will cause a blockage of cerebrospinal fluid, causing hydrocephalus. Subdural bleeding, can suppress the cerebral cortex, causing spastic paralysis.

3) Prematurity
Preterm babies have suffered a brain hemorrhage is more likely than term infants, because the blood vessels, enzymes, clotting factors and others are still not perfect.

4) Jaundice
Jaundice in the newborn period can cause lasting damage to brain tissue caused by the entry of bilirubin into the basal ganglia, such as abnormalities in blood group incompatibility.

5) Meningitis purulenta
Purulenta meningitis in infancy when the late or improper treatment will result in residual symptoms of "cerebral palsy"

c. postnatal
Any damage to brain tissue that interferes with the development could cause "cerebral palsy". For example, in trauma capitis, encephalitis and meningitis scarring.


Nursing Diagnosis for Cerebral Palsy. Nursing Care Plan for Cerebral Palsy

a. Risk for injury

b. Impaired physical mobility

c. Growth and development alteration

d. Impaired verbal communication

e. Risk for aspiration

f. Thought processes disturbed

g. Self-Care Deficit

h. Knowledge Deficit

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Headaches Nursing Care Plan Interventions

Headaches is one of the most important human physical complaints. Headache in fact is a symptom not a disease and may indicate organic disease (neurological or other disease), stress response, vasodilation (migraine), skeletal muscle tension (tension headache) or a combination of these responses (Brunner & Suddan).

Headaches classification of the most recently issued by the Headache Classification Comitte of the International Headache Society as follows:

1. Migraine (with or without aura)
2. Tension headaches
3. Cluster headache and paroxysmal hemikranial
4. A variety of headaches associated with structural lesions.
5. Headache associated with head trauma.
6. Headache associated with vascular disorders (eg, subarachnoid hemorrhage).
7. Headache associated with non-vascular intracranial disorders (eg brain tumors)
8. Headaches associated with the use of chemicals tau drug withdrawal.
9. Headache associated with non-cephalic infection.
10. Headache associated with metabolic disorders (hypoglycemia).
11. Headache or facial pain associated with disorders of the head, neck or head around the structure (eg, acute glaucoma)
12. Cranial neuralgia (persistent pain from cranial nerves)
    

Nursing Care Plans for Headaches

Acute pain r/t stess and tension, irritation / nerve pressure, vasospasm, increased intracranial pressures.

Nursing Interventions for Headaces

1. Make sure the duration / episode problems, who have been consulted, and drug and / or what therapy has been used
2. Thorough complaints of pain, record itensitasnya (on a scale 0-10), characteristics (eg, heavy, throbbing, constant) location, duration, factors that aggravate or relieve.
3. Note the possible pathophysiological characteristic, such as brain / meningeal / sinus infection, cervical trauma, hypertension, or trauma.
4. Observe for nonverbal signs of pain, are like: facial expression, posture, restlessness, crying / grimacing, withdrawal, diaphoresis, changes in heart rate / breathing, blood pressure.
5. Assess the relationship of physical factors / emotional state of a person
6. Evaluation of pain behavior
7. Note the influence of pain such as: loss of interest in life, decreased activity, weight loss.
8. Assess the degree of making a false step in person from the patient, such as isolating themselves.
9. Determine the issue of a second party to the patient / significant others, such as insurance, spouse / family
10. Discuss the physiological dynamics of tension / anxiety with the patient / person nearest
11. Instruct patient to report pain immediately if the pain arises.
12. Place on a rather dark room according to the indication.
13. Suggest to rest in a quiet room.
14. Give cold compress on the head.
15. Massage the head / neck / arm if the patient can tolerate the touch.
16. Use the techniques of therapeutic touch, visualization, biofeedback, hypnosis itself, and stress reduction and relaxation techniques to another.
17. Instruct the patient to use a positive statement "I am cured, I'm relaxing, I love this life". Instruct the patient to be aware of the external-internal dialogue and say "stop" or "delay" if it comes up negative thoughts.
18. Observe for nausea / vomiting. Give the ice, drinks containing carbonate as indicated.

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Nursing Care Plan For Tetanus

Nursing Care Plan for Tetanus. Nursing Assessment - Nursing Care Plan for Tetanus History of present illness: a severe injury, burns and inadequate immunization. *Respiratory System: dyspnea, cyanosis and asphyxia due to respiratory muscle contraction.

Nursing Assessment - Nursing Care Plan for Tetanus

• History of present illness: a severe injury, burns and inadequate immunization.
• *Respiratory System: dyspnea, cyanosis and asphyxia due to respiratory muscle contraction.
• Cardiovascular System : dysrhythmias, tachycardia, hypertension and bleeding, initially the body temperature 38-40 ° C or febrile up to the terminal 43-44 ° C.
• Neurologic System: irritability (early), weakness, convulsions (late), paralysis of one or several nerves of the brain.
• Urinary System l: urinary retention (bladder distension and urine output does not exist / oliguria)
• Digestive System: constipation due to no bowel movements.
• Integument and muskuloskletal System: pain, tingling at the site of injury, sweating, initially trismus, muscle spasms face with increasing contraction eyebrows, risus sardonicus, stiff muscles and difficulty swallowing.
• If this continues there will be the status of general convulsions and seizures.

Nursing Diagnosis for Tetanus

1. Ineffective airway clearance related to the accumulation of sputum in the trachea and respiratory muscle spasms.
2. Breathing pattern disorders related to impaired airway due to spasm of respiratory muscles
3. Increased body temperature (hyperthermia) related to the effects of toxins (bacteremia)
4. Changes in nutrition, less than body requirements related to the mastication muscle stiffness
5. Disturbed interpersonal relationships related to speech difficulties
6. Impaired daily needs related to the condition of weak and frequent seizures
7. The risk of fluid and electrolyte imbalances related to intake of less and oliguria
8. Risk of injury related to frequent seizures
9. Lack of knowledge of the client and family about tetanus disease related to lack of information.
10. Lack of rest requirements related to frequent seizures.

Nursing Diagnosis and Nursing Intervention for Neonatal Tetanus

Nursing Diagnosis for Neonatal Tetanus

1. Ineffective breathing pattern related to respiratory muscle fatigue
2. Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.

Nursing Intervention for Neonatal Tetanus
Nursing Diagnosis I
Ineffective breathing pattern related to respiratory muscle fatigue
Nursing Intervention:

• Assess the frequency and pattern of breath
• Note the presence of apnea, the frequency change of heart, muscle tone and skin color.
• Perform cardiac and respiratory monitoring continuously.
• Suction airway as needed.
• Give the tactile stimulation immediately after apnea.
• Monitor laboratory tests as indicated.
• Give oxygenation as indicated.
• Give medications as indicated.

Nursing Diagnosis II
Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.
Nursing Intervention:

• Assess the maturity of the reflex with respect to feeding, sucking, swallowing and coughing.
• Auscultation bowel sounds.
• Review the signs of hypoglycemia.
• Give appropriate medication electrolyte supplements.
• Give parenteral nutrition.
• Monitor laboratory tests as indicated.
• Make provision of drinking according to tolerance.

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Nursing Care Plan for Urinary Tract Infection UTI

Nursing Care Plan for Urinary Tract Infection. Drinking the recommended 10-12 eight ounce glasses of water everyday.

Urinary tract infection (UTI) is basically an infection that happens anywhere along urinary tract. Thee are several organs that if infected would constitute UTI or bladder infection, these organs are as follows: (1) The Kidneys (2) The Ureters (3) The Urinary Bladder and (4) The Urethra.

Urinary tract infection (UTI) implies multiplication of organisms in the urinary tract, and is defined by the presence of more than 100,000 organisms per ml in a midstream sample of urine (MSU).
Risk factors include urinary tract malformations, pregnancy, calculus or renal stones, urinary tract obstruction, prostatic obstruction, bladder diverticulum, spinal injury, trauma, urinary tract tumor, diabetes mellitus and immunosuppression as in case of AIDS.
Some of the symptoms of urinary tract infections are very similar. For example, while not painful discomfort, total or burning during urination, constant need to urinate are common symptoms of urinary tract infections. This is one of the most frustrating, because the symptoms usually associated with a constant desire to urinate inability to actually produce urine.

As mentioned above the site of infection can cause symptoms of urinary tract infections. If a urinary tract infection (called urethritis), the main symptom is a burning sensation during urination. If a bladder infection (cystitis called) symptoms including abdominal discomfort or pelvic pressure, frequent urination, painful, and can also be blood in the urine.

If symptoms of urinary tract infections, upper and / or lateral (side) pain, high fever, chills, or tremors, can cause nausea or vomiting, urinary tract infections develop into a kidney infection is called pyelonephritis. This is a serious infection and should seek professional medical help as soon as possible.

Nursing Care Plan for Urinary Tract Infection
1. Drinking the recommended 10-12 8 ounce glasses of water everyday can also help your body defeat the urinary tract infection. The levels of acidity in your urine Will be diluted with the increase of the intake of water. Increased water consumption can benefit many areas of your body as well, so be sure to drink plenty of water every day.

2. Unsweetened cranberry juice is one home remedy That almost everyone has heard of. By drinking 16-24 ounces of unsweetened cranberry juice a day you can help your body to protect the lining of your bladder free from bacteria. The cranberry juice makes it virtually impossible for the bacteria to hold on to the walls.

3. Vitamin C is a great deterrent for bacteria growth. Ask your doctor if you are getting enough everyday. If you are not you Should Be Able to take a vitamin supplement to increase of your intake of vitamin C. Or dietary modifications Should Be Made to Ensure you are getting enough vitamin C.

4. If you have the urge to relieve your bladder, do so. Holding it in. Will cause your bladder to stretch the which Will leave small abrasions for bacteria to grow and multiply.

5. There are some herbal supplements Could you check with your doctor about. One of the most popular is the horseradish root. This works wonders on urinary tract infections and it is thought to have antibiotic properties within it. However, some herbs can cause serious damage to other medical conditions, so consult your doctor Should you before you begin an herbal remedy treatment for your urinary tract infection.

Read more: http://healthmad.com/conditions-and-diseases/sample-nursing-care-plan-for-urinary-tract-infection/#ixzz1k055pdbX

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Nursing Care Plan for Delirium

Delirium or acute confusional state is a transient global disorder of cognition. The condition is a medical emergency associated with increased morbidity and mortality rates. Early diagnosis and resolution of symptoms are correlated with the most favorable outcomes. Therefore, it must be treated as a medical emergency.

Delirium is not a disease but a syndrome with multiple causes that result in a similar constellation of symptoms. Delirium is defined as a transient, usually reversible, cause of cerebral dysfunction and manifests clinically with a wide range of neuropsychiatric abnormalities. The clinical hallmarks are decreased attention span and a waxing and waning type of confusion.

Delirium often is unrecognized or misdiagnosed and commonly is mistaken for dementia, depression, mania, an acute schizophrenic reaction, or part of old age (patients who are elderly are expected to become confused in the hospital).

The word delirium is derived from the Latin term meaning "off the track." This syndrome was reported during Hippocrates' time, and, in 1813, Sutton described delirium tremens. Later, Wernicke described the encephalopathy that bears his name.

Epidemiology

Frequency

United States
Delirium is common in the United States. It has been found in 14-56% of elderly patients who are hospitalized. Delirium is present in 10-22% of elderly patients at the time of admission, with an additional 10-30% of cases developing after admission. Delirium has been found in 40% of patients admitted to intensive care units. Prevalence of postoperative delirium following general surgery is 5-10% and as high as 42% following orthopedic surgery. As many as 80% of patients develop delirium near death. Delirium is extremely common among nursing home residents.

Mortality/Morbidity
In patients who are admitted with delirium, mortality rates are 10-26%.
Patients who develop delirium during hospitalization have a mortality rate of 22-76% and a high rate of death during the months following discharge.
In patients who are elderly and patients in the postoperative period, delirium may result in a prolonged hospital stay, increased complications, increased cost, and long-term disability.

Age
Delirium can occur at any age, but it occurs more commonly in patients who are elderly and have compromised mental status. Delirium can occur on top of an underlying dementia. This diagnosis here requires not only a careful mental status but also a thorough history from the patient's family and the staff as well as a comprehensive chart review.

emedicine.medscape.com

Assessment Nursing Care Plan for Delirium

1. Identity


2. The main complaint


3. Predisposing factors


4. Physical examination


5. Psychosocial
   • Genogram
   • The self concept
   • Social relationships
   • Spiritual
   
   
6. Mental status
   • Appearance
   • Talk loud, fast and incoherent.
   • Motor activity
   • Natural feelings
   • Affect and emotion
   • Interaction during the interview
   • Perception
   • The process of thinking
   • Level of consciousness
   • Memory
   • Levels of concentration
   • Capability assessment
   
   
7. Day-to-day needs of clients
   • Sleep
   • Appetite
   • Elimination
   
   
8. Coping mechanisms


9. Impact of problem

Nursing Diagnosis Nursing Care Plan for Delirium

1. Risk for torturing themselves, others and the environment related to the response in mind delusions and hallucinations.
2. Ineffective individual coping related to the inability to express in a constructive way.
3. Change the thought process related to the inability to trust people
4. Risk for Imbalanced Nutrition : Less Than Body Requirements related to intake is less, the status emoosional increased.
5. Impaired Verbal Communication related to communication pattern that is not logical or inkohern and side effects of drugs, the pressure to talk and hyperactivity.
6. Lack of social interaction (social isolation) are related to inadequate support systems.
7. Lack of self-care related to a decreased willingness

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Nursing Care Plan for Hemorrhoids

Hemorrhoids, also called "'piles," are swollen tissues that contain veins. They are located in the wall of the rectum and anus and may cause minor bleeding or develop small blood clots. Hemorrhoids occur when the tissues enlarge, weaken, and come free of their supporting structure. This results in a sac-like bulge that extends into the anal area.

Hemorrhoids are unique to humans - no other animal develops them. They are very common - up to 86% of people will report they have had hemorrhoids at some time in their life, though people often use this as a catch-all label for any ano-rectal problem including itching. They can occur at any age but are more common as people get older. Among younger people, they are most common in women who are pregnant.

Although they can be embarrassing to talk about, anyone can get hemorrhoids, even healthy young people in good shape. They can be painful and annoying but aren't usually serious. Hemorrhoids differ depending on their location and the amount of pain, discomfort, or aggravation they cause.

Internal hemorrhoids are located up inside the rectum. They rarely cause any pain, as this tissue doesn't have any sensory nerves. These hemorrhoids are graded for severity according to how far and how often they protrude into the anal passage or protrude out of the anus (prolapse):

• Grade I is small without protrusion. Painless, minor bleeding occurs from time to time after a bowel movement.
• A grade II hemorrhoid may protrude during a bowel movement but returns spontaneously to its place afterwards.
• In grade III, the hemorrhoid must be replaced manually.
• A grade IV hemorrhoid has prolapsed - it protrudes constantly and will fall out again if pushed back into the rectum. There may or may not be bleeding. Prolapsed hemorrhoids can be painful if they are strangled by the anus or if a clot develops.

External hemorrhoids develop under the skin just inside the opening of the anus. The hemorrhoids may swell and the area around it may become firm and sore, turning blue or purple in colour when they get thrombosed. A thrombosed hemorrhoid is one that has formed a clot inside. This clot is not dangerous and will not spread through the body, but does cause pain and should be drained. External hemorrhoids may itch and can be very painful, especially during a bowel movement. They can also prolapse. (bodyandhealth.canada.com)
hemorrhoids

Nursing Assessment for Hemorrhoids

1. The identity of patients


2. The main complaint
   Patients came with complaints of continuous bleeding during defecation. There was a lump in the anus or pain during defecation.


3. History of disease
   • History of present illness
     Patients were found in a few weeks there was only a bump coming out and a few days after defecation there is blood dripping out.
   • Past history of disease
     Have there been previous hemorrhoidal disease, heal / reoccur. In patients with hemorrhoids when not in doing the surgery will be back.
   • Family history of disease
     Are there family members who suffer from the disease
   • Social History
     Disease in question to be asked.

Pre-operative and Post-operative Nursing Diagnosis Nursing Care Plan for Hemorrhoids

Pre-operative Nursing Diagnosis and Nursing Interventions

Impaired sense of comfort: acute pain related to the mass of the anal or anus, anal area marked lumps, pain and itching in the anal region

PURPOSE:
To fulfill the criteria of comfort with reduced pain itching reduced mass decreases.

INTERVENTION:

1. Give soak seat
Rationalization: Reduce local discomfort, reduce edema and promote healing.

2. Give lubricant during defecation would

Rationalization: Assist in the conduct of defecation so it does not need straining.

3. Give a diet low in residual
Rationalization: Reduce stimulation of the anus and weaken the feces.

4. Instruct the patient to do a lot of standing or sitting (must be in balance).
Rationalization: The force of gravity will affect the incidence of hemorrhoids and sitting can increase intra-abdominal pressure.

5. Observation of patient complaints
Rationalization: It helps to evaluate the degree of discomfort and lack of effectiveness of actions or states of complications.

6. Provide an explanation of the emergence of pain and explain briefly
Rationalization: Education about it helps in patient participation to prevent / reduce pain.

7. Give the patient suppository
Rationalization: It can soften the stool and can reduce the patient to avoid straining during defecation.

Post-operative Nursing Diagnosis and Nursing Interventions

Impaired sense of comfort: acute pain related to the sutures in surgical wound

PURPOSE:
Fulfillment of comfort with the criteria there is no pain, and patients can perform light activity.

INTERVENTION:

1. Give the patient a pleasant sleeping position.
Rationalization: May decrease the voltage of the abdomen and increase the sense of control.

2. Change the bandage every morning according to aseptic techniques
Rationalization: Protecting the patient from cross contamination during replacement of bandages. Wet bandage acts as an absorber of external contamination and cause discomfort.

3. Exercise road as early as possible
Rationalization: It can reduce the problems that occur due to immobilization.

4. Observation of the rectal area if there is bleeding
Rationalization: Bleeding on the network, local imflamasi or the occurrence of infection may increase the pain.

5. Chimney anus is released according to physician advice (orders)
Rationalisation: Improve physiological functions anus and gives comfort to the patient's anal region because there is no blockage.

6. Provide an explanation of the purpose of installation of flue-anus (anus to funnel to drain the remnants of bleeding that occurs in order to get out).
Rationalization: Knowledge of the benefits of the chimney can make the patient understand the anus to funnel anus to cure the wound.

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Nursing Assessment Nursing Care Plan for Pneumonia

Pneumonia

Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States.

Nursing Care Plan for Pneumonia

Nursing Assessment for Pneumonia

1. Health History :
   • A history of previous respiratory tract infection / cough, runny nose, takhipnea, fever.
   • Anorexia, difficulty swallowing, vomiting.
   • History of disease associated with immunity, such as; morbili, pertussis, malnutrition, immunosuppression.
   • Other family members who suffered respiratory illness.
   • Productive cough, breathing nostrils, rapid and shallow breathing, restlessness, cyanosis.
   
   
2. Physical Examination :
   • Fever, takhipnea, cyanosis, nostrils.
   • Auscultation of lung: wet ronchi, stridor.
   • Laboratory: leukocytosis, AGD abnormal, the LED increases.
   • Chest X-rays: abnormal (scattered patches of consolidation in both lungs).
   
   
3. Psychosocial Factors :
   • Age, growth.
   • Tolerance / ability to understand the action.
   • Coping.
   • The experience of parting with the family / parents.
   • The experience of previous respiratory tract infections.
   
   
4. Family Knowledge, Psychosocial :
   • The level family knowledge about the disease bronchopneumonia.
   • Experience in dealing with the family of respiratory disease.
   • Readiness / willingness of families to learn to care for her child.
   • Family Coping
   • The level of anxiety.

http://free-nursingcareplan.blogspot.com/2011/06/nursing-care-plan-for-pneumonia.html

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Nursing Care Plan Books

Delmar's maternal-infant nursing care plans



Delmar's Maternal-Infant Nursing Care Plans, 2nd edition, provides detailed information on caring for clients during pregnancy, labor and delivery, the postpartum period, and the newborn/infant period. All the information needed to develop specific and effective nursing care plans for clients in the maternal and newborn periods is included. Each care plan presents information to guide users in developing comprehensive individualized nursing care plans based on solid scientific understanding of the physiological, psychological, and social events surrounding childbirth. Care plans solicit specific client data and prompt the user to individualize the interventions, consider cultural relevance, and evaluate the client's individual response.

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Nursing Care Plan Examples

Nursing Care Plan Examples



A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Read More : http://free-nursingcareplan.blogspot.com/

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Nursing Care Plan

A nursing care plan outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Characteristics of the nursing care plan

Its focus is holistic, and is based on the clinical judgment of the nurse, using assessment data collected from a nursing framework.
It is based upon identifiable nursing diagnoses (actual, risk or health promotion) - clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
It focuses on client-specific nursing outcomes that are realistic for the care recipient
It includes nursing interventions which are focused on the etiologic or risk factors of the identified nursing diagnoses.
It is a product of a deliberate systematic process.
It relates to the future.

Elements of the nursing care plan

The nursing care plan consists of a nursing diagnosis with defining characteristics (subjective and objective data that support the diagnosis), related factors or risk factors, expected outcomes/goals, and nursing interventions.

http://en.wikipedia.org/wiki/Nursing_care_plan

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