Nursing Care Plan for Obesity

Obesity is a global problem that plagued the world today. Lifestyle changes including the propensity to consume foods high in fat is a factor contributing to obesity.

The majority of obesity is due to overeating. It is considered the primary obesity. And others, caused by disease or hormonal disorders or genetic disorders that are in the secondary obesity.

Efforts to streamline the body have been conducted, including the dietary, lifestyle changes, medication and surgery to reduce fat or remove some of the intestines.

Food intake should always be sufficient to meet the needs of the body's metabolism and is also not excessive, causing obesity. Also, because the foods contain different proportions of protein, carbohydrate, and fat are different, then a reasonable balance must be maintained among all of these foods so that all segments of the body's metabolic system can be supplied with the materials needed.

Definition of Obesity

Obesity is defined as the excess accumulation of body fat, at least 25% of the average weight for age, sex, and height.

Obesity is also a pathological condition with the presence of an excessive accumulation of fat than is necessary for bodily functions. Nutritional problems due to excess calories usually accompanied by excess fat and protein, fiber and micro-nutrient excess. Nutrients that would be a risk factor for the occurrence of various types of degenerative diseases such as diabetes, hypertension, coronary heart disease, rheumatism and various types of malignant disease (cancer) and other health problems that would require a very large medical expenses.

Clinical Manifestations of Obesity

Obesity can occur in all age groups, but usually occurs in children and adolescents in the period ahead of teens, especially girls, in addition to body weight increased rapidly, as well as more rapid growth and development (apparently if you check the age of the bones), so that ultimately adolescents rapidly grow and mature it will have a relatively low height compared to children her own age.

Body shape, appearance and expression in patients with obesity:

a. Thighs look great, especially on the proximal, relatively small hands with fingers shaped tapered.

b. Emotional expression disorder, nose and mouth appears to be relatively small with a double chin shaped.

c. Chest and enlarged breasts, breast forms similar to the breast that had been grown in male children such circumstances lead to an unpleasant feeling.

d. Abdomen, and hung bulge, similar to the form of pendulum clocks, there are sometimes white or purple strie.

e. Upper arms enlarged, the enlargement of the upper arm is usually found in the biceps and triceps.

In people, common symptoms of emotional distress which may be the cause or circumstances of obesity.

Nursing Care Plan for Obesity

Nursing Assessment for Obesity

Physical Examination

1. Activity / Rest
symptoms:
- Weakness, drowsiness trended
- Inability / lack of desire to be active or exercise regularly
- Dyspnea with work
signs:
- Increased heart rate / breathing with activity

2. circulation
symptoms:
- History of cultural factors / lifestyle affects food choices
- Weight loss can / can not be accepted as a problem
- Eating may relieve feelings of pleasure, such as loneliness, frustration, boredom
- Prisoners of the closest people to lose weight

3. Food / fluid
symptoms:
- Digesting food with excess / normal
- Experiment with different types of diet with little results
- History repeated and decreased weight gain
signs:
- Weight loss is not right with height
- Endormofik body type (soft / about)
- Failed to determine the input of food to reduce demand (eg, changes in lifestyle from active to not exercise, aging)

4. Pain / Comfort
Symptoms: Pain / discomfort in the joints that support weight loss or spine

5. Breathing
Symptoms: Dyspnea
Signs: cyanosis, respiratory distress

6. Sexuality
Symptoms: menstrual disorders, amenorrhea

7. Education / learning
symptoms:
- Problems can be either lifetime or in connection with life events
- Family history of obesity
- Health problems that accompany diabetes, including hypertension, gallbladder disease and cardiovascular disease, hypothyroidism


Nursing Diagnosis  for Obesity

Nursing Interventions for  Obesity

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Nursing Interventions for Impaired Physical Mobility related to Stroke

Nursing Diagnosis and Interventions for Impaired Physical Mobility

In general, vascular disorders of the brain or stroke is a disorder of cerebral circulation. Is a focal neurologic disorder that can occur secondary to a pathological process in the cerebral blood vessels, such as thrombosis, embolus, rupture the vessel wall or vascular disease basis, such as atherosclerosis, arteritis, trauma, aneurysm and developmental abnormalities.

Stroke can also be interpreted as a functional disorder of the brain that are:

• and focal or global
• acute
• last between 24 hours or more
• caused disturbances of brain blood flow
• not caused by tumor / infection

Classification based on pathology:

1. Hemorrhage stroke: a stroke that occurs because blood vessels in the brain ruptures causing ischemic and hypoxia in the downstream. Causes of hemorrhage stroke include: hypertension, aneurysm rupture, arterivenosa malformations,

2. Non-hemorrhage stroke: stroke caused by embolus and thrombus.


Nursing Diagnosis for Stroke: Impaired Physical Mobility related to neuromuscular weakness, the inability of cognitive perception

Evidenced by:

Inability to move, on the physical environment: weakness, coordination, limited range of motion, decreased muscle strength.

The patient goals / evaluation criteria;

• No contractures, foot drop.
• There is an increasing function of the ability of feeling, or compensation of the body
• Appears behavioral skills / engineering activities
• The maintenance of skin integrity

Nursing Interventions: Impaired Physical Mobility - Nursing Care Plan for Stroke

Independent

• Change position every two hours (prone, supine, oblique)
• Start training active / passive range of motion in all extremities
• Support your limb in a functional position, use a foot board at the time during the period of paralysis. Keep head in neutral.
• Evaluate the use of assistive devices regulatory position
• Help improve sitting balance
• Help manipulated to influence the skin color of edema or normalize circulation
  
  

Collaborative

• Consul assigned to physiotherapy
• Assist in electrical stimulation gave the
• Use a special bed as indicated

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Ineffective Airway Clearance related to Sinusitis

Nursing Diagnosis Ineffective Airway Clearance related to Sinusitis

Sinusitis or sinus infection can cause a great deal of pain. It is the result of an inflammation of the sinus or nasal passages or both. When someone has a sinus infection there are several symptoms that will help him or her to recognize that that is what he or she are suffering from. Sinusitis is often accompanied by a feeling of tenderness or pressure around the nose, eyes, cheeks or forehead. Sometimes it is accompanied by headache pain.

Sinusitis can come on suddenly and then leave after the correct treatment, lasting a few weeks, or it can be a chronic problem that lasts more than eight weeks at a time with at least four occurrences yearly. Surprisingly most cases of sinusitis are chronic in nature.

Sinusitis treatment through medical or home methods can be done to make you feel better. The goals of these treatments are the improvement of drainage of mucus, reduce swelling in the sinuses, relieve pain and pressure, clear up any infection, prevent the formation of scar tissue, and avoid permanent damage to the tissues lining the nose and sinuses.

Ineffective Airway Clearance Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness.

Nursing Care Plan for Sinusitis

Ineffective Airway Clearance related to obstruction / secret is thickened.

Purpose: Purpose: return airway is effective, within 10-15 minutes.

Expected outcomes are:

a) The client no longer uses the nostril breathing

b) The absence of additional breath sounds

c) Ronchi (-)

d) Respiration = 16-20 times / minute

e) The absence of chest wall retraction in 10-15 minutes.

No	Nursing Interventions	Rational
1.	Collaboration: Give neutralizer	Nebulizier can dilute the secret and act as bronchodilators to widen the airway.
2.	Chest X-ray and do clapping or vibration	Knowing the location of secret
3.	Teach effective cough (in patients who did not experience a decrease in consciousness and is able to cough effectively).	Removing the secret of the airway especially in patients who did not experience a decrease disturbance of consciousness and can perform an effective cough.
4.	Observation of vital signs	To find out the healthy development of clients.

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Nursing Diagnosis for Sinusitis

Nursing Diagnosis Nursing Care Plan for Sinusitis

Sinusitis

Sinusitis is the inflammation or infection of the paranasal sinuses (cavities) that are adjacent to the nasal cavity in your face. If the infection or inflammation lasts for not more than 8 weeks, then it is considered as an acute sinusitis. If the condition lasts for more than 3 months, then you are suffering from chronic sinusitis.

The most common cause of acute sinusitis is common cold. But chronic sinusitis can be due to many other reasons. The inflammation or infection of the sinusitis is caused due to infection of viruses, fungus or bacteria. It can also be due to some allergic reactions in your body or nasal cavity. Pollens, dust particles, and other such suspended particles in the air can be responsible for the allergic reaction in the sinuses. In rare cases the cause of the problem could be autoimmune response. In this particular trait the immune system of your body attacks the good part of your body.

Sinusitis Symptoms may include:

• Pain and pressure in the facial area which gets worse when leaning forward.
• Congested nasal passages with green or yellow mucus secretion that drains down at the back of your nose and into your throat.
• Severe headache

On the other hand, less common symptoms of a sinus infection may include:

• Fatigue
• Bad breath
• Reduced sense of smell and taste
• Fever

Nursing Diagnosis for Sinusitis - Nursing Care Plan for Sinusitis


1. Acute Pain / Chronic Pain: head, throat, sinus related to inflammation of the nose.

2. Anxiety related to lack of client knowledge about diseases and medical procedures (sinus irrigation / operation).

3. Ineffective Airway Clearance related to obstruction / secret is thickened.
4. Disturbed Sleep Pattern related to clogged nose, nasal inflammation secondary pain.
5. Imbalanced Nutrition: Less than Body Requirements related to decreased appetite secondary to sinus inflammation.
6. Self-concept disturbance related to bad breath and a runny nose.

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Pathophysiology of Hydrocephalus

Hydrocephalus is a condition wherein there is an interruption to the normal flow, absorption, and production of the brain's CSF (Cerebrospinal Fluid), which is the medium that carries all the nutrients needed by the brain to remain healthy and fully-functional. If there's an interruption or overproduction of CSF - such as in hydrocephalus - it will build up inside the brain that is shown through the swelling of a child's or adult's skull.

Pathophysiology of Hydrocephalus


If there is obstruction in the ventricular system or the subarachnoid space, dilated cerebral ventricles, causing ventricular surface wrinkle, and tearing ependymal lines. White mater below it will atrophy and reduced to a thin ribbon. In the gray matter there is maintenance that is selective, so that although ventricular enlargement gray matter has been experiencing a disruption. Dilation process can be a sudden process / acute and can also selectively depending on the position of the blockage. The process was a case of acute emergency. In infants and small children cranial suture folds and widened to accommodate increased cranial mass. If the anterior fontanela not closed then it will not expand and feel tight in touch. Stenosis aquaductal (family illness / adrift offspring sex) causes dilation of the ventricles laterasl point and center, this dilation causes the appearance of distinctive shaped head protruding forehead is dominant (dominant frontal blow). Syndroma dandy walkker would happen if there is obstruction at the foramina outside the IV ventricle. Fourth ventricle dilated and prominent posterior fossae meet most of the space under the tentorium. Clients with type hydrocephalus above will have an enlarged cerebrum which is symmetric and disproportionately small face.

In older people, cranial sutures had closed thus limiting the expansion of the brain, as the result showed the symptoms: increase in ICP before the cerebral ventricles, becomes greatly enlarged. Damage in the absorption and circulation of CSF in hydrocephalus incomplete. CSF exceeds the normal capacity of the ventricular system, every 6-8 hours and the total absence of absorption will cause death.
In ventricular dilation causes tearing of the line normal ependyma, which allows an increase in the wall cavity absorption. If the route collateral sufficient to prevent further ventricular dilatation there will be a state of compensation.

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Hyperthermia related to - Tetanus

Nursing Diagnosis for Tetanus : Hyperthermia related to efeks toxin (bacteremia)

Hyperthermia

Definition: The body temperature rises above the normal range.

Characteristics :

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

Tetanus is a disease caused by a toxin produced by the bacteria called Clostridium tetani. This toxin can be found in soils heavy in manure or other organic material, particularly in tropical or humid regions of the hemisphere. Once the bacteria enters open wounds or cuts it generates spores, which in turn creates neurotoxins.

The symptoms of tetanus :

• Lockjaw
• Stiff neck
• Seizures or spasms
• Inability to swallow
• Fever
• High blood pressure

Purpose: Normal body temperature

Criteria: 36-37 ° C, the results of laboratory white blood cells (leukocytes) between 5.000-10.000/mm3


Nursing Interventions for Hyperthermia related to - Tetanus

1. Set the temperature a comfortable environment
Rational: the environment can affect the condition and temperature of individual body as a process of adaptation through the process of evaporation and convection.

2. Monitor body temperature every 2 hours
Rational: Identify the symptoms progress toward exhaution shock.

3. Provide adequate hydration or adequate drinking
Rational: Fluids help refresh the body and is a compression body from within.

4. Take action aseptic and antiseptic techniques in wound care.
Rational: Nursing wounds eliminate the possibility of toxins that are still located around the wound.

5. Give cold compress if no seizures occur external stimuli.
Rational: cold compress is one way to lower body temperature by means of conduction process.

6. Implement programs and antipiretic antibiotic treatment
Rational: These drugs can have broad spectrum antibacterial to treat gram-positive or gram negative bacteria. Antipiretic worked as a process of thermoregulation to anticipate an increase in body temperature.

7. Collaborative laboratory examination of leukocytes.
Rational: Test results leukocyte increased by more than 10,000 / mm 3 indicates infection and treatment or to follow the development of the programmed.

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Risk for Injury related to Dementia

Dementia can be defined as cognitive and memory impairment that can affect daily activities. People with dementia often show some disruption and changes in daily behavior (behavioral symptoms) that interfere (disruptive) or do not disturb (non-disruptive) (Volicer, L., Hurley, AC, Mahoney, E. 1998). Grayson (2004) mentioned that dementia is not just an ordinary disease, but rather a collection of symptoms caused by multiple diseases or conditions resulting in changes in personality and behavior.

Mentioned in the literature that a disease that can cause symptoms of dementia there are some seventy-five. Some diseases can be cured while most can not be cured. (Mace, N.L. & Rabins, P.V. 2006). Most researchers in the research agreed that the main cause of the symptoms of dementia is Alzheimer's disease, vascular disease (blood vessel), Lewy body dementia, frontotemporal dementia and ten percent of which are caused by other diseases.

Fifty to sixty percent of the causes of dementia is Alzheimer's disease. Alzhaimer is a condition in which nerve cells in the brain die, making the signal from the brain can not be transmitted as it should (Grayson, C. 2004). Alzheimer's sufferers experiencing memory impairment, the ability to make decisions and also a decrease in the thinking process.

Nursing Diagnosis : Risk for Injury related to Dementia


Nursing Interventions Risk for Injury related to Dementia

A. Action for patients with Dementia 

Goal:

1. Patients are spared from injury
2. Patients are able to control activities that can prevent injuries.

Action

1. Describe risk factors that could cause injury, with simple language
2. Teach ways to prevent injuries: if the fall do not panic but cry out for help
3. Give praise to the patient's ability mentions ways to prevent injuries.

B. Action for patients families

Goal: Families of patients are able to:

1. Identifying factors that could cause injury to the patient
2. Families are able to provide a safe environment to prevent injury

Action

1. Discuss with family factors that may cause injury to the patient
2. Encourage families to create a safe environment such as: floors are not slippery, keep sharp objects out of reach of patients, provide adequate lighting, the lights on during the day, give the tool handle and watch if the patient smokes, cap plugs and other electrical equipment with plaster, avoid power tools other than the reach of the client, provide a low bed
3. Encourage families to always accompany the patient at home and monitor the daily activities undertaken

Evaluation  Risk for Injury related to Dementia

To measure the success of nursing care that you do, it can be done by assessing the ability of clients and families:

The ability of the patient:
1. Mention the simple language of the factors that cause injury
2. Using the proper way to prevent injury
3. Controlling the activity according to ability

The ability of family
1. Families can reveal factors that may cause injury to the patient
2. Providing safety in the home
3. Distancing power tools out of reach of patients
4. Always accompany the patient at home
5. Monitor the daily activities of patients conducted

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Nursing Diagnosis for Dementia NANDA

Dementia is a medical condition that affects the brain. It is more common in older people, starting at about the age of sixty years and over.

Ageing is one cause of this condition, but there are other causes such as a stroke, Alzheimer's disease, or an injury to the brain from head trauma. Someone with Dementia may forget simple things that should be familiar to them.

People generally go through Dementia in three stages. During the first stage, a person will have trouble remembering things that they would typically know otherwise. Things such as phone numbers, how to get home, where they parked their car, and other common daily tasks are some of the things that will not be remembered by a person affected by Dementia. The next stage of Dementia is more serious and noticeable by people that know the person. In this stage the individual often does not know how to complete tasks around their own home such as cooking, getting dressed properly and washing themselves. Sometimes in this stage, the person affected also has trouble with their speech. The last stage begins to affect the body as well as the mind. The person may have weakness in certain parts of their body. It may cause them to not be able to move their arms and legs. Their ability to speak may worsen to the point of not making any sense when they talk.

Nursing Diagnosis for Dementia NANDA

1. Impaired Verbal Communication

related to cerebral impairment as demonstrated by altered memory, judgment, and word finding

2. Bathing or Hygiene Self-Care Deficit

related to cognitive impairment as demonstrated by inattention and inability to complete ADLs

3. Risk for Injury

related to cognitive impairment and wandering behavior

4. Impaired Social Interaction

related to cognitive impairment

5. Risk for Violence: Self-directed or Other-directed

related to suspicion and inability to recognize people or places

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Nanda Nursing Diagnosis - Risk for Self-Mutilation and Other related to Auditory Hallucinations

Nanda Nursing Diagnosis


Risk for Self-Mutilation and Other related to Auditory Hallucinations


General Objectives: The client does not injure others.

Specific Objectives 1. Clients can build a trusting relationship

Expected Outcomes:
- Facial expressions are friends.
- Showing a sense of fun.
- There is eye contact or want to shake hands.
- Want to name.
- Want to call and answer the greeting.
- Want to sit down and side by side with the nurses.
- Want to express the problems encountered.

Nursing Intervention:

Construct a trusting relationship with the principles of therapeutic communication.
a. Greet the client with a friendly both verbally and non verbally.
b. Introduce yourself politely.
c. Ask the client's full name and nickname are preferred clients.
d. Explain the purpose of the meeting.
e. Honest and keep their promises.
f. Show empathy and clients receive what they are.
g. Pay attention to the client and the client base kebutuan notice.
Rationalization: The relationship of mutual trust is the foundation for a smooth relationship interactions.


Specific Objective 2. Clients can recognize hallucinations
Expected Outcomes:

a. Clients can mention the time, content, frequency of hallucinations.
b. Clients can express her feelings towards hallucination.
c. Help clients recognize hallucinations.
1) If it finds a client who was hallucinating, ask what is being heard.
2) Tell the client that the nurse believes that voice heard, but the nurse did not see it.
3) Tell them that other clients also like the client.
4) Tell the nurse is ready to assist clients.
d. Discuss with the client
1) The situation that creates or does not cause hallucinations.
2) Time and frequency occur hallucinations.
e. Discuss with the client what is felt in the event of a hallucination.

Specific Objective 3. Clients can control the hallucinations

Expected Outcomes:
- Clients can mention what you can do to control hallucinations.
- Clients can mention a new way.
- Clients can choose how you have chosen to control hallucinations.
- Klin can follow the therapy group activities.

Nursing Interventions:

a. Identify with the client how to do in case of hallucination.
Rational: an attempt to break the cycle of hallucinations.

b. Discuss the ways in which benefits the client, if the beneficial give a compliment.
Rational: positive reinforcement can increase the client's self-esteem.

c. Discuss new ways to control the onset of hallucinations.

1) Say "I do not want to hear you"
2) Meet with others to converse.
3) Looking at the schedule of daily activities that hallucinations could not appear.
4) Ask the nurse / friend / family to say hello if the client is daydreaming.
Rational: provides alternative mind for clients

d. Help clients decide to train and hallucinations gradually.
Rational: Motivating can enhance the client's desire to try to choose one way of controlling hallucinations.

e. Give a chance to perform the way they are trained, the evaluation of the results and give praise if successful

f. Encourage clients to follow the orientation of reality.
Rational: The stimulation can reduce the perception of reality changes in the interpretation of the client.

Nursing Care Plan Risk for Self-Mutilation and Other related to Auditory Hallucination

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Ineffective Cerebral Tissue Perfusion Nursing Care Plan for Hydrocephalus

Hydrocephalus

Hydrocephalus is a condition wherein there is an interruption to the normal flow, absorption, and production of the brain's CSF (Cerebrospinal Fluid), which is the medium that carries all the nutrients needed by the brain to remain healthy and fully-functional. If there's an interruption or overproduction of CSF - such as in hydrocephalus - it will build up inside the brain that is shown through the swelling of a child's or adult's skull.


Hydrocephalus of one kind or another is especially prevalent at the two extremes of the life cycle -- in the very young and the very old -- but can occur at any age. In infancy, hydrocephalus can be caused by malformed brain-tissue. In contrast, adults with hydrocephalus were usually born with normal brain anatomy, but acquired a blockage due to a tumor, injury, bleed or infection. However, many cases of hydrocephalus in adults occur without a history of these preceding illnesses.

All of these ventricles, passageways, and spaces are filled with a special fluid called cerebrospinal fluid (CSF). This fluid is constantly moving. It begins in one of the ventricles. Located inside each of the four ventricles is a structure called a choroid plexus. An essential component of the choroid plexus is a compact network of blood capillaries. The function of the choroid plexus is to remove fluid from the blood inside the capillaries and place that fluid inside the ventricle. Once the fluid is inside the ventricle, it is called cerebrospinal fluid.


Nursing Diagnosis Nursing Care Plan for Hydrocephalus

Ineffective cerebral tissue perfusion related to increased volume of cerebrospinal fluid

NOC: Circulation Status

Expected outcomes NOC

1. Indicates the status of circulation, characterized by the following indicators:
   • Systolic and diastolic blood pressure in the range expected
   • No orthostatic hypotension
   • No noisy large blood vessels
2. Demonstrate cognitive abilities, characterized by indicators:
   • Communicate clearly and in accordance with the age and ability
   • Show attention, concentration and orientation
   • Demonstrate long-term memory and is currently
   • Process information
   • Making the right decision

NIC interventions

Monitor the following matters :

• Vital signs
• Headache
• Level of awareness and orientation
• Nystagmus diplopia, blurred vision, visual acuity
• Monitoring ICT
  • Monitoring of ICT and the patient's neurological response to maintenance activities
  • Monitor the pressure of tissue perfusion
  • Note the change in the patient in response to stimulus

1. Management of peripheral sensation
   • Monitor the presence of paresthesias: a sense of numbness or tingling
   • Monitor the status of fluid intake and output including
2. Collaborative activity
   
   • Keep the thermodynamic parameters within the recommended range
   • Give the drugs to increase intravascular volume, as requested
   • Give the drug which causes hypertension to maintain cerebral perfusion pressure according to demand
   • Elevate the head of the bed 0 to 45 degrees, depending on the patient's condition and medical demands
   • Give loap and osmotic diuretics, according to demand.

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