Imbalanced Nutrition and Knowledge Deficit related to Bladder Cancer

Neoplasm is an abnormal collection of cells formed by cells that grow continuously on a limited basis, is not coordinated with the surrounding tissue and are not useful for the body.

Cancer is a general term used to describe cellular growth disorder and is a group of diseases and not just a single disease.

Cancer is a general term that includes any malignant growth in any part of the body. This growth was not intended, parasitic and developing at the expense of a man who became the host.

Bladder cancer is a malignant tumor that is found in the bladder (nurse87, 2009)

Symptoms can include:

• Hematuria (blood in the urine).
• Burning or pain when urinating.
• Urge to urinate.
• Frequent urination, especially at night and on the next phase of difficult urination.
• Body felt hot and weak.
• Low back pain due to nerve compression.
• Pain on one side because hydronefrosis.

1. Imbalanced Nutrition: Less Than Body Requirements
related to:

• hyper-metabolic-related cancer, the consequences of chemotherapy, radiation, surgery (anorexia, gastric irritation, lack of sense of taste, nausea), emotional distress, fatigue, inability to control pain

characterized by:

• inadequate intake,
• loss of sense of taste,
• loss of appetite,
• weight down to 20% or more below the ideal,
• decreased muscle mass and subcutaneous fat,
• constipation,
• abdominal cramping.

Goal:

• Showed a stable weight, normal laboratory results and no sign of malnutrition.
• Stated understanding of the need for adequate intake.
• Participate in the management of diet-related illness.

Interventions :

• Monitor food intake every day, whether eating in accordance with the needs of the client.
• Measure weight, triceps size and observed weight loss.
• Assess pale, slow wound healing and parotid gland enlargement.
• Encourage clients to consume high-calorie foods with adequate fluid intake. Instruct too little food to clients.
• Control of environmental factors such as foul odors or noise. Avoid foods that are too sweet, fatty and spicy.
• Create a pleasant dining atmosphere for example, a meal with friends or family.
• Encourage relaxation techniques, visualization, moderate exercise before eating.
• Encourage open communication about anorexia problems experienced by clients.

Collaboration:

• Observe laboratory studies such as total lymphocytes, serum transferrin and albumin.
• Give treatment as indicated.
• Attach a nasogastric tube for enteral feeding, balanced with infusion.

Rational:

• Provide information about nutritional status.
• Provides information about the addition and weight loss.
• Showed very poor nutritional state.
• Calories are energy sources.
• Prevent nausea and vomiting, excessive distension, dyspepsia which causes a decrease in appetite and reduce harmful stimulus which can increase anxiety.
• In order for the client to feel like being at home alone.
• To induce a feeling of wanting to eat / arouse appetite.
• In order to overcome together (with a dietitian, nurse and client).
• To determine / establish the occurrence of nutritional deficiencies as a result of the course of disease, treatment and care of the client.
• Facilitate the intake of food and beverages with maximum results and right as needed.

2. Knowledge Deficit about the disease, prognosis and treatment
related to:

• lack of information,
• misinterpretation,
• cognitive limitations.

characterized by:

• often asked,
• stating the problem,
• statement misconceptions, is not accurate in mengikiuti instruction / prevention of complications.

Goal:

• Can accurately say about diagnosis and treatment at the level of proximity ready.
• Following the procedure well and explain the reasons to follow those procedures.
• Having the initiative of changing lifestyles and participate in treatment.
• In cooperation with the furnisher.

Interventions:

• Review understanding of the client and family about the diagnosis, treatment and consequences.
• Determine the client's perception about cancer and its treatment, tell the client about the experience of other clients who have cancer.
• Give accurate and factual information. Answer the questions specifically, avoid unnecessary information.
• Provide guidance to client / family before following the treatment procedure, the old therapy, complications. Be honest with the client.
• Encourage clients to provide verbal feedback and correct misconceptions about the disease.
• Review client / family about the importance of optimal nutrition status.
• Encourage clients to assess the oral mucous membranes regularly, note the presence of erythema, ulceration.
• Encourage clients to maintain the cleanliness of the skin and hair.

Rational:

• Avoid duplication and repetition of the client's knowledge.
• Lets do justification to errors as well as errors of perception and conception of understanding.
• Assist the client in understanding the disease process.
• Assist clients and families in making treatment decisions.
• Knowing the extent of understanding the client and client's family about the disease.
• Increasing knowledge of the client and family regarding adequate nutrition.
• Reviewing the development of the processes of healing and signs of infection and problems with oral health can affect the intake of food and beverages.
• Improving the integrity of the skin and head.

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Acute Pain and Anxiety - NCP for Bladder Cancer

Bladder cancer is a cancer of the bladder organ. Bladder is the organ that serves to accommodate the urine from the kidneys. If the bladder is full of urine then it will be removed.

The exact cause of bladder cancer is not known. But studies have shown that these cancers have multiple risk factors, namely:

• Age, the risk of bladder increases with age.
• Smoking is a major risk factor.
• Work environment, some workers have a higher risk of developing this cancer because of its place works found carcinogenic substances (cancer-causing).
• Race, white people have a 2 times greater risk, there is the smallest risk among Asians.
• Men, are at risk 2 - 3kali greater.
• Family history, people whose family is suffering from bladder cancer have a higher risk of developing this cancer. Researchers are studying the change of certain genes that may increase the risk of this cancer.

Nursing Diagnosis and Interventions for Bladder Cancer

1. Acute Pain
related to:

• disease process (suppression / destruction of nerve tissue, nerve supply system infiltration, nerve pathway obstruction, inflammation),
• side effects of cancer therapy

characterized by:

• clients say pain,
• clients have difficulty sleeping,
• not able to focus, expressions of pain, weakness.

Goal:

• Clients are able to control pain through activity.
• Reported experiencing pain.
• Following treatment program.
• Demonstrate techniques of relaxation and diversion of pain through activity.

Interventions:

• Determine history of pain, location, duration and intensity.
• Evaluation of therapy: surgery, radiation, chemotherapy, biotherapy, teach the client and family about how to deal with.
• Give diversion such as repositioning and fun activities such as listening to music or watching TV.
• Encourage stress management techniques (relaxation techniques, visualization, guidance), happy, and provide therapeutic touch.
• Evaluation of pain, provide treatment if necessary.
• Discuss pain management with doctor and also with clients.
• Give analgesics as indicated.

Rational:

• Provide the necessary information for planning care.
• To determine the appropriate therapy is carried out or not, or even cause complications.
• To improve the comfort of the clients distract from pain.
• Improving self-control over side effects by lowering stress and anxiety.
• To determine the effectiveness of pain management, pain levels and to the extent the client is able to withstand, and to investigate the needs of the client will be anti-pain medication.
• In order for a given targeted therapy.
• To cope with the pain.

2. Anxiety
related to:

• crisis situations (cancer),
• changes in health,
• socio-economic,
• roles and functions,
• forms of interaction,
• preparation for death,
• separation of the family

characterized by:

• increase in tension,
• fatigue,
• express awkwardness role,
• feeling dependent,
• inadequate ability to help themselves,
• sympathetic stimulation.

Goal:

• Clients can relieve anxiety.
• Relax and be able to see themselves objectively.
• Demonstrate effective coping and able to participate in treatment.

Interventions:

• Determine the client's previous experience of the illness.
• Provide accurate information about prognosis.
• Give the client a chance to express anger, fear, confrontation. Give the information with reasonable emotions and expressions appropriate.
• Explain the treatment, the purpose and side effects. Help clients prepare for the treatment.
• Record ineffective coping as less social interaction, lack of empowerment, etc..
• Encourage to develop interaction with the support system.
• Provide a quiet and comfortable environment.
• Maintain contact with clients, talk and touch with the fair.

Rational:

• Data about previous client experience will provide a basis for extension and avoid duplication.
• Provision of information to assist clients in understanding the disease process.
• Can reduce client anxiety.
• Assist the client in understanding the need for treatment and side effects.
• Knowing and explore coping patterns and handle client / provide solutions in an effort to improve the strength in overcoming anxiety.
• So that clients receive support from the closest person / family.
• Give the client a chance to think / contemplate / break.
• Clients gain confidence and belief that he really helped.

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NCP for Hypoglycemia - Nursing Diagnosis and Interventions

Nursing Care Plan for Hypoglycemia

Hypoglycemia is a condition where the fasting plasma blood sugar levels less than 50 mg /%.

Populations that have a high risk of experiencing hypoglycemia are:

• Diabetes mellitus.
• Parenteral nutrition.
• Sepsis.
• Enteral feeding.
• Corticosteroid therapy.
• Infants with mothers with diabetic.
• Infants, with small for gestational age.
• Infants whose mothers drug addiction.
• Burns.
• Cancer of the pancreas.
• Addison's disease.
• Hyperfunctioning adrenal glands.
• Liver disease.

Type of hypoglycemia are classified into several types namely:

• Early neonatal transitional: large size or normal baby, with damage to the pancreatic production system, resulting in hyper-insulin.
• Classic Transient Neonatal: occurs when infants are malnourished, so the deficiency of fat and glycogen reserves.
• Secondary: as a response to the stress of the newborn resulting in increased metabolism that requires a lot of glycogen reserves.
• Recurrent: caused by the enzymatic breakdown, or impaired insulin metabolism.

Assessment

Basic data that needs to be examined are:
1. The main complaint: often unclear, but usually symptomatic, more frequent hypoglycemia and a secondary diagnosis that accompanies other previous complaints such as asphyxia, seizures, sepsis.

2. History:

• ANC.
• Perinatal.
• Post natal.
• Immunization.
• Diabetes mellitus in the elderly / family.
• The use of parenteral nutrition.
• Sepsis.
• Enteral feeding.
• Use of Corticosteroid therapy.
• Mothers who use or drug addiction.
• Cancer.

3. Focus Data
Subjective Data:

• Often entered with complaints that are not clear.
• Complaining baby cold sweat that much.
• Hunger (babies often cry).
• Headache.
• Frequent yawning.
• Irritabel.

Objective data:

• Parestisia on the lips and fingers, restlessness, nervousness, tremors, convulsions, stiff,
• Hight-pitched cry, lethargy, apathy, confusion, cyanosis, apnea, irregular rapid breathing, sweating, eye circles, refusing to eat and coma.
• Plasma glucose less than 50 g /%.

Nursing Diagnosis and Interventions

1. Risk for complications
related to lower plasma glucose levels such as mental disorders, behavioral disorders, autonomic nerve function disorders, hypoglycemic coma

Interventions:

• Check serum glucose before and after meals.
• Monitor: glucose, pallor, cold sweat, skin moist.
• Monitor vital signs.
• Monitor consciousness.
• Monitor sign of nerves, irritability.
• Perform oral administration of sweet milk 20 cc X 12.
• Analysis of environmental conditions that could potentially cause hypoglycemia.
• Weight checks every day.
• Check for signs of infection.
• Avoid the occurrence of hypothermia.
• Collaborate provision of oxygenation.

2. Risk for infection
related to a decrease in endurance

Inerventions:

• Perform maintenance procedures hands before and after the action.
• Ensure that every object that is used in contact with baby be clean or sterile.
• Prevent contact with others who suffer from respiratory tract infections.
• Note the condition of the baby feces.
• Encourage families to follow aseptic procedures septic.
• Give antibiotics as profolaksis in accordance with the order.

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Epilepsy - 3 Nursing Diagnosis and Interventions

Epilepsy is a symptom or manifestation of excessive loss of electrical charge in neuronal cells of the central nervous which can cause loss of awareness, involuntary movements, abnormal sensory phenomena, the increase in autonomic activity and a variety of physical disorders (Doenges, 2000).

Signs and symptoms of Epilepsy

1. Generalized seizures

• Tonic: muscle contraction, leg and elbow lasts approximately 20 seconds, with marked neck and back arched, screams epilepsy for about 60 seconds.
• Clonic seizures: intermittent flexion spasm, relaxation, hypertension lasted approximately 40 seconds, with a marked mydriasis, tachycardia, hyperhidrosis, hypersalivation.
• Post-attack: halt muscle activity is characterized by the patient regained consciousness, muscle aches and headaches, sufferers fall asleep 1 to 2 hours.

2. Partial seizures

• There are simple with no disturbance of consciousness
• Complex with disorders of consciousness.

Epilepsy - 3 Nursing Diagnosis and Interventions

Nursing Diagnosis I : Risk for Injury 

related to a change of consciousness, weakness, loss of large and small muscle coordination.

1). Assess the originator of the emergence of seizures in patients.
The goal: a controlled seizure.
Rational: alcohol, various medications, and other stimulation (lack of sleep, bright lights, watching television too long), can enhance brain activity which further increases the risk of seizures.

2). Maintain a soft cushion on the bed barrier attached with a low bed position.
Rationale: reducing trauma during seizures.

3). Supervise activities of clients after the seizure occurred.
Rationale: improving patient safety.

4). Record the patient's type of seizure activity such as location, duration, motor, loss of consciousness, incontinence.
Rationale: helps to localize the brain regions affected.


Nursing Diagnosis II : Low Self - Esteem, self-identity is not related to perception of control,
characterized by : fear, and less cooperative medical treatment.

1). Assess the patient's feelings regarding diagnostic, self-perception of the treatment performed on the patient.
Rational : the reaction is between the individual and knowledge is the beginning of the acceptance of the client's medical treatment.

2). Identify and anticipate possible reactions of others to the disease state.
Rationale : provide an opportunity to respond to the problem-solving process and provide control over the situation.

3). Assess the patient's response to the success obtained, or who will be achieved from its strengths.
Rational : focus on the positive aspects can help to eliminate the feelings of failure or awareness of self and patients receiving treatment.

4). Discuss referral to psychotherapy with patients or people nearby.
Rationale : seizures has a profound influence on a person's self esteem and the patient, significant others, probably due to the emergence of stigma from society.


Nursing Diagnosis III : Knowledge Deficit (learning needs), and rules regarding the treatment of conditions related to lack of understanding, misinterpretation of information, lack of recall.

1). Assess the patient's level of knowledge of the type of illness
Rational : to know the extent of the client's ability to understand the type of illness will be more cooperative client understanding the importance of prevention, treatment and so on.

2). Explain again about the pathophysiology or disease prognosis, treatment, and management in the long run according to the procedure.
Rationale : provide an opportunity to clarify misperceptions and the state of the illness.

3). Review the medication, dosage, instructions, and discontinuation of medication as instructed doctors.
Rational : will add to the understanding of the client's health condition suffered.

4). Discuss the benefits of good general health, such as adequate diet, adequate rest, and exercise and moderate exercise regularly, and avoid foods adan beverages containing harmful substances.

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Ineffective Airway Clearance and Ineffective Breathing Pattern NCP for Epilepsy

Definition of Epilepsy

Epilepsy is a chronic neurological disease that causes seizures periodically. The disease is caused by the normal activity of brain cells. Symptoms of seizures that appears may vary. Some people with epilepsy when seizures have an empty view. Mild seizures require treatment, because it can be dangerous in the event when doing activities like driving or swimming.

Treatments such as medical treatment and sometimes surgery is usually successful in eliminating the symptoms or reduce the frequency and intensity of seizures. In some children with epilepsy, they can overcome this condition with age.

Recently, the researchers found, epilepsy affects neurological function disrupt social functioning in the brain, the same properties are also seen in people with autism. These characteristics include impairments in social interaction and communication.

Symptoms of Epilepsy

Because epilepsy is not normally caused by the activity of brain cells, seizures can have an impact on your brain coordination process. Convulsions can result in:

• Temporary confusion.
• Uncontrolled jerking movements of the hands and feet.
• Lost consciousness completely.

Differences symptoms occur depending on the type of seizures. In many cases, people with epilepsy will tend to have this type of seizure is the same every time, so it will be the same symptoms that occur from incident to incident.

Doctors classify partial seizures or generalized, based on how abnormal brain activity begins. In some cases, seizures can be initiated by partial and later became general.

Partial Seizures

When seizures arise as a result of abnormal brain activity on the part of the brain, scientists call it partial seizures. Seizures of this type consists of two categories.

• Simple partial seizures. These seizures do not result in loss of consciousness. These seizures may be changing emotions or changing way of looking at, smell, feel, taste, or hear. These seizures can also produce buffeting parts of the body by accident, such as the hands or feet, and sensory symptoms such as tingling spontaneously, vertigo and blinking against the light.
• Complex partial seizures (complex partial seizures). These seizures resulted in the change of consciousness, it is because you lose vigilance for some time.

General Seizures

Seizures involving all parts of the brain called the general convulsions. Four types of general convulsions are:

• Absence seizures (also called petit mal). This seizure is characterized by the movement of the body has a smooth and striking, and can cause loss of consciousness briefly.
• Myoclonic seizures. These seizures usually cause a jerk or twitch suddenly in the hands and feet.
• Atonic seizures. Also known as drop attacks, these seizures cause loss of harmony with the muscles and the sudden collapse and fall.
• Tonic-clonic seizures (also called grand mal). Convulsions that have most frequently occurring intensity. Having characteristics with loss of consciousness, stiff and trembling, and loss of bladder control.

Nursing Care Plan for Epilepsy

Nursing Diagnosis : Ineffective Airway Clearance and Ineffective Breathing Pattern

related to damage nuromuskuler , tracheobronchial obstruction .

Nursing Interventions:

1) Encourage clients to release the use of objects from the mouth preformance, hammer and other tooth samples.
Rationale: lowering the risk of aspiration or the entry of foreign objects into the pharynx.

2). Place the patient in the lateral position, a flat surface, tilt the head during a seizure occurs.
Rationale: improving drainage secret, to prevent the tongue falling, and obstruct the airway.

3). Remove clothing at the neck, chest and abdomen clients.
Rational: to help clients breathe.

4). Insert the tongue into the mouth spatel clients.
Rational: to prevent biting the tongue and help perform suction mucus, and help open the airway.

5). Perform suction as indicated.
Rationale: lowering the risk of aspiration or asphyxia.

6). Collaboration in the provision of supplemental oxygen.
Rational: can decrease cerebral hypoxia, due to reduced oxygen due to vascular spasm during seizures.

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Pleural Effusion - Assessment and Nursing Diagnosis

Pleural effusion is a medical condition where there is an excessive accumulation of fluid in the lungs, particularly in the pleural space. This fluid is responsible for lubricating the lungs so that they do not experience friction from rubbing against the ribs or other components of the thoracic cavity. Normally, the space around the lungs contains 10-15 milliliters of this fluid.

There are types of pleural effusion, depending on what is causing the issue. These include:

Hemothorax : This occurs when blood builds up in the chest cavity. It is most often due to injury
Hydrothorax : This is the general term for when any fluid accumulates in the chest cavity.
Pneumothorax : This condition arises when the entire lung collapses, which can be the result of pressure from fluid buildup.
Chylothorax : This happens when blood or pleural fluid remains in the thoracic cavity. While this can also be attributed to injury, it is most often related to lymphoma, or cancer of the lymph nodes.


Assessment for Pleural Effusion

1. Systemic Examination

a) Cardiovascular System
Hypotension, increased pulse, temperature sometimes rose.

b) Respiratory System
From this system, the assessment needs to be done related to pleural effusion is dyspnea, tachypnea, cough, fremitus focal weakness, chest wall is more convex on the side that contains fluid.

c) Digestive System
On the client with pleural effusion usually found loss of appetite, nausea, vomiting, hyperactive bowel sounds.

e) Musculoskeletal System
Physical weakness, prefer to lay on the direction that contains fluid.

f) Integumentary System
Dry skin, increased skin temperature, poor turgor.


2. Pattern of Daily Activities
That needs to be studied in daily activities are:

• Personal hygiene: Due to a decrease in the ability or increased need help doing everyday activities.
• Nutrition: There is a change and a problem in meeting the nutritional needs due to the tightness and lack of appetite.
• Elimination: No problem.
• Activities and sports: On the client with pleural effusion occurs fatigue, weakness, malaise, inability to perform daily activities because of difficulty breathing, fatigue or activity intolerance. Can not exercise because of pain due to tightness WSD installation actions.
• Rest and sleep: There was difficulty sleeping at night due to coughing, tightness, pain, fever and sweating.

3. Psychological Data

• Status of emotions: emotional instability can be found facing the disease.
• The concept of self: changes in self-concept for fear of disease, negative views of themselves, due to the changing role of dependence.
• Coping patterns: what is being done to overcome the problem client is maladaptive actions and to whom the client to ask for help or tell me if there is a problem.

4. Social Data
Behavior occurs withdraw from social interactions due to the inability to communicate.

5. Spirituality Data
Difficulty to perform the religious obligations because of illness and limited activity.


6. Diagnostic examination
According Doenges et al (2002) Diagnostic examination consists of:

• Chest X-ray: to declare lung hyperinflation, flattening of the diaphragm, increased retrosternal air area.
• Lung Function Tests: performed to determine the cause of dyspnea, to determine whether the abnormal function is obstruction or retraction.
• Blood gas analysis: estimating progression of chronic disease processes.
• Blood chemistry: to convince deficiency and emphysema primary diagnosis.
• Sputum cultures to determine the presence of infection, identify the pathogen, sitolitik examination to determine malignancy or allergic disorders.
• ECG right axis deviation, P wave elevation, atrial dysrhythmias, P wave elevation leads I, III, aVF, ventricular QRS axis.

7. Care and Treatment
Management of pulmonary tuberculosis disease is the provision of a high-calorie diet and high protein, WSD installation.


Nursing Diagnosis for Pleural Effusion

According Doenges et al (2002), nursing diagnoses that appear in patients with pleural effusion is:

1. Acute pain r / t surgical action (WSD).

2. Ineffective airway clearance r / t inflammatory process and secret accumulation in the respiratory tract.

3. Imbalanced Nutrition: Less Than Body Requirements r / t lack of food intake.

4. Activity intolerance r / t physical weakness

5. Knowledge Deficit: the conditions, rules and precautionary measures r / t the wrong interpretation of the cognitive limitations of the information, the information is inadequate / incomplete information.

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4 Nursing Diagnosis and Interventions for Tuberculous Meningitis

Nursing Diagnosis I

Ineffective breathing pattern related to the emphasis on the central respiratory regulation

Goal :
1. Long-term goal
Effective breathing pattern.
2. Short-term goals
Breathing pattern gradually improved

Outcomes:

• Frequency breath : normal 16-20x/menit
• Breath rhythm : regular

Intervention
1. Assess and monitor the frequency of the pattern and rhythm of the breath.
rational :
Ineffective breathing pattern changes a sign of an increase in intracranial pressure weight that presses the medulla oblongata.

2. Maintain effective airway by performing airway clearance such as suctioning and oral hygiene.
rational :
Excessive mucus will accumulate and lead to airway obstruction.

3. Give oxygenation appropriate order and monitor the effectiveness of oxygen administration.
rational :
To meet the need of oxygen in the blood and tissues.

4. Maintain airway patency with neck and neutral position.
rational :
Position neck extension / bending resulted obstructed airway.


Nursing Diagnosis II

Hyperthermia related to inflammation of the meninges

Goal :
1. Long-term goal
Body temperature within normal limits

2. Short-term goals
Body temperature gradually improved

Outcomes:

• The client is able to mobilize .
• The body temperature of 36-37 ° C, reduced perspiration.

Intervention :
1. Give cold compress on the area's many blood vessels until the temperature returns to normal.
rational :
Cold compresses can cause conduction process where there is heat transfer from one object to another by physical contact between the two objects.

2. Instruct the client to wear thin and absorbs sweat.
rational :
With thin clothing facilitate the absorption of sweat and gives a sense of comfort.

3. Observation vital signs : temperature, blood pressure, respiration and pulse.
rational :
To find out more action to be done.

4. Collaboration of antipyretic therapy.
rational :
Antipyretics inhibit heat on hypothalamic function.


Nursing Diagnosis III

Risk for impaired skin integrity related to prolonged bed rest

Goal :
1. Long-term goal
Impaired skin integrity is not happening

2. Short-term goals
Signs of impaired skin integrity is not happening

Outcomes:

• No signs of impaired skin integrity such as : redness and blisters on the skin.

Intervention :
1. Set and change the position of the patient's sleep , every 2 hours.
rational :
Can reduce the pressure that causes continuous optimal circulation in the area of emphasis.

2. Give bearing on areas of the body and are prominent on the surface of the bed.
rational :
With a bearing on area of ​​emphasis is given to reduce the pressure of circulation effects which are not smooth.

3. Do a massage every day.
rational :
Massage action as a stimulus for vasodilatation to vascular kontriksi on the surface so that the experience will help the circulation in the area.

4. Observation sign decubitus like blisters , redness on elbows , heels and back area every day.
rational :
If found signs of decubitus immediately take action to anticipate the occurrence of excessive tissue damage.



Nursing Diagnosis IV

Self - care deficit related to changes in the central nervous system , physical weakness

Goal :
1. Long-term goal
Self-care are met

2. Short-term goals
Less care is gradually being met.

Outcomes:

• Daily activities can be conducted of patients, while pain and can be performed after discharge from the hospital.
• Body weight did not decrease.
• Intact skin.
• Normal bowel and bladder.

Intervention :
1 . Observation of the patient's level of function.
rational :
Determine the patient's level of need.

2. Instruct the patient to express his feelings about his inability to perform self-care.
rational :
Assist patients in getting a better level of functioning.

3. Provide assistance and support as needed such as bathing, defecation and urination, hygiene , dressing and eating.
rational :
Will increase the feeling of independent (standalone).

4. Give all measurements / tools and food hygiene.
rational :
To save energy.

5. Maintain indwelling catheter if necessary.
rational :
To empty the bladder in a patient unconscious.

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Acute Pain and Fatigue - NCP for Systemic Lupus Erythematosus

Nursing Care Plan for Systemic Lupus Erythematosus

SLE (Systemic Lupus Erythematosus) is an autoimmune condition that affects multiple organ systems. Its pathology is related to the release of antibodies that bind to normal nuclear components. Lupus can attack any organ and system in the body. For unknown reasons, in systemic lupus erythematosus, the body forms auto-antibodies against these normal molecules.

The signs and symptoms of lupus may occur rapidly or develop slowly. They may be either mild or severe and may be either temporary or permanent. Most people with lupus will experience episodes or "flares". This is simply where the signs and symptoms get worse or they can improve or even disappear completely for a period of time.


Nursing Diagnosis and Interventions 

1. Acute Pain related to inflammation and tissue damage.

Goal: improvement in comfort level

Intervention:

1. Carry out a number of actions that provide comfort (heat / cold; massage, position changes, break; foam mattresses, pillows buffer, splints; relaxation techniques, activity that distracts)
2. Provide anti-inflammatory preparations, analgesics as recommended.
3. Adjust treatment schedule to meet the needs of patients to pain management.
4. Encourage the patient to express his feelings about the nature of chronic pain and illness.
5. Describe the pathophysiology of pain and helping patients to realize that pain is often brought him to the method of unproven therapies.
6. Assist in identifying a person's life that brings pain to the patient cases using unproven therapies.
7. Perform an assessment of the subjective changes in pain.

2. Fatigue related to an increase in disease activity, pain, depression.

Goal: include action as part of the activities of daily living necessary for change.

Intervention:
1. Give an explanation of fatigue:

• The relationship between disease activity and fatigue.
• Explain the actions to provide comfort while executing.
• Develop and maintain a sleep routine actions fatherly (warm water bath and relaxation techniques that facilitate sleep).
• Explaining the importance of rest to reduce systemic stress, articular and emotional.
• Explains how to use traditional techniques to save energy.
• Identify the factors that lead to physical and emotional exhaustion.

2. Facilitating the development schedule of the activity / rest right.
3. Encourage patients' adherence to treatment programs.
4. Refer and thrust conditioning program.
5. Encourage adequate nutrition including iron from food sources and supplements.

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Acute Pain and Impaired Physical Mobility NCP for Tuberculous Meningitis

Tuberculosis meningitis is a TB infection of the brain and the spinal cord. The initial symptoms can be irritability and restlessness. Later the patient may develop other symptoms such as a stiff neck, headaches, vomiting, variations in mental behaviour, seizures, or coma.

Nursing Care Plan for Tuberculous Meningitis

Nursing Diagnosis I :

Acute pain related to the process of infection in the central nervous system

Goal:
1. Long-term goal
Pain is gone.

2. Short-term goals
The pain gradually diminished

Outcomes:

• Clients reported no pain, or pain can be controlled.
• Shows posture relaxed and able to sleep / rest appropriately.

Intervention
1. Provide a quiet environment, the room is rather dark as indicated.
rational:
Lowering the reaction to outside stimulation or sensitivity to light and improve the rest / relaxation.

2. Put an ice bag on head, clothes on cold eyes.
rational:
Increases vasoconstriction, blunting sensory perception which will further decrease the pain.

3. Support to find a comfortable position, such as head a little bit higher.
rational:
Lowering of meningeal irritation, discomfort resultant further.

4. Give range of motion exercises active / passive appropriately and do massase muscular shoulder or neck area.
rational:
Can help relax the muscle tension that increases the reduction of pain or discomfort.


Nursing Diagnosis II :

Impaired physical mobility related to neuromuscular damage

Goal:
1. Long-term goal
Physical mobility increased / improved

2. Short-term goals
Impaired physical mobility gradually decreased

Outcomes:
Client is able to mobilize.

Intervention
1. Check back ability and the functional state of the damage.
rational :
Identify possible damage affecting functionally and intervention options that will be done.

2. Assess the degree of immobilization of the client by using the scale dependence.
rational :
The client is able to self (value 0) or need help / tools are minimal (score 1) ; need help being supervised / taught (score 2) ; need help / tools that continuously and special tools (value 3) , or depending on the total the provision of care (Grade 4) ; someone in all categories are equally at risk of accidents , but the category with a value of 2-4 has the greatest risk for the occurrence of such hazards in connection with immobilization.

3. Give or aids to perform range of motion exercises / ROM.
rational :
Mobilization and maintain joint function / normal position and reduce the occurrence of venous limb static.

4. Provide meticulous skin care, massage with moisturizer and change linen / clothes wet and keep the linens are kept clean and free of wrinkles.
rational :
Improves circulation and skin elasticity and reduce the risk of skin excoriation.

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Retinoblastoma - Management, Complication, Signs and Symptoms

Retinoblastoma is eye cancer, which is found on the surface of the retina. This cancer is usually present in children below the age of six years and is usually diagnosed in children aged 1 to 2 years. Generally the two classifications are intraocular and extraocular retinoblastoma. About a two quarters of the cases are hereditary and have been
linked to a specific gene mutation. The cancer can occur in one or both eyes.

Examination for this condition includes an ophthalmic examination, ultrasound of the eyes, CT or MRI of the orbits, and examination of the cerebro- spinal fluid, and possibly bone marrow examination. Treatment of retinoblastoma includes laser surgery, cryotherapy, radiation therapy and chemotherapy.

Signs and Symptoms of Retinoblastoma

• Leukocoria complaints and symptoms are most often found.
• Early sign of retinoblastoma is crossed eyes, red eyes or the presence of abnormal iris color.
• Tumors with moderate size will give hypopyon symptoms, in the anterior chamber, uveitis, endophthalmitis, or a panoftalmitis.
• Eyeball be great, if a tumor has spread widely within the eyeball.
• If there is a tumor necrosis, there will be symptoms of severe sight.
• Greatly decreased visual acuity.
• Painful
• In large tumors, the glass fills the entire cavity of the body so that the body of glass visible lumps yellowish white with veins on it.

Complication of Retinoblastoma

Complications of retinoblastoma among others; rubeosis iridis with glaucoma, lens dislocation into the anterior, uveitis, endophthalmitis, and pseudo inflammation. These symptoms can occur due to inflammation of retinoblastoma that are endophytic growth, and tumor cells escape into the corpus vitreous and anterior chamber and cause inflammation.

Management of Retinoblastoma

Depending on the size and location of the tumor

Small tumors:

• cryotherapy
• laser therapy
• plaque radiotherapy
• thermotherapy

Larger tumors:

• chemotherapy
• radiotherapy
• surgery

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Fluid and Electrolyte Imbalances - Acute Diarrhea Care Plan

Acute diarrhea is a bowel movement with a frequency of more than 3 times per day, with liquid stool consistency, is suddenly and lasts less than 7 days in infants and in previously healthy children.

Etiology

• Acute diarrhea in distinguishing 2 are:
• Acute watery diarrhea without blood.
• Acute diarrhea with blood (in the form of acute diarrhea dysentery).

Cause

• Infections factors: viruses (rotavirus, adenovirus, enterovirus), bacteria (shigella, salmonella, E. coli), parasites (worms), candida (candida albicons).
• Parental factors: infection in other body parts.
• Immunodeficiency factors .
• Malabsorption factors: carbohydrates, proteins, fats.
• Dietary factors: stale food, toxic, too much fat, cooked vegetables undercooked.
• Psychological factors: fear, anxiety.

Examination

Feces examination
Macroscopic and microscopic germs to search for and test resistance to various antibiotics (on persistent diarrhea).

Blood examination
Complete peripheral blood, blood gases and electrolytes.
Examination of blood urea and creatinine levels to determine kidney function.
Daudinal Intibatian
To find out the germs that cause quantitatively and qualitatively, especially in chronic diarrhea.


Nursing Diagnosis for Diarrhea : Fluid and Electrolyte Imbalances related to excessive loss through feces and vomit and limited intake.

Goal: fluid and electrolyte balance.

Outcomes:

• Normal bowel movements (1-2 times daily).
• Mucosa of the mouth and lips moist.
• Client's condition improved.
• Not sunken eyes and fontanel.
• Good skin turgor (back in 2 seconds).

Intervention:
1. Give oral and parenteral fluids in accordance with rehydration program.
Rationale: In an effort rehydration to replace the fluid that comes out with the stool.

2. Monitor intake and output.
Rationale: Provide status information to establish the fluid balance fluid needs replacement.

3. Suggest to much to drink.
Rationale: Replacing body fluids.

4. Assess vital signs, signs / symptoms of dehydration and laboratory test results.
Rationale: Assessing hydration status, electrolyte and acid-base balance.

5. Collaborative execution of definitive therapy
Rationale: The provision of medicines known to causally important after diarrhea.

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Nursing Diagnosis and Interventions for Glomerulonephritis

Acute glomerulonephritis is also called acute post streptococcal glomerulonephritis is a non-suppurative inflammatory process involving the glomeruli, as a result of beta-haemolytic streptococcus bacterial infection of group A, type nephritogenic elsewhere. This disease often affects children.

Chronic glomerulonephritis is one of the important causes of end-stage renal disease that manifests as chronic renal failure.

Assessment

Activity / Rest

• Symptoms: fatigue, weakness (malaise).
• Symptoms: muscle weakness, loss of tone

Circulation

• Symptoms: hypotension / hypertension

Elimination

• Symptoms: changes in the pattern of urination, abdominal bloating, diarrhea / constipation
• Signs: change the color of urine

Food /fluid

• Symptoms: weight gain, weight loss, nausea, vomiting
• Signs: Changes in skin turgor

Neuro-sensory

• Symptoms: headache, blurred vision.
• Signs: impaired mental status and seizures

Pain / comfort

• Symptoms: body aches, headache
• Signs: cautious behavior, restless.

Breathing

• Symptoms: shortness of breath
• Signs: tachypnea, increased frequency, depth.

Security

• Symptoms: transfungsi reaction
• Signs: fever, pruritus

Nursing Diagnosis and Interventions for Glomerulonephritis

1. Risk for fluid volume deficit r / t excessive fluid loss.

Goal : Increased homeostasis

Outcomes: Shows the input and output approaching a balanced, good skin turgor, moist mucous membranes, peripheral pulse, weight and vital signs stable, electrolytes within normal limits

Intervention:

• Measure the input and output accurately.
• Give fluid permitted during the period of 24 hours.
• Monitor blood pressure.
• Note the signs / symptoms of dehydration.
• Collaboration (laboratory tests, eg, barium).

2. Fatigue r / t anemia

Goal: Accept the fact situation
Outcomes: Report a sense of energy improvements

Intervention:

• Evaluation report fatigue, difficulty completing tasks.
• Assess the ability to participate in desired activities.
• Identification of stress factors / psychological aggravate.
• Collaboration (electrolyte levels include: calcium, magnesium and potassium)

3. Imbalanced Nutrition: Less Than Body Requirements r / t anorexia

Goal: Indicates a stable weight

Outcomes: Maintaining / increasing weight, as indicated by an individual, free edema.

Intervention:

• Assess / record dietary intake.
• Give eat little and often.
• Give the patient a list of foods / liquids are permitted and encouraged involvement in the selection menu.
• Measure body weight each day.
• Collaboration (laboratory tests, eg, BUN, albumin, serum transferrin, sodium and potassium and consult with a nutritionist)

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Nursing Care Plan for Patent Ductus Arteriosus

Assessment

• Health history: a physiological response to the defect (cyanosis, limited activity).
• Assess for signs of heart failure, rapid breathing, shortness of breath, retractions, extra heart sounds (machinery mur-mur), hepatomegaly.
• Assess for chronic hypoxia: Clubbing finger
• Assess for hyperemia at the fingertips
• Assess diet, weight gain
• Psychosocial Assessment include: age of the child, the task of child development, coping is used, the child's habits, family response to childhood diseases, family coping and family adaptation to stress.

Nursing Diagnosis for for Patent Ductus Arteriosus

1. Decreased cardiac output r / t cardiac malformations.
2. Impaired gas exchange r / t pulmonary congestion.
3. Activity intolerance r / t imbalance between oxygen consumption by the body, and the supply of oxygen to the cells.
4. Altered Growth and Development r / t inadequate supply of oxygen and nutrients to the tissues.
5. Imbalanced Nutrition, Less Than Body Requirements r / t fatigue at mealtime and increased caloric needs.
6. Risk for infection r / t decrease in health status.

Nursing Interventions for for Patent Ductus Arteriosus

1. Maintain adequate cardiac output:

• Observation of the quality and strength of heart rate, peripheral pulses, skin color and warmth.
• Enforce the degree of cyanosis (circumoral, mucous membranes, clubbing).
• Monitor signs of CHF (restlessness, tachycardia, tachypnea, tightness, fatigue, periorbital edema, oliguria, and hepatomegaly).
• Collaboration of digoxin appropriate order, using the toxicity hazard prevention techniques.
• Give treatment to reduce afterload.
• Give diuretics as indicated.

2. Reduce the increase in pulmonary vascular resistance:

• Monitor the quality and respiratory rhythm.
• Adjust the position of the child with Fowler position.
• Avoid child of an infected person.
• Give adequate rest.
• Provide optimal nutrition.
• Give oxygen if indicated.

3. Maintaining adequate levels of activity:

• Allow the child to rest frequently, and avoid disturbances during sleep.
• Encourage games and activities to do lightly.
• Help the child to choose activities appropriate to the age, condition and ability of the child.
• Avoid the ambient temperature is too hot or too cold.
• Avoid the things that cause fear / anxiety in children.

4. Provide support for the growth and development

• Assess the level of development of the child.
• Give the stimulation of growth and development, play activities, gaming, watching TV, puzzles, drawing, and others according to the condition and age of the child.
• Involve the family in order to keep providing stimulation for treatment.

5. Maintaining growth in weight and height appropriate

• Provide a balanced diet, high nutrients to achieve adequate growth.
• Monitor height and weight, documented in the form of graphs to identify trends in the growth of the child.
• Measure body weight each day with the same weight and the same time.
• Record intake and output correctly.
• Give food with small portions but often to avoid fatigue at meals.
• Children who receive diuretics are usually very thirsty, therefore not restricted fluid.

6. Children will not show signs of infection

• Avoid contact with infected individuals.
• Give adequate rest.
• Give the optimal nutritional needs.

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Causes, Signs and Symptoms of Dissociative Disorders

Dissociative Disorders

In general, dissociative disorders can be defined as a loss of (some or all) of the normal integration (under conscious control) includes memories of the past, awareness of identity and immediate senses (awareness of identity and immediate sensations) as well as control of body movement.

Dissociative disorders in diagnosis there must be a disorder that causes failure coordinate identity, memory or consciousness perception, and cause significant disruption in social functioning, work and take advantage of free time.

There are several penggolonga in dissociative disorders, among others Dissociative Amnesia, Dissociative Fugue, Dissociative Stupor, Trance and Trance disorders, motor skills disorders Dissociative, Dissociative Convulsions and Dissociative Anesthetics and Sensory Loss.


Causes of Dissociative Disorders

Dissociative Disorders exact cause is not yet known, but it usually occurs as a result of severe trauma of the past, but no organic disorder experienced. This disorder occurs when the first children but not distinctive and can not be identified, dissociative disorders in the course of the disease can occur at any time and trauma of the past never happen again, and again and again so that the symptoms of dissociative disorders.

In some references say that the trauma that occurs in the form of:

• Unstable personality.
• Sexual harassment
• Physical abuse
• Domestic violence (father and mother divorced)
• Social environment that often show violence.

Personal identity is formed during childhood, and during even then, the children more easily step out of himself and observe trauma although it happens to someone else.


Signs and Symptoms of Dissociative Disorders

Dissociative disorders, under the control of consciousness and ability to selectively control the disturbed to the extent that can last from a day to day or even hour to hour.

Symptoms common to all types of dissociative disorders, including:

• Loss of memory (amnesia) against certain period of time, events and people,
• Problems of mental disorders, including depression and anxiety,
• Perception of the people and objects around him are not real (derealization)
• The identity of the opaque
• Depersonalization

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Definition, Clinical Manifestations and Etiology Dementia

Definition of Dementia

Dementia is a decline in mental ability that usually progresses slowly, where there is a disturbance of memory, thought, judgment and ability to focus, and personality deterioration can occur. At a young age, dementia may occur suddenly if severe injury, disease or toxic substances (eg carbon monoxide) causing the destruction of brain cells. But dementia usually occurs slowly and attack aged over 60 years. But dementia is not part of the normal aging process.

Along with age, the changes in the brain can cause a loss of some memory (especially short-term memory) and a decrease in some learning abilities. These changes do not affect the normal function. Forgotten in the elderly bukn a sign of dementia or early-stage disease Alzameir. Dementia is a decline in mental abilities are more serious, that the longer
getting worse.

In normal aging , a person may forget the details of things but people with dementia may forget the whole event has just occurred .

Dementia is a condition of progressive collapse intellectual ability after reaching the highest growth and development (age 15 years) due to organic brain disorder, followed by the collapse of behavior and personality, manifested in the form of impaired cognitive functions such as memory, orientation, sense of heart and formation of the conceptual mind. Usually this condition is not reversible, otherwise progressive. Diagnosis is carried out by clinical examination, and imaging studies laboratorlum (imaging), is intended to look for treatable causes. Treatment is usually supportive only. Kolines feels inhibitor (cholinesterase inhibitors) may improve cognitive function for a while, and make some antipsychotics drugs are more effective than just with one drug alone. Dementia can occur at any age, but more on the elderly.

Most of them were treated in homes and occupy some 50% of the bed. Dementia can be defined as cognitive and memory disorders that can affect daily activities. People with dementia often show some disturbances and changes in daily behavior (behavioral symptoms) that interfere with (disruptive) or do not disturb (non-disruptive) (Voicer. L., Hurley, AC, Mahoney, E.1998). Grayson (2004) states that dementia is not just ordinary disease, but rather a collection of symptoms caused by multiple diseases or conditions resulting in changes in personality and behavior.

Dementia is an illness that involves the brain cells that die abnormally. Only the terminology used to describe progressive degenerative brain disease. This disease may be experienced by all people of various educational and cultural backgrounds. Although there is not yet any treatment for dementia care to deal with the symptoms may be obtained through. Dementia is a decline in mental ability that usually progresses slowly, where there is a disturbance of memory, thought, judgment and ability to focus, and personality deterioration can occur.


Clinical Manifestations of Dementia

1. Decline in memory that continues to happen. In patients with dementia, "forget" become a part of daily life that can not be separated.
2. Impaired orientation of time and place, for example : forget the day, week, month, year, where people with dementia are.
3. The decline and inability to arrange words into correct sentences, using words that are not appropriate for a condition, repeat the word or the same story many times.
4. Excessive expression, for example, excessive crying when she saw a television drama, furious at small mistakes committed by others, fear and nervousness unwarranted. People with dementia often do not understand why these feelings arise.
5. The change of behavior, such as : indifferent, withdrawn and anxious.
6. The whole range of cognitive function is damaged.
7. Originally impaired short-term memory.
8. Personality and behavioral disorders, mood swings.
9. Motors and focal neurologic deficits.
10. Irritability, hostility , agitation and seizures.
11. Psychotic Disorders : hallucinations, illusions, delusions and paranoia.
12. Agnosia, apraxia, aphasia.
13. ADL ( Activities of Daily Living ) difficult.
14. Regulate the use of financial difficulties.
15. Not be able to go home when traveling.
16. Forgot to put the important stuff.
17. Difficult bathing, eating, dressing, toileting.
18. Patients can walk away from the house and can not go home.
19. Easy to fall, bad balance.
20. Finally paralysis, incontinence of urine and bowel movements.
21. Unable to eat and swallow.
22. Coma and death.

Etiology of Dementia

The most frequent cause of dementia is Alzheimer's disease. The cause of Alzheimer's disease is unknown, but is thought to involve genetic factors, because the disease seems to be found in some families and are caused or influenced by some specific gene abnormality. In Alzheimer's disease, some parts of the brain decline, resulting in cell damage and reduced response to a chemical signal channel in the brain. Found in the brain of abnormal tissue (called senile plaques and tangled nerve fibers) and abnormal proteins, which can be seen at autopsy. Dementia Lewy figure closely resembles Alzheimer's disease, but have differences in the microscopic changes that occur in the brain. The second most common cause of dementia is a stroke that row. Single stroke is small and causes mild weakness or weaknesses that arise slowly. This small strokes gradually cause damage to brain tissue, brain regions that were damaged due to blockage of blood flow is called infarction. Dementia is derived from several small strokes called multi - infarct dementia. The majority of sufferers have high blood pressure or diabetes, both of which cause damage to blood vessels in the brain.

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