Nursing Care Plan for HNP Herniated Nucleus Pulposus wih 4 Diagnosis and Interventions

 Herniated Nucleus Pulposus

Intervertebral Discs are the cartilage plates that form a cushion between the vertebral bodies. Hard and fibrous material is combined in one capsule. Such as ball bearings in the middle of the disc called the nucleus pulposus. Herniated nucleus pulposus is a rupture of the nucleus pulposus.

Herniated nucleus pulposus into the vertebral bodies can be above or below it, can also directly into the vertebral canal.

Pain can occur in any part such as cervical spine, thoracic (rarely) or lumbar. Clinical manifestations depend on the location, speed of development (acute or chronic) and the effect on surrounding structures. Lower back pain is severe, chronic and recurring (relapse).

Diagnostic Examination
1. Spinal RO: Shows the degenerative changes in the spine
2. MRI: to localize even small disc protrusion, especially for lumbar spinal disease.
3. CT Scan and Myelogram if the clinical and pathological symptoms are not visible on MRI
4. Electromyography (EMG): to localize the specific spinal nerve roots are exposed.


Assessment Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Anamnesa
The main complaint, history of present treatments, medical history past, family health history.

2. Physical examination
Assessment of the patient's problem consists of onset, location and spread of pain, paresthesias, limited mobility and limited function of the neck, shoulders and upper extremities.
Assessment in the area include palpation of the cervical spine which aims to assess muscle tone and rigidity.

3. Examination Support


Diagnosis Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute Pain

2. Impaired physical mobility

3. Anxiety

4. Knowledge deficient


Intervention Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute pain related to nerve compression, muscle spasm

a. Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10
b. Maintain bed rest, semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position
c. Use logroll (board) during a change of position
d. Auxiliary mounting brace / corset
e. Limit your activity during the acute phase according to the needs
f. Teach relaxation techniques
g. Collaboration: analgesics, traction, physiotherapy

2. Impaired physical mobility related to pain, muscle spasms, and damage neuromuskulus restrictive therapy

a. Give / aids patients to perform passive range of motion exercises and active
b. Assist patients in ambulation activity progressively
c. Provide good skin care, massage point pressure after rehap change of position. Check the state of the skin under the brace with a specific time period.
d. Note the emotional responses / behaviors in immobilizing
e. Demonstrate the use of auxiliary equipment such as a cane.
f. Collaboration: analgesic

3. Anxiety related to ineffective individual coping

a. Assess the patient's anxiety level
b. Provide accurate information
c. Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities.
d. Review of secondary problems that may impede the desire to heal and may hinder the healing process.
e. Involve the family

4. Knowledge deficient related to the lack of information about the condition, prognosis

a. Explain the process of disease and prognosis, and restrictions on activities
b. Give information about your own body mechanics to stand, lift and use the shoes backer
c. Discuss about treatment and side effects.
d. Suggest to use the board / mat is strong, a small pillow under your neck a little flat, bed side with knees flexed, avoid the tummy.
e. Avoid the use of heaters in a long time
f. Give information about the signs that need attention such as puncture pain, loss of sensation / ability to walk.

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4 Cataract Nursing Diagnosis and Interventions

4 Nursing Diagnosis and Interventions for Cataracts

1. Nursing Diagnosis for Cataract: Anxiety related to lack of knowledge.
   
   Goal:
   
   1. Lowering the emotional stress, fear and depression.
   2. Acceptance and understanding instructions surgery.
   
   Nursing Interventions for Cataract:
   
   1. Assess the degree and duration of visual impairment. Encourage conversation to find out the patient's concerns, feelings, and the level of understanding.
   Rational: Information can eliminate the fear of the unknown. Coping mechanisms can help patients with kegusara compromise, fear, depression, tension, despair, anger, and rejection.
   
   2. Orient the patient to the new environment.
   Rationale: The introduction to the environment helps reduce anxiety and increase security.
   
   3. Explain the perioperative routines.
   Rationale: Patients who have a lot of information easier to receive treatment and follow instructions.
   
   4. Describes intervention much detail as possible.
   Rationale: Patients who experience visual disturbances rely on other senses salts input information.
   
   5. Push to perform daily living habits when able.
   Rationale: Self-care and will increase the sense of healthy independence.
   
   6. Encourage participation of family or the people who matter in patient care.
   Rationale: Patients may not be able to perform all duties in connection with the handling of personal care.
   
   7. Encourage participation in social activities and diversion whenever possible (visitors, radio, audio recording, TV, crafts, games).
   Rationale: Social isolation and leisure time is too long can cause negative feelings.
2. Nursing Diagnosis for Cataract: Risk for injury related to blurred vision
   
   Goal: Prevention of injury.
   
   Nursing Intervenion for Cataract:
   
   1. Help the patient when able to do until postoperative ambulation and achieve stable vision and adequate coping skills, using techniques of vision guidance.
   Rational: Reduce the risk of falling or injury when the step stagger or have no coping skills for vision impairment.
   
   2. Help the patient set the environment.
   Rationale: Providing facilities of independence and lower the risk of injury.
   
   3. Orient the patient in the room.
   Rationale: Improving safety and mobility in the environment.
   
   4. Discuss the need for the use of metal shields or goggles when instructed
   Rational: shield l; ogam or goggles protect the eyes against injury.
   
   5. Do not put pressure on the affected eye trauma.
   Rational: The pressure in the eye may cause further serious damage.
   
   6. Use proper procedures when providing eye drugs.
   Rational: Injury can occur if the container touch the eye medication.
3. Nursing Diagnosis for Cataract: Acute pain related to trauma to the incision and increased IOP
   
   Goal: Reduction of pain and the IOP.
   
   Nursing Interventions for Cataract:
   
   1. Give medications to control pain and the IOP as prescribed.
   Rational: Use the recipe will reduce pain and the IOP and increase comfort.
   
   2. Give cold compress on demand for blunt trauma.
   Rational: reduce the edema will reduce the pain.
   
   3. Reduce the level of pencayahaan
   Rationale: The level of lighting is more nyakan lower after surgery.
   
   4. Encourage use of sunglasses in strong light.
   Rasioanal: Strong light causes discomfort after use of eye drops dilator.
4. Nursing Diagnosis for Cataract: Risk for infection related to trauma to the incision
   
   Goal: Complications can be avoided or promptly reported to the doctor.
   
   Nursing Interventions for Cataract:
   
   1. Maintain strict aseptic technique, do wash your hands frequently.
   Rationale: It would minimize infection.
   
   2. Supervise and report immediately any signs and symptoms of complications, such as: bleeding, increased IOP or infection.
   Rational: The discovery of early complications can reduce the risk of permanent vision loss.
   
   3. Explain the recommended position.
   Rational: Elevation of the head and avoid lying on the side of the operation may reduce the edema.
   
   4. Instruct the patient to know bedrest activity restrictions, with flexibility to the bathroom, according to a gradual increase in activity tolerance.
   Rational: Limitation of activity prescribed to speed healing and avoid further damage to the injured eye.
   
   5. Describe the actions that should be avoided, as prescribed by coughing, sneezing, vomiting (ask for medication for it).
   Rational: It can lead to complications such as vitreous prolapse or dehisensi injury due to increased tension on the suture wounds that are very subtle.
   
   6. Give medications as prescribed, according to prescribed techniques.
   Rational: Drugs are administered in a way that is inconsistent with prescriptions can interfere with healing or cause complications.

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Nursing Diagnosis Activity Intolerance related to Congestive Heart Failure (CHF)

Nursing Diagnosis for Congestive Heart Failure (CHF)

Activity Intolerance

related to imbalance between oxygen supply. General weakness, long bedrest / immobilized.

Characterized by:

• Weakness,
• fatigue,
• changes in vital signs,
• presence of dysrhythmias,
• dyspnea,
• pallor,
• sweating.

Goals / evaluation criteria:

Clients will participate in desired activities, meet self-care, achieve increased tolerance activity can be measured, evidenced by a decrease in weakness and fatigue.

Nursing Interventions Activity Intolerance related to Congestive Heart Failure (CHF) :

1. Check vital signs before and immediately after activity, especially when the client is using vasodilators, diuretics and beta blockers.
Rational: Orthostatic hypotension can occur with activity due to drug effects (vasodilation), the displacement of fluid (diuretics) or influence cardiac function.

2. Note the cardiopulmonary response to activity, note tachycardia, dysrhythmias, dyspnea sweaty and pale.
Rationale: Decrease / inability of the myocardium to increase the volume of activity during dpat sekuncup cause an immediate increase heart rate and oxygen demand is also increasing fatigue and weakness.

3. Evaluation of increased activity intolerant.
Rational: It can show increased activity of cardiac decompensation rather than excess.

4. Implementation of cardiac rehabilitation programs / activities (collaboration)
Rationale: Increasing gradual to avoid the activity of cardiac work / oxygen consumption is excessive. Strengthening and improvement of cardiac function under stress, if cardiac function can not be improved again.

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Nursing Care Plan for Hypertension : Assessment, Diagnosis and Interventions

 Hypertension

The definition of hypertension, many raised by health experts. WHO suggests that hypertension occurs when blood pressure above 160/95 mmHg, meanwhile, Smelttzer & Bare (2002:896) suggests that hypertension is a persistent blood pressure or continuous thus exceeding the normal limit in which the systolic pressure above 140 mmHg and diastolic pressure above 90 mmHg.

There are differences about the limits of hypertension as proposed by Kaplan (1990:205), namely men, aged less than 45 years, said hypertension when blood pressure when lying above or equal to 130/90 mm ​​Hg, whereas at the age of 45 years, said hypertension when blood pressure above 145/95 mmHg.Whereas in women with blood pressure above 160/95 mmHg.

Based on these definitions can be concluded that hypertension is an increase in blood pressure where systolic pressure over 140 mmHg or diastolic over 90 mmHg.

The classification of hypertension are also expressed by many experts, including WHO set a classification of hypertension into three levels namely:

Level I: increased blood pressure without symptoms of the disorder or damage to the cardiovascular system.
Level II: blood pressure with symptoms of cardiovascular hypertrophy, but without any symptoms of damage or disruption of the appliance or other organs.
Level III: blood pressure increased with obvious symptoms of damage and disruption of the target organ physiology.

The cause of hypertension varied are: stress, obesity, smoking, hypernatremia, water and salt retention that is not normal, sensitivity to angiotensin, obesity, hypercholesterolemia, adrenal gland disease, kidney disease, toxemia gravidarum, increased intra-cranial pressure, caused by brain tumors, influence of certain drugs eg oral contraceptives, high salt intake, lack of exercise, genetics, obesity, atherosclerosis, kidney abnormalities, but largely unknown cause.

Nursing Care Plan for Hypertension

Nursing Assessment Nursing Care Plan for Hypertension


According to Doenges, (2004:41-42) and argued that the assessment of patients with hypertension include:

a. Activity and rest include: weakness, fatigue, shortness of breath, heart frequency increases, changes in heart rhythm.

b. Circulation includes: a history of hypertension, coronary heart disease, episodes of palpitations, increased blood pressure, tachycardia, sometimes sounding S2 heart sounds at the base of S3 and S4.

c. Ego integrity include: anxiety, depression, euphoria, irritability, facial muscle tension, anxiety, respiratory haul, increased speech patterns.

d. Elimination include: history of kidney disease.

e. Food / fluids include: food preferences especially those containing high salt, high fat, and cholesterol, nausea, vomiting, weight changes, a history of diuretic drugs, presence of edema.

f. Neuro-sensory include: complaints headache, throbbing, sub-occipital headache, weakness on one side of the body, visual disturbances (diplopia, blurred vision), epistaxis.

g. Pain / discomfort: include intermittent pain in the limbs, sub-occipital headaches severe abdominal pain, chest pain.

h. Respiratory include: shortness of breath after activity, cough with or without sputum, smoking history, medication use respiratory Bantu, additional breath sounds, cyanosis.

i. Security include: gait disturbance, paresthesia, postural hypotension.

j. Pembalajaran / extension in the presence of family risk factors are arteriosclerosis, heart disease, diabetes, kidney disease.


Nursing Diagnosis Nursing Care Plan for Hypertension (Doengoes, 2004)

a. Decreased cardiac output

b. Activity intolerance

c. Acute pain

d. Imbalanced Nutrition: More Than Body Requirements

e. Ineffective coping


 Nursing Diagnosis and Interventions for Hypertension

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Nursing Diagnosis of Acute Pain related to Constipation

Acute pain related to the accumulation of hard stool in the abdomen

Goal: show pain has been reduced

Expected Outcomes:

• Relaxation techniques individually demonstrate effective to achieve comfort
• Maintaining the level of pain on a small scale
• Reported physical and psychological health
• Recognize factors and using measures to prevent pain
• Using action to reduce the pain with analgesics and non-analgesic appropriately

Nursing Interventions Acute Pain related to Constipation

1. Help the patient to focus more on the activity of the pain by doing penggalihan through television or radio.
Rationale: The client can distract from pain.

2. Note that the elderly have increased sensitivity to the analgesic effects of opiates.
Rational: Be careful in giving anlgesik opiates.

3. Consider the possibility of drug interactions in the elderly.
Rational: Be careful in the provision of drugs in the elderly.

4. Ask the patient to assess pain or lack of comfort on a scale of 0-10
Rationale: Knowing the client's level of perceived pain

5. Use the pain flow sheet
Rationale: Knowing the characteristics of pain

6. Perform a comprehensive pain assessment
Rational: In order for the specific pain mngetahui

7. Instruct patient to meminformasikan on nurses if the pain-reducing achieved less
Rationale: Nurses can perform appropriate action in addressing the client's pain

8. Give pain neighbor information
Rational: In order for the patient does not feel anxious.

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Constipation Nursing Care Plan: Diagnosis and Interventions

Nursing Diagnosis: Constipation related to irregular bowel habit

Purpose: patients can defecate regularly (every day)

Expected outcomes:

• Defecation can be done once a day
• The consistency of soft stool
• Elimination of feces without the need for excessive straining

Nursing Interventions for Constipation

Independent

• Determine the pattern of defecation for clients and train clients to do so.
• Set the time is right for clients such as defecation after meals.
• Provide coverage of nutritional fiber according to the indication.
• Give fluids if not contraindicated 2-3 liters per day.

Collaboration

• Provision of laxatives or enemas as indicated

Rational:

• To restore the regularity of bowel habit clients.
• To facilitate the defecation reflex.
• High fiber nutrition to launch fecal elimination.
• To soften the stool elimination.

Nursing Diagnosis : Alteration in Nutrition: Less Than Body Requirements related to loss of appetite

Purpose: demonstrate good nutritional status

Expected Outcomes:

• Tolerance to dietary needs.
• Maintain body mass and body weight within normal limits.
• Laboratory values ​​within normal limits.
• Reported adequacy of energy levels.

Nursing Interventions Alteration in Nutrition: Less Than Body Requirements for Constipation

1. Create a meal plan with the patient to put in a feeding schedule.
Rationale: Maintain a diet of patients so that patients eat regularly.

2. Encourage family members to bring the patient's favorite foods from home.
Rationale: The patient feels comfortable with food brought from home and can improve the patient's appetite.

3. Offer large meals during the day when a high appetite.
Rationale: By providing a large portion can keep the adequacy of nutrient intake.

4. Make sure the diet meets the needs of the body as indicated.
Rationale: High carbohydrate, protein and calories needed or required during treatment.

5. Make sure the patient's diet is preferred or not preferred.
Rationale: To support the increasing appetite of the patient.

6. Monitor input and output and body weight periodically.
Rationale: Knowing the balance of intake and expenditure of food intake.

7. Assess the patient's skin turgor
Rationale: As the data supporting the existence of changes in nutrition that is less than demand.

8. Monitor laboratory values, such as hemoglobin, albumin, and blood glucose levels.
Rational: To be able to ascertain the level of content deficiency of hemoglobin, albumin, and glucose in the blood.

9. Teach patients and families about nutritious food.
Rationale: Maintaining adequacy of intake of nutrients needed.

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Nursing Diagnosis and Interventions for Heart Failure

Nursing Diagnosis for Heart Failure 1.

Decreased cardiac output related to changes in myocardial contractility.

Goal: show vital signs within acceptable limits, decreased dyspnea episodes of angina (report).

Nursing Interventions :

a. Auscultation apical pulse, assess the frequency and rhythm of the heart
b. Record the heart sounds
c. Palpation of peripheral pulses
d. Assess the skin of cyanosis and pallor
e. Provide a comfortable and quiet environment

Nursing Diagnosis for Heart Failure 2.

Activity intolerance related to imbalance between supply oxygenation needs.

Goal : Participate in a desired activity, meets the needs of self-tolerance achieving increased activity can be measured, evidenced by a decrease in fatigue and weakness and vital signs during exercise.

Nursing Interventions :

a. Check vital signs before and after the activity, particularly when patients using vasodilator, diuretic.
b. Note the cardiopulmonary response to activity, note tachycardia, distrimia, dyspnea, sweating, pale.
c. Assess the precipitator / causes weakness example: treatment, pain, medication.
d. Evaluation of an increase in activity intolerance.
e. Provide assistance in self-care activities in accordance with the indication.

Nursing Diagnosis for Heart Failure 3.

Excess fluid volume related to decreased glomerular filtration rate (GFR).

Goal : The balance of inputs and outputs, clean breath sounds, vital signs within acceptable range, stable weight, no edema. Stating an understanding of individual fluid restriction.

Nursing Interventions :

a. Monitor urine output
b. Monitor / calculate the balance of income and output 24 hours.
c. Maintain a sitting / semi-Fowler position during the acute phase.
d. Auscultation of breath sounds, or sound record and an additional reduction.
e. Monitor blood pressure.

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Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD) with 10 Nursing Diagnosis

Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease is progressive, meaning the disease lasts a lifetime and is slowly deteriorating from year to year. In the course of this disease there are phases of acute exacerbation. Various factors play a role in the course of the disease, among other risk factors are factors that cause or exacerbate illnesses such as smoking, air pollution, environmental pollution, infection, genetic and weather changes.

The degree of airway obtruksi happened, and identification of components that allow for reversibility. Stage of the disease outside the lung and other diseases such as chronic sinusitis and pharyngitis. That ultimately these factors make further deterioration occurs sooner. To perform the management of COPD should consider these factors, so that the treatment of COPD for the better.

Chronic obstructive pulmonary disease is a broad classification of disorders that includes chronic bronchitis, bronchiectasis, emphysema and asthma, which is an irreversible condition associated with dyspnea on exertion and decreased air flow in and out of the lungs.

Chronic obstructive pulmonary disease is a lung disorder characterized by impaired lung function in the form of prolonged expiratory period caused by the narrowing of the airways and not much changed in the period of observation for some time.

Signs and symptoms will lead to two basic types:

• Have a dominant direction of the clinical picture of chronic bronchitis (blue bloater).
• Have a clinical picture towards emphysema (pink puffers).

Signs and symptoms are as follows:

• body weakness
• cough
• shortness of breath
• Shortness of breath on exertion and breath sounds
• wheezing
• prolonged expiratory
• form the barrel chest (Barrel Chest) in advanced disease
• the use of accessory muscles
• decreased breath sounds
• sometimes found paradoxical breathing
• leg edema, ascites and clubbing

10 List of Nanda Nursing Diagnosis for COPD

1. Ineffective airway clearance related to: bronchoconstriction, increased sputum production, ineffective cough, fatigue / lack of energy, bronchopulmonary infection.

2. Ineffective breathing pattern related to: shortness of breath, mucus, bronchoconstriction, airway irritants.

3. Impaired gas exchange related to: ventilation perfusion inequality.

4. Activity intolerance related to: imbalance between oxygen supply with demand.

5. Imbalanced Nutrition: less than body requirements related to: anorexia.

6. Disturbed sleep pattern related to: discomfort, sleeping position.

7. Bathing / Hygiene Self-care deficit related to: fatigue secondary to increased respiratory effort and ventilation and oxygenation insufficiency.

8. Anxiety related to: threat to self-concept, threat of death, purposes that are not being met.

9. Ineffective individual coping related to: lack of socialization, anxiety, depression, low activity levels and an inability to work.

10. Deficient Knowledge related to: lack of information, do not know the source of information.

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Activity Intolerance related to - COPD

Nursing Diagnosisi Activity intolerance related to imbalance between oxygen supply with demand.

Goal : Shows the progress at a higher level of activity possible.

Nursing Interventions Activity intolerance - COPD:

• Assess the individual response to the activity; pulse, blood pressure, respiration.
• Measure vital signs immediately after the activity, the client rest for 3 minutes then measuring the vital signs again.
• Support the patient in establishing a regular exercise using a treadmill and exercycle, walking or other exercise appropriate, such as walking slowly.
• Assess the patient's level of function of the last and develop training plans based on the status of basic functions.
• Recommend consultation with a physical therapist to determine the specific training program on the ability of the patient.
• Provide oxygen as represented is required before and during the run of activity just in case.
• Increase activity gradually; clients currently or long bed rest started doing range of motion at least 2 times a day.
• Increase tolerance to the activity by encouraging clients to do the activity more slowly, or a shorter time, with more rest or with a lot of help.
• Gradually increase exercise tolerance by increasing the time out of bed until 15 minutes per day 3 times a day.

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Ineffective Airway Clearance related to - COPD

Nursing Diagnosis Ineffective airway clearance related to :

•  bronchoconstriction,
• increased mucus formation, 
• ineffective cough, 
• bronchopulmonary infection.

Goal: Achievement of client airway clearance

Nursing Interventions Ineffective airway clearance:

• Give the patient 6 to 8 glasses of fluid / day unless there is a cor pulmonale.
• Teach and give encouragement use of diaphragmatic breathing and coughing techniques.
• Assist in the provision of action nebulizer, metered dose inhalers.
• Perform postural drainage with percussion and vibration in the morning and evening according to the required.
• Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
• Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in sputum color, viscosity of sputum, increased shortness of breath, chest tightness, fatigue.
• Give antibiotics as required.
• Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.

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Physical Assessment for COPD

Physical Assessment for COPD

The assessment includes information about the symptoms last and previous disease manifestations. Here are some guidelines to get data question the health history of the disease process:

1. How long the patient has trouble breathing?
2. Does the activity increase of dyspnea?
3. How far the patient's tolerance limit activity?
4. When patients complain of fatigue and shortness of breath most?
5. Are eating and sleeping habits affected?
6. History of smoking?
7. The drugs used every day?
8. The drugs used in acute attacks?
9. What is known about the condition of the patient and his disease?

Additional data collected through observation and examination as follows:

1. Patient's pulse rate and breathing?
2. Is breathing the same regardless of effort?
3. Is there a contraction of abdominal muscles during inspiration?
4. Is there any use of accessory respiratory muscles during breathing?
5. Barrel chest?
6. Does seem cyanosis?
7. Is there a cough?
8. Are there any peripheral edema?
9. Are the neck veins look bigger?
10. What is the color, amount and consistency of sputum of patients?
11. What is the status of patients sensorium?
12. Is there an increase in stupor? Anxiety?
13. The results of diagnostic tests such as:

Physical Assessment for COPD

Palpation:

1. Palpation reduction in chest development?
2. Is there decreased tactile fremitus?

Percussion:

1. Is there hiperesonansi on percussion?
2. The diaphragm moves just a little?

Auscultation:

1. Is there a loud wheezing sound?
2. Is there ronkhi sound?
3. Nomal or decreased vocal fremitus?

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3 Nursing Diagnosis for Epistaxis with Interventions and Rational

Nursing Diagnosis

1. Risk for Bleeding

Goal: minimize bleeding

Expected Outomes: No bleeding, vital signs within normal limits, no anemis.

Interventions:

• Monitor the patient's general condition
• Monitor vital signs
• Monitor the amount of bleeding patients
• Monitor the event of anemia
• Collaboration with the doctor about the problems that occur with bleeding: transfusion, medication.

(Diagnosis NANDA, NIC, NOC)


2. Ineffective airway clearance

Goal: to be effective airway clearance

Expected Outcomes: Frequency of normal breathing, no additional breath sounds, do not use additional respiratory muscles, dyspnoea and cyanosis does not occur.

Independent

• Assess the sound or the depth of breathing and chest movement.
  Rational: Decreased breath sounds may lead to atelectasis, Ronchi, and wheezing showed accumulation of secretions.
• Note the ability to remove mucous / coughing effectively
  Rational: bright lumpy or bloody sputum may result from damage to lungs or bronchial injury.
• Give Fowler's or semi-Fowler position.
  Rational: Positioning helps maximize lung expansion and reduce respiratory effort.
• Clean secretions from the mouth and trachea
  Rational: To prevent obstruction / aspiration.
• Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated.
  Rational: Helping dilution of secretions.

Collaboration

• Give medication in accordance with the indications mucolytic, expectorant, bronchodilator.
  Rational: Mucolytic to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce bronchial spasms and analgesics are given to reduce discomfort.

3. Acute pain

Goal: pain diminished or disappeared

Expected Outcomes:

• Clients express the pain diminished or disappeared
• Clients do not grimace in pain

Interventions:

• Assess client's level of pain
  Rational: Knowing the client's level of pain in determining further action.
• Explain the causes and consequences of pain to the client and his family.
  Rational: The causes and consequences of pain the client is expected to participate in treatment to reduce pain.
• Teach relaxation and distraction techniques.
  Rational: The client knows the distraction, and relaxation techniques can be practiced so as if in pain.
• Observation of vital signs and client complaints.
  Rational: Knowing the prevailing circumstances and conditions of client development.

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Nursing Care Plan for Epistaxis

Definition


Epistaxis is bleeding from the bottom of the nose can be primary or secondary, spontaneous or due to stimulation and is located next to the posterior or anterior.

Care Management

Blood flow will stop after the blood had frozen in the process of blood clotting. A medical opinion says that when the bleeding occurs, it is better if the head is tilted forward position (sitting position) to drain the blood and prevent entry into the esophagus and stomach.

First aid in case of epistaxis is to squeeze the front of your nose for three minutes. During the emphasis should breathe through the mouth. Mild bleeding will usually stop in this way. Do the same thing in case of recurrent bleeding, if it does not stop you should visit a doctor for help.

For chronic nose bleeds due to dryness of the nasal mucosa, is usually prevented by spraying saline in the nose up to three times a day.

If due to pressure, ice packs can be used to shrink blood vessels (vasoconstriction). If it still does not work, can be used nasal tampons. Tampons can stop a bleeding nose and the media is mounted 1-3 days.

Deaths from bleeding nose is something that is rare. However, if it caused damage to the maxillary artery can cause heavy bleeding through the nose and difficult to cure. Action of pressure, vasoconstrictor less effective. Possible healing maksillaris arterial structure (which can damage the facial nerve) is the only solution.

Nursing Care Plan for Epistaxis

Nursing Assessment Nursing Care Plan for Epistaxis

1. Bios: Name, age, gender, address, ethnicity, nation, education, employment.
2. History of present illness
3. The main complaint: the patient normally complain of difficulty breathing, throat.
4. Past history of disease:
   • The patient had suffered from acute illness or trauma and nose bleeding
   • The patient had a history of ENT disease
   • The patient had suffered from toothache molars
5. Family history: Are there any illnesses suffered by family members and that may be something to do with the client's current illness.
6. Psychosocial History
   • Intrapersonal: the perceived feelings of the client (anxious / sad)
   • Interpersonal: relationships with others.
7. Patterns of health functions
   • Pattern perception and management of healthy living
     • To reduce the flu is usually the client taking the drug without regard to side effects
   • Patterns of nutrition and metabolism :
     • Usually the client's appetite is reduced because an interruption in the nose
   • Patterns of Rest and sleep
     • During inditasi client feels unable to rest because the client is often a cold
   • Pattern perception and self-concept
     • The client is often cold and smelled causing continuous self-concept decreased.
       
   • Pattern of sensory
     • The power of smell impaired clients as a result of clogged nasal continuous cold (both purulent, serous, mukopurulen).
8. Physical examination
   • General health status: general condition, vital signs, consciousness.
   • Physical examination data: focus nose.

Subjective Data:

• Complaining of weakness

Objective Data

• Bleeding at the nose / pouring a lot of
• Restlessness
• Decrease in blood pressure
• Increased pulse
• Anemia

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Decreased Cardiac Output Congestive Heart Failure Nursing Care Plan

Decreased Cardiac Output NANDA Definition:

Inadequate blood pumped by the heart to meet metabolic demands of the body

Nursing Diagnosis:

Decreased cardiac output related to Altered heart rate and rhythm AEB bradycardia

characterized by:

• with pale conjunctiva, nail beds and buccal mucosa
• irregular rhythm of the pulse
• bradycardic
• pulse rate of 34 beats / min
• generalized weakness

Short-Term Objectives:
the patient Will Participate in activities That Reduced the workload of the heart.

Long-Term Objectives:
Will the patient be Able to display hemodynamic stability.

Nursing Interventions Decreased Cardiac Output Congestive Heart Failure:

1. Auscultation apical pulse; examine the frequency, the heart rhythm.
Rational: Usually tachycardia (even at rest) to compensate for the decrease in ventricular contractility.

2. Record the heart sounds.
Rational: S1 and S2 may be weak due to decreased pumping action. Gallop rhythm common (S3 and S4) is generated as the flow of blood to the porch of distension. Mur-mur may indicate incompetence / stenosis of the valve.

3. Palpation of peripheral pulses.
Rational: The decrease in cardiac output may show decreased radial artery, popliteal, dorsalis, pedis and posttibial. The pulse may disappear fast or irregular pulse to be palpable and alternan.

4. Monitor blood pressure.
Rational: In Congestive Heart Failure early, moderate or chronic blood pressure may increase. In Congestive Heart Failure-up body could no longer compensate and hypotension can not be normal again.

5. Assess against pale skin and cyanosis.
Rational: Pale, indicating reduced peripheral perfusion secondary to cardiac output adekutnya not; vasoconstriction and anemia. Cyanosis may occur as refrakstori Congestive Heart Failure. The area of ​​pain is often colored blue striped atu because of increased venous congestion.

6. Give supplemental oxygen by nasal cannula / mask and drugs as indicated (collaboration).
Rationale: Increased dosage of oxygen to the need to counter the effects of myocardial hypoxia / ischemia.

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Nursing Diagnosis Ineffective Airway Clearance - Pulmonary Tuberculosis

Nursing Diagnosis Ineffective Airway Clearance


related to:

• thick secretions or blood secretions,
• weakness,
• bad cough effort,
• edema, tracheal / pharyngeal.

Goal :

• Maintaining a patient's airway.
• Removing secretions without help.
• Demonstrate behaviors to improve airway clearance.
• Participate in treatment programs according to the conditions. Identify potential complications and appropriate action.

Nursing Interventions Ineffective Airway Clearance - Pulmonary Tuberculosis:

a. Assess respiratory function: breath sounds, speed, rhythm, depth and accessory muscle use.
Rationale: Decreased breath sounds indicate atelectasis, Ronchi indication of accumulation of secretions / inability of clearing the airway so that the accessory muscle use and increased work of breathing.

b. Note the ability to remove secretions or cough effectively, record the character, amount of sputum, presence of hemoptysis.
Rational: Expenditures difficult when thick secretions, sputum, bleeding from the bronchial lung damage or injury that requires evaluation / intervention information.

c. Give the patient or the semi-Fowler position, Help / teach effective coughing and breathing exercises.
Rationale: Increased lung expansion, maximum ventilation opening areas of atelectasis and increased secretions movement to be easily removed.

d. Clean secretions from the mouth and trachea, suction if necessary.
Rationale: To prevent obstruction / aspiration. Suction done when patients are unable to remove secretions.

e. Maintain a fluid intake of at least 2500 ml / day unless contraindicated.
Rationale: Helps thin the secretions so easily removed.

f. Moisten the air / oxygen inspiration.
Rationale: Prevents drying of mucous membranes.

g. Give medications: bronchodilators, corticosteroids as indicated.
Rational: Lowering the viscosity of secretions, circle trakeabronkial lumen size, handy in case of hypoxemia in a wide cavity.

h. Help incubation emergency if necessary.
Rational: It takes the rare cases bronkogenik. with laryngeal edema or acute pulmonary hemorrhage.

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5 Nursing Diagnosis for TB Tuberculosis

Tuberculosis is a contagious infectious disease caused by Mycobacterium tubeculosis.

Tuberculosis is classified as airborne disease that is spread by droplet nuclei are expelled into the air by infected individuals in the active phase. Whenever the patient is coughing may issue a 3000 droplet nuclei. Transmission generally occurs indoors where droplet nuclei can stay in the air for much longer. Under direct sunlight tubercle bacilli die rapidly but in a dark humid chamber can last up to several hours. Two critical success factors in new individual exposure Tuberculosis ie the concentration of droplet nuclei in the air and the length of time individuals breathe in contaminated air in addition to the immune system is concerned.

In addition to transmission through the respiratory tract (most frequently), M. tuberculosis can also enter the body through the digestive tract and open sores on the skin (more rarely).

Tuberculosis is often dubbed "the great imitator" is a disease that has many similarities with other diseases that also gives common symptoms such as weakness and fever. In some patients the symptoms are not clear so neglected sometimes even asymptomatic.

Clinical Manifestation of pulmonary TB can be divided into 2 groups, symptoms of respiratory and systemic symptoms:
Respiratory symptoms, including:
a. cough
Cough symptoms occur earliest and is the disorder most often complain about. At first non productive and sputum mixed with blood even when there is tissue damage.
b. coughing up blood
Blood in the sputum varied issued, it may seem in the form of lines or spots of blood, blood clots or fresh blood in a number of very much. Coughing up blood due to rupture of blood vessels. Cough severity depending on the size of blood vessels to rupture.
c. shortness of breath
This phenomenon is found when the damage was extensive lung parenchyma or because there are things that accompany such as pleural effusion, pneumothorax, anemia and others.
d. chest pain
Chest pain in pulmonary TB include a mild pleuritic pain. These symptoms occur when the neural system in the pleura is affected.

5 Nursing Diagnosis for TB Tuberculosis

Nursing diagnoses that commonly occurs in clients with pulmonary tuberculosis are as follows:

1. Ineffective airway clearance

relate to:

• thick secretions or blood secretions,
• weakness,
• bad cough effort,
• edema, tracheal / pharyngeal.

2. Impaired gas exchange

• related to:
• reduced effectiveness of the surface of the lung,
• atelectasis,
• alveolar capillary membrane damage,
• secretions are thick,
• bronchial edema.

3. Risk for Infection and spread of infection

related to:

• decreased immune system,
• decreased ciliary function,
• secretions are settled,
• tissue damage caused by the spread of infection,
• malnutrition,
• contaminated by the environment,
• lack of knowledge about infectious germs.

4. Imbalanced Nutrition Less Than Body Requirements

related to:

• fatigue,
• frequent coughing,
• production of sputum,
• dyspnea,
• anorexia,
• decline in financial capability.

5. Knowledge Deficit: about the condition, treatment, prevention

related to:

• nothing is explained,
• interpretation is wrong,
• the information is incomplete / inaccurate,
• limited knowledge / cognitive.

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List of The Famous Nurses

Florence Nightingale

Florence Nightingale, the daughter of the wealthy landowner, William Nightingale of Embly Park, Hampshire, was born in Florence, Italy, on 12th May, 1820. Her father was a Unitarian and a Whig who was involved in the anti-slavery movement. As a child, Florence was very close to her father, who, without a son, treated her as his friend and companion. He took responsibility for her education and taught her Greek, Latin, French, German, Italian, history, philosophy and mathematics.


Betty Neuman

Born 1924 near Lowell, Ohio.
In 1947 she received RN Diploma from Peoples Hospital School of Nursing, Akron, Ohio. She then moved to California and gained experience as a hospital, staff, and head nurse; school nurse and industrial nurse; and as a clinical instructor in medical-surgical, critical care and communicable disease nursing. In 1957 Dr. Neuman attended the University of California at Los Angeles (UCLA) with double major in psychology and public health. She received BS in nursing from UCLA. In 1966 she received Masters degree in Mental Health, Public Health Consultation fom UCLA.

Dr. Neuman is recognized as pioneer in the field of nursing involvement in community mental health. She began developing her model while lecturing in community mental health at UCLA. In 1972 her model was first published as a 'Model for teaching total person approach to patient problems' in Nursing Research. In 1985 she received her doctorate in Clinical Psychology from Pacific Western University. In 1998 she received a second honorary doctorate, this one from Grand Valley State University, Allendale, Michigan.


Virginia Henderson

Virginia Henderson was born on November 30, 1897 in Kansas City, Missouri, and was the fifth of eight children in her family.

In 1921, Henderson graduated from the Army School of Nursing at Walter Reed Hospital in Washington, D.C. In 1932, she earned her Bachelor's Degree and in 1934 earned her Master's Degree in Nursing Education, both from Teachers College at Columbia University.

Henderson died on March 19, 1996.


Sister Calista Roy

Sr. Callista Roy, PhD, RN, FAAN was born in Los Angeles, CA, the second child of 7 sons and 7 daughters of Pirth Hemenway and Fabien Roy. Following a BA with a major in Nursing from Mount St. Mary’s College, Los Angeles, she earned masters degrees in Pediatric Nursing and Sociology and a PhD in Sociology from University of California, Los Angeles.


Ida Jean Orlando

Ida Jean Orlando was born in 1926 with an Irish American descent. She received her nursing diploma from New York Medical College, Lower Fifth Avenue Hospital, School of Nursing, her BS in public health nursing from St. John’s University, Brooklyn, NY, and her MA in mental health nursing from Teachers College, Columbia University, New York. Orlando was an Associate Professor at Yale School of Nursing where she was Director of the Graduate Program in Mental Health Psychiatric Nursing.


Martha Elizabeth Rogers

Martha Elizabeth Rogers was born on May 12, 1914; sharing a birthday with Florence Nightingale. She began her academic career when she entered the University of Tennessee in Knoxville in 1931 where she remained for 2 years.

She stated that: "I took the science-med course. It was more substantial than straight pre-med and included more science and maths. I took psychology, French, Zoology, Genetics, Embryology and many other courses" (Hektor, 1989).


Hildegard Peplau

Hildegard Peplau was born in Reading Pennsylvania on September 1st, 1909. After graduating from the Pootstown, Pennsylvania Hospital School of Nursing in 1931 she worked as an operating room supervisor at Pottstown Hospital. She later recieved a B. A. in interpersonal psychology from Bennington College, Vermont, in 1943, an M.A in psychiatric nursing from Teacher's College, Columbia, New York, in 1947, and an Ed. D in curriculum development from Columbia in 1953.

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Acute Pain related to the Presence of Surgical Wound

Acute pain related to the presence of surgical wound on abdomen secondary to periampullary carcinoma

Desired Outcome/goal : Patient will get relief from pain as evidenced by a reduction in the pain scale score and verbalization.

Nursing Actions

Primary Prevention

• Assess severity of pain by using a pain scale
• Check the surgical site for any signs of infection or complications
• Support the areas with extra pillow to allow the normal alignment and to prevent strain
• Handle the area gently. Avoid unnecessary handling as this will affect the healing process
• Clean the area around the incision and do surgical dressing at the site of incision to prevent any form of infections
• Provide non-pharmacological measures for pain relief such as diversional activity which diverts the patients mind.
• Administer the pain medications as per the prescription by the pain clinics to relieve the severity of pain.
• Keep the patients body clean in order to avoid infection

Secondary Prevention

• Teach the patient about the relaxation techniques and make him to do it
• Encourage the patient to divert his mind from pain and to engage in pleasurable activities like taking with others
• Do not allow the patient to do strenuous activities. And explain to the patient why those activities are contraindicated.
• Involve the patient in making decisions about his own care and provide a positive psychological support
• Provide the primary preventive care when ever necessary.

Tertiary Prevention

• Educate the client about the importance of cleanliness and encourage him to maintain good personal hygiene.
• Involve the family members in the care of patient
• Encourage relatives to be with the client in order provide a psychological well being to patient .
• Educate the family members about the pain management measures.
• Provide the primary and secondary preventive measures to the client whenever necessary.

Evaluation – patient verbalized that the pain got reduced and the pain scale score also was zero. His facial expression also reveals that he got relief from pain.

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2 Nanda Nursing Diagnosis and Interventions for Leukemia

Leukemia

Definition

Leukemia is a neoplasm of acute or chronic blood-forming cells in bone marrow and spleen (Reeves, 2001). The other characteristic of leukemia is the proliferation of irregular or accumulation of white blood cells in bone marrow, replace normal bone marrow elements. Proliferation also occurs in the liver, spleen, and lymph nodes. The invasion of non-haematological organs such as the meninges, gastrointestinal tract, kidney, and skin.

Acute lymphocytic leukemia (ALL) often occurs in children. Leukemia classified as acute if there is proliferation of the blastocyst (young blood cells) from bone marrow. Acute leukemia is a malignant primary bone marrow resulting in normal blood components late decision by abnormal blood components (blastocyst), accompanied by the spread of other organs. Leukemia is classified as chronic if found cell expansion and accumulation of old and young cells (Tejawinata, 1996).

In addition to acute and chronic, there is also a congenital leukemia is leukemia were found in infants aged 4 weeks or younger infants.


Etiology

The cause of ALL until now not clear, but most likely due to a virus (oncogenic viruses).

Other factors that play a role include:

1. Exogenous factors such as X rays, radioactive rays, and chemicals (benzol, arsenic, sulfate preparations), infections (viruses and bacteria).
2. Endogenous factors such as race
3. Constitutional factors such as chromosomal abnormalities, hereditary (sometimes encountered cases of leukemia in siblings or twins one egg).

Predisposing factors:

1. Genetic factors: a certain virus causes changes in gene structure (T cell leukemia-lymphoma virus / HTLV)
2. Ionizing radiation: the work environment, prenatal care, previous cancer treatment
3. Exposure to chemicals such as benzene, arsenic, chloramphenicol, phenylbutazone, and anti-neoplastic agents.
4. Immunosuppressive medications, drugs carcinogens such as diethylstilbestrol
5. Hereditary factors such as the twins one egg
6. Chromosomal abnormalities

If the cause of leukemia is caused by a virus, the virus will easily fit into the human body if the structure of the viral antigen is consistent with the structure of the human antigen. The structure of the human antigen is formed by the antigen structure of various organs, especially the skin and mucous membranes located on the surface of the body (tissue antigen). By WHO, tissue antigens defined by the term HL-A (human leucocyte locus A).


Signs and Symptoms

1. Anemia
Caused by red blood cell production is less a result of the failure of the bone marrow to produce red blood cells. Characterized by reduced hemoglobin concentration, a decrease in hematocrit, red blood cell count less. Children with leukemia have pale, tiredness, shortness of breath sometimes.

2. High body temperature and easy to infections
Due to a decrease in leukocytes, it will automatically lower the body resistance due to leukocytes serves to maintain the immune system can not work optimally.

3. Bleeding
Signs of bleeding can be viewed and analyzed from the presence of mucosal bleeding such as gums, nose (epistaxis) or bleeding under the skin which is often called petechiae. Bleeding may occur spontaneously or due to trauma. If very low levels of platelets, bleeding can occur spontaneously.

4. Decreased consciousness
Due to infiltration of abnormal cells to the brain can cause a variety of disorders such as seizures to coma.

5. Decrease in appetite

6. Weakness and physical exhaustion.



Clinical Manifestation

Typical symptoms of pale (may occur suddenly), body heat, and bleeding accompanied by splenomegaly and sometimes hepatomegaly and lymphadenopathy. Bleeding can be diagnosed ecchymoses, petekia, epistaxis, bleeding gums, etc..
Symptoms are not typical is joint pain or bone pain can be mistaken for rheumatic diseases. Other symptoms can arise as a result of infiltration of leukemic cells in organs such as purpuric lesions on the skin, pleural effusion, cerebral seizures in leukemia.

2 Nursing Diagnosis and Interventions for Leukemia

1. Risk for Fluid Volume Deficit

related to

• fluid intake and output,
• excessive loss: vomiting, bleeding, diarrhea
• decrease in fluid intake: nausea, anorexia
• increased need for fluids: fever, hypermetabolic.

Purpose : the volume of fluid being met

Expected outcomes:

• Adequate fluid volume
• The mucosa moist
• Vital signs are stable: BP 90/60 mm Hg, pulse 100x/menit, RR 20x/menit
• Pulse palpated
• Urine output 30 ml / hour
• Capillaries and refill less than 2 seconds

Intervention:

• Monitor fluid intake and output
• Monitor body weight
• Monitor BP and heart frequency
• Evaluation of skin turgor, capillary refill and mucous membrane conditions
• Give fluid intake 3-4 L / day
• Inspection of skin / mucous membranes for petechiae, ecchymoses area; noticed bleeding gums, blood color of rust or vague in feces and urine, bleeding from the puncture further invasive.
• Implement measures to prevent tissue injury / bleeding
• Limit oral care to wash mouth when indicated
• Give diet a smooth
• Collaboration:
  • Give IV fluids as indicated
  • Supervise laboratory tests: platelet count, Hb / Ht, freezing
  • Provide HR, platelets, clotting factors
  • Maintain a central vascular access device external (sub-clavicle artery catheter, tunneld, implantable ports)

2. Acute pain 

related to an agent of physical injury

Purpose: pain is resolved

Expected outcomes:

• The patient stated the pain disappeared or controlled
• Shows the behavior of pain management
• Looks relaxed and able to rest, sleep

Intervention:

• Assess complaints of pain, notice changes in the degree of pain (using a scale of 0-10)
• Monitor vital signs, note the non-verbal clues such as muscle tension, anxiety
• Provide quiet environment and reduce stressful stimuli.
• Place the client in a comfortable position and prop joints, extremities with pillows.
• Change the position of periodic and soft assistive range of motion exercises.
• Provide comfort measures (massage, cold compresses and psychological support)
• The review / enhance client comfort interventions
• Evaluate and support the client's coping mechanisms
• Encourage the use of pain management techniques. Example: relaxation exercises / breathing in, touch.
• Auxiliary therapeutic activity, relaxation techniques.
• Collaboration: Monitor levels of uric acid, give the medication as indicated.

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Urethral Stricture Nursing Diagnosis , Interventions, Implementation and Evaluation

Nursing Diagnosis 1.

Impaired Urinary Elimination related to postoperative cystostomy

Goal :
No interference elimination urinary elimination pattern

Nursing Interventions :
1) Monitoring of urine output and characteristics.
Rational: Detecting bladder elimination disorders at an early stage.
2) Maintain a constant bladder irrigation for 24 hours.
Rationale: Prevents blood clots obstruct the flow of urine.
3) Maintain the catheter with irrigation.
Rationale: Prevents blood clots clogging the catheter.
4) Pursue fluid intake (2500-3000).
Rational: Smooth flow of urine.
5) Once the catheter is removed, continue to monitor the symptoms of impaired bladder elimination patterns
Rational: Detecting early bladder elimination disorders.


Nursing Diagnosis 2.

Impaired sense of comfort: Pain related to postoperative cystostomy.

Goal:
Patient said, feeling more comfortable.

Nursing Interventions :
1) Extension to the patient not to urinate all around the catheter.
Rational: Reduce the possibility spasmus.
2) Monitoring of patients at regular intervals for 24 hours, to recognize early symptoms of bladder spasmus.
Rationale: Determining the presence spasmus bladder so that medications can be given.
3) Providing ordered drugs (analgesic, antispasmodic).
Rationale: Symptoms disappeared.
4) Tell the patient that the intensity and frequency will be reduced within 24 hours to 28 hours.
Rational: Inform patients that the discomfort is only temporary.


Nursing Diagnosis 3.

Risk for infection, hemorrhage related to surgery.

Goal:
No infection, bleeding is minimal.

Nursing Interventions :
1) Monitoring of vital signs, reported symptoms of shock and fever.
Rationale: Prevents before the shock.
2) Monitoring of fresh red blood urine color, not dark red just a few hours after surgery.
Rational: The color changed from red fresh urine becomes dark red on days 2 and 3 after surgery.
3) Guidance to patients in order to prevent the Valsalva maneuver.
Rational: Can be irritating, prostate bleeding in early postoperative period due to the pressure.
4) Prevent the use of a rectal thermometer, rectal examination at least 1 week.
Rational: It can cause bleeding.
5) Maintain aseptic technique of urine drainage systems, irrigation, if necessary alone.
Rationale: Minimizing the risk of entry of germs that can cause infection.
6) Pursue intake that much.
Rational: May decrease the risk of infection.


Nursing Implementation for Urethral Stricture

Implementation is the embodiment of the nursing intervention, which includes the actions planned by the nurse. In implementing the nursing process should be collaboration with other health team, family and clients with the clients, which include three things: Implement nursing actions by observing the code of ethics with standard practices and resources available.
Identify the client's response.
Documenting / evaluating the implementation of nursing actions and patient response.
Factors to consider:
Client's needs.
The basis of the action.
Individual capabilities and expertise / skills of nurses.
The sources of his own family and clients.


Nursing Evaluation for Urethral Stricture

Evaluation is a measurement of the success of nursing intervention in meeting client needs. Evaluation phase is the key to success in using the nursing process. Postoperative Evaluation of clients with urethral strictures, which fitted with a catheter still be performed based on the criteria previously set goals and nursing care is successful if the criteria in the evaluation of visible achievement of the goals of care provided.

Nursing Care Plan for Urethral Stricture

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Nursing Care Plan for Urethral Stricture

Definition of Urethral Stricture

A urethral stricture is a narrowing of a section of the urethra. It causes a blocked or reduced flow of urine which can lead to complications.


Symptoms and signs

Symptoms of urethral stricture is a typical small stream of urine and branched irritation and other symptoms of infection such as frequency, urgency, dysuria, sometimes with infiltrates, abces and fistula. Symptoms are retained urine.


Physical Examination

Anamnese

To find the absence of symptoms and signs of urethral stricture also to look for causes of urethral stricture.

General and local examination

To check on the patient also to change in urethral fibrosis, infiltrates, abscesses or fistulas.

Examination Support

Laboratory: urea, creatinine, to see the renal physiology. Radiological Diagnosis must be made with urethrography. Retrograde urethrography to see the anterior urethra. Antegrade urethrography to see the posterior urethra. Bipoler urethrography is a combination of antegrade and retrograde urethrography examinations. With this examination can be expected in addition to the diagnosis of urethral strictures can be also determined the length of urethral stricture are important for therapy planning / operations.


Basic Concepts of Nursing Care

In nursing care is carried out by using the nursing process. The nursing process is a form of dynamic problem-solving process in an effort to improve and maintain optimal patient through a systematic approach to help patients. Nursing theories and concepts are implemented in an integrated manner in which organized phases which include:

Assessment, Nursing Diagnosis, Interventions, Implementation, Evaluation.

1. Assessment

Assessment of clients with urological disorders including data collection and data analysis. In data collection, sources of client data obtained from the client's own self, family, nurse, physician or from medical records.

Data collection include:
Biodata client and the client responsible. Biodata clients consist of the name, age, gender, education, occupation, status, religion, address, date of hospital admission, register number, and medical diagnostics.

Past medical history will provide information about health or disease of the past who have suffered in the past.

Physical Examination
Done by inspection, palpation, percussion, auscultation of the body's system, it will be found to any of the following: general state of the client postoperative urethral stricture should be viewed in terms of: a state generally include appearance, awareness, style of speech. On postoperative urethral stricture impaired bladder elimination patterns that do permanent catheter.

Respiratory system
Needs to be studied starting from the nose shape, presence or absence of pain in the nostrils, the movement of the nostrils during breathing, symmetry chest movement during breathing, auscultation of breath sounds and respiratory problems that arise. Is it clean or there Ronchi, as well as the frequency of breath. This is important because it affects the development of immobilization and mobilization of pulmonary secretions in the airway.

Cardiovascular system
Began to be studied conjunctival color, lip color, presence or absence of elevation of the jugular vein can be assessed by auscultation of heart sounds in the chest and the measurement of blood pressure by palpation of the pulse frequency can be calculated.

Digestive System
That were examined include the state of teeth, lips, tongue, appetite, intestinal peristalsis, and bowel movements. The purpose of this assessment to find out early deviations in this system.

Genitourinary system
Can be assessed from the presence or absence of swelling and pain in the waist area, observation and palpation of the lower abdominal area to determine the presence of urinary retention and review of the state of genitourinary tools shape the outside of the presence or absence of tenderness and lumps and how spending urine, smooth or there painful micturition time, and how the color of urine.

Musculoskeletal system
What needs to be studied on this system Range of Motion is the degree of movement joints from head to lower limbs, discomfort or pain were reported when the client moves, the tolerance time clients move and observation of injuries to the muscles must be studied as well, because the client usually immobility tonus and decreased muscle strength.

Integumentary System
What needs to be studied is the state of skin, hair and nails, skin examination include: texture, moisture, turgor, color and function of touch.

Neurosensori System
Studied is consistent Neurosensori cerebral function, cranial nerve function, sensory function and reflex function.

The pattern of daily activities
The pattern of daily activities on clients who experience post op urethral strictures include the frequency of meals, food types, portion sizes, types and quantity of drinking and elimination that includes defecation (frequency, color, consistency) and urination (frequency, number of urine that come out every day and the color of urine). Personal hygiene (frequency of bathing, washing hair, brushing teeth, changing clothes, combing hair and nails). Sports (frequency and type) and recreation (frequency and recreation).

Urethral Stricture Nursing Diagnosis, Interventions, Implementation and Evaluation

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